[Epidemiology, diagnostics, therapy, prevention and management of uncomplicated bacterial outpatient acquired urinary tract infections in adult patients : Update 2017 of the interdisciplinary AWMF S3 guideline]. / Epidemiologie, Diagnostik, Therapie, Prävention und Management unkomplizierter, bakterieller, ambulant erworbener Harnwegsinfektionen bei erwachsenen Patienten : Aktualisierung 2017 der interdisziplinären AWMF S3­Leitlinie.

BACKGROUND: Update of the 2010 published evidence-based S3 guideline on epidemiology, diagnostics, therapy and management of uncomplicated, bacterial, outpatient-acquired urinary tract infections in adult patients. The guideline contains current evidence for the rational use of antimicrobial substances, avoidance of inappropriate use of certain antibiotic classes and development of resistance. METHODOLOGY: The update was created under the leadership of the German Association of Urology (DGU). A systematic literature search was conducted for the period 01 January 2008 to 31 December 2015. International guidelines have also been taken into account. Evidence level and risk of bias were used for quality review. RESULTS: Updated information on bacterial susceptibility, success, collateral damage and safety of first- and second-line antibiotics was given. For the treatment of uncomplicated cystitis the first line antibiotics are fosfomycin trometamol, nitrofurantoin, nitroxoline, pivmecillinam, trimethoprim (with consideration of the local resistance rates). Fluoroquinolones and cephalosporins should not be used as first choice antibiotics. In the case of uncomplicated pyelonephritis of mild to moderate forms, preferably cefpodoxime, ceftibuten, ciprofloxacin or levofloxacin should be used as oral antibiotics. CONCLUSION: The updated German S3 guideline provides comprehensive evidence- and consensus-based recommendations on epidemiology, diagnostics, therapy, prevention and management of uncomplicated bacterial outpatient acquired urinary tract infections in adult patients. Antibiotic stewardship aspects have significantly influenced the therapeutic recommendations. A broad implementation in all clinical practice settings is necessary to ensure a foresighted antibiotic policy and thus t improve clinical care.

[National S3 guideline on uncomplicated urinary tract infection: recommendations for treatment and management of uncomplicated community-acquired bacterial urinary tract infections in adult patients]. / Nationale S3-Leitlinie "Unkomplizierte Harnwegsinfektionen" : Empfehlungen zu Therapie und Management unkomplizierter bakterieller ambulant erworbener Harnwegsinfektionen bei erwachsenen Patienten.

BACKGROUND: Urinary tract infections (UTI) belong to the most frequent bacterial infections in outpatients. Increasing antibiotic resistance rates and a new appreciation of the epidemiological side effects of antibiotics ("collateral damage") have warranted an update of the guidelines on uncomplicated UTI as an S3 clinical guideline. METHODS: The guideline was developed by the Deutsche Gesellschaft für Urologie (DGU) in collaboration with the Deutsche Gesellschaft für Allgemein- und Familienmedizin (DEGAM), Deutsche Gesellschaft für Gynäkologie und Geburtshilfe (DGGG), Deutsche Gesellschaft für Hygiene und Mikrobiologie (DGHM), Deutsche Gesellschaft für Infektiologie (DGI), Deutsche Gesellschaft für Nephrologie (DGfN), Paul-Ehrlich-Gesellschaft für Chemotherapie (PEG) and a patient representative. The systematic review of the literature on the topics of the guideline was performed for the time period of 1 January 1998 to 30 April 2008 in the databases of the Cochrane Library and MEDLINE. International guidelines of the years 1999-2007 were included. RESULTS: Uncomplicated UTI comprise uncomplicated cystitis and uncomplicated pyelonephritis. The leading uropathogen is Escherichia coli. The choice of the antibiotic substance follows the five primary aspects: (1) individual patient risk and antibiotic pretreatment; (2) bacterial spectrum and antibiotic susceptibility; (3) effectivity of the antimicrobial substance demonstrated in clinical studies; (4) epidemiological effects ("collateral damage"); and (5) adverse effects. If antibiotics such as trimethoprim/sulfamethoxazole or fluoroquinolones have previously been given, the risk for pathogens to become resistant against these substances is increased. Because of increasing resistance rates of E. coli against trimethoprim/sulfamethoxazole also in uncomplicated UTI, trimethoprim alone or in combination with sulfamethoxazole is no longer regarded as the first-line agent in the empiric treatment of uncomplicated cystitis, unless the regional resistance rate is below 20%. The antibiotic resistance rates of fluoroquinolones in uncomplicated UTI are still below 10% in Germany, but there is a significant emergence of resistance compared to earlier years. Moreover, fluoroquinolones and group 3 cephalosporins exhibit negative epidemiological effects resulting in selection of multi-resistant pathogens. Because these antibiotic classes are needed in therapy of life-threatening infections, such effects should be taken seriously. For substances like fosfomycin, nitrofurantoin or mecillinam"collateral damage" has not been documented or only to a lesser degree. Therefore, for empiric therapy of frequent uncomplicated cystitis fosfomycin-trometamol, nitrofurantoin or pivmecillinam (not listed in Germany) are recommended as first-line antibiotics. For oral first-line treatment of uncomplicated pyelonephritis, fluoroquinolones are still recommended in sufficiently high dosage due to the resistance rates of E. coli still being below 10% and the superior effectivity compared to other antibiotics. Asymptomatic bacteriuria (ASB) should only be treated in exceptional cases such as pregnant women or prior to expected mucocutaneous traumatising interventions of the urinary tract. CONCLUSION: The S3 guideline on uncomplicated urinary tract infections is a comprehensive set of evidence- and consensus-based recommendations dealing with epidemiology, diagnosis, therapy and management of uncomplicated bacterial UTI of adult outpatients. A broad implementation in all disciplines taking care of patients with UTI is necessary in order to ensure a prudent antibiotic policy in these frequent infections and thus improve patient care.

Bed, bath and beyond: pitfalls in prompt eradication of methicillin-resistant Staphylococcus aureus carrier status in healthcare workers.

Healthcare workers (HCWs) in close contact with patients colonized with methicillin-resistant Staphylococcus aureus (MRSA) were screened for MRSA acquisition. From 1995 to 2001, MRSA was identified from the nasopharyngeal swabs of 87 HCWs, collected one to two weeks after contact with 592 known MRSA-positive patients. These HCWs were withdrawn from work and treated with topical antibiotics/antiseptics. They were advised to disinfect their bathrooms and personal hygiene articles, and to wash bed linen and pillows. They were screened for successful eradication for up to three months. Seventy-three (84%) HCWs lost their carrier status. The eradication regimen failed in 14 cases. In 11 of these MRSA was detected only in later nasopharyngeal swabs (suspected recolonization). Screening identified nasal colonization of close household contacts in eight of these 11 cases. Environmental sampling detected contamination in seven out of eight screened home environments. When eradication treatment was applied to household contacts and when household surfaces were cleaned and disinfected, the carriage cleared in most cases within a few weeks. However, when home environments are heavily contaminated, despite adequate medical treatment, eradication took upto two years. Due to withdrawal from work, the 14 carriers without prompt and lasting eradication after the first course of treatment accounted for about 70% of all lost working days. These experiences support the hypothesis that control measures should not be restricted to antibiotic or antiseptic treatment of long-term carriers (HCWs as well as patients), but must also include cleaning and disinfection of the household.

Pseudo-outbreak of toxigenic Bacillus cereus isolated from stools of three patients with diarrhoea after oral administration of a probiotic medication.

From December 2000 to January 2001 toxigenic Bacillus cereus was isolated from stools of three patients with diarrhoea at two tertiary hospitals in southwest Germany. Two cases with nosocomial diarrhoea were apparently epidemiologically related (same time and ward), a third case was unrelated with respect to time and location. In order to investigate the epidemiology of these three cases, clinical isolates and isolates from an unexpected, possible common source (probiotic medication) were compared by toxin assay, biotyping and randomly amplified polymorphic DNA (RAPD) analysis. The three clinical isolates, as well as the two isolates from different lots of the probiotic medication (Bactisubtil containing 'Bacillus IP 5832'; Cassella-med, Cologne, Germany), were indistinguishable by toxin assay, biotyping and RAPD, when compared with other distinguishable clinical B. cereus strains. As the diarrhoeal disease had begun before the probiotic medication had been administered to overcome it, the isolated B. cereus probably was at least initially, not the cause of the observed diarrhoeal disease. Isolation of toxigenic B. cereus from stools appeared to be a diagnostically misleading epiphenomenon after oral medication with the probiotic. We conclude, that probiotic medication with Bactisubtil (Bacillus IP 5832) may result in diagnostically misleading results when culturing stool specimens from patients with diarrhoea. The clonal identity of isolates may be misinterpreted as an outbreak. Stool specimens should be taken before start of probiotic treatment and clinicians should state probiotic medication when ordering stool examinations to allow correct interpretation of results. Nevertheless, it is noteworthy that a probiotic medication contains potentially toxigenic material.

Cerebral gnathostomiasis as a cause of an extended intracranial bleeding.

This is a report of a fourteen year old Thai-girl who presented with acute hemiparesis because of intracranial haemorrhage six weeks after immigrating to Germany. Marked blood eosinophilia and raised IgE in serum in comparison with her origin led to the suspected diagnosis of parasitosis. Angiography showed mycotic aneurysm typical for cerebral gnathostomiasis one of the major causes of intracranial haemorrhage in children in Thailand. This diagnosis was confirmed by detecting specific antibodies against Gnathostoma spinigerum in serum and CSF by Western blot. Therapy was started with albendazole and dexamethasone and the girl made a complete recovery. In case of intracranial haemorrhage cerebral gnathostomiasis should be considered if the patient originates from an endemic area.

[Triclosan, a topical dermatologic agent. In vitro- and in vivo studies on the effectiveness of a new preparation in the New German Formulary]. / Triclosan, ein dermatologisches Lokaltherapeutikum In-vitro- und In-vivo-Untersuchungen zur antibakteriellen Wirksamkeit einer neuen Arzneibuchrezeptur.

BACKGROUND AND OBJECTIVE: Triclosan (2,4,4'-trichloro-2'-hydroxydiphenyl ether) is an antiseptic suitable for formulation as a W/O emulsion. The objective of the present study was to explore its potential utility in atopic dermatitis and prophylactic skin care following leg eczema and leg ulcer treatment. SUBJECTS AND METHODS: We performed in vitro susceptibility testing using the agar diffusion test on 602 isolates from swabs of our institution's Division of Dermatology. Additionally in an in vivo study with 15 healthy volunteers, the occlusion test and the expanded flora test were performed following the application of Hydrophobic Triclosan Cream 2% NRF (New German Formulary) 11.122. (TC) versus untreated, triclosan-free vehicle, 1% chlorhexidine digluconate solution, and ethanol 70%. RESULTS: In vitro susceptibility testing showed excellent activity against Staphylococcus aureus, Klebsiella species, and Proteus species. TC had little or no effect on Pseudomonas, beta-hemolytic streptococci, enterococci, and Candida species. In the in vivo study, TC produced a highly significant, quantitatively substantial reduction in aerobic bacterial counts versus untreated and versus vehicle. The 1% chlorhexidine digluconate solution was significantly more effective than TC in the expanded flora test. CONCLUSIONS: As S. aureus is a relevant pathogen in atopic dermatitis, and gram-negative organisms, including Klebsiella and Proteus species, as well as S. aureus play a major role in the prophylactic skin care after leg eczema and leg ulcer treatment, TC appears to be suitable for maintenance therapy in these indications.

Rupture of therapeutic oleothorax leading to paraffin oil aspiration and dissemination of tuberculosis--a fatal late complication of tuberculosis therapy in the 1940s.

In the 1940s, oleothorax (paraffin oil instillation) was widely used to treat patients with apical tuberculosis. The oil plombage should have been removed after a few years; however, since oleothoraces were usually asymptomatic, removal was uncommon. These in the meantime elderly patients are at risk of late complications, such as rupture of the oleothorax and aspiration of oil. We report the case of a 69-year-old man with a spontaneous rupture of an oleothorax leading to oil aspiration, lipid pneumonia and culture-proven disseminated tuberculosis with fatal outcome. Unexpected positive PCR for M. tuberculosis-DNA in tracheal secretions was one of the leading signs in this case. Thus oil plombage in patients with oleothorax may be "time bombs". Primary physicians should be aware of this life-threatening complication.