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A man from Surinam presented at the Department of Internal Medicine with a perforated septum and progressive collapse of the nose. This condition had existed for 22 years, though earlier analysis had not revealed the cause. Microscopic analysis showed a granulomatous inflammatory reaction, with cultures revealing of Leishmania. The diagnosis was mucocutaneous leishmaniasis and PCR indicated Leishmania braziliensis complex. The patient was treated for mucocutaneous leishmaniasis by a 28-day course of intravenous sodium-stibogluconate therapy. Initially, treatment was stopped briefly due to neurotoxicity, but was recommenced and successfully completed. After treatment the infection parameters returned to normal and the patient was referred for reconstructive nasal surgery. Due to a low parasitic load mucocutaneous leishmaniasis can be difficult to detect, especially in chronic cases. However, the use of molecular techniques has improved both the sensitivity and specificity of detection. The ability to distinguish between different species and sub-species is of prognostic and therapeutic relevance.

The 'Stichting Werkgroep Antibioticabeleid' (Dutch Working Party on Antibiotic Policy) has developed an electronic national antibiotic guide for the antibiotic treatment and prophylaxis of common infectious diseases in hospitals. This guide also contains information on the most important characteristics of antimicrobial drugs. Advice on antibiotic treatment is based on existing national evidence-based guidelines, where available. Where no guideline is available, the advice is based on an inventory of the antibiotic policies of the 12 Dutch centres with an infectious disease or medical microbiology training programme. The national antibiotic guide can be accessed through the SWAB website (www.swab.nl) and can also be downloaded on PDA/PocketPC, free of charge. Every hospital antibiotic formulary committee in the Netherlands will be offered the opportunity to edit The national version for local use.

Objective: To assess adherence to antiretroviral therapy (ART) in Dutch and non-Dutch HIV-infected patients., Design: Observational, cross-sectional study., Methods: Consecutive HIV-infected patients taking ART and visiting the internal medicine outpatients' clinic at the Rotterdam Dijkzigt University Hospital between 1 February until 30 April 2001 were interviewed by a multilingual interviewer using a standard questionnaire. Classification of adherence was based on the interview data. Multivariate analysis was used to determine independent predictors of adherence. Nationality was defined as 'Dutch' if the person was born in the Netherlands, and otherwise as 'non-Dutch'., Results: The 203 patients included in this study comprised 131 men and 69 women with an average age of 42 years. There were no data available on treatment adherence for 3 of the patients. Of the 81 Dutch patients, 60 (74%) adhered to the treatment compared with 68 (57%) of the 119 non-Dutch patients. However, after correction for sex, risk group, race and duration of treatment, there was no difference in treatment adherence between these two groups (OR: 0.6; 95% CI: 0.2-1.9). Failure to adhere to treatment was seen most frequently in the 109 heterosexually infected patients (OR: 2.6; 0.98-6.7), the 22 intravenous drug users (OR: 3.3; 1.04-10.1), as well as in the group of Negroid patients (OR: 3.5; 1.1-11.3) and Latin-American patients (OR: 8.5; 1.7-42.7).

A 23-year-old Turkish woman was admitted with an infection of the left thumb. The clinical picture was typical for cutaneous anthrax. Microbiological tests confirmed the diagnosis 'infection by Bacillus anthracis'. She recovered when treated with penicillin, although later tests revealed that the bacteria were resistant to this antibiotic. The patient became infected in Belgium as a result of wounding herself on the teeth of an illegally slaughtered sheep, which had possibly become infected in the pasture. Recognising the characteristic clinical picture of cutaneous anthrax is essential for prompt treatment and a favourable prognosis.

The Stichting Werkgroep Antibioticabeleid (SWAB, Foundation Antibiotics Policy Team) has issued guidelines for perioperative antibiotic prophylaxis in Dutch hospitals. Antibiotic prophylaxis is generally recommended for surgical procedures with relatively high postoperative infection rates and those in which consequences of infection are really serious. Studies have revealed that prophylaxis given within two hours before incision is most effective. Short-term, preferably single-dose prophylaxis, is as effective as multiple-dose prophylaxis in most procedures. For reasons of cost effectiveness and prevention of induction of resistance, single-dose prophylaxis is recommended. The antimicrobial agent of choice for perioperative prophylaxis should not be widely used as a therapeutic agent, should be selectively active against micro-organisms most frequently isolated from surgical site infections, and should have a plasma-half-life that makes single-dosing possible for most operations. Therefore cefazoline is an agent that is widely used for perioperative prophylaxis.

Major reasons to conduct antibiotic policies are to improve the quality of patient care, to limit the emergence of resistance, and to contain costs. Many studies have addressed overconsumption and misuse of antibiotics. Studies have shown a correlation between antibiotic use in hospitals and the development of microbial resistance. Recommendations for the content and management of future antibiotic policy strategies in hospitals include educational programmes, consultation by infectious diseases physicians, restriction of the formulary, timely narrowing of empirical broad spectrum therapy ('streamlining'), and automatic stop orders. A recent study in a Dutch university hospital revealed overconsumption of antibiotics for prophylaxis in surgery and undertreatment with antibiotics in internal medicine departments. Intervention resulted in better compliance with guidelines, reduction of the consumption of antibiotics in surgical prophylaxis, and cost containment. However optimation of antimicrobial therapy also sometimes resulted in an increase of antimicrobial drug consumption.

In a 17-year-old male patient with acute lymphoblastic leukaemia, who was being treated with chemotherapy, a Staphylococcus epidermidis infection with several septicaemias developed during a period of protracted neutropenia. The patient was treated with vancomycin and fusidic acid, but blood cultures remained positive. The patient also developed staphylococcal meningitis. After the antibiotic regimen was supplemented by fosfomycin, the blood cultures became sterile. Combination treatment with vancomycin and fosfomycin was continued for two months without apparent toxicity. In individual cases of infection with multiresistant S. epidermidis fosfomycin may be included in the antibiotic regimen. This is the first report of parenteral use of fosfomycin in the Netherlands.

Objective: To evaluate the characteristics of HIV infected patients in the Rijnmond region during 1985-1993., Design: Descriptive., Setting: University Hospital Rotterdam-Dijkzigt (AZR)., Method: Data of medical records of all HIV infected patients in AZR were prospectively collected from 1988 on and retrospectively for 1985-1987., Results: During the period 1985-1993 510 HIV positive patients consulted an internist at AZR (eight were infected with HIV-2). During the study 255 patients developed AIDS. Since 1991 fewer than 50% of the new HIV infected individuals belonged to the risk group of homosexual and bisexual men. The majority was infected by intravenous drug abuse or by heterosexual intercourse. Half the population infected by heterosexual transmission came from HIV endemic areas. The increasing number of HIV infection among heterosexuals was associated with an increasing number of HIV infected women., Conclusion: The Rijnmond region showed a noticeable shift of risk groups with HIV infection: heterosexual transmission and intravenous drug abuse were the cause of HIV infection in more than half of the HIV infections at AZR in 1992 and 1993. Counselling, health care and treatment should take account of the diversity of cultural backgrounds of the patient groups.

Postanginal sepsis or Lemierre's syndrome is characterised by septic thrombophlebitis of the jugular vein, metastatic abscesses in the lungs, soft tissues, joints or elsewhere, occurring several days to two weeks after tonsillitis or pharyngitis. The primary pathogen is a Gram-negative anaerobic rod, mostly Fusobacterium necrophorum. Previously healthy, young adults are affected mainly and the syndrome was seen more frequently in the pre-antibiotic era than it is nowadays. In the three young patients described here, a girl aged 15 and two boys aged 18 and 16, F. necrophorum was isolated from blood or pus. Histories and examinations were suggestive of Lemierre's syndrome. Ultrasound and CT scanning of the neck and other localisations proved to be important diagnostic tools in assessing the diagnosis. Response to therapy was slow and depended in at least one case on adequate drainage of abscesses. If the syndrome is suspected, initial antibiotic treatment should provide adequate coverage of anaerobic bacteria. In previously healthy patients with chills and fever occurring several days after a sore throat, Lemierre's syndrome should be considered.

We describe a case of severe sulfasalazine allergy. Exacerbation of the symptoms occurred after unintentional rechallenge with co-trimoxazole, indicating that the reaction was triggered by the sulphonamide component. The clinical picture consisted of generalised adenopathy, hepatitis, high fever and a maculopapular skin rash. A bone marrow biopsy and skin biopsy both showed noncaseating granulomas. The white blood cell count rose to 90.10(9)/l with 40% atypical lymphocytes (plasmacytoid). They were identified by flow cytometry as activated T lymphocytes.