[Splenectomy in a large general hospital: often caused by iatrogenic injury, often causing multiple complications; poor adherence to post-operative guidelines for vaccination and prophylaxis]. / Splenectomie in een groot algemeen ziekenhuis: vaak iatrogeen letsel als oorzaak, veel complicaties tot gevolg; naleving postoperatieve richtlijnen voor vaccinatie en profylaxe gebrekkig.

OBJECTIVE: To assess the indications, complications and mortality associated with splenectomy in a large general hospital, and to evaluate adherence to guidelines for postoperative vaccination and prophylactic antibiotics. DESIGN: Retrospective, descriptive. METHOD: Data were collected on 106 patients who underwent splenectomy between 1999 and 2004. Indications for surgery, complications, duration of hospitalisation, and vaccination status were investigated retrospectively. Patients were contacted by telephone for a structured interview regarding vaccination and antibiotic prophylaxis. RESULTS: Of the 95 patients with sufficient data for analysis, 41 underwent elective surgery and 54 underwent non-elective surgery, including 37 who required splenectomy due to iatrogenic injury. Posteroperative complications arose in 45 patients, including 23 who developed serious complications. 10 patients died due to complications, including 7 who died within one month after the procedure. Vaccination coverage for the entire group was 58%. CONCLUSION: In this large general hospital, splenectomy was often performed due to iatrogenic injury and was associated with a relatively high complication rate. Adherence to guidelines on vaccination and prophylactic antibiotics could be improved.

Methicillin-resistant Staphylococcus aureus and Acinetobacter baumannii: an unexpected difference in epidemiologic behavior.

BACKGROUND: The Dutch guideline on hospital policy for the prevention of nosocomial spread of methicillin-resistant Staphylococcus aureus (MRSA) states that patients transferred from hospitals abroad must be placed in strict isolation immediately on admission to a hospital in the Netherlands. Three patients colonized with both MRSA and a multiresistant Acinetobacter were transferred from hospitals in Mediterranean countries to 3 different hospitals in the Netherlands. Despite isolation precautions, Acinetobacter spread in 2 of the 3 hospitals, whereas nosocomial spread of MRSA did not occur. METHODS: For outbreak analysis, the Acinetobacter isolates, identified as Acinetobacter baumannii by the use of amplified ribosomal DNA restriction analysis, were comparatively typed by 4 methods. Comparison of isolation measures in the hospitals was performed retrospectively. RESULTS: In the 2 hospitals in which nosocomial spread of Acinetobacter occurred, most of the epidemiologically related isolates were indistinguishable from the index strains. In these 2 hospitals, isolation measures were in concordance with those recommended for the prevention of contact transmission. The precautions of the hospital in which no outbreak occurred included the prevention of airborne transmission. CONCLUSIONS: Precautions recommended for multiresistant gram-negative organisms are insufficient for the prevention of nosocomial spread of multiresistant Acinetobacter. The airborne mode of spread of acinetobacters should be taken into account, and guidelines should be revised accordingly.

Determining risk factors for methicillin-resistant Staphylococcus aureus carriage after discharge from hospital.

At the University Medical Center, Utrecht, methicillin-resistant Staphylococcus aureus (MRSA) patients are considered lifelong MRSA carriers and potentially contagious when readmitted. The purpose of this study was to determine whether patients who become MRSA carriers while in hospital remain colonized after discharge, and whether risk factors for prolonged carriage exist. Thirty-six patients colonized with MRSA during three outbreaks at University Medical Center, Utrecht (group I: 1986-1989), and twenty patients already colonized with MRSA on, or during, admission to the hospital (group II: 1990-1995) were screened for MRSA in two studies. The patients had been discharged from the hospital for periods varying from 15 days to 4.6 years. MRSA was found in five (9%). Four of these patients had skin lesions (wounds), one with an external fixture. The presence of skin- and underlying diseases differed significantly between carriers and non-carriers, supporting the hypothesis that wounds are a major risk factor for long-term MRSA carriage. This study led us to revise our policy concerning readmission of former MRSA patients. We now consider that patients who contracted MRSA in the past no longer need isolation if the following two criteria are met. Absence for at least six months of open wounds, skin lesions, tracheostomy, infections and sources of infection such as abscesses and furuncles, orthopaedic implants, drains, catheters, or tubes. Three MRSA-negative sets of swabs from nose, throat, perineum, urine, and sputum taken at least one hour apart after this six-month period.

Long-term carriage, and transmission of methicillin-resistant Staphylococcus aureus after discharge from hospital.

The purpose of this study was to determine whether patients who become carriers of methicillin-resistant Staphylococcus aureus (MRSA) during their stay in hospital, remain colonized after discharge. Thirty-six patients colonized with MRSA during one of three outbreaks at Utrecht University Hospital (1986-89) were screened 2 or 3 years after they had become carriers. Patients were also interviewed to determine factors contributing to persistent carriage, such as antibiotics, re-admissions to the hospital, presence of skin lesions and chronic diseases. At the same time transmission of MRSA to family members was determined. The epidemic MRSA strain was still found in three patients (8%). One was a cystic fibrosis patient who had had frequent re-admissions to the hospital and had received several course of antibiotic treatment. Both of the other patients had skin lesions: a fistula and a colostomy respectively. None of the 44 family members of the patients was colonized or infected with MRSA. We conclude that long-term MRSA carriage occurs with low frequency and is comparable to persistent carriage of methicillin-sensitive Staphylococcus aureus (MSSA). Transmission of MRSA to healthy individuals in an antibiotic-free environment is a rare event.

Intracerebral Nocardia asteroides abscess treated by neurosurgical aspiration and combined therapy with sulfadiazine and cefotaxime.

We present a patient with a Nocardia brain abscess who failed to respond to repeated neurosurgical aspiration in combination with sulfadiazine therapy but improved after additional treatment with cefotaxime.

[Spread and control of a methicillin-resistant Staphylococcus aureus in an academic hospital]. / Verspreiding en bestrijding van een meticilline-resistente Staphylococcus aureus in een academisch ziekenhuis.

Between December 1988 and March 1989 twelve patients in the Utrecht University Hospital developed an infection with a methicillin-resistant Staphylococcus aureus (MRSA). Twenty other patients and 39 personnel members became colonized with the same MRSA strain. In spite of early isolation measures, progression of this epidemic was probably caused by the extreme degree of contagiousness of the first patient, who had a drug-induced allergic skin eruption. It seems likely that spread occurred via personnel and via a computer tomographic scanner. To contain the epidemic it was necessary to institute a special isolation ward with dedicated personnel. Although several MRSA strains have been introduced in the University Hospital since 1986, the strain we describe here is the only one which spread epidemically.

Control of epidemic methicillin-resistant Staphylococcus aureus in a Dutch university hospital.

Between 1986 and 1989 a single strain of a methicillin- and multiply-resistant Staphylococcus aureus caused three distinct outbreaks at Utrecht University Hospital, involving 11, 19 and 32 patients, respectively. In all three episodes, members of staff were screened for MRSA carriage, and 58 persons were found to have positive nose cultures. In each outbreak it became necessary to isolate colonized and infected patients on a separate isolation ward. Staff carriers were also treated. Over the 18 months since the last outbreak, no new acquisitions of this epidemic MRSA strain have occurred. Between 1986 and 1989, the strain which caused the three outbreaks was not the only MRSA strain which was introduced into the hospital. Six other strains, which differed from the epidemic strain as shown by phage typing and antimicrobial susceptibility pattern, were found in single patients. The experience at Utrecht University Hospital illustrates the need for strict measures to eradicate epidemic strains of MRSA as well as the differences in "epidemicity" among various strains of MRSA.

Discrimination of epidemic and nonepidemic methicillin-resistant Staphylococcus aureus strains on the basis of protein A gene polymorphism.

The X region of the protein A gene of Staphylococcus aureus contains a highly polymorphic sequence which is composed of repeats of 24 bp. We used amplification by PCR to investigate whether this region could be used to discriminate between epidemic and nonepidemic methicillin-resistant S. aureus (MRSA) strains. Most epidemic MRSA strains (24 of 33) harbored more than seven repeats, while most nonepidemic MRSA strains (10 of 14) contained seven or fewer repeats. It is conceivable that a longer X region results in a better exposition of the Fc-binding region of protein A, thereby facilitating colonization of host surfaces and contributing to the epidemic phenotype.

Molecular typing of methicillin-resistant Staphylococcus aureus on the basis of protein A gene polymorphism.

The polymorphic X-region of the protein A gene (spa) was used for molecular typing of methicillin-resistant Staphylococcus aureus (MRSA) strains. The X-region is characterized by a variable number (between 3 and 15) of small repeats. DNA sequencing of MRSA strains revealed 25 distinct repeats. Analysis of MRSA strains grown in vitro and in vivo revealed that the X-region was sufficiently stable for epidemiologic typing of MRSA strains. Spa typing of MRSA strains was compared to phage typing and, in general, concordance was found between the two methods. However, spa typing was more sensitive, allowing differentiation of strains within a particular phage type. Results obtained with spa typing suggest that hospital outbreaks may be caused by two or more MRSA strains. Spa typing may be an important tool in unravelling the spread of MRSA strains within and between hospitals.