Clinical and laboratory features of brucellosis in a university hospital in Tunisia.

AIM OF THE STUDY: The increase in the number of brucellosis cases between 2014 and 2017 (14 and 90 cases respectively) led us to study the biological and clinical-epidemiologic characteristics patients hospitalized in Rabta hospital of Tunis. MATERIAL AND METHODS: This retrospective study was conducted in Rabta Hospital in Tunis between 2016 and 2017. It includes 131 patients who had a positive bacteriological diagnosis of Brucella between 2016 and 2017. Diagnosis of brucellosis was made in blood culture by using Bactalert (Biomerieux®). Identification of Brucella was realized by Gram staining, catalase, oxydase. Serological diagnosis was made by testing sera for brucellosis agglutinins with Rose Bengale and the standard agglutination test. The collected data were analyzed by SPSS softcare version 24. RESULTS: The prevalence of Brucellosis in Rabta hospital increases from 14 cases in 2014 to 90 cases in 2017. The mean age was 45 years and ages range from 16 to 84 years. Rural origin was found in 75 cases (68%). Ninety-seven patients (89%) were hospitalized in the infectious diseases department. The average length of hospitalization was 17.25 days. Fifty-seven patients (52%) had a history of consuming unpasteurized dairy products and 45 (41%) were farmers. Fever was the predominant symptom in 104 cases (95%). Osteoarticular involvement is the most common complication of brucellosis and it occurred in 28% of patients. Blood cultures were 73 cases and 42 (57%) were positive for Brucella spp. Rose Bengale was positive in 100% of cases. High titles of the standard agglutination test (superior to 1/1280) were noted in 24 cases (22%). CONCLUSION: Brucellosis is still endemic In Tunisia. Contact with domestic animals and consumption of raw milk and milk products seems to be the major mode of transmission. Control of animal infection by vaccination, occupational and personal hygiene, farm sanitation and preventive measures can reduce disease incidence.

Diagnostic value of high-sensitivity troponin T in postmortem diagnosis of sudden cardiac death.

INTRODUCTION: Ischemic heart disease is the most common cause of sudden cardiac death. By autopsy, there may be no histologic evidence of acute myocardial damage few hours after death. The use of cardiac troponins in the postmortem diagnosis of sudden cardiac death is well known in the forensic setting. However, high-sensitivity cardiac troponin T (Hs-TnT) assay in cadaver fluids was tested in few studies. The aim of this study is to assess the diagnostic value of postmortem dosage of Hs-TnT in the diagnosis of sudden cardiac death. MATERIAL AND METHODS: Our study is prospective, dealing with cadavers autopsied at the Department of Forensic Medicine of the University Hospital Habib Bourguiba of Sfax-Tunisia from December 2016 to April 2018. Were excluded from the study resuscitated cases, severely traumatized victims and cadavers that were examined more than 36 h after death. Levels of Hs-TnT were measured in pericardial fluid, cardiac blood and peripheral blood. RESULTS: A total of 80 cases were identified with an average age of 44.5 ± 19 years. Hs-TnT levels in pericardial fluid and heart blood were correlated significantly between cardiac and non-cardiac groups with a p-value respectively at 0.14 and 0.04. Receiver-operator characteristic curves analysis showed that the pericardial fluid had the best sensibility (75%) and specificity (64%) with a cut-off level at 17.72 ng/ml and an area under the curve at 0.747. We found also a significant correlation between postmortem interval and Hs-TnT levels in pericardial fluid, cardiac and peripheral blood. CONCLUSION: Our data indicate that determination of cardiac troponin T by a highly sensitive assay in pericardial fluid may be a powerful aid in the postmortem diagnosis of sudden cardiac death.

COVID-19 circuit management: la Rabta experience.

Covid-19 pandemic was associated to fear among patients, doctors and nurses, it was responsible of a work impairment in health structures organisation. All patients were at home, only Covid patients were at hospital. Our country has a quick reaction, we declared the pandemic as a social disease with free management. All hospital had the order to create their own Covid-19 circuit. We report the experience of our hospital in the crisis management with the creation of the circuit, its organisation, the management of the different financial, technical, human, sanitary, psychological and logistical aspects. The great point of this crisis was the fear, stress of caregivers for themselves and their families. The other point for members of Covid Cell was the race against time, the learning of a new job: a manager or a polyvalent chief. The presence of a Covid-19 circuit is necessary for each hospital at the epidemic time but it must be managed by infectious diseases doctors, lung specialists, intensive care givers and emergency room caregivers in collaboration. An enhancement of the structures is necessary at the level of medical wards and beds of intensive care.

[Clinical and microbiological profile of patients experiencing relapses of tuberculosis in Tunisia]. / Profil clinique et microbiologique des patients en situation de rechute tuberculeuse en Tunisie.

INTRODUCTION: Relapse of tuberculosis (TB) is known to be as one of the major risk factors for resistant TB. The aim of this study is to focus on clinical, radiological and bacteriological features of patients with pulmonary TB relapse. METHODS: We performed a retrospective survey in the respiratory department of the teaching hospital La Rabta in Tunis between January 2000 and December 2014. Data of patients with a pulmonary TB relapse were analyzed. RESULTS: During the study period, among 1250 patients hospitalized for pulmonary TB, 44 had a TB relapse. The TB relapse rate was estimated to be at 3.5%. The average age was 43.95±16.7 years. Sex ratio was 5,2. Eighty one percent of patients were current smokers. Alcoholism was found in 40.9% of cases. The mean time to relapse was 6.37±3.7 years. The radiological lesions were moderately extended at least in 54.6% of cases. A resistant TB was found in 33% of cases (mono-resistance: 33.3%, multi-drug resistance (TB-MR): 11,1%, poly-resistance: 55.5%). The most incriminated drugs were isoniazid, rifampicin and pyrazinamide. One patient received TB-MR treatment regimen for 18 months. In the other cases, the duration of treatment was prolonged. Recovery was obtained in 72.7% of cases, two patients died and 22.7% of patients were lost to follow up. CONCLUSION: In Tunisia, TB relapse usually affects young male patients who are often alcoholic and smokers. Resistant TB is frequent among these patients. These findings lead us to emphasize the need of rapid diagnosis tools and adapted treatment regimen in these patients.

Forensic examination after exhumation: Contribution and difficulties after more than thirty years of burial.

We report a case of a Tunisian footballer who was found dead abroad under suspicious circumstances. The cause of death was, originally, attributed to a lightning strike. The corpse was buried without/autopsy. Over thirty years later, the family requested the exhumation to verify the identity and the cause of death. The exhumation was performed in 2011. DNA profiling from teeth and femur bone samples confirmed the identity of the deceased. The dry bone study revealed defects in the skull and the pelvis evoking firearm injuries. Post-mortem CT with three-dimensional (3-D) reconstruction allowed to confirm the characteristics of firearms injuries and to speculate about the number and the trajectories of potential shots. Nevertheless, the vitality of these injuries as well as the eventual fatal shot and the shooting distance could not be determined. Likewise, the type of the eventual weapon could not be clarified as there were no bullets or any metallic projectile fragments. Despite all doubts, the forensic explorations have allowed to verify the identity of the deceased, to evoke firearms injuries and, mainly, to deny the proposed cause of death after more than thirty years of burial. Moreover, the loss of soft tissues and bone fragility were the major obstacles.

[Arthrogryposis: clinical manifestations and management]. / L'arthrogrypose : manifestations cliniques et prise en charge.

INTRODUCTION: Arthrogryposis is a condition existing at birth, seen in different diseases that have in common the existence of multiple joint stiffness. The clinical presentation is diversified and the functional prognosis depends on the etiology, which makes therapeutic options different from one case to another. The objective of this study was to describe clinical manifestations observed in arthrogrypotic patients and show the different therapeutic methods and functional results. METHODS: This was a retrospective study over a period of 12 years from 2000 to 2012, based on clinical examinations of 23 patients with arthrogryposis. RESULTS: The mean age of the patients was 6.6 years. The four limbs were involved in 19 cases and only the lower limbs in four cases. The etiology was amyoplasia in nine patients, distal arthrogryposis in three, peripheral neuropathy in two, and muscular atrophy in one infantile patient. Foot deformities were observed in 22 cases, with 25 talipes equinovarus deformities (clubfoot), six convex feet, and five valgus feet. The Ponseti method was applied in 12 clubfeet with recurrence in eight cases. The other clubfeet had functional treatment and necessitated surgical release in 11 cases. Deformation of the knee was seen in 15 patients, flessum in 16 knees, restriction of flexion in eight cases, genu recurvatum in three, stiffness in extension in two, and agenesis of the patella in one case. Surgical treatment was carried out in only one case. Other cases of deformity of the knee were treated by rehabilitation with slight improvement. Deformation of the hip was seen in 15 patients, with 16 hips dislocated and four hips in flessum. The dislocation of the hip was treated orthopaedically in two cases and surgically in six cases, with reduction in all cases but persistence of stiffness. Involvement of the shoulders was observed in eight cases, the elbow in seven cases, the wrist in ten cases, and the fingers in 16 cases. The treatment was based on physical therapy and orthotics in all cases, and improvement was better in the wrist and fingers. CONCLUSION: Arthrogryposis has different clinical presentations. Successful treatment is not constant. Multidisciplinary care is necessary and should be early and continued in order to gain the maximum autonomy and facilitate patients' social integration.

Geographical distribution updating of Tunisian leishmaniasis foci: about the isoenzymatic analysis of 694 strains.

Over a period of ten years, a series of 694 Leishmania strains from Tunisian leishmaniasis foci were isolated and identified by isoenzymatic analysis. Strains were obtained from human cutaneous and visceral leishmaniasis in immunocompetent subjects, visceral leishmaniasis in imunocompromised individuals and from dogs with visceral leishmaniasis. Two classically dermotropic species, Leishmania (L.) major and Leishmania killicki were found. L. major with the single zymodeme MON-25 was the most isolated in cutaneous leishmaniasis foci of the Centre and South of Tunisia with a recent northern extension. L. killicki zymodeme MON-8 was sporadically found both in its classical microfocus of Tataouine in southeastern Tunisia as well as in some new foci in Southwestern, Central and Northern Tunisia. Leishmania infantum with its three zymodemes MON-1, MON-24 and MON-80 was isolated from both visceral and cutaneous human cases. The majority of L. infantum strains were found in the Northern part of the country; however, some strains were reported for the first time in the Southern part. L. infantum MON-1 was the only zymodeme isolated from canine leishmaniasis.

Multiresistance and endemic status of acinetobacter baumannii associated with nosocomial infections in a tunisian hospital: a critical situation in the intensive care units

Acinetobacter baumannii is often implicated in hospital outbreaks in Tunisia. It's a significant opportunistic pathogen associated with serious underlying diseases such as pneumoniae, meningitis and urinary tract infections. The aim of our study was to evaluate its degree of endemicity and its antibiotic resistance evolution essentially in the unit care where its isolation was predominant (57 percent). This study used 3 methods: antibiotyping, RAPD using 2 primers VIL 1, VIL5 and PFGE with ApaI restriction enzyme. The presence of integron1 and 2 was also studied. Antibiotyping showed that 92 percent of patients were resistant of all ß- lactams (except Imipenem) and that the resistance to Imipenem occurred in 47 percent of cases. RAPD profiles obtained with the 2 arbitrarily primers VIL1 and VIL5 gave respectively 5 and 4groups and PFGE fingerprinting patterns revealed 22 different pulsotypes. Integron 1 was present in 25 percent of unrelated strains and type 2 integron was not detected in any of the studied strains. Among 204 strains, multiple and heterogeneous groups were detected with the genomic studies. In addition, any correlation was obtained with the antibiotyping results. These findings demonstrate the endemic status of A. baumannii in our hospital and the persistence of a large number of multiresistant strains in the unit's care. When outbreaks of A. baumannii occur, it's essential to develop restricted hygiene procedures and a serious surveillance of critical units such as ICU for very ill patients.

[Cleidocranial dysplasia: report of 2 cases and literature review]. / La dysplasie cleidocrânienne : rapport de 2 cas et revue de la littérature.

Cleidocranial dysplasia or dysostosis involves dental anomalies, bone abnormalities with membranous ossification (clavicles, cranium, face, pelvis), rarely of the spine and the remainder of the skeleton. We report 2 new cases and describe the different clinical aspects of this disorder and the orthopedic problems that it can pose. The clinical demonstrations of this disease are highly variable and inconsistent, which explains the diversity of circumstances of discovery. Abnormalities of the face and clavicles, as well as of pelvic ossification are most frequent and can be regarded as major signs. These clinical demonstrations do not require treatment in the majority of the cases. Dental anomalies, coxa vara and scoliosis require regular monitoring and treatment in the event of progressive aggravation. The incomplete penetrance of this autosomal dominant disease and its good tolerance explain the frequency of undiagnosed forms, whose clinical expression is discrete.

[Evolution of group A Rotavirus strains circulating in Tunisia over a 3-year period (2005-2007)]. / Évolution des souches de Rotavirus du groupe A en circulation en Tunisie sur une période de trois ans (2005-2007).

BACKGROUND: Rotaviruses are the most frequent agents associated with diarrhoea in children worldwide. Analysis of mobility of the 11 segments of genomic RNA by polyacrylamide gel electrophoresis (PAGE) yields a pattern which is characteristic for a particular rotavirus isolate. The group A rotaviruses can be further characterized by analysis of VP7 and VP4 genes specificities, responsible for rotavirus classification into G and P genotypes, respectively. The aim of the present study was to determine the evolution of group A Rotavirus strains circulating in Tunisia over a 3-year period (2005-2007). MATERIAL AND METHODS: A total of 1503 stool samples collected from children less than five years old, consulting or hospitalised in Tunisia for diarrhoea between 2005 and 2007, were screened for the presence of group A Rotaviruses. Rotavirus-positive specimens were further analyzed by PAGE and G/P-genotyped by multiplex semi-nested RT-PCR. RESULTS: Rotaviruses were detected in 323 stool samples over 1503 (21 %). Long electropherotypes predominated in Tunisia during the whole period of study (N=158 vs N=82 short electropherotypes). VP7 genotyping showed the cocirculation of five different genotypes: G1, G2, G3, G4 and G9. VP4 typing detected four different P-genotypes: P[8], P[4], P[6] and P[11]. Rotavirus strains with G3P[8] specificity were predominating in Tunisia in 2005 and 2006, replaced by G2P[4] strains in 2007.

[Prevalence of hepatitis G, B and C virus infections among positive HIV population in a Tunisian Hospital, La Rabta, Tunis]. / Prévalence de l'hépatite G et des hépatites virales B et C dans la population VIH (+) de l'hôpital La Rabta, Tunis, Tunisie.

OBJECTIVE: The viral hepatitis G and HIV coinfection has been largely treated in the litterature. The aim of this study was to evaluate the coinfection rate in our hospital and to compare the HGV frequency to other hepatitis viruses (B and C) in positive HIV subjects at the Rabta hospital in Tunis, Tunisia. PATIENTS AND METHODS: The studied population included 125 HIV positives patients from the infectious diseases unit. The detection of the hepatitis B and C was carried out using serologic test (Elisa-Biorad). The molecular detection of the HGV was realized by reverse transcriptase polymerase chain reaction (RT-PCR). RESULTS: The prevalence of serological markers of hepatitis B (antibodies and/or antigens) and C (antibodies) was respectively 32.25% and 26.4%. HGV RNA was detected in 36.8% of the studied population. The unprotected intercourse was the predominant risk factor of the HGV contamination. Among the HGV (+) patients, 28.2% were carriers of the hepatitis C antibodies (anti-HCV). CONCLUSION: This work was the first study enabling to assess the coinfection rate of viral hepatitis B, C and G with HIV patients (+) in Rabta Hospital. The regular screening of HGV is recommended regarding its high frequency and the possibility of its pathogenic role.

[Detection of the first strain of glycopeptide intermediary Staphylococcus aureus in Tunis Rabta hospital]. / Détection de la première souche de Staphylococcus aureus de sensibilité diminuée aux glycopeptides à l'hôpital la Rabta de Tunis.

Since the advent of the first glycopeptide intermediately susceptible Staphylococcus aureus (GISA) and its heterogeneous variant hGISA in 1997, debate still ensues as their clinical significance. We report here the first case of GISA in Rabta hospital of Tunisia. Antimicrobial resistance was determined by the disk diffusion method in accordance with CA-SFM (Comity of Antibiogramm of French society of Microbiology). The MIC of vancomycin and teicoplanin was determined by E-test. The detection of mec A gene, virulence factors genes and agr groups (1-4) was performed by multiplex PCR. spa types were determined with the assistance of Ridom of Staph Type software (Ridom GmbH, Wurburg, Germany). The allelic profiles of MRSA were assigned on the basis of their MLST type using the eBURST program. A MRSA bacteraemia patient was treated with teicoplanin for 14 days. S. aureus isolated from patient's blood culture was identified as MRSA and GISA with teicoplanin MIC of 16 mg/l. The molecular study of this strain showed that it belongs to the clonal complex CC8 and is attached to the iberian clone (agr1, enterotoxin A, ST 247, spa type t052). Clinicians and laboratories alike are increasingly aware that patients on long-term vancomycin therapy may signal the presence and potential spread of hGISA/GISA strains. hGISA/GISA strains emerged from lineages with agr types I and II. The multiresitance of the Iberian clone ST247 could be explained by the presence of several resistance genes.

Relationship between electropherotypes and VP7/VP4 genotypes of group A rotaviruses detected between 2000 and 2007 in Tunisian children.

BACKGROUND: Rotaviruses are the most frequent agents associated with diarrhoea in children worldwide. Analysis of mobility of the 11 segments of genomic RNA by polyacrylamide gel electrophoresis (PAGE) yields a pattern which is characteristic for a particular rotavirus isolate. The group A rotaviruses can be further characterized by analysis of VP7 and VP4 genes specificities, responsible for rotavirus classification into G and P genotypes, respectively. The aim of the present study was to detect a relationship between electropherotype pattern and molecular characteristics of the rotavirus strains. MATERIAL AND METHODS: Were analyzed 278 rotavirus-positive specimens by PAGE and G/P-genotyped by multiplex semi-nested RT-PCR. Pearson's correlation tests were used for statistical analysis. RESULTS: Twelve different electropherotypes were visualized, eight with a long profile (186 cases) and four with a short one (87 cases). Concerning VP7 types, G2 viral strains were found to be predominant and were detected in 91 specimens (32.7%). Strains with G1, G3, G4, G8 and G9 specificities were detected in 62 (22.3%), 82 (29.5%), 13 (4.7%), two (0.7%) and seven cases (2.5%), respectively. The results of VP4 genotyping showed a predominance of P[8] genotype which comprised half of the strains identified (139 cases, 50%). VP4 P[4], P[6] and P[11] were found in 83 (29.9%), 31 (11.1%) and 11 (4.0%) specimens, respectively. A high rate of mixed strains was also found (1.8% mixed electropherotypes, 7.6% G-mixed and 5% P-mixed strains). Electropherotype pattern of rotavirus strains was significantly correlated with VP7 genotype (p=0.018) and with VP4 genotype specificities (p<0.001).

Multiresistance and endemic status of acinetobacter baumannii associated with nosocomial infections in a tunisian hospital: a critical situation in the intensive care units.

Acinetobacter baumannii is often implicated in hospital outbreaks in Tunisia. It's a significant opportunistic pathogen associated with serious underlying diseases such as pneumoniae, meningitis and urinary tract infections. The aim of our study was to evaluate its degree of endemicity and its antibiotic resistance evolution essentially in the unit care where its isolation was predominant (57%). This study used 3 methods: antibiotyping, RAPD using 2 primers VIL 1, VIL5 and PFGE with ApaI restriction enzyme. The presence of integron1 and 2 was also studied. Antibiotyping showed that 92% of patients were resistant of all ß- lactams (except Imipenem) and that the resistance to Imipenem occurred in 47% of cases. RAPD profiles obtained with the 2 arbitrarily primers VIL1 and VIL5 gave respectively 5 and 4groups and PFGE fingerprinting patterns revealed 22 different pulsotypes. Integron 1 was present in 25% of unrelated strains and type 2 integron was not detected in any of the studied strains. Among 204 strains, multiple and heterogeneous groups were detected with the genomic studies. In addition, any correlation was obtained with the antibiotyping results. These findings demonstrate the endemic status of A. baumannii in our hospital and the persistence of a large number of multiresistant strains in the unit's care. When outbreaks of A. baumannii occur, it's essential to develop restricted hygiene procedures and a serious surveillance of critical units such as ICU for very ill patients.

First report of molecular characterization of fluoroquinolone-resistant Mycobacterium tuberculosis isolates from a Tunisian hospital.

Fluoroquinolones are increasingly used for the treatment of infections caused by multidrug-resistant Mycobacterium tuberculosis. Our study was designed to determine the frequency of the emergence of ciprofloxacin-resistant isolates in a university hospital (Rabta University Hospital Tunis, Tunisia) and to characterize the mutations responsible for the resistance phenotype. A total of 495 clinical M. tuberculosis isolates obtained from January 2005 to July 2008 were investigated for their susceptibility to ciprofloxacin, using the standard proportion method, PCR and DNA sequencing. Four resistant isolates (0.8%) were identified. Among these, only two carried point mutations in gyrA leading to amino acid changes other than the phenotypically silent S95T substitution. No gyrB missense mutations were found in any of the clinical isolates. Although fluoroquinolone resistance is still rare in Tunisia, accurate surveillance is needed in order to control the possible emergence of resistance to fluoroquinolones, which are essential for the successful treatment of multidrug-resistant tuberculosis.

Seroprevalence of Helicobacter pylori among Tunisian blood donors (outpatients), symptomatic patients and control subjects.

OBJECTIVES: Helicobacter pylori is a worldwide infection, although little data are available in the Tunisian population. The aims of our study were to detect the prevalence of H. pylori in a blood-donor population (n=250) and in another population of hospital-consulting patients comprising 87 symptomatic patients and 59 controls, and to determine the factors that influence the prevalence. MATERIALS AND METHODS: Study subjects answered a standardized questionnaire, and IgG anti-H. pylori and anti-cag were detected by ELISA. In the second population, culture and cagA polymerase chain reaction were performed. RESULTS: The seroprevalence of H. pylori in blood donors was 64%, and 11% had anti-cag. All patients positive for anti-cag were also positive for anti-H. pylori antibodies. The seroprevalence of H. pylori was 99.3% in the hospital-consulting patients, of whom 55.5% were positive for anti-cag. The difference between the anti-cag and symptomatic patients (66.7%) and controls (39%) was significant. Symptomatic patients had a higher rate of anti-cag (66.7%) compared with the controls (39%) and blood donors (11%). CONCLUSION: H. pylori seroprevalence in blood donors is low (64%) compared with symptomatic patients (99.3%), and anti-cag was statistically associated with symptomatic patients and pathology. Also, some environmental factors were correlated with H. pylori seroprevalence.

[Diagnosis of peripheral tuberculous lymphadenitis in Tunisia]. / Diagnostic de la tuberculose ganglionnaire périphérique en Tunisie.

OBJECTIVE: The aim of the study was to evaluate the contribution of microbiology, cytology, and anatomopathology in 50 cases of peripheral tuberculous lymphadenitis. METHODOLOGY: Our patients underwent bacteriological tests and cytology and/or histopathology for lymphadenitis. RESULTS: Ziehl-Neelsen stains and cultures were positive in only 29.7% and 10.8% of cases respectively. The diagnosis was confirmed by cytology in 31.3% of cases (10/32) and by histology in 58.6% of cases (27/46). Granulomas were observed in 46.8% (15/32) of needle aspirates and 76% (35/46) of surgical biopsies. CONCLUSION: Our study reveals a weak contribution of conventional microbiological techniques. Cytology remains the procedure of choice in endemic countries. Excisional biopsy may be performed in case of doubt.

[Staphylococcus aureus skin infections: a hospital study]. / Les infections cutanées staphylococciques: à propos d'une série hospitalière.

INTRODUCTION: Staphylococcus skin infections (SSI) are common. The emergence methicillin-resistant Staphylococcus aureus (MRSA) is a growing concern. AIM: To describe the epidemiological, clinical and bacteriological features of SSI in a hospital department. PATIENTS AND METHODS: This was a prospective study performed in the Dermatology and Bacteriology Department of the La Rabta Hospital during a period of three months (February-April 2008). Were included all cases presenting with a primary SSI. For each patient wee collected epidemiological, clinical, bacteriological and therapeutic features. RESULTS: Twenty-five patients were included in the study concerning 15 men and 10 women, with a mean age of 47 years. Clinical exam revealed a unique lesion in 52% of cases. The abscess was the predominant clinical form (40%). The bacteriological study isolated a Staphylococcus aureus in the lesion in 40 % of cases and in the other sites of staphylococcus portage in 24% of cases. 32 % of patients had MRSA. CONCLUSION: Dermatologists are increasingly faced with cutaneous infections caused by MRSA. Bacterial samples should be taken routinely and probabilistic antibiotic therapy for MRSA instituted in severe infections.