MRSA prevalence rates detected in a tertiary care hospital in Austria and successful treatment of MRSA positive patients applying a decontamination regime with octenidine.

Methicillin-resistant Staphylococcus aureus (MRSA) decontamination regimens predominantly use chlorhexidine bathing in combination with mupirocin nasal ointment. However, resistances in Staphylococcus aureus strains are increasingly common and there is a need of alternative, safe and feasible protocols. This interventional cohort study performed at the Albert Schweitzer Hospital in Graz, Austria, aimed to (1) determine MRSA prevalence at different body sites and (2) assess the efficacy of the decontamination using octenidine-based leave-on products added to existing robust infection control measures. All inpatients of this tertiary care hospital being treated in geriatric medical wards (GWs) and apallic care units (ACUs) were screened for MRSA and decontamination rates were determined after one, two or three decontamination cycles, respectively. At baseline, MRSA was detected in 25 of the 126 patients screened (19.8%). We found MRSA in 13/126 (10.3%) swabs from nasal vestibules, in 12/126 (9.5%) skin swabs, in 11/51 (21.6%) swabs from PEG-stomata or suprapubic catheters and in 8/13 (61.5%) tracheostomata swabs. A maximum of three 5-day decontamination cycles reduced the number of MRSA positive patients by 68.0%. Excluding non-compliant and deceased patients, decontamination reduced MRSA carriage by 93.3% (n = 15). No adverse events related to the applied decontamination regimen occurred. Exclusive screening of the nose might underreport MRSA prevalence rates. In this study, decontamination with octenidine-based leave-on products was safe and effective in a critical patient population.

Soluble urokinase plasminogen activator receptor predicts mortality in patients with systemic inflammatory response syndrome.

OBJECTIVE: The soluble urokinase plasminogen activator receptor (suPAR) reflects inflammation. However, the prognostic value of suPAR measurements, particularly at the very early onset of systemic inflammatory response syndrome (SIRS), is less well defined. METHODS: The prognostic potential of suPAR levels in patients with SIRS was evaluated. From November 2010 until April 2013, 902 adult patients presenting with SIRS were investigated. Blood samples for laboratory testing of inflammation markers were collected simultaneously with initial blood cultures. suPAR testing was performed using suPARnostic(©) assay. RESULTS: Analyses of receiver operating characteristics curves revealed areas under the curve (AUCs) of 0.818 for predicting overall mortality within 48 h (36/902 patients died), 0.739 for 30-day mortality (117/902 died) and 0.706 for predicting 90-day mortality (151/902 died). AUCs for procalcitonin (0.777, 0.671 and 0.638), interleukin-6 (0.709, 0.593 and 0.569) and C-reactive protein (0.66, 0.594 and 0.586) as well as renal function and age were markedly lower. Using multivariable regression analyses, suPAR levels (P < 0.001) remained significant predictors of 48-h mortality, whereas suPAR levels (P < 0.001) and bacteraemia (P = 0.002 and P = 0.001, respectively) remained significant predictors of 30- and 90-day mortality. Using Kaplan-Meier survival plots, patients with suPAR <9.15 ng mL(-1) at SIRS onset had a clear benefit. CONCLUSION: suPAR plasma level determined at early SIRS is predictive for mortality.

Clinical presentation of Puumala virus infections in southern Austria in the peak year 2012.

In 2012, an extraordinary rise in Puumala infections causing nephropathia epidemica (NE) was observed in southern Austria. We investigated differences in epidemiology, clinical presentation, laboratory results, treatment parameters, and outcome between patients in 2012 and previous years (2007-2011). All patients diagnosed with Puumala virus infections between 2007 and 2012 using a point of care Puumala IgM test at the microbiology laboratory, Department of Internal Medicine, Medical University of Graz, were included. In 2012, 42 and in 2007-2011 a total of 40 patients were diagnosed with NE. In 2007-2011, patients presented more frequently with arthromyalgias (25% vs 7%, p = 0.027), while lower back pain was reported more often in 2012 (21% vs 5%, p = 0.029). Other symptoms occurred at the same rate. In 2012, patients were diagnosed significantly faster (time from first contact with a physician to diagnosis 1.3 ± 0.2 vs 2.7 ± 0.4 days, p = 0.01). Significantly fewer patients required haemodialysis in 2012 (2.4% vs 20%, p = 0.01). There were no significant differences in laboratory parameters between the two groups. In the peak year 2012, patients were diagnosed faster and fewer patients required haemodialysis possibly because of the earlier diagnosis and earlier onset of therapy.

Comparison of clinical presentation and laboratory values at admission between PCR-confirmed influenza A H1N1 infection and influenza-like disease, South-East Austria.

PURPOSE: Reliable and rapid diagnosis of influenza A H1N1 is essential to initiate the appropriate antiviral therapy and preventive measures. As PCR assays are time-consuming and rapid antigen tests have a limited sensitivity, official influenza case definitions are used in many clinical settings. These, however, are based exclusively on clinical criteria and have only a moderate potential to differentiate between influenza and other febrile diseases. Only limited data on the differences in clinical and laboratory parameters between influenza and non-influenza febrile diseases are available to date. METHODS: This was a retrospective case-negative control series that was conducted in Styria, southeast Austria. We analyzed the differences in clinical presentation and laboratory admission parameters between patients with PCR-confirmed H1N1 influenza infection (n = 199) and those with influenza-like disease and negative influenza PCR results (ILD group; n = 252). RESULTS: In the multivariable analysis lower C-reactive protein (CRP) level, lower white blood cell (WBC) count, fever, wheezing, cough, and the absence of nausea or sudden onset remained significant predictors of H1N1 influenza in adult patients (n = 263). Lower CRP level, lower WBC count, and cough remained significant predictors in pediatric patients (<16 years; n = 188). CONCLUSION: Lower CRP level, lower WBC count, and cough were significant predictors of H1N1 in both the adult and pediatric patient group. These data may help to develop an improved case definition for suspected H1N1 infection which combines clinical findings and easily available laboratory parameters.

Procalcitonin fails to predict bacteremia in SIRS patients: a cohort study.

BACKGROUND: Procalcitonin (PCT) has previously been proposed as useful marker to rule out bloodstream-infection (BSI). The objective of this study was to evaluate the sensitivity of different PCT cut-offs for prediction of BSI in patients with community (CA)- and hospital-acquired (HA)-BSI. METHODS: A total of 898 patients fulfilling systemic-inflammatory-response-syndrome (SIRS) criteria were enrolled in this prospective cohort study at the Medical University of Graz, Austria. Of those 666 patients had positive blood cultures (282 CA-BSI, 384 HA-BSI, enrolled between January 2011 and December 2012) and 232 negative blood cultures (enrolled between January 2011 and July 2011 at the emergency department). Blood samples for determination of laboratory infection markers (e.g. PCT) were collected simultaneously with blood cultures. RESULTS: Procalcitonin was significantly (p < 0.001) higher in SIRS patients with bacteremia/fungemia than in those without. Receiver operating characteristic curve analysis revealed an area under the curve (AUC) value of 0.675 for PCT (95% CI 0.636-0.714) for differentiating patients with BSI from those without. AUC for IL-6 was 0.558 (95% CI 0.515-0.600). However, even at the lowest cut-off evaluated (i.e. 0.1 ng/ml) PCT failed to predict BSI in 7% (n = 46) of patients. In the group of patients with SIRS and negative blood culture 79% (n = 185) had PCT levels > 0.1. CONCLUSION: Procalcitonin was significantly higher in patients with BSI than in those without and superior to IL-6 and CRP. The clinical importance of this is questionable, because a suitable PCT threshold for excluding BSI was not established. An approach where blood cultures are guided by PCT only can therefore not be recommended.

Which lumen is the source of catheter-related bloodstream infection in patients with multi-lumen central venous catheters?

PURPOSE: Paired blood cultures, drawn from the catheter and a peripheral vein, used for calculation of the differential time to positivity (DTP), have been proposed for the detection of catheter-related bloodstream infections (CRBSIs). The most relevant catheter lumen to be sampled in multi-lumen central venous catheters (CVCs) has not been recommended. METHODS: Forty-four febrile neutropaenic patients, following haematopoietic stem cell transplantation (HSCT) and with multi-lumen CVCs in place, were investigated using the DTP method of blood samples drawn from every lumen of the CVC and a peripheral vein. RESULTS: Twelve of 44 patients (27 %) had CRBSIs, as determined by the DTP method. In 10 of 12 (83 %) febrile neutropaenic patients, after HSCT, CRBSIs originated from the CVC lumen used for parenteral nutrition and blood products only. 17 % had CRBSI originating from the other CVC lumen (p = 0.039). CONCLUSION: In most patients, CRBSIs originated from the CVC lumen used for parenteral nutrition and blood products, indicating that this lumen is the main source of CRBSI. However, since 17 % of patients had CRBSIs originating from another lumen, each lumen of multi-lumen CVCs has to be considered as a potential source of CRBSI and should, ideally, be sampled in order to avoid failure in diagnostic procedures.

Epidemiology of invasive fungal infections and rationale for antifungal therapy in patients with haematological malignancies.

Invasive fungal infections (IFIs) in patients with haematological malignancies are difficult to diagnose and outcome is often fatal. Over the 7-month study period, 117 cases with haematological malignancies receiving systemic antifungal treatment were included. Data regarding antifungal agents, dosage and reason for administration were recorded. Fungal infections in study patients were classified as possible, probable or proven according to recent European Organization for Research and Treatment of Cancer criteria. During the study period, 690 cases with haematological malignancies were admitted. A total of 117 cases received systemic antifungal therapy. Twenty-four of 117 patients (21%) had possible, six (5.1%) had probable and four (3.4%) had proven IFI. Seven of 10 probable and proven infections were caused by Candida spp., 2 by Aspergillus spp. and 1 by a fungus belonging to Zygomycetes. Fifty-two of 117 patients (44%) received antifungal prophylaxis, 81 of 117 (69%) received empirical (31/117; 26%) or pre-emptive (50/117; 43%) antifungal therapy and four of 117 patients (3.4%) directed antifungal therapy. Mostly, systemic antifungal therapy was administered empirically or pre-emptively. Twenty-nine per cent of cases receiving systemic antifungal treatment met the international consensus criteria of mostly possible IFI, whereas 71% did not. Proven invasive fungal infections were rare.

Dalbavancin for the Treatment of Prosthetic Joint Infections: A Narrative Review.

Dalbavancin (DAL) is a lipoglycopeptide with bactericidal activity against a very wide range of Gram-positive microorganisms. It also has unique pharmacokinetic properties, namely a prolonged half-life (around 181 h), which allows a convenient weekly dosing regimen, and good diffusion in bone tissue. These features have led to off-label use of dalbavancin in the setting of bone and joint infection, including prosthetic joint infections (PJI). In this narrative review, we go over the pharmacokinetic and pharmacodynamic characteristics of DAL, along with published in vitro and in vivo experimental models evaluating its activity against biofilm-embedded bacteria. We also examine published experience of osteoarticular infection with special attention to DAL and PJI.

Multicenter clinical experience of real life Dalbavancin use in gram-positive infections.

Dalbavancin, a lipoglycopeptide with prolonged half-life approved for the treatment of acute bacterial skin and soft tissue infections, can be used for the treatment of infections caused by gram-positive bacteria requiring long term treatment such as endocarditis, prosthetic joint infections (PJI) or osteomyelitis. Clinical data are limited in these settings. OBJECTIVES: To evaluate indications, safety, tolerability and long-term outcomes of dalbavancin-treated patients. Patients and methods Our multicenter, retrospective study includes patients who received dalbavancin in Austria from September 2016 to March 2018. 90-day outcomes and tolerability were determined. RESULTS: A total of 101 patients were included in 3 centers (57% male, median age 65 years). The treated infections were PJI (31%), osteomyelitis (29%), endocarditis (25%) and acute bacterial skin and soft tissue infections (12%). Concomitant use of other antimicrobial substances was common (63%). The mean total cumulative dose of dalbavancin was 3,357mg (±2,283mg). Clinical success rate was 89%. Side effects occurred in 3/101 patients. CONCLUSION: In this real-life study dalbavancin was primarily used in off-label indications for treatment of PJI, osteomyelitis and endocarditis. Success rate was high (89%), tolerability and safety were excellent in this setting. Dalbavancin may therefore be used in these off-label indications as alternative treatment approach.

Facilitation of gastric compliance and cardiovascular reaction by repeated isobaric distension of the rat stomach.

Gastric distension causes cardiovascular reactions and enhances gastric compliance. Here, we investigated how these responses are related to each other, whether they change upon repeated distension and which neural mechanisms are involved. Mean arterial blood pressure (MAP) in phenobarbital-anaesthetized rats was recorded from a carotid artery and gastric compliance determined with an electronic barostat. Runs of intermittent gastric distension were generated by stepwise increments (5 mmHg) of intragastric (IG) pressure. While gastric compliance peaked at IG pressures of 20 mmHg, the change in MAP (predominantly hypotension) was largest at IG pressures beyond 30 mmHg. Repeated distension enhanced the MAP response to IG pressures beyond 35 mmHg, whereas gastric compliance was facilitated primarily at IG pressures below 20 mmHg. This facilitation of gastric compliance depended on the magnitude of the preceding distension. The MAP response to distension was enhanced by nitric oxide synthase inhibition, inhibited by subdiaphragmatic vagotomy but hardly affected by coeliac ganglionectomy. The facilitation of gastric compliance was changed by vagotomy in a complex manner but left unaltered by the other interventions. These findings show that isobaric gastric distension elicits both MAP and gastric compliance responses whose characteristics, mechanisms and sensitization properties differ profoundly.

Therapy of acute gastroenteritis: role of antibiotics.

Acute infectious diarrhoea remains a very common health problem, even in the industrialized world. One of the dilemmas in assessing patients with acute diarrhoea is deciding when to test for aetiological agents and when to initiate antimicrobial therapy. The management and therapy of acute gastroenteritis is discussed in two epidemiological settings: community-acquired diarrhoea and travellers' diarrhoea. Antibiotic therapy is not required in most patients with acute gastroenteritis, because the illness is usually self-limiting. Antimicrobial therapy can also lead to adverse events, and unnecessary treatments add to resistance development. Nevertheless, empirical antimicrobial therapy can be necessary in certain situations, such as patients with febrile diarrhoeal illness, with fever and bloody diarrhoea, symptoms persisting for >1 week, or immunocompromised status.

Anti-hyperalgesic effect of octreotide in patients with irritable bowel syndrome.

BACKGROUND: Octreotide has been found to be beneficial in the treatment of chronic pain, although the mechanisms underlying its therapeutic effect are incompletely understood. AIMS: To assess the effect of octreotide on perceptual responses to rectal distension in irritable bowel syndrome patients and healthy controls at baseline and following the experimental induction of rectal hyperalgesia. METHODS: In study 1, rectal perception thresholds for discomfort were determined in seven irritable bowel syndrome patients and eight healthy controls on three separate days using a computer-controlled barostat. Subjects received saline, low-dose and high-dose octreotide in a random double-blind fashion. In study 2, perceptual responses to rectal distension were obtained in nine irritable bowel syndrome patients and seven controls before and after repetitive high-pressure mechanical sigmoid stimulation. RESULTS: Octreotide increased the discomfort thresholds in irritable bowel syndrome patients, but not in controls, without changing rectal compliance. Repetitive sigmoid stimulation resulted in decreased rectal discomfort thresholds in the patient group only. In irritable bowel syndrome patients, octreotide prevented the sensitizing effect of repetitive sigmoid stimulation on rectal discomfort thresholds. CONCLUSIONS: Octreotide effectively increased discomfort thresholds in irritable bowel syndrome patients, but not in controls, at baseline and during experimentally induced rectal hyperalgesia. These findings suggest that octreotide exerts primarily an anti-hyperalgesic rather than analgesic effect on visceral perception.

The pathophysiology of irritable bowel syndrome.

Recent studies have provided evidence to suggest a possible role for mucosal immune activation in the pathophysiology of irritable bowel syndrome (IBS). On the other hand, novel findings using functional brain-imaging techniques support the concept that altered perception of visceral stimuli plays a key role in IBS symptom generation. These seemingly contradictory findings have revived the discussion about the relative contribution of peripheral versus central mechanisms in the symptom generation of IBS. In this review, we will provide evidence for the hypothesis that, in the absence of changes in visceral perception and alterations in endogenous pain modulation systems, chronic inflammatory mucosal changes in the gut are not a plausible mechanism to explain the presence of chronic abdominal pain, a clinical hallmark of IBS.

Blurred vision and myopic shift in Puumala virus infections are independent of disease severity.

Puumala virus infection causes epidemic nephropathia (NE), a certain type of haemorrhagic fever with renal syndrome (HFRS). Myopic shift is considered a pathognomonic sign of NE and HFRS but rates of ocular involvement vary. The aim of the study was to evaluate whether clinical and laboratory findings are associated with ophthalmic involvement in NE in Austria. We found that blurred vision and myopic shift are frequent in Puumala virus infections in Austria but are independent of disease severity.

Comparison of fluorescence in situ hybridisation using peptide nucleic acid probes, Gram stain/acridine orange leukocyte cytospin and differential time to positivity methods for detection of catheter-related bloodstream infection in patients after haematopoietic stem cell transplantation.

In 46 febrile neutropenic patients who had undergone haematopoietic stem cell transplantation, the fluorescence in situ hybridisation using peptide nucleic acid probes (PNA FISH), Gram stain/acridine orange leukocyte cytospin (Gram/AOLC), and differential time to positivity (DTP) methods were performed for detection of catheter-related bloodstream infections (CRBSIs). As compared with the DTP method (which detected 11 patients with CRBSI), the PNA FISH and the Gram/AOLC methods detected ten of 11 CRBSI patients, resulting in a sensitivity, specificity, negative predictive value and positive predictive value of 91%, 100%, 97% and 100%, respectively, for the PNA FISH method as well as for the Gram/AOLC method.

Pulmonary histoplasmosis in three Austrian travelers after a journey to Mexico.

Three Austrian travelers (a 37-year-old woman, a 47-year-old woman and a 47-year-old man) presented with fever, dyspnea, thoracodynia, cephalea, arthralgia and fatigue 4 weeks after visiting a bat cave in Mexico. Computed tomography of the lungs showed bilateral nodular infiltrates in all three patients and enlarged mediastinal lymph nodes in two patients. In all patients, specific IgM antibodies against Histoplasma capsulatum could be detected. After treatment with itraconazole 200 mg q.d. orally for 2 months, the patients had no further complaints and the pulmonary infiltrates had resolved.

Delayed processing of blood samples influences time to positivity of blood cultures and results of Gram stain-acridine orange leukocyte Cytospin test.

We investigated in vitro whether storage of blood samples influences the time to positivity used for the calculation of the differential time to positivity (DTP) and the results of the Gram stain-acridine orange leukocyte Cytospin (AOLC) test. A 24-hour storage of blood samples at room temperature may lead to false-negative DTP and false-positive Gram stain-AOLC test results, whereas storage at 4 degrees C does not.

Effect of sildenafil on oesophageal motor function in healthy subjects and patients with oesophageal motor disorders.

BACKGROUND AND AIMS: Sildenafil blocks phosphodiesterase type 5 which degrades nitric oxide (NO) stimulated 3'5'-cyclic monophosphate (cGMP), thereby relaxing smooth muscle cells in various organs. We used sildenafil as a tool to investigate the role of the NO-cGMP pathway in the oesophagus of healthy volunteers and patients with hypercontractile oesophageal motility disorders. METHODS: Six healthy male volunteers participated in a randomised double blind study on two separate days before and one hour after oral intake of either sildenafil 50 mg or placebo. Oesophageal manometry was performed to determine vector volume of the lower oesophageal sphincter (LOS) and pressure amplitudes of the oesophageal body. Four of the volunteers underwent 12 hour ambulatory oesophageal manometry on two separate days, once with sildenafil 50 mg and once with placebo. An activity index for spontaneous swallowing was calculated for every hour of the study. Eleven patients with hypercontractile oesophageal motility disorders took part in an open study of the effect of 50 mg sildenafil on manometric features of their disorder and on the clinical response to sildenafil taken as required. RESULTS: In healthy subjects, sildenafil significantly reduced LOS pressure vector volume and pressure amplitudes in the distal half of the oesophageal body. In three of four subjects the inhibitory effect of sildenafil lasted at least eight hours. In nine of 11 patients, manometric improvement after sildenafil was observed but only four had an improvement in oesophageal symptoms with sildenafil taken as required. Two of these four patients however experienced side effects and did not want to continue treatment. CONCLUSIONS: Sildenafil lowers LOS pressure and propulsive forces in the body of the oesophagus of healthy subjects as well as in patients with nutcracker oesophagus, hypertensive LOS, and achalasia. The effect of sildenafil on the oesophageal body may last for up to eight hours in healthy volunteers. A subset of patients with hypertensive LOS or nutcracker oesophagus may benefit from sildenafil but side effects are a limiting factor.