Editorial

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Clinical and epidemiological characteristics of pyogenic spondylodiscitis in hospitalized patients

Prospektivno i retrospektivno je analizirano 36 bolesnika s piogenim spondilodiscitisom (SD) koji su hospitalizirani u Klinici za infektivne bolesti "Dr. Fran Mihaljević" u Zagrebu u razdoblju od 1. siječnja 2013. do 31. ožujka 2014. godine. Muškaraca je bilo 21 (58%), a starijih od 50 godina 29 (81%). Približno polovica (16 ili 44%) bolesnika imala je neku od poticajnih bolesti, a komplikaciju SD-a više od polovice (19 ili 54%). Većina bolesnika imala je subakutno-kronični tijek bolesti. Svi bolesnici su imali bol u leđima, vrućicu 28 ili 78%, a neurološke simptome 10 ili 28% bolesnika. Ubrzana sedimentacija eritrocita (31 ili 86%) i povišene vrijednosti C-reaktivnog proteina (34 ili 97%) bilježe se u većine, a leukocitoza (14 ili 39%) u manje od polovice bolesnika. Najčešće je bila zahva}ena lumbalna (23 ili 64%), a potom torakalna (7 ili 19%) kralježnica. Promjena na koži (8 ili 22%) su bile najčešće ishodište infekcije, a postoperativni SD imalo je 7 ili 19% bolesnika. Etiologija bolesti dokazana je u 22 ili 61% bolesnika, a najčešći uzročnik bio je Staphylococcus aureus (10 ili 32%). Zbog neučinkovitosti konzervativne terapije u 8 ili 22% bolesnika učinjen je kirurški tretman. Jedan bolesnik je umro zbog akutnog infarkta miokarda koji je potvrđen obdukcijom.A prospective and retrospective analysis was performed on 36 patients with pyogenic spondylodiscitis (SD) hospitalized at the University Hospital for Infectious Diseases "Dr. Fran Mihaljević" Zagreb in the period from January 1, 2013 until March 31, 2014. The study included 21 (58%) male patients, and 29 (81%) patients older than 50 years of age. Approximately half of the patients (16 or 44%) had some type of a triggering factor, and more than half of the patients experienced disease complications (19 or 54%). The majority of patients had a subacute-chronic course of disease. All patients had back-pain, fever was recorded in 28 or 78%, and neurologic symptoms in 10 or 28% of patients. Elevated erythrocyte sedimentation rate (in 31 or 86%) and high C-reactive protein (in 34 or 97%) were recorded in the majority of patients, and leukocytosis in less than half of the patients (14 or 39%). Lumbar spine was most frequently affected (in 23 or 64% of patients), followed by thoracic spine (in 7 or 19%). Skin changes (in 8 or 22%) were most commonly the focus of infection, and postoperative SD was recorded in 7 or 19% patients. Disease etiology was detected in 22 or 61% patients, and the most common pathogen was Staphylococcus aureus (in 10 or 32%). Due to unsuccessful conservative treatment, a surgical procedure was performed in 8 or 22% of patients. One patient died due to acute myocardial infarction that was later on confirmed by autopsy

Suvremeni pristup dijagnostici i liječenju legionarske bolesti

Legionarska bolest je pneumonija koju uzrokuje Legionella pneumophila. Čovjek se inficira inhalacijom kontaminiranoga vodenog aerosola. Legionella je odgovorna za 2 do 15% pneumonija u općoj populaciji. Od legionarske bolesti obolijevaju sve dobne skupine, a češće stariji ljudi, poglavito oni s kroničnim bolestima srca, pluća i bubrega. Posebno su ugroženi bolesnici s oslabljenim imunosnim sustavom. Bolest se klinički očituje različitom težinom i pojavnošću, od blagih oblika do vrlo teških pneumonija. Etiološka dijagnoza legionarske bolesti može se postaviti samo specifičnim mikrobiološkim testovima: kultivacija, otkrivanje antigena u uzorcima dišnog sustava ili u mokraći, serološkim testovima i metodama molekularne dijagnostike. U liječenju legionarske bolesti najvažnije je što prije primijeniti odgovarajući antibiotik. Zakašnjenje u primjeni učinkovitog antibiotika rezultira lošom prognozom. Lijekovi izbora su azitromicin ili fluorokinoloni. U blagim do umjereno teškim oblicima bolesti liječenje se provodi 10–14 dana. Ako se liječenje provodi azitromicinom, dovoljna je terapija tijekom pet, odnosno tri dana. U teškim oblicima bolesti ili u imunokompromitiranih bolesnika preporučuje se liječenje od tri tjedna. U slučaju neuspjeha mogu se kombinirati te dvije skupine antibiotika s rifampicinom

Clinical Features of Influenza in High Risk Patient

Teži klinički tijek i veći broj težih komplikacija u tijeku influence pojavljuju se u mlađe djece, djece i adolescenata na terapiji salicilatima, trudnica, pretilih osoba, starijih osoba, bolesnika s kroničnim bolestima te imunokompromitiranih osoba. S poboljšanom zdravstvenom skrbi i napretkom medicine, postotak starijih osoba, bolesnika s kroničnim bolestima, kao i imunokompromitiranih osoba u svijetu u stalnom je porastu. Taj podatak, kao i veća prevalencija stanja koja su visokorizična za influencu, kao što su kardiovaskularne i cerebrovaskularne bolesti važan su čimbenik koji dovodi do povećanja broja hospitalizacija i smrti zbog influence. Prisutnost kroničnih bolesti može maskirati kliničku sliku influence pa bolest ostane neprepoznata. Ipak u tih bolesnika vodeći simptomi bolesti su vrućica i kašalj. U tijeku influence u visokorizičnih bolesnika nerijetko se pojavljuju komplikacije bolesti od kojih je najteža pneumonija. Stoga se u slučaju pojave simptoma influence preporučuje što ranija terapija inhibitorima neuraminidaze. U kasnijem tijeku bolesti moguće su superinfekcije drugim, poglavito bakterijskim uzročnicima. Imunosni je odgovor organizma na cijepljenje protiv influence u starijih i imunokompromitiranih bolesnika slabiji. Ipak, redovito cijepljenje dovelo je do smanjenja morbiditeta i mortaliteta u tih bolesnika te se preporučuje za sve visokorizične osobe.A more severe clinical course and a higher number of serious complications occur in young children, children and adolescents on salicylate therapy, pregnant women, obese or elderly people, patients with chronic diseases and immunocompromised persons. With an improved healthcare and advances in medicine, the percentage of elderly persons, patients with chronic diseases and immunocompromised persons is continuously increasing on the global level. This increase and a higher prevalence of high risk conditions, such as cardiovascular and cerebrovascular diseases, are significant factors leading to an increased number of hospitalizations and deaths due to influenza. As the presence of chronic diseases may mask the clinical features of influenza, the disease remains unrecognized. However, the leading symptoms in these patients are fever and cough. In the course of influenza, complications often occur in high-risk patients, the most severe being pneumonia. Therefore, when symptoms of influenza occur, neuraminidase inhibitor treatment is recommended as early as possible. In the later course of the disease, superinfections with other primarily bacterial pathogens are possible. The immune response to vaccination against influenza in elderly and immunocompromised patients is weaker. However, regular immunization has resulted in reduced morbidity and mortality rates in these patients and is therefore recommended for all high-risk persons

Non-necrotising bacterial infections of the skin

Koža je barijera koja je kolonizirana apatogenim bakterijama koje ograničavaju invaziju i rast patogenih bakterija. Najčešće bakterijske infekcije kože jesu piodermije uzrokovane beta hemolitičkim streptokokom (BHS) ili zlatnim stafilokokom (SA). Impetigo je površinska infekcija kože najčešće djece predškolske dobi uzrokovana BHS ili SA. Terapijski pristup ovisi o broju i veličini kožnih promjena. Apsces kože zahtjeva inciziju, evakuaciju gnoja, a ponekad i antimikrobnu terapiju. Folikulitis, furunkul i karbunklu su infekcije folikula dlake u pravilu uzrokovane SA koje se razlikuju u opsežnosti inflamacije. Erizipel i celulitis se patohistološki razlikuju po dubini zahvaćene kože, a klinički po izgledu i morfologiji kožnih lezija. Promjenama na koži prethode sistemske manifestacije infekcije. Etiološka dijagnoza erizipela/celulitisa rijetko se uspije postaviti. Osim BHS i SA i neke druge bakterije mogu uzrokovati celulitis, ali u nekim posebnim situacijama. Dijagnoza erizipela/celulitisa postavlja se na temelju kliničke slike. No, u pravilu se ne može uočiti klinička razlika između streptokokne i stafilokokne infekcije kože. Od značaja je na vrijeme prepoznati nekrotizirajuće infekcije mekih česti koje zahtjevaju brzi kiruški tretman. Liječenje erizipela/celultiisa podrazumijeva antimikrobnu terapiju u trajanju od 10 dana, a ponekad i duže. U osoba s ponavljajućim erizipelom/celulitisom potrebno je nakon uspješno provedenog liječenja provoditi odgovarajuće preventivne mjere koju uključuju odgovarajuće higijenske mjere, liječenje popratnih čimbenika rizika, eradikaciju potencijalnog kliconoštva, a u nekim slučajevima i profilaktičku primjenu antibiotika. Celulitis orbite je ozbiljna bolest koja može izazvati ozbiljne komplikacije te ga je potrebno razlikovati od preseptalnog celulitisa koji je blaga bolest. Perianalni apsces zahtijeva neodgodivu kirušku drenažu te ponekad i antimikrobnu terapiju.The skin is a barrier colonized with apathogenic bacteria that limit the invasion and growth of pathogenic bacteria. The most common bacterial infections of the skin are pyodermas caused by Beta-hemolytic streptococcus (BHS) or Staphylococcus aureus (SA). Impetigo is a superficial skin infection caused by BHS or SA, that most commonly affects preschool children. Therapeutic approach depends on the number and size of skin changes. Skin abscess requires incision, pus drainage, and sometimes antimicrobial therapy. Folliculitis, furuncles, and carbuncles are infections of the hair follicle in general caused by SA that differ in the extensiveness of inflammation. Erysipelas and cellulitis pathohistologically differ in depth of the affected skin, and clinically in the appearance and morphology of skin lesions. Skin changes are preceded by systemic manifestations of infection. Etiological diagnosis of erysipelas/cellulitis is rarely established. Apart from BHS and SA, also some other bacteria may cause cellulitis, in some special circumstances. Diagnosis of erysipelas/cellulitis is based on clinical presentation of disease. However, streptococcal and staphylococcal skin infections cannot be clinically distinguished. It is important to timely recognize necrotizing soft tissue infections that require rapid surgical intervention. The treatment of erysipelas/cellulitis includes antimicrobial therapy lasting for 10 days, and sometimes even longer. After successful completion of treatment, in patients with recurrent erysipelas/cellulitis appropriate preventive measures need to be implemented, which include proper hygiene measures, treatment of accompanying risk factors, eradication of carriage of potential pathogens, and in some cases, prophylactic use of antibiotics. Orbital cellulitis is a serious condition that can cause severe consequences and should be distinguished from preseptal cellulitis which is a mild disease. Perianal abscess requires immediate surgical drainage and sometimes also antimicrobial therapy

Antiviral Drugs and Influenza Treatment

Osnovno je liječenje influence simptomatsko, a teže oblike bolesti i hospitalizirane bolesnike te bolesnike s rizičnim čimbenicima za nastanak komplikacija u influenci poželjno je liječiti specifičnim protuvirusnim lijekovima. Stariji protuvirusni lijekovi (blokatori M2-ionskih kanala), amantadin i rimantadin vrlo su se rijetko upotrebljavali zbog toksičnosti i rezistencije virusa te neučinkovitosti prema virusu influence B. Novi protuvirusni lijekovi blokiraju aktivnost virusne neuraminidaze (inhibitori neuraminidaze) i tako sprečavaju izlazak virusa iz inficirane stanice. Inhibitori neuraminidaze dobro djeluju na sve viruse influence A i B. Danas se rabe dva inhibitora neuraminidaze – zanamivir i oseltamivir, a završnu fazu kliničkih istraživanja prošao je peramivir, dok je laninamivir u pretkliničkoj fazi istraživanja. Inhibitori neuraminidaze u sezonskoj i pandemijskoj influenci skraćuju trajanje bolesti i ublažuju simptome, smanjuju broj i težinu komplikacija, potrošnju antibiotika i potrebu hospitalizacije bolesnika. Liječenje treba početi u samome početku, odnosno u prvih 48 sati od početka bolesti.The treatment of influenza is primarily symptomatic, while more serious disease forms and hospitalized patients, as well as patients with risk factors for complications, should be preferably treated with specific antiviral medicines. Old antiviral medicines (M2 ion channel blockers), i.e. amantadine and rimandatine, have been used very rarely due to their toxicity, viral resistance and lack of efficiency against influenza B virus. New antiviral medicines block the activity of viral neuraminidases (neuraminidase inhibitors) and thus prevent the virus from exiting the infected cell. Neuraminidase inhibitors are efficient against all influenza A and B viruses. Currently two neuraminidase inhibitors, zanamivir and oseltamivir, are used. Paramivir has completed the final phase of clinical trials, while laninamivir is in non-clinical trials. Neuraminidase inhibitors in seasonal and pandemic influenza reduce the duration of the disease and alleviate its symptoms, and they also reduce the number and severity of complications, the consumption of antibiotics and the need for hospitalization. The treatment should start at the onset of the disease, i.e. within the first 48 hours

Infectious gangrene as a clinical entity

Infektivne gangrene ili nekrotizirajuće infekcije mekih česti su teške infekcije potkožnog tkiva s visokim mortalitetom. Infekciji najčešće prethodi kirurški tretman ili trauma. Postoje brojne klasifikacije infektivnih gangrena, a u praksi je uobičajena mikrobiološka podjela na tip I (polimikrobni) i tip II (uzrokovan streptokokom). Klinička slika infektivne gangrene uključuje intezivnu bol u području rane, krepitacije, prisutnu sekreciju, pojavu bula i brzi razvoj septičkog šoka. Vanjski izgled rane nerijetko ne korelira s stvarnim stanjem te može biti razlogom za kasnu dijagnozu. Dijagnoza bolesti postavlja se temeljem kliničke slike, laboratorijskih nalaza, radioloških pretraga, mikrobioloških nalaza, a potvrđuje i kirurškom ekploracijom zahvaćenog područja koja je i terapijski postupak. Pojava plina u mekim tkivima je tipičan znak za nekrotizirajuće infekcije i indicira početak liječenja. Izostanak pravovremene i agresivne terapije najčešće dovodi do nepovoljnog ishoda bolesti. Liječenje se sastoji od brze i ekstenzivne kirurške ekploracije i odstranjena nekrotičnih masa, kombinirane antibiotske terapije, te potrebite simptomatske i suportivne terapije.Infectious gangrenes or necrotizing soft tissue infections are severe subcutaneous tissue infections with high mortality rates. Infections are often preceded by a surgical procedure or trauma. There are many classifications of infectious gangrenes, however the most commonly used in practice is microbiological classification into type I (polymicrobial) and type II (caused by Streptococcus). The clinical presentation of infectious gangrene includes intense pain in the wound area, crepitations, secretion, the occurrence of bullae and rapid development of septic shock. The external appearance of the wound often does not correlate with the actual condition and may be the reason for late diagnosis. The diagnosis of the disease is based on clinical features, laboratory findings, radiological examinations, microbiological results, and is confirmed by surgical exploration of the affected area which is also a therapeutic procedure. Gas formation in the soft tissues is a typical sign of necrotizing infections and indicates the beginning of treatment. Lack of timely and aggressive treatment usually leads to poor disease outcome. Optimal treatment consists of prompt and extensive surgical wound exploration and necrotic tissue removal, combined antibiotic therapy and necessary symptomatic and supportive therapy