Epidemiological, diagnostic, clinical, and therapeutic aspects of Brucella bacteremia in children in southern Israel: a 7-year retrospective study (2005-2011)

BACKGROUND

Data on the various aspects of brucellosis in children living in southern Israel are missing.

OBJECTIVES

Our aim was to study the epidemiological, microbiological, diagnostic, clinical, therapeutic and outcome features of brucellosis in children <19 years of age in southern Israel during 2005-2011.

PATIENTS AND METHODS

The study population included all patients hospitalized with a diagnosis of brucellosis, established according to a clinical presentation compatible with brucellosis+presence of Brucella bacteremia (BB).

RESULTS

A total of 128 (50.8%) of 252 patients admitted with a diagnosis of brucellosis had BB (all with Brucella melitensis). All patients were of Muslim Bedouin ethnicity. The mean incidence of BB in southern Israel was 16 cases/100,000 Bedouin, with no significant changes during the study period. Overall duration of symptoms before diagnosis was 10.1±10.9 days. Fever at diagnosis was recorded in <20% of the patients. The most frequent symptoms were arthralgia (61.7%), weakness (32.8%), gastrointestinal disturbances (27.3%), myalgia (25%), and headache (18.8%). The main clinical findings included monoarthritis (36.7%), hepatosplenomegaly (25%), lymphadenopathy (17.2%), heart murmur (11.7%), and skin rash (9.4%), respectively. Anemia, leukopenia, thrombocytopenia, and pancytopenia were reported in 17.6%, 29.6%, 12.8%, and 2.3% of the patients, respectively. Twenty-nine (30.5%) patients with BB had serum agglutinin titers ≤1/160 (13, 13.7%%, had titers <1/160). Twenty-seven (93%) of the 29 patients aged 0-4 years were treated with gentamicin and trimethoprim-sulfamethoxazole; a total of 77 (60.2%) patients received gentamicin and doxycycline.

CONCLUSIONS

Childhood brucellosis remains an important public health problem in southern Israel. BB was diagnosed in >50% of the children with brucellosis, and B. melitensis was identified in all cases. Arthralgia, weakness, and gastrointestinal complaints were the most common symptoms, and monoarthritis, hepatosplenomegaly, and lymphadenopathy were the most common clinical findings. A considerable number of patients with BB had undetectable/low serum agglutinin titers, suggesting insufficient reliability on serology alone in diagnosis of brucellosis.

Impact of Conversion from an Open Ward Design Paediatric Intensive Care Unit Environment to All Isolated Rooms Environment on Incidence of Bloodstream Infections and Antibiotic Resistance in Southern Israel (2000 to 2008)

We studied the epidemiology, microbiology, clinical aspects and outcome of bloodstream infections (BSI) in a tertiary paediatric intensive care unit. All BSI episodes were prospectively identified and analysed. The paediatric intensive care unit moved in 2006 from an open-plan unit to a new (all single room) unit. Three hundred and fifty-three BSI episodes occurred in 299 of 4162 patients. Overall, BSI incidence was 85 per 1000 hospitalised children. Fewer BSI episodes occurred during the last two years of the study (2007 to 2008), compared with 2000 to 2006 (70 of 1061 admissions, 6.5% versus 283 of 3101 admissions, 9.1%, respectively, P=0.01). There were 127 of 340 (37.4%) community-acquired and 213 of 340 (62.6%) nosocomial BSI episodes (31 of 1000 and 51 of 1000, respectively). Nosocomial BSI episodes decreased during 2007 to 2008 versus 2000 to 2006 (37.7% versus 55.8%, P=0.03). In 448 instances, pathogens were isolated, 231 (52%) Gram-positive and 188 (42%) Gram-negative. Coagulase-negative Staphylococci, S. pneumoniae and S. aureus (41.1%, 19.9% and 11.7%, respectively) were the most common Gram-positive and Enterobacteriaceae spp. the most frequent Gram-negative organisms (45.2%, of them Klebsiella spp. and E. coli 40% and 29.4%, respectively). A significant decrease was recorded during 2007 to 2008 in Enterobacteriaceae resistance to piperacillin, gentamicin and ciprofloxacin. Thirty of 299 (10%, 9 with S. pneumoniae-BSI) patients died. A significant decrease in BSI and nosocomial incidence and Enterobacteriaceae spp. antibiotic resistance was recorded following the conversion of the paediatric intensive care unit from an open ward to an all isolated rooms environment.

Acute mastoiditis in children under 15 years of age in Southern Israel following the introduction of pneumococcal conjugate vaccines: a 4-year retrospective study (2009-2012)

OBJECTIVES

To describe the epidemiologic, microbiologic, clinical and therapeutic aspects of acute mastoiditis (AM) in children <15 years of age during the 4-year period (2009-2012) following the introduction of pneumococcal conjugate vaccines in Israel.

PATIENTS AND METHODS

The medical records of all children with a discharge diagnosis of AM were reviewed.

RESULTS

A total of 66 AM episodes occurred in 61 patients. Forty-four (66.6%) cases occurred among patients <4 years, recent acute otitis media (AOM) history was reported in 27.1% and 28.8% patients received previous antibiotics for AOM. Postauricular swelling, postauricular sensitivity, protrusion of auricle and postauricular edema (93.8%, 90.6%, 85.9% and 95.7%, respectively) were the most common signs of AM. Leukocytosis >15,000 WBC/mm(3) was found in 39 (59.1%) cases. Cultures were performed in 52/66 episodes (positive in 27, 51.92% episodes), with recovery of 32 pathogens. The most frequently isolated pathogens were Streptococcus pneumoniae (15/52, 28.85%), Streptococcus pyogenes (9, 17.3%) and nontypeable Haemophilus influenzae (5, 9.62%). Eight (53.3%) S. pneumoniae isolates were susceptible to penicillin. Mean incidence of overall and pneumococcal AM were 11.1 and 2.58 cases/100000, with no significant changes during the study years. Surgical intervention was required in 19 (28.8%) patients.

CONCLUSIONS

(1) AM occurs frequently in patients without previous AOM history and with no previous antibiotic treatment; (2) S. pneumoniae and S. pyogenes continued to be the main etiologic agents of AM during the postvaccination period; (3) No changes were recorded in overall AM incidence and in pneumococcal AM incidence during the postvaccination period.

Near-elimination of otitis media caused by 13-valent pneumococcal conjugate vaccine (PCV) serotypes in southern Israel shortly after sequential introduction of 7-valent/13-valent PCV

BACKGROUND

Otitis media (OM) is common in early childhood. Streptococcus pneumoniae caused approximately 30%-60% of episodes before the pneumococcal conjugate vaccine (PCV) era. The 7-valent PCV (PCV7) was introduced to the Israeli National Immunization Plan in July 2009, and was gradually replaced by the 13-valent PCV (PCV13) starting in November 2010. We aimed at assessing the impact of PCV7/PCV13 sequential introduction on pneumococcal and overall OM necessitating middle ear fluid culture in children aged <2 years in southern Israel.

METHODS

This was a prospective, population-based, active surveillance. Our medical center is the only one in the region, enabling incidence calculation. All pneumococcal episodes submitted for culture between July 2004 and June 2013 were included. Three subperiods were defined: pre-PCV, PCV7, and PCV13.

RESULTS

Overall, 6122 OM episodes were recorded, and 1893 were pneumococcal. Compared with the pre-PCV period, OM caused by PCV7 plus serotype 6A and the 5 additional PCV13 serotypes (5VT : 1, 3, 5, 7F, 19A) decreased by 96% and 85%, respectively (incidence rate ratios [IRRs], 0.04 [95% confidence interval {CI}, .02-.08] and 0.15 [95% CI, .07-.30], respectively) in a 2-step pattern: In the PCV7 period, only OM caused by PCV7 + 6A serotypes was decreased; in the PCV13 period, 5VT OM rates decreased, along with an additional PCV7 + 6A OM reduction. A nonsignificant increase in non-PCV13 serotype OM was observed (IRR, 1.07 [95% CI, .72-1.58]). In total, 77% and 60% reductions of all-pneumococcal and all-cause OM incidences, respectively, were observed.

CONCLUSIONS

A substantial 2-step reduction of pneumococcal OM rates, with near-elimination of PCV13 disease, was observed shortly after PCV7/PCV13 introduction.

Adherence to acute otitis media treatment guidelines among primary health care providers in Israel

Aims

To determine the appropriateness of the acute otitis media antibiotic treatment prescribed in the community in relation to the therapeutic guidelines.

Methods

Children aged 3 months–3 years diagnosed with simple uncomplicated acute otitis media in 6 community primary care clinics were enrolled. Data on the antibiotic treatment were collected using computerized medical files.

Results

689 simple uncomplicated acute otitis media patients were enrolled; 597 (86.9%) were treated with antibiotics by 38 family medicine practitioners, 12 pediatricians and 7 general practitioners. 461 (77.2%) patients were <2 years of age. Amoxicillin was administered to 540 (90.5%) patients, with no differences between the various medical specialties. 127/540 (23.5%) patients did not receive the appropriate dosage; 140/413 (33.9%) patients treated with appropriate dosage did not receive the treatment for the appropriate duration of time. 258/357 (72.3%) evaluable patients <2 years of age received an antibiotic considered inappropriate to guidelines (38 not treated with amoxicillin, 94 received inappropriate dosage and 126 not treated for 10 days); 53/100 (53%) evaluable children >2 years of age received an inappropriate antibiotic treatment.

Conclusions

The majority of primary care physicians treat simple uncomplicated acute otitis media with the recommended antibiotic drug. However, incorrect dosage and shorter than recommended duration of therapy may jeopardize the quality of care in children with simple uncomplicated acute otitis media.

Epidemiological trends and patterns of antimicrobial resistance of Shigella spp. isolated from stool cultures in two different populations in Southern Israel

Southern Israel is inhabited by Bedouins, living in conditions similar to developing countries and Jews, living in conditions similar to developed countries. We determined the epidemiology of Shigella spp. in these populations. We retrospectively reviewed Shigella spp. stool isolations between 2005-2009. Overall, 3295 isolates were analyzed. S. sonnei was isolated in 2057/3295 (62.4%) and S. flexneri in 1058 (32.1%). S. sonnei was isolated in 1567/1707 (91.8%) from Jewish patients and S. flexneri in 931/1542 (60.4%) from Bedouin patients. Ampicillin resistance increased linearly from 217/373 (58.2%) in 2005 to 186/256 (72.7%) in 2009, (P < 0.001). Trimethoprim-sulfamethoxazole resistance decreased linearly from 328/373 (87.9%) in 2005 to 133/256 (51.9%) in 2009 (P < 0.001). Higher resistance of Shigella spp. to ampicilin and trimethoprim-sulfamethoxazole were found in Jewish patients: 1527/1706 (89.5%) versus 977/1542 (63.4%) (P < 0.0001), 1635/1706 (95.8%) versus 1026/1542 (66.5%) (P < 0.0001). The epidemiology of Shigella spp. infections can differ in populations residing in the same geographical area.

A prospective study of the patterns and dynamics of colonization with Candida spp. in very low birth weight neonates

BACKGROUND

Knowledge of fungal colonization patterns in very low birth weight infants (VLBWI) admitted to the neonatal intensive care unit (NICU) is essential in understanding the process of fungal infections in neonates. We analyzed prospectively, during 2009-2010, the patterns and dynamics of fungal colonization in VLBWI, including timing, colonization sites, and species involved.

METHODS

Weekly skin, oropharynx, and rectum/stool surveillance fungal cultures were collected from admission until discharge in VLBWI in the NICU. None received antifungal prophylaxis.

RESULTS

Overall, 118 VLBWI provided 1723 samples; 34 (29%) had 104 positive samples at least once during the first 10 hospitalization weeks. Thirty-nine (33%) weighed < 1000 g; 68 were delivered by cesarean section. Candida albicans (57/104, 55%) and Candida parapsilosis (26/104, 25%) were the main fungi isolated. Eight (24%) VLBWI were colonized during the first week and 23 (68%) during the second week. No differences in colonization were recorded between cesarean section and vaginally delivered VLBWI. The colonization risk at least once during the first 10 weeks was 23% for skin, 14% for oropharynx, 27% for rectum/stool, and 38% for any anatomic site sampled. Persistent colonization was recorded in 5/34 (15%), while transient colonization was found in 14/34 (41%) VLBWI; 16/34 (47%) were discharged or died colonized with Candida spp. Candidemia was diagnosed in 4 (3%) VLBWI and previous/simultaneous colonization was found in 3/4.

CONCLUSIONS

The cumulative risk of colonization, at any sampled site and at least once during follow-up, was high. Initial colonization occurred most often during the first 2 weeks of life. Colonization dynamics were characterized by various persistence, disappearance, and recolonization patterns. Candidemia was rare.

Panel 7: Treatment and comparative effectiveness research

BACKGROUND AND OBJECTIVES

Otitis media (OM) is one of the most common reasons for antibiotic treatment in children. Controversies regarding antibiotic treatment for OM have accumulated in the past decade, and there seem to be more dilemmas than certainties. The objectives of this article are to provide the state-of-the art review on achievements in treatment of all different stages of OM, including acute otitis media (AOM), otitis media with effusion (OME), and chronic suppurative otitis media, and to outline the future research areas.

DATA SOURCES

PubMed, Ovid Medline, the Cochrane Database, and Clinical Evidence (BMJ Publishing).

REVIEW METHODS

All types of articles related to OM treatment published in English between January 2007 and June 2011 were identified. A total of 286 articles related to OM treatment were reviewed by the panel members; 114 relevant quality articles were identified and summarized.

RESULTS

New evidence emerged on beneficial results of antibiotic treatment, compared with observation of AOM in young children who were diagnosed based on stringent criteria. In OME, the main results were related to a nonsignificant benefit of adenoidectomy versus tympanostomy tube placement alone in the treatment of chronic OME in younger children. Other modalities of OM treatment were studied and described herein.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Significant progress has been made in advancing the knowledge on the treatment of OM. Areas of potential future research have been identified and outlined.

Malnutrition risk in newly hospitalized overweight and obese individuals: Mr NOI

BACKGROUND/OBJECTIVES

Malnutrition risk and its consequences have not been reported in obese and overweight newly hospitalized patients. To estimate malnutrition risk among newly hospitalized overweight or obese patients, and to assess the effect of body mass index (BMI) on duration of hospitalization and risk of in-hospital death among hospitalized adults at increased risk of malnutrition.

SUBJECTS/METHODS

In this survey, all adults newly admitted to internal medicine and surgical departments at a large tertiary medical center, during the 5-week data acquisition period in 2010, were screened for malnutrition risk using the Nutrition Risk Screen (NRS 2002). Malnutrition risk was compared across body weight categories. In addition, overweight/obese subjects were compared by malnutrition risk category.

RESULTS

Of the 431 individuals analyzed, 138 were overweight and 105 were obese. Among overweight or obese patients, 23.2% and 24.8%, respectively, were at increased risk for malnutrition. Elevated risk for malnutrition prolonged hospitalization for both overweight and obese patients (from 5.6 ± 7.9 to 10.0 ± 10.3 days (P=0.04) and from 4.8 ± 4.6 to 15.1 ± 25.7 days (P=0.001), respectively). Prolonged hospital stay remained associated with malnutrition risk after controlling for age and BMI. Malnutrition risk significantly increased odds of in-hospital death: odds ratio (OR) 6.4, 95% confidence interval (CI) 1.2-33.2, P=0.03, even after controlling for age and BMI.

CONCLUSIONS

Increased malnutrition risk is a frequent finding in newly hospitalized overweight/obese adults, prolongs length of hospital stay and increases risk of in-hospital mortality.

Central venous catheter-associated bloodstream infections

BACKGROUND

To investigate the epidemiologic and microbiological aspects of long-term central vein catheter (CVC)-associated bloodstream infections (CABSI) in children <18 years old treated at the hemato-oncology unit during 1998-2008.

PATIENTS AND METHODS

The two long-term access devices used were Hickman and Port-A-Cath catheters. Information retrieved included demographic data, baseline pathologies, methods of insertion, anatomical insertion sites, duration of use, microbiological, and antibiotic susceptibility data and outcome.

RESULTS

There were 178 CABSI episodes; average number of episodes/1,000 catheter days was 4.7. More CABSI episodes were recorded among patients with Hickman catheter than in patients with Port-A-Cath catheter (5.05 vs. 3.57/1,000 catheter days, P = 0.059). The CVC was removed due to BSI in 52/178 (29.2%) episodes. Overall, 243 pathogens were isolated (144 Gram-negative, 92 Gram-positive, and 7 Candida spp). More Enterobacteriaceae spp. were isolated in CABSI in patients with Hickman catheters than in patients with Port-A-Cath catheters (35/103, 34%, vs. 10/65, 15%, P = 0.008); more coagulase-negative staphylococci were isolated in patients with Port-A-Cath catheters than in patients with Hickman catheters (25/65, 38.5%, vs. 23/103, 22.3%, P = 0.02). No differences in pathogen distribution were found between CABSI recorded for jugular versus subclavian veins, open versus close inserted-CVC or for CVC requiring removal versus those treated conservatively. No fatalities directly related to CABSI were recorded.

CONCLUSIONS

CABSI rates were higher in patients with Hickman catheters compared with those with Port-A-Cath catheters; Gram-negative organisms were the dominant etiologic agents of CABSI; CABSI in patients with Hickman catheters had different etiologies compared with patients with Port-A-Cath catheters.

Strategies for the prevention of neonatal candidiasis

Invasive fungal infections represent the third-leading cause of late-onset sepsis in very-low-birth-weight infants (VLBWI) and have a high rate of infection-associated mortality. The infants at high risk for fungal sepsis are VLBWI with presence of additional risk factors that contribute to increased colonization and concentration of fungal organisms. Colonization with Candida spp. in neonates is secondary to either maternal vertical transmission or nosocomial acquisition in the nursery. Multiple sites may become colonized and a direct correlation between fungal colonization and subsequent progression to invasive candidemia was determined. Randomized, single and multiple-center, placebo-controlled trials found intravenous fluconazole prophylaxis to be effective in decreasing fungal colonization and sepsis for at-risk preterm infants <1500 g birth weight. The prophylactic use of fluconazole was found to be safe with no significant development of fungal resistance. Fluconazole prophylaxis administered to preterm neonates with birth weight <1000 g and/or 27 weeks' gestation or less has the potential of reducing and potentially eliminating invasive fungal infections and Candida-related mortality.

[Joint cartilage lesions caused by quinolones in young animals--can we generalize to children?]

A number of new generation fluoroquinolone antibiotics are currently available for use in hospital and community-based settings. This antibiotic class possesses a broad anti-bacterial spectrum of activity, can be administered orally as well as intravenously, and is, generally, well-tolerated, causing few adverse drug reactions. Lesions in articular cartilage were observed in animal studies conducted in young animals, mostly Beagle dogs and rats. For this reason the use of fluoroquinolones is contraindicated in pregnant women, infants, children and adolescents up to the age of 18 years. Nevertheless, the rate of fluoroquinolone use in children has increased over the last decade. Use of fluoroquinolones has been associated with reversible musculoskeletal events in both children and adults. The putative mechanism of fluoroquinolone damage to articular cartilage is believed to be related to their tendency to form stable complexes with magnesium ions, resulting in decreased concentrations of this ion in cartilage. Magnesium is known to play an essential role in several biochemical processes that take place in cartilage.

Prevalence of pilus-encoding islets among acute otitis media Streptococcus pneumoniae isolates from Israel

We evaluated the distribution of the two known Streptococcus pneumoniae pilus encoding islets (PI-1 and PI-2) among a panel of 113 acute otitis media clinical isolates from Israel. PI-1 was present in 30.1% (n = 34) of the isolates tested, and PI-2 was present in 7% (n = 8). In addition, we found that: (i) the PI positive isolates, 50% of which belong to the international clones Spain(9V)-3 (ST156) and Taiwan(19F)-14 (ST236), correlate with the genotype (as determined by multilocus sequence typing) but not with the serotype; (ii) PI-2 was not present in the absence of Pl-1; and (iii) the frequency of PI-1 was higher among antibiotic-resistant isolates.

Distribution, dynamics and antibiotic resistance patterns of Streptococcus pneumoniae serotypes causing acute otitis media in children in southern Israel during the 10 year-period before the introduction of the 7-valent pneumococcal conjugate vaccine

OBJECTIVES

To determine the dynamics of serotype prevalence, potential coverage by pneumococcal conjugate vaccines (PCV) and antibiotic resistance patterns of Streptococcus pneumoniae causing acute otitis media (AOM) in children in southern Israel before PCV7 introduction in the routine immunization program in Israel.

METHODS

All S. pneumoniae isolates from middle ear fluid from children with AOM during 1999-2008 were included. Prospectively collected demographic data on S. pneumoniae serotypes and antibiotic resistance patterns were analyzed.

RESULTS

A total of 14,911 tympanocenteses yielded 5281 (35%) S. pneumoniae. Proportion of S. pneumoniae-AOM did not vary significantly (overall 35%; 33% in 2007; 38% in 2002 and 2003). The most frequent serotypes were 19F, 14, 23F and 19A; in both Jewish and Bedouin children; serotypes 6A and 19A contributed 6% and 10%, respectively, of all S. pneumoniae isolates. Serotypes included in PCV7, PCV10 and PCV13 represented 60%, 64%, 85% in Jewish children vs. 49%, 55% and 74%, respectively, in Bedouin children (P < 0.001). Nonsusceptibility to TMP/SMX decreased significantly, in parallel with a significant increase in the nonsusceptibility to erythromycin, clindamycin and in multidrug resistant (MDR) isolates. No changes were recorded in the proportion of S. pneumoniae isolates with penicillin MIC ≥ 1.0 μg/ml. The proportion of penicillin- and erythromycin-nonsusceptible and of MDR serotype 6A and 19A isolates increased significantly in Bedouin children.

CONCLUSIONS

(1) No significant changes were recorded in the yearly proportions of serotypes 23F, 19F, 19A, 14 and 6A in both ethnic populations; (2) Potential coverage of the 3 PCVs was higher in Jewish children than in Bedouin children; (3) The relatively high coverage of macrolides- and multidrug-resistant S. pneumoniae by PCV13 and lack of increase in penicillin, erythromycin and multidrug nonsusceptibility among non-PCV13 isolates is encouraging.

Hospitalization of children with influenza A(H1N1) virus in Israel during the 2009 outbreak in Israel: a multicenter survey

OBJECTIVES

To describe the clinical characteristics of children hospitalized with 2009 influenza A(H1N1) infection in Israel and the risk factors associated with this infection.

DESIGN

Prospective collection of data on children hospitalized with 2009 influenza A(H1N1) infection.

SETTING

Seven medical centers around Israel. Patients From July 12, 2009, to December 24, 2009, all patients 18 years or younger hospitalized with acute respiratory or acute unspecified febrile illness were screened for 2009 influenza A(H1N1) virus by reverse transcription-polymerase chain reaction.

INTERVENTION

Prospective data collection for patients with confirmed infection.

MAIN OUTCOME MEASURES

Clinical characteristics of patients and hospitalization rates.

RESULTS

The mean age of 478 patients studied was 6.1 years. Forty-two patients (8.8%) were admitted to the pediatric intensive care unit; 3 patients (0.6%) died. The most frequent clinical presentations were pneumonia, influenza-like illness, wheezing exacerbation, and convulsions. Predisposing underlying illnesses were detected in 48.7% of patients. Patients with metabolic and neurologic disorders were at highest risk for severe complications (relative risk, 6.5 and 2.9, respectively). In addition, patients with cyanotic heart lesions and infants 3 months or younger who were born at 33 weeks' gestation or earlier tended to require higher rates of mechanical ventilation. The hospitalization rate for 2009 influenza A(H1N1) was 0.7 per 1000 children. The mortality rate was 3.6 per 1 000 000 children.

CONCLUSIONS

The severity variables for 2009 influenza A(H1N1) were similar to the figures reported for seasonal influenza. Patients with underlying metabolic and neurologic metabolic disorders and presumably patients with cyanotic heart lesions and infants born prematurely are at highest risk for severe complications following 2009 influenza A(H1N1) infection.

Health benefits of nut consumption

We investigated the effect of a mixture of long-chain fructo-oligosaccharides, galacto-oligosaccharides and acidic oligosaccharides on the number and consistency of stools and on immune system biomarkers in 104 supplemented and non-supplemented subjects (aged 9-24 months) with acute diarrhea. Interleukin-1 (IL-1), IL-1RA, IL-6, IL-8, IL-10, TNF-α and sIL-2R cytokine levels were determined. The significant decrease in number of stools and increase in stool consistency in the supplemented group was of little clinical relevance. The only significant change in pro- and anti-inflammatory cytokines was decreased TNF-α levels in the supplemented group. Prebiotic supplementation during acute diarrhea episodes did not influence the clinical course.

Increasing importance of multidrug-resistant serotype 6A Streptococcus pneumoniae clones in acute otitis media in southern Israel

BACKGROUND

The major aim of this study was to establish the molecular epidemiology dynamics of Streptococcus pneumoniae serotype 6A in acute otitis media, before the introduction of the 7-valent pneumococcal conjugate vaccine.

METHODS

Acute otitis media in Jewish and Bedouin children <5 years old undergoing tympanocentesis during 1999 to 2006, were studied. Serotype 6A was identified by the Quellung reaction and by polymerase chain reaction (PCR) of the wciN gene, to differentiate between 6A and 6C. Antibiogram and molecular typing by pulsed field gel electrophoresis were performed on all 6A isolates. Multilocus sequence typing was performed on representative isolates of each clone. The 7-valent conjugate vaccine had not yet been licensed in Israel during the study period.

RESULTS

Serotype 6A constituted 5.8% (254/4408) of all pneumococcal acute otitis media episodes. The yearly proportion of serotype 6A among the Jewish children showed no distinct trend, whereas among the Bedouin children serotype 6A exhibited a significant increase, from 3.0% in 1999 to 7.6% in 2006. Among the Jewish children a single penicillin-nonsusceptible and erythromycin-resistant clone, ST-473, constituted 73.6% of the strains and dominated throughout the study period. Among the Bedouin children, the proportions of the most common, penicillin-nonsusceptible clone, ST-1988, gradually decreased, from 44.1% in 1999 to 2000 to 21.4% in 2005 to 2006, concurrently with the expansion of a multidrug-resistant clone, ST-457, from 5.9% in 1999 to 2000 to 28.6% in 2005 to 2006.

CONCLUSIONS

The expansion of multidrug-resistant serotype 6A clone occurred before the introduction of the vaccine. Continued surveillance following vaccine introduction is warranted to further investigate its efficacy on vaccine-related serotypes.

Bacteremic methicillin-resistant Staphylococcus aureus deep neck abscess in a newborn--case report and review of literature

We describe an unusual localization of methicillin-resistant Staphylococcus aureus infection (MRSA) in a very young newborn. A 3-week-old male infant was admitted with fever, irritability, sialorrhea and stiffed left neck. The ENT examination revealed a deep neck mass and an ultrasound examination showed diffuse swelling of the left latero-pharyngeal area. A CT examination confirmed a deep neck abscess with difficult-to-define borders. Blood and nasopharyngeal cultures returned positive for MRSA. Treatment was started with intravenous teicoplanin and continued for 14 days with a marked decrease in abscess's dimensions and improvement in patient's general condition. MRSA should be suspected in the etiology and treatment of neck abscesses in newborns, infants and young children.

Community-acquired bloodstream infections in children > one month old in southern Israel (1992–2001): Epidemiological, clinical and microbiological aspects

We studied the epidemiology, microbiology, clinical picture and outcome of community-acquired bloodstream infections (CABI) in children in southern Israel during 1992-2001. Information was collected prospectively by daily surveillance. CABI was diagnosed when a positive blood culture was reported in a patient discharged from the emergency room or during <48 h since admission if hospitalized. There were 1439 CABI episodes in 1396 children aged 1 month to 14 y. CABI incidence was 100/100,000 children with no increase during the study period. Risk of CABI was 3.8 times higher in a Bedouin than in a Jewish child. 1561 bacteria (793, 50%, gram-positive and 768, 49% gram-negative organisms, respectively) and 13 fungi were recovered. Most frequent gram-positive organisms were Streptococcus pneumoniae (509 isolates, 32% of all isolates, 64% of all gram-positive), Staphylococcus aureus (137, 9%, 17%) and Streptococcus pyogenes (46, 3%, 6%). Enterobacteriaceae spp. were the most frequent gram-negative pathogens (279, 18%, 36%), followed by Brucella (205, 13%, 27%). S. pneumoniae was the most common pathogen in children <12 months and 1-5 y age; Brucella was the most frequent pathogen in children >5 y of age. Coverage of 7-valent pneumococcal conjugated vaccine for CABI was 38.5%. 38 (2.7%) patients died; 16 cases were caused by S. pneumoniae.

Salmonella diskitis in a 2-year old immunocompetent child

Brucellosis is a disease of domestic and wild animals that is transmitted to humans and exists worldwide. We assessed the in vitro activity of moxifloxacin, ciprofloxacin, tetracycline, doxicycline, rifampin, streptomycin and trimethoprim-sulfamethoxazole (TMP/SMX) against 97 Brucella strains isolated from clinical samples, animals and dairy products in Mexico. Fluoroquinolones showed an antibacterial activity similar to that of tetracyclines (MIC(90) 0.5). Other drugs commonly used against brucellosis were less active, such as rifampin (MIC(90) 2.0 microg/ml) and streptomycin (MIC(90) 4.0 microg/ml). TMP/SMX showed the poorest activity (MIC(90) 8.0 microg/ml). Fluoroquinolones, either first-generation or the newer 8-methoxi derivatives, might be useful in the therapy of brucellosis, which remains to be assessed in clinical trials.

Introduction and proliferation of multidrug-resistant Streptococcus pneumoniae serotype 19A clones that cause acute otitis media in an unvaccinated population

BACKGROUND

Introduction of the 7-valent pneumococcal conjugate vaccine (PCV7) in the United States in 2000 was temporally associated with an increase in the incidence of disease caused by Streptococcus pneumoniae serotype 19A (Sp19A) and with increasing drug resistance within this serotype. A causative role of PCV7 was speculated. We prospectively studied the dynamics of acute otitis media (AOM) caused by Sp19A in southern Israel before the introduction of PCV7.

METHODS

AOM in children < 5 years old undergoing tympanocentesis during 1999-2006 was studied. Antibiotic prescriptions for approximately 20% of children < 5 years old were recorded. Sp19A isolates were studied for antibiotic-resistance and pulsed-field gel electrophoresis patterns; multilocus sequence typing of representative isolates was compared with that of international clones.

RESULTS

Sp19A caused 438 (9.8%) of 4449 pneumococcal AOM episodes, increasing by 63.1% from 1999-2001 (mean +/- SD, 8.4% +/- 0.8%) to 2004-2006 (mean +/- SD, 13.7% +/- 0.9%) among Bedouin children, who were characterized by overcrowding and high antibiotic use. Penicillin, erythromycin, and multidrug resistance increased from < 10% to 78.6%, 50.0%, and 50.0%, respectively (P < .001), and was associated with the introduction and proliferation of 2 multidrug-resistant clones that were not previously associated with multidrug resistance. This was temporally associated with the introduction of and rapid increase in azithromycin use and the frequent use of oral cephalosporins.

CONCLUSIONS

The introduction and proliferation of multidrug-resistant Sp19A occurred before the introduction of PCV7. The increasing proportion of antibiotic-resistant Sp19A suggests that antibiotic use plays an important role in the community.

Complicated community acquired pneumonia in children prior to the introduction of the pneumococcal conjugated vaccine

Increasing prevalence of pleural empyema (PE) complicating community acquired pneumonia (CAP) is reported worldwide. We compared hospitalized children with PE or non-purulent pleural effusion (NP-PEF) prior to the inclusion of the pneumococcal conjugated vaccine (PCV7) in the Israeli immunization schedule. We conducted a retrospective analysis of medical files of all children <18 y of age hospitalized with either PE or NP-PEF and CAP during 1990-2002. 75 children with NP-PEF and 37 with PE were identified. PE annual incidence increased from 0.5 in 1990 to 4.2 per 100,000 children in 2002. Higher WBC and absolute neutrophils counts were found in sera and pleural fluid of PE. The leading pathogens included Streptococcus pneumoniae (42%, all penicillin-susceptible) and Staphylococcus aureus (23%, all methicillin-susceptible). Blood cultures were positive only in children with PE (12/37, 32.4%). Patients with PE presented with higher respiratory rate and required longer hospitalization, more PICU admission, and more patients needed mechanical ventilation. PE prevalence increased in southern Israel during the study period. Streptococcus pneumoniae (62.5% serotype 1) was the most common pathogen causing PE before the introduction of PCV7. Future introduction of PCV7 or equivalents in the immunization schedule may impact clinical presentation and epidemic trends and will require future consideration.

Increased adhesiveness of white blood cells in patients with unstable angina: additional evidence for an involvement of the immune-inflammatory system

BACKGROUND

Data are being accumulated on the presence of inflammatory response in patients with acute coronary syndromes.

HYPOTHESIS

The study was undertaken to confirm that the adhesive state of the peripheral blood leukocytes can provide information on an inflammatory process in patients with unstable angina pectoris.

METHODS

The study included 21 patients with unstable angina, 32 patients with stable angina, and 13 patients with chest pain and no evidence of coronary artery disease.

RESULTS

The percentage of aggregated leukocytes in patients with unstable angina (5.8 +/- 3.2%) was significantly (p < 0.02) increased compared with that of patients with no evidence of active coronary disease (3.2 +/- 2.6%).

CONCLUSION

Additional evidence for an existing smoldering inflammatory process in unstable angina pectoris can be provided by testing the percentage of aggregated leukocytes in peripheral blood.

The appearance of L-selectin(low) polymorphonuclear leukocytes in the circulating pool of peripheral blood during myocardial infarction correlates with neutrophilia and with the size of the infarct

BACKGROUND

It is assumed that not only leukocytosis, but also the activation of white blood cells (WBC) may play a role in the pathogenesis and prognosis of patients with myocardial infarction (MI). Activation of WBC includes upregulation of CD11b/CD18 and downregulation of CD62L (L-selectin) antigens.

HYPOTHESIS

The activation of WBC is associated with the appearance of a larger MI.

METHODS

CD11b/CD18 and CD62L were measured on the surface of WBC on Day 1 and Day 3 from the onset of MI. The size of the infarct with estimated by calculating the area under the curve of the creatine kinase enzyme, which was measured every 6 h.

RESULTS

A negative correlation was noted between the absolute polymorphonuclear count and the availability of the CD62L on these cells during Day 1 (r = -0.46, p = 0.003) and Day 3 (r = -0.35, p = 0.05). There was a positive correlation between the size of MI and the WBC count (r = 0.46, p = 0.004) and a negative correlation with CD62L on polymorphonuclears (r = -0.35, p = 0.03). During Day 3, the CD11b/CD18 on the polymorphonuclears increased despite a decrement in the absolute number of these cells.

CONCLUSION

The neutrophilia during the early phases of acute MI correspond to the appearance of the L-selectin(low) population of polymorphonuclear leukocytes. There is a correlation between the appearance of this population and the size of the infarct.

Acute otitis media in children: association with day care centers--antibacterial resistance, treatment, and prevention

Children attending day care centers (DCCs) frequently carry antibacterial-resistant organisms in their nasopharynx, leading to acute otitis media (AOM) that may be refractory to antibacterial treatment. The development and spread of resistant organisms are facilitated in DCCs as a result of the following: (i) large numbers of children; (ii) frequent close person-to-person contact; and (iii) a wide use of antimicrobial medications. Intensive antimicrobial usage provides the selection pressure that favors the emergence of resistant organisms, while DCCs provide an ideal environment for transmission of these organisms. The American Academy of Pediatrics and American Academy of Family Physicians' guidelines recommend high-dose amoxicillin/clavulanic acid (rather than amoxicillin alone) as the first therapeutic choice in the treatment of AOM in children attending DCCs. The introduction of the 7-valent pneumococcal conjugated vaccine (PCV7) had a major role in decreasing the number of episodes of Streptococccus pneumoniae AOM secondary to the serotypes included in the vaccine. It also had a major role in reducing the nasopharyngeal carriage of vaccine-type S. pneumoniae (and in particular of antibacterial-resistant organisms), preventing, in this way, its spread to contacts in the community. However, the recent observation of increased rates of antibacterial-resistant non-vaccine serotype S. pneumoniae may erode the success of PCV7.

Clinical/otologic score before and during treatment of acute otitis media

OBJECTIVES

To determine clinical characteristics of AOM at presentation and during therapy according to specific etiologies.

PATIENTS AND METHODS

1003 patients studied during 1996-2001 in antibiotic efficacy studies underwent tympanocentesis and middle ear fluid culture at enrollment and on Day 4-6 (in initially culture-positive patients only). We used a clinical/otologic (CO) score for evaluating severity of fever, irritability and tympanic membrane redness and bulging (0-3 each parameter, maximal score=12).

RESULTS

Seven hundred sixty-three patients had positive cultures with 392 (39%) Haemophilus influenzae, 198 (20%) Streptococcus pneumoniae and 173 (17%) mixed H. influenzae and S. pneumoniae infection. Mean CO score was higher in culture-positive versus culture-negative patients (8.21+/-2.17 vs. 7.73+/-2.32, p=0.003) regardless of isolated organism. A marked improvement in CO score was observed on Day 4-6 in all patients: 1.83+/-2.18 in children initially culture-positive and 0.9+/-1.67 in those initially culture-negative (p<0.001). The improvement was greater in patients with eradication versus those with bacteriological failure (CO score 1.52+/-1.82 vs. 2.77+/-2.85, p<0.001).

CONCLUSIONS

CO score before treatment, after bacterial eradication or in bacteriologic failures are similar in bacterial AOM and are not predictive of the etiology of the disease.

Is bilateral acute otitis media clinically different than unilateral acute otitis media?

BACKGROUND

Information regarding the specific characteristics of bilateral acute otitis media (BAOM) versus unilateral acute otitis media (UAOM) is lacking.

OBJECTIVES

To compare the epidemiologic, microbiologic, and clinical characteristics of BAOM with UAOM in children.

PATIENTS AND METHODS

1026 children aged 3-36 months (61%, <1 year of age) with AOM were enrolled during 1995-2003. All patients had tympanocentesis and middle ear fluid (MEF) culture at enrollment. Clinical status was determined by a clinical/otologic score evaluating severity (0 = absent to 3 = severe, maximal score 12) of patient's fever and irritability and tympanic membrane redness and bulging. Multivariate logistic regression models were used to estimate the risk of BAOM and UAOM presenting with a high severity score (> or =8).

RESULTS

Six-hundred twenty-three (61%) patients had BAOM. Positive MEF cultures were recorded in 786 (77%) patients. More patients with BAOM had positive MEF cultures than patients with UAOM (517 of 623, 83% versus 269 of 403, 67%; P < 0.01). Nontypable Haemophilus influenzae was more common in BAOM than in UAOM (390 of 623, 63% versus 170 of 430, 42%; P < 0.01). Overall, the clinical/otologic score showed higher severity in culture-positive than in culture-negative patients (8.2 +/- 2.0 versus 7.7 +/- 2.2; P < 0.001) and in BAOM than in UAOM (8.3 +/- 2.1 versus 7.8 +/- 2.1; P = 0.001). Clinical/otologic score of > or =8 was more frequent in BAOM than in UAOM patients (371, 61.8% versus 200, 51.3%; P = 0.001). The estimated risk for BAOM patients (compared with UAOM patients) to present with a score > or =8 was 1.5. The association between BAOM and clinical/otologic score > or = 8 was maintained after adjustment for age, previous AOM history, and culture results at enrollment.

CONCLUSIONS

(1) BAOM is frequent; (2) Nontypable H. influenzae is more frequently involved in the etiology of BAOM than of UAOM; (3) The clinical picture of BAOM is frequently more severe than that of UAOM, but overlap of clinical symptoms is common.

Antibiotic susceptibility, serotype distribution and vaccine coverage of nasopharyngeal and oropharyngeal Streptococcus pneumoniae in a day-care centre in St. Petersburg, Russia

The objectives were to study serotypes and antibiotic susceptibility of Streptococcus pneumoniae carried by healthy children attending a day-care centre in St. Petersburg. S. pneumoniae colonization was investigated in 125 children aged 16-70 months. Antibiotic susceptibility was determined by E-test and disk diffusion. 83 S. pneumoniae cases were isolated in 75/125 (60%) children: 36/75 (48%) in the nasopharynx, 12/75 (16%) in the oropharynx and 27/75 (36%) in both. Carriage rates were 100%, 68%, 72%, 46% and 54% in children aged 12-23, 24-35, 36-47, 48-59 and >or=60 months, respectively. 97.6% of isolates were susceptible to penicillin. 61.4%, 32.5%, 19.3%, 16.7% and 6% isolates were non-susceptible to trimethoprim/sulfamethoxazole, tetracycline, clindamycin, erythromycin and chloramphenicol, respectively. 20.5% of isolates were multidrug resistant (MDR). 45% of isolates were of serotypes included in the 7-valent pneumococcal conjugate vaccine (7V-PCV); 64.9%, 56.8%, 32.4% and 27% of 7V-PCV serotypes were resistant to trimethoprim/sulfamethoxazole, tetracycline, clindamycin and erythromycin, respectively. The respective figures for MDR isolates were 100%, 94.1%, 70.6% and 76.5%; 76.5% of all MDR isolates were covered by 7V-PCV.

IN CONCLUSION

1) resistance to trimethoprim/sulfamethoxazole and tetracycline was high; 2) resistance to macrolides was higher than in other Russian regions; 3) 7V-PCV coverage was modest, but the vaccine may potentially reduce MDR-S. pneumoniae.

Activity of faropenem against middle ear fluid pathogens from children with acute otitis media in Costa Rica and Israel

Faropenem was tested against 1,188 middle ear fluid pathogens from children in Israel and Costa Rica. Against Streptococcus pneumoniae and Haemophilus influenzae, faropenem was the most active beta-lactam, with activity that was similar to or greater than of the other oral antimicrobial classes studied. Faropenem was also active against Moraxella catarrhalis and Streptococcus pyogenes.

Acute otitis media in children aged less than 2 years: drug treatment issues

The management of acute otitis media (AOM) in childhood has evolved considerably during recent years as a result of the new insights provided by publication (in 2004) of the American Academy of Pediatrics and the American Academy of Family Physicians guidelines for the treatment of AOM. The new treatment guidelines establish a clear hierarchy among the various antibacterials used in the treatment of this disease and also the use of an age-stratified approach to AOM by recommending an observation strategy ('watchful waiting') without the use of antibacterials for some groups of patients with AOM. Infants and young children aged <2 years represent a target population characterized by a high incidence of AOM (and in particular of recurrent disease), lack of anatomic and physiologic maturity of airways, age-related immune humoral and cellular deficiencies, the presence of antibacterial-resistant pathogens, and a less efficient response to antibacterial treatment. Presently, the evidence accumulated in the literature is not sufficient to conclude that the role of antibacterials is only minimal in the management of AOM and that the watchful waiting policy is the most appropriate choice for patients aged <2 years with a certain AOM diagnosis. However, adherence to such a policy in patients with an uncertain or questionable AOM diagnosis and/or mild-to-moderate symptoms, in addition to its implementation in patients aged >2 years, could reduce substantially the use of antibacterials in children and play a major role in the strategy of decreasing antibacterial resistance.

An open-label, double tympanocentesis study of levofloxacin therapy in children with, or at high risk for, recurrent or persistent acute otitis media

BACKGROUND

Levofloxacin has excellent activity against common respiratory pathogens and therefore is likely to be effective in treating children with persistent or recurrent otitis media.

OBJECTIVE

The objective of this study was to assess the efficacy and safety of levofloxacin treatment in the eradication of bacterial pathogens from the middle ear fluid (MEF) of children with, or at high risk for, persistent or recurrent otitis media.

METHODS

An open-label multicenter trial was conducted that involved tympanocentesis at entry and selectively 3 to 5 days after starting levofloxacin (10 mg/kg twice a day for 10 days).

RESULTS

: Two hundred five children (80% < or =2 years) were enrolled. One child did not have a confirmed diagnosis of acute otitis media and did not return for follow-up visits. Of the remaining 204 children, 94 (46%) had bilateral infection and 63 (31%) were receiving antimicrobials immediately before entry. One hundred five isolates of Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis and Streptococcus. pyogenes were recovered in pure or mixed cultures. All isolates were susceptible to levofloxacin. During-treatment bacterial eradication from MEF occurred in 88% (78 of 89) of bacteriologically evaluable patients, including 90% (65 of 72) of children < or =24 months of age. Bacteria initially isolated from MEF were eradicated in 31 of 37 (84%) children infected with S. pneumoniae and in 54 of 54 (100%) children infected with H. influenzae. Overall, clinical success rate after therapy was 94% for the total study population and 92% for the bacteriologically evaluable population. Levofloxacin was well tolerated. Vomiting (4%) was the most common treatment-limiting adverse event.

CONCLUSIONS

Levofloxacin was safe and effective in treating and eradicating common bacterial pathogens from MEF in children with, or at risk for, recurrent or persistent otitis media.

Will reduction of antibiotic use reduce antibiotic resistance?: The pneumococcus paradigm

Community-acquired respiratory infections in general, and those caused by S. pneumoniae in particular, are the main reason for prescribing antimicrobials in young children. Antibiotic drug abuse is common. This is the basis for the initiative for the reduction in antibiotic use. However, failure to consider that not all antibiotics are similar in their effect on promotion of resistance has led to continuous emerging resistance. In the present article, the trends in prescribing antibiotics in young children and their interrelation with antibiotic resistance among clinical respiratory isolates of S. pneumoniae in children will be reviewed, along with theoretical considerations and research evidence that led to concluding that among antibiotics, the least resistance-promoting drug for S. pneumoniae is amoxicillin (+/- clavulanate), whereas oral cephalosporins and azithromycin demonstrate a higher resistance-promotion potential in the individual population in the community. Although antibiotics differ in their resistant-promotion potential, all still do promote resistance.

Long-term thyrotropin-suppressive therapy with levothyroxine impairs small and large artery elasticity and increases left ventricular mass in patients with thyroid carcinoma

BACKGROUND

Exogenous subclinical hyperthyroidism, caused by long-term thyrotropin (TSH)-suppressive treatment with levothyroxine (LT(4)), is associated with several cardiovascular abnormalities. In order to assess the effect of long-term thyroid hormone-suppressive therapy on the blood vessels and myocardium, we determined the arterial elasticity, using the pulse wave contour analysis.

METHODS AND RESULTS

Twenty-six athyreotic patients receiving TSH-suppressive LT(4) therapy for periods ranging from 3 to 21 years at a mean daily dose of 2.25 +/- 0.5 microg/kg per day were included in the study. Twenty six age- and gender-matched healthy subjects served as controls. Arterial elasticity of large and small arteries was evaluated using pulse wave contour analysis method (HDI CR 200, Eagen, MN). Cardiac structure was assessed by two-dimensional echocardiography. We found decreased large artery elasticity in subclinical hyperthyroidism (sHT) patients compared to controls (14.14 +/- 3.38 versus 10.53 +/- 2.43 L/mm Hg x 100, p < 0.000). Small artery elasticity was also lower in patients than in controls (5.42 +/- 1.82 versus 4.30 +/- 1.75 mL/mm Hg x 100, p < 0.056). The echocardiographic data showed significantly increased left ventricular (LV) mass index (101.90 +/- 18.61 versus 88.03 +/- 22.01 g/m(2), p < 0.049) and interventricular septum thickness (10.61 +/- 1.46 versus 9.11 +/- 1.13 mm, p < 0.002) in LT(4)-treated patients compared to controls.

CONCLUSIONS

We found impaired vascular elasticity of large and small arteries and increased LV mass in patients receiving long-term TSH-suppressive therapy with LT(4).