Thomas Haustein

Wards cohorting infected orthopaedic patients may be particularly prone to transmitting extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E). We analyze their epidemic pattern by performing molecular typing of ESBL-E isolated from patients and healthcare workers (HCW) from our septic ward. Between March 2010 and November 2011, 186 patients were admitted. Among 565 anal swabs, ESBL-E were detected in 204 samples from 45 patients, suggesting prolonged carriage in affected patients. Among 25 cases with identical ESBL-E species and positive epidemiological links, only 9 were really attributable to our service. We also screened 41 healthcare workers (HCW) on 49 occasions during the study period. Six samples (13%) were positive. None of the ESBL-E detected in HCW were related to any of the patient isolates. Among 60 environmental samples taken at the peak of the epidemic none revealed ESBL-E. We conclude that HCW also were anal carriers of ESBL-E, however the ESBL- strains from the HCW were not the same strains isolated from patients in the septic ward. Moreover, the epidemiological attribution of ESBL by simple vicinity, timing, and species identification might grossly overestimate transmission within a given unit.

To investigate the reliability of the public health event notification assessment process under the International Health Regulations (2005) (IHR). In 2009, 193 National IHR Focal Points (NFPs) were invited to use the decision instrument in Annex 2 of the IHR to determine whether 10 fictitious public health events should be notified to WHO. Each event's notifiability was assessed independently by an expert panel. The degree of consensus among NFPs and of concordance between NFPs and the expert panel was considered high when more than 70% agreed on a response. Overall, 74% of NFPs responded. The median degree of consensus among NFPs on notification decisions was 78%. It was high for the six events considered notifiable by the majority (median: 80%; range: 76-91) but low for the remaining four (median: 55%; range: 54-60). The degree of concordance between NFPs and the expert panel was high for the five events deemed notifiable by the panel (median: 82%; range: 76-91) but low (median: 51%; range: 42-60) for those not considered notifiable. The NFPs identified notifiable events with greater sensitivity than specificity (P < 0.001). When used by NFPs, the notification assessment process in Annex 2 of the IHR was sensitive in identifying public health events that were considered notifiable by an expert panel, but only moderately specific. The reliability of the assessments could be increased by expanding guidance on the use of the decision instrument and by including more specific criteria for assessing events and clearer definitions of terms.

Timely diagnosis of primary HIV infection is important to prevent further transmission of HIV. Primary HIV infection may take place without symptoms or may be associated with fever, pharyngitis or headache. Sometimes, the clinical presentation includes aseptic meningitis or cutaneous lesions. Intestinal ulceration due to opportunistic pathogens (cytomegalovirus, Epstein-Barr virus, Toxoplasma gondii) has been described in patients with AIDS. However, although invasion of intestinal lymphoid tissue is a prominent feature of human and simian lentivirus infections, colonic ulceration has not been reported in acute HIV infection. A 42-year-old Caucasian man was treated with amoxicillin-clavulanate for pharyngitis. He did not improve, and a rash developed. History taking revealed a negative HIV antibody test five months previously and unprotected sex with a male partner the month before admission. Repeated tests revealed primary HIV infection with an exceptionally high HIV-1 RNA plasma concentration (3.6 × 10⁷ copies/mL) and a low CD4 count (101 cells/mm³, seven percent of total lymphocytes). While being investigated, the patient had a life-threatening hematochezia. After angiographic occlusion of a branch of the ileocaecal artery and initiation of antiretroviral therapy, the patient became rapidly asymptomatic and could be discharged. Colonoscopy revealed a bleeding colonic ulcer. We were unable to identify an etiology other than HIV for this ulcer. This case adds to the known protean manifestation of primary HIV infection. The lack of an alternative etiology, despite extensive investigations, suggests that this ulcer was directly caused by primary HIV infection. This conclusion is supported by the well-described extensive loss of intestinal mucosal CD4⁺ T cells associated with primary HIV infection, the extremely high HIV viral load observed in our patient, and the rapid improvement of the ulcer after initiation of highly active antiretroviral therapy. This case also adds to the debate on treatment for primary HIV infection, especially in the context of severe symptoms and an extremely high viral load.