[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.

[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.

[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.

[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.

[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.

[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.

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.

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.

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.

[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.

Failures of 1 week on, 1 week off antiretroviral therapies in a randomized trial.

BACKGROUND: Scheduled treatment interruptions are being evaluated in an effort to decrease costs and side effects of highly active antiretroviral therapy (HAART). A schedule of 1 week on and 1 week off therapy offers the promise of 50% less drug exposure with continuously undetectable HIV RNA concentration. METHODS: In the Staccato study 600 patients on successful HAART were to be randomized to either continued therapy, CD4-guided therapy, or one week on, one week off therapy. A scheduled preliminary analysis evaluated effectiveness in the 1-week-on-1-week-off arm. RESULTS: Of 36 evaluable patients, 19 (53%) had two successive HIV RNA concentrations > 500 copies/ml at the end of the week off therapy, and were classified as virological failure. Most of those who failed took didanosine, stavudine, saquinavir, and ritonavir (11 patients). In these patients, there was no evidence of mutations suggestive of drug resistance, and plasma saquinavir levels were within the expected range. Two of three patients failing on triple nucleotides had drug resistance mutations, but nonetheless responded to reintroduction of triple nucleotide therapy. One of two patients taking nevirapine, and one of eight taking efavirenz, also failed. Both had resistance mutations at the time of failure, but not at baseline. CONCLUSIONS: The 1-week-on-1-week-off schedule, as tested in the Staccato study, showed an unacceptably high failure rate and was therefore terminated.

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.

Prospective epidemiologic survey of patients with community-acquired pneumonia requiring hospitalization in Switzerland.

BACKGROUND: Community-acquired pneumonia (CAP) is a common problem and the principal infection requiring hospitalization, but its treatment is complicated by the difficulty in microbiological diagnosis and the increasing incidence of antibiotic resistance among respiratory pathogens. The purpose of this paper is to present the main epidemiologic features of patients with CAP requiring hospitalization in our country. METHODS: We enrolled three hundred and eighteen adult patients with CAP requiring hospitalization in seven large medical centers in Switzerland during two winter periods. The patients' mean age was 70.4 years. This study describes the epidemiology of these patients. Clinical, radiologic and microbiological evaluations were performed at study entry during treatment, and at 4 weeks post-therapy. For microbiological diagnostic purposes, sputum culture, throat swab culture, PCR, blood cultures, Legionella urinary antigen and serologic evaluations were also performed. RESULTS: Despite the higher mean age, the overall mortality rate was 8%, lower than in other comparable studies. The most common underlying diseases present at study entry were cardiac failure (23%), chronic obstructive pulmonary disease (20%), renal failure (15%), and diabetes (12%); 40% of the patients were smokers. Although dyspnea, cough and positive pulmonary auscultation findings were present in about 90% of patients, fever >38 degrees C was present in only 64%. The most frequently isolated respiratory pathogens were Streptococcus pneumoniae (12.6%), Haemophilus influenzae (6%), Staphylococcus aureus (1.6%), and Moraxella catarrhalis (1.6%). Atypical pathogens were frequently found, with the following distribution: Mycoplasma pneumoniae, 7.5%; Chlamydia pneumoniae, 5.3%; and Legionella pneumophila, 4.4%. The mean duration between onset of symptoms and hospital admission was 4.8 days, and the mean treatment duration was 12.1 days. Two weeks after the start of therapy, although clinical symptoms were absent, radiologic infiltrates were still present in 24% of patients. CONCLUSIONS: The microbiological diagnosis in CAP can be established in only about 50% of cases with the combination of several diagnostic tools. Epidemiologic surveys of CAP should be performed on a regular basis, regionally, as a way to improve the management of these infections.

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.

Recurrent nocardial brain abscesses treated by repeated stereotactic aspirations.

A case of a 61-year-old diabetic patient who had a new onset simple partial seizure is presented. Past medical history was remarkable for pulmonary sarcoidosis for which the patient was on chronic steroid therapy. Computed tomography scan demonstrated a postcentral abscess which was aspirated under stereotactic guidance. Nocardia asteroides was identified. The patient was placed on intravenous trimethoprim and sulfamethoxazole. He required two further stereotactic aspirations of recrudescences until symptoms resolved. The use of repeated stereotactic aspiration in place of an open surgical procedure is advocated for the treatment of nocardial abscesses.