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BACKGROUND Multicentre intervention studies tackling urinary catheterization and its infections and non-infectious complications are lacking. AIM To decrease urinary catheterization and consequently catheter-associated urinary tract infections (CAUTI) and non-infectious complications. METHODS Before/after non-randomized multicenter intervention study in seven hospitals in Switzerland. Intervention bundle consisting of 1) a concise list of indications for urinary catheterization, 2) daily evaluation of the need for ongoing catheterization, and 3) education on proper insertion and maintenance of urinary catheters. The primary outcome was urinary catheter utilization. Secondary outcomes were CAUTI, non-infectious complications, and process indicators such as proportion of indicated catheters and frequency of catheter evaluation. FINDINGS We included 25,880 patients [13,171 before the intervention (August-October 2016) and 12,709 after the intervention (August-October 2017)]. Catheter utilization dropped from 23.7% to 21.0% (p=0.001), and catheter-days per 100 patient-days from 17.4 to 13.5 (p=0.167). CAUTI remained stable on a low level with 0.02 infections per 100 patient-days (before) and 0.02 infections (after), (p=0.98). Measuring infections per 1,000 catheter-days, the rate was 1.02 (before) and 1.33 (after), (p=0.60). Non-infectious complications dropped significantly, from 0.79 to 0.56 events per 100 patient-days (p

We describe the case of a forest worker with a Gustilo-Anderson III dislocation fracture of the ankle joint. After initial external fixation, round necrotic skin lesions with hyperemic border walls appeared on the entire lower leg. Recurrent débridements worsened the soft tissue instead of improving it. An immunoglobulin and corticosteroid treatment was initiated, which diminished the inflammatory reaction and granulation of soft tissue began. Posttraumatic pyoderma gangrenosum is a rare diagnosis. Nevertheless, it needs to be on the list of differential diagnoses if uncommon soft tissue reactions appear.Es geht um den Fall eines Waldarbeiters mit einer Gustilo-Anderson-III-Dislokationsfraktur des oberen Sprunggelenks. Nach anfänglicher externer Fixation zeigten sich am gesamten Unterschenkel runde Hautnekrosen mit hyperämischem Grenzwall. Débridements verschlechterten das Weichteilgewebe, anstatt es zu verbessern. Die Histologie erwies das Pyoderma gangraenosum (PG). Es wurde eine Immunglobulin- und Kortikosteroidtherapie begonnen, die die Entzündungsreaktion verminderte und die Granulation förderte. Das posttraumatische PG ist selten. Es sollte aber als Differenzialdiagnose bedacht werden, wenn ungewöhnliche Weichteilreaktionen auftreten.

Clinical questionWhat is the role of gastrointestinal bleeding prophylaxis (stress ulcer prophylaxis) in critically ill patients? This guideline was prompted by the publication of a new large randomised controlled trial.Current practiceGastric acid suppression with proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) is commonly done to prevent gastrointestinal bleeding in critically ill patients. Existing guidelines vary in their recommendations of which population to treat and which agent to use.RecommendationsThis guideline panel makes a weak recommendation for using gastrointestinal bleeding prophylaxis in critically ill patients at high risk (>4%) of clinically important gastrointestinal bleeding, and a weak recommendation for not using prophylaxis in patients at lower risk of clinically important bleeding (≤4%). The panel identified risk categories based on evidence, with variable certainty regarding risk factors. The panel suggests using a PPI rather than a H2RA (weak recommendation) and recommends against using sucralfate (strong recommendation).How this guideline was createdA guideline panel including patients, clinicians, and methodologists produced these recommendations using standards for trustworthy guidelines and the GRADE approach. The recommendations are based on a linked systematic review and network meta-analysis. A weak recommendation means that both options are reasonable.The evidenceThe linked systematic review and network meta-analysis estimated the benefit and harm of these medications in 12 660 critically ill patients in 72 trials. Both PPIs and H2RAs reduce the risk of clinically important bleeding. The effect is larger in patients at higher bleeding risk (those with a coagulopathy, chronic liver disease, or receiving mechanical ventilation but not enteral nutrition or two or more of mechanical ventilation with enteral nutrition, acute kidney injury, sepsis, and shock) (moderate certainty). PPIs and H2RAs might increase the risk of pneumonia (low certainty). They probably do not have an effect on mortality (moderate certainty), length of hospital stay, or any other important outcomes. PPIs probably reduce the risk of bleeding more than H2RAs (moderate certainty).Understanding the recommendationIn most critically ill patients, the reduction in clinically important gastrointestinal bleeding from gastric acid suppressants is closely balanced with the possibility of pneumonia. Clinicians should consider individual patient values, risk of bleeding, and other factors such as medication availability when deciding whether to use gastrointestinal bleeding prophylaxis. Visual overviews provide the relative and absolute benefits and harms of the options in multilayered evidence summaries and decision aids available on MAGICapp.

Background: Eosinophilic meningitis (EOM) is a rare condition that is caused by various communicable and noncommunicable factors. The rat-lungworm Angiostrongylus cantonensis, which is associated with consumption of raw or undercooked paratenic or intermediate hosts, is the most common cause of parasitic eosinophilic meningitis worldwide. While the majority of A. cantonensis cases are reported from endemic regions, cases in travelers pose a challenge to clinicians in non-endemic countries. Here we report a rare case of eosinophilic meningitis caused by A. cantonensis in a Swiss traveler who was diagnosed after returning from Thailand.Case presentation: A 33-year old woman with a travel history to rural north-eastern Thailand presented to an emergency department in Switzerland with severe headache and vomiting. Eosinophilic meningitis was confirmed as the cause of the symptoms; however, serologic investigations failed to confirm an A. cantonensis infection on the first evaluation. Nevertheless, empirical treatment with an anthelminthic and steroid regimen led to a rapid alleviation of symptoms. Repeated serology confirmed seroconversion 2 weeks after treatment initiation.Discussion: Parasitic etiology must be considered in returning travelers who present with symptoms compatible with a central nervous system infection. A thorough medical history, including types of food consumed, is paramount and can often suggest differential diagnosis. Neuroangiostrongyliasis is rare and might be missed if serology does not cover possible seroconversion.

Background In acute care hospitals, urinary catheters are often inserted and kept without proper indication, and may lead to catheter-associated urinary tract infection (CAUTI) and various non-infectious complications. In this pilot study, we attempted to decrease urinary catheterization via an awareness campaign and an intervention bundle, consisting of (1) an indication list for urinary catheterization, (2) daily evaluation of the need for ongoing catheterization, and (3) education on proper catheter insertion and maintenance. Methods We conducted a before/after intervention study in seven small, mid-size and academic hospitals distributed across Switzerland. After a 3-month pre-intervention surveillance, the intervention period started with a workshop for local project leaders who then implemented the intervention bundle. During the 3-month post-intervention surveillance, the primary outcome was catheter utilization; secondary outcomes were CAUTI, non-infectious outcomes, and process indicators (proportion of indicated catheters, frequency of catheter evaluation). Results We analyzed data on 25,880 mostly general medical or surgical patients, 13,171 of which pre-intervention (August–October 2016) and 12,709 post-intervention (August–October 2017). Catheter utilization dropped from 23.7% to 21.0% [adjusted odds ratio 0.9 (95% confidence interval, CI, 0.84–0.96); P = 0.001]. There were 1.02 CAUTI per 1,000 catheter-days (before) and 1.33 (after) [aOR 1.2 (0.6–2.4); P = 0.6]. Non-infectious complications decreased slightly from 39.4 to 35.4 events per 1,000 catheter-days [aOR 0.9 (0.77–1.07); P = 0.2]. The proportion of catheters with a documented proper indication went from 74.5% to 90.0% [aOR 4.1 (3.35–4.95); P < 0.001]. Reevaluations increased from 167 to 623 per 1,000 catheter-days [aOR 3.12 (2.92–3.36); P < 0.001]. Conclusion In this before/after intervention study, a simple bundle of 3 evidence-based measures reduced catheter utilization and led to increases in indicated urinary catheters and daily evaluations. The intervention had a small impact on non-infectious complications, whereas the CAUTI rate remained on a low level. The next step is planning the national rollout of both the surveillance module and the intervention bundle. Disclosures All authors: No reported disclosures.

The hospital epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) has changed in the past few years due to the encroachment of community-associated MRSA (CA-MRSA) strains into health care settings. MRSA strains that were isolated during a 2-year period from patients of the Luzerner Kantonsspital were analyzed to elucidate their epidemiology. Moreover, extended surveillance of individuals who were contacts of those patients was carried out for 6 months to identify the routes of spread and to assess the quality of the infection control measures used in our setting. Patient data were collected to distinguish CA-MRSA strains from health care-associated MRSA (HA-MRSA) strains by epidemiological criteria, as defined by the Centers for Disease Control and Prevention (CDC). On the basis of the CDC definition, the majority of the strains were considered to be HA-MRSA. However, 87% of them belonged to staphylococcal cassette chromosome mec (SCC mec ) types IV and V, which are traditionally associated with CA-MRSA. Surprisingly, classical nosocomial SCC mec types I and II represented a minority, whereas SCC mec type III was completely absent. By PFGE analysis, four predominant clonal lineages and 21 highly variable sporadic genotypes were detected. Twenty-eight percent of the MRSA strains studied carried the genes encoding the Panton-Valentine leukocidin (PVL), of which 21% and 83% were associated with SCC mec types IV and V, respectively. Among 289 contact individuals screened for MRSA carriage throughout the extended surveillance, a single secondary patient was discovered. The possibility of nosocomial transmission could be excluded. The high proportions of SCC mec type IV and V strains as well as PVL-positive strains suggest strong infiltration of CA-MRSA into our institution. Moreover, the low endemic prevalence of MRSA demonstrates that current infection control measures are sufficient to limit its spreading and the emergence of large epidemic outbreaks.

Die Zuweisung der 49-jahrigen Patientin erfolgte wegen akuter Dyspnoe und Ikterus. Seit drei Wochen bestehen ein allgemeines Krankheitsgefuhl, Inappetenz, Gliederschmerzen, hartnackiger Husten und Atemnot. Seit dem Vortag ist der Urin dunkel verfarbt, am Eintrittstag bestand zudem eine Gelbfarbung der Haut.

Eine 32-jahrige Frau aus Osteuropa litt unter abdominalen Schmerzen, unblutiger Diarrhoe und Gewichtsverlust von 5 kg. Wegen chronischem Husten wurde ein Thoraxrontgenbild angefertigt - mit uberraschendem Befund.

We report 5 cases of disseminated infection caused by Blastoschizomyces capitatus yeast in central Switzerland. The emergence of this yeast in an area in which it is not known to be endemic should alert clinicians caring for immunocompromised patients outside the Mediterranean region to consider infections caused by unfamiliar fungal pathogens.

The hospital epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) has changed in the past few years due to the encroachment of community-associated MRSA (CA-MRSA) strains into health care settings. MRSA strains that were isolated during a 2-year period from patients of the Luzerner Kantonsspital were analyzed to elucidate their epidemiology. Moreover, extended surveillance of individuals who were contacts of those patients was carried out for 6 months to identify the routes of spread and to assess the quality of the infection control measures used in our setting. Patient data were collected to distinguish CA-MRSA strains from health care-associated MRSA (HA-MRSA) strains by epidemiological criteria, as defined by the Centers for Disease Control and Prevention (CDC). On the basis of the CDC definition, the majority of the strains were considered to be HA-MRSA. However, 87% of them belonged to staphylococcal cassette chromosome mec (SCCmec) types IV and V, which are traditionally associated with CA-MRSA. Surprisingly, classical nosocomial SCCmec types I and II represented a minority, whereas SCCmec type III was completely absent. By PFGE analysis, four predominant clonal lineages and 21 highly variable sporadic genotypes were detected. Twenty-eight percent of the MRSA strains studied carried the genes encoding the Panton-Valentine leukocidin (PVL), of which 21% and 83% were associated with SCCmec types IV and V, respectively. Among 289 contact individuals screened for MRSA carriage throughout the extended surveillance, a single secondary patient was discovered. The possibility of nosocomial transmission could be excluded. The high proportions of SCCmec type IV and V strains as well as PVL-positive strains suggest strong infiltration of CA-MRSA into our institution. Moreover, the low endemic prevalence of MRSA demonstrates that current infection control measures are sufficient to limit its spreading and the emergence of large epidemic outbreaks.