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Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) have emerged worldwide. These CA-MRSA are different from classical hospital-acquired MRSA. They share common characteristics: they affect mainly young subjects, without past medical history. The majority of strains produce the Panton-Valentine leukocidin. They are mainly responsible for suppurative skin infections and rarely for invasive infections such as necrotizing pneumonia. The situation in the US is alarming with a main circulating clone the USA300 clone, whereas in Europe, the diffusion of CA-MRSA strains remains limited. It is important to take advantage of the experience acquired from the US to limit the potential spread of such CA-MRSA strains., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Community-acquired pneumonia (CAP) is a common cause of morbidity and mortality worldwide, and since 1993, guidelines for management have been available. The process, which first began in the United States and Canada, has now been implemented in numerous countries throughout the world, and often each geographic region or country develops locally specific recommendations. It is interesting to realize that guidelines from different regions often interpret the same evidence base differently, and guidelines differ from one country to another, even though the bacteriology of CAP is often more similar than different from one region to another. One of the unique contributions of the 2007 US guidelines is the inclusion of quality and performance measures. In addition, US guidelines emphasize management principles that differ from some of the principles in European guidelines because of unique epidemiological considerations. In addition, certain therapy principles apply in the United States that differ from those in other regions, including the need for all patients to receive routine therapy for atypical pathogens, the emergence of community-acquired methicillin-resistant Staphylococcus aureus in some patients following influenza, and the need for all patients admitted to the intensive care unit to receive at least two antimicrobial agents. In the future, as guidelines evolve, there will be an important place for regional guidelines, particularly if these guidelines can recommend locally specific strategies to implement guidelines, which if successful, can lead to improved patient outcomes., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

To account for the current evidence in the field of infective endocarditis and to harmonize deviant national guidelines, in 2009 the European Society of Cardiology published novel recommendations on the prevention, diagnosis and treatment of infective endocarditis.The most important changes can be found concerning antimicrobial prophylaxis for endocarditis, the antimicrobial treatment of endocarditis caused by S. aureus and the indications for surgical treatment.Due to the weak evidence about prophylactic administration of antibiotics before procedures at risk for bacteraemia to prevent infective endocarditis, the novel guidelines recommend prophylaxis only in patients with the highest risk for infection and lethal course of endocarditis. These are patients with prosthetic valves or prosthetic material used for cardiac repair, patients with previous endocarditis and patients with congenital heart disease. A narrow definition of procedures at risk was proposed only including dental procedures requiring manipulation of the gingival or periapical region of teeth.For endocarditis caused by S. aureus an additional gentamicin administration was previously recommended but this is now seen only as optional due to its nephrotoxicity. In methicillin-resistant strains daptomycin is a possible alternative to vancomycin. In strains susceptible to methicillin, beta-lactamic antibiotics were definitively preferred than the usage of vancomycin due to better outcome. The current guidelines recommend definitive timing and risk constellations for surgical treatment of infective endocarditis. For example, cardiac shock due to valvular lesions refractory to medical treatment should give rise to an emergency intervention within 24 h. Other indication groups contain uncontrolled infection and prevention of embolism and indications were defined as urgent or elective depending on the clinical situation.

DISTURBING EPIDEMIOLOGICAL DATA: Over the past decade there has been a continuous progression in the percentage of Staphylococcus aureus strains resistant to methicillin (MRSA), a slight progression in coagulase-negative staphylococci strains resistant to methicillin and a spectacular progression of enterococci resistant to glycopeptides, not only in hospitals but also in intensive care settings. The increase in nosocomial septicemia is currently a major patient safety issue. HIGHER MORTALITY IN BACTEREMIC PATIENTS: The excess mortality globally observed in cases of bacteremia (compared with patients without bacteremia) is markedly enhanced with regard to secondary bacteremia. Bacteremia is responsible for a significant increase in the overall duration of hospitalization. PROGNOSTIC FACTORS OF STAPHYLOCOCCI BACTEREMIA: The mortality rate is significantly higher in patients in whom initial therapy was inappropriate compared with those in whom it was adequate. The isolation of MRSA strains is a negative prognostic factor. PATIENTS AT RISK OF MRSA BACTEREMIA: Independent risk factors for MRSA bacteremia include prior exposure to antibiotics, a nosocomial origin, a history of hospitalization within the 6 preceding months, and the presence of a decubitus ulcer. To avoid MRSA bacteremias related to catheters, alternatives should be found to their use, all hygiene rules should be carefully respected, the insertion point should be carefully disinfected and protected, and the catheter should be removed as rapidly as possible.