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.

[Acute pericarditis]. / La péricardite aiguë.

Acute pericarditis is an inflammation of the pericardium. Different etiologies are known, and can be classified in three groups: infectious, neoplastic and auto-immun. The diagnosis is based essentially on clinical signs and should be raised by position and respiratory dependent chest pain, especially when it follows a viral infection, and a pericardial friction rub on cardiac auscultation. An ECG and an echocardiography should be performed to assess the presence of a pericardial effusion. A diffuse and concave ST elevation permits the distinction with myocardial ischemia. The first line therapy is an association between NSAR and colchicine, the latter has shown to reduce the risk of recurrence.

[Advice for those that want to specialize in infectious diseases in Switzerland]. / Conseils à celles et ceux qui désirent embrasser une carrière d'infectiologue.

In Switzerland the specialty of Infectious Diseases attracts many young physicians. In this article we describe the place of infec- tious diseases in Switzerland. We review its usefulness for patients, the requirements to obtain a title of specialist, its different subs- pecialists and the potential job openings of this training.

[Norovirus gastroenteritis: frequent, often epidemic, with potentially severe complications]. / Gastroentérites à norovirus: fréquentes, souvent épidémiques et potentiellement graves.

Norovirus are the most frequent causes of epidemic gastroenteritis. Infections generally resolve spontaneously, but may lead to severe complications including death, or become chronic in immunocompromised hosts. Complications preferentially occur in immunocompromised hosts and their consequences are sometimes severe in vulnerable individuals living in confined spaces, such as healthcare settings. Norovirus have a high capacity to mutate. This and their capacity to persist in the water and on everyday objects of our surroundings favor the occurrence of epidemics. As a vaccination protective against most relevant strains is currently not available and in view of their high contagiousness, the prevention and control of the norovirus gastroenteritis remains a major clinical challenge.

[Cellulitis: clinical manifestations and management]. / Erysipèle: manifestations cliniques et prise en charge.

Cellulitis is an acute bacterial non-necrotizing dermal-hypodermal infection predominantly affecting the lower limbs. It is characterised by a circumscribed erythema with a raised border and fever. The predisposing factors are skin wounds, edema from any cause and systemic factors (diabetes, immunosuppression). The diagnosis is clinical and the most common complication is recurrence. Other complications include local abscess, fasciitis and bacteremia. The germ is rarely identified. The majority of infections (85%) is due to group A beta-hemolytic streptococcus. The treatment of cellulitis consists of an association of an antibiotic with rest of the concerned area.

[Unprotected fellatio: what are the risks?]. / Fellation non protégée: quels risques?

Unprotected fellatio, which has been practiced by all civilizations since mists of time, is now becoming a cause of concern due to the AIDS epidemic. Most of the sexually transmitted infectious diseases are concerned by fellatio and only few medical studies deal with this topic. This paper is therefore a non exhaustive review of risks brought upon by unprotected fellatio. It is almost impossible to assess the exact risk for a given infection because of the complexity of sexual intercourse, which is rarely exclusively oro-genital.

Actinobaculum schaalii: clinical observation of 20 cases.

Actinobaculum schaalii is a new species that has so far been isolated from human blood, urine and pus. Its importance has probably been underestimated and other Actinobaculum spp. may also have been underdiagnosed. This retrospective study comprises all known cases of A. schaalii infections identified since 2004 in the canton of Neuchâtel (170,000 inhabitants), Switzerland. Strains were cultivated and isolated in the bacteriology laboratory using its routine procedure. Identification included a Rapid ID 32 A strip (bioMérieux) and 16S rRNA gene sequencing. Twenty-one positive samples were found in 19 patients (11 male, 8 female) of all ages (range 16-91 years): 10 from urine (50%), six from blood (30%), one from both blood and urine (5%), and three from pus (15%). Thirteen out of 17 (76%) cases with either blood or urine specimens had underlying genitourinary tract pathologies. When urine cultures were positive for A. schaalii, leucocytes were found in all samples (10/10, 100%) but all nitrite tests were negative (10/10, 100%). The onset of appropriate treatment was delayed due to the diminished sensitivity of A. schaalii to the antibiotics commonly used for UTIs (i.e. ciprofloxacin and trimethoprim/sulfamethoxazole) and to the delay in microbiological diagnosis. A. schaalii should specifically be searched in all cases of leukocyturia with a negative nitrite test but with Gram-positive rods in the Gram stain, in patients with underlying genitourinary tract pathology, instead of dismissing these findings as clinically irrelevant colonization by coryneform bacteria. This infection may be much more common than previously thought.

[Acute community-acquired bacterial meningitis in adults]. / Méningites bactériennes communautaires aiguës chez l'adulte.

Bacterial meningitis in adults is fatal in 20% of patients and leads to sequels in 30%. The clinical presentation includes two of the following four symptoms and signs: fever, headache, stiff neck, altered mental status. The essential ancillary test is the analysis of the cerebrospinal fluid. Sometimes, the lumbar puncture is not feasible or deferred (brain computer tomography), requiring antibiotics and corticosteroids early. 80% of bacterial meningitis are secondary to pneumococcus or meningococcus. Empirical antibiotics must be given as soon as possible and provide coverage for these both bacteria. Corticosteroids are also recommended for some meningitis. A score can predict the evolution. Preventive measure must be taken for close contacts of a patient with a meningococcal meningitis.

[Antibiotics: drug and food interactions]. / Antibiothérapie: interactions médicamenteuses et alimentaires.

Antibiotics are widely prescribed in medical practice. Many of them induce or are subject to interactions that may diminish their anti-infectious efficiency or elicit toxic effects. Food intake can influence the effectiveness of an antibiotic. Certain antibiotics can lower the effectiveness of oral contraception. Oral anticoagulation can be influenced to a great extent by antibiotics and controls are necessary. Interactions are also possible via enzymatic induction or inhibition of cytochromes. The use of an interaction list with substrates of cytochromes enables to anticipate. Every new prescription should consider a possible drug or food interaction.

Outbreak of human listeriosis associated with tomme cheese in northwest Switzerland, 2005.

During an eight week period in spring 2005, 10 cases of listeriosis were reported in a small area of northwest Switzerland (150,000 inhabitants). Eight cases were in older immunocompromised patients who became ill with bacteraemia (three deaths), and two cases were in pregnant women who had septic abortion. All cases were due to a serotype 1/2a isolate with one of two pulsovars found by PFGE. Patient interviews quickly revealed that a locally made and distributed soft cheese (known as 'tomme') was the food source responsible for the outbreak. Samples of this cheese, and of butter made in the same factory, revealed Listeria monocytogenes sv 1/2a of the same pulsovar in amounts of 1000-10 000 and 10-100 cfu/g, respectively. The prompt suspension of production, the market recall of the product, and a public alert terminated the outbreak. However, two cases of febrile gastroenteritis due to the same strains were reported within 10 days of product recall. The restricted distribution area of the contaminated cheese and the collaboration of local physicians, medical microbiologists and food health services all contributed to a rapid and successful investigation. This small outbreak of listeriosis reinforces the need for a laboratory-based surveillance system with rapid typing, as well as collaboration between physicians and microbiologists.

Analysis of factors that contribute to treatment failure in patients with community-acquired pneumonia.

To determine the causes of treatment failure and to evaluate the prognostic factors in patients hospitalized for community-acquired pneumonia, a prospective, observational study of 228 adult patients hospitalized for a community-acquired pneumonia in the University Hospital of Geneva and the La Chaux-de-Fonds Community Hospital, Switzerland, was conducted. The percentage of patients who failed to improve (as defined by guidelines of the Infectious Disease Society of America) and the causes of treatment failure were assessed, and patients who failed to improve under antimicrobial therapy were compared with those who did improve. In the 54 (24%) patients who failed to improve, a mean increase in length of hospitalization of 4 days was observed. Most causes of treatment failure could be attributed to host factors (61%) rather than to the pathogen (16%) or to an inappropriate antibiotic regimen (3%). After adjusting for potentially confounding variables, concomitant neoplasia (OR 3.25; 95%CI 1.11-9.56), neurological disease (OR 2.34; 95%CI 1.07-5.13), and aspiration pneumonia (OR 2.97; 95%CI 29-6.86]) were associated with failure to improve, whereas monocytosis improved prognosis (OR 0.40; 95%CI 0.20-0.80). Almost one out of four patients hospitalized for community-acquired pneumonia failed to respond to empirical antibiotic treatment. Aspiration pneumonia, concomitant neoplasia, and neurological disease were factors positively associated with failure to improve, whereas monocytosis was linked to a better prognosis.

Outbreak of human listeriosis associated with tomme cheese in northwest Switzerland, 2005.

During an eight week period in spring 2005, 10 cases of listeriosis were reported in a small area of northwest Switzerland (150 000 inhabitants). Eight cases were in older immunocompromised patients who became ill with bacteraemia (three deaths), and two cases were in pregnant women who had septic abortion.

[Community-acquired pneumonia: attitude case of treatment failure]. / Pneumonie: que faire en cas d'echec de traitement?

It can be determined that for nearly one out of five patients hospitalized for a community-acquired pneumonia the empirical treatment chosen will fail. Those for whom the treatment failed face a bad outcome with a mortality rate as a high as 43%. Most causes of failure can be attributable to the patient rather than to the antibiotic or to the pathogen. The studies related to treatment failure show that resistance of the causal agent to antibiotic is rarely the cause, as opposed to discordant therapy (causal agent not covered by chosen antibiotherapy), which plays an important role. In these studies the multivariate analysis were able to show that concordant therapy (causal agent covered by chosen antibiotherapy), vaccination against influenza, monocytosis and old age were possible protective factors against treatment failure.

Antibiotic misuse in medium-sized Swiss hospitals.

Antibiotics account for a substantial proportion of hospital drug expenditures and tend to be misused or overused, generating unnecessary costs and causing the emergence of resistant bacteria. Antibiotic use was evaluated in a one-day prevalence study performed on the surgical and medical wards of eight Swiss non-university hospitals. 173 of the 695 inpatients present (25%) were on antibiotics and 163 could be evaluated. 35 prescriptions were secondary to an infectious disease consultation. 60 of the remaining 128 (47%) were considered inappropriate, of which 17 (28%) lacked any indication for antibiotic use. The rates of misuse were higher in surgery than in medicine (58 vs. 34%; OR = 2.5 [95% CI: 1.1-5.9]), and higher for prophylaxis than for treatment (72 vs. 41%; OR = 4.1 [95% CI: 1.3-15.5]). Savings of 545 euros (95% CI: from -116 to 1,206 euros) on the study day and 6,256 euros (95% CI: from -2,221 to 14,732 euros) for the total treatments or prophylaxis administered would have resulted from infectious disease consultations.

Community-acquired pneumonia: causes of treatment failure in patients enrolled in clinical trials.

In order to determine the causes of treatment failure in community-acquired pneumonia (CAP) clinical trials, a MEDLINE search for all CAP studies published between 1990 and 1997 was performed. Prospective, randomized studies comparing the efficacy of two or more antibiotics in CAP were selected. Treatment failure was defined as persistent fever, deterioration of patient's condition, or a change in the prescribed antibiotic regimen. In 16% of the cases included in the clinical trials, the treatment of CAP is unsuccessful. A significant number of identified failure cases were owing to antibiotic side-effects. Resistant pathogens are an unusual cause of failure whatever the antibiotic used.