D-dimer levels for Risk Stratification in Patients with Suspected COVID-19 - A Prospective Observational Study.

BACKGROUND: Elevated D-dimer levels have been observed in COVID-19 and are of prognostic value, but have not been compared to an appropriate control group. METHODS: Observational cohort study including emergency patients with suspected or confirmed COVID-19. Logistic regression defined the association of D-dimer levels, COVID-19 positivity, age, and gender with 30-day-mortality. RESULTS: 953 consecutive patients (median age 58, 43% women) presented with suspected COVID-19: 12 (7.4%) patients with confirmed SARS-CoV-2-infection died, compared with 28 (3.5%) patients without SARS-CoV-2-infection. Overall, most (56%) patients had elevated D-dimer levels (≥0.5mg/l). Age (OR 1.07, CI 1.05-1.10), D-dimer levels ≥0.5mg/l (OR 2.44, CI 0.98-7.39), and COVID-19 (OR 2.79, CI 1.28-5.80) were associated with 30-day-mortality. CONCLUSION: D-dimer levels are effective prognosticators in both patient groups.

Frequency of use and acceptability of clinical prediction rules for pulmonary embolism among Swiss general internal medicine residents.

INTRODUCTION: Whether clinical prediction rules for pulmonary embolism are accepted and used among general internal medicine residents remains uncertain. We therefore evaluated the frequency of use and acceptability of the Revised Geneva Score (RGS) and the Pulmonary Embolism Severity Index (PESI), and explored which factors were associated with rule use. MATERIALS/METHODS: In an online survey among general internal medicine residents from 10 Swiss hospitals, we assessed rule acceptability using the Ottawa Acceptability of Decision Rules Instrument (OADRI) and explored the association between physician and training-related factors and rule use using mixed logistic regression models. RESULTS: The response rate was 50.4% (433/859). Overall, 61% and 36% of the residents reported that they always or regularly use the RGS and the PESI, respectively. The mean overall OADRI score was 4.3 (scale 0-6) for the RGS and 4.1 for the PESI, indicating a good acceptability. Rule acceptability (odds ratio [OR] 6.19 per point, 95% confidence interval [CI] 3.64-10.51), prior training in emergency medicine (OR 5.14, CI 2.20-12.01), and availability of internal guidelines recommending RGS use (OR 4.25, CI 2.15-8.43) were associated with RGS use. Rule acceptability (OR 6.43 per point, CI 4.17-9.92) and rule taught at medical school (OR 2.06, CI 1.24-3.43) were associated with PESI use. CONCLUSIONS: The RGS was more frequently used than the PESI. Both rules were considered acceptable. Rule acceptability, prior training in emergency medicine, availability of internal guidelines, and rule taught at medical school were associated with rule use and represent potential targets for quality improvement interventions.

Impact of MALDI-TOF-MS-based identification directly from positive blood cultures on patient management: a controlled clinical trial.

OBJECTIVES: Rapid identification of pathogens directly from positive blood cultures (BC) in combination with an antimicrobial stewardship programme (ASP) is associated with improved antibiotic treatment and outcomes, but the effect of each individual intervention is less clear. The current study investigated the impact of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF) versus conventional identification on antibiotic management in a setting with a well-established ASP and low resistance rates. METHODS: In this single-centre open label, controlled clinical trial 425 patients with positive BCs were allocated by weekday during a 1-year period to either MALDI-TOF directly from positive BCs or conventional processing. ASP was identical throughout the study period. The primary outcome was duration of intravenous antimicrobial therapy and was analysed in an intention-to-treat approach. RESULTS: In all, 368 patients were analysed (MALDI-TOF n = 168; conventional n = 200) with similar baseline characteristics. Mean duration of intravenous antimicrobial therapy (12.9 versus 13.2 days, p 0.9) and length of stay (16.1 versus 17.9 days, p 0.3) were comparable. In the clinically significant bloodstream infection subgroup (n = 242) mean time from Gram-stain to active treatment was significantly shorter (3.7 versus 6.7 h, p 0.003). Admission to the intensive care unit after bloodstream infection onset was less frequent in the MALDI-TOF group (23.1 versus 37.2%, p 0.02). CONCLUSIONS: Rapid identification of contaminated BCs (n = 126) resulted in a shorter duration of intravenous antimicrobial therapy (mean 4.8 versus 7.5 days, p 0.04). Rapid identification using MALDI-TOF directly from positive BCs did not impact on duration of intravenous antimicrobial therapy, but provided fast and reliable microbiological results and may improve treatment quality in the setting of an established ASP.

Low sensitivity of needle aspiration cultures in patients with cellulitis/erysipelas.

PURPOSE: Cellulitis is normally treated without knowledge of the responsible pathogen. Blood cultures are positive in about 2-4 %, and superficial swabs are of no value. Needle aspiration has been proposed with identifying the likely pathogen in up to 29 %, but these studies are of older date and the technique is not widely used. METHODS: We prospectively evaluated the sensitivity of needle aspiration cultures in all patients with erysipelas/cellulitis. Diagnosis was made clinically by the treating physician. Needle aspiration was done with a 1 ml syringe and a 26G needle. The needle was removed and the syringe brought to the microbiological laboratory and analysed according to standard procedures. RESULTS: 95 Patients were seen during a period of 22 month. 4 Patients were excluded, as diagnosis was not confirmed. Cellulitis was present in 10/91 and erysipelas in 81/91 patients. In the first 25 patients with needle aspiration from the margin, none was positive. In 8/66 (12 %) patients where needle aspiration was done at the site of maximum inflammation, the pathogen was identified. 4/8 Cultures were positive for S. aureus, 2/8 for streptococci and 2/8 for other bacteria. In 11/66 (16.6 %) patients, skin colonisation flora was detected. In the subgroup of patients without prior antibiotic treatment and needle aspiration from the site of maximum inflammation, sensitivity was slightly better 8/55 (14.5 %; 95 % CI 7.5-25.8 %). CONCLUSIONS: Needle aspiration culture had a low sensitivity for detecting responsible pathogen in patients with cellulitis/erysipelas. No impact in antibiotic treatment could be observed.

Influence of procalcitonin on decision to start antibiotic treatment in patients with a lower respiratory tract infection: insight from the observational multicentric ProREAL surveillance.

Procalcitonin (PCT)-guided antibiotic stewardship is a successful strategy to decrease antibiotic use. We assessed if clinical judgement affected compliance with a PCT-algorithm for antibiotic prescribing in a multicenter surveillance of patients with lower respiratory tract infections (LRTI). Initiation and duration of antibiotic therapy, adherence to a PCT algorithm and outcome were monitored in consecutive adults with LRTI who were enrolled in a prospective observational quality control. We correlated initial clinical judgment of the treating physician with algorithm compliance and assessed the influence of PCT on the final decision to initiate antibiotic therapy. PCT levels correlated with physicians' estimates of the likelihood of bacterial infection (p for trend <0.02). PCT influenced the post-test probability of antibiotic initiation with a greater effect in patients with non-pneumonia LRTI (e.g., for bronchitis: -23 % if PCT ≤ 0.25 µg/L and +31 % if PCT > 0.25 µg/L), in European centers (e.g., in France -22 % if PCT ≤ 0.25 µg/L and +13 % if PCT > 0.25 µg/L) and in centers, which had previous experience with the PCT-algorithm (-16 % if PCT ≤ 0.25 µg/L and +19 % if PCT > 0.25 µg/L). Algorithm non-compliance, i.e. antibiotic prescribing despite low PCT-levels, was independently predicted by the likelihood of a bacterial infection as judged by the treating physician. Compliance was significantly associated with identification of a bacterial etiology (p = 0.01). Compliance with PCT-guided antibiotic stewardship was affected by geographically and culturally-influenced subjective clinical judgment. Initiation of antibiotic therapy was altered by PCT levels. Differential compliance with antibiotic stewardship efforts contributes to geographical differences in antibiotic prescribing habits and potentially influences antibiotic resistance rates.

[Skin and soft tissue infections]. / Haut- und Weichteilinfektionen: Grundprinzipien und Fallstricke.

Skin- and Soft tissue infections are a frequent problem in hospital as well as in ambulatory care. Diagnostic procedures and treatment principles have to include the most frequent pathogens. While the acute forms of skin and soft tissue infections, with, necrotising fasciitis as important exception, rarely cause diagnostic or therapeutic problem, the treatment of patients with recurrent furunculosis, chronic wounds and diabetic feet is often difficult and frustration for patients and physicians. This article gives an overview of the most important problems and treatment strategies.

[Transmission of Influenza A]. / Transmission von Influenza A.

The pandemic influenza A 2009 virus led to new discussions about proper protection measures in hospitals and in the general population. To implement efficacious protection measures against the influenza A virus, we have to know its way of transmission. Influenza A transmission occurs primarily via droplets and contact. However, several experimental studies and observations of outbreaks indicate that influenza can also be transmitted through the airborne route (via aerosols). The possibility of airborne transmission of influenza should be taken in consideration for pandemic influenza planning and recommendations. In case of influenza epidemics with high (or not yet defined) mortality, exposed healthcare personnel should be protected using precautions against airborne transmission, including the use of FFP2 (N95) respirators.

Low transmission rate of 2009 H1N1 Influenza during a long-distance bus trip.

BACKGROUND: Current data on the risk of transmission of 2009 H1N1 Influenza in public transportation systems (e.g., public trains, busses, airplanes) are conflicting. The main transmission route of this virus is thought to be via droplets, but airborne transmission has not been completely ruled out. METHODS: This is a contact tracing investigation of a young woman subsequently diagnosed with the 2009 H1N1 Influenza virus who was symptomatic during a long-distance bus trip from Spain to Switzerland. Fever and cough had begun 24 h earlier, 2 h before she stepped onto a bus for a long-distance trip. After the 2009 H1N1 virus had been confirmed in the patient, the other bus travellers were contacted by telephone on day 7 and 10 after the bus trip. RESULTS: Of the 72 individuals travelling on the bus with the H1N1-infected young woman, 52 (72%) could be contacted. Only one of these 52 developed fever, with onset of symptoms 3 days after the bus trip, and rRT-PCR analysis of the nasopharyngeal swab showed the infection to be caused by the 2009 H1N1 virus. One other person complained of coughing 1 day after the bus trip, but without fever, and no further investigation was carried out. All other passengers remained without fever, coughing, or arthralgia. The risk of transmission was calculated as 1.96% (95% confidence interval 0-5.76%). CONCLUSION: The transmission rate of 2009 H1N1 Influenza was low on a long-distance bus trip.

How much money can be saved by applying intravenous antibiotics once instead of several times a day?

BACKGROUND: The preparation, administration and monitoring of intravenous (IV) applications are time consuming and require human resources. We estimated the potential time and cost savings by replacing antibiotics given 3-4 times daily with antibiotics with similar spectrum and efficacy given once daily. METHODS: The savings of indirect costs were estimated based on the antibiotic consumption data of a two-year period (i.e. 2007 and 2008), a nurse's mean workload per application and the average nurse's salary in Switzerland. RESULTS: The consumption of IV antibiotics in 2007 and 2008 at the University Hospital of Basel was 29.0 and 32.2 defined daily doses (DDD) per 100 patient days, respectively. Nurses spent an estimated 13,786 h on the application of the estimated 82,715 does of IV antibiotics. A total of 56,404 applications or nursing staff time costs of 338,436 Swiss Francs (CHF; 236,669 ), equal to 16% of the overall costs spent on purchasing antibiotics in the year 2008, may have been saved by switching multiple-dose antibiotics to a hypothetical once-daily antibiotic. Including disposable materials, 21% or 456,884 CHF (319,499 ) could be saved annually (purchase costs not taken into account). CONCLUSION: We found a potential cost saving of 21% of the purchase costs in a 750-bed institution. Hence, indirect costs should be included in the calculation of the total cost for the application of broad-spectrum IV antibiotics. Switching from a 3-4 times daily application to a once-daily antibiotic should be considered if a once-daily antibiotic is deemed equally effective and has a similar spectrum.

Vertebral osteomyelitis caused by Actinobaculum schaalii: a difficult-to-diagnose and potentially invasive uropathogen.

We report the first case of vertebral osteomyelitis caused by Actinobaculum schaalii and review all cases of A. schaalii identified at our institution between 2002 and 2005. A. schaalii causes urinary tract infections - especially in elderly people - occasionally with septic complications.

Visceral leishmaniasis: a threat to immunocompromised patients in non-endemic areas?

Visceral leishmaniasis is rare in western Europe, but may be life-threatening in immunocompromised patients. It is therefore important to understand the incidence of the disease in a non-endemic area and its relationship with immunosuppressive conditions. Between 1990 and 2005, 12 patients were diagnosed with leishmaniasis at Basel University Hospital, Switzerland. Eleven presented with visceral symptoms and ten had an underlying immunosuppressive condition. Since increasing numbers of immunosuppressed patients have a history of travel to endemic countries, an association of visceral leishmaniasis with cellular immunosuppression (other than that associated with human immunodeficiency virus) might become more frequent in non-endemic areas.

Legionella bozemanii, an elusive agent of fatal cavitary pneumonia.

A 67-year-old patient died of Legionella bozemanii pneumonia with negative urinary antigen and negative serology. Cystic lesions in pneumonia of unknown origin should lead to the differential diagnosis of L. bozemanii infections.

[Diagnostics for pulmonary tuberculosis in adults]. / Diagnostik der pulmonalen Tuberkulose beim Erwachsenen.

The incidence of pulmonary tuberculosis (TB) is decreasing in Western Europe. However, TB should not be considered to be a rare disease, particularly in immigrants and in immunocompromised persons (i.e. HIV infection). The clinical presentation is often atypical in immunocompromised persons. In general, the extent of the disease is underestimated by the clinical presentation. X-ray and a sequential investigation of three samples of sputum including microscopy, culture and susceptibility testing for the first-line drugs should be obtained. Tuberculin testing is useful in the diagnosis of latent TB and in screening persons with close contact to patients with active disease. New blood tests based on the detection of interferon-g released by antigen specific T-cells have some advantages compared to tuberculin testing.

[Atypical erythema induratum Bazin with tuberculous osteomyelitis]. / Atypisches erythema induratum Bazin bei tuberkulöser osteomyelitis.

Diagnosis of all types of cutaneous tuberculosis is challenging because the clinical picture of these diseases is highly variable. We describe the case of a 79-year old woman with an atypical presentation of Erythema induratum Bazin (EIB) on the chest and left arm in association with a tuberculous osteomyelitis of the left olecranon. Surprisingly, M. tuberculosis grew also from biopsies of the EIB-lesions. This contradicts the conventional view that considers EIB (a tuberculid) to be caused by a hypersensitivity reaction to mycobacteria. The presented case supports the hypothesis that EIB may also be caused by hematogenous or lymphatic spread of viable M. tuberculosis.

Course and outcome of Staphylococcus aureus bacteraemia: a retrospective analysis of 308 episodes in a Swiss tertiary-care centre.

Staphylococcus aureus bacteraemia (SAB) is associated with substantial morbidity and mortality worldwide. The charts of adult patients with SAB who were hospitalised in a Swiss tertiary-care centre between 1998 and 2002 were studied retrospectively. In total, 308 episodes of SAB were included: 2% were caused by methicillin-resistant strains; 49% were community-acquired; and 51% were nosocomial. Bacteraemia without focus was the most common type of community-acquired SAB (52%), whereas intravenous catheter-related infection predominated (61%) among nosocomial episodes of SAB. An infectious diseases (ID) specialist was consulted in 82% of all cases; 83% received appropriate antibiotic treatment within 24 h of obtaining blood cultures. Overall hospital-associated mortality was 20%. Community-acquired SAB was associated independently with a higher mortality rate than nosocomial SAB (26% vs. 13%; p 0.009). Independent risk-factors for a fatal outcome were age (p < 0.001), immunosuppression (p 0.007), alcoholism (p < 0.001), haemodialysis (p 0.03), acute renal failure (p < 0.001) and septic shock (p < 0.001). Consultation with an ID specialist was associated with a better outcome in univariate analysis (p < 0.001). Compared with a previous retrospective analysis performed at the same institution between 1980 and 1986, there was a 140% increase in community-acquired SAB, a 60% increase in catheter-related SAB, and a 14% reduction in mortality. In conclusion, mortality in patients with SAB remained high, despite effective antibiotic therapy. Patients with community-acquired SAB were twice as likely to die as patients with nosocomial SAB. Consultation with an ID specialist may reduce mortality in patients with SAB.