[Microbiological diagnosis of Clostridium difficile infection]. / Diagnostic microbiologique des infections à Clostridium difficile.

The clinical microbiology laboratory plays an essential role in the management of Clostri- dium difficile infections, showing an increase in frequency and severity. Many tests (culture, EIA, PCR), detecting bacteria or their antigens, toxin genes or free toxins, allow the microbio- logist to provide the clinician and the infection control specialist with a reliable diagnosis as- sistance, which meet essential criteria for ra- pidity, sensitivity and specificity. This review presents the diagnostic algorithms currently used.

[Loco-regional complications of pharyngitis: the example of Lemierre's syndrome]. / Complications locorégionales des pharyngites: 1'exemple du syndrome de Lemierre.

Pharyngitis is a common cause of consultation in ambulatory medicine. Although it is benign in most cases, serious complications may happen and must be recognized quickly. Lemierre's syndrome is one of them. It consists in the association of thrombosis of the internal jugular vein and septic emboli that generally involve the lungs and is classically associated with Fusobacterium necrophorum. It is usually found in young and healthy adults and has an estimated mortality of 5%. Diagnosis relies essentially on the characteristic presentation of the disease. Therapy consists of surgical drainage of purulent collections and necrotic tissues associated with a prolonged course of antibiotics. Some authors also recommend a anticoagulation.

CSF lactate for accurate diagnosis of community-acquired bacterial meningitis.

CSF lactate measurement is recommended when nosocomial meningitis is suspected, but its value in community-acquired bacterial meningitis is controversial. We evaluated the diagnostic performance of lactate and other CSF parameters in a prospective cohort of adult patients with acute meningitis. Diagnostic accuracy of lactate and other CSF parameters in patients with microbiologically documented episodes was assessed by receiver operating characteristic (ROC) curves. The cut-offs with the best diagnostic performance were determined. Forty-five of 61 patients (74%) had a documented bacterial (n = 18; S. pneumoniae, 11; N. meningitidis, 5; other, 2) or viral (n = 27 enterovirus, 21; VZV, 3; other, 3) etiology. CSF parameters were significantly different in bacterial vs. viral meningitis, respectively (p < 0.001 for all comparisons): white cell count (median 1333 vs. 143/mm(3)), proteins (median 4115 vs. 829 mg/l), CSF/blood glucose ratio (median 0.1 vs. 0.52), lactate (median 13 vs. 2.3 mmol/l). ROC curve analysis showed that CSF lactate had the highest accuracy for discriminating bacterial from viral meningitis, with a cutoff set at 3.5 mmol/l providing 100% sensitivity, specificity, PPV, NPV, and efficiency. CSF lactate had the best accuracy for discriminating bacterial from viral meningitis and should be included in the initial diagnostic workup of this condition.

[Tularemia, an emerging disease in Switzerland]. / La tularémie, une maladie émergente en Suisse.

Tularemia is an infection caused by Francisella tularensis. This zoonose is transmitted to human through contact with infected animals or by vectors such as ticks. It has been a rare disease in Switzerland until recently, but its incidence is increasing. The clinical manifestations of tularemia are diverse and the ulcero-glandular disease is the most common form. It presents with an ulcerative lesion at the site of inoculation and regional lymphadenopathy which can be massive. Diagnosis is based on culture, PCR or serology with antibody titer rise approximately 2 weeks after the onset of illness. Antibiotics with clinical efficacy include doxycycline, fluoroquinolones and aminoglycosides.

[Headache and transient aphasia in a 35-year-old female patient]. / Kopfschmerzen und passagere Aphasie bei einer 35-jährigen Patientin.

We describe the case of a 35-year-old female patient who suffered from fulminant tick-borne encephalitis and subsequently died. Remarkable about this case was that the woman was not living in an endemic area and that the disease occurred outside the usual season. Furthermore, this indicates that an increase in transmission of tick-borne encephalitis can be expected outside the classical endemic areas in higher altitudes, possibly as a consequence of climate changes.

Investigation of classical epidemiological links between patients harbouring identical, non-predominant meticillin-resistant Staphylococcus aureus genotypes and lessons for epidemiological tracking.

According to molecular epidemiology theory, two isolates belong to the same chain of transmission if they are similar according to a highly discriminatory molecular typing method. This has been demonstrated in outbreaks, but is rarely studied in endemic situations. Person-to-person transmission cannot be established when isolates of meticillin-resistant Staphylococcus aureus (MRSA) belong to endemically predominant genotypes. By contrast, isolates of infrequent genotypes might be more suitable for epidemiological tracking. The objective of the present study was to determine, in newly identified patients harbouring non-predominant MRSA genotypes, whether putative epidemiological links inferred from molecular typing could replace classical epidemiology in the context of a regional surveillance programme. MRSA genotypes were defined using double-locus sequence typing (DLST) combining clfB and spa genes. A total of 1,268 non-repetitive MRSA isolates recovered between 2005 and 2006 in Western Switzerland were typed: 897 isolates (71%) belonged to four predominant genotypes, 231 (18%) to 55 non-predominant genotypes, and 140 (11%) were unique. Obvious epidemiological links were found in only 106/231 (46%) patients carrying isolates with non-predominant genotypes suggesting that molecular surveillance identified twice as many clusters as those that may have been suspected with classical epidemiological links. However, not all of these molecular clusters represented person-to-person transmission. Thus, molecular typing cannot replace classical epidemiology but is complementary. A prospective surveillance of MRSA genotypes could help to target epidemiological tracking in order to recognise new risk factors in hospital and community settings, or emergence of new epidemic clones.

[Pet-associated infections]. / Infections transmises par les animaux domestiques.

Pet-related infections in humans are diverse, rather infrequent considering the high number of pets in households and often unrecognized. This article briefly covers a couple of them, caused by bacteria (salmonellosis and campylobacteriosis, cat-scratch disease, fish tank granuloma, psittacosis), fungi (dermatophytosis), viruses (lymphocytic choriomeningitis) and parasites (toxoplasmosis, toxocariasis, cutaneous larva migrans, echinococcosis) and describes their epidemiology and clinical presentation. Widening of public tastes in this area opens doors for emerging diseases (e.g. Cowpox virus with rats).

[Occupational exposures with risk of transmission of HIV, HBC and HCV in health care workers]. / Accidents avec risque de transmission, du VIH, du virus de l'hépatite B et du virus de l'hépatite C dans le secteur médical.

Health care workers are often victims of occupational injuries by contaminated sharps or projection of contaminated fluids to mucous membranes and are therefore at risk for transmission of HIV, HBV and HCV. Every technical and organisation-related measure useful to prevent injuries should be implemented and personal protection equipment must be made available to workers. Promotion of hepatitis B immunization is a key issue. Immediate evaluation of injured employee is necessary to assess the risk related to exposure and the indication for post-exposure prophylaxis (anti-retroviral therapy for HIV, immunoglobulins and vaccination for hepatitis B). When a health care worker has been exposed to one of the blood-born viruses, thorough information and follow-up should be offered by a specialist.

[Blood culture negative endocarditis: a diagnostic challenge]. / Endocardites a hémocultures négatives: un défi diagnostique.

Blood culture negative endocarditis (BCNE) account for about 5% of all cases of endocarditis. Diagnosis and initiation of antimicrobial therapy may be delayed, with a negative impact on clinical outcome. The most common cause of BCNE is antimicrobial drug therapy before blood sampling. Other common causes include slow growing and non cultivable organisms. Identification of the etiologic agent is critical in the management of BCNE and molecular tools such as broad range 16SrRNA PCR technique followed by direct automated sequencing and microorganism-specific PCR are promising. Some authors have proposed to include these techniques among major Duke's criteria for the diagnosis of BCNE.

[Positive blood cultures during a 2 years period at Hôspital cantonal de Fribourg]. / Revue des hémocuttures positives sur deux ans a l'Hôpital cantonal de Fribourg.

Several authors, mainly from the United States, have reported on the microbiology and interpretation of positive blood cultures. We conducted a retrospective study over a 2 years period to address this issue in a medium-size swiss hospital: two hundred and thirty-two episodes of positive blood culture were recorded, with 403 microorganisms; Escherichia coli (22%), Staphylococcus aureus (21%) and coagulase-negative staphylococci (110%) were the most frequent isolates. The latter were considered as contaminants in 38% of cases. Half the episodes were nosocomial, 23% originated from the urinary tract and 18% were linked to a vascular catheter. Attributable mortality of bacteremia/fungemia was 9%, significantly higher for fungi (36%) than for bacteria (8%; p 0.009).

Effect of sputum induction by hypertonic saline on specimen quality.

Microbiologic work-up of expectorated material is routinely used to search for the etiology of pulmonary infections, but sputum is often contaminated by saliva. Inhalation of hypertonic saline induces bronchial secretions and theoretically may improve specimen quality. We compared in a laboratory-blinded, randomized study the quality of sputum obtained either with induction by saline or without induction in patients with respiratory tract infection and a history of productive cough. The quality of sputum was considered good if the polymorphonuclear neutrophils (PMNs)/squamous epithelial cells (SECs) ratio was > or = 2 or the Q (quality) score was > or = +1 on Gram stain. Forty-nine and 50 patients were able to expectorate in the induced and spontaneous sputum groups, respectively. PMNs/SECs ratio was > or = 2 in 65% and 74% of the patients in the induced and spontaneous sputum groups (p = 0.47); for the Q score, a value > or = +1 was found in 55% and 66% of the patients of each group (p = 0.37). In conclusion, sputum induction by hypertonic saline inhalation does not improve specimen quality as judged by the PMNs/SECs ratio on Gram stain.

[Vaccination against influenza in the hospital milieu and by family physicians in Fribourg in 1997: facts and opinions]. / Vaccination contre la grippe en milieu hospitalier et par les médecins praticiens à Fribourg en 1997: faits et opinions.

The influenza vaccine was underused in Switzerland in 1996, as less than half of people at risk for the disease were vaccinated. We performed this study in 1997 to determine (1) the immunisation rate in the patients admitted to the internal medicine ward of the Cantonal Hospital, Fribourg and in those seen by family physicians, (2) the reasons underlying the decision of the physician to vaccinate their patients or not, (3) the physicians' opinion of the vaccination. The study was retrospective and included 383 patients hospitalised in the medicine ward between October 15 and November 25, 1997. 249 of them (65%) had an indication for vaccination against influenza according to the recommendations of the Federal Office of Public Health. Only 20 patients (8%) were vaccinated during their hospital stay. 86 family physicians (83%) answered the questionnaire concerning 141 patients (57%) whom they examined after their hospital discharge. Of these patients, 77 (55%) were vaccinated by the family physician. The main reason for not vaccinating the patients was the patient's refusal (33%). The effectiveness of the vaccine was considered to be very good (effectiveness > 80%) by 40% of the family physicians and good (effectiveness 60-80%) by 50%. The local and systemic side effects were reported to be rare (incidence < 5%) by 55% and 71% of family physicians respectively. The cost and the route of administration were not felt to have any effect on acceptance of the vaccine. In decreasing importance the family physicians considered the recommendations of the Federal Office of Public Health useful for (1) chronic pulmonary disease, (2) immunosuppression, (3) chronic cardiac disease, (4) chronic renal insufficiency and residency in homes or institutions, (5) diabetes, (6) age over 64, (7) health care workers. In conclusion, the influenza immunisation rate in Fribourg was very low at the hospital but was higher than the Swiss figures for the family physicians. Patient's refusal was the main reason for non-vaccination. The family physicians have a favourable opinion of the effectiveness and tolerance of the influenza vaccine.