Outbreak of imported trichinellosis in Verona, Italy, January 2008

We describe an outbreak of trichinellosis in Verona, Italy, in early 2008 that was imported from Romania.

Recreational substance use and tolerance of efavirenz in HIV-1 infected patients

During the past few years, efavirenz has been increasingly used in the treatment of HIV1 infection. Its main side effect is a syndrome of central nervous system stimulation occurring in 40-50% of adults in the first few weeks of therapy which might be observed at increased frequency in subjects concurrently using recreational substances. We therefore conducted a single center, retrospective study in 134 patients treated with efavirenz and found no significant differences in CNS side effects or discontinuation rates between recreational substance (cocaine, ecstasy, cannabis) users and non-users. Although our study is limited, the results support the idea that efavirenz can be safely prescribed to patients using recreational substances.

Secular trends in nosocomial candidaemia in non-neutropenic patients in an Italian tertiary hospital

A retrospective study was performed in an Italian tertiary hospital to evaluate trends in candidaemia between 1992 and 2001, and to compare the characteristics of episodes of fungaemia between 1992--1997 and 1998--2001. In total, 370 episodes of candidaemia were identified, with an average incidence of 0.99 episodes/10 000 patient-days/year (range 0.49--1.29 episodes). On an annual trend basis, the overall incidence was essentially stable in surgical and medical wards, but decreased in intensive care units (ICUs) (p 0.0065). The average use of fluconazole was 37.9 g/10 000 patient-days/year (range 21.4--56.1 g), and did not change significantly during the 10-year period. Nearly two-thirds of patients were in ICUs at the onset of candidaemia, but none was neutropenic in either study period. Candida albicans remained the predominant species isolated (53.8% vs. 48.1%), followed by Candida parapsilosis, Candida glabrata and Candida tropicalis, the distribution of which did not change significantly. The 30-day crude mortality rate was essentially similar (44% vs. 35%) in both study periods. Thus the incidence of nosocomial candidaemia, although high in this institution, decreased among critically-ill patients during the 10-year period. This finding seemed to be related to an improvement in infection control practices, particularly regarding the prevention of intravascular catheter-related infections in ICUs. Although the overall use of fluconazole was considerable, no increase in azole-resistant non-albicans Candida spp. was detected.

Clinical and demographic aspects of extrathoracic tuberculosis: experience of an Italian university hospital

OBJECTIVE

The decline of tuberculosis in industrialised countries concerns mainly its pulmonary forms. We have analysed all the cases of non-respiratory tuberculosis admitted to our hospital between January 2000 and June 2002, and compared epidemiological, clinical and diagnostic features in our area with those observed in other industrialised countries with high immigration rates.

DESIGN

Patients' records were retrospectively analysed for demographic, clinical, laboratory and instrumental data. Delays in the introduction of treatment were also measured. Characteristics of immigrants were compared with those of native-born persons. We also investigated specific features of extrathoracic tuberculosis affecting different body sites.

RESULTS

Forty-eight patients were identified, two thirds of whom were from industrialised countries. Age distribution was characteristically bimodal. Vertebral (n = 18) and lymph node (n = 11) tuberculosis were the most frequently detected forms. The therapeutic delay among individuals from industrialised countries was found to be significantly longer than that of their counterparts from developing countries (P = 0.05).

CONCLUSION

We hypothesise that the complex and non-standardised diagnostic approach to the different forms of extrathoracic tuberculosis forms and physicians' lack of awareness of the specific risk of each epidemiological group strongly influence the unacceptably long therapeutic delay. Extrathoracic tuberculosis was more neglected in native-born individuals than in immigrants.

Nosocomial Cluster of Candida guillermondii Fungemia in Surgical Patients

A nosocomial cluster of Candida guillermondii fungemia ( n=5 episodes) occurred in a surgical unit over a 2-week period. The five infected patients had received parenteral nutrition through central lines and three of them had catheter-related candidemia. All of the isolates were resistant to 5-flucytosine (MIC >32 microg/ml) and they had strictly related fingerprints, as generated by randomly amplified polymorphic DNA analysis. Although no isolate of Candida guillermondii was recovered from other clinical, surveillance or environmental samples, nosocomial spread of this yeast stopped following the reinforcement of infection control measures. Candida guillermondii may require an intravascular foreign body to cause fungemia, but the outbreak reported here shows that it can be transmitted nosocomially and cause epidemics.

Impact of antibiotic changes in empirical therapy on antimicrobial resistance in intensive care unit-acquired infections

We conducted a one-year prospective study on intensive care unit (ICU)-acquired infections and antimicrobial resistance patterns in an 18-bed medical-surgical ICU of a tertiary-care university hospital. We divided the study into two six-month periods in order to evaluate the impact of antibiotic changes in empirical therapy on antimicrobial resistance profiles of the principal isolated micro-organisms. In the first period no changes were made to the previously applied empirical antibiotic protocol; at the end of this period we found high rates of methicillin resistance (MR) among staphylococci, 93% for Staphylococcus aureus (69 isolates) and 79% for coagulase-negative staphylococci (CNS) (48 isolates), and of multiple drug resistance for Pseudomonas aeruginosa (57 isolates), in particular 67% resistance to piperacillin/tazobactam (PIP/TZ). We therefore decided to substitute PIP/TZ with imipenem in nosocomial pneumonia and with cefepime plus metronidazole in peritonitis. We also considered the previous use of amoxicillin/clavulanate (AM/CL) at admission in critically ill patients inadequate; we therefore advised that no antibiotics should be given unless fever developed and eventually to replace AM/CL with trimethoprim/sulfamethoxazole (TMP/SMX). At the end of this intervention period, we observed a significant decrease of S. aureus MR (93 vs. 73%, P = 0.003) and of P. aeruginosa resistance to PIP/TZ (67 vs. 29%, P < 0.001). A reduction in MR was also seen in CNS (79 vs. 64%, P = 0.09). Other resistance patterns also improved among staphylococci; in contrast P. aeruginosa resistance to imipenem increased in the second period (24 vs. 41%, P = 0.06). A non-premeditated change of antibiotics in empirical therapy, on the basis of detected resistance patterns, provided promising results in reducing some antimicrobial resistance rates. We believe, however, that antibiotic changes must be tailored to local microbiological situation monitoring, and that a repeated rotation is crucial to limit the emergence of new resistance profiles. Furthermore the adoption of this policy should be accompanied by other infection control practices aimed at reducing antimicrobial resistance and nosocomial infection rates.

Interaction between levothyroxine and indinavir in a patient with HIV infection

Drug interactions are an important and emerging problem in the treatment of HIV-infected patients. Protease inhibitors, like nonnucleoside reverse transcriptase inhibitors, are metabolized by the cytochrome P-450 enzyme system and each of these antiretroviral agents may interact with other drugs metabolized by this system. Some protease inhibitors may also interact with glucuronosyl transferase activity affecting plasma concentrations of drugs metabolized through this pathway. We describe a case of an HIV-infected patient, taking levothyroxine for hypothyroidism and clinically stable, who, after the introduction of an antiretroviral regimen containing indinavir, developed a pharmacological hyperthyroidism.

[Prevalence of nosocomial infections in Intensive Care Units in Triveneto area, Italy]

BACKGROUND

Nosocomial infection is one of the most common complications affecting patients admitted in intensive care units (ICU). The aim of this study is to evaluate rates of ICU-acquired infections, potential risk factors for these infections, causative microorganisms and antibiotic resistance patterns.

METHODS

A 1-day point-prevalence study was conducted in 39 ICUs in Triveneto area (Italy) in November 1998. The overall study population included 188 patients with mean age of 61.4+/-19.3 years; the mean SAPS II score at entry into the ICU was 44.4+/-16.8 and the median duration of hospitalization was 9 days (range 2-636).

RESULTS

A total of 59 patients (31.4%) had 79 episodes of ICU-acquired infections; pneumonia (45.5%), bloodstream infection (30.4%), and urinary tract infection (11.4%) were the most frequent types of infection. The leading causative microorganisms were S. aureus (24.4%, 77% of them were resistant to methicillin), Enterobacteriaceae (24.4%), P. aeruginosa (23.2%), fungi (12.2%), coagulase-negative staphylococci (7.3%) and Enterococcus spp (4.9%). Independent risk factors for nosocomial infections were duration of hospitalization >7 days (OR 4.29, 95% CI 1.82-10.1), SAPS II score >30 (OR 3.34, 95% CI 1.0-11.18), total parenteral nutrition (OR 2.69, 95% CI 1.19-6.07) and tracheostomy (OR 1.88, 95% CI 0.84-4.20).

CONCLUSIONS

Nosocomial infections are relatively frequent in Triveneto area ICUs. The predominance of pneumonia and bloodstream infection, and the high frequency of antibiotic-resistant pathogens indicate that resources had to be assigned towards the implementation of control programs of those infections, monitoring of antibiotic resistance and prescription, and antibiotic therapy guidelines.