[Update on current care guidelines. Current care guideline: Acute lower respiratory tract infection in adults]. / Kaypa hoite-suosituksen paivitystiivistelma. Alahengitystieinfektiot (aikuiset).

Pneumonia is recognised in patients suffering from acute cough or deteriorated general condition. Patients with acute cough without pneumonia-related symptoms or clinical findings do not benefit from antimicrobial treatment. Those with suspected or confirmed pneumonia are treated with antibiotics, amoxicillin being the first choice. Most patients with pneumonia can be treated at home. Those with severe symptoms are referred to hospital. Patients are always encouraged to contact his/her physician if the symptoms worsen or do not ameliorate within 2-3 days. Patients aged 50 years or older and smokers are controlled by thoracic radiography in 6-8 weeks.

Short-term outcomes of tonsillectomy in adult patients with recurrent pharyngitis: a randomized controlled trial.

BACKGROUND: Limited evidence exists as to the benefit of tonsillectomy in adult patients. We sought to determine the short-term efficacy of tonsillectomy for recurrent pharyngitis in adults. METHODS: We conducted a randomized, controlled, parallel-group trial at a tertiary care ear, throat and nose centre in Oulu, Finland, between October 2007 and December 2010. Adult patients with recurrent pharyngitis were randomly assigned to the control group (watchful waiting) or the tonsillectomy group. Our primary outcome was the difference in the proportion of patients with severe pharyngitis (severe symptoms and C-reactive protein level > 40 mg/L) within 5 months. Our secondary outcomes included differences between groups in proportions of patients who had episodes of pharyngitis with or without medical consultation, rates of pharyngitis and numbers of days with symptoms. RESULTS: Of 260 patients referred for tonsillectomy because of recurrent pharyngitis, we recruited 86 participants for our study. Of these, 40 patients were randomly allocated to the control group, and 46 were randomly allocated to the tonsillectomy group. One patient in the control group and no patients in the tonsillectomy group had a severe episode of pharyngitis (difference 3%, 95% confidence interval [CI] -2% to 7%). Seventeen patients in the control group (43%) and 2 patients in the tonsillectomy group (4%) consulted a physician for pharyngitis (difference 38%, 95% CI 22% to 55%). Overall, 32 patients in the control group (80%) and 18 patients in the tonsillectomy group (39%) had an episode of pharyngitis during the 5-month follow-up (difference 41%, 95% CI 22% to 60%). The rate of pharyngitis and number of symptomatic days were significantly lower in the tonsillectomy group than in the control group. INTERPRETATION: There was no significant difference in the number of episodes of severe pharyngitis between the control and treatment groups, and episodes were rare. However, tonsillectomy resulted in fewer symptoms of pharyngitis, consequently decreasing the number of medical visits and days absent from school or work. For this reason, surgery may benefit some patients. TRIAL REGISTRATION: ClinicalTrials.gov, no. NCT00547391.

Comparison of antigen and two molecular methods for the detection of Clostridium difficile toxins.

BACKGROUND: Clostridium difficile (CD) is considered an important cause of diarrhoea associated with the antimicrobial treatment of infections. The pathogenicity of CD is due to toxins A and B, produced by toxigenic CD strains. METHODS: We evaluated 3 methods for detecting CD toxins: the RIDASCREEN® enzyme immunoassay (EIA) (R-Biopharm)--one detecting toxins directly in the stool specimens and another detecting toxins from isolated CD strains--and 2 molecular methods, the illumigene™ loop-mediated isothermal amplification (LAMP) assay (Meridian) and RIDA®GENE polymerase chain reaction (PCR) assay (R-Biopharm), as direct identification methods from stool specimens. Toxigenic culture (TC) was used as the reference method. RESULTS: Altogether 884 stool samples were analyzed, of which 253 (29%) were positive by TC. Six hundred and seventy-two specimens were tested by RIDASCREEN EIA, 430 were tested with the illumigene LAMP assay, and 212 were tested with the RIDA GENE PCR assay. CD toxin A and B antigen tests by EIA were very insensitive, both directly from stool specimens (2 series; 57-61%) and in isolated CD strains (53%); consequently the negative predictive value remained low (84-93% and 91%, respectively). Specificity, however, was very good at 98-100%. The 2 molecular methods detected CD toxin genes excellently and equally, resulting in sensitivities, specificities, and positive and negative predictive values of 98%, 100%, 100%, and 98%, respectively. CONCLUSIONS: Both molecular assays were easy to use, rapid, sensitive, and specific for the detection of toxigenic CD strains.

Molecular typing of vancomycin-resistant Enterococcus faecium with an automated repetitive sequence-based PCR microbial typing system compared with pulsed-field gel electrophoresis and multilocus sequence typing.

BACKGROUND: Pulsed-field gel electrophoresis (PFGE) is the main typing method used for the molecular typing of vancomycin-resistant Enterococcus faecium (VREfm). However, more rapid and unambiguous typing methods are needed. DiversiLab, a repetitive sequence-based PCR (rep-PCR), offers an alternative method for strain typing. METHODS: Thirty-nine VREfm isolates with known epidemiological relationships were characterized by semi-automated rep-PCR (DiversiLab), PFGE, and multilocus sequence typing (MLST). RESULTS: The DiversiLab results were analysed in 2 ways: first relying solely on the DiversiLab software, and second by DiversiLab analysis combined with manual interpretation. The analysis with interpretation yielded more DiversiLab profiles, correlated better with PFGE and MLST, and grouped the isolates better according to their relatedness in time and space. However, most of the DiversiLab groups also included isolates with different PFGE and MLST types. CONCLUSIONS: DiversiLab provides rapid information when investigating a potential hospital outbreak. However, the interpretation of E. faecium DiversiLab results cannot be fully automated and is not always straightforward. Other typing methods may be necessary to confirm the analysis.

Comparison of the epidemiology, risk factors, outcome and degree of organ failures of patients with candidemia acquired before or during ICU treatment.

INTRODUCTION: The aim of this study was to compare the epidemiology, risk factors, severity and outcome of two types of ICU-treated candidemias: namely, ICU-acquired candidemia (acquired after 48-hour ICU stay) (ICUAC group), and those needing ICU treatment for candidemia acquired before ICU admission or during the first 48-hour ICU stay (non-ICUAC group). METHODS: A retrospective cohort study was conducted between 2000 and 2009 in a mixed tertiary ICU among patients with blood-culture-confirmed candidemia. RESULTS: The study involved 82 patients (53 men). The ICUAC group consisted of 38 patients (46.3%) and the non- ICUA group included 44 patients (53.6). The ICUAC group had undergone previous surgery more often and had ICU stays that were 3.7 times longer than the non-ICUAC group, whose members more often had co-morbidities (95.6% versus 73.7%, P = 0.001). The ICUAC group had significantly more frequent organ failures with cardiovascular, renal, central nervous and coagulation systems than the non-ICUAC group. ICU, hospital and one-year mortality rates did not differ between the groups (23%, 36.8% and 65.8%, respectively, in the ICUAC group and 26%, 44.4% and 64.4%, respectively, in the non-ICUAC group). Among patients with APACHE II scores greater than 25, the ICUAC group had lower one-year mortality (65.0% versus 87.5%). Among patients with APACHE II scores of 25 or less, the ICUAC group had higher mortality (66.7% versus 50.0). Candida albicans was most common cause of candidemia in both groups (76.3% and 68.9%, respectively). CONCLUSIONS: More than half of the ICU-treated candidemias were acquired prior to admission to the ICU. Patients with ICU- and non-ICU-acquired candidemias had different risk factors and different needs for ICU resources. Hospital mortality was similar in both groups; however, the groups had different mortality rates when the severity of disease and underlying diseases were taken into account.

Intestinal bacterial translocation and tight junction structure in acute porcine pancreatitis.

BACKGROUND/AIMS: To examine whether intestinal bacterial translocation occurs early in acute mild and severe pancreatitis and whether the intestinal expression of tight junction proteins (claudins-2, -3, -4, -5, -7), apoptosis or proliferation would explain the possible translocation. METHODOLOGY: Fifteen pigs were randomized to controls (n=5) or to develop mild edematous pancreatitis (n=5, saline infusion to pancreatic duct) or severe necrotic pancreatitis (n=5, taurocholic acid infusion). Translocation was studied by measuring bacterial cultures from portal vein blood and mesenteric lymph nodes. Immunohistochemical expression of the tight junction proteins, apoptosis rate (TUNEL) and Ki-67 were analyzed quantitatively from the epithelium of the jejunum and colon. RESULTS: There was no bacterial translocation during the 6 hours followup, nor changes in the expression of tight junction proteins claudins-2 and -5 in jejunum or colon. Saturation and proportional area of claudin-3 staining decreased in the colon, as did claudins-4 and -7 staining in the jejunum of the necrotic pancreatitis group. Increased apoptosis was found in all samples from controls and the edematous pancreatitis group but not in jejunum in the necrotic pancreatitis group. Ki-67 activity tended to increase in the upper half of the villus in edematous and necrotic pancreatitis. There were no changes in the basic histology. CONCLUSIONS: The major finding of this study was that bacterial translocation from the gut is not present at the beginning of acute pancreatitis. Tight junction proteins claudin-2 and -5 do not become altered in the early stages of pancreatitis. Claudin-3 decreases in the colon and claudins-4 and -7 in the jejunum in necrotic pancreatitis. Laparotomy itself causes increased apoptosis in the colon and the jejunum.

Clinical Candida krusei isolates remain susceptible during extensive exposure to antifungal drugs.

We have previously reported a Candida krusei outbreak during which a number of our patients were infected or colonized by several different closely related Candida krusei genotypes. The treatment response in many of our patients was at best modest and the patients remained positive for Candida krusei. We speculated that extended exposure to antifungals in patients with an incomplete treatment response might lead to the conditions for selection of drug resistance in the multiple Candida krusei clones. Therefore, we followed the in vitro susceptibility of the Candida krusei isolates taken from our patients before and during the antifungal treatment. A total of 28 Candida krusei isolates from 11 patients with prolonged exposure to antifungal medication were analyzed for their in vitro susceptibility to commonly used drugs. We found that MIC(50) values of all Candida krusei isolates was 12 microg/ml for fluconazole, 0.19 microg/ml for voriconazole, 1.0 microg/ml for amphotericin B, and 1.0 microgt/ml for caspofungin with the corresponding MIC(90) values being 16 microg/ml, 0.5 microg/ml, 2.0 microg/ml, and 1.0 micro/ml, respectively. Extended antifungal exposure did not change these MIC values. We conclude that resistance development in Candida krusei during prolonged antifungal treatment may not be common and the treatment failure of our patients was not likely due to the development of drug resistance by the etiologic agent.

A cluster of Candida krusei infections in a haematological unit.

BACKGROUND: Candida krusei infections are associated with high mortality. In order to explore ways to prevent these infections, we investigated potential routes for nosocomial spread and possible clonality of C. krusei in a haematological unit which had experienced an unusually high incidence of cases. METHODS: We searched for C. krusei contamination of the hospital environment and determined the level of colonization in patients and health care workers. We also analyzed the possible association between exposure to prophylactic antifungals or chemotherapeutic agents and occurrence of C. krusei. The C. krusei isolates found were genotyped by pulsed-field electrophoresis method in order to determine possible relatedness of the cases. RESULTS: Twelve patients with invasive C. krusei infection and ten patients with potentially significant infection or mucosal colonization were documented within nine months. We were unable to identify any exogenic source of infection or colonization. Genetic analysis of the isolates showed little evidence of clonal transmission of C. krusei strains between the patients. Instead, each patient was colonized or infected by several different closely related genotypes. No association between medications and occurrence of C. krusei was found. CONCLUSION: Little evidence of nosocomial spread of a single C. krusei clone was found. The outbreak may have been controlled by cessation of prophylactic antifungals and by intensifying infection control measures, e.g. hand hygiene and cohorting of the patients, although no clear association with these factors was demonstrated.

Territorial waters of the Baltic Sea as a source of infections caused by Vibrio cholerae non-O1, non-O139: report of 3 hospitalized cases.

A fatal infection with temporal relation to 2 other febrile infections caused by Vibrio cholerae non-O1, non-O139 (NCV) occurred in Finland in 2003. All infections were associated with contact with seawater. The patient who died had also eaten home-salted whitefish, tested positive for NCV, preceding his symptoms. All patients had compromising factors, and all strains were distinguishable by pulsed-field gel electrophoresis and negative for the ctx gene. These 3 cases illustrate that, despite being uncommon in Finland, NCVs can cause clinically significant and even fatal infections.

Ciprofloxacin-releasing bioabsorbable polymer is superior to titanium in preventing Staphylococcus epidermidis attachment and biofilm formation in vitro.

Antibiotic coating systems have been successfully used to prevent bacterial attachment and biofilm formation. Our purpose was to evaluate whether bioabsorbable polylactide-co-glycolide (PLGA) 80/20 on its own, and PLGA together with ciprofloxacin (PLGA+C) have any advantages over titanium in preventing Staphylococcus epidermidis attachment and biofilm formation in vitro. Cylindrical specimens of titanium, PLGA, and PLGA+C in triplicate were examined for S. epidermidis ATCC 35989 attachment and biofilm formation after incubation with a bacterial suspension of about 10(5) cfu/mL for 1, 3, 7, 14, and 21 days, using scanning electron microscopy. Growth inhibition properties of PLGA and PLGA+C cylinders were tested on agar plates. On days 1, 3, and 21, no bacterial attachment was seen in 19.5, 9.2, and 41.4% of the titanium specimens; in 18.4, 28.7, and 34.5% of the PLGA specimens; and in 57.5, 62.1, and 57.5% of the PLGA+C specimens, respectively. During the whole study period, no biofilm was observed on 74-93% of the titanium specimens, 58-78% of the PLGA specimens, and 93-100% of the PLGA+C specimens. PLGA+C showed clear bacterial growth inhibition on agar plates, while PLGA and titanium did not show any inhibition. PLGA+C bioabsorbable material was superior to titanium in preventing bacterial attachment and biofilm formation and may have clinical applicability, for example, in prevention of infection in trauma surgery or in the treatment of chronic osteomyelitis.

Blood culture Gram stain and clinical categorization based empirical antimicrobial therapy of bloodstream infection.

Early antimicrobial treatment has a great influence on the outcome of patients with blood stream infections (BSI). The study was designed to see if the simple practice of patient categorization (community acquired, nosocomial or infection in haematological unit) combined with Gram stain data could be used to guide empirical treatment of BSI in 1901 consecutive positive blood culture findings. There were considerable differences in the occurrence of common pathogens and their antimicrobial susceptibilities between patient categories especially for Gram-positive cocci. For example, second generation cephalosporins covered more than 70% cocci in clusters and over 80% of cocci in chains in community acquired infections whereas in hospital acquired infections the corresponding figures were only 47 and 44%. We conclude that Gram stain results of positive blood cultures along with the knowledge of where the infection was acquired, would allow early accurate targeting of antimicrobial therapy for BSI.

The role of microbes in the pathogenesis of acute rhinosinusitis in young adults.

OBJECTIVES/HYPOTHESIS: To provide information on the course of acute rhinosinusitis (ARS) with sequential nasal and paranasal microbiological data and their correlation with clinical outcomes. STUDY DESIGN: We conducted a prospective cohort study among 50 Finnish military recruits with clinically diagnosed ARS in spring 2012. METHODS: We collected symptom, nasal endoscopy, and cone-beam CT (CBCT) scores during the early (2-3 days from onset) and later phases (9-10 days). We took viral samples from the nasopharynx (multiplex respiratory virus polymerase chain reaction [PCR]), bacterial culture from the middle meatus during both phases, and both viral and bacterial samples from the maxillary sinus aspirate (respiratory virus PCR, bacterial culture, broad-range bacterial PCR) during the later phase. Cilia destruction and microbial biofilms were sought from a nasal mucosal biopsy sample. RESULTS: We found that 42 (84%) of the subjects had viral nucleic acid in the nasopharynx during ARS. During the early phase, 28 (56%) of the subjects had nontypeable H. influenzae (NTHi) in the middle meatus, which was associated with wider paranasal mucosal changes in CBCT scans and increased symptoms during the study period. After 9 to 10 days from the onset, NTHi was found in the maxillary sinus in eight subjects (40%, 8/20) and led to prolonged symptoms. Bacterial biofilm was ruled out in 39 (78%) cases, and cilia destruction did not correlate with microbiological or clinical outcomes. CONCLUSION: Nasal and paranasal H. influenzae coinfection during viral infection may modify the symptoms and the extent of sinonasal mucosal disease observed in CBCT scans already from the beginning of the ARS episode.

Major age group-specific differences in conjunctival bacteria and evolution of antimicrobial resistance revealed by laboratory data surveillance.

PURPOSE: We hypothesized that observation and analysis of microbiological laboratory statistics from patients with suspected bacterial conjunctivitis should increase our understanding of microbiological epidemiology of the disease in age categories. We further assumed that the statistical data should expose evolution of antimicrobial resistance that may eventually have an influence on clinical decisions. MATERIALS AND METHODS: We analyzed statistical data of bacterial isolates (1139 strains) and their resistance to common antibiotics from 2494 patients with suspected bacterial conjunctivitis. RESULTS: Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus displayed their presence in 0- to 5-year-old children. Staphylococcus aureus and Pseudomonas aeruginosa were the most common in the elderly (>age 70) among whom a rapid increase in resistance of Staphylococcus aureus to methicillin (MRSA) was recognized. CONCLUSIONS: Our study demonstrates that the spectrum of conjunctival bacteria varies among age groups. In addition, our results confirm that a shift in antimicrobial susceptibility can be rapid and age-group specific, thus emphasizing the need for continuous surveillance of bacterial findings.

Influence of chemotherapy courses on the rate of bloodstream infections during neutropenia in adult acute myeloid leukaemia.

To evaluate the effect of various chemotherapy courses on the rate of bloodstream infections (BSI) during therapy-related neutropenia, all infection episodes of adult patients with acute myeloid leukaemia (AML) during 7 y were retrospectively analysed in a university hospital. Of the 182 infection episodes in 76 AML patients, 37% (n = 68) were BSI. The riskratio (RR) of BSI was highest after regimens containing high-dose cytarabine (2.4 with 95% confidence interval (CI) 1.3-4.4) and lowest after thioguanine-containing courses (RR: 0.2, 95% CI 0.2-0.5). Chemotherapy courses per se may have an influence on the rate of BSI during neutropenia.

Diagnostics of fungal infections in the Nordic countries: we still need to improve!

A Nordic External Quality Assessment programme in medical mycology was established in 2005. In order to monitor not 'best practice' but the level of routine diagnostics, specimens were designed to resemble clinical samples and laboratories were asked to handle the samples like routine samples. Five simulated clinical samples were distributed to 59 participating Nordic laboratories of clinical microbiology. The specimens contained the following microorganisms: 1) Candida glabrata and C. albicans in a ratio of 1:20; 2) Cryptococcus neoformans; 3) Aspergillus fumigatus, C. albicans and Enterobacter cloacae; 4) C. tropicalis, Klebsiella pneumonia and Enterococcus faecium; 5) None. 66% of the laboratories failed to detect the C. glabrata isolate in sample no. 1. 34% of the laboratories reporting susceptibility results incorrectly reported the Cryptococcus neoformans isolate as fluconazole susceptible. 24% of the laboratories failed to detect Aspergillus fumigatus in specimen no. 3 despite the accompanying clinical information notifying that it was a BAL sample from a neutropenic patient in an ICU. In conclusion, this distribution of simulated clinical samples illustrates that the traditional quality assessment programmes may give a false sense of satisfactory performance, that mycological diagnosis is difficult, and that there is a need of further improvement and attention.

Tonsillectomy versus watchful waiting in recurrent streptococcal pharyngitis in adults: randomised controlled trial.

OBJECTIVE: To determine the short term efficacy and safety of tonsillectomy for recurrent streptococcal pharyngitis in adults. Design Randomised controlled trial. SETTING: Academic referral centre in Finland. PARTICIPANTS: 70 adults with documented recurrent episodes of streptococcal group A pharyngitis. INTERVENTION: Instant tonsillectomy (n=36) or remaining on waiting list as control (n=34). MAIN OUTCOME MEASURES: Percentage change in the risk of an episode of streptococcal pharyngitis at 90 days. Rates of all episodes of pharyngitis and days with symptoms and adverse effects. RESULTS: The mean (SD) follow-up was 164 (63) days in the control group and 170 (12) days in the tonsillectomy group. At 90 days, streptococcal pharyngitis had recurred in 24% (8/34) in the control group and 3% (1/36) in the tonsillectomy group (difference 21%; 95% confidence interval 6% to 36%). The number needed to undergo tonsillectomy to prevent one recurrence was 5 (3 to 16). During the whole follow-up, the rates of other episodes of pharyngitis and days with throat pain and fever were significantly lower in the tonsillectomy group than in the control group. The most common morbidity related to tonsillectomy was postoperative throat pain (mean length 13 days, SD 4). CONCLUSIONS: Adults with a history of documented recurrent episodes of streptococcal pharyngitis were less likely to have further streptococcal or other throat infections or days with throat pain if they had their tonsils removed. TRIAL REGISTRATION: Clinical Trials NCT00136877.

Occurrence of Scopulariopsis and Scedosporium in nails and keratinous skin. A 5-year retrospective multi-center study.

A 5-year retrospective multicenter study was performed for microascaceous moulds (Microascaceae, Ascomycetes) in Finnish clinical specimens. The files from 1993-1997 of six clinical mycology laboratories in Finland were searched for reports of these fungi, mainly Scopulariopsis and Scedosporium anamorphs in keratinous specimens. From the 521 primary findings, 165 cases were selected for further study based on direct microscopy, colony numbers and accompanying fungi. The clinical records of 148 cases (141 Scopulariopsis, 7 Scedosporium) were studied. Of the nail infections from which Scopulariopsis was recovered, 39 cases were further separated which showed clinical or laboratory-based evidence of dermatophytosis. In the remaining 90 'non-dermatophyte' nail cases, Scopulariopsis spp. were the only documented fungal agents (c. 6 cases/million/year). The patients were mainly elderly, 66% of whom had problems involving their big toe nails. For 74% of them, the nail problem was mentioned as their reason for visiting the physician. However, only 18% had documented benefit from treatment. The Scopulariopsis nail infections seem to be treatment-resistant and the pathogenesis and etiological role of Scopulariopsis remain poorly understood.

Self-reinforced ciprofloxacin-releasing polylactide-co-glycolide 80/20 inhibits attachment and biofilm formation by Staphylococcus epidermidis: an in vitro study.

We have observed the efficiency of antibiotic-releasing polylactide-co-glycolide (PLGA) 80/20 in preventing Staphylococcus epidermidis attachment and biofilm formation in vitro. The aim of the present study was to evaluate the effect of self-reinforced (SR) implants with enhanced antibiotic release on bacterial attachment and biofilm formation rates, and also on growth inhibition of Staphylococcus epidermidis. Cylindrical SR-PLGA+AB specimens (length 30 mm, diameter 3 mm) were examined by scanning electron microscopy (SEM) for attachment of S. epidermidis ATCC 35989 on biomaterial surface and formation of biofilm, after incubating with bacterial suspension of ca. 10 cfu/mL for 1, 3, 7, 14 and 21 days. SR-PLGA and SR-PLGA+AB implants were tested on agar plates by measuring the inhibition distance around implants. On the surface of SR-PLGA+AB, at days 1, 3, 7, 14 and 21, the percentage of areas with not a single bacteria attached, was 88.6%, 71.1%, 73.7%, 73.7%, and 68.4%, respectively. On the areas where bacteria were detected, the number of bacterial cells remained low during whole study period, and no significant increase by time was seen. There was no biofilm observed on 97-99% of the examined areas during the whole study period on SR-PLGA+AB. In agar plates, the SR-PLGA+AB showed inhibition of bacterial growth, with (mean) 53.2 mm diameter of inhibition area with peeled implants and 50.5 mm with non-peeled implants. There was no inhibition seen around implants without ciprofloxacin. Bioabsorbable ciprofloxacin-releasing self-reinforced PLGA (SR-PLGA+AB) was superior to plain SR-PLGA in preventing bacterial attachment, biofilm formation, and also the growth of Staphylococcus epidermidis.

Activities of telithromycin, erythromycin, fluoroquinolones, and doxycycline against Campylobacter strains isolated from Finnish subjects.

The in vitro susceptibilities of 478 Campylobacter jejuni and Campylobacter coli strains isolated from Finnish subjects during 2002 to 2004 were determined. Susceptibility to erythromycin remained high, and telithromycin did not offer any advantage over erythromycin. Reduced susceptibilities to fluoroquinolones and doxycycline were detected almost exclusively among isolates of foreign origin.