[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.

Antibiotic treatment can be safely stopped in asymptomatic patients with prosthetic joint infections despite persistent elevated C-reactive protein values.

OBJECTIVE: Prosthetic joint infection should be treated for a prolonged time (3 months for hip, 6 months for knee infection). Most authors require normalization of CRP before stopping antimicrobial therapy. However, in some patients the CRP values remain slightly elevated despite adequate treatment. METHOD: We observed 14 patients with prosthetic joint infection (6 knee, 9 hip infections), in whom the CRP values never fell below the upper limit of normal. Eleven patients were surgically treated with débridement and retention of the prosthesis, in one patient one-staged reimplantation and in two patients two-staged reimplantations were performed. Antibiotic treatment was stopped according the guidelines, if the patient was clinically without signs of persistent infection and the CRP values reached a plateau, albeit above the cut-off (5 mg/L). All patients were followed for 2 years after primary diagnosis of infection. RESULTS: Only one patient developed a periprosthetic infection five months after stopping antibiotic therapy. However, the isolated pathogen was different from that of the patient's first infection, so we postulate a reinfection rather than a relapse. All other patients remained free of infection for the observed period. CONCLUSION: Antibiotic treatment can safely be stopped in patients with prosthetic joint infection, even if CRP is not normalized, given that there are no clinical signs of persistent infection and a plateau of CRP level is obtained.

[Urothelial carcinoma--fever and weight loss after intravesical instillation of BCG]. / Fieber und Gewichtsverlust nach BCG-Instillation in die Harnblase bei Urothelkarzinom.

We report the case of a patient, who suffered from an acute BCG-pneumonitis after the fourth treatment of his bladder cancer with intravesical instillation of BCG. The chest-x-ray presented a bilateral reticulonodular infiltration. Mycobacterium tuberculosis could not be detected by culture, biopsy or PCR assay. Under treatment with Rifampicine, Isoniazid and Ethambutol the patient recovered within a short time and the follow up chest-x-ray became normal. A supplementary steroid therapy was not needed.

[Accidental fall and word finding problems in heart valve disease]. / Sturz und Wortfindungsstörungen bei valvulärer Herzkrankheit.

Abscesses of the spleen are rare and, if untreated, lead to death. The usual mode of development is by hematogenous spread of infection. Treatment options are splenectomy, percutaneous drainage and in selected cases an antibiotic therapy. We report a case of a splenic abscess due to Streptococcus bovis treated with antibiotics only.

Fatal sepsis in an AIDS patient during therapy for Pneumocystis carinii pneumonia.

The case of a patient with a newly diagnosed HIV infection and Pneumocystis carinii pneumonia is presented. Despite treatment with high-dose trimethoprim/sulfamethoxazole (TMP/SMX) and prednisone with initial improvement, the patient acutely deteriorated with severe acidosis and died on the 4th day of hospitalization. Cryptococcus neoformans grew the next day in broncheoalveolar lavage (BAL) and blood culture. As simultaneous presence of more than one opportunistic infection can occur in these patients, systematic workup for other common opportunistic infections must be performed.

Dysregulation of atrial natriuretic factor in hypertension-prone man.

To evaluate the hypothesis of an atrial natriuretic factor (ANF) deficiency in hypertension-prone humans, we investigated plasma ANF and other variables in 116 white offspring of normotensive parents (ONorm) or essential hypertensive parents (OHyp). Ten ONorm and 10 OHyp, all men matched for age and body habitus, were studied after 4 days of low (70 mmol/day) and high (350 mmol/day) dietary sodium intake. After mild sodium restriction, plasma ANF did not differ between ONorm and OHyp (9.7 +/- 0.7 vs. 9.0 +/- 1.3 fmol/L). On high sodium intake, plasma ANF increased in ONorm, but not in OHyp (to 18.3 +/- 1.7 vs. 11.7 +/- 1.7 fmol/L; P less than 0.001). On the other hand, acute responses of plasma immunoreactive ANF (irANF) to saline loading or a norepinephrine-induced rise in blood pressure did not differ significantly between 8 ONorm and 8 OHyp. Fifty-one additional ONorm and 45 OHyp were evaluated during liberal sodium intake. Groups were further subdivided according to whether 24-h urinary sodium excretion was 91 mmol/m2 or less (modest salt intake) or more than 91 mmol/m2 (high salt intake). Twenty-four-hour urinary sodium was similar in the 26 ONorm and 21 OHyp on a modest salt intake (121 +/- 6 vs. 116 +/- 9 mmol) and in the 25 ONorm and the 24 OHyp on a high salt intake (226 +/- 10 vs. 221 +/- 9 mmol). However, compared with ONorm, plasma irANF in OHyp was slightly lower on modest sodium intake (7.7 +/- 0.7 vs. 5.3 +/- 0.7 fmol/L; P less than 0.05) and markedly reduced on high sodium intake (15.0 +/- 1.3 vs. 8.0 +/- 1.3 fmol/L; P less than 0.001). Moreover, the slope of the relationship between plasma irANF and 24-h urinary sodium was flatter in OHyp than in ONorm (z test = 2.4). We postulate a new endocrine syndrome characterized by a relative plasma ANF deficiency during high sodium intake in some hypertension-prone humans. This functional defect becomes apparent during chronic, rather than acute, stimulation of ANF release. It occurs as a familial disturbance and may potentially predispose to the development of hypertension.