Association of Receiving a Fourth Dose of the BNT162b Vaccine With SARS-CoV-2 Infection Among Health Care Workers in Israel

IMPORTANCE

Despite the high 3-dose vaccination rate among health care workers (HCWs) in Israel, a high rate of SARS-CoV-2 breakthrough infections in this group was observed during the Omicron wave. As a result, the Israeli Ministry of Health decided to recommend a fourth vaccine dose to medical staff.

OBJECTIVE

To evaluate the benefit of a fourth BNT162b2 vaccine dose on the breakthrough infection rate among HCWs.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter cohort study was performed in January 2022, the first month of the 4-dose vaccination campaign, during a surge of the Omicron variant wave. All health care workers at 11 general hospitals in Israel who had been vaccinated with 3 doses up to September 30, 2021, and had not contracted COVID-19 before the vaccination campaign were included.

EXPOSURES

Vaccination with a fourth dose of the BNT162b2 vaccine during January 2022.

MAIN OUTCOMES AND MEASURES

Breakthrough COVID-19 infections in 4-dose recipients vs 3-dose recipients measured by a polymerase chain reaction test result positive for SARS-CoV-2. Health care workers were tested based on symptoms or exposure.

RESULTS

A total of 29 611 Israeli HCWs (19 381 [65%] female; mean [SD] age, 44 [12] years) had received 3 vaccine doses between August and September 2021; of these, 5331 (18%) received the fourth dose in January 2022 and were not infected by the first week after vaccination. Overall breakthrough infection rates were 368 of 5331 (7%) in the 4-dose group and 4802 of 24280 (20%) in the 3-dose group (relative risk, 0.35; 95% CI, 0.32-0.39). Similar reductions were found in a matched analysis by the exact day of receiving the third vaccine (relative risk, 0.61; 95% CI, 0.54-0.71) and in a time-dependent Cox proportional hazards regression model (adjusted hazard ratio, 0.56; 95% CI, 0.50-0.63). In both groups, no severe disease or death occurred.

CONCLUSIONS AND RELEVANCE

In this cohort study, the fourth BNT162b2 vaccine dose resulted in a reduced breakthrough infection rate among hospital staff. This reduction was lower than that observed after the third dose; nevertheless, considering the high infectivity of the Omicron variant, which led to critical medical staff shortages, a fourth vaccine dose should be considered to mitigate the infection rate among HCWs.

Translating a theory-based positive deviance approach into an applied tool: Mitigating barriers among health professionals (HPs) regarding infection prevention and control (IPC) guidelines

Background

Although a wide range of intervention programs and methods have been implemented to increase health professionals’ (HPs) adherence with infection prevention and control (IPC) guidelines and decrease the incidence of healthcare associated infections (HAIs), a significant discrepancy remains between the guidelines and their implementation in practice.

Objectives

This study proposes an applied tool based on the integrated theoretical framework of the positive deviance (PD) approach for developing more effective interventions to mitigate this discrepancy.

Methods

A qualitative study guided by the PD approach based on data from two sources: (1) in-depth archival analysis of systematic review articles, and (2) integration and synthesis of findings based on an extensive empirical study we conducted, involving 250 HPs (nurses, physicians, support staff and cleaning staff) from three governmental hospitals in Israel, over 35 months (January 2017 to November 2020).

Results

The barriers faced by HPs were classified into four main categories: (1) individual-motivational, (2) social-cultural, (3) organizational, and (4) work environment and resource-centered. For each barrier, we constructed a set of questions based on the PD approach. For each question, we adapted and applied methodological tools (e.g., in-depth interviews, focus groups, social network maps, video clips and simulations) to help solve the problem.

Conclusion

Translating a theory-based approach into an applied tool that offers step-by-step actions can help researchers and practitioners adopt and implement the approach within intervention programs to mitigate barriers.

Therapeutic Potential of Injectable Nano-Mupirocin Liposomes for Infections Involving Multidrug-Resistant Bacteria

Antibiotic resistance is a global health threat. There are a few antibiotics under development, and even fewer with new modes of action and no cross-resistance to established antibiotics. Accordingly, reformulation of old antibiotics to overcome resistance is attractive. Nano-mupirocin is a PEGylated nano-liposomal formulation of mupirocin, potentially enabling parenteral use in deep infections, as previously demonstrated in several animal models. Here, we describe extensive in vitro profiling of mupirocin and Nano-mupirocin and correlate the resulting MIC data with the pharmacokinetic profiles seen for Nano-mupirocin in a rat model. Nano-mupirocin showed no cross-resistance with other antibiotics and retained full activity against vancomycin-, daptomycin-, linezolid- and methicillin- resistant Staphylococcus aureus, against vancomycin-resistant Enterococcus faecium, and cephalosporin-resistant Neisseria gonorrhoeae. Following Nano-mupirocin injection to rats, plasma levels greatly exceeded relevant MICs for >24 h, and a biodistribution study in mice showed that mupirocin concentrations in vaginal secretions greatly exceeded the MIC₉₀ for N. gonorrhoeae (0.03 µg/mL) for >24 h. In summary, Nano-mupirocin has excellent potential for treatment of several infection types involving multiresistant bacteria. It has the concomitant benefits from utilizing an established antibiotic and liposomes of the same size and lipid composition as Doxil^®, an anticancer drug product now used for the treatment of over 700,000 patients globally.

Utilization of the Public Health Ordinance to prevent nosocomial spread in a case of acute measles-associated psychosis

Measles is a highly contagious disease. A 24 years old patient, recently exposed to measles (unvaccinated), presented in the emergency department with severe agitation, compatible with an acute psychotic episode, during the measles epidemic which spread in Israel in 2018-2019. Upon hospital admission, strict isolation was instructed, yet, without compliance, probably due to the patient's status. Measles diagnosis was promptly confirmed. As measles transmission was eminent, public health measures were employed through immediate implementation of the section 15 of the Public Health Ordinance, allowing for compulsory short-term isolation. The patient's condition improved within a few days and the measures were no longer necessary. This measles case occurred in the pre-Coronavirus disease 2019 (COVID-19) epidemic when use of a Public Health Ordinance was considered an extreme measure. This is in contrast to the current global use of Public Health laws to enforce strict quarantine and isolation on persons infected or potentially exposed to COVID-19. Nevertheless, minimizing infectious diseases transmission is a core function of public health law. Utilizing legal enforcement in circumstances of immediate public health hazard, such as nosocomial measles transmission, necessitates careful consideration. The integrative clinical and public health approach and prompt measures employed in this exceptional case, led to prevention of further infection spread.

Successful Treatment of Antibiotic-resistant, Poly-microbial Bone Infection With Bacteriophages and Antibiotics Combination

A patient with a trauma-related left tibial infection associated with extensively drug-resistant Acinetobacter baumannii and multidrug-resistant Klebsiella pneumoniae was treated with bacteriophages and antibiotics. There was rapid tissue healing and positive culture eradication. As a result, the patient's leg did not have to be amputated and he is undergoing rehabilitation.

Is it financially beneficial for hospitals to prevent nosocomial infections?

Background

Financial incentives represent a potential mechanism to encourage infection prevention by hospitals. In order to characterize the place of financial incentives, we investigated resource utilization and cost associated with hospital-acquired infections (HAI) and assessed the relative financial burden for hospital and insurer according to reimbursement policies.

Methods

We conducted a prospective matched case-control study over 18 months in a tertiary university medical center. Patients with central-line associated blood-stream infections (CLABSI), Clostridium difficile infection (CDI) or surgical site infections (SSI) were each matched to three control patients. Resource utilization, costs and reimbursement (per diem for CLABSI and CDI, diagnosis related group (DRG) reimbursement for SSI) were compared between patients and controls, from both the hospital and insurer perspective.

Results

HAIs were associated with increased resource consumption (more blood tests, imaging, antibiotic days, hospital days etc.). Direct costs were higher for cases vs. controls (CLABSI: $6400 vs. $2376 (p < 0.001), CDI: $1357 vs $733 (p = 0.047) and SSI: $6761 vs. $5860 (p < 0.001)). However as admissions were longer following CLABSI and CDI, costs per-day were non-significantly different (USD/day, cases vs. controls: CLABSI, 601 vs. 719, (p = 0.63); CDI, 101 vs. 93 (p = 0.5)). For CLABSI and CDI, reimbursement was per-diem and thus the financial burden ($14,608 and $5430 respectively) rested on the insurer, not the hospital. For SSI, as reimbursement was per procedure, costs rested primarily on the hospital rather than the insurer.

Conclusion

Nosocomial infections are associated with both increased resource utilization and increased length of stay. Reimbursement strategy (per diem vs DRG) is the principal parameter affecting financial incentives to prevent hospital acquired infections and depends on the payer perspective. In the Israeli health care system, financial incentives are unlikely to represent a significant consideration in the prevention of CLABSI and CDI.

2223. Real-time Prediction of Respiratory Pathogen Infection Based on Machine Learning Decision Support Tool

Background

Respiratory pathogens are a common cause of disease. Currently there is not a practical tool to predict the putative etiology of each case with an inexpensive, fast point-of-care assay. Here, we describe a decision support tool that enables the prediction of both bacterial and viral respiratory pathogen infections in a single patient, using a Machine Learning model.

Methods

The data were obtained from the Hadassah-Hebrew University Medical Center during a period of 10 years beginning from 2007 and contained more than 40,000 patients from a 1,000,000-population community for whom specimens were tested by either PCR or culture. The pathogens included were, H. influenzae; M. catarrhalis; S. pneumoniae; M. pneumoniae; Adenovirus; Human metapneumovirus; Influenza H1N1, A, B; parainfluenza 1,2 and 3; and RSV. We then created a Machine-Learning algorithm to simulate the spread of infection in the entire Jerusalem area. We defined transmission areas based on geographical distances of patients’ home-addresses. Then we prospectively tested the tool accuracy over a 4-month period, in addition to real-time improvement of the model.

Results

Initial model was created based on gender, age, home addresses and the diagnostics test results. We then reconstructed a putative spread pattern for each of the pathogens that can be correlated to potential “transmission routes.” The initial prediction tool had an AUC for most pathogens around 0.85. It ranged from 0.75 to 0.8 for the bacterial and 0.82 to 0.89 for the viral pathogens. In almost all pathogens the NPV was 0.98–0.99. We then tested the decision support tool prospectively over four consecutive months (January to April 2019—1,700 patients with respiratory complaints from whom samples were sent to the lab). While the AUC in the prospective cohort was 0.81 on average, the NPV remained high on 0.98.

Conclusion

The implementation of the decision support tool on respiratory pathogen diagnostics enables better prediction of patients not infected with either viral or bacterial pathogens. The use of such a tool can save more than 50% of diagnostic tests expenses as well as real-time mapping of disease spread. Improvement of the Machine Learning protocol may further promote the optimization of positive predictive values.

Disclosures

All authors: No reported disclosures.

Deconstruction of central line insertion guidelines based on the positive deviance approach-Reducing gaps between guidelines and implementation: A qualitative ethnographic research

Background

Despite a proven association between the implementation of prevention guidelines for central line associated blood stream infections (CLABSI) and reduction in CLABSI rates, in practice there is poor adherence. Furthermore, current guidelines fail to address the multiple process on the care continuum. This research is based on the bottom-up "Positive Deviance" (PD) approach, through which multiple creative and safer solutions for central line (CL) insertion were identified that were not previously described in the guidelines. The aim of the study was to deconstruct CLABSI prevention guidelines ("during insertion" process only) through the PD approach, working with physicians to identify additional actions that, in practice, help maintain a sterile environment and contribute to patient safety.

Methods and findings

Our study included a qualitative ethnographic study involving 76 physicians, working in a division of internal medicine and two intensive care units (ICUs). We triangulated findings from a combination of data-collection methods: semi-structured interviews, focused observations, video documentation, Discovery & Action Dialogue (DAD), and simulations. Deconstruction analysis was performed. A total of 23 creative extensions and variations of CL insertion practices were identified.

Conclusions

The PD approach enables the identification of vital nuggets of hidden wisdom missing from the formal explicit CLABSI guidelines, and therefore helps bridge the gap between theory and praxis. During the guideline's deconstruction process, through collaborative staff learning, the written procedure is transformed into a living, breathing and cooperative one. It can reduce hospital stays and save lives, and therefore needs careful attention of healthcare scholars and practitioners.

A simplified blood culture sampling protocol for reducing contamination and costs: a randomized controlled trial

OBJECTIVES

Blood culture contamination carries risks for patients, such as unnecessary antimicrobial therapy and other additional hazards and costs. One method shown to be effective in reducing contamination is initial blood specimen diversion during collection. We hypothesized that initial blood specimen diversion without a designated device or procedure would suffice for reduction in blood culture contamination rate.

METHODS

From 1 September 2017 through to 6 September 2018, we conducted a randomized controlled trial to assess the effect of an initial-specimen diversion technique (ISDT) on the rate of blood-culture contamination by changing the order of sampling using regular vacuum specimen tubes instead of commercially available sterile diversion devices. We included adults from whom the treating physician planned to take blood cultures and additional blood chemistry tests. Additionally, we evaluated the potential economic benefits of an ISDT. This was a researcher-initiated trial, Clinicaltrials.gov NCT03088865.

RESULTS

In all, 756 patients were enrolled. This method, compared with the standard procedure in use at our medical centre, reduced contamination by 66% (95% CI 17%-86%), from 20/400 (5%) with the standard method to 6/356 (1.6%) with the ISDT, without compromising detection of true bloodstream infection and at no additional cost. Hospital-wide implementation of ISDT was associated with a 1.1% saving in hospitalization days.

CONCLUSIONS

We offer this novel approach as a simple, cost-effective measure to reduce risks to patient safety from contaminated blood cultures, without the need for using costly devices.

Early onset, non-rheumatic, group A streptococcal-associated myocarditis

OBJECTIVES

Group A streptococcal (GAS) tonsillitis is reported as an uncommon cause of acute non-rheumatic fever (non-RF) myocarditis. The aim of this research was to study the occurrence, diagnosis, management and prognosis of this condition.

METHODS

We conducted a retrospective computerised search through medical records of patients admitted to our tertiary medical center between 1998-2016 with the diagnosis of either acute rheumatic fever or non-RF streptococcal myocarditis based on criteria we developed and review the relevant literature from 1973-2016.

RESULTS

We identified 283 cases diagnosed with acute myocarditis. Eight patients with non-RF GAS-myocarditis were identified, 7 of whom were men. Average age was 28.5 (22-35) years, and average latency period between onset of sore throat and chest pain 4.8 (3-10) days. Most patients presented with ST-segment elevations on the ECG and 2 underwent coronary catheterisation with presumed diagnosis of myocardial infarction. Three patients had heart failure, as documented by echocardiogram. All patients were treated with antibiotics and 6 patients received non-steroidal anti-inflammatory drugs (NSAIDs). All patients recovered with no evidence of heart failure a few months after the initial infection. One patient had a recurrent episode.

CONCLUSIONS

Non-RF GAS myocarditis typically affects healthy young males and represents about 3% of all hospitalised patients with myocarditis. These patients may be mistakenly diagnosed with an acute rheumatic fever or myocardial infarction. The prognosis in generally good following treatment with antibiotics and possibly NSAIDs.

Access-related infections in two haemodialysis units: results of a nine-year intervention and surveillance program

Background

Access-related infections are a major cause of morbidity and mortality in haemodialysis patients. Our goal was to decrease the rate of these infections by implementing an intervention and surveillance program.

Methods

This intervention took place in two haemodialysis units (Units A and B) and was a joint effort by the haemodialysis staff and the unit for infection prevention and control. It included reviewing the work methods and work space, observations on compliance with standard precautions and handling of the vascular access, creating a checklist and a designated kit for handling the vascular access and prospective surveillance of access-related infections.

Results

During a nine-year period, the haemodialysis units A and B treated 4471 and 7547 patients (mean number of patients per year: 497 (range 435–556) and 839 (range 777–1055), respectively). For most patients, the procedure was done through an arteriovenous fistula (66.7%, range 50.3–81.5%). The access-related infection rate decreased significantly in both haemodialysis units: from 3 to 0.9% (trend: p < 0.05, linear regression: p < 0.001) in Unit A and from 0.9 to 0.2% (trend: p < 0.05, linear regression: p = 0.01) in Unit B.

Conclusions

An intervention which included introduction of a checklist and designated kit, together with ongoing surveillance and feedback, resulted in a significant decrease in the access-related infection rates in both haemodialysis units.

Staphylococcus aureus Bacteremia in Children: Antibiotic Resistance and Mortality

BACKGROUND

Staphylococcus aureus (SA) is a major cause of bacteremia in children. Methicillin-resistant SA (MRSA) is considered a public health threat; however, the differences in the prognosis of children with methicillin-susceptible SA (MSSA) versus MRSA bacteremia are not well defined.

METHODS

Data from all SA bacteremia events in children (0-16 years) from 2002 to 2016 in a single Israeli tertiary center were collected. Positive cultures within 48 hours of hospitalization were considered community associated (CA). Those obtained afterward or from children hospitalized within the previous year were considered health-care associated (HA).

RESULTS

We recorded 427 events, 284 (66%) were HA, 64 (15%) were MRSA and 9 (2%) were CA-MRSA. There was no increase in MRSA during the study period. In-hospital, 30-day and 1-year mortality were 3% (12 cases), 3.5% (16 cases), and 12% (50 cases), respectively. A multivariable analysis controlling for demographics, admitting department and prior morbidity showed an increased 1-year mortality in children with HA bacteremia (hazard ratio [HR] 4.1; 95% confidence interval [CI]: 1.3-12) and prior chronic disease (HR 3.4; 95% CI 1.2 to 9.0). MRSA was not independently associated with increased one-year mortality compared with MSSA: HR (95% CI: 1.4 [0.6-3.1]).

CONCLUSIONS

Short-term pediatric mortality after SA bacteremia is low. HA-SA bacteremia has an increased long-term risk for mortality, particularly in children with chronic diseases. Our data suggest mortality was not increased for MRSA compared with MSSA bacteremia. The very low rate of CA-MRSA bacteremia justifies the current practice not to include glycopeptides in the empiric treatment of CA bacteremia in Israel.

Obstacles to the successful introduction of an electronic hand hygiene monitoring system, a cohort observational study

Background

Hand hygiene (HH) compliance remains low in many intensive care units (ICU). Technology has been suggested to improve HH compliance.

We describe the introduction of an electronic HH surveillance and intervention system into the general ICU of a tertiary care teaching hospital, the obstacles to success and reasons for the system’s ultimate failure and removal.

Methods

The system was based on radiofrequency transmitters in patient areas, on HH dispensers, and individual personal bracelets. The transmitters were connected to a central computer. The system was designed to detect entry and exit from patient areas and provide real time alerts of missed HH performance.

A staff satisfaction questionnaire was administered followed by validation of system accuracy. Electronic data were compared to human observer data collected during defined observation periods.

Results

Data from 41 questionnaires revealed low satisfaction rate (21/41, 51%). Low system accuracy (31/41, 76%) and inconvenience (18/41, 44%) being the most frequent reasons.

During 44 one hour observation periods the observer recorded more HH opportunities and performances than the electronic system (mean number of HH opportunities/hour 10.9 ± 7.6 vs 6.8 ± 6.9, p < 0.001, correlation r = 0.75, p < 0.001, and performances/hour 8.7 ± 3.9 vs 6.0 ± 3.1, p < 0.001, correlation r = 0.60, p < 0.001, respectively). Correlation between observer and HH electronic system was very low (correlation coefficient r = 0.03, p = 0.91).

Conclusions

The electronic HH system was not accepted by ICU staff principally due to inaccuracy and inconvenience. Inaccuracies were verified by direct observations. In order for an electronic HH system to succeed we suggest it must be highly accurate and comfortable to use.

Seroprevalence of anti-Toxoplasma gondii IgG antibody and risk factors among abattoir workers in Uyo, Southern Nigeria

Context

The asymptomatic nature of toxoplasmosis with its severe consequences, especially in populations with high HIV infection rate, makes it a disease of public health importance. Being a zoonosis, Toxoplasma gondii infection may be high among people who work with animals. Thus, there is the need to determine the prevalence of the infection among abattoir workers in Uyo, where HIV prevalence rate is in double digits, which could lead to reactivation of toxoplasmosis in those with immunosuppression.

Aim

To determine the prevalence and associated risk factors of T. gondii infection in abattoir workers in Uyo.

Settings and Design

A descriptive cross-sectional study that was conducted among persons who work with livestock and birds, in Uyo and its environs.

Methodology

The study was conducted among 339 workers in abattoirs in Uyo and its environs. Data were collected using interviewer-administered questionnaire and detection of IgG antibodies to T. gondii using ELISA technique and HIV testing using the national algorithm. Data were analyzed using STATA statistical software version 20, and statistically significant level was set at P < 0.05.

Results

The seroprevalence of T. gondii IgG antibodies among the study participants was 55.8%. At a univariate level, many factors were associated with T. gondii seropositivity; they were age, sex, level of education, ethnicity, occupation in the abattoir, type of animal exposure, always washing hands before eating in the workplace, and taking of raw/unpasteurized milk. However, after multivariate analysis, participants exposed to poultry, butchers/raw meat sellers, and those who had worked for more than 5 years in abattoirs were at a greater risk of being T. gondii IgG seropositive; odds ratio (OR) 5.46 [confidence interval (CI) 1.88, 15.86]; OR 1.89 (CI 1.14, 3.14), and OR 1.25 (CI 1.25, 6.42), respectively.

Conclusion

T. gondii IgG seroprevalence is high among abattoir workers in Uyo, and there is a need for Akwa Ibom State government to establish enlightenment and prevention programs for these occupationally exposed and other populations at risk of infection.

Risk factors, clinical course and outcomes of pregnancy-related group A streptococcal infections: retrospective 13-year cohort study

OBJECTIVES

To investigate the incidence, risk factors, clinical course and outcomes of pregnancy-related group A streptococcus (GAS) infection.

METHODS

A retrospective 13-year cohort study of culture-proven pregnancy-related GAS infection was performed at two university hospitals serving heterogeneous, multicultural, urban and rural populations.

RESULTS

Of 124 women diagnosed with pregnancy-related GAS infection, 115 (93%) were in the puerperium, an incidence of 0.8 cases per 1000 live births (95% confidence interval, 0.7-0.9). A multivariate analysis showed primiparity and cesarean delivery to be independent protective factors against puerperal GAS infection (adjusted odds ratios (95% confidence interval), 0.60 (0.38, 0.97) and 0.44 (0.23, 0.81), respectively). Of the nine remaining patients, eight were diagnosed after first trimester abortions and one had an infected ectopic pregnancy. Among the entire cohort (n = 124), the predominant manifestations were fever and abdominal tenderness. Twenty-eight patients (23%) had severe GAS infections. All were treated with β-lactams, and most (n = 104, 84%) received clindamycin. Only four (3%) required surgical intervention; the rest fully recovered with conservative medical treatment including antibiotics. No recurrences, maternal deaths or neonatal complications were noted.

CONCLUSIONS

Pregnancy-related GAS infection is not rare; it lacks specific signs and still carries significant morbidity. Primiparity, a presumable surrogate for diminished exposure to children and thus less GAS carriage, and cesarean delivery in which perioperative antibiotic prophylaxis was uniformly provided, appear as protective factors against puerperal GAS infection. This hints to the importance of community-acquired GAS and may support shifting efforts from infection-control-oriented nosocomial investigations to screening and prevention-driven policies.

Clinically applicable irreversible electroporation for eradication of micro-organisms

Irreversible electroporation (IRE) damages cell membranes and is used in medicine for nonthermal ablation of malignant tumours. Our aim was to evaluate the antimicrobial effect of IRE. The pathogenic micro-organisms, Staphylococcus aureus, Streptococcus pyogenes, Escherichia coli, Pseudomonas aeruginosa and Candida albicans were subjected to IRE. Survival was measured as a function of voltage and the number of pulses applied. Combined use of IRE and oxacillin for eradication of Staph. aureus was also tested. Log10 reduction in micro-organisms positively correlated with the number of applied pulses. The colony count of Strep. pyogenes and E. coli declined by 3·38 and 3·05 orders of magnitude, respectively, using an electric field of 2000 V and 100 pulses. Killing of Staph. aureus and P. aeruginosa was achieved with a double cycle of IRE (2000, 1500 V and repeated 1250 V respectively) of 50-100 IRE pulses. The addition of subclinical inhibitory concentrations of oxacillin to the Staph. aureus suspension prior to IRE led to total bacterial death, demonstrating synergism between oxacillin and IRE. Our results demonstrate that using IRE with clinically established parameters has a marked in vitro effect on pathogenic micro-organisms and highlights the potential of IRE as a treatment modality for deep-seated infections, particularly when combined with low doses of antibiotics.

SIGNIFICANCE AND IMPACT OF THE STUDY

Irreversible electroporation (IRE) is utilized in interventional radiology to treat cancer patients. In this study we evaluated in vitro the antimicrobial effect of IRE. We demonstrated that using IRE with clinically established parameters has a marked effect on pathogenic micro-organisms and is synergistic to antimicrobials when both are combined. Our results point to the potential of IRE as a treatment modality for deep-seated infections.

Reduction of health care-associated infection indicators by copper oxide-impregnated textiles: Crossover, double-blind controlled study in chronic ventilator-dependent patients

BACKGROUND

Copper oxide has potent wide-spectrum biocidal properties. The purpose of this study is to determine if replacing hospital textiles with copper oxide-impregnated textiles reduces the following health care-associated infection (HAI) indicators: antibiotic treatment initiation events (ATIEs), fever days, and antibiotic usage in hospitalized chronic ventilator-dependent patients.

METHODS

A 7-month, crossover, double-blind controlled trial including all patients in 2 ventilator-dependent wards in a long-term care hospital. For 3 months (period 1), one ward received copper oxide-impregnated textiles and the other received untreated textiles. After a 1-month washout period of using regular textiles, for 3 months (period 2) the ward that received the treated textiles received the control textiles and vice versa. The personnel were blinded to which were treated or control textiles. There were no differences in infection control measures during the study.

RESULTS

There were reductions of 29.3% (P = .002), 55.5% (P < .0001), 23.0% (P < .0001), and 27.5% (P < .0001) in the ATIEs, fever days (>37.6°C), days of antibiotic treatment, and antibiotic defined daily dose per 1,000 hospitalization days, respectively, when using the copper oxide-impregnated textiles.

CONCLUSIONS

Use of copper oxide-impregnated biocidal textiles in a long-term care ward of ventilator-dependent patients was associated with a significant reduction of HAI indicators and antibiotic utilization. Using copper oxide-impregnated biocidal textiles may be an important measure aimed at reducing HAIs in long-term care medical settings.

Analysis of Influenza and RSV dynamics in the community using a 'Local Transmission Zone' approach

Understanding the dynamics of pathogen spread within urban areas is critical for the effective prevention and containment of communicable diseases. At these relatively small geographic scales, short-distance interactions and tightly knit sub-networks dominate the dynamics of pathogen transmission; yet, the effective boundaries of these micro-scale groups are generally not known and often ignored. Using clinical test results from hospital admitted patients we analyze the spatio-temporal distribution of Influenza Like Illness (ILI) in the city of Jerusalem over a period of three winter seasons. We demonstrate that this urban area is not a single, perfectly mixed ecology, but is in fact comprised of a set of more basic, relatively independent pathogen transmission units, which we term here Local Transmission Zones, LTZs. By identifying these LTZs, and using the dynamic pathogen-content information contained within them, we are able to differentiate between disease-causes at the individual patient level often with near-perfect predictive accuracy.

Increased rates of intensive care unit admission in patients with Mycoplasma pneumoniae: a retrospective study

Mycoplasma pneumoniae is a leading cause of respiratory disease. In the Intensive Care Unit (ICU) setting M. pneumoniae is not considered a common pathogen. In 2010-13 an epidemic of M. pneumoniae-associated infections was reported and we observed an increase of M. pneumoniae patients admitted to ICU. We analysed the cohort of all M. pneumoniae-positive patients' admissions during 2007 to 2012 at the Hadassah-Hebrew University Medical Centre (a 1100-bed tertiary medical centre). Mycoplasma pneumoniae diagnosis was made routinely using PCR on throat swabs and other respiratory samples. Clinical parameters were retrospectively extracted. We identified 416 M. pneumoniae-infected patients; of which 68 (16.3%) were admitted to ICU. Of these, 48% (173/416) were paediatric patients with ICU admission rate of 4.6% (8/173). In the 19- to 65-year age group ICU admission rate rose to 18% (32/171), and to 38.8% (28/72) for patients older than 65 years. The mean APACHE II score on ICU admission was 20, with a median ICU stay of 7 days, and median hospital stay of 11.5 days. Of the ICU-admitted patients, 54.4% (37/68) were mechanically ventilated upon ICU admission. In 38.2% (26/68), additional pathogens were identified mostly later as secondary pathogens. A concomitant cardiac manifestation occurred in up to 36.8% (25/68) of patients. The in-hospital mortality was 29.4% (20/68) and correlated with APACHE II score. Contrary to previous reports, a substantial proportion (16.3%) of our M. pneumoniae-infected patients required ICU admission, especially in the adult population, with significant morbidity and mortality.

Nano-mupirocin: enabling the parenteral activity of mupirocin

Mupirocin is an antibiotic having a unique mode of action, not shared by any other therapeutically available antibiotic. However, due to its rapid elimination following injection and high protein binding, current therapeutic use is limited to topical administration. Computational methods have identified mupirocin as a good candidate for delivery via long-circulating nano-liposomes. Formulating mupirocin in such liposomes to form Nano-mupirocin protects the drug in the circulation, enabling therapeutic efficacy. This was demonstrated using two different animal models that served as a proof of concept: the mice

Sandfly virus seroconversion associated with neurologic presentation

Objective:

To describe the clinical presentation and unique neurologic manifestations of sandfly viruses (SFVs) in the Jerusalem area.

Methods:

We identified all patients with acute seroconversion to SFV at the Hadassah-Hebrew University Medical Centers during the years 2008–2013 and retrospectively collected and analyzed the clinical and imaging data.

Results:

Nine patients (ranging from 1.5 to 85 years old) were identified. Presentation included acute neurologic disease, mostly with fever, change in consciousness and behavior, seizures, headache, meningitis, limb paresis, or myelitis. Eight patients had clinical signs of meningitis, meningoencephalitis, or encephalitis alone. Four patients had myelitis. MRI identified pathologic symmetrical changes in the basal ganglia, thalami, and other deep structures in 5 patients, and additional myelitis of the spine was noted on imaging in 3 patients. Seven patients had long-term follow-up: 4 completely recovered and 3 had remaining neurologic sequelae, among them 1 with permanent severe brain damage.

Conclusion:

Neurologic involvement associated with acute SFV infections is considered to be benign. However, in this series, all 9 patients presented with significant neurologic pathology associated with a unique finding of myelitis and symmetrical basal ganglia, thalami, or white matter involvement. Thus, acute SFV infection should be included in the differential diagnosis in febrile onset of neurologic manifestations and neuroradiologic changes.

Reduction in incidence of invasive fungal infection in patients receiving allogeneic stem cell transplantation using combined diagnostic-driven approach and itraconazole oral solution

Invasive fungal infections are an important cause of morbidity and mortality after allogeneic haematopoietic stem cell transplantation. We evaluated, in our allogeneic stem cell transplant patients, the effect on the incidence of invasive fungal infection during neutropenia of a strategy combining a diagnostic-driven approach with chemoprophylaxis during higher risk periods of graft vs. host disease and prolonged neutropenia, using itraconazole oral solution with parenteral voriconazole bridging. One hundred and thirty patients admitted for allogeneic stem cell transplantation within two predefined 20 month periods were included in the study. Data for all patients were collected prospectively. Implementation of the protocol resulted in the administration of more prophylactic antifungals to more patients. Following implementation, there was a non-significant decrease in the overall number of invasive fungal infections (IFI) [11 of 65 patients (17.2%) vs. 4 of 65 patients (6.2%, P = 0.051)], as well as in the occurrence of invasive mould infections [8 of 65 patients (12.5%) vs. 2 of 65 patients (3.1%, P = 0.054)]. Survival rates at three and 6 months were not significantly affected. A combined diagnostic-driven approach and antifungal prophylaxis with oral itraconazole and an intravenous voriconazole bridging protocol, was associated with a reduced, albeit non-statistically significant, number of IFI in our medical centre.

The CD48 receptor mediates Staphylococcus aureus human and murine eosinophil activation

BACKGROUND

Allergy is characterized by eosinophilia and an increased susceptibility to microbial infection. Atopic dermatitis (AD) is typically associated with Staphylococcus aureus (SA) colonization. Some of the mechanisms by which SA and its exotoxins interact with eosinophils remain elusive. CD48, a glycosylphosphatidylinositol-anchored receptor belonging to the CD2 family, participates in mast cells-SA stimulating cross-talk, facilitates the formation of the mast cell/eosinophils effector unit and as expressed by eosinophils, mediates experimental asthma.

OBJECTIVE

To investigate the role of CD48 expressed on human peripheral blood and mouse bone marrow-derived eosinophils (BMEos) in their interaction with heat-killed SA and its three exotoxins, Staphylococcal enterotoxin B (SEB), protein A (PtA) and peptidoglycan (PGN).

METHODS

Eosinophils were obtained from human peripheral blood and BM of WT and CD48-/- mice. SA was heat killed and eosinophils-SA/exotoxins interactions were analyzed by confocal microscopy, adhesion and degranulation, cell viability, cytokine release and cell signalling. In addition, peritonitis was induced by SEB injection into CD48-/- and WT mice. CD48 expression was studied in AD patients' skin and as expressed on their leucocytes in the peripheral blood.

RESULTS

We provide evidence for the recognition and direct physical interaction between eosinophils and SA/exotoxins. Skin of AD patients showed a striking increase of eosinophil-associated CD48 expression while on peripheral blood leucocytes it was down-regulated. SA/exotoxins enhanced CD48 eosinophil expression, bound to CD48 and caused eosinophil activation and signal transduction. These effects were significantly decreased by blocking CD48 on human eosinophils or in BMEos from CD48-/- mice. We have also explored the role of CD48 in a SEB-induced peritonitis model in CD48-/- mice by evaluating inflammatory peritoneal cells, eosinophil numbers and activation.

CONCLUSIONS

These data demonstrate the important role of CD48 in SA/exotoxins-eosinophil activating interactions that can take place during allergic responses and indicate CD48 as a novel therapeutic target for allergy and especially of AD.

Institutional Control Measures to Curtail the Epidemic Spread of Carbapenem-Resistant Klebsiella pneumoniae: A 4-Year Perspective

Objective.

To describe the implementation of an institution-wide, multiple-step intervention to curtail the epidemic spread of carbapenem-resistant Klebsiella pneumoniae (CRKP).

Design.

Consecutive intervention analyses.

Patients and Setting.

All patients admitted to a 775-bed tertiary care medical center in Jerusalem, Israel, from 2006 through 2010.

Interventions.

The effects of 4 interventions were assessed: (1) a policy of isolation for patients colonized or infected with CRKP in single rooms, which was started in March 2006; (2) cohorting of CRKP patients with dedicated nursing staff and screening of patients neighboring a patient newly identified as a carrier of CRKP, which was started in March 2007; (3) weekly active surveillance of intensive care unit patients, which was started during August 2008; and (4) selective surveillance of patients admitted to the emergency department, which was started in March 2009. Interrupted regression analysis and change-point analysis were used to assess the effect of each intervention on the CRKP epidemic.

Results.

Patient isolation alone failed to control the spread of CRKP, with incidence increasing to a peak of 30 new cases per 1,000 hospital beds per month. Institution of patient cohorting led to a steep decline in the incidence of CRKP acquisition (P< .001). Introduction of active surveillance interventions was followed by a decrease in the incidence of CRKP-positive clinical cultures but an increase in the incidence of CRKP-positive screening cultures. The mean prevalence of CRKP positivity for the period after cohorting began showed a statistically significant change from the mean prevalence in the preceding period (P< .001).

Conclusions.

The cohorting of patients with dedicated staff, combined with implementation of focused active surveillance, effectively terminated the epidemic spread of CRKP. Cohorting reduced cross-infection within the hospital, and active surveillance allowed for earlier detection of carrier status. Both interventions should be considered in attempts to contain a hospital epidemic.

False negative β-2 transferrin in the diagnosis of cerebrospinal fluid leak in the presence of Streptococcus pneumoniae

OBJECTIVES/HYPOTHESIS

The objectives of this study were to examine the presence of β-2 transferrin (β2TRNSF) in cerebrospinal fluid (CSF) contaminated in vitro by various bacteria and explore the mechanism (passive or active) responsible for β2TRNSF elimination. Early diagnosis of CSF leakage may change treatment decisions and minimize the risk of meningitis and encephalitis. β2TRNSF is a protein present exclusively in CSF. Its detection is highly useful in cases of CSF leakage, although it has never been examined in the presence of central nervous system infection.

STUDY DESIGN

Prospective patient analysis.

METHODS

Sterile CSF drawn from patients was contaminated in vitro with several microorganisms chosen for their ability to cause neurosurgical-related infections: Streptococcus pneumoniae, methicillin-sensitive Staphylococcus aureus, Staphylococcus epidermidis, and Pseudomonas aeruginosa. β2TRNSF was examined at two time points: following immediate inoculation (t0) and following an overnight incubation (t18) over various bacterial concentrations. Samples of CSF inoculated with S pneumoniae were also examined in the presence of ciprofloxacin. For β2TRNSF analysis we used immunoblotting electrophoresis and enzyme-linked immunosorbent assay (ELISA).

RESULTS

CSF samples collected from nine patients were analyzed. β2TRNSF was not detected following S pneumoniae inoculation at both time points when immunoblotting electrophoresis was used. Quantitative analysis using ELISA demonstrated significant β2TRNSF concentration decrease. The addition of ciprofloxacin led to the same results.

CONCLUSIONS

CSF leak detection using β2TRNSF may be deceiving in the presence of a S pneumoniae cerebral nervous system infection. A passive process is suggested, as β2TRNSF disappeared either immediately or following incubation with inactive bacteria.

Epidemiology of infective endocarditis in a tertiary-center in Jerusalem: a 3-year prospective survey

BACKGROUND

Epidemiological features of infective endocarditis have changed during the last decades because of increases in the prevalence of health care exposure and of Staphylococcus aureus bloodstream infection. Consequently, the role of surgery is evolving. We aim to provide a contemporary profile of epidemiological, microbiological, and clinical features of infective endocarditis in a tertiary medical center, and identify predictors of mortality.

METHODS

A prospective observational cohort study of consecutive adult patients with definite endocarditis according to the modified Duke criteria. Data were collected from January 1, 2009 through October 31, 2011 following a predefined case report form designed by the ICE-PCS.

RESULTS

Among 70 endocarditis episodes, 25.7% involved prosthetic valves and 11.5% were device related. Forty-four percent of episodes were health-care associated. The predominant causative microorganism on native valve, prosthetic valve and device related endocarditis was Staphylococcus aureus (33.3%). Viridans group streptococci accounted for the majority of community-acquired endocarditis (36.1%). At least one complication occurred in 50% of the episodes. One third of the patients who had an indication for surgery were operated upon. Six month case fatality ratio was 40%. Sixty-five percent of patients with a contraindication to surgery died, compared with 9% and 28.5% who were treated surgically and medically, respectively. In multivariable analysis, age was a predictor of mortality.

CONCLUSION

Compared with other series, we observed more health-care associated endocarditis, and a higher mortality. Nearly half of all deaths were in patients who had a contraindication to surgery. Careful evaluation of contraindications to surgery is warranted.

Visceral cat scratch disease with endocarditis in an immunocompetent adult: a case report and review of the literature

Infective endocarditis and hepatosplenic abscesses are rare manifestations of cat scratch disease (CSD), especially among immunocompetent adults. An otherwise healthy woman who presented with fever and abdominal pain was diagnosed with multiple abscesses in the spleen and the liver, as well as a mitral valve vegetation. PCR on spleen tissue was positive for Bartonella henselae. Prolonged treatment with doxycycline and gentamicin led to complete recovery. Review of the literature revealed 18 cases of hepatosplenic CSD in immunocompetent adults; the majority presented with fever of unknown origin and abdominal pain. In most cases the causative organism was B. henselae and the pathological findings were necrotizing granulomas, similar to the pathological features in classic CSD. Concomitant endocarditis was diagnosed in one case. Because Bartonella is one of the leading pathogens of culture-negative endocarditis, we raise the question of whether a comprehensive evaluation for endocarditis is needed in cases of systemic CSD.

Déjà vu: Ralstonia mannitolilytica infection associated with a humidifying respiratory therapy device, Israel, June to July 2011

Following a bloodstream infection in June 2011 with Ralstonia mannitolilytica in a premature infant treated with a humidifying respiratory therapy device, an investigation was initiated at the Hadassah Medical Centres in Jerusalem. The device delivers a warmed and humidified mixture of air and oxygen to patients by nasal cannula. The investigation revealed colonisation with R. mannitolilytica of two of 15 patients and contamination of components of five of six devices deployed in the premature units of the Hadassah hospitals. Ten isolates from the investigation were highly related and indistinguishable from isolates described in an outbreak in 2005 in the United States (US). Measures successful in containing the US outbreak were not included in user instructions provided to our hospitals by the distributor of the device.

Déjà vu: Ralstonia mannitolilytica infection associated with a humidifying respiratory therapy device, Israel, June to July 2011

Following a bloodstream infection in June 2011 with Ralstonia mannitolilytica in a premature infant treated with a humidifying respiratory therapy device, an investigation was initiated at the Hadassah Medical Centres in Jerusalem. The device delivers a warmed and humidified mixture of air and oxygen to patients by nasal cannula. The investigation revealed colonisation with R. mannitolilytica of two of 15 patients and contamination of components of five of six devices deployed in the premature units of the Hadassah hospitals. Ten isolates from the investigation were highly related and indistinguishable from isolates described in an outbreak in 2005 in the United States (US). Measures successful in containing the US outbreak were not included in user instructions provided to our hospitals by the distributor of the device.

Continuous surveillance to reduce extended-spectrum β-lactamase Klebsiella pneumoniae colonization in the neonatal intensive care unit

BACKGROUND

Clinical illness caused by resistant bacteria usually represents a wider problem of asymptomatic colonization. Active surveillance with appropriate institution of isolation precautions represents a potential mechanism to control colonization and reduce infection. The neonatal intensive care unit (NICU) is an environment particularly appropriate for such interventions. Neonates are rarely colonized by resistant bacteria on admission and staff enthusiasm for infection control is high.

OBJECTIVE

To reduce extended-spectrum β-lactamase-producing Klebsiella pneumoniae (ESBL-KP) acquisition amongst neonates through a continuous active surveillance intervention.

METHODS

Fecal ESBL-KP cultures were performed weekly on all neonates over 4 years. Neonates with positive cultures were managed with contact precautions by dedicated nurses separately from other neonates. ESBL-KP acquisition amongst neonates staying >7 days was compared for the consecutive years. A subset of ESBL-KP isolates was typed with pulsed-field gel electrophoresis (PFGE).

RESULTS

Surveillance cultures were obtained from 1,482/1,763 (84%) neonates over 4 years. ESBL-KP acquisition decreased continuously from 94/397 (24%) neonates in 2006 to 33/304 (11%) in 2009 (p < 0.001, hazard ratio 0.75, 95% confidence interval 0.66-0.85, p < 0.001 for comparison of years). Hospital-wide ESBL-KP acquisition did not decrease outside the NICU. PFGE identified identical ESBL-KP strains from multiple neonates on six occasions and different strains from single neonates on seven occasions.

CONCLUSIONS

ESBL-KP is probably both imported into and spread within the NICU. Continuous long-term surveillance with cohorting was associated with a decrease in ESBL-KP acquisition within the NICU. This low-risk intervention should be considered as a means to decrease neonatal acquisition of resistant bacteria.

Antimicrobial use in the ICU: indications and accuracy--an observational trial

BACKGROUND

In intensive care unit (ICU) patients, signs of infection and inflammation are similar, making diagnosis of bacterial infections difficult. Antimicrobials may therefore be overused, contributing to development of antimicrobial-resistant bacteria.

OBJECTIVES

To measure the accuracy of clinician decisions to start antimicrobials; to correlate clinician certainty with the presence of infection; and to examine whether physiological variables correlate with clinician certainty.

DESIGN

Prospective observational study.

SETTING AND PATIENTS

Patients staying >48 hours in a general ICU of a tertiary care hospital.

MEASUREMENTS

The ICU clinician's certainty for the presence of infection was recorded when starting antimicrobials. An independent infectious diseases (ID) specialist determined if antimicrobials were required and if infection was present. Clinician antibiotic start decisions were tested for accuracy according to the ID determination for the presence of infection.

RESULTS

Empirical antimicrobial therapy was justified by the presence of infection on 67/125 (54%) occasions. Clinician certainty for infection correlated well with the presence of defined infection (r(2) = 0.78), however, infection was defined on 6/19 (31%) occasions when ICU clinician certainty was low (≤2), and antimicrobials were prescribed even when clinician certainty was minimal. Antimicrobial course length was similar whether infection was defined or not (11.5 ± 9.2 vs 10.7 ± 9.1 days; P = 0.65). Physiological variables were not associated with clinician certainty of infection.

CONCLUSIONS

Antimicrobial therapy is probably overused in the ICU, possibly resulting from difficulties in diagnosis and the perceived greater risk of untreated infection when compared to the risks of potentially unnecessary antimicrobial therapy. Efforts to improve antimicrobial-related decision-making should be mandatory.

The spread of Mycoplasma pneumoniae is polyclonal in both an endemic setting in France and in an epidemic setting in Israel

Mycoplasma pneumoniae infections occur both endemically and epidemically, and macrolide resistance has been spreading for 10 years worldwide. A substantial increased incidence of M. pneumoniae infections has been reported in several countries since 2010. Whether this increased incidence is attributed to different or to the same M. pneumoniae genotype is unknown. We have developed a multilocus variable-number tandem-repeat (VNTR) analysis (MLVA) for the molecular typing of M. pneumoniae isolates. In this study, the MLVA typing method was modified and validated to be applicable directly to respiratory tract specimens without culture. This method was applied to 34 M. pneumoniae-positive specimens received at the Bordeaux Hospital, France, between 2007 and 2010 in an endemic setting, and to 63 M. pneumoniae-positive specimens collected during an epidemic surge of M. pneumoniae infections in 2010 in Jerusalem, Israel. The M. pneumoniae endemic spread was shown to be polyclonal in France, with 15 MLVA types identified. Strikingly, the Israeli epidemic surge was also a multi-clonal phenomenon, with 18 circulating MLVA types. The macrolide resistance-associated substitution, A2058G, was found in 22% of the Israeli patients. Macrolide-resistant M. pneumoniae belonged to four MLVA types, the MLVA type Z being the most frequent one. An association between the MLVA type Z and macrolide resistance might exist since macrolide resistance was present or generated during the course of illness in all patients infected with this MLVA type. In conclusion, the discriminatory power of the MLVA showed that the spread of M. pneumoniae strains in France in an endemic setting was polyclonal as well as the surge of M. pneumoniae infections in Israel in 2010.

Comparison of two carbapenem-resistant Klebsiella pneumoniae clones: from a contained outbreak in a paediatric population and from a national epidemic

OBJECTIVES

A refractory epidemic of carbapenem-resistant Klebsiella pneumoniae (CRKP) emerged in the adult population at our hospital in 2005, as in most Israeli hospitals. Contemporaneously, a different clone of CRKP caused an easily contained outbreak in a paediatric long-term care facility (LTCF) in Jerusalem. While previously identified host-related risk factors for colonization by these organisms undoubtedly contributed to these outbreaks, it is very likely that bacterial factors might be crucial in explaining the striking differences in transmissibility between the implicated strains. We therefore sought bacterial factors associated with these different epidemiological behaviours.

METHODS

Seven CRKP isolated at our hospital and the LTCF during 2008-09 were examined by antimicrobial susceptibility testing and PFGE, and further analyses of these two clones was done using multilocus sequence typing and competition experiments. Plasmids were analysed by conjugation, restriction mapping, PCR and sequencing.

RESULTS

Both clones were multidrug resistant and harboured identical plasmids carrying the bla(KPC-3) gene. The hyper-transmissible epidemic clone carried additional antibiotic resistance genes and hosted an additional plasmid. The clone from the LTCF did not demonstrate hyper-transmissible properties despite its presence in an institution of a type commonly plagued by the epidemic clone. Competition assays showed the more easily contained strain to be fitter.

CONCLUSIONS

These findings suggest that neither the presence of the plasmid carrying the bla(KPC-3) gene nor relative survival fitness account for the hyper-transmissibility of the epidemic strain. The role of patient age in susceptibility to colonization by the epidemic strain should be investigated.

Ongoing epidemic of Mycoplasma pneumoniae infection in Jerusalem, Israel, 2010 to 2012

A substantial epidemic of Mycoplasma pneumoniae infection was reported in late 2011 in some European countries. We report here an epidemic of M. pneumoniae infection that began in Jerusalem during 2010 and is still ongoing. This report complements current information on what might be a worldwide epidemic of M. pneumoniae infection that might require substantial coordinated international public health intervention.

Ongoing epidemic of Mycoplasma pneumoniae infection in Jerusalem, Israel, 2010 to 2012

A substantial epidemic of Mycoplasma pneumonia infection was reported in late 2011 in some European countries. We report here an epidemic of M. pneumonia infection that began in Jerusalem during 2010 and is still ongoing. This report complements current information on what might be a worldwide epidemic of M. pneumoniae infection that might require substantial coordinated international public health intervention.

Macrolide resistance in Mycoplasma pneumoniae, Israel, 2010

Macrolide resistance in Mycoplasma pneumoniae is often found in Asia but is rare elsewhere. We report the emergence of macrolide-resistant M. pneumoniae in Israel and the in vivo evolution of such resistance during the treatment of a 6-year-old boy with pneumonia.

Macrolide resistance in Mycoplasma pneumoniae, Israel, 2010

Macrolide resistance in Mycoplasma pneumoniae is often found in Asia but is rare elsewhere. We report the emergence of macrolide-resistant M. pneumoniae in Israel and the in vivo evolution of such resistance during the treatment of a 6-year-old boy with pneumonia.

Oral syphilis lesions--a diagnostic approach and histologic characteristics of secondary stage

Syphilis is among the oldest recognized sexually transmitted diseases. In the past decade, its incidence has risen significantly in the developed world. Oral syphilitic lesions, the most common extragenital sign of infection, are a diagnostic challenge to dentists, who are usually the first to examine the oral lesions. Biopsies are occasionally the first examination performed, but histologic findings are considered nonspecific. We present two new cases as well as an additional 25 published cases, suggesting that plasma cell arteritis and plasma cell neuritis is a combination that has not been reported in any other pathologic condition of the oral cavity and may be specific enough to direct the clinician toward a diagnosis of syphilis prior to clinical confirmation.

Severe influenza A (H1N1): the course of imaging findings

BACKGROUND

An outbreak of respiratory illness caused by a novel swine-origin influenza virus (influenza A/H1N1 2009) that began in Mexico was declared a global pandemic by the World Health Organization in June 2009. The pandemic affected many countries, including Israel.

OBJECTIVES

To compare the course of chest radiographic and computed tomography findings in patients who survived and those who died following admission to the intensive care unit (ICU) or intubation due to severe laboratory-confirmed swine-origin influenza A/H1N1 2009.

METHODS

We retrospectively reviewed the patient records (267 radiographs, 8 CTs) of 22 patients (10 males, 12 females) aged 3.5-66 years (median 34) with confirmed influenza A/ H1N1 2009, admitted to the ICU and/or intubated in five major Israeli medical centers during the period July-November 2009. We recorded demographic, clinical, and imaging findings--including pattern of opacification, extent, laterality, distribution, zone of findings, and presence/absence of nodular opacities--at initial radiography and during the course of disease, and compared the findings of survivors and non-survivors. Statistical significance was calculated using the Wilcoxon (continuous variables) and Fisher exact tests.

RESULTS

The most common findings on the initial chest radiography were airspace opacities, which were multifocal in 17 patients (77%) and bilateral in 16 (73%), and located in the lower or lower and middle lung zones in 19 patients (86%). Large airspace nodules with indistinct margins were seen in 8 patients (36%). Twelve patients survived, 10 died. Patients who died had multiple background illnesses and were significantly older than survivors (P = 0.006). Radiologic findings for the two groups were not significantly different.

CONCLUSION

Airspace opacities, often with nodular appearance, were the most common findings among patients with severe influenza A/H1N1 2009. The course of radiologic findings was similar in patients with severe influenza A/ H1N1 2009 who survived and those who died.

Improved ICU design reduces acquisition of antibiotic-resistant bacteria: a quasi-experimental observational study

Introduction

The role of ICU design and particularly single-patient rooms in decreasing bacterial transmission between ICU patients has been debated. A recent change in our ICU allowed further investigation.

Methods

Pre-move ICU-A and pre-move ICU-B were open-plan units. In March 2007, ICU-A moved to single-patient rooms (post-move ICU-A). ICU-B remained unchanged (post-move ICU-B). The same physicians cover both ICUs. Cultures of specified resistant organisms in surveillance or clinical cultures from consecutive patients staying >48 hours were compared for the different ICUs and periods to assess the effect of ICU design on acquisition of resistant organisms.

Results

Data were collected for 62, 62, 44 and 39 patients from pre-move ICU-A, post-move ICU-A, pre-move ICU-B and post-move ICU-B, respectively. Fewer post-move ICU-A patients acquired resistant organisms (3/62, 5%) compared with post-move ICU-B patients (7/39, 18%; P = 0.043, P = 0.011 using survival analysis) or pre-move ICU-A patients (14/62, 23%; P = 0.004, P = 0.012 on survival analysis). Only the admission period was significant for acquisition of resistant organisms comparing pre-move ICU-A with post-move ICU-A (hazard ratio = 5.18, 95% confidence interval = 1.03 to 16.06; P = 0.025). More antibiotic-free days were recorded in post-move ICU-A (median = 3, interquartile range = 0 to 5) versus post-move ICU-B (median = 0, interquartile range = 0 to 4; P = 0.070) or pre-move ICU-A (median = 0, interquartile range = 0 to 4; P = 0.017). Adequate hand hygiene was observed on 140/242 (58%) occasions in post-move ICU-A versus 23/66 (35%) occasions in post-move ICU-B (P < 0.001).

Conclusions

Improved ICU design, and particularly use of single-patient rooms, decreases acquisition of resistant bacteria and antibiotic use. This observation should be considered in future ICU design.

Costs of appropriate and inappropriate use of antibiotics in the emergency department

BACKGROUND

Appropriate antibiotic use is of both clinical and economic significance to any health system and should be given adequate attention. Prior to this study, no in-depth information was available on antibiotic use patterns in the emergency department of Hadassah Medical Center.

OBJECTIVES

To describe the use and misuse of antibiotics and their associated costs in the emergency department of Hadassah Medical Center.

METHODS

We analyzed the charts of 657 discharged patients and 45 admitted patients who received antibiotics in Hadassah's emergency department during a 6 week period (29 April - 11 June 2007). A prescription was considered appropriate or inappropriate if the choice of antibiotic, dose and duration by the prescribing physician after diagnosis was considered suitable or wrong by the infectious diseases consultant evaluating the prescriptions according to Kunin's criteria.

RESULTS

The overall prescribing rate of antibiotics was 14.5% (702/4830) of which 42% were broad-spectrum antibiotics. The evaluated antibiotic prescriptions numbered 1105 (96 prescriptions containing 2 antibiotics, 2 prescriptions containing 3 antibiotics), and 54% of them were considered appropriate. The total inappropriate cost was 3583 NIS (1109 USD PPP) out of the total antibiotic costs of 27,300 NIS (8452 USD PPP). The annual total antibiotic cost was 237,510 NIS (73,532 USD PPP) and the annual total inappropriate cost was 31,172 NIS (9648 USD PPP). The mean costs of inappropriate prescriptions were highest for respiratory (112 NIS, 35 USD PPP) and urinary tract infection (93 NIS, 29 USD PPP). There were more cases when the optimal cost was lower than the actual cost (N = 171) than when optimal cost was higher than the actual cost (N = 9). In the first case, the total inappropriate costs were 3805 NIS (1178 USD PPP), and in the second case, -222 NIS (68.7 USD PPP).

CONCLUSIONS

The use of antibiotics in emergency departments should be monitored, especially in severely ill patients who require broad-spectrum antibiotics and for antibiotics otherwise restricted in the hospital wards. Our findings indicate that 12% of the total antibiotic costs could have been avoided if all prescriptions were optimal.

An outbreak of achromobacter xylosoxidans associated with ultrasound gel used during transrectal ultrasound guided prostate biopsy

PURPOSE

We describe an outbreak of Achromobacter xylosoxidans after transrectal ultrasound guided prostate biopsy at a urology unit at a tertiary care center as well as clinical and microbiological investigation, and intervention.

MATERIALS AND METHODS

In September 2008, several days after undergoing transrectal ultrasound guided prostate biopsy, 4 patients were hospitalized with fever. We reviewed the procedure and infection control practices in the urology service. Environmental cultures were obtained from equipment and materials used for the procedure. Isolates were identified by routine laboratory procedures with molecular confirmation and characterized by pulsed field gel electrophoresis.

RESULTS

A. xylosoxidans was isolated from the urine of 2 patients, of whom 1 also had a positive blood culture. Review of transrectal ultrasound guided prostate biopsy revealed that the lubricant gel used in the procedure, which the biopsy needle passes through, was held in a plastic container that was repeatedly refilled from a large bag. A. xylosoxidans was isolated from this container. Pulsed field gel electrophoresis showed that the isolates obtained from patients and the gel were identical.

CONCLUSIONS

Contaminated lubricant gel was the cause of this outbreak. The practice of repeatedly refilling gel containers with nonsterile gel was replaced by the use of individual sterile gel sachets in each patient. No further cases occurred. During an invasive procedure involving a sterile body site, such as transrectal ultrasound guided prostate biopsy, using sterile gel is essential. Our experience emphasizes the crucial need to review all invasive procedures from an infection control perspective.

End-of-life treatment and bacterial antibiotic resistance: a potential association

BACKGROUND

Great variability exists in the occurrence of antibiotic-resistant bacteria in ICUs around the world. The contribution of specific ICU care variables to these geographic variations is unknown.

METHODS

ICU patients from two ICUs (in Jerusalem and Toronto) who were admitted for > 48 h and who grew a resistant bacteria in any culture during ICU admission were compared with those without resistant organisms across a range of demographic and ICU care interventions. Significant variables were investigated with logistic regression to identify factors predictive of infection/colonization with a resistant organism.

RESULTS

Resistant organisms were acquired by 82/423 (19%) patients. Patients acquiring a resistant organism had a higher incidence of diabetes mellitus (21/82, 26% vs 52/341, 15%; P = .026), were more frequently admitted from another ICU (17/82, 21% vs 33/341, 10%; P = .005), received more antibiotics in the ICU (19 +/- 17 vs 14 +/- 14 days; P = .005), and had more ventilator (10 +/- 10 vs 7 +/- 8; P = .031) and central line days (10 +/- 8 vs 7 +/- 8; P < .001). These patients had a lower incidence of limitation-of-therapy orders (9/82, 11% vs 78/341, 23%; P = .015). Only the absence of a limitation-of-therapy order (odds ratio, 2.62; 95% CI, 1.21-5.68; P = .014) was independently associated with the acquisition of resistant organisms. Further, among ICU fatalities, 5/45 (11%) patients acquired a resistant organism prior to withdrawal vs 17/44 (39%) nonwithdrawal fatalities (P = .003). Nonwithdrawal fatalities received significantly more third-line antibiotics (7 +/- 14 vs 2 +/- 4; P = .031) despite similar ICU lengths of stay (15 +/- 21 days for nonwithdrawal fatalities vs 10 +/- 11 for withdraw fatalities; P = .210)

CONCLUSIONS

End-of-life treatment is independently associated with acquisition of resistant bacteria. Patients dying without withdraw orders receive more antibiotics and develop more resistant organisms. These patients may represent a reservoir of resistant bacteria in the ICU.

Imported melioidosis, Israel, 2008

In 2008, melioidosis was diagnosed in an agricultural worker from Thailand in the southern Jordan Valley in Israel. He had newly diagnosed diabetes mellitus, fever, multiple abscesses, and osteomyelitis. Burkholderia pseudomallei was isolated from urine and blood. Four of 10 laboratory staff members exposed to the organism received chemoprophylaxis, 3 of whom had adverse events.

Vancomycin-resistant enterococci in long-term care facilities

Knowledge of the prevalence rates and associated risk markers of vancomycin-resistant enterococci (VRE) colonization among long-term care facility (LTCF) residents could be used to improve screening policies among newly admitted hospital inpatients. In a cross-sectional survey among 1,215 residents of LTCFs in Jerusalem, the VRE carriage rate was 9.6%. Previous hospitalization and antibiotic treatment were associated with elevated VRE colonization rate. In contrast, moderate and severe levels of dependency and prolonged stay in an LTCF were associated with a decrease in the VRE colonization rate.