Shift in bacterial etiology from the CAPNETZ cohort in patients with community-acquired pneumonia: data over more than a decade.

To determine the most relevant pathogens for CAP in Germany, patients with radiologically confirmed pulmonary infiltrates and at least one clinical sign of lung infection were prospectively recruited within the CAPNETZ cohort from 2004 until 2016. In 990 out of 4.672 patients (21%) receiving complete diagnostics the most prominent change of pathogens was a decrease of S. pneumoniae (58% in 2004 to 37.5% in 2016; p ≤ 0.001, ρ = - 0.148) and an increase of H. influenzae (12.2% to 20.8%; p = 0.001, ρ = 0.104).

Bacterial sepsis : Diagnostics and calculated antibiotic therapy.

The mortality of patients with sepsis and septic shock is still unacceptably high. An effective calculated antibiotic treatment within 1 h of recognition of sepsis is an important target of sepsis treatment. Delays lead to an increase in mortality; therefore, structured treatment concepts form a rational foundation, taking relevant diagnostic and treatment steps into consideration. In addition to the assumed infection and individual risks of each patient, local resistance patterns and specific problem pathogens must be taken into account during the selection of anti-infective treatment. Many pathophysiologic alterations influence the pharmacokinetics (PK) of antibiotics during sepsis. The principle of standard dosing should be abandoned and replaced by an individual treatment approach with stronger weighting of the pharmacokinetics/pharmacodynamics (PK/PD) index of the substance groups. Although this is not yet the clinical standard, prolonged (or continuous) infusion of ß­lactam antibiotics and therapeutic drug monitoring (TDM) can help to achieve defined PK targets. Prolonged infusion is sufficient without TDM, but for continuous infusion, TDM is generally necessary. A further argument for individual PK/PD-oriented antibiotic approaches is the increasing number of infections due to multidrug-resistant (MDR) pathogens in the intensive care unit. For effective treatment, antibiotic stewardship teams (ABS teams) are becoming more established. Interdisciplinary cooperation of the ABS team with infectious disease (ID) specialists, microbiologists, and clinical pharmacists leads not only to rational administration of antibiotics, but also has a positive influence on treatment outcome. The gold standards for pathogen identification are still culture-based detection and microbiologic resistance testing for the various antibiotic groups. Despite the rapid investigation time, novel polymerase chain reaction(PCR)-based procedures for pathogen identification and resistance determination are currently only an adjunct to routine sepsis diagnostics, due to the limited number of studies, high costs, and limited availability. In complicated septic courses with multiple anti-infective therapies or recurrent sepsis, PCR-based procedures can be used in addition to treatment monitoring and diagnostics. Novel antibiotics represent potent alternatives in the treatment of MDR infections. Due to the often defined spectrum of pathogens and the practically (still) absent resistance, they are suitable for targeted treatment of severe MDR infections (therapy escalation). (Contribution available free of charge by "Free Access" [ https://link.springer.com/article/10.1007/s00101-017-0396-z ].).

S. aureus endocarditis: Clinical aspects and experimental approaches.

Infective endocarditis (IE) is a life-threatening disease, caused by septic vegetations and inflammatory foci on the surface of the endothelium and the valves. Due to its complex and often indecisive presentation the mortality rate is still about 30%. Most frequently bacterial microorganisms entering the bloodstream are the underlying origin of the intracardiac infection. While the disease was primarily restricted to younger patients suffering from rheumatic heart streptococci infections, new at risk categories for Staphylococcus (S.) aureus infections arose over the last years. Rising patient age, increasing drug resistance, intensive treatment conditions such as renal hemodialysis, immunosuppression and long term indwelling central venous catheters but also the application of modern cardiac device implants and valve prosthesis have led to emerging incidences of S. aureus IE in health care settings and community. The aetiologic change has impact on the pathophysiology of IE, the clinical presentation and the overall patient management. Despite intensive research on appropriate in vitro and in vivo models of IE and gained knowledge about the fundamental mechanisms in the formation of bacterial vegetations and extracardiac complications, improved understanding of relevant bacterial virulence factors and triggered host immune responses is required to help developing novel antipathogenic treatment strategies and pathogen specific diagnostic markers. In this review, we summarize and discuss the two main areas affected by the changing patient demographics and provide first, recent knowledge about the pathogenic strategies of S. aureus in the induction of IE, including available experimental models of IE used to study host-pathogen interactions and diagnostic and therapeutic targets. In a second focus we present diagnostic (imaging) regimens for patients with S. aureus IE according to current guidelines as well as treatment strategies and surgical recommendations.

Dual antiretroviral therapy with tenofovir (TDF) and darunavir/ritonavir (DRV/RTV) in an HIV-1 positive patient: a case report, review, and meta-analysis of the literature on dual treatment strategies using protease inhibitors in combination with an NRTI.

BACKGROUND: Here, we report the case of an HIV positive patient under a dual antiretroviral drug regimen with tenofovir disoproxil and darunavir/ritonavir with stable clinical, virological, and immunological response over 126 weeks. Dual antiretroviral therapy has the advantage of reduced toxicity and lower health care costs, treatment failure and fostering drug resistance are perceived risks. Optimal drug combinations and indication criteria for dual treatment remain controversial. Nevertheless, first clinical trials indicate non-inferiority for combinations of nucleoside reverse transcriptase inhibitors and protease inhibitors. This case presents the combination of tenofovir disoproxil in combination with a protease inhibitor as a new potential dual treatment regimen. METHOD: We performed a systematic literature search and meta-analysis of trials comparing dual to triple ART. RESULTS: Literature review revealed nine studies in which dual therapy with a protease inhibitor and an NRTI was compared to triple therapy. We performed a meta-analysis of six trials that reported a 48-week follow-up. In treatment-naïve patients as well when ART switch was assessed, there was no difference in the treatment success in patients with dual ART versus triple. CONCLUSION: We conclude that dual therapy with a protease inhibitor and NRTI is safe and effective. The use of tenofovir in dual treatment as described in our case needs to be assessed in future clinical trials.

Impact of perioperative liver dysfunction on in-hospital mortality and long-term survival in infective endocarditis patients.

PURPOSE: Infective endocarditis (IE) is often associated with multiorgan dysfunction and mortality. The impact of perioperative liver dysfunction (LD) on outcome remains unclear and little is known about factors leading to postoperative LD. METHODS: We performed a retrospective, single-center analysis on 285 patients with left-sided IE without pre-existing chronic liver disease referred to our center between 2007 and 2013 for valve surgery. Sequential organ failure assessment (SOFA) score was used to evaluate organ dysfunction. Chi-square, Cox regression, and multivariate analyses were used for evaluation. RESULTS: Preoperative LD (Bilirubin >20 µmol/L) was present in 68 of 285 patients. New, postoperative LD occurred in 54 patients. Hypoxic hepatitis presented the most common origin of LD, accompanied with high short-term mortality. In-hospital mortality was higher in patients with preoperative and postoperative LD compared to patients without LD (51.5, 24.1, and 10.4%, respectively, p < 0.001). 5-year survival was worse in patients with pre- or postoperative LD compared to patients without LD (20.1, 37.1, and 57.0% respectively). A landmark analysis revealed similar 5-year survival between groups after patient discharge. Quality of life was similar between groups when patients survived the perioperative period. Logistic regression analysis identified duration of cardiopulmonary bypass and S. aureus infection as independent predictors of postoperative LD. CONCLUSIONS: Perioperative liver dysfunction in patients with infective endocarditis is an independent predictor of short- and long-term mortalities. After surviving the hospital stay, 5-year prognosis is not different and quality of life is not affected by LD. S. aureus and duration of cardiopulmonary bypass represent risk factors for postoperative LD.

[Bacterial sepsis : Diagnostics and calculated antibiotic therapy]. / Bakterielle Sepsis : Diagnostik und kalkulierte Antibiotikatherapie.

The mortality of patients with sepsis and septic shock is still unacceptably high. An effective antibiotic treatment within 1 h of recognition of sepsis is an important target of sepsis treatment. Delays lead to an increase in mortality; therefore, structured treatment concepts form a rational foundation, taking relevant diagnostic and treatment steps into consideration. In addition to the assumed focus and individual risks of each patient, local resistance patterns and specific problem pathogens must be taken into account for selection of anti-infection treatment. Many pathophysiological alterations influence the pharmacokinetics of antibiotics during sepsis. The principle of standard dosing should be abandoned and replaced by an individual treatment approach with stronger weighting of the pharmacokinetics/pharmacodynamics (PK/PD) index of the substance groups. Although this is not yet the clinical standard, prolonged (or continuous) infusion of beta-lactam antibiotics and therapeutic drug monitoring (TDM) can help to achieve defined PK targets. Prolonged infusion is sufficient without TDM but for continuous infusion TDM is basically necessary. A further argument for individual PK/PD-oriented antibiotic approaches is the increasing number of infections due to multidrug resistant pathogens (MDR) in the intensive care unit. For effective treatment antibiotic stewardship teams (ABS team) are becoming more established. Interdisciplinary cooperation of the ABS team with infectiologists, microbiologists and clinical pharmacists leads not only to a rational administration of antibiotics but also has a positive influence on the outcome. The gold standards for pathogen detection are still culture-based detection and microbiological resistance testing for the various antibiotic groups. Despite the rapid investigation time, novel polymerase chain reaction (PCR)-based procedures for pathogen identification and resistance determination, are currently only an adjunct to routine sepsis diagnostics due to the limited number of studies, high costs and limited availability. In complicated septic courses with multiple anti-infective treatment or recurrent sepsis, PCR-based procedures can be used in addition to therapy monitoring and diagnostics. Novel antibiotics represent potent alternatives in the treatment of MDR infections. Due to the often defined spectrum of pathogens and the practically absent resistance, they are suitable for targeted treatment of severe MDR infections (therapy escalation).

[Strategies for the Treatment of Community-Acquired Pneumonia in HIV-Positive Patients]. / Strategien zur Behandlung von ambulant erworbener Pneumonie bei HIV-positiven Patienten.

Study purpose According to the Robert Koch Institute, 84,700 people in Germany suffer from HIV infection. One-third of the affected persons is over 50 years old. In Germany, community-acquired pneumonia (CAP) is a widespread disease with more than 250,000 cases per year. Incidence and mortality increase with the age of the affected individuals. For this reason, diagnostic and therapeutic strategies are needed to guide medical care of HIV-infected patients presenting with CAP. Methodology HIV therapists were interviewed about their diagnostic approach, risk stratification strategy and therapeutic approach to HIV-associated community-acquired pneumonia (HIV +/CAP) using a questionnaire. 56 completed questionnaires were analysed. Results Half of the respondents reported that CAP occurred in 1 to 5 % of HIV-infected individuals per year. This indicates an estimated number of up to 4200 HIV +/CAP cases per year in Germany - a much higher number than expected from the literature. 58.9 % of respondents considered that the pathogenic spectrum did not differ in HIV +/CAP from non-HIV/CAP. 80.3 % of respondents applied the same antibiotic regimens in HIV +/CAP as used in patients with non-HIV/CAP. Conclusion Even though over 40 % of HIV therapists agree that the pathogenic spectrum of HIV +/CAP differs from that of non-HIV/CAP, over 80 % of therapists managed these patients in accordance with the S3-guidelines for non-immunocompromised CAP-patients, because specific guidelines for the treatment of HIV +/CAP are lacking. Since specific data on the aetiology and the clinical course of HIV +/CAP depending, for instance, on CD4-count and antiretroviral therapy are missing, we feel that the clinical course of HIV +/CAP should be further analysed in the context of prospective cohort studies.

[Antibiotic Stewardship 2.0. Individualization of therapy]. / Antibiotic Stewardship 2.0 : Individualisierung der Therapie.

Antibiotic resistance is a part of bacterial evolution and therefore unavoidable. In the context of missing novel treatment options, the restrictive use of available antibiotics in order to decelerate the spread of resistance is of high importance. This is the aim of Antibiotic Stewardship (ABS). ABS consists of two sides: a structural one and an individual one. The former deals with the formation of ABS teams, the analysis of antibiotic usage and resistance development, and the implementation of certain measures to improve antibiotic use; the latter is reflected by concrete bedside decisions: How can (broad) spectrum antibiotics be spared without harming the patient? This can be achieved, for example, by de-escalation, limiting duration of treatment, and avoiding nonindicated use. Typical nonindicated uses in both in- and outpatients are viral respiratory tract infections, asymptomatic bacteriuria and nonbacterial exacerbations of chronic obstructive pulmonary disease. Furthermore, respiratory colonization in ventilated patients, ventilator-associated tracheobronchitis, "prolonged" perioperative prophylaxis, and contaminated blood cultures reflect situations where antibiotics should be avoided. In the future, ABS will benefit from accelerated pathogen and resistance detection because early adequate treatment not only lowers the usage of antibiotics but can also improve patient outcome.

Should daptomycin-rifampin combinations for MSSA/MRSA isolates be avoided because of antagonism?

PURPOSE: There is increasing clinical evidence from observational studies, that combination therapy of daptomycin with rifampin is a valuable treatment option for biofilm-associated difficult to treat Staphylococcus aureus infections such as osteomyelitis, prosthetic joint infection and endocarditis. However, two studies analyzing a limited number of S. aureus isolates reported an antagonism of those two drugs questioning the benefit of this combination. METHODS: To estimate the frequency of this possible antagonism, we performed in vitro checkerboard assays on 58 consecutive clinical isolates of S. aureus (MSSA n = 9, MRSA n = 49). We determined the fractional inhibitory concentration index (FICI) and the susceptible breakpoint index (SBPI). All isolates were characterized by a microprobe array detecting 336 different genes/alleles to ensure their non-clonal origin. RESULTS: For all isolates, the FICI was between 1.00 and 1.25 indicating additive effects for the daptomycin/rifampin combination. Neither antagonism nor synergism as defined by the FICI was found for any of the isolates. CONCLUSION: Based on these data, there is no evidence to advise against the daptomycin/rifampin combination therapy.

Febrile patients admitted to remote hospitals in Northeastern Kenya: seroprevalence, risk factors and a clinical prediction tool for Q-Fever.

BACKGROUND: Q fever in Kenya is poorly reported and its surveillance is highly neglected. Standard empiric treatment for febrile patients admitted to hospitals is antimalarials or penicillin-based antibiotics, which have no activity against Coxiella burnetii. This study aimed to assess the seroprevalence and the predisposing risk factors for Q fever infection in febrile patients from a pastoralist population, and derive a model for clinical prediction of febrile patients with acute Q fever. METHODS: Epidemiological and clinical data were obtained from 1067 patients from Northeastern Kenya and their sera tested for IgG antibodies against Coxiella burnetii antigens by enzyme-linked-immunosorbent assay (ELISA), indirect immunofluorescence assay (IFA) and quantitative real-time PCR (qPCR). Logit models were built for risk factor analysis, and diagnostic prediction score generated and validated in two separate cohorts of patients. RESULTS: Overall 204 (19.1 %, 95 % CI: 16.8-21.6) sera were positive for IgG antibodies against phase I and/or phase II antigens or Coxiella burnetii IS1111 by qPCR. Acute Q fever was established in 173 (16.2 %, 95 % CI: 14.1-18.7) patients. Q fever was not suspected by the treating clinicians in any of those patients, instead working diagnosis was fever of unknown origin or common tropical fevers. Exposure to cattle (adjusted odds ratio [aOR]: 2.09, 95 % CI: 1.73-5.98), goats (aOR: 3.74, 95 % CI: 2.52-9.40), and animal slaughter (aOR: 1.78, 95 % CI: 1.09-2.91) were significant risk factors. Consumption of unpasteurized cattle milk (aOR: 2.49, 95 % CI: 1.48-4.21) and locally fermented milk products (aOR: 1.66, 95 % CI: 1.19-4.37) were dietary factors associated with seropositivity. Based on regression coefficients, we calculated a diagnostic score with a sensitivity 93.1 % and specificity 76.1 % at cut off value of 2.90: fever >14 days (+3.6), abdominal pain (+0.8), respiratory tract infection (+1.0) and diarrhoea (-1.1). CONCLUSION: Q fever is common in febrile Kenyan patients but underappreciated as a cause of community-acquired febrile illness. The utility of Q fever score and screening patients for the risky social-economic and dietary practices can provide a valuable tool to clinicians in identifying patients to strongly consider for detailed Q fever investigation and follow up on admission, and making therapeutic decisions.

Q fever is an old and neglected zoonotic disease in Kenya: a systematic review.

BACKGROUND: Q fever is a neglected zoonosis caused by the bacterium Coxiella burnetii. The knowledge of the epidemiology of Q fever in Kenya is limited with no attention to control and prevention programs. The purpose of this review is to understand the situation of Q fever in human and animal populations in Kenya in the past 60 years, and help identify future research priorities for the country. METHODS: Databases were searched for national and international scientific studies or reports on Q fever. We included studies and reports published between 1950 and 2015 if they reported on Q fever prevalence, incidence, and infection control programs in Kenya. Data were extracted with respect to studies on prevalence of Coxiella infections, study design, study region, the study populations involved, and sorted according to the year of the study. RESULTS: We identified 15 studies and reports which qualified for data extraction. Human seroprevalence studies revealed evidence of C. burnetii infections ranging from 3 to 35.8% in all regions in which surveys were made and two Q fever outbreak episodes. Coxiella burnetii infections found in cattle 7.4-51.1%, sheep 6.7-20%, camels 20-46%, and goats 20-46% revealed variation based on ecoregions and the year of study. Farming and lack of protective clothing were associated with increased seropositivity among humans. However, high quality data is lacking on Q fever awareness, underlying cultural-economic factors influencing C. burnetii infection, and how the pathogen cycles may be embedded in livestock production and management systems in the economically and ecologically different Kenyan regions. We found no studies on national disease incidence estimates or disease surveillance and control efforts. CONCLUSION: Coxiella burnetii infections are common in human and in a wide range of animal populations but are still unrecognized and underestimated thus presenting a significant human and animal health threat in Kenya. The factors influencing pathogen transmission, persistence and spread are poorly understood. Integrated disease surveillance and prevention/control programs are needed in Kenya.

Systematic review of brucellosis in Kenya: disease frequency in humans and animals and risk factors for human infection.

BACKGROUND: Brucellosis is a debilitating zoonotic disease affecting humans and animals. A comprehensive, evidence-based assessment of literature and officially available data on animal and human brucellosis for Kenya are missing. The aim of the current review is to provide frequency estimates of brucellosis in humans, animals and risk factors for human infection, and help to understand the current situation in Kenya. METHODS: A total of accessible 36 national and international publications on brucellosis from 1916 to 2016 were reviewed to estimate the frequency of brucellosis in humans and animals, and strength of associations between potential risk factors and seropositivity in humans in Kenya. RESULTS: The conducted studies revealed only few and fragmented evidence of the disease spatial and temporal distribution in an epidemiological context. Bacteriological evidence revealed the presence of Brucella (B.) abortus and B. melitensis in cattle and human patients, whilst B. suis was isolated from wild rodents only. Similar evidence for Brucella spp infection in small ruminants and other animal species is unavailable. The early and most recent serological studies revealed that animal brucellosis is widespread in all animal production systems. The animal infection pressure in these systems has remained strong due to mixing of large numbers of animals from different geographical regions, movement of livestock in search of pasture, communal sharing of grazing land, and the concentration of animals around water points. Human cases are more likely seen in groups occupationally or domestically exposed to livestock or practicing risky social-cultural activities such as consumption of raw blood and dairy products, and slaughtering of animals within the homesteads. Many brucellosis patients are misdiagnosed and probably mistreated due to lack of reliable laboratory diagnostic support resulting to adverse health outcomes of the patients and routine disease underreporting. We found no studies of disease incidence estimates or disease control efforts. CONCLUSION: The risk for re-emergence and transmission of brucellosis is evident as a result of the co-existence of animal husbandry activities and social-cultural activities that promote brucellosis transmission. Well-designed countrywide, evidence-based, and multidisciplinary studies of brucellosis at the human/livestock/wildlife interface are needed. These could help to generate reliable frequency and potential impact estimates, to identify Brucella reservoirs, and to propose control strategies of proven efficacy.

Yellow fever vaccination during treatment with infliximab in a patient with ulcerative colitis: A case report.

We report the case of a 59-year-old patient who accidentally underwent live vaccination against yellow fever during continuous treatment with the TNF-α-antibody (AB) infliximab for ulcerative colitis. The clinical course showed fever of short duration and elevation of liver enzymes without further clinical complications. Yellow fever viremia was not detectable and protective antibodies were developed. A primary vaccination against yellow fever under infliximab has not been reported in the literature before, although vaccination is an important topic in IBD. Live vaccinations, like Stamaril(®) against yellow fever, are contraindicated during TNF-α-AB treatment. Treatment regimens containing TNF-α-AB are of growing importance, not only in gastroenterology, but also in rheumatology and dermatology. We discuss this topic by presenting our case and reviewing the current literature.

Ross River virus infection in a Thuringian traveller returning from south-east Australia.

Ross River virus (RRV) is an arbovirus transmitted by Aedes and Culex mosquitos. It is endemic in Australia, New Zealand and south-east Asia. Clinical manifestation rates in adults range about 20-40%. Symptoms involve arthralgia, myalgia, lymphadenopathy, fever and rash. Here we report a case of RRV in a Thuringian traveller who visited the urban South-East of Australia.

Lung disease and ulcerative colitis--mesalazine-induced bronchiolitis obliterans with organizing pneumonia or pulmonary manifestation of inflammatory bowel disease?

Ulcerative colitis can be associated with numerous extraintestinal organ manifestations. Pulmonary disease in inflammatory bowel disease (IBD) is supposed to be a rare entity and has to be distinguished from infectious complications and side-effects of medications used in the treatment of IBD. We present the case of a 20-year-old male patient with ulcerative colitis and a 4-week history of respiratory symptoms, malaise, fever and respiratory insufficiency under a medication with mesalazine. Computed tomography showed bilateral subpleural consolidations, bronchoscopy revealed signs of acute bronchitis. The diagnostic work-up ruled out an infectious cause. Under the tentative diagnosis of a mesalazine-induced bronchiolitis obliterans with organizing pneumonia (BOOP) the medication with mesalazine was withdrawn and the patient received a corticosteroid trial. The symptoms quickly improved and prednisone was tapered and stopped after 6 months. Unexpectedly, lung function after complete resolution of respiratory symptoms revealed a residual obstructive ventilatory defect that might be due to an asymptomatic pulmonary manifestation of ulcerative colitis. A review of the literature shows that pulmonary manifestations in IBD as well as pulmonary toxicity of mesalazine might not be as rare as expected and should be included as differential diagnoses in the work-up of respiratory symptoms in patients with IBD. A pragmatic therapeutic approach is reasonable in critically ill patients as it is not always easy to distinguish both entities.

[Position Paper on Adult Pneumococcal Vaccination: Position Paper of the German Respiratory Society and the German Geriatric Society]. / Stellungnahme zur Empfehlung der Pneumokokken-Impfung für Erwachsene: Positionspapier der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin (DGP) und der Deutschen Gesellschaft für Geriatrie (DGG).

Currently, the German Advisory Committee on Immunization Practices recommends the pneumococcal polysaccharide vaccine (PSV23) instead oft the pneumococcal conjugate vaccine (PCV13) for standard vaccination of adults > 60 years. Whereas the efficacy of PSV23 against bacteraemia has been proven by numerous studies, there is increasing evidence that there is no efficacy against non-bacteraemic pneumococcal pneumonia. This is in contrast to PCV13, for which the CAPITA study has recently revealed an efficacy of 45% against non-bacteraemic pneumonia by the 13 vaccine types.In this position paper we argue that this decision is not justified by the available evidence for the following reasons: i) the main burden of pneumococcal diseases is non-bacteraemic pneumoniaii) the clinical evidence for the efficacy against pneumonia is of higher quality for PCV13 than for PSV23 iii) the duration of clinical efficacy PSV23 starts to decrease after 2 years, whereas this has not yet been observed for PCV13 in the CAPITA study for at least four years, and iv) herd protection effects observed after PCV7 infant vaccination program on invasive pneumococcal disease must not be extrapolated to PCV13 and non-invasive pneumococcal diseases.

[Pneumococcal vaccination for prevention of pneumonia]. / Pneumonieprävention durch Pneumokokkenimpfung.

Aging of the immune system, so-called immunosenescence, is well documented as the cause of increased infection rates and severe, often complicated courses of infections in older adults. This is particularly true for pneumococcal pneumonia in older adults; therefore, the standing committee on vaccination of the Robert Koch Institute (STIKO) recommends a once only vaccination with 23-valent pneumococcal polysaccharide vaccine for all persons aged 60 years and over. Furthermore, the 13-valent pneumococcal conjugate vaccine is also available for administration in adults and is recommended by the STIKO for particular indications. The advantage of the pneumococcal conjugate vaccine is the additional induction of a T-cell dependent immune response that leads to good immunogenicity despite immunosenescence. Initial data from a recent randomized controlled trial, so far only presented at conferences, confirm that the conjugate vaccine also provides protection against non-bacteremic pneumococcal pneumonia, which is not provided by the polysaccharide vaccine. Thus, there are two vaccines for prevention of pneumococcal diseases: one with a broader range of serotype coverage but with an uncertain protection against non-bacteremic pneumococcal pneumonia and another one with less serotype coverage but more effective protection. Vaccination of children with the conjugate vaccine also leads to a rapid decrease of infections by the 13 vaccine serotypes even in adults because of herd protection effects. For prevention of pneumonia in older adults the additional benefit of a concurrent application of influenza vaccine and pneumococcal vaccine should be considered.

[Vaccinations from the pulmonologist's point of view]. / Impfungen aus pneumologischer Sicht.

BACKGROUND: The best strategy for prevention of acute respiratory tract infections is primary prophylaxis against diseases preventable by vaccination. From the pulmonologist's point of view, vaccinations against pneumococci, influenza A and B viruses and Bordetella pertussis are of particular clinical relevance. OBJECTIVES: This review article discusses the disease burden of these pathogens and the recommendations for immunization in adults. CURRENT DATA: For immunization against pneumococci a less immunogenic but broad-spectrum 23-valent polysaccharide vaccine (PPV23) and a highly immunogenic 13-valent conjugate vaccine (PCV13) with a more narrow-spectrum are approved. A sequential vaccination with PCV13 followed by PPV23 is a new option in adults. In the US this vaccination strategy is recommended as routine vaccination for all adults over 65. In Germany sequential pneumococcal vaccination is proposed only in special indications such as patients with asplenia. Trivalent and quadrivalent split-virus vaccines are the standard vaccines against seasonal influenza in adults. The Standing Committee on Vaccinations (STIKO) recommends a yearly vaccination as standard over 60 and in indications for special risk groups (e.g. infants with underlying diseases, immunocompromised patients, chronically ill patients and pregnant women). For the primary prophylaxis of pertussis only an acellular vaccine is available. Neither vaccination nor a previous infection provide lifelong immunity; therefore, the STIKO recommends an additional booster vaccine for all adults. CONCLUSION: Vaccination against pneumococci, influenza A and B viruses as well as Bordetella pertussis are recommended as standard and in special indications for adults by the STIKO at the Robert Koch Institute. For selection of the various vaccines individual factors such as age, immune status, comorbidities and pregnancy have to be considered.

Placental Schistosoma haematobium infection in a German returnee from Malawi.

Schistosomiasis is a widespread helminthic infection which sometimes may affect travelers to endemic areas. We report on a case of urogenital and placental schistosomiasis in a 28-year-old German woman who had been exposed to schistosomiasis in Lake Malawi one year earlier. She experienced painless macrohaematuria in her 21st week of pregnancy. Cystoscopy revealed vesical lesions typical for urogenital schistosomiasis. Histopathology confirmed ova of Schistosoma (S.) haematobium. The patient was treated with praziquantel 40 mg/kg/body weight/day for 3 days. After 285 days of gestation and 18 weeks post treatment, the patient delivered a healthy girl. Histopathology of placenta revealed eggs of S. haematobium in placental stroma. The infant proved negative for anti-Schistosoma spp. antibodies at the age of 15 months. This is the first report on placental schistosomiasis since 1980 and the first case occurring in a traveler.

Coxiella burnetii (Q fever) as a cause of community-acquired pneumonia during the warm season in Germany.

Q fever is a notifiable disease in Germany. The majority of the reported cases are related to outbreaks. The objective of our study was to evaluate the general role of Q fever in community-acquired pneumonia (CAP). We investigated respiratory samples and sera from 255 patients with CAP, who were enrolled into a CAPNETZ cohort in summer 2005. Altogether, our data showed a significant prevalence of Q fever as CAP (3·5%). If a patient's condition leads to a diagnostic test for Chlamydophila sp., Mycoplasma sp. or Legionella sp., then a Q fever diagnostic test should also be included. In particular, ELISA as a first diagnostic step is easy to perform. PCR should be performed at an early stage of the disease if no antibodies are detectable. Because of our highly promising findings we suggest performing PCR in respiratory samples.