[Quality assurance in the diagnosis of indoor fungi]. / Ringversuch "Innenraumrelevante Schimmelpilze".

In co-ordination with the Umweltbundesamt Berlin, the Landesgesundheitsamt Baden-Wurttemberg (LGA) initiated external quality assurance in the diagnosis of indoor fungi in autumn 2001. Four of six fungal strains commonly found indoors have to be fully identified (on the genus and species level). There are two distributions per year; the six distributions hitherto carried out resulted in correct identification by 46-89% of laboratories (40-71 participants, total 148). It is clear from the results that repeat participants were more successful. In addition to the pure cultures sent out we offered actual samples (two air samples, one wood material, one sample of house dust, hitherto); 43- 69% of participating laboratories also took part in this facultative investigation of actual samples and 29-62% were successful. Results that differed considerably revealed problems while treating and evaluating actual samples. Therefore, activities in this field should be enhanced. In conclusion, external quality assurance in the diagnosis of indoor fungi is a useful management aid in the maintenance and improvement of laboratory performance.

[Chronic mucocutaneous candidosis with severe esophageal stricture]. / Chronisch mukokutane Candidose mit hochgradiger Osophagusstenose.

Since seven years, the 23-year-old woman suffered from severe dysphagia and cutaneous Candida-granulomas on the right side of the head, the nose and both hands. The therapy with different oral antimycotics was ineffective. Intravenously and orally administered high-dose fluconazole has induced healing of the mucocutaneous lesions. The esophageal stenosis, most likely caused by esophageal candidosis, was found as the origin of dysphagia. It was successfully treated by fluconazole and endoscopic dilatations.

[Tinea capitis et corporis due to Microsporum canis in an immunocompromised female adults patient]. / Microsporum-canis-bedingte Tinea capitis et corporis bei einer immunsupprimierten erwachsenen Patientin.

Tinea capitis as well as tinea corporis in adults may occur under conditions of immunosuppression. If suspected clinically, direct microscopy and examination by culture is indispensable. Therapeutic intervention should start without delay. A proven fungal infection of scalp hairs warrants immediate initiation of systemic treatment. Hereby prevention of disfiguring hair loss, permanent formation of scar tissue, spread of fungal organisms to other cutaneous regions as well as infection of other persons is possible.

[Strategies and targets for establishing a multicenter trial: "Identification of indoor relevant moulds"]. / Strategien und Ziele der Etablierung eines Ringversuchs. "Differenzierung von innenraumrelevanten Schimmelpilzen".

Quality control is universally recognised as fundamentally important in ensuring that diagnostic laboratories are performing appropriate tests at acceptable levels of competence. Therefore, the working group "Quality assurance--Fungi in Indoor Environments" which was initiated by the Public Health Service Baden-Württemberg (LGA BW) started with the external quality assurance in the diagnosis of indoor fungi in autumn 2001. Up to now we carried out the third mailing based on pure cultures. The results are reported and will be discussed. Exchanging experience on the international level is intended.

High prevalence of superantigens associated with the egc locus in Staphylococcus aureus isolates from patients with atopic eczema.

The present study was aimed at identifying a possible correlation between disease severity and colonization with superantigen-producing Staphylococcus aureus strains in patients with atopic eczema. To this end, Staphylococcus aureus strains from 91 patients with atopic eczema were screened for various staphylococcal superantigens such as SEA, SEB, SEC, SED, TSST1, the recently described enterotoxin gene cluster egc (which encodes the enterotoxins SEG, SEI, SEK, SEM, and SEO), and the see, seh, and sej loci. Swabs were taken from seven different sites in each patient. The rate of colonization with Staphylococcus aureus was 87.9%. Of those patients colonized, 35% were colonized with more than one different strain. Of the 120 genetically different strains investigated, the egc locus was found in 48.3% and the sej locus in 7.5%. The see and seh loci were not found in any strain. The presence of the classical superantigens SEA-SED or TSST1 was found in 38.3%. Overall, 71.3% of the Staphylococcus aureus-positive patients harbored at least one superantigen-producing strain on their skin. There was no difference in the prevalence of superantigens between atopic eczema patients and healthy volunteers. Moreover, there was no difference in the extent of disease expression between patients colonized by superantigen-positive Staphylococcus aureus strains and those with superantigen-negative strains as measured by the SCORAD system. However, patients colonized with Staphylococcus aureus had a significantly higher SCORAD score than those not colonized.

[Tinea capitis. Therapeutic options in the post-griseofulvin era]. / Tinea capitis Therapieoptionen im Post-Griseofulvin-Zeitalter.

Tinea capitis is the most common dermatophyte infection during childhood. In Germany, only griseofulvin is approved for therapy by regulatory agencies. In recent years, several newer antifungal agents such as itraconazole, fluconazole and terbinafine have broadened the therapeutic armamentarium and are used for the treatment of childhood tinea capitis. Itraconazole and terbinafine seem to be equally or more effective in treatment of tinea capitis within a shorter period of time than griseofulvin. Fluconazole is probably also effective for this indication, although supporting data is limited. Encountered side effects as well as interactions with other drugs appear to be well within acceptable limits for all three drugs. In conclusion, systemic therapy of scalp ringworm with itraconazole and terbinafine, as well as perhaps fluconazole, seems to be an equivalent or a superior therapeutic approach as compared to the use of griseofulvin. For the future, regulatory approval for the use of these newer antifungal agents in tinea capitis of childhood is recommended.

[Contagious impetigo--pathogen spectrum and therapeutic consequences]. / Impetigo contagiosa--Erregerspektrum und therapeutische Konsequenzen.

OBJECTIVE: The aim of this prospective study was to compare the clinical picture of contagious impetigo (C.I.) with the causative organism and to generate data of the susceptibility of bacteria as the basis for adequate therapy. PATIENTS AND METHODS: In 126 patients with C.I. (86 children, 66 of them younger than 10 years) bacterial swabs were taken and antibiotic sensitivity testing for isolated organisms was tested. RESULTS: In all cases in which contents of vesicles or pustules were analysed, Staphylococcus aureus was the only pathogen isolated. In non-bullous variants of C.I. Staphylococcus aureus was the most often isolated organism as well. Both staphylococci and streptococci were isolated in 12 cases, whereas in just 9 cases streptococci were the only pathogen detected. All Staphylococcus aureus isolates were sensitive to flucloxacillin and cefotaxime. Erythromycin-resistance amounted to more than 20 percent. The percentage of resistant staphylococci against the predominantly topically applied antibiotics fusidinic acid and mupirocin was 2 and 0 per cent, respectively. CONCLUSION: For all manifestations of C.I. Staphylococcus aureus is at present the leading organism which has to be taken into consideration for treatment. If oral antibiotic therapy is indicated, penicillinase-stable penicillins or cephalosporins, preferably of the cefalexin-type, are the drugs of choice. Macrolides are no longer recommended for initiating of C.I. treatment.

Optimizing the therapeutic approach in tinea capitis of childhood with itraconazole.

BACKGROUND: Tinea capitis is the most common dermatophytosis of childhood with increasing incidence. Whereas griseofulvin is considered by many as the mainstay of treatment, newer oral antifungal agents, including fluconazole, itraconazole and terbinafine have demonstrated higher efficacy, resulting in shorter treatment durations. OBJECTIVES: We aimed to determine the optimum regimen for the treatment of childhood tinea capitis with itraconazole. METHODS: A mycological culture outcome-dependent combination of a 28-day continuous and facultative additional 14-day courses with itraconazole was used in 42 children (20 girls; 22 boys) aged 12-140 months (mean 66) with tinea capitis due to Microsporum canis (n = 26) and Trichophyton violaceum (n = 16). The drug was given orally according to the patients' body weight (50 mg daily for < 20 kg; 100 mg daily for > or = 20 kg) over 4 weeks. Direct microscopy and fungal culture as a parameter for efficacy were repeated 2 weeks after termination of treatment. Assessment of efficacy was based on the evaluation of results from light microscopy and culture at 8 weeks after initiation of treatment, and in the case of a further positive mycological culture at 14 and 20 weeks, respectively. A positive fungal culture at these times resulted in an additional course for 2 weeks with the initially chosen itraconazole dosage. RESULTS: In 34 of 42 patients a single 4-week course of itraconazole resulted in a complete mycological cure of lesions as demonstrated by light microscopy and mycological culture. Four of 42 patients had to be treated by a second itraconazole course for 2 weeks, and four children received a third course of itraconazole for 2 weeks until all lesions showed negative direct microscopy and mycological culture. No abnormal haematological or biochemical results occurred. Apart from transient, completely reversible indigestion in two children, no side-effects were observed. CONCLUSIONS: A culture-based 28-day continuous therapeutic regimen plus facultative cultural outcome-dependent additional 14-day courses of a body weight-adapted dosage of itraconazole in tinea capitis due to M. canis and T. violaceum is discussed; this offers the advantage of an effective therapy with complete negative direct microscopy as well as negative cultural results, within a shorter active treatment period (cf. previous studies with continuous administration of itraconazole).

In vitro evaluation of voriconazole against clinical isolates of yeasts, moulds and dermatophytes in comparison with itraconazole, ketoconazole, amphotericin B and griseofulvin.

The in vitro activity of voriconazole (UK-109, 496), a new antifungal triazole derivative, against 650 clinical isolates of yeasts, moulds and dermatophytes was compared with that of itraconazole, ketoconazole, amphotericin B and griseofulvin. The geometric means of the minimum inhibitory concentrations (MICs) of voriconazole were 0.05 microgram ml-1 against yeasts (n = 187), 0.58 microgram ml-1 against moulds (n = 260) and 0.08 microgram ml-1 against dermatophytes (n = 203). The overall activity of voriconazole against yeasts and moulds was good, being similar to that of itraconazole, ketoconazole and amphotericin B. Voriconazole was highly effective against Aspergillus fumigatus (mean MIC 0.23 microgram ml-1) and other Aspergillus species and showed noteworthy activity (mean MICs 0.08-0.78 microgram ml-1) against emerging and less common clinical isolates of opportunistic moulds, such as Alternaria spp., Cladosporium spp., Acremonium spp., Chrysosporium spp. and Fusarium spp. On the other hand, voriconazole was less active in vitro than the comparative agents studied against various species of zygomycetes, such as Mucor spp., Rhizopus spp. and Absidia spp. Voriconazole and the other two azoles, itraconazole and ketoconazole, were more active than griseofulvin in vitro against most dermatophytes tested.

In vitro activity of voriconazole against yeasts, moulds and dermatophytes in comparison with fluconazole, amphotericin B and griseofulvin.

Voriconazole (CAS 137234-62-9, UK-109,496), a new antifungal triazole derivative, was studied in vitro against 650 clinical isolates, representing yeasts, moulds and dermatophytes, and was compared with fluconazole (CAS 86386-73-4), amphotericin B (CAS 1397-89-3), and griseofulvin (CAS 126-07-8). The mean minimum inhibitory concentrations (MICs) of voriconazole were 0.06 microgram/ml against yeasts (n = 187), 0.74 microgram/ml against moulds (n = 260) and 0.10 microgram/ml against dermatophytes (n = 203). Data from these in vitro studies showed that voriconazole was more potent than fluconazole against most species studied, but particularly against the isolates of moulds and dermatophytes. Overall, voriconazole and amphotericin B indicated comparably good activity against yeasts and moulds. Voriconazole was highly potent against 13 Aspergillus species studied (mean MIC 0.35 microgram/ml) and also showed noteworthy activity (mean MICs 0.08-0.78 microgram/ml) against emerging and less common clinical isolates of opportunistic moulds such as of Alternaria spp., Cladosporium spp., Acremonium spp., Chrysosporium spp., and Fusarium spp. In addition, voriconazole was more active in vitro than griseofulvin against most dermatophytes tested. The in vitro results confirmed that voriconazole has indeed a broad antifungal spectrum and could also be effective against a wide range of fungal infections in patients.

Comparison of the in vitro activity of fluconazole against Candida albicans and dermatophytes.

Fluconazole (CAS 86386-73-4, Diflucan, Fungata is an antimycotic agent of established value in the treatment of systemic infections with yeasts; more recently this drug has been used in the oral treatment of dermatomycoses. The in vitro activity of fluconazole against 51 strains of C. albicans and 207 isolates of four different species of dermatophytes was therefore measured and the results collated. The mean minimal inhibitory concentrations (MIC) show that in vitro fluconazole is a significantly stronger inhibitor of the proliferation of C. albicans (0.34 micrograms/ml) than of the dermatophytes T. rubrum (6.4 micrograms/ml), T. mentagrophytes (23.9 micrograms/ml), M. canis (18.3 micrograms/ml) and E. floccosum (3.5 micrograms/ml). On the other hand, the distribution of the MIC values shows that the sensitivity to fluconazole within a single species is also very variable. It is evident that the concentrations of fluconazole reached particularly in the stratum corneum of the skin after oral therapy are adequate to inhibit the growth of the yeasts and of the dermatophytes examined.

Bioavailability of fluconazole in the skin after oral medication.

Fluconazole is an antimycotic drug which until now has been used mostly in the systemic therapy of yeast infections. We have now demonstrated the presence of this drug in various skin structures. After administration of 50 mg of fluconazole per day for 12 days to healthy volunteers, the following mean drug concentrations were measured: serum 1.81 micrograms ml-1, sweat 4.58 micrograms ml-1, dermis-epidermis (without stratum corneum) 2.77 micrograms g-1 and stratum corneum 73 micrograms g-1. Thus, 4 h after the last dose the antimycotic attains a 40-fold higher concentration in the stratum corneum than in serum. One week after ending the oral treatment, 5.8 micrograms g-1 fluconazole was present in stratum corneum. After daily ingestion of 200 mg of fluconazole for 5 days there was a further increase in the mean concentration of fluconazole in stratum corneum, to 127 micrograms g-1. Even 4-5 months after completing the oral treatment, fluconazole was detectable in the head hair and toenails of healthy volunteers. Fluconazole is eliminated from the stratum corneum about 2-3 times more slowly than from serum or plasma. After oral administration fluconazole evidently accumulated rapidly and intensively into the stratum corneum. The concentrations then attained or exceeded the in vitro minimal inhibitory concentrations of fluconazole for most of the dermatophytes and yeasts which are involved in cutaneous mycoses.

Chemical composition and structure of cell wall teichoic acids of staphylococci.

The cell wall teichoic acid structures of 22 staphylococci including 13 type strains were determined. Most of the strains contain a poly(polyolphosphate) teichoic acid with glycerol and/or ribitol as polyol component. The polyolphosphate backbone is partially substituted with various combinations of sugars and/or amino sugars. Most of the substituents occur in a monomeric form but some strains also contain dimers of N-acetylglucosamine as substituents. Staphylococcus hyicus subsp. hyicus NCTC 10350 and S. sciuri DSM 20352 revealed rather complex cell wall teichoic acids. They consist of repeating sequences of phosphate-glycerol-phosphate-N-acetylglucosamine. The amino sugar component is present in this case as a monomer or an oligomer (n less than or equal to 3). Moreover, the glycerol residues are partially substituted with N-acetylglucosamine. The cell wall teichoic acid of S. auricularis is a poly(N-acetylglucosaminyl-phosphate) polymer similar to that found in S. caseolyticus ATCC29750. The cell wall teichoic acid structures for type strains of S. auricularis, S. capitis, S. cohnii, S. haemolyticus, S. hominis, S. hyicus subsp. hyicus, S. sciuri, S. xylosus and S. warneri were determined for the first time in detail. The structures of some of the previously described teichoic acids had to be revised (S. epidermidis, S. simulans, S. aureus phage type 187).

Threo-beta-hydroxyornithine: a natural constituent of the peptidoglycan of Corynebacterium species Co 112.

Peptidoglycan of Corynebacterium species Co 112 (DSM 20606) exhibits an unknown amino acid. The amino acid was isolated from cell wall hydrolysates and identified as threo-beta-hydroxyornithine. This amino acid is found in the interpeptide bridge of the peptidoglycan of Corynebacterium sp. Co 112. The primary structure of this peptidoglycan is rather similar to that of Microbacterium liquefaciens. The only difference is the replacement of ornithine by threo-beta-hydroxyornithine. The mode of linkage of threo-beta-hydroxyornithine indicates that it is present as D-isomer.

[Skin reactions to isolated bacterial cell wall components, bacterial peptidoglycan in particular]. / Hautreaktionen gegen isolierte bakterielle Zellwand-komponenten, insbesondere bakterielle Peptidoglycane.

To elucidate the pathogenetic mechanism of bacterial-allergical diseases and of reactions provoked by bacterial test substances (e.g. the intracutaneous test), it is necessary to analyse carefully various factors involved in these reactions. To try to separate toxic from immunological reactions minute amounts of peptidoglycan in four different preparations were applied to humans by intracutaneous injections. Peptidoglycan, an immunologically well defined wall components of almost all bacteria and which is therefore ubiquitous, was isolated from staphylococci and streptococci. The skin reactions were evaluated by macroscopical, microscopical and immunohistological observations, as well as by electromicroscopy and statistical means. Several findings indicate the involvement of immunological factors in the observed skin reactions. In some cases no measurable reaction was seen, whereas in others typical skin reactions occurred. Similar reactions were produced by the antigenically related peptidoglycans isolated from Staphylococcus aureus and Staphylococcus epidermis. These reactions differed, however, from those elicited by peptidoglycan preparations from Streptococcus pyogenes type A. Patients with chronic bacterial infections and who were injected by four bacterial preparations demonstrated a significant increase in delayed hypersensitivity reaction compared with two other groups of patients (atopic patients without chronic infection). Because of the very low test dose, necrotic skin reactions, which occur in animal experiments, were not observed.