Epidemiology and outcome of invasive pneumococcal disease among adults in Belgium, 2009-2011.

This epidemiological study examined morbidity and case fatality of invasive pneumococcal disease (IPD) in adults in Belgium as well as distribution and antibiotic susceptibility of Streptococcus pneumoniae serotypes.Adults hospitalised with microbiologically proven IPD were prospectively enrolled. The study started in 2009 with patients aged ≥50 years, whereas in 2010 and 2011, patients aged ≥18 years were included. The clinical presentation, patient profile, treatment, outcome, and mortality were recorded during hospitalisation.Outcome was also assessed one month afterdischarge. Of the 1,875 patients with IPD identified, 1,332 were included in the analysis. Bacteraemic pneumonia, affecting 1,049 of the patients, was the most frequent IPD type (79%), and chronic obstructive pulmonary disease and cancer were the main comorbidities.One-third of patients required admission to intensive care unit. A total of 208 (16%) patients died during hospitalisation and an additional 21 (2%) within one month after discharge. Case fatality rates of ≥20%were observed in patients with chronic heart failure, hepatic disease, and renal insufficiency. Serotypes 7F, 1, 19A, and 3 were the most prevalent and together accounted for 47% (569/1,214) of all IPD cases and 42% (80/189) of mortality. Of the patient isolates, 21% (255/1,204) were resistant to erythromycin and 22% (264/1,204) to tetracycline. Penicillin non-susceptibility was mostly found in serotype 19A isolates. These baseline data are essential when assessing the impact of pneumococcal conjugate vaccination in adults in the future.

Reactivation of Plasmodium infection during a treatment with infliximab: A case report.

We describe a symptomatic Plasmodium falciparum infection in a 29-year-old Guinean man receiving Infliximab for one year and without recent travel. The reactivation of submicroscopic malaria following the inhibition of TNF-alpha by infliximab is suspected.

[Meningitis and renal cancer]. / Méningite et néoplasie rénale.

A 51 year-old man with a renal cancer (pT3N0M0) consulted at the emergency department for persistent headache initiated a week before and recent vomiting. Physical examination and blood analyses were not remarkable. Cerebral magnetic resonance imaging demonstrated radiological signs of meningitis. The differential diagnosis of meningitis is discussed.

Pseudomonas aeruginosa: resistance and therapeutic options at the turn of the new millennium.

Pseudomonas aeruginosa is a major cause of nosocomial infections. This organism shows a remarkable capacity to resist antibiotics, either intrinsically (because of constitutive expression of beta-lactamases and efflux pumps, combined with low permeability of the outer-membrane) or following acquisition of resistance genes (e.g., genes for beta-lactamases, or enzymes inactivating aminoglycosides or modifying their target), over-expression of efflux pumps, decreased expression of porins, or mutations in quinolone targets. Worryingly, these mechanisms are often present simultaneously, thereby conferring multiresistant phenotypes. Susceptibility testing is therefore crucial in clinical practice. Empirical treatment usually involves combination therapy, selected on the basis of known local epidemiology (usually a beta-lactam plus an aminoglycoside or a fluoroquinolone). However, therapy should be simplified as soon as possible, based on susceptibility data and the patient's clinical evolution. Alternative drugs (e.g., colistin) have proven useful against multiresistant strains, but innovative therapeutic options for the future remain scarce, while attempts to develop vaccines have been unsuccessful to date. Among broad-spectrum antibiotics in development, ceftobiprole, sitafloxacin and doripenem show interesting in-vitro activity, although the first two molecules have been evaluated in clinics only against Gram-positive organisms. Doripenem has received a fast track designation from the US Food and Drug Administration for the treatment of nosocomial pneumonia. Pump inhibitors are undergoing phase I trials in cystic fibrosis patients. Therefore, selecting appropriate antibiotics and optimising their use on the basis of pharmacodynamic concepts currently remains the best way of coping with pseudomonal infections.

Treatment of onchocerciasis.

Onchocerciasis ('river blindness') has for several centuries been the scourge of people living in certain areas of the world where the disease is endemic. The treatment available up to 10 years ago, diethylcarbamazine, had very severe secondary effects. The availability of ivermectin--a well tolerated and highly effective microfilaricidal drug--has completely changed this scenario. Ivermectin is now considered to be the drug of choice for the treatment of onchocerciasis. The prognosis for people with onchocerciasis has changed greatly. It is now possible to avoid the heavy infection loads seen previously, and patients, especially expatriates, may have their symptoms relieved by treatment. Ivermectin, used in mass treatment, may also improve the epidemiological situation, reducing the level of microfilariae in the skin of infected people and thus reducing the source for vector infestation. However, the treatment has to be repeated because the drug has no macrofilaricidal effect. Research today is focused on the finding of a drug able to destroy the adult worms that go on producing microfilariae for the length of their lives.

Contaminated enteral nutrition solutions as a cause of nosocomial bloodstream infection: a study using plasmid fingerprinting.

In July 1984, two patients fed enteral nutrition solutions contaminated with Enterobacter cloacae developed nosocomial bacteremia. Despite careful review of the preparation procedures as well as repeated microbiological surveys, 83 (27%) of the 309 formula bottles tested over a 1-yr period were contaminated and the source of contamination remained unknown. E. cloacae was the most frequent organism isolated (34%). The plasmid profiles of E. cloacae recovered from enteral nutrition solutions remained identical for several months. Blood culture isolates from 10 of the 40 patients who had developed E. cloacae nosocomial sepsis over a 7-yr period (1979-1985) had plasmid profiles linking them to contaminated enteral nutrition solutions. Epidemiological data from a case control study revealed that these 10 patients were indeed more likely to be exposed to enteral nutrition than the 30 others: 9/10 vs 10/30 (odds ratio 18, p = 0.002). Similarly, two of seven nosocomial Klebsiella pneumoniae bacteremias over a 6-month period in 1986 could be ascribed to administration of contaminated enteral liquid feeds prompting a general policy for using sterile commercially prepared solutions. Our results suggest that contaminated enteral nutrition solutions represent a significant cause of nosocomial sepsis.

About five cases of acute rheumatic fever in the adult.

We describe five cases of acute rheumatic fever in adults (applying Jones's criteria and exclusion of other common causes of acute polyarthritis in adults). The polyarthritis was migratory in three patients and additive in two. Severe tenosynovitis was present in three patients. Only one patient had carditis and received corticoids. The others improved with aspirin. The disease subsided after a time period varying from one week to two months and did not relapse.

[Pulmonary manifestations of acquired immunodeficiency syndrome]. / Les manifestations pulmonaires du syndrome d'immunodéficience acquise.

After reviewing the immunological anomalies provoked by the human immuno-deficiency virus (HIV) as well as their implications in pulmonary pathology, the authors enumerate the diagnostic and therapeutic methods currently available in the treatment of patients suffering from AIDS and pulmonary diseases. The clinical features as well as the chest radiograph--an essential first line tool--may lead to atypical features. Respiratory function tests and scintigraphy to Gallium may be a useful additional diagnostic technique but for a full pulmonary investigation a bronchoalveolar lavage is required and/or transbronchial biopsy. Open lung biopsy is rarely required, and then only as a last resort. The treatment of pneumocystis remains centred on Trimethoprim sulfamethoxazole and Pentamidine, with a similar efficacy (80% care) but both have side-effects which are less frequent but more severe with Pentamidine. Administration of Pentamidine by aerosol, Eflornithine and Trimetrexate are under study. The level of lactic dehydrogenase (LDH) seems to be a prognostic factor. The value of prophylaxis is discussed. If the treatment of tuberculosis, an infection which is seen more and more frequently, still rests on classical triple therapy, the treatment of atypical mycobacterial infections is even more deceptive than in non-immuno-suppressed hosts. The same is true with pneumonia due to cytomegalovirus. The treatment of lymphoid interstitial pneumonia which is probably a direct result of HIV infection, remains controversial. On the other hand, pulmonary Kaposi's sarcoma is associated with an elevated mortality, and all treatment (interferon and chemotherapy) is disappointing.

[Vaccinations for the traveler]. / Les vaccinations du voyageur.

Long distance journeys are more and more frequent. Beside malaria prophylaxis, the general practitioner shall consider several points. Vaccinations against tetanus, diphtheria and (for a few years at least) polio should be done every ten years. Hepatitis A vaccine shall often be done (with > 20 years protection) but typhoid fever vaccine shall be limited to advanturous and/or long stays. Yellow fever vaccine (10 years validity) is only administrated in specialised centers; this is the only mandatory vaccine for certain african or south american countries. In certains instances, one shall consider vaccination against hepatitis B, meningococcal meningitis or, less often, against rabies, central european or japanese encephalitis. The vaccine against cholera (numerous side effects and poor efficacy) is no more available.

[Vaccinations for the traveller]. / Les vaccinations du voyageur.

Long distance journeys are more and more frequent. Beside malaria prophylaxis, the general practitioner shall consider several points. Vaccinations against tetanus, diphtheria and (for a few years at least) polio should be done every ten years. Hepatitis A vaccine shall often be done (with > 20 years protection) but typhoid fever vaccine shall be limited to adventurous and/or long stays. Yellow fever vaccine (10 years validity) is only administrated in specialised centers; this is the only mandatory vaccine for certain african or south american countries. In certain instances, one shall consider vaccination against hepatitis B, meningococcal meningitis or, less often, against rabies, central european or japanese encephalitis. The vaccine against cholera (numerous side effects and poor efficacy) is no more available.

[Vaccinations and useful advice for travelers]. / Vaccinations et conseils utiles pour les voyageurs.

International travels are increasingly frequent. Beside malaria prophylaxis, the general practitioner will review several vaccinations.e Tetanus and poliomyelitis vaccines should be administered once every ten years. It will often be useful to give a protection against hepatitis A, and less often, against typhoid fever. The yellow fever vaccine, which may be required or recommended to visit several African and South American countries, is injected only by officially recognised centres. For some travels, vaccination against hepatitis B, meningococcal meningitis or, rarely, against rabies may be considered. The vaccine against cholera will never be administered, due to its lack of efficacy and high frequency of side effects. Travellers diarrhoea will be discussed, and a "pocket" treatment prescribed. Finally, general information will be provided, including those on STD.

[Prevention of malaria in travelers]. / Prophylaxie de la malaria chez les voyageurs.

Malaria is still a major health problem at the end of the 20th century. Each year, more than 250 patients present a malaria in Belgium. Most of them are travellers from Africa and are infected with P. falciparum. Due to widespread resistance to chloroquine of P. falciparum overall in the world (Africa, South America and Far East), prophylaxis based on the association of chloroquine+proguanil is necessary in most cases. In several regions, mefloquine is now the only active prophylaxis. However, travellers (and their doctors) must know that no antimalarial prophylactic regimen gives complete protection. Therefore, the use of repellents and/or (bed) nets has to be underlined. In some cases, stand-by treatment may be more indicated than prophylaxis.

[Transmissible diseases through the intermediary of transfusions]. / Maladies transmissibles par l'intermédiaire des transfusions.

Blood transfusions may lead to immunologic but also infectious problems. If bacterial pathogens are rarely involved, blood pathogens - especially malaria - and viruses are dominant. Non-a non-b hepatitis is the most frequently encountered viral infection, with a risk of 1% for each blood unit. Screening of SGPT and anti Hbc antibodies should diminish the transmission risk by 30-40%. Since August 1985, HIV antibody screening of blood donors has dramatically reduced the risk of blood transmission; however, patients Ag HIV+/Ac HIV (first weeks of infection, ...) imply that severe voluntary exclusion procedures are maintained for the donors; similar measures are also valid for malaria prevention.

[Vaccination of general practitioners]. / La vaccination des médecins généralistes.

The vaccination of general practitioners represents significant problems for two reasons: they can be a reservoir of infectious diseases for the patients they are in contact with and their attitudes towards vaccination can influence their preventative acts and consequently the vaccination coverage of the population. The anti-influenza vaccination of the care providers is associated with a decrease of mortality amongst patients. Hepatitis B is one of the most frequent professional occupational infectious diseases and vaccination is necessary for all the professionals at risk. Concerning the whooping-cough we can observe at the present time an increase in the number of cases. The "Conseil Supérieur d'Hygiène" advises to propose vaccination of the people in contact with infants and people who have not HAD vaccination supplements in childhood. The rubella vaccination for unprotected women is also recommended for the care providers, to avoid the risk of infection and the possible implications for the foetus. The existing data in Belgium on the vaccination coverage of general practitioners is poor, but leads us to believe there is an insufficient vaccination coverage against these diseases. A study will shortly be undertaken to analyze the vaccination status of the Belgian French-speaking doctors and to further analyse their reasoning for any possible non-vaccination.

[Telithromycin, first ketolide]. / La télithromycine, premier kétolide.

Telithromycine is the first ketolide on the market. Its characteristics are the two sites fixation on the bacterial ribosomia and and as a consequence a good activity on the majority of penicillin and macrolides resistant bacteria, included S. pneumonia and S. pyogenes. Telithromycine represents an alternative to beta-lactames and moxifloxacine to treat communautary pneumonia, bacterial pharyngoamygdalitis, suppurative sinusitis and bronchitis. There are nevertheless problems with drugs interactions and risk of resistance development.

[Linezolid (Zyvoxid)]. / Le linézolide (Zyvoxid).

Linezolid is a novel antibiotic administrable by the intravenous as well as the oral route. It is aimed by its re-imbursement conditions at treating proven beta-lactam- or glycopeptide-resistant staphylococcal and enterococcal infections in the hospital and post-discharge outpatient. It has various indications: pulmonary infections, complicated skin and soft tissue infections, infections in the febrile neutropenic patient, urinary tract infections, intra-abdominal infections, chronic osteitis. Bacteriologic documentation of the infection is required to avoid overconsumption and development of resistance. The oral forms exhibit complete bio-availability. Caution is recommended with regard to linezolid's MAO inhibitory effect and the risk of thrombocytopenia requiring weekly hematologic monitoring.

[Pertussis vaccine in adolescents and adults]. / La vaccination de l'adolescent et de l'adulte contre la coqueluche.

Despite high immunisation rates in infancy, Bordetella pertussis is still circulating in industrialised countries, causing severe infections in infants too young to be vaccinated, as well as an important number of long lasting cough episodes in older children, adolescents and young adults. The limited duration of the protection resulting from vaccination in the 2 first years of life is probably responsible for the insufficient control of the disease. The development of acellular pertussis vaccines has allowed immunisation of school age children, and an adult formulation is now available. The indications of this vaccine will be discussed.