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Cohen-Gihon I, Israeli O, Bilinsky G, Vasker B, Lazar S, Beth-Din A, Zvi A, Ghanem-Zoubi N, Atiya-Nasagi Y. Insights from genomic analysis of a novel Coxiella burnetii strain isolated in Israel. New Microbes New Infect 2024; 59:101242. [PMID: 38577384 PMCID: PMC10993178 DOI: 10.1016/j.nmni.2024.101242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 03/25/2024] [Accepted: 03/25/2024] [Indexed: 04/06/2024] Open
Abstract
The diagnosis of Q fever is challenging due to nonspecific symptoms and negative standard blood culture results. Serological testing through immunofluorescence assay (IFA) is the most commonly used method for diagnosing this disease. Polymerase chain reaction (PCR) tests can also be used to detect bacterial DNA if taken at an appropriate time. Once the presence of bacteria is confirmed in a sample, an enrichment step is required before characterizing it through sequencing. Cultivating C. burnetii is challenging as it can only be isolated by inoculation into cell culture, embryonated eggs, or animals. In this article, we describe the isolation of C. burnetii from a valve specimen in Vero cells. We conducted genome sequencing and taxonomy profiling of this isolate and were able to determine its taxonomic affiliation. Furthermore, Multispacer sequence typing (MST) analysis suggests that the infection originated from a local strain of C. burnetii found around northern Israel and Lebanon. This novel strain belongs to a previously described genotype MST6, harboring the QpRS plasmid, never reported in Israel.
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Affiliation(s)
- Inbar Cohen-Gihon
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness Ziona, Israel
| | - Ofir Israeli
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness Ziona, Israel
| | - Gal Bilinsky
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness Ziona, Israel
| | - Barak Vasker
- Department of Infectious Diseases, Israel Institute for Biological Research, Ness Ziona, Israel
| | - Shirley Lazar
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness Ziona, Israel
| | - Adi Beth-Din
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness Ziona, Israel
| | - Anat Zvi
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness Ziona, Israel
| | | | - Yafit Atiya-Nasagi
- Department of Infectious Diseases, Israel Institute for Biological Research, Ness Ziona, Israel
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Ghanem-Zoubi N, Atiya-Nasagi Y, Stoyanov E, Szwarcwort M, Darawsha B, Paul M, Shinar E. Cross-Sectional Study of Q Fever Seroprevalence among Blood Donors, Israel, 2021. Emerg Infect Dis 2024; 30:941-946. [PMID: 38666592 PMCID: PMC11060453 DOI: 10.3201/eid3005.230645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
We evaluated Q fever prevalence in blood donors and assessed the epidemiologic features of the disease in Israel in 2021. We tested serum samples for Coxeilla burnetii phase I and II IgG using immunofluorescent assay, defining a result of >200 as seropositive. We compared geographic and demographic data. We included 1,473 participants; 188 (12.7%) were seropositive. The calculated sex- and age-adjusted national seroprevalence was 13.9% (95% CI 12.2%-15.7%). Male sex and age were independently associated with seropositivity (odds ratio [OR] 1.6, 95% CI 1.1-2.2; p = 0.005 for male sex; OR 1.2, 95% CI 1.01-1.03; p<0.001 for age). Residence in the coastal plain was independently associated with seropositivity for Q fever (OR 1.6, 95% CI 1.2-2.3; p<0.001); residence in rural and farming regions was not. Q fever is highly prevalent in Israel. The unexpected spatial distribution in the nonrural coastal plain suggests an unrecognized mode of transmission.
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Affiliation(s)
| | | | - Evgeniy Stoyanov
- Rambam Health Care Campus, Haifa, Israel (N. Ghanem-Zoubi, M. Szwarcwort, M. Paul)
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa (N. Ghanem-Zoubi, B. Darawsha, M. Paul)
- Israel Institute for Biological Research, Ness-Ziona, Israel (Y. Atiya-Nasagi)
- Magen David Adom National Blood Services, Ramat Gan, Israel (E. Stoyanov, E. Shinar)
| | - Moran Szwarcwort
- Rambam Health Care Campus, Haifa, Israel (N. Ghanem-Zoubi, M. Szwarcwort, M. Paul)
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa (N. Ghanem-Zoubi, B. Darawsha, M. Paul)
- Israel Institute for Biological Research, Ness-Ziona, Israel (Y. Atiya-Nasagi)
- Magen David Adom National Blood Services, Ramat Gan, Israel (E. Stoyanov, E. Shinar)
| | - Basel Darawsha
- Rambam Health Care Campus, Haifa, Israel (N. Ghanem-Zoubi, M. Szwarcwort, M. Paul)
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa (N. Ghanem-Zoubi, B. Darawsha, M. Paul)
- Israel Institute for Biological Research, Ness-Ziona, Israel (Y. Atiya-Nasagi)
- Magen David Adom National Blood Services, Ramat Gan, Israel (E. Stoyanov, E. Shinar)
| | - Mical Paul
- Rambam Health Care Campus, Haifa, Israel (N. Ghanem-Zoubi, M. Szwarcwort, M. Paul)
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa (N. Ghanem-Zoubi, B. Darawsha, M. Paul)
- Israel Institute for Biological Research, Ness-Ziona, Israel (Y. Atiya-Nasagi)
- Magen David Adom National Blood Services, Ramat Gan, Israel (E. Stoyanov, E. Shinar)
| | - Eilat Shinar
- Rambam Health Care Campus, Haifa, Israel (N. Ghanem-Zoubi, M. Szwarcwort, M. Paul)
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa (N. Ghanem-Zoubi, B. Darawsha, M. Paul)
- Israel Institute for Biological Research, Ness-Ziona, Israel (Y. Atiya-Nasagi)
- Magen David Adom National Blood Services, Ramat Gan, Israel (E. Stoyanov, E. Shinar)
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Ghanem-Zoubi N, Mustafa-Hellou M, Zahran M, Gazit L, Shalaginov R, Dabaja-Younis H, Szwarcwort M. The integration of Coxiella burnetii PCR testing in serum into the diagnostic algorithm of suspected acute Q fever in an endemic setting. J Clin Microbiol 2024; 62:e0170323. [PMID: 38470022 PMCID: PMC11005359 DOI: 10.1128/jcm.01703-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 02/21/2024] [Indexed: 03/13/2024] Open
Abstract
Serum polymerase chain reaction (PCR) for the detection of Coxiella burnetii DNA has been suggested for rapid Q fever diagnosis. We evaluated the role of PCR testing in serum in the diagnosis of acute Q fever in an endemic setting. We examined patients suspected of acute Q fever tested for C. burnetii-specific serum real-time PCR in a tertiary hospital between January 2019 toand December 2022. In the first half, PCR orders were consultation-based by infectious diseases specialists, while in the second half, they were guided by serology, positive IgM2, and negative IgG1 and IgG2, indicating early acute infection. Logistic regression analyzed independent predictors for positive PCR. PCR positivity rates were calculated using various clinical criteria in the diagnostic algorithm. Out of 272 patients, 13 (4.8%) tested positive and 130 exhibited serologically suspected early infection. Presentation during April-July and aspartate aminotransferase (AST) > 3× upper normal limit (UNL) were independently associated with positive PCR with an odds ratio (OR) = 15.03 [95% confidence interval (CI), 1.58-142.46], P = 0.018 and OR = 55.44 [95% CI, 6.16-498.69], P < 0.001, respectively. PCR positivity rate was 8.5% in serologically suspected early infection vs 1.4% in other serology, yielding OR = 6.4 [95% CI, 1.4-29.7], P = 0.009. Adding AST > 3× UNL increased OR to 49.5 [95% CI, 5.9-408.7], P ≤ 0.001 reducing required PCR tests for a single acute Q fever case from 11.8 to 3. Elevated AST in serologically suspected early Q fever is proposed to be used in a diagnostic stewardship algorithm integrating PCR in serum in an endemic setting. IMPORTANCE Our study suggests in a diagnostic stewardship approach the integration of molecular testing (Coxiella burnetii targeted PCR) for the diagnosis of acute Q fever in a reliable time in the endemic setting. Integrating PCR detecting Coxiella burnetii in serum in routine testing of suspected early acute Q fever based on serology result increased the PCR positivity rate significantly. Adding increased transaminases optimizes PCR utility which is highly requested particularly in endemic areas.
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Affiliation(s)
- Nesrin Ghanem-Zoubi
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | | | - Maram Zahran
- Department of Medicine A, Rambam Health Care Campus, Haifa, Israel
| | - Liat Gazit
- Microbiology Laboratory, Rambam Health Care Campus, Haifa, Israel
| | - Raya Shalaginov
- Microbiology Laboratory, Rambam Health Care Campus, Haifa, Israel
| | - Halima Dabaja-Younis
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
- Pediatric Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel
| | - Moran Szwarcwort
- Microbiology Laboratory, Rambam Health Care Campus, Haifa, Israel
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Ghanem-Zoubi N, Abu-Elhija J, Kagna O, Mustafa-Hellou M, Qasum M, Haber D, Paul M, Keidar Z. Predictors of infectious foci on FDG PET/CT in Staphylococcus aureus bacteremia. Sci Rep 2023; 13:14063. [PMID: 37640802 PMCID: PMC10462707 DOI: 10.1038/s41598-023-41336-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 08/24/2023] [Indexed: 08/31/2023] Open
Abstract
We looked for predicting factors for the detection of infectious foci on 18F-fluorodeoxyglucose-positron emission tomography in combination with computed tomography (FDG PET/CT) among patients with Staphylococcus aureus bacteremia (SAB) who participated in an interventional study that was conducted at Rambam Health Care Campus, between July 1, 2015 and February 1, 2019. The primary outcome was an infectious focus detected by FDG PET/CT. Independent predictors for detection of focal infection were identified using univariate followed by a logistic regression multivariate analysis. We included 149 patients with 151 separate episodes of SAB who underwent FDG-PET/CT. Focal infections were detected in 107 patients (70.8%). Independent predictors for focal infection detection were community acquisition of bacteremia with odds ratio (OR) 3.03 [95% confidence interval (CI) 1.04-8.77], p-0.042 and C reactive protein (CRP) with OR 1.09 [95% CI 1.04-1.14], p < 0.001. Primary bacteremia was inversely associated with focal infection detection with OR 0.27 [0.10-0.69], p = 0.007, as were the pre-scan blood glucose levels OR 0.9 [0.98-0.99], p-0.004. The latter stayed significant in the subgroup of patients with diabetes mellitus. To conclude, patients with community-acquired bacteremia or high CRP levels should be carefully investigated for focal infection. Patients who present with primary bacteremia seem to be at low risk for focal infection.
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Affiliation(s)
- Nesrin Ghanem-Zoubi
- Infectious Diseases Institute, Rambam Health Care Campus, Ha-Aliya 8 St, 3109601, Haifa, Israel.
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.
| | - Jawad Abu-Elhija
- Internal Medicine Department E, Rambam Health Care Campus, Haifa, Israel
| | - Olga Kagna
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Mona Mustafa-Hellou
- Infectious Diseases Institute, Rambam Health Care Campus, Ha-Aliya 8 St, 3109601, Haifa, Israel
| | - Majd Qasum
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
- Department of Cardiology, Rambam Health Care Campus, Haifa, Israel
| | - Daniel Haber
- Infectious Diseases Institute, Rambam Health Care Campus, Ha-Aliya 8 St, 3109601, Haifa, Israel
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Ha-Aliya 8 St, 3109601, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Zohar Keidar
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
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Badarni K, Weiner Z, Szwarcwort-Cohen M, Zaltzman-Bershadsky N, Paul M, Ghanem-Zoubi N. Q fever screening among pregnant women with pre-term delivery in northern Israel: An observational study. Zoonoses Public Health 2023; 70:160-165. [PMID: 36225104 DOI: 10.1111/zph.13006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 09/12/2022] [Accepted: 10/02/2022] [Indexed: 02/02/2023]
Abstract
The relationship between Q fever, caused by Coxiella burnetii, and obstetrical complications is debatable. Since Q fever is endemic in Israel, we aimed to assess its seroprevalence and clinical characteristics in pre-term deliveries. Between 1 August 2017 and 31 December 2019, we conducted serological screening for C. burnetii in pregnant women who presented to Rambam Health Care Campus with pre-term delivery (before 37 weeks of gestation). Anti-C. burnetii antibodies were tested first by enzyme-linked immunosorbent assay for the detection of phase I-IgG, phase II-IgG and phase II-IgM. Positive results were confirmed by indirect immunofluorescence with titre determination. Seropositivity was classified into past, acute and chronic infection. Demographic and clinical data of mothers and neonates were collected and compared between seropositive and seronegative women. Out of 386 pregnant women screened for anti-C. burnetii antibodies, 16 (4.1%) were seropositive, of whom three were diagnosed with past, 12 with acute and one with chronic infection. A higher percentage of seropositive women were immunosuppressed, 2/16 (12.5%) compared with 7/370 (1.9%) in seronegative women, (p = .05). Neonates with small for gestational age were born to 2/16 (12.5%) seropositive women compared with 29/370 (7.8%) to seronegative women, (p = .35). The seroprevalence of Q fever among pregnant women with pre-term birth reached 4% in northern Israel. This high rate in an endemic setting encourages investigating the role of routine screening for Q fever during pregnancy. Special attention should be given to pregnant immunosuppressed women at risk for exposure to Q fever.
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Affiliation(s)
- Karawan Badarni
- Critical Care Division, Rambam Health Care Campus, Haifa, Israel
| | - Zeev Weiner
- The Obstetrics & Gynecology Division, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | | | | | - Mical Paul
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Nesrin Ghanem-Zoubi
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
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Dabaja-Younis H, Atarieh M, Paul M, Nasrallah E, Geffen Y, Kassis I, Ghanem-Zoubi N. Predictive factors for focal disease in human brucellosis, an observational cohort study. Eur J Clin Microbiol Infect Dis 2023; 42:221-226. [PMID: 36547765 DOI: 10.1007/s10096-022-04541-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
This retrospective cohort study aimed to identify predictors for focal disease in human brucellosis. The study included patients with brucellosis diagnosed between January 2000 and December 2021. Overall, 247 patients were identified. Focal disease was diagnosed in 64 (25.9%) patients. The most common focal infection was bone and joint in 56 patients (23.4%). Disease duration > 14 days was significantly associated with focal illness [OR = 2.2 (1.08-4.47), p = 0.030], although febrile illness was inversely associated with focal illness this did not reach statistical significance [OR = 0.46 (0.21-1.00), p = 0.050]. Focal brucellosis should be suspected in patients with prolonged illness.
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Affiliation(s)
- Halima Dabaja-Younis
- Pediatric Infectious Diseases Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel. .,The Ruth and Bruce Rappaport Faculty of Medicine, Israel Institute of Technology, Technion, Haifa, Israel.
| | - Menas Atarieh
- The Ruth and Bruce Rappaport Faculty of Medicine, Israel Institute of Technology, Technion, Haifa, Israel
| | - Michal Paul
- The Ruth and Bruce Rappaport Faculty of Medicine, Israel Institute of Technology, Technion, Haifa, Israel.,Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel
| | - Elias Nasrallah
- Pediatric Infectious Diseases Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Yuval Geffen
- Microbiology Laboratory, Rambam Health Care Campus, Haifa, Israel
| | - Imad Kassis
- Pediatric Infectious Diseases Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Israel Institute of Technology, Technion, Haifa, Israel
| | - Nesrin Ghanem-Zoubi
- The Ruth and Bruce Rappaport Faculty of Medicine, Israel Institute of Technology, Technion, Haifa, Israel.,Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel
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Ghanem-Zoubi N, Kagna O, Dabaja-Younis H, Atarieh M, Nasrallah E, Kassis I, Keidar Z, Paul M. The Role of Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in the Management of Brucellosis: An Observational Cohort Study. Open Forum Infect Dis 2023; 10:ofac704. [PMID: 36686638 PMCID: PMC9846188 DOI: 10.1093/ofid/ofac704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/30/2022] [Indexed: 01/03/2023] Open
Abstract
Background Diagnosis of focal infection in brucellosis is important to direct optimal treatment. Fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) may be helpful in this aspect. Methods The clinical and imaging data of all patients with brucellosis, who underwent FDG PET/CT as part of the investigation in Rambam Health Care Campus, where FDG PET/CT became the recommended imaging modality for suspected focal infection in brucellosis since 2016, were analyzed retrospectively. The detection of focal infection as well as management modification before and after FDG PET/CT were recorded. Results FDG PET/CT was performed in 30 episodes of brucellosis occurring in 27 patients: 20 primary episodes and 10 suspected relapse episodes. The mean age of the patients was 50 ± 15.07 years. Focal disease was diagnosed in 18 of 30 (60%) episodes, of which 8 (26.6%) were diagnosed for the first time by FDG PET/CT, all of whom had spinal infection, with a concomitant additional focus in 5. Overall, multifocal disease was diagnosed in 10 of 18 (55.5%) of patients with focal disease. Management modification following FDG PET/CT was recorded in 17 of 30 (56.6%) episodes, mainly by treatment extension in spinal infection and withholding treatment in patients with suspected relapse but no evidence of active disease by FDG PET/CT. Conclusions FDG PET/CT was found to be helpful in the diagnosis of focal infection in brucellosis. Multifocal disease seems more prevalent than previously described. The clinical impact of adding FDG PET/CT to the diagnostic workup of brucellosis should be evaluated in future studies.
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Affiliation(s)
- Nesrin Ghanem-Zoubi
- Correspondence: Nesrin Ghanem-Zoubi, MD, Infectious Diseases Institute, Rambam Health Care Campus, Ha-Aliya 8 St, Haifa 3109601, Israel ()
| | - Olga Kagna
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel,Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Halima Dabaja-Younis
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel,Pediatric Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel
| | - Menas Atarieh
- Internal Medicine Department A, Rambam Health Care Campus, Haifa, Israel
| | - Elias Nasrallah
- Pediatric Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel
| | - Imad Kassis
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel,Pediatric Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel
| | - Zohar Keidar
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel,Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
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Abstract
The limited performance of echocardiography in specific infectious processes involving the heart led to the search for additional diagnostic tools. Fluorodeoxyglucose positron emission tomography computed tomography (FDG PET/CT) has been proposed for its diagnostic abilities in several infectious diseases including cardiac infections. A literature review of studies evaluating FDG PET/CT in native valve infective endocarditis (IE), prosthetic valve IE, cardiac implantable electrical device (CIED) infection, and left ventricular assist device (LVAD) infection is presented, focusing on studies published in recent years. Overall, in prosthetic valve endocarditis (PVE), FDG PET/CT demonstrate high sensitivity (73-93%) and specificity (80-95%), while in native valve endocarditis (NVE) the sensitivity is very low (22-68%), with high specificity (97-100%) similar to PVE. For CIED, LVAD infection, and transcatheter aortic valve implantation associated endocarditis, data come from small studies and show good diagnostic performance of FDG PET/CT. International guidelines are increasingly recommending FDG PET/CT for the diagnosis of specific conditions of cardiac infections. Beyond the diagnostic performance ability, few studies have evaluated the added benefit of FDG PET/CT in terms of clinical outcomes of patients with suspected cardiac infection. This should be the focus in future studies.
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Affiliation(s)
- Nesrin Ghanem-Zoubi
- Infectious Diseases Institute, Rambam Health Care Campus, Ha-Aliya 8 St, 3109601, Haifa, Israel. .,The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.
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9
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Turjeman A, Koppel F, Franceschini E, Yahav D, Dolci G, Babich T, Bitterman R, Neuberger A, Ghanem-Zoubi N, Santoro A, Eliakim-Raz N, Pertzov B, Stern A, Dickstein Y, Maroun E, Zayyad H, Meschiari M, Bishara J, Goldberg E, Venturelli C, Mussini C, Paul M, Leibovici L. Risk factors for functional decline among survivors of Gram-negative bloodstream infection: A prospective cohort study. PLoS One 2021; 16:e0259707. [PMID: 34788325 PMCID: PMC8598031 DOI: 10.1371/journal.pone.0259707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 10/26/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To identify risk factors for functional decline after hospitalization for Gram-negative bacteremia. PATIENTS AND METHODS A prospective cohort study based on a randomized controlled trial conducted between January 1, 2013 and August 31, 2017 in Israel and Italy. Hospitalized patients with Gram-negative bacteremia who survived until day 90 and were not bedridden at baseline were included. The primary end point was functional decline at 90 days. RESULTS Five hundred and nine patients were included. The median age of the cohort was 71 years (interquartile range [IQR], 60-80 years), 46.4% (236/509) were male and 352 of 509 (69%) patients were independent at baseline. Functional decline at 90 days occurred in 24.4% of patients (124/509). In multivariable analysis; older age (odds ratio [OR], 1.03; for an one-year increment, 95% confidence interval [CI] 1.01-1.05), functional dependence in instrumental activities of daily living at baseline (OR, 4.64; 95% CI 2.5-8.6), low Norton score (OR, 0.87; 95% CI 0.79-0.96) and underlying comorbidities: cancer (OR, 2.01; 95% CI 1.14-3.55) and chronic pulmonary disease (OR, 2.23 95% CI 1.12-4.42) and longer length of hospital stay (OR 1.09; for one-day increment, 95% CI 1.04-1.15) were associated with functional decline. Appropriate empirical antibiotic treatment was associated with lower rates of functional decline within 90 days (OR, 0.4; 95% CI 0.21-0.78). CONCLUSIONS Patients surviving bloodstream infections have poor long term trajectories after clinical recovery and hospital discharge. This has vast implications for patients, their family members and health policy makers.
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Affiliation(s)
- Adi Turjeman
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- * E-mail:
| | - Fidi Koppel
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Erica Franceschini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Dafna Yahav
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Giovanni Dolci
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Tanya Babich
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Roni Bitterman
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Ami Neuberger
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Nesrin Ghanem-Zoubi
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Antonella Santoro
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Noa Eliakim-Raz
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Barak Pertzov
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pulmonary Division, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Anat Stern
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Yaakov Dickstein
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Elias Maroun
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Hiba Zayyad
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Marianna Meschiari
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Jihad Bishara
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Elad Goldberg
- Department of Medicine F, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Claudia Venturelli
- Clinical Microbiology Lab, University of Modena and Reggio Emilia, Modena, Italy
| | - Cristina Mussini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Leonard Leibovici
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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10
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Saydam FN, Erdem H, Ankarali H, El-Arab Ramadan ME, El-Sayed NM, Civljak R, Pshenichnaya N, Moroti RV, Mahmuodabad FM, Maduka AV, Mahboob A, Prakash Kumari PH, Stebel R, Cernat R, Fasanekova L, Uysal S, Tasbakan M, Arapović J, Magdalena DI, Angamuthu K, Ghanem-Zoubi N, Meric-Koc M, Ruch Y, Marino A, Sadykova A, Batirel A, Khan EA, Kulzhanova S, Al-Moghazi S, Yegemberdiyeva R, Nicastri E, Pandak N, Akhtar N, Ozer-Balin S, Cascio A, Dimzova M, Evren H, Puca E, Tokayeva A, Vecchi M, Bozkurt I, Dogan M, Dirani N, Duisenova A, Khan MA, Kotsev S, Obradovic Z, Del Vecchio RF, Almajid F, Barac A, Dragovac G, Pishmisheva-Peleva M, Rahman MT, Rahman T, Le Marechal M, Cag Y, Ikram A, Rodriguez-Morales AJ. Vector-borne and zoonotic infections and their relationships with regional and socioeconomic statuses: An ID-IRI survey in 24 countries of Europe, Africa and Asia. Travel Med Infect Dis 2021; 44:102174. [PMID: 34699956 DOI: 10.1016/j.tmaid.2021.102174] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 09/25/2021] [Accepted: 10/12/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND In this cross-sectional, international study, we aimed to analyze vector-borne and zoonotic infections (VBZI), which are significant global threats. METHOD VBZIs' data between May 20-28, 2018 was collected. The 24 Participatingcountries were classified as lower-middle, upper-middle, and high-income. RESULTS 382 patients were included. 175(45.8%) were hospitalized, most commonly in Croatia, Egypt, and Romania(P = 0.001). There was a significant difference between distributions of VBZIs according to geographical regions(P < 0.001). Amebiasis, Ancylostomiasis, Blastocystosis, Cryptosporidiosis, Giardiasis, Toxoplasmosis were significantly more common in the Middle-East while Bartonellosis, Borreliosis, Cat Scratch Disease, Hantavirus syndrome, Rickettsiosis, Campylobacteriosis, Salmonellosis in Central/East/South-East Europe; Brucellosis and Echinococcosis in Central/West Asia; Campylobacteriosis, Chikungunya, Tick-borne encephalitis, Visceral Leishmaniasis, Salmonellosis, Toxoplasmosis in the North-Mediterranean; CCHF, Cutaneous Leishmaniasis, Dengue, Malaria, Taeniasis, Salmonellosis in Indian Subcontinent; Lassa Fever in West Africa. There were significant regional differences for viral hemorrhagic fevers(P < 0.001) and tick-borne infections(P < 0.001), and according to economic status for VBZIs(P < 0.001). The prevalences of VBZIs were significantly higher in lower-middle income countries(P = 0.001). The most similar regions were the Indian Subcontinent and the Middle-East, the Indian Subcontinent and the North-Mediterranean, and the Middle-East and North-Mediterranean regions. CONCLUSIONS Regional and socioeconomic heterogeneity still exists for VBZIs. Control and eradication of VBZIs require evidence-based surveillance data, and multidisciplinary efforts.
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Affiliation(s)
- Fatma Nurhayat Saydam
- Department of Infectious Diseases and Clinical Microbiology, Yuksek Ihtisas University, Faculty of Medicine, Batikent Medical Park Hospital, Ankara, Turkey
| | - Hakan Erdem
- ID-IRI Lead Coordinator, Ankara, Turkey; Department of Infectious Diseases, Bahrain Oncology Center, King Hamad University Hospital, Busaiteen, 24343, Bahrain.
| | - Handan Ankarali
- Istanbul Medeniyet University, School of Medicine, Department of Biostatistics and Medical Informatics, Istanbul, Turkey
| | | | | | - Rok Civljak
- "Dr. Fran Mihaljevic" University Hospital for Infectious Diseases, University of Zagreb School of Medicine, Zagreb, Croatia
| | | | - Ruxandra Valentina Moroti
- National Institute for Infectious Diseases 'Matei Bals', and 'Carol Davila' University of Medicine and Pharmacy', Bucharest, Romania
| | | | | | - Amjad Mahboob
- Gajju Khan Medical College/Bacha Khan Medical Complex, Swabi, Khyber Pakhtunkhwa, Pakistan
| | | | - Roman Stebel
- Department of Infectious Diseases, University Hospital Brno and Faculty of Medicine, Masaryk University, Czech Republic
| | - Roxana Cernat
- Clinical Infectious Disease Hospital Constanta, Ovidius University of Constanta, Romania
| | - Lenka Fasanekova
- Department of Infectious Diseases, University Hospital Brno and Faculty of Medicine, Masaryk University, Czech Republic
| | - Serhat Uysal
- Department of Infectious Diseases and Clinical Microbiology, Firat University Faculty of Medicine, Elazig, Turkey
| | - Meltem Tasbakan
- Department of Infectious Diseases and Clinical Microbiology, Ege University Medical School, Izmir, Turkey
| | - Jurica Arapović
- Department of Infectious Diseases, Mostar University Clinical Hospital, Mostar, Bosnia and Herzegovina
| | | | | | | | - Meliha Meric-Koc
- Department of Infectious Diseases and Clinical Microbiology, Bezmialem Vakif University, Hospital of Medical Faculty, Istanbul, Turkey
| | - Yvon Ruch
- Strasbourg University Hospital (Nouvel Hôpital Civil - Centre Hospitalo-Universitaire de Strasbourg), Strasbourg, France
| | - Andrea Marino
- Department of Infectious Diseases, Garibaldi Nesima Hospital, Italy
| | - Ainur Sadykova
- Department of Infectious and Tropical Diseases, Asfendiyarov Kazakh National Medical University, Almaty, Kazakhstan
| | - Ayse Batirel
- Department of Infectious Diseases and Clinical Microbiology, University of Health Sciences, Dr. Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey
| | - Ejaz Ahmed Khan
- Shifa Tameer-E-Millat University, Shifa International Hospital, Islamabad, Pakistan
| | - Sholpan Kulzhanova
- Department of Infectious Diseases, Astana Medical University, Nur-Sultan, Kazakhstan
| | - Samir Al-Moghazi
- National Institute for Infectious Diseases L. Spallanzani IRCCS, Italy
| | - Ravilya Yegemberdiyeva
- Department of Infectious and Tropical Diseases, Asfendiyarov Kazakh National Medical University, Almaty, Kazakhstan
| | - Emanuele Nicastri
- National Institute for Infectious Diseases L. Spallanzani IRCCS, Italy
| | | | - Nasim Akhtar
- Pakistan Institute of Medical Sciences, G-8/3, Islamabad, Pakistan
| | - Safak Ozer-Balin
- Department of Infectious Diseases and Clinical Microbiology, Firat University, Faculty of Medicine, Elazıg, Turkey
| | - Antonio Cascio
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE) - Infectious Disease Unit, Policlinico "P. Giaccone", University of Palermo, Italy
| | - Marija Dimzova
- Clinic for Infectious Diseases and Febrile Conditions, Medical University, Skopje, Macedonia
| | - Hakan Evren
- Department of Infectious Diseases and Clinical Microbiology, University of Kyrenia, Kyrenia, Cyprus
| | | | - Alma Tokayeva
- Department of Infectious Diseases, Semey Medical University, Semey, Kazakhstan
| | | | - Ilkay Bozkurt
- Department of Infectious Diseases, Ondokuz Mayis University, School of Medicine, Samsun, Turkey
| | - Mustafa Dogan
- Namik Kemal University, Faculty of Medicine, Tekirdag, Turkey
| | - Natalia Dirani
- Department of Infectious Diseases, Dar Al Amal University Hospital, Douris, Baalbak, Lebanon
| | - Amangul Duisenova
- Department of Infectious and Tropical Diseases, Asfendiyarov Kazakh National Medical University, Almaty, Kazakhstan
| | | | - Stanislav Kotsev
- Pazardzhik Multiprofile Hospital for Active Treatment, Department of Infectious Diseases, Bulgaria
| | - Zarema Obradovic
- Faculty for Health Studies University of Sarajevo, Bosnia and Herzegovina
| | | | | | - Aleksandra Barac
- Clinic for Infectious and Tropical Diseases, University of Belgrade, Faculty of Medicine, Belgrade, Serbia
| | - Gorana Dragovac
- Centre of Disease Prevention and Control, Institute of Public Health of Vojvodina, Faculty of Medicine, University of Novi Sad, Serbia
| | - Maria Pishmisheva-Peleva
- Pazardzhik Multiprofile Hospital for Active Treatment, Department of Infectious Diseases, Bulgaria
| | - Md Tanvir Rahman
- Department of Microbiology and Hygiene, Faculty of Veterinary Science, Bangladesh Agricultural University, Mymensingh 2202, Bangladesh
| | | | - Marion Le Marechal
- Grenoble Alpes University, CHUGA, Infectious Diseases Department, 38043, Grenoble, France
| | - Yasemin Cag
- Department of Infectious Diseases and Clinical Microbiology, Istanbul Medeniyet University, Faculty of Medicine, Istanbul, Turkey
| | - Aamer Ikram
- National Institute of Health, Islamabad, Pakistan
| | - Alfonso J Rodriguez-Morales
- Grupo de Investigación Biomedicina, Faculty of Medicine, Fundación Universitaria Autónoma de las Américas, Pereira, Risaralda, Colombia; Master of Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Perú
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11
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Ghanem-Zoubi N, Paul M, Szwarcwort M, Agmon Y, Kerner A. Screening for Q Fever in Patients Undergoing Transcatheter Aortic Valve Implantation, Israel, June 2018-May 2020. Emerg Infect Dis 2021; 27:2205-2207. [PMID: 34287127 PMCID: PMC8314821 DOI: 10.3201/eid2708.204963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Q fever infective endocarditis frequently mimics degenerative valvular disease. We tested for Coxiella burnettii antibodies in 155 patients in Israel who underwent transcatheter aortic valve implantation. Q fever infective endocarditis was diagnosed and treated in 4 (2.6%) patients; follow-up at a median 12 months after valve implantation indicated preserved prosthetic valvular function.
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12
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Ghanem-Zoubi N, Graves SR. The prognostic value of serological titres in chronic Q fever: treat the patient, not the laboratory data. Clin Microbiol Infect 2021; 27:1202-1203. [PMID: 34153455 DOI: 10.1016/j.cmi.2021.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/06/2021] [Accepted: 06/11/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Nesrin Ghanem-Zoubi
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.
| | - Stephen R Graves
- Australian Rickettsial Reference Laboratory, Geelong University Hospital, Geelong, VIC, Australia
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13
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Abstract
BACKGROUND Q fever osteoarticular infections are a rare complication of the chronic form of Q fever. We aimed to characterize chronic Q fever vertebral osteomyelitis through our experience and a review of the literature. METHODS Four adult patients with Q fever vertebral osteomyelitis diagnosed in a tertiary hospital in northern Israel between 2016 to 2020 are described. In addition, a 30 years' literature review of Q fever vertebral osteomyelitis, characterizing predisposing factors, clinical presentation, course of disease, treatment and outcomes, was performed. RESULTS Thirty-four adult patients with Q fever vertebral osteomyelitis were identified. The vast majority were male (30/34, 88%) with a mean age of 67.2 ± 10 years. Involvement of the adjacent aorta, likely the origin of the infection, was observed in 23/34 (68%) of the patients, usually among patients with aortic graft or aneurysm. Clinical presentation was insidious and fever was frequently absent. Delayed diagnosis for months to years after symptoms onset was frequently reported. Vascular infections were managed with or without extraction of the infected aneurysm/aorta and graft placement. The outcome was variable with limited follow-up data in most cases. Patients were usually treated with prolonged antimicrobial therapy, most commonly doxycycline and hydroxychloroquine combination therapy. CONCLUSION Q fever should be included in the differential diagnosis of vertebral osteomyelitis in endemic settings, in particular when concomitant adjacent vascular infection exists.
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Affiliation(s)
- Nesrin Ghanem-Zoubi
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Tony Karram
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.,Department of Vascular Surgery, Rambam Medical Center, Haifa, Israel
| | - Olga Kagna
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.,Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Goni Merhav
- Department of Radiology, Rambam Health Care Campus, Haifa, Israel
| | - Zohar Keidar
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.,Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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14
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Abstract
Query (Q) fever is a zoonotic bacterial infection caused by Coxiella burnetii. In a minority of patients, chronic disease can occur after acute infection. Endocarditis and infections of aneurysms or vascular prostheses are the most common forms of chronic Q fever in adults. We report a case of an elderly female patient with chronic Q fever vertebral osteomyelitis at the site of her previous cement vertebroplasty, complicated by paravertebral abscess. Patient treatment required prolonged drainage in addition to the long duration of antibiotic treatment by doxycycline and hydroxychloroquine. Osteomyelitis is a rare clinical presentation in adults with chronic Q fever. However, it is important to consider Q fever in the differential diagnosis of culture-negative osteomyelitis, especially in countries where C. burnetii is endemic, such as Israel.
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Affiliation(s)
- Karina Dorfman
- Radiology Department, Bnai-Zion Medical Center, Haifa, Israel
- To whom correspondence should be addressed. E-mail:
| | - Ayelet Eran
- Department of Radiology, Rambam Health Care Campus, Haifa, Israel
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15
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Mustafa-Hellou M, Sagi N, Ofran Y, Geffen Y, Ghanem-Zoubi N. Endovascular Infection with Kingella kingae Complicated by Septic Arthritis in Immunocompromised Adult Patient. Emerg Infect Dis 2020; 26:2999-3001. [PMID: 33219654 PMCID: PMC7706982 DOI: 10.3201/eid2612.191665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
We report a case of Kingella kingae endovascular infection in an immunocompromised elderly patient in Israel who had culture-negative septic arthritis. This case highlights potential sources of metastatic infection other than infective endocarditis, and emphasizes the need for molecular diagnostic methods in detection of pathogens in culture-negative septic arthritis in immunocompromised patients.
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16
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Yahav D, Franceschini E, Koppel F, Turjeman A, Babich T, Bitterman R, Neuberger A, Ghanem-Zoubi N, Santoro A, Eliakim-Raz N, Pertzov B, Steinmetz T, Stern A, Dickstein Y, Maroun E, Zayyad H, Bishara J, Alon D, Edel Y, Goldberg E, Venturelli C, Mussini C, Leibovici L, Paul M. Seven Versus 14 Days of Antibiotic Therapy for Uncomplicated Gram-negative Bacteremia: A Noninferiority Randomized Controlled Trial. Clin Infect Dis 2020; 69:1091-1098. [PMID: 30535100 DOI: 10.1093/cid/ciy1054] [Citation(s) in RCA: 225] [Impact Index Per Article: 56.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 12/07/2018] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Gram-negative bacteremia is a major cause of morbidity and mortality in hospitalized patients. Data to guide the duration of antibiotic therapy are limited. METHODS This was a randomized, multicenter, open-label, noninferiority trial. Inpatients with gram-negative bacteremia, who were afebrile and hemodynamically stable for at least 48 hours, were randomized to receive 7 days (intervention) or 14 days (control) of covering antibiotic therapy. Patients with uncontrolled focus of infection were excluded. The primary outcome at 90 days was a composite of all-cause mortality; relapse, suppurative, or distant complications; and readmission or extended hospitalization (>14 days). The noninferiority margin was set at 10%. RESULTS We included 604 patients (306 intervention, 298 control) between January 2013 and August 2017 in 3 centers in Israel and Italy. The source of the infection was urinary in 411 of 604 patients (68%); causative pathogens were mainly Enterobacteriaceae (543/604 [90%]). A 7-day difference in the median duration of covering antibiotics was achieved. The primary outcome occurred in 140 of 306 patients (45.8%) in the 7-day group vs 144 of 298 (48.3%) in the 14-day group (risk difference, -2.6% [95% confidence interval, -10.5% to 5.3%]). No significant differences were observed in all other outcomes and adverse events, except for a shorter time to return to baseline functional status in the short-course therapy arm. CONCLUSIONS In patients hospitalized with gram-negative bacteremia achieving clinical stability before day 7, an antibiotic course of 7 days was noninferior to 14 days. Reducing antibiotic treatment for uncomplicated gram-negative bacteremia to 7 days is an important antibiotic stewardship intervention. CLINICAL TRIALS REGISTRATION NCT01737320.
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Affiliation(s)
- Dafna Yahav
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Erica Franceschini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Italy
| | - Fidi Koppel
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa
| | - Adi Turjeman
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva
| | - Tanya Babich
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva
| | - Roni Bitterman
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa
| | - Ami Neuberger
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa
| | | | - Antonella Santoro
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Italy
| | - Noa Eliakim-Raz
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Barak Pertzov
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva
| | - Tali Steinmetz
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva
| | - Anat Stern
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa
| | | | - Elias Maroun
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa
| | - Hiba Zayyad
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa
| | - Jihad Bishara
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Danny Alon
- Department of Medicine B, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Yonatan Edel
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Medicine C, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Elad Goldberg
- Department of Medicine F, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Claudia Venturelli
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Italy
| | - Cristina Mussini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Italy
| | - Leonard Leibovici
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa
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17
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Ghanem-Zoubi N, Kagna O, Abu-Elhija J, Mustafa-Hellou M, Qasum M, Keidar Z, Paul M. Integration of FDG-PET/CT in the diagnostic workup for Staphylococcus aureus bacteremia: a prospective interventional matched-cohort study. Clin Infect Dis 2020; 73:e3859-e3866. [PMID: 32639560 DOI: 10.1093/cid/ciaa929] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 07/01/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Staphylococcus aureus bacteremia (SAB) is uniquely characterized by focal pyogenic complications that might not be apparent clinically. We investigated the benefit of adding FDG-PET/CT in the workup of patients with SAB. METHODS Matched-cohort study. Patients with SAB (intervention group) were prospectively recruited to undergo FDG-PET/CT 7-14 days after diagnosis. Treatment was directed by FDG-PET/CT findings. Clinical outcomes were compared to a control group of patients with SAB who had not undergone FDG-PET/CT, matched by age, Charlson score, methicillin susceptibility and survival duration to FDG-PET/CT. The primary outcome was 90-day mortality. Residual confounding was controlled through regression analyses. RESULTS During the study period 149 patients with 151 separate episodes of SAB underwent FDG-PET/CT and were compared to 150 matched patients with 151 SAB episodes. Patients in the intervention group acquired infections more frequently in the community, had less frequently solid malignancies and more frequently high-risk SAB. Ninety-day mortality in the intervention group was significantly lower than in the control group [21/151 (13.9%) vs. 43/151 (28.5%), p=0.002]. The difference remained significant in a subgroup analysis of patients with community-onset infections without malignancy and among patients with low-risk SAB. Controlling for other risk factors for mortality, FDG-PET/CT performance among all patients was independently associated with lower mortality, odds ratio 0.39, 95% confidence interval 0.18-0.84. Patients in the intervention group had longer duration of treatment and more focus control procedures performed compared to the control group. CONCLUSION FDG-PET/CT in patients with SAB seems to improve survival through guidance of treatment duration and co-interventions.
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Affiliation(s)
- Nesrin Ghanem-Zoubi
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Olga Kagna
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Jawad Abu-Elhija
- Internal Medicine Department E, Rambam Health Care Campus, Haifa, Israel
| | | | - Majd Qasum
- Internal Medicine Department D, Rambam Health Care Campus, Haifa, Israel
| | - Zohar Keidar
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.,Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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18
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Ghanem-Zoubi N, Paul M. Q fever during pregnancy: a narrative review. Clin Microbiol Infect 2019; 26:864-870. [PMID: 31682987 DOI: 10.1016/j.cmi.2019.10.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 10/21/2019] [Accepted: 10/22/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Coxiella burnetii, the causative agent of Q fever, causes abortions in animals. Its effects on pregnancy in humans and the management of Q fever in pregnancy are uncertain. OBJECTIVES To summarize data on the effects of Q fever on pregnancy in women, the effects of pregnancy on Q fever complications and the optimal screening and management of Q fever during pregnancy. SOURCES We searched for studies reporting on Q fever during pregnancy in women. We included randomized and observational studies, seroprevalence studies, case series and case reports, including clinical and histopathological studies. CONTENT The accumulating data seems convincing that Q fever increases the risk of abortions in early pregnancy and prematurity or intrauterine fetal demise in late pregnancy. Data are based on sero-epidemiological associations of Q fever and adverse pregnancy outcomes and case reports showing the presence and effects of C. burnetii on the placenta and the fetus. Based on observational studies, acquisition of Q fever during pregnancy also increases the risk for maternal chronic Q fever. Treatment of recently infected women seems to improve these outcomes, based on case series only, but the optimal duration of treatment has not been studied. The efficacy of active surveillance during pregnancy, timing and frequency have not been determined in high-endemicity settings. Obstetricians should be aware of the risk for transmission of the disease during delivery. Currently available data are based mostly on case series and case reports, with some discrepancy between the French experience in chronic endemicity settings and Dutch experience in outbreak settings. IMPLICATIONS Since infection with Q fever is largely asymptomatic, we believe that the accumulating information linking Q fever to adverse pregnancy outcomes justifies screening in the high-endemicity setting and treatment of infected women. High-quality research addressing the questions raised by this review is needed to determine the optimal public health policy.
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Affiliation(s)
- N Ghanem-Zoubi
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.
| | - M Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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19
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Ghanem-Zoubi N, Qasum M, Khoury J, Zorbavel D, Arnon M, Geffen Y, Paul M. The association between fluconazole dose and MIC with mortality and persistence in candidemia. Eur J Clin Microbiol Infect Dis 2019; 38:1773-1780. [PMID: 31197619 DOI: 10.1007/s10096-019-03611-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 06/04/2019] [Indexed: 01/27/2023]
Abstract
To evaluate the association between fluconazole exposure parameters and clinical outcomes in patients with candidemia. We retrospectively included all adults with candidemia in a single center from January 2009 to December 2017, treated initially with fluconazole for fluconazole-susceptible candidemia. We assessed the association between fluconazole exposure parameters and 30-day mortality or 14-day clinical failure, a composite of mortality at day 14 or persistent candidemia ≥ 72 h, in all patients and in patients with C. glabrata candidemia. During the study period, 158 patients fulfilled the inclusion criteria. Main species were C. albicans 66 (41.8%), C. glabrata 35 (22.2%), and C. parapsilosis 31 (19.6%). Sixty patients (38%) died within 30 days. Sixty-one patients (38.6%) experienced 14-day failure. In 30-day survivors, the median AUC24/MIC was 2279 [398, 5989] versus 1764 [238, 6714] h in non-survivors, p = 0.75. Median fluconazole MIC was 0.75 [0.25, 4] and 1 [0.22, 5.50] mg/L, p = 0.54, respectively. Similar non-significant differences were found for other fluconazole exposure parameters and in the 14-day clinical failure analysis. For C. glabrata, a higher AUC24/MIC was observed among 30-day survivors with a median of 230 [77, 539] compared to 96 [75, 164] h in non-survivors, p = 0.008, in parallel with a trend for lower MIC values (median 7 [1, 2] versus 16 [8, 24] mg/L, p = 0.06, respectively). Currently used fluconazole dosing has no association with clinical outcome in Candida with low MIC values. For Candida species with high MICs, attention to dosing is needed.
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Affiliation(s)
- Nesrin Ghanem-Zoubi
- Infectious Diseases Institute, Rambam Health Care Campus, Ha-aliya 8 St, 3109601, Haifa, Israel.
| | - Majd Qasum
- Internal Medicine Department D, Rambam Health Care Campus, Ha-aliya 8 St, 3109601, Haifa, Israel
| | - Johad Khoury
- Internal Medicine Department B, Rambam Health Care Campus, Ha-aliya 8 St, 3109601, Haifa, Israel
| | - Danny Zorbavel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Efron 1 St, 3525433, Haifa, Israel
| | - Merav Arnon
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Efron 1 St, 3525433, Haifa, Israel
| | - Yuval Geffen
- Microbiology Laboratory, Rambam Health Care Campus, Ha-aliya 8 St, 3109601, Haifa, Israel
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Ha-aliya 8 St, 3109601, Haifa, Israel
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Erdem H, Puca E, Ruch Y, Santos L, Ghanem-Zoubi N, Argemi X, Hansmann Y, Guner R, Tonziello G, Mazzucotelli JP, Como N, Kose S, Batirel A, Inan A, Tulek N, Pekok AU, Khan EA, Iyisoy A, Meric-Koc M, Kaya-Kalem A, Martins PP, Hasanoglu I, Silva-Pinto A, Oztoprak N, Duro R, Almajid F, Dogan M, Dauby N, Gunst JD, Tekin R, Konopnicki D, Petrosillo N, Bozkurt I, Wadi J, Popescu C, Balkan II, Ozer-Balin S, Zupanc TL, Cascio A, Dumitru IM, Erdem A, Ersoz G, Tasbakan M, Ajamieh OA, Sirmatel F, Florescu S, Gulsun S, Ozkaya HD, Sari S, Tosun S, Avci M, Cag Y, Celebi G, Sagmak-Tartar A, Karakus S, Sener A, Dedej A, Oncu S, Del Vecchio RF, Ozturk-Engin D, Agalar C. Portraying infective endocarditis: results of multinational ID-IRI study. Eur J Clin Microbiol Infect Dis 2019; 38:1753-1763. [PMID: 31187307 DOI: 10.1007/s10096-019-03607-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 05/29/2019] [Indexed: 01/18/2023]
Abstract
Infective endocarditis is a growing problem with many shifts due to ever-increasing comorbid illnesses, invasive procedures, and increase in the elderly. We performed this multinational study to depict definite infective endocarditis. Adult patients with definite endocarditis hospitalized between January 1, 2015, and October 1, 2018, were included from 41 hospitals in 13 countries. We included microbiological features, types and severity of the disease, complications, but excluded therapeutic parameters. A total of 867 patients were included. A total of 631 (72.8%) patients had native valve endocarditis (NVE), 214 (24.7%) patients had prosthetic valve endocarditis (PVE), 21 (2.4%) patients had pacemaker lead endocarditis, and 1 patient had catheter port endocarditis. Eighteen percent of NVE patients were hospital-acquired. PVE patients were classified as early-onset in 24.9%. A total of 385 (44.4%) patients had major embolic events, most frequently to the brain (n = 227, 26.3%). Blood cultures yielded pathogens in 766 (88.4%). In 101 (11.6%) patients, blood cultures were negative. Molecular testing of vegetations disclosed pathogens in 65 cases. Overall, 795 (91.7%) endocarditis patients had any identified pathogen. Leading pathogens (Staphylococcus aureus (n = 267, 33.6%), Streptococcus viridans (n = 149, 18.7%), enterococci (n = 128, 16.1%), coagulase-negative staphylococci (n = 92, 11.6%)) displayed substantial resistance profiles. A total of 132 (15.2%) patients had cardiac abscesses; 693 (79.9%) patients had left-sided endocarditis. Aortic (n = 394, 45.4%) and mitral valves (n = 369, 42.5%) were most frequently involved. Mortality was more common in PVE than NVE (NVE (n = 101, 16%), PVE (n = 49, 22.9%), p = 0.042).
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Affiliation(s)
| | - Edmond Puca
- Department of Infectious Diseases, University Hospital Center "Mother Teresa", Tirana, Albania
| | - Yvon Ruch
- Department of Infectious Diseases, Strasbourg University Hospital, Nouvel Hôpital Civil, Strasbourg, France
| | - Lurdes Santos
- Infectious Diseases Department, Centro Hospitalar São João and Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | | | - Xavier Argemi
- Department of Infectious Diseases, Strasbourg University Hospital, Nouvel Hôpital Civil, Strasbourg, France
| | - Yves Hansmann
- Department of Infectious Diseases, Strasbourg University Hospital, Nouvel Hôpital Civil, Strasbourg, France
| | - Rahmet Guner
- Ataturk Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Yildirim Beyazit University, Ankara, Turkey
| | - Gilda Tonziello
- Clinical & Research Department for Infectious Diseases, National Institute for Infectious Diseases "Lazzaro Spallanzani", IRCCS,, Via Portuense, 292, 00149, Rome, Italy
| | - Jean-Philippe Mazzucotelli
- Department of Cardiovascular Surgery, Strasbourg University Hospital, Nouvel Hôpital Civil, Strasbourg, France
| | - Najada Como
- Service of Infectious Disease, UHC, Tirana, Albania
| | - Sukran Kose
- Department of Infectious Diseases and Clinical Microbiology, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Ayse Batirel
- Department of Infectious Diseases and Clinical Microbiology, Dr. Lutfi Kirdar Training and Research Hospital, Health Sciences University, Istanbul, Turkey
| | - Asuman Inan
- Department of Infectious Diseases and Clinical Microbiology, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - Necla Tulek
- Department of Microbiology, Atilim University, School of Medicine, Ankara, Turkey
| | - Abdullah Umut Pekok
- Department of Infectious Diseases and Clinical Microbiology, Pendik Medical Park Hospital, Istanbul, Turkey
| | - Ejaz Ahmed Khan
- Shifa International Hospital and Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Atilla Iyisoy
- Department of Cardiology, Gulhane Training and Research Hospital, Health Sciences University, Ankara, Turkey
| | - Meliha Meric-Koc
- Department of Infectious Diseases and Clinical Microbiology, Bezmialem Vakıf University School of Medicine, Istanbul, Turkey
| | - Ayse Kaya-Kalem
- Ataturk Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Yildirim Beyazit University, Ankara, Turkey
| | - Pedro Palma Martins
- Infectious Diseases Department, Centro Hospitalar São João and Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Imran Hasanoglu
- Ataturk Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Yildirim Beyazit University, Ankara, Turkey
| | - André Silva-Pinto
- Infectious Diseases Department, Centro Hospitalar São João and Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Nefise Oztoprak
- Department of Infectious Diseases and Clinical Microbiology, Antalya Training and Research Hospital, Health Sciences University, Antalya, Turkey
| | - Raquel Duro
- Infectious Diseases Department, Centro Hospitalar São João and Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Fahad Almajid
- Department of Medicine, Infectious Diseases Division, King Saud University Hospital, Riyadh, Saudi Arabia
| | - Mustafa Dogan
- Department of Infectious Diseases and Clinical Microbiology, Corlu State Hospital, Tekirdag, Antalya, Turkey
| | - Nicolas Dauby
- Department of Infectious Diseases, Centre Hospitalier Universitaire Saint-Pierre, Université libre de Bruxelles (ULB), 322 rue Haute, 1000, Brussels, Belgium
| | | | - Recep Tekin
- Department of Infectious Diseases and Clinical Microbiology, Dicle University Faculty of Medicine, Diyarbakır, Turkey
| | - Deborah Konopnicki
- Department of Infectious Diseases, Centre Hospitalier Universitaire Saint-Pierre, Université libre de Bruxelles (ULB), 322 rue Haute, 1000, Brussels, Belgium
| | - Nicola Petrosillo
- Clinical & Research Department for Infectious Diseases, National Institute for Infectious Diseases "Lazzaro Spallanzani", IRCCS,, Via Portuense, 292, 00149, Rome, Italy
| | - Ilkay Bozkurt
- Department of Infectious Diseases and Clinical Microbiology, Ondokuz Mayis University School of Medicine, Samsun, Turkey
| | - Jamal Wadi
- Department of Infectious Diseases, School of Medicine, The University of Jordan, Amman, Jordan
| | - Corneliu Popescu
- Dr Victor Babes Clinical Hospital of Infectious and Tropical Disease, Bucharest, Romania
| | - Ilker Inanc Balkan
- Department of Infectious Diseases and Clinical Microbiology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Safak Ozer-Balin
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Firat University, Elazig, Turkey
| | | | - Antonio Cascio
- Department of Health Promotion Sciences and Mother and Child Care "G. D'Alessandro", University of Palermo, Palermo, Italy
| | | | - Aysegul Erdem
- Department of Pathology, Kecioren Training and Research Hospital, Ankara, Turkey
| | - Gulden Ersoz
- Department of Infectious Diseases and Clinical Microbiology, Mersin University School of Medicine, Mersin, Turkey
| | - Meltem Tasbakan
- Department of Infectious Diseases and Clinical Microbiology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Oday Abu Ajamieh
- Department of Infectious Diseases, School of Medicine, The University of Jordan, Amman, Jordan
| | - Fatma Sirmatel
- Department of Infectious Disease and Clinical Microbiology, Izzet Baysal University School of Medicine, Bolu, Turkey
| | - Simin Florescu
- Dr Victor Babes Clinical Hospital of Infectious and Tropical Disease, Bucharest, Romania
| | - Serda Gulsun
- Department of Infectious Diseases and Clinical Microbiology, Diyarbakir Training and Research Hospital, Diyarbakir, Turkey
| | - Hacer Deniz Ozkaya
- Department of Infectious Diseases and Clinical Microbiology, Cigli Regional Education Hospital, Izmir, Turkey
| | - Sema Sari
- Department of Intensive Care Unit, Turkey Advanced Specialty Education and Research Hospital, Ankara, Turkey
| | - Selma Tosun
- Department of Infectious Diseases and Clinical Microbiology, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Meltem Avci
- Department of Infectious Disease and Clinical Microbiology, Usak University School of Medicine, Usak, Turkey
| | - Yasemin Cag
- Department of Infectious Diseases and Clinical Microbiology, Medeniyet University, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Guven Celebi
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Bulent Ecevit University, Zonguldak, Turkey
| | - Ayse Sagmak-Tartar
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Firat University, Elazig, Turkey
| | - Sumeyra Karakus
- Department of Infectious Diseases and Clinical Microbiology, Medeniyet University, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Alper Sener
- Department of Infectious Diseases and Clinical Microbiology, Onsekiz Mart University School of Medicine, Canakkale, Turkey
| | - Arjeta Dedej
- Department of Nephrology, American Hospital, Tirana, Albania
| | - Serkan Oncu
- Department of Infectious Diseases and Clinical Microbiology, Adnan Menderes University School of Medicine, Aydin, Turkey
| | - Rosa Fontana Del Vecchio
- Department of Clinical and Molecular Biomedicine, Section of Infectious Diseases, University of Catania, Catania, Italy
| | - Derya Ozturk-Engin
- Department of Infectious Diseases and Clinical Microbiology, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Canan Agalar
- Department of Infectious Diseases and Clinical Microbiology, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
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Ghanem-Zoubi N, Khoury J, Arnon M, Zorbavel D, Geffen Y, Paul M. Risk Factors for Non-Albicans Candidemia Focusing on Prior Antifungal and Immunosuppressive Therapy. Isr Med Assoc J 2019; 21:303-307. [PMID: 31140219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND With the widespread use of antifungal agents, the frequency of non-albicans Candida (NAC) blood-stream infections (BSI) is increasing. OBJECTIVES To describe the epidemiology, clinical manifestations, and risk factors for NAC BSI, focusing on prior antifungal and immunosuppressive therapy. METHODS The authors conducted an observational, retrospective cohort study among adult patients with candidemia at the Rambam Health Care Campus, a tertiary medical center in Israel, between 2009 and 2015. Comparisons between patients with Candidemia albicans and NAC candidemia were performed. Regression analysis, with NAC BSI as the dependent variable and significant risk factors for NAC as independent variables, was performed. RESULTS A total of 308 episodes of candidemia were included. C. albicans was isolated in 30.8% of patients (95/308), while NAC spp. were isolated in the rest. Significant independent risk factors for NAC included immunosuppression therapy (odds ratio [OR] 0.38, 95% confidence interval [95%CI] 0.19-0.76) and previous azole use (OR 0.2, 95%CI 0.06-0.710). The interaction between prior azole and immunosuppression therapy in the model was not significant, and after its inclusion in the model only immunosuppression remained significantly associated with NAC. In the subgroup of patients who did not receive prior azoles, immunosuppression therapy, neutropenia, and bone marrow transplantation were significantly associated with NAC. CONCLUSIONS Independent of previous azole treatment, immunosuppressive therapy was a significant risk factor for NAC in our cohort.
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Affiliation(s)
- Nesrin Ghanem-Zoubi
- Institute of Infectious Diseases, Rambam Health Care Campus, affiliated with Technion-Israel Institute of Technology, Haifa, Israel
| | - Johad Khoury
- Department of Medicine B, Rambam Health Care Campus, affiliated with Technion-Israel Institute of Technology, Haifa, Israel
| | - Merav Arnon
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Danny Zorbavel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Yuval Geffen
- Department of Microbiology Laboratory, Rambam Health Care Campus, affiliated with Technion-Israel Institute of Technology, Haifa, Israel
| | - Mical Paul
- Institute of Infectious Diseases, Rambam Health Care Campus, affiliated with Technion-Israel Institute of Technology, Haifa, Israel
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Ghanem-Zoubi N, Pessah Eljay S, Anis E, Paul M. Reemergence of Human Brucellosis in Israel. Isr Med Assoc J 2019; 21:10-12. [PMID: 30685898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND The epidemiology of human brucellosis (HB) continues to evolve. OBJECTIVES To describe the current epidemiology of HB in Israel in general and in the population at risk. METHODS We calculated the incidence of HB in Israel for the period 2009-2015, overall and for the Arab population. Data are based on mandatory reporting of HB in Israel, defined clinically with either laboratory confirmation or epidemiological linkage to a laboratory-confirmed case. We mapped the geographic distribution of HB throughout the study period according to localities. We specified localities with high incidence (≥ 10 per 100,000 population) and mapped the distribution of dense localities with time. RESULTS The incidence of HB in the general population in Israel increased sharply from 1.9 per 100,000 in 2009 to a peak of 7.3 per 100,000 in 2014. Each year, 95-100% of cases occurred among Arabs, thus the incidence in the Arab population increased from 10 per 100,000 in 2009 to 33.5 per 100,000 in 2014. Throughout this period 133 different localities reported at least one case of HB, and of these 20 were high-incidence localities during one year at least. During the period 2009-2013 the number of affected localities ranged from 35 to 44 per year and the disease was local, while in 2014 there were 82 localities distributed across the country. CONCLUSIONS We demonstrate the importance of analyzing incidence in the population at risk for a disease. HB is an urgent public health issue in the Arab population in Israel, mandating an immediate and long-term eradication and control program.
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Affiliation(s)
| | | | - Emilia Anis
- Division of Epidemiology, Ministry of Health, Jerusalem, Israel
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Ghanem-Zoubi N, Eljay SP, Anis E, Paul M. Association between human brucellosis and adverse pregnancy outcome: a cross-sectional population-based study. Eur J Clin Microbiol Infect Dis 2018; 37:883-888. [PMID: 29344838 DOI: 10.1007/s10096-017-3181-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 12/25/2017] [Indexed: 10/18/2022]
Abstract
To investigate the association between the incidence of human brucellosis (HB) and adverse pregnancy outcomes (APOs), a population-based, cross-sectional aggregate data study was conducted in Israel between 2010 and 2014. HB-endemic localities were matched by ethnicity, population size and socioeconomic status to localities with a low incidence of HB. We compared APO rates in high-incidence vs low-incidence localities. The primary outcome was intrauterine fetal demise (IUFD). Secondary outcomes were premature birth (less than 37 weeks), early or threatened labour and poor fetal growth. APOs are expressed as events per 1,000 live or dead births. Eleven high-incidence localities, all Arab villages or cities, were matched to 11 low-incidence localities. Localities were well-matched with regard to the matching criteria, fertility indices, health insurance access and education, but were imbalanced geographically. All defined APOs occurred significantly more frequently in the high-incidence localities. The associations translated to an absolute increase of 3.6 cases of IUFD (95% CI 1.6-5.3), 11.7 preterm births (4.8-18.3), 6.6 cases of early or threatened labour (2.2-10.9) and 7 cases of poor fetal growth (3-10.8), per 10,000 live or dead births. Owing to a geographic imbalance between high- and low-incidence localities, we conducted an analysis restricted to Southern localities of Arab Bedouins showing a significant association between yearly HB incidence and IUFD incidence, odds ratio 1.05 (1.03-1.06). HB incidence is epidemiologically linked to serious pregnancy complications. Early detection of infection through active surveillance during pregnancy followed by appropriate treatment should be evaluated as additional public heath strategy in endemic settings.
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Affiliation(s)
- Nesrin Ghanem-Zoubi
- Infectious Diseases Institute, Rambam Health Care Campus, 3109601, Haifa, Israel.
| | | | - Emilia Anis
- Division of Epidemiology, Ministry of Health, 9101002, Jerusalem, Israel
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, 3109601, Haifa, Israel
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Korytny A, Nasser R, Geffen Y, Friedman T, Paul M, Ghanem-Zoubi N. Ureaplasma parvum causing life-threatening disease in a susceptible patient. BMJ Case Rep 2017; 2017:bcr-2017-220383. [PMID: 28814589 DOI: 10.1136/bcr-2017-220383] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
A 56-year-old man with lymphoma developed orchitis followed by septic arthritis of his right glenohumeral joint. Synovial fluid cultures were negative but PCR amplification test was positive forUreaplasmaparvum. The patient was treated with doxycycline. Two and a half years later, the patient presented with shortness of breath and grade III/IV diastolic murmur on auscultation. Echocardiography revealed severely dilated left heart chambers, severe aortic regurgitation and several mobile masses on the aortic valve cusps suspected to be vegetations. He underwent valve replacement; valve tissue culture was negative but the 16S rRNA gene amplification test was positive for U. parvumHe was treated again with doxycycline. In an outpatient follow-up 1 year and 3 months later, the patient was doing well. Repeated echocardiography showed normal aortic prosthesis function.
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Affiliation(s)
- Alexander Korytny
- Department of Internal Medicine B, Rambam Health Care Campus, Haifa, Israel
| | - Roni Nasser
- Department of Internal Medicine B, Rambam Health Care Campus, Haifa, Israel
| | - Yuval Geffen
- Microbiology Laboratory, Rambam Health Care Campus, Haifa, Israel
| | - Tom Friedman
- Department of Cardiac Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
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25
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Kagna O, Kurash M, Ghanem-Zoubi N, Keidar Z, Israel O. Does Antibiotic Treatment Affect the Diagnostic Accuracy of 18F-FDG PET/CT Studies in Patients with Suspected Infectious Processes? J Nucl Med 2017; 58:1827-1830. [PMID: 28473596 DOI: 10.2967/jnumed.117.192062] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 04/11/2017] [Indexed: 11/16/2022] Open
Abstract
18F-FDG PET/CT plays a significant role in the assessment of various infectious processes. Patients with suspected or known sites of infection are often referred for 18F-FDG imaging while already receiving antibiotic treatment. The current study assessed whether antibiotic therapy affected the detectability rate of infectious processes by 18F-FDG PET/CT. Methods: A 5-y retrospective study of all adult patients who underwent 18F-FDG PET/CT in search of a focal source of infection was performed. The presence, duration, and appropriateness of antibiotic treatment before 18F-FDG imaging were recorded. Diagnosis of an infectious process was based on microbiologic or pathologic data as well as on clinical and radiologic follow-up. Results: Two hundred seventeen patients underwent 243 PET/CT studies in search of a focal source of infection and were included in the study. Sixty-seven studies were excluded from further analysis because of a final noninfectious etiology or lack of further follow-up or details regarding the antibiotic treatment. The final study population included 176 18F-FDG PET/CT studies in 153 patients (107 men, 46 women; age range, 18-86 y). One hundred nineteen studies (68%) were performed in patients receiving antibiotic therapy for a range of 1-73 d. A diagnosis of infection was made in 107 true-positive cases (61%), including 63 studies (59%) in patients receiving appropriate antibiotic therapy started before the performance of the 18F-FDG PET/CT study. There were 52 true-negative (29%) and 17 false-positive (10%) 18F-FDG PET/CT studies. No false-negative results were found. Conclusion:18F-FDG PET/CT correctly identified foci of increased uptake compatible with infection in most patients, including all patients receiving appropriate antimicrobial therapy, with no false-negative cases. On the basis of the current study results, the administration of antibiotics appears to have no clinically significant impact on the diagnostic accuracy of 18F-FDG PET/CT performed for evaluation of known or suspected infectious processes.
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Affiliation(s)
- Olga Kagna
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel; and
| | - Marina Kurash
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel; and
| | | | - Zohar Keidar
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel; and
| | - Ora Israel
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel; and
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26
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Muady GF, Bitterman H, Laor A, Vardi M, Urin V, Ghanem-Zoubi N. Hemoglobin levels and blood transfusion in patients with sepsis in Internal Medicine Departments. BMC Infect Dis 2016; 16:569. [PMID: 27737630 PMCID: PMC5064795 DOI: 10.1186/s12879-016-1882-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 09/29/2016] [Indexed: 12/29/2022] Open
Abstract
Background Acute reduction in hemoglobin levels is frequently seen during sepsis. Previous studies have focused on the management of anemia in patients with septic shock admitted to intensive care units (ICU’s), including aggressive blood transfusion aiming to enhance tissue oxygenation. Aim To study the changes in hemoglobin concentrations during the first week of sepsis in the setting of Internal Medicine (IM) units, and their correlation to survival. Design Observational prospective study. Methods We recorded hemoglobin values upon admission and throughout the first week of hospital stay in a consecutive cohort of septic patients admitted to IM units at a community hospital, the patients were enrolled into a prospective registry. Data on blood transfusions was also collected, we examined the correlation between hemoglobin concentrations during the first week of sepsis and survival, the effect of blood transfusion was also assessed. Results Eight hundred and fifteen patients (815) with sepsis were enrolled between February 2008 to January 2009. More than 20 % of them had hemoglobin levels less than 10g/dL on admission, a rate that was doubled during the first week of sepsis. Overall, 68 (8.3 %) received blood transfusions, 14 of them (20.6 %) due to bleeding. Typically, blood transfusion was given to older patients with a higher rate of malignancy and lower hemoglobin levels. While hemoglobin concentration on admission had strong correlation with in-hospital mortality (O.R-0.83 [95 % C.I. 0.74–0.92], blood transfusion was not found to be an independent predicting factor for mortality. Conclusion Anemia is very common in sepsis. While hemoglobin level on admission exhibit independent correlation with survival, blood transfusion do not.
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Affiliation(s)
- Gassan Fuad Muady
- Internal Medicine Department, Carmel Medical Center, Michal 7, 34362, Haifa, Israel.
| | - Haim Bitterman
- Internal Medicine Department, Carmel Medical Center, Michal 7, 34362, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Arie Laor
- Internal Medicine Department, Carmel Medical Center, Michal 7, 34362, Haifa, Israel
| | - Moshe Vardi
- Harvard Clinical Research Institute, Boston, MA, USA.,School of Public Health, Boston University, Boston, MA, USA
| | - Vitally Urin
- Internal Medicine Department, Carmel Medical Center, Michal 7, 34362, Haifa, Israel
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Paul M, Bishara J, Yahav D, Goldberg E, Neuberger A, Ghanem-Zoubi N, Dickstein Y, Nseir W, Dan M, Leibovici L. Trimethoprim-sulfamethoxazole versus vancomycin for severe infections caused by meticillin resistant Staphylococcus aureus: randomised controlled trial. BMJ 2015; 350:h2219. [PMID: 25977146 PMCID: PMC4431679 DOI: 10.1136/bmj.h2219] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2015] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To show non-inferiority of trimethoprim-sulfamethoxazole compared with vancomycin for the treatment of severe infections due to meticillin resistant Staphylococcus aureus (MRSA). DESIGN Parallel, open label, randomised controlled trial. SETTING Four acute care hospitals in Israel. PARTICIPANTS Adults with severe infections caused by MRSA susceptible to trimethoprim-sulfamethoxazole and vancomycin. Patients with left sided endocarditis, meningitis, chronic haemodialysis, and prolonged neutropenia were excluded. INTERVENTIONS Trimethoprim-sulfamethoxazole 320 mg/1600 mg twice daily versus vancomycin 1 g twice daily for a minimum of seven days and then by indication. MAIN OUTCOME MEASURES The primary efficacy outcome was treatment failure assessed at day 7, consisting of death, persistence of haemodynamic instability or fever, stable or worsening Sequential Organ Failure Assessment score, and persistence of bacteraemia. The primary safety outcome was all cause mortality at day 30. Non-inferiority was defined by a difference of less than 15% for treatment failure. RESULTS 252 patients were included in the trial, of whom 91 (36%) had bacteraemia. No significant difference in treatment failure was seen for trimethoprim-sulfamethoxazole (51/135, 38%) versus vancomycin (32/117, 27%)-risk ratio 1.38 (95% confidence interval 0.96 to 1.99). However, trimethoprim-sulfamethoxazole did not meet the non-inferiority criterion-absolute difference 10.4% (95% confidence interval -1.2% to 21.5%). For patients with bacteraemia, the risk ratio was 1.40 (0.91 to 2.16). In a multivariable logistic regression analysis, trimethoprim-sulfamethoxazole was significantly associated with treatment failure (adjusted odds ratio 2.00, 1.09 to 3.65). The 30 day mortality rate was 32/252 (13%), with no significant difference between arms. Among patients with bacteraemia, 14/41 (34%) treated with trimethoprim-sulfamethoxazole and 9/50 (18%) with vancomycin died (risk ratio 1.90, 0.92 to 3.93). CONCLUSIONS High dose trimethoprim-sulfamethoxazole did not achieve non-inferiority to vancomycin in the treatment of severe MRSA infections. The difference was particularly marked for patients with bacteraemia. Trial registration Clinical trials NCT00427076.
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Affiliation(s)
- Mical Paul
- Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Jihad Bishara
- Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Dafna Yahav
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel Unit of Infectious Diseases, Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva
| | - Elad Goldberg
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel Unit of Infectious Diseases, Medicine F, Rabin Medical Center, Beilinson Hospital, Petah-Tikva
| | - Ami Neuberger
- Division of Infectious Diseases, Medicine B, Rambam Health Care Campus, Haifa, Israel Technion-Israel Institute of Technology and the Ruth & Bruce Rappaport Faculty of Medicine, Haifa
| | | | - Yaakov Dickstein
- Technion-Israel Institute of Technology and the Ruth & Bruce Rappaport Faculty of Medicine, Haifa Division of Infectious Diseases, Medicine A, Rambam Health Care Campus, Haifa
| | - William Nseir
- Internal Medicine Department, Holy Family Hospital, Nazareth, Faculty of Medicine in the Galilee, Bar-Ilan Univesity, Safed, Israel
| | - Michael Dan
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel Infectious Diseases Unit, E Wolfson Hospital, Holon, Israel
| | - Leonard Leibovici
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel Unit of Infectious Diseases, Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva
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Ghanem-Zoubi N, Bitterman H, Laor A, Yurin V, Vardi M. The accuracy of clinical prediction of prognosis for patients admitted with sepsis to internal medicine departments. Ann Med 2015; 47:555-60. [PMID: 26426517 DOI: 10.3109/07853890.2015.1089361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Prognosis estimation offered by physicians for patients inflicted by sepsis on their admission to Internal Medicine (IM) departments is considered a challenge. Early prognosis estimation is critical and determines the intensity of treatment offered. The accuracy of prognosis estimation made by physicians has previously been investigated mainly among intensive care physicians and oncologists. OBJECTIVE To ascertain the accuracy of prognosis prediction made by internists for septic patients on admission to IM departments. METHODS Physicians were asked to estimate the prognosis of every patient identified to have sepsis on admission. Their intuitive assessment of prognosis was incorporated into the patients' electronic medical record. Survival follow-up was recorded until death or for at least 2 years. Later we compared survival with physicians' prognosis estimations. RESULTS Prognosis estimation was recorded for 1,073 consecutive septic patients admitted throughout the years 2008-2009 to IM departments. The mean age of patients was 74.7 ± 16.1 years. A total of 42.4% were suspected to have pneumonia, and 65.4% died during a mean follow-up time of 661.1 ± 612.3 days. Almost half of the patients classified to have good prognosis survived compared to 14.9% and 4.9% of those with intermediate and bad prognosis estimation, respectively (P < 0.001). CONCLUSION Internists can discriminate well between septic patients with good, intermediate, and bad prognosis.
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Affiliation(s)
| | - Haim Bitterman
- b Internal Medicine Department , Carmel Medical Center , Haifa , Israel.,c The Ruth and Bruce Rappaport Faculty of Medicine , Technion-Israel Institute of Technology , Haifa , Israel
| | - Arie Laor
- b Internal Medicine Department , Carmel Medical Center , Haifa , Israel
| | - Vitaly Yurin
- b Internal Medicine Department , Carmel Medical Center , Haifa , Israel
| | - Moshe Vardi
- d Harvard Clinical Research Institute , Boston , MA , USA.,e School of Public Health, Boston University , Boston , MA , USA
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