[Occupational exposures with risk of transmission of HIV, HBC and HCV in health care workers]. / Accidents avec risque de transmission, du VIH, du virus de l'hépatite B et du virus de l'hépatite C dans le secteur médical.

Health care workers are often victims of occupational injuries by contaminated sharps or projection of contaminated fluids to mucous membranes and are therefore at risk for transmission of HIV, HBV and HCV. Every technical and organisation-related measure useful to prevent injuries should be implemented and personal protection equipment must be made available to workers. Promotion of hepatitis B immunization is a key issue. Immediate evaluation of injured employee is necessary to assess the risk related to exposure and the indication for post-exposure prophylaxis (anti-retroviral therapy for HIV, immunoglobulins and vaccination for hepatitis B). When a health care worker has been exposed to one of the blood-born viruses, thorough information and follow-up should be offered by a specialist.

[Blood culture negative endocarditis: a diagnostic challenge]. / Endocardites a hémocultures négatives: un défi diagnostique.

Blood culture negative endocarditis (BCNE) account for about 5% of all cases of endocarditis. Diagnosis and initiation of antimicrobial therapy may be delayed, with a negative impact on clinical outcome. The most common cause of BCNE is antimicrobial drug therapy before blood sampling. Other common causes include slow growing and non cultivable organisms. Identification of the etiologic agent is critical in the management of BCNE and molecular tools such as broad range 16SrRNA PCR technique followed by direct automated sequencing and microorganism-specific PCR are promising. Some authors have proposed to include these techniques among major Duke's criteria for the diagnosis of BCNE.

[Positive blood cultures during a 2 years period at Hôspital cantonal de Fribourg]. / Revue des hémocuttures positives sur deux ans a l'Hôpital cantonal de Fribourg.

Several authors, mainly from the United States, have reported on the microbiology and interpretation of positive blood cultures. We conducted a retrospective study over a 2 years period to address this issue in a medium-size swiss hospital: two hundred and thirty-two episodes of positive blood culture were recorded, with 403 microorganisms; Escherichia coli (22%), Staphylococcus aureus (21%) and coagulase-negative staphylococci (110%) were the most frequent isolates. The latter were considered as contaminants in 38% of cases. Half the episodes were nosocomial, 23% originated from the urinary tract and 18% were linked to a vascular catheter. Attributable mortality of bacteremia/fungemia was 9%, significantly higher for fungi (36%) than for bacteria (8%; p 0.009).

Prospective epidemiologic survey of patients with community-acquired pneumonia requiring hospitalization in Switzerland.

BACKGROUND: Community-acquired pneumonia (CAP) is a common problem and the principal infection requiring hospitalization, but its treatment is complicated by the difficulty in microbiological diagnosis and the increasing incidence of antibiotic resistance among respiratory pathogens. The purpose of this paper is to present the main epidemiologic features of patients with CAP requiring hospitalization in our country. METHODS: We enrolled three hundred and eighteen adult patients with CAP requiring hospitalization in seven large medical centers in Switzerland during two winter periods. The patients' mean age was 70.4 years. This study describes the epidemiology of these patients. Clinical, radiologic and microbiological evaluations were performed at study entry during treatment, and at 4 weeks post-therapy. For microbiological diagnostic purposes, sputum culture, throat swab culture, PCR, blood cultures, Legionella urinary antigen and serologic evaluations were also performed. RESULTS: Despite the higher mean age, the overall mortality rate was 8%, lower than in other comparable studies. The most common underlying diseases present at study entry were cardiac failure (23%), chronic obstructive pulmonary disease (20%), renal failure (15%), and diabetes (12%); 40% of the patients were smokers. Although dyspnea, cough and positive pulmonary auscultation findings were present in about 90% of patients, fever >38 degrees C was present in only 64%. The most frequently isolated respiratory pathogens were Streptococcus pneumoniae (12.6%), Haemophilus influenzae (6%), Staphylococcus aureus (1.6%), and Moraxella catarrhalis (1.6%). Atypical pathogens were frequently found, with the following distribution: Mycoplasma pneumoniae, 7.5%; Chlamydia pneumoniae, 5.3%; and Legionella pneumophila, 4.4%. The mean duration between onset of symptoms and hospital admission was 4.8 days, and the mean treatment duration was 12.1 days. Two weeks after the start of therapy, although clinical symptoms were absent, radiologic infiltrates were still present in 24% of patients. CONCLUSIONS: The microbiological diagnosis in CAP can be established in only about 50% of cases with the combination of several diagnostic tools. Epidemiologic surveys of CAP should be performed on a regular basis, regionally, as a way to improve the management of these infections.

Life-threatening complications of hepatitis B virus-related polyarteritis nodosa developing despite interferon-alpha2b therapy: successful treatment with a combination of interferon, lamivudine, plasma exchanges and steroids.

Polyarteritis nodosa (PAN) is a rare vasculitis associated with hepatitis B virus (HBV) infection in a significant proportion of cases. When used to treat HBV-related PAN, immunosuppressive agents may enhance viral replication and relaspes are frequent. In recent years the use of antiviral drugs has been proposed. We report the case of a patient with HBV-related PAN who, despite 6 weeks of interferon-alpha2b (IFN-alpha2b) monotherapy, developed life-threatening complications with bowel perforation. He was thereafter successfully treated with a combination of IFN-alpha2b, lamivudine, plasma exchanges and short-term steroids. In contrast to IFN-alpha2b, lamivudine is effective in rapidly suppressing viral replication. This may be valuable in the treatment of HBV-related PAN by contributing to a faster diminution of circulating immune complex levels. This case report highlights the importance of aggressive combined therapy in patients with HBV-related PAN.

Effect of sputum induction by hypertonic saline on specimen quality.

Microbiologic work-up of expectorated material is routinely used to search for the etiology of pulmonary infections, but sputum is often contaminated by saliva. Inhalation of hypertonic saline induces bronchial secretions and theoretically may improve specimen quality. We compared in a laboratory-blinded, randomized study the quality of sputum obtained either with induction by saline or without induction in patients with respiratory tract infection and a history of productive cough. The quality of sputum was considered good if the polymorphonuclear neutrophils (PMNs)/squamous epithelial cells (SECs) ratio was > or = 2 or the Q (quality) score was > or = +1 on Gram stain. Forty-nine and 50 patients were able to expectorate in the induced and spontaneous sputum groups, respectively. PMNs/SECs ratio was > or = 2 in 65% and 74% of the patients in the induced and spontaneous sputum groups (p = 0.47); for the Q score, a value > or = +1 was found in 55% and 66% of the patients of each group (p = 0.37). In conclusion, sputum induction by hypertonic saline inhalation does not improve specimen quality as judged by the PMNs/SECs ratio on Gram stain.

Repeated transient anuria following losartan administration in a patient with a solitary kidney.

We report the case of a 70-year-old hypertensive man with a solitary kidney and chronic renal insufficiency who developed two episodes of transient anuria after losartan administration. He was hospitalized for a myocardial infarction with pulmonary edema, treated with high-dose diuretics. Due to severe systolic dysfunction losartan was prescribed. Surprisingly, the first dose of 50 mg of losartan resulted in a sudden anuria, which lasted eight hours despite high-dose furosemide and amine infusion. One week later, by mistake, losartan was prescribed again and after the second dose of 50 mg, the patient developed a second episode of transient anuria lasting 10 hours. During these two episodes, his blood pressure diminished but no severe hypotension was noted. Ultimately, an arteriography showed a 70-80% renal artery stenosis. In this patient, renal artery stenosis combined with heart failure and diuretic therapy certainly resulted in a strong activation of the renin-angiotensin system (RAS). Under such conditions, angiotensin II receptor blockade by losartan probably induced a critical fall in glomerular filtration pressure. This case report highlights the fact that the angiotensin II receptor antagonist losartan can cause serious unexpected complications in patients with renovascular disease and should be used with extreme caution in this setting.

[Vaccination against influenza in the hospital milieu and by family physicians in Fribourg in 1997: facts and opinions]. / Vaccination contre la grippe en milieu hospitalier et par les médecins praticiens à Fribourg en 1997: faits et opinions.

The influenza vaccine was underused in Switzerland in 1996, as less than half of people at risk for the disease were vaccinated. We performed this study in 1997 to determine (1) the immunisation rate in the patients admitted to the internal medicine ward of the Cantonal Hospital, Fribourg and in those seen by family physicians, (2) the reasons underlying the decision of the physician to vaccinate their patients or not, (3) the physicians' opinion of the vaccination. The study was retrospective and included 383 patients hospitalised in the medicine ward between October 15 and November 25, 1997. 249 of them (65%) had an indication for vaccination against influenza according to the recommendations of the Federal Office of Public Health. Only 20 patients (8%) were vaccinated during their hospital stay. 86 family physicians (83%) answered the questionnaire concerning 141 patients (57%) whom they examined after their hospital discharge. Of these patients, 77 (55%) were vaccinated by the family physician. The main reason for not vaccinating the patients was the patient's refusal (33%). The effectiveness of the vaccine was considered to be very good (effectiveness > 80%) by 40% of the family physicians and good (effectiveness 60-80%) by 50%. The local and systemic side effects were reported to be rare (incidence < 5%) by 55% and 71% of family physicians respectively. The cost and the route of administration were not felt to have any effect on acceptance of the vaccine. In decreasing importance the family physicians considered the recommendations of the Federal Office of Public Health useful for (1) chronic pulmonary disease, (2) immunosuppression, (3) chronic cardiac disease, (4) chronic renal insufficiency and residency in homes or institutions, (5) diabetes, (6) age over 64, (7) health care workers. In conclusion, the influenza immunisation rate in Fribourg was very low at the hospital but was higher than the Swiss figures for the family physicians. Patient's refusal was the main reason for non-vaccination. The family physicians have a favourable opinion of the effectiveness and tolerance of the influenza vaccine.

Outbreak of echovirus 30 meningitis in Switzerland.

This study includes 80 patients (38 children and 42 adults) who contracted aseptic meningitis in the summer of 1996 in Fribourg, Switzerland. Virological studies revealed an enteroviral infection in 65 out of 70 (93%) investigated patients. In 47 out of the 53 cases (89%) where a precise virus could be identified, the causative agent was an Echovirus 30. More than 50 patients lived in an area within a 5-km radius. The patients presented with the classic symptoms and signs of aseptic meningitis. In contrast, polymorphonuclear leukocytes predominated in the cerebrospinal fluid in the first 24 h and 32% of the cases had a left shift in their peripheral blood smear. The patients' age did not influence white blood cell count, the proportion of polymorphonuclear leukocytes or protein concentration in the cerebrospinal fluid. Thirty-three patients (41%) received antibiotic treatment, and 38 patients (48%) left the hospital within 24 h. Only 2 neuroradiological procedures and 1 electroencephalographic recording were performed. The outcome was favourable in all patients.

Pasteurella multocida pneumonia with empyema.

We report a case of Pasteurella multocida pneumonia and empyema in an otherwise healthy patient. The most frequently observed human complication with this microorganism is a local wound infection. Only a few cases of pneumonia have been described, and most of the patients were immunodeficient.

Once-daily sparfloxacin versus high-dosage amoxicillin in the treatment of community-acquired, suspected pneumococcal pneumonia in adults. Sparfloxacin European Study Group.

The objective of this randomized, double-blind, multicenter study of 329 adult patients requiring hospitalization was to compare the safety and efficacy of sparfloxacin at a dosage of 200 mg once daily (following a 400-mg loading dose on day 1) with those of amoxicillin given as a 1-g oral dose three times daily for treatment of community-acquired pneumonia suspected to be due to Streptococcus pneumoniae. Success of treatment was determined by a combination of clinical assessment and chest radiography. Pneumococcal pneumonia was the confirmed diagnosis for 177 patients (54%). Overall rates of success among evaluable patients were equivalent between drugs, both at the end of treatment (sparfloxacin, 92%; amoxicillin, 87%) and at follow-up (sparfloxacin, 89%; amoxicillin, 84%). Sparfloxacin was well-tolerated and produced fewer gastrointestinal effects than amoxicillin. In conclusion, sparfloxacin is a safe and effective alternative to high-dose amoxicillin for the treatment of suspected pneumococcal community-acquired pneumonia.

[Epidemiology and care of myocardial infarct at the Fribourg Canton Hospital 1995]. / Epidémiologie et prise en charge de l'infarctus du myocarde à l'Hôpital cantonal de Fribourg en 1995.

PURPOSE: This study evaluates epidemiological data in a population of patients admitted for acute myocardial infarction in a large Swiss community hospital. It focuses on the application of recent drug treatment and newer therapeutic techniques. METHOD: Data acquisition was based on medical records of all patients who were admitted to the Cantonal Hospital of Fribourg in 1995. Their one-year follow-up was obtained through questionnaires sent to general practitioners. RESULTS: During the study period: 146 myocardial infarctions were diagnosed in 144 patients. Median age was 67.1 and 35% of patients were female. Nineteen percent were diabetics, 51% had hypertension and 28% had a positive family history for coronary artery disease. Active smokers made up 32%, 17% were past smokers. Myocardial infarction was anterior in 40%, inferior in 36% and non-Q wave myocardial infarction in 35%. Eighteen percent were subacute myocardial infarction. Killip class on admission were as follow: class I 65%, class II 21%, class III 1% and class IV 11%. Thrombolytic treatment was administered in 29% of patients. Vasoactive amines were used in 27% of patients and 8% were intubated some time during their hospital stay. At hospital discharge 81% were treated with Aspirin, 31% with anticoagulants, 47% with an ACE inhibitor, 38% with a beta-blocker, 34% with nitrates and 25% with a calcium antagonist. Among this population, 62% had an echocardiogram, 30% a stress test and 8% a Holter recording. Coronary angiography was performed in 52%, which revealed 33% one-vessel disease, 28% two-vessel disease, 25% three-vessel disease and 9% normal coronary arteries. Percutaneous coronary angioplasty was done in 53% of cases and a coronary stent implanted in 22%. Twelve percent had surgical revascularization. The mean hospital stay was 16.3 +/- 10.8 days, with in hospital mortality of up to 19.2% and a one-year mortality of 25.3%. CONCLUSION: Treatment modalities of patients admitted for acute myocardial infarction at the Hospital of Fribourg are comparable with literature data. Hypolipemic treatment has not been prescribed as often as recent guidelines recommend, but the use of ACE inhibitors was more common. As in other studies, older patients have the highest mortality. The absence of hospital coronarography facility did not seem to influence the prognosis of that population.

[Multi-systemic toxicity of colchicine and renal failure: apropos of a case]. / Toxicité multisystémique de la colchicine et insuffisance rénale: à propos d'un cas.

The use of colchicine can produce various side effects, but multiorgan toxicity is rare. We report the first Swiss case of multiorgan toxicity involving typical neuromuscular lesions. Muscular biopsy is a valuable tool in confirming the diagnosis. Renal insufficiency and hepatobiliary diseases are predisposing factors for such complications. Colchicine pharmacology in the case of renal insufficiency is discussed.