Association between urinary community-acquired fluoroquinolone-resistant Escherichia coli and neighbourhood antibiotic consumption: a population-based case-control study

BACKGROUND

It is unknown whether increased use of antibiotics in a community increases the risk of acquiring antibiotic resistance by individuals living in that community, regardless of prior individual antibiotic consumption and other risk factors for antibiotic resistance.

METHODS

We used a hierarchical multivariate logistic regression approach to evaluate the association between neighbourhood fluoroquinolone consumption and individual risk of colonisation or infection of the urinary tract with fluoroquinolone-resistant Escherichia coli. We did a population-based case-control study of adults (aged ≥22 years) living in 1733 predefined geographical statistical areas (neighbourhoods) in Israel. A multilevel study design was used to analyse data derived from electronic medical records of patients enrolled in the Clalit state-mandated health service.

FINDINGS

300 105 events with E coli growth and 1 899 168 cultures with no growth were identified from medical records and included in the analysis. 45 427 (16·8%) of 270 190 women and 8835 (29·5%) of 29 915 men had fluoroquinolone-resistant E coli events. We found an independent association between residence in a neighbourhood with higher antibiotic consumption and an increased risk of bacteriuria caused by fluoroquinolone-resistant E coli. Odds ratios (ORs) for the quintiles with higher neighbourhood consumption (compared with the lowest quintile) were 1·15 (95% CI 1·06-1·24), 1·31 (1·20-1·43), 1·41 (1·29-1·54), and 1·51 (1·38-1·65) for women, and 1·17 (1·02-1·35), 1·24 (1·06-1·45), 1·35 (1·15-1·59), and 1·50 (1·26-1·77) for men. Results remained significant when the analysis was restricted to patients who had not consumed fluoroquinolones themselves.

INTERPRETATION

These data suggest that increased use of antibiotics in specific geographical areas is associated with an increased personal risk of acquiring antibiotic-resistant bacteria, independent of personal history of antibiotic consumption and other known risk factors for antimicrobial resistance.

FUNDING

None.

Infectious disease burden and antibiotic prescribing in primary care in Israel

BACKGROUND

Antibiotics are frequently prescribed at many of the visits to primary care clinics, often for conditions for which they provide no benefit, including viral respiratory tract infections.

OBJECTIVES

The aim was to evaluate primary care visits due to infectious diseases, and to estimate antibiotic prescribing and antibiotic dispensing by pharmacies.

METHODS

Diagnosis of infectious disease, antibiotic prescribing and dispensing data at the individual patient level were extracted for 2015 from Clalit Health Services' electronic medical records and linked to determine the condition for which the antimicrobial was prescribed.

RESULTS

There were 6.6 million visits due to infections, representing 22% of all primary care visits. The most common events were upper respiratory tract infections (38%) and pharyngitis (10%). Highest prescription rates were for urinary tract infections (80%), otitis media (64%), pharyngitis (71%), sinusitis (63%), and lower respiratory tract infections (76%). The highest rates of undispensed prescriptions were for acute gastroenteritis, urinary tract infections, and pharyngitis (24, 23, and 16%, respectively).

CONCLUSIONS

Infectious diseases constitute a heavy burden on primary care, with overprescribing of antibiotics. Intervention to reduce unwarranted antibiotic use is needed. In pediatric care, interventions should focus on better controlling antibiotic consumption and encouraging adherence to guidelines for upper respiratory tract infections, pharyngitis, and otitis media. In adults interventions should aim to monitor antibiotic prescribing for upper respiratory tract infections and improve adherence to guidelines for urinary tract infections.

Susceptibility of Group A Streptococcus to Antimicrobial Agents in Northern Israel: A Surveillance Study

BACKGROUND

Resistant pathogens are an increasing threat affecting millions of people globally. More complicated patients are presented with pathogens harboring new resistance mechanisms, while the pipeline of new antimicrobials hardly proposes solutions. In such a scenario, more severely ill patients remain with no adequate treatment to offer. In addition, massive misuse of antimicrobials, including excessive length of treatment or wrong dosage, also contributes to increasing the rate of pathogens resistance to antimicrobials. Isolation of Streptococcus pyogenes (Group A Streptococcus-GAS) is the main indication for antibiotic treatment to patients diagnosed with acute tonsillitis. Hence, GAS resistance to antibiotics requires periodic monitoring.

OBJECTIVES

To assess susceptibility rates of GAS to penicillin, macrolides, clindamycin, and tetracycline in northern Israel and to compare the findings to the high antimicrobial susceptibility of GAS isolates reported in the same region in 2004 and to other geographical areas.

METHODS

Throat samples from 300 outpatients were collected and cultured at the regional laboratory of Emek Medical Center during September to October 2011.

RESULTS

In 300 samples, the susceptibility rates of GAS to penicillin, erythromycin, azithromycin, clindamycin, and tetracycline in northern Israel still remain very high.

CONCLUSIONS

Continuous control of antimicrobials usage and periodic surveillance of susceptibility rates, together with educational programs and appropriate and targeted treatment protocols, are essential and highly recommended to keep these high susceptibility rates for as long as possible.

Chloramphenicol use and susceptibility patterns in Israel: a national survey

BACKGROUND

Due to increasing antimicrobial resistance, there has been renewed interest in old drugs that have fallen into disuse because of toxic side effects. One such drug is chloramphenicol. Data on the use and susceptibility patterns to chloramphenicol in developed countries in recent years are limited.

OBJECTIVES

To assess the susceptibility of bacteria to chloramphenicol, and evaluate the use of chloramphenicol in Israeli hospitals as influenced by infectious disease specialists' attitudes with regard to its potential harms.

METHODS

A national survey was conducted in all Israeli hospitals. Questionnaires were sent to the directors of infectious disease units and included items on chloramphenicol susceptibility in clinical isolates, use of chloramphenicol for the treatment of inpatients, local recommendations for use of chloramphenicol, and concerns regarding side effects.

RESULTS

Chloramphenicol is used in 83.3% of hospitals, mostly for the treatment of aspiration pneumonia. While 22.2% of infectious disease unit directors believe that chloramphenicol should be avoided because of dangerous side effects, 88.9% believe there is a place for chloramphenicol in the treatment of patients in this era of increasing antibiotic resistance. Chloramphenicol susceptibility is routinely assessed in 44.4% of hospitals, with high susceptibility rates found among gram-positive, gram-negative and anaerobic bacteria.

CONCLUSIONS

In an era of increasing antibiotic resistance, many Israeli infectious disease unit directors believe that chloramphenicol has a role in the treatment of respiratory tract and other infections in hospitalized patients.

Clostridium difficile and inflammatory bowel disease: Role in pathogenesis and implications in treatment

Clostridium difficile (C. difficile) is the leading cause of antibiotic associated colitis and nosocomial diarrhea. Patients with inflammatory bowel disease (IBD) are at increased risk of developing C. difficile infection (CDI), have worse outcomes of CDI-including higher rates of colectomy and death, and experience higher rates of recurrence. However, it is still not clear whether C. difficile is a cause of IBD or a consequence of the inflammatory state in the intestinal environment. The burden of CDI has increased dramatically over the past decade, with severe outbreaks described in many countries, which have been attributed to a new and more virulent strain. A parallel rise in the incidence of CDI has been noted in patients with IBD. IBD patients with CDI tend be younger, have less prior antibiotic exposure, and most cases of CDI in these patients represent outpatient acquired infections. The clinical presentation of CDI in these patients can be unique-including diversion colitis, enteritis and pouchitis, and typical findings on colonoscopy are often absent. Due to the high prevalence of CDI in patients hospitalized with an IBD exacerbation, and the prognostic implications of CDI in these patients, it is recommended to test all IBD patients hospitalized with a disease flare for C. difficile. Treatment includes general measures such as supportive care and infection control measures. Antibiotic therapy with either oral metronidazole, vancomycin, or the novel antibiotic-fidaxomicin, should be initiated as soon as possible. Fecal macrobiota transplantation constitutes another optional treatment for severe/recurrent CDI. The aim of this paper is to review recent data on CDI in IBD: role in pathogenesis, diagnostic methods, optional treatments, and outcomes of these patients.

Trends in the burden of infectious disease hospitalizations among the elderly in the last decade

BACKGROUND

Infectious disease is a leading cause of hospitalization. We investigated trends in infectious disease hospitalizations among the elderly in the last decade.

METHODS

A total of 81,077 hospitalizations of elderly patients between 2001 and 2010 were available on the computerized database of the Ha'emek Medical Center, Israel. The proportion of hospitalizations attributable to infectious diseases was calculated.

RESULTS

Overall, lower respiratory tract infection (LRTI) accounted for 41.0% of hospitalizations attributable to infectious diseases followed by kidney, urinary tract and bladder infections (UTI) (21.4%), upper respiratory tract infections (URTI) (10.2%), and hepatobiliary tract infections (9.8%). The proportion of hospitalizations attributable to infectious diseases increased by 14.2% during the study period, rising from 16.9% in 2001 (1023 infectious disease hospitalizations of a total of 6043 hospitalizations) to 19.3% in 2010 (1907 infectious disease hospitalizations of a total of 9876 hospitalizations) (P for trend<0.001). A significant increasing trend persisted after adjustment for age, ethnicity, and season, resulting in an increase from 16.9% in 2001 to 18.8% in 2010 (P for trend=0.001). A significant increasing trend was observed in males (P for trend<0.001) and a borderline significant trend was observed in females (P for trend=0.062). The proportion of hospitalizations attributable to infectious diseases was higher in males and increased with age. LRTI and URTI were the major contributors to the increasing trend (P for trend=0.018 and <0.001, respectively).

CONCLUSIONS

This study shows an increasing trend in infectious disease hospitalizations among the elderly in the last decade. Public health measures are needed to reduce infectious disease hospitalizations.

Trends in outpatient antibiotic use in Israel during the years 2000-2010: setting targets for an intervention

PURPOSE

The abundant use of antibiotics (Abs) in the community plays a major role in inducing Ab resistance, but the literature concerning patterns in outpatient Ab use is limited. This study aims to lay the foundations for future policy and interventional programs to address the rise in Ab resistance by looking at long-term trends in Ab usage in Israel.

METHODS

Defined daily doses per 1,000 inhabitants per day (DID) of total Ab use, consumption in different age groups, and of different Ab preparations were calculated for the years 2000, 2005, and 2010 in the eight districts of Israel. Data were collected from the pharmacy registries of "Clalit Health Services", the largest Health Maintenance Organization (HMO) in Israel, covering 4 million patients, representing 53 % of the population. Trends in use over time were analyzed.

RESULTS

The overall Ab usage in Israel has remained constant in the last decade. Three significant trends were identified in this study: an increase in the consumption of expensive, broad-spectrum Abs, paralleled by a reduction in narrow-spectrum Abs; an increase in Ab consumption among the elderly, counteracted by reduced usage among children; large regional variations in the overall and specific use of Ab agents.

CONCLUSIONS

Our main findings of increased broad-spectrum Ab consumption, primarily among the adult population in Israel, and a wide variability in Ab use between the regions in Israel, can focus our future studies on searching for the factors behind these trends to aid in constructing interventional methods for decreasing outpatient Ab overuse.

Uptake of Pap smears among women in a large Israeli HMO between 2006 and 2008

OBJECTIVES

The Papanicolaou (Pap) smear test is used in many countries as a screening procedure for cervical cancer and precancerous lesions. The actual uptake of this screening test among women at risk for cervical cancer is unknown. The aim of this study was to estimate the percentage of women who are screened by Pap smears from the relevant population at risk, and to detect factors that are independently associated with uptake of cervical screening.

STUDY DESIGN

Retrospective database study.

METHODS

This study was undertaken at Maccabi Healthcare Services (MHS), the second largest publicly funded health maintenance organization in Israel. The study population consisted of Israeli women aged 21-59 years who were insured by MHS between 2006 and 2008. Logistic regression analyses were used to determine the independent relationships between immigration and socio-economic status and cervical screening.

RESULTS

The study population included 489,663 women who had a total of 313,602 Pap smears between 2006 and 2008. Fifty-four percent of the women did not have a Pap smear during the study period, 32% had at least one smear, and 14% had at least two smears. Living in a low socio-economic neighbourhood and recent immigration were independently and negatively associated with screening uptake.

CONCLUSION

Despite the clinical guidelines and the low costs, many Israeli women who are at risk for cervical cancer are not screened.

Urinary tract infection in postmenopausal women

Urinary tract infection (UTI) is the most common bacterial infection in women in general and in postmenopausal women in particular. Two groups of elderly women with recurrent UTI should be differentiated regarding age and general status: healthy, young postmenopausal women aged 50 to 70 years who are neither institutionalized or catheterized and elderly institutionalized women with or without a catheter. Bacteriuria occurs more often in elderly functionally impaired women, but in general it is asymptomatic. However, the risk factors associated with recurrent UTI in elderly women are not widely described. In a multivariate analysis it was found that urinary incontinence, a history of UTI before menopause, and nonsecretor status were strongly associated with recurrent UTI in young postmenopausal women. Another study described the incidence and risk factors of acute cystitis among nondiabetic and diabetic postmenopausal women. Independent predictors of infection included insulin-treated patients and a lifetime history of urinary infection. Borderline associations included a history of vaginal estrogen cream use in the past month, kidney stones, and asymptomatic bacteriuria at baseline. Another important factor in postmenopausal women is the potential role that estrogen deficiency plays in the development of bacteriuria. There are at least two studies showing a beneficial effect of estrogen in the management of recurrent bacteriuria in elderly women. One of these studies showed that vaginal estrogen cream reduced vaginal pH from 5.5±0.7 to 3.6±1.0, restored lactobacillus, and decreased new episodes of UTI. Another study reported similar results using an estriol vaginal ring. However, contradictory results are found in the literature. For example, additional studies found that the use of estriol-containing vaginal pessaries was less effective than oral nitrofurantoin macrocrystals in preventing UTI in postmenopausal women. Two other studies also did not find any benefit in the reduction of UTI by oral estrogen therapy. Unfortunately, the use of estrogen in preventing UTI in postmenopausal women remains questionable. New strategies have been researched for reducing the use of antibiotics in the prevention and treatment of UTI. Two of them are probiotics and cranberry juice or capsules. Although several studies regarding probiotics and cranberry juice or capsules have reported a reduction of episodes of UTI, there is no conclusive evidence that they are useful in the prevention of UTI in postmenopausal women. As for the optimal drug, dosage, and length of treatment for UTI in the elderly, there are no studies comparing these data with the treatment for young women.

Mannose-binding lectin in pre-menopausal women with recurrent urinary tract infections

Mannose-binding lectin (MBL) comprises an oligomeric serum protein that is a member of the collectin class of the C-type lectin superfamily. Its deficiency is genetically determined and confers predisposition to recurrent infections as well as increased infection severity. This correlation has been demonstrated in recurrent furunculosis caused by Staphylococcus aureus, and in pneumococcal and Candida infections. The present study aimed to determine whether there is a correlation between MBL serum levels and recurrent urinary tact infections (UTI) in pre-menopausal women. The present aged-matched double-blind controlled study was conducted in 100 pre-menopausal adult women: 50 who suffered from recurrent UTI and 50 without UTI. The MBL concentration was measured in a single serum sample from each patient using an enzyme-linked immunosorbent assay. MBL serum levels [median (range)] were 2500 (4-12,000) ng/mL and 2105 (4-22,800) ng/mL for the research and control groups, respectively. The results from the two groups were compared and were not statistically different (p 0.4). According to these results, MBL serum levels are not associated with an increased risk for recurrent UTI in pre-menopausal women.

Executive Summary: International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases

A Panel of International Experts was convened by the Infectious Diseases Society of America (IDSA) in collaboration with the European Society for Microbiology and Infectious Diseases (ESCMID) to update the 1999 Uncomplicated Urinary Tract Infection Guidelines by the IDSA. Co-sponsoring organizations include the American Congress of Obstetricians and Gynecologists, American Urological Association, Association of Medical Microbiology and Infectious Diseases–Canada, and the Society for Academic Emergency Medicine. The focus of this work is treatment of women with acute uncomplicated cystitis and pyelonephritis, diagnoses limited in these guidelines to premenopausal, non-pregnant women with no known urological abnormalities or co-morbidities. The issues of in vitro resistance prevalence and the ecological adverse effects of antimicrobial therapy (collateral damage) were considered as important factors in making optimal treatment choices and thus are reflected in the rankings of recommendations.

International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases

A Panel of International Experts was convened by the Infectious Diseases Society of America (IDSA) in collaboration with the European Society for Microbiology and Infectious Diseases (ESCMID) to update the 1999 Uncomplicated Urinary Tract Infection Guidelines by the IDSA. Co-sponsoring organizations include the American Congress of Obstetricians and Gynecologists, American Urological Association, Association of Medical Microbiology and Infectious Diseases–Canada, and the Society for Academic Emergency Medicine. The focus of this work is treatment of women with acute uncomplicated cystitis and pyelonephritis, diagnoses limited in these guidelines to premenopausal, non-pregnant women with no known urological abnormalities or co-morbidities. The issues of in vitro resistance prevalence and the ecological adverse effects of antimicrobial therapy (collateral damage) were considered as important factors in making optimal treatment choices and thus are reflected in the rankings of recommendations.

Nail puncture wound through a rubber-soled shoe: a retrospective study of 96 adult patients

Nail punctures through rubber-soled shoes expose the foot to the possibility of deep infection and foreign body retention. In this article, we describe characteristics of adult patients who sustained nail puncture wounds through a rubber-soled shoe and were treated at our institution from January 1, 2000, to January 8, 2008. Of the 96 patients, 36 (37.5%) were treated conservatively and 60 (62.5%) were treated surgically in the operating room. Of those treated surgically, 15 (25%) had a foreign body extracted during the operation. The operated group had a longer duration of time from injury to hospital admission than did the nonoperated group (5.0 +/- 6.8 days versus 2.7 +/- 3.8 days, P < .05). Treatment success was observed in 91 (94.8%) of the patients, and the median lag time before admission for the less successfully treated group was longer than that for the successfully treated group (10 days versus 2 days, P < .002); and, the less successfully treated group was more likely to receive antibiotics in the community before hospitalization (100.0% versus 47.2%, P < .06), and was more likely to be diabetic (40.0% versus 9.9%, P < .10). Fever, white blood cell count, and erythrocyte sedimentation rate were not significantly associated with treatment outcome. Success of the treatment did not depend on white blood cell count, erythrocyte sedimentation rate, or fever. Ultrasonography was useful in detecting the presence of a foreign body.

Etiology of community-acquired pneumonia in hospitalized patients in northern Israel

BACKGROUND

Community-acquired pneumonia is a common infection and is associated with high rates of morbidity and mortality. Most patients with CAP are treated empirically.

OBJECTIVES

To identify common pathogens causing CAP in hospitalized patients in northern Israel and to evaluate the correlation between etiology and disease severity.

METHODS

We conducted a prospective study of patients with CAP hospitalized at HaEmek Medical Center, Afula. We collected demographic, clinical and laboratory data (blood and sputum cultures, serology, pneumococcal urinary antigen test, and respiratory multiplex-polymerase chain reaction from nasopharyngeal swab). Radiologic evaluation was performed.

RESULTS

A total of 126 patients and 24 controls were enrolled. At least one pathogen was identified in 84 cases (66.7%), more than one in 43 patients (34.1%), and no pathogens in 42 (33.3%). Typical bacteria were found in 23 (18.3%), atypical bacteria in 66 (52.4%), and viruses in 42 (33.3%). The number (%) of patients with pathogens isolated was: Chlamydophila pneumoniae 26 (20.6%), Streptococcus pneumoniae 23 (18.3%), Mycoplasma pneumoniae 23 (18.3%), influenza virus A-B 20 (15.9%), Coxiella burnetti 8 (6.3%), and parainfluenza and adenovirus 13 (10.3%) each. A correlation was found only between a high PORT score on admission and S. pneumoniae, although atypical pathogens did not show class predominance.

CONCLUSIONS

S. pneumoniae, M. pneumoniae and C. pneumoniae were the most common pathogens isolated, while co-infection was very frequent. PORT score did not predict any of the pathogens involved. The choice of empiric antimicrobial treatment for CAP should be made according to local epidemiologic data.

Seasonal variation in Escherichia coli bloodstream infections in northern Israel

Seasonal variation in the infection rate with certain Gram-negative organisms has been previously described, but few studies have been published regarding Escherichia coli. The aim of this study was to investigate the incidence rate of E. coli bloodstream infection (BSI) and the association with temperature in different seasons in the Yizrael Valley. Positive blood cultures sent to the microbiology laboratory of Ha'Emek Medical Centre over a period of 8 years (January 2001 to December 2008) were included. The mean monthly temperature in the Yizrael Valley in the same period was compared with the monthly E. coli BSI rate. We divided the year into three periods: winter (December to February: mean temperature <15°C), transitional (March, April and November: mean temperature 15-19°C) and summer (May to October: mean temperature ≥20°C). In addition, we correlated the mean monthly antibiotic use in the same period measured as total defined daily doses for the whole regional population with E. coli BSI. During the study period, 2810 BSIs were recorded (35%E. coli). In 67.4% of the cases of E. coli bacteraemia, the source was urinary tract infection. The crude incidence of E. coli BSI was 4.1/1000 admissions. There was no difference in the number of cultures/month (mean: 29 ± 6). However, E. coli BSI was 19% and 21% more frequent in summer than in the transitional and winter seasons, respectively (p 0.01). The antibiotic consumption was significantly higher in the winter period. We found significantly higher rates of E. coli BSI in the summer period. Host, bacterial and ecological factors, together with high consumption of antibiotics during the winter season, could partially explain these findings.

Epidemiology and susceptibility to antimicrobials in community, hospital and long-term care facility bacteremia in northern Israel: a 6 year surveillance

BACKGROUND

Identification of pathogens and their susceptibility to antimicrobials is mandatory for successful empiric antibiotic treatment.

OBJECTIVES

To compare the clinical characteristics of patients with bacteremia, as well as the bacterial distribution and antimicrobial susceptibility in community, hospital and long-term care facilities during two periods (2001-2002 and 2005-2006).

METHODS

The study was conducted at the HaEmek Medical Center, a community 500-bed teaching hospital in northern Israel serving a population of approximately 500,000 inhabitants. All episodes of bacteremia (n = 1546) during two 2 year periods (2001-2 and 2005-6) were prospectively recorded, evaluated and compared (755 in 2001-2 and 791 in 2005-6).

RESULTS

In both periods the urinary tract was the main port of entry in community and long-term care facility bacteremia, while the urinary tract--primary and catheter-related--were similar in frequency as sources of hospital bacteremia. Escherichia coli was the most frequent pathogen isolate. No significant changes in the frequency of methicillin-resistant Staphylococcus aureus and extended-spectrum beta-lactamase-producing bacteria were seen between the two 2 year periods (2001-2 and 2005-6). The susceptibility of non-ESBL-producing E. coli decreased for some antibiotics while non-ESBL-producing Klebsiella pneumoniae susceptibility profile improved in the same period. A non-statistically significant trend of increased resistance in gram-negative isolates to quinolones, piperacillin and piperacillin-tazobactam was observed, but most isolates still remained highly susceptible to carbapenems. There was a small increase in mortality rate in hospital bacteremia during the second period.

CONCLUSIONS

Continuous surveillance is imperative for monitoring the local epidemiology and for developing local treatment guidelines.

Varicella zoster virus in health care workers in northern Israel: seroprevalence and predictive value of history of varicella infection

Health care workers (HCWs) are susceptible to hospital acquired varicella zoster virus (VZV). We evaluated seroprevalence and predictive value of a history of varicella disease (VD) with VZV serology in HCWs in northern Israel. A total of 200 HCWs were enrolled. A high rate of seropositivity for VZV-IgG was found: 98.5% seropositive and only 1.5% seronegative. A positive history of VD was an excellent predictor for the presence of VZV-IgG; however, a negative history of VD does not rule out the presence of VZV-IgG.

Antibiotic use in 26 departments of internal medicine in 6 general hospitals in Israel: variability and contributing factors

OBJECTIVES

Increased antibiotic consumption is associated with increased bacterial resistance worldwide. We aimed to analyse antibiotic consumption and potential contributory factors in internal medicine departments in Israel.

METHODS

Data (2003-04) from 26 departments in 6 hospitals were retrieved. Defined daily doses (DDD)/100 bed-days were calculated for total antibiotic use and by antibiotic class. Patterns identified were correlated with 15 patients' and departmental variables by univariate and multivariate analyses.

RESULTS

Total antibiotic consumption differed by a factor of 2.3 (115 DDD/100 bed-days to 49.1 DDD/100 bed-days) between the highest and lowest consuming departments. Antibiotic classes differed by a factor of 22.8 for macrolides, a factor of 20 for piperacillin/tazobactam, a factor of 17 for carbapenems, a factor of 13.3 for quinolones, a factor of 9 for vancomycin, a factor of 6.8 for amoxicillin/clavulanate, a factor of 6.6 for aminoglycosides, a factor of 5.3 for penicillins and a factor of 2.8 for cephalosporins. Even among departments within hospitals, there was a difference of up to 1.5-fold for total use and antibiotic class differences ranged between 2.5- and 7.2-fold for third- and fourth-generation cephalosporins, despite similar Charlson scores and other patient variables. In the multivariate analysis, hospital affiliation and rate of 1 day hospitalization were the only significant variables predicting total antibiotic use, contributing 43% and 7.3%, respectively, to the variance. By antibiotic class, controlling for hospital affiliation, patients with neutropenia, lower respiratory tract infections and assisted ventilation were the most common significant contributors, ranging from 3.5% for quinolones to 7.7% for piperacillin/tazobactam.

CONCLUSIONS

Patterns of antibiotic use vary widely among internal medicine departments in Israel, which cannot be explained by objective parameters related either to patients or wards. Ongoing monitoring and guideline formulation are needed to regulate antibiotic prescription.

Ten years surveillance of antimicrobial susceptibility of community-acquired Escherichia coli and other uropathogens in northern Israel (1995-2005)

BACKGROUND

In an era of increasing antimicrobial resistance, knowledge of local antimicrobial susceptibility patterns of common uropathogens is essential for prudent empiric therapy of community-acquired urinary tract infections.

OBJECTIVES

To define antimicrobial susceptibility of Gram-negative uropathogens in northern Israel over a 10 year period and to compare it with patterns of antibiotic use in the same community.

METHODS

We tested the susceptibility of all Gram-negative urinary isolates from outpatients at HaEmek Medical Center over the years 1995, 1999, 2002 and 2005 to common antimicrobial agents. MIC90 of Escherichia coli to some of these agents was determined and antibiotic consumption data over the years 2000-2005 (DDD/1000/day) were obtained.

RESULTS

We observed a rise in susceptibility rates of E. coli to amoxicillin-clavulanate, trimethoprim-sulfamethoxazole and nitrofurantoin and of other Gram-negative isolates to amoxicillin-clavulanate, ceftriaxone and cephalothin. Susceptibility rates of all Gram-negative uropathogens to ciprofloxacin decreased significantly. MIC90 of E. coli for all drugs tested remained stable. There was a significant decrease in the use of nitrofurantoin and TMP-SMX and a significant increase in the use of ampicillin, cephalothin and ceftriaxone.

CONCLUSIONS

Antibiotic resistance patterns mostly remained unchanged or improved slightly. There was, however, a constant decrease in susceptibility of all Gram-negative uropathogens to ciprofloxacin. Antibiotic use patterns could not explain the changes seen in antibiotic susceptibility patterns.

Nontuberculous mycobacterial infections of the skin: A retrospective study of 25 cases

BACKGROUND

Absence of a pathognomonic clinical picture and variable histologic findings often delay diagnosis of nontuberculous mycobacteria (NTM)-induced cutaneous infections, and antimicrobial therapy varies.

OBJECTIVE

We sought to investigate the clinical, microbiologic, and pathological findings of cutaneous NTM infections and response to different treatments.

METHODS

Records of patients with NTM infections of the skin confirmed by positive cultures or histologic findings were reviewed. Clinical, microbiologic, and epidemiologic data were collected and skin biopsy specimens were reassessed.

RESULTS

The series included 25 cases, one diagnosed by histology and 24 by positive culture: 16 cases with Mycobacterium marinum, 3 of atypical Mycobacterium without species identification, and one each with M chelonae, M xenopi, M abscessus, M gordonae, and M fortuitum. One of 16 patients with M marinum developed tenosynovitis. Mean interval between clinical presentation and diagnosis was 7.1 months (range: 1-27.3 months). All isolates analyzed for antimicrobial susceptibility pattern were sensitive to clarithromycin.

LIMITATIONS

Limitations include methods of case collection, retrospective study, and relatively small number of patients.

CONCLUSIONS

Diagnosis of NTM should be confirmed by histology and bacteriology studies of tissue cultures. Strong clinical suggestion of M marinum infection warrants initial empirical treatment to prevent progression to deep infection. The recommended treatment as indicated by the results of the in vitro susceptibility and clinical response is clarithromycin.

Epidemiology and clinical characteristics of patients with Staphylococcus saprophyticus bacteriuria in Israel

BACKGROUND

Staphylococcus saprophyticus is a leading cause of lower urinary tract infections (UTI) in young women in the USA, Canada and Scandinavian countries, but seems to be very rare in other countries like Israel. The goal of this study was to investigate the incidence of S. saprophyticus in Northern Israel and to compare demographic and clinical characteristics of patients with S. saprophyticus and Escherichia coli bacteriuria.

PATIENTS AND METHODS

Data from all patients with S. saprophyticus bacteriuria isolated in two major laboratories in northern Israel during a 1-year period were analyzed and clinical and epidemiological findings from 129 patients with S. saprophyticus bacteriuria were compared to that of 129 patients with E. coli bacteriuria.

RESULTS

The incidence of S. saprophyticus in our region was 0.09% among all urine cultures requested. Patients with S. saprophyticus bacteriuria are mainly young women, more likely suffering asymptomatic bacteriuria, complain less of dysuria and burning and are less hospitalized than those infected with E. coli. Reported risk factors associated to S. saprophyticus bacteriuria such us seasonal variation, occupation in meat products industry, use of contraceptives, or sexual activity were not found by us. No nasal, vaginal, or rectal carriage was demonstrated.

CONCLUSION

S. saprophyticus is a very uncommon urinary pathogen in Northern Israel. The natural reservoir of this uropathogen in our region remains unknown.

Antibiotic consumption successfully reduced by a community intervention program

BACKGROUND

The association between antibiotic use in the community and antimicrobial resistance is known. Attention has recently focused on the type of agents being prescribed.

OBJECTIVES

To implement, evaluate and compare the efficacy of two community intervention programs--continuous versus seasonal medical education--oriented to primary care physicians with emphasis on the appropriate use of antimicrobial drugs.

METHODS

From October 2000 to April 2003 we conducted two interventions: a) a monthly educational campaign in selected clinics promoting appropriate diagnosis of common infectious diseases and prudent antibiotic use (continuous intervention group); and b) a massive educational campaign, conducted before two consecutive winters, promoting the judicious use of antibiotics for treating respiratory infections (continuous intervention group and seasonal intervention group). Sixteen similar clinics were randomized (8 to each group). The total antibiotic use was measured as defined daily dose/1000 patients/day, and compared between the groups.

RESULTS

The total use of antibiotics decreased between 1999-2000 and 2002-2003 in both groups, but slightly more significantly in the continuous intervention group. The DDD/1000 patients/day for the seasonal group in 1999-2000 was 27.8 vs. 23.2 in 2002-2003; and for the continuous group 28.7 in 1999-2000 vs. 22.9 in 2002-2003, a reduction of 16.5% and 20.0% respectively (P < 0.0001). The main change in antibiotic use was noted for broad-spectrum antibiotics.

CONCLUSIONS

We present a successful community intervention program aimed to reduce unnecessary antibiotic use. Amplification of this type of intervention is imperative to stop the increase in antimicrobial resistance.

Clinical significance of bacteriuria with low colony counts of Enterococcus species

The clinical significance of low counts of enterococci in urine cultures remains unclear. The goal of this study was to investigate the clinical significance of enterococci growing in numbers lower than 100,000 colony-forming units per milliliter (cfu/ml) in urine samples. Clinical parameters were collected from patients whose midstream clean-catch urine samples grew Enterococcus spp. in amounts between >or=10,000 and 100,000 cfu/ml and who were not previously treated with antibiotics. Only those patients who had leukocyturia in addition to positive culture were considered to have true urinary tract infection (UTI). Of the 208 patients included in the study, 54% were diagnosed with true UTI. Patients with true UTI were older by 6 years (p=0.03), were more likely to be hospitalized (p=0.016), had higher rates of dysuria (p=0.0001), urgency (p=0.0001), and frequency (p=0.0001), and had more solid tumors (p=0.03). By multivariate analysis, urgency (OR=7.1) and hospitalization (OR=4.4) were identified as independent risk factors for true UTI with enterococci in low counts. Enterococcal counts in patients with true UTI were randomly distributed all along the scale between 10,000 and 100,000 cfu/ml, and no differential cutoff could be determined. In conclusion, more than half of the patients whose urine cultures grow Enterococcus spp. in counts lower than 100,000 cfu/ml may have true UTI, especially if they are hospitalized and have symptoms of dysuria, urgency, or frequency. Microbiology laboratories should perform a complete work-up on samples containing low counts of enterococci, and the final interpretation should be done by physicians, using additional clinical information.

Efficacy and safety of ertapenem versus piperacillin-tazobactam for the treatment of intra-abdominal infections requiring surgical intervention

Complicated intra-abdominal infections usually mandate prompt surgical intervention supplemented by appropriate antimicrobial therapy. The aim of this study was to demonstrate that ertapenem was not inferior to piperacillin-tazobactam for the treatment of community-acquired intra-abdominal infections. A randomized open-label active-comparator clinical trial was conducted at 48 medical centers on four continents from December 2001 to February 2003. Adult patients with intra-abdominal infections requiring surgery were randomized to receive either ertapenem 1 g daily or piperacillin/tazobactam 13.5 g daily in 3-4 divided doses. The primary analysis of efficacy was the clinical response rate in clinically and microbiologically evaluable patients at the test-of-cure assessment 2 weeks after completion of therapy. All treated patients were included in the safety analysis. Patient demographics, disease characteristics, and treatment duration in both treatment groups were generally similar. The most commonly isolated pathogens at baseline were E coli (greater than 50% of cases in each group) and B fragilis ( approximately 9%). Favorable clinical response rates were 107/119 (90%) for ertapenem recipients and 107/114 (94%) for piperacillin/tazobactam recipients. The frequencies of drug-related adverse events, most commonly diarrhea and elevated serum alanine aminotransferase levels, were similar in both treatment groups. Six of 180 ertapenem recipients (3%) and two of 190 piperacillin/tazobactam recipients (1%) had serious drug-related adverse experiences. In this study, ertapenem and piperacillin/tazobactam were comparably safe and effective treatments for adult patients with complicated intra-abdominal infections.

Usefulness of blood cultures in the management of febrile patients in long-term care facilities

The aims of the study presented here were to identify the risk factors associated with bacteremia in a long-term-care facility and to evaluate the role of blood cultures in the management of elderly patients with sepsis. All blood cultures performed during a 2-year period (3,177 from 1,588 patients) were screened, and 252 (15.8%) of them grew a pathogen. The first 100 bacteremic patients identified were enrolled in the study together with a control group of 100 non-bacteremic patients matched by sex, age and functional status. Chronic renal failure, urinary tract infection, severe sepsis, leukocytosis, eosinopenia and thrombocytopenia were identified as risk factors associated with bacteremia. Five bacteremic patients died during the first 48 h following the onset of infection, while all of the non-bacteremic patients survived this time period. Of 58 bacteremic patients receiving adequate treatment, 17 patients died, and of 39 receiving inadequate treatment, 12 patients died. These results indicate the usefulness of performing blood cultures in elderly patients with sepsis is questionable.

Are blood cultures necessary in the management of women with complicated pyelonephritis?

OBJECTIVES

Data from previous studies suggest that blood cultures in women with uncomplicated acute pyelonephritis (APN) are of limited value. Our objective was to assess the role of blood cultures in the management of complicated APN in women, and to examine the demographic and clinical characteristics, and the outcome as related to the bacteremic status of these patients.

METHODS

Data from medical records of 158 women hospitalized with complicated APN over a 2-year period were analyzed retrospectively. It included demographic, clinical and laboratory data, details of the empiric antimicrobial therapy, urine and blood culture results, complications and clinical outcome.

RESULTS

Out of 158 women with complicated APN, in 155 (98%) pathogens grew in the urine culture, and 33 (20.9%) of them had bacteremia. In the great majority of patients (98.7%), the blood cultures were sterile, or contained the same phenotypically profiled pathogen that was isolated from the urine. Only in two patients (1.3%), the blood cultures grew pathogens different from those found in the urine. The initial empiric antimicrobial therapy was not changed in any of the patients. No significant difference existed between the bacteremic and nonbacteremic patients in the demographic and clinical characteristics, the severity of disease or the outcome.

CONCLUSION

In the management of complicated APN, routine cultures of blood should be reevaluated.

Cat scratch disease encephalopathy in an immunocompetent patient

Cat scratch disease (CSD) is typically a self-limited regional lymphadenopathy in children and young adults that is caused by Bartonella henselae. The majority of CSD cases resolve spontaneously; however, many systemic complications have been described. We report an unusual case of CSD presenting as an epitrochlear arm mass and complicated by encephalopathy. Identification of B. henselae DNA in the affected lymph node and cerebrospinal fluid confirmed the diagnosis of CSD. Systemic antibiotic therapy was administered and the patient improved without any neurological deficit.

Spontaneous conversion to quinolone and fluoroquinolone resistance among wild-type Escherichia coli isolates in relation to phylogenetic background and virulence genotype

Human clinical isolates of Escherichia coli that are resistant to quinolone or fluoroquinolone agents typically exhibit fewer extraintestinal virulence factors (VFs) than susceptible isolates, along with a different phylogenetic background. To experimentally assess the basis for this as-yet-unexplained phenomenon, 40 E. coli strains (20 E. coli Reference collection members and 20 Israeli cystitis isolates) were subjected to serial selective passaging to obtain derivatives resistant to nalidixic acid (NA) and ciprofloxacin (C). PCR-based VF profiling and phylotyping were performed on the parents and their respective resistant derivatives. All 40 susceptible parent strains yielded NA- and C-resistant derivatives after a median of 6 (range, 4 to 12) serial selective passages on agar plates containing increasing concentrations of NA and C. The numbers of passages required for resistance did not differ by collection origin, phylogenetic group, basal VF profile, source (urine versus fecal), or host group (human versus animal). With the development of C resistance, only one VF was lost in a single strain. Resistant derivatives exhibited the same phylotype as their susceptible parents. These findings suggest that the sparse VF profiles and the low-virulence phylogenetic background of NA- and C-resistant E. coli clinical isolates probably are not attributable to the loss of VFs from intrinsically high-virulence strains during conversion to resistance or to enhanced emergence of drug resistance among intrinsically low-virulence strains. A more likely explanation is the importation of resistant strains from an as-yet-undefined low-virulence external selection reservoir.

Self-medication with antibiotics by a population in northern Israel

BACKGROUND

The current study is part of a larger study--Self-Medication with Antibiotics and Resistance Levels in Europe (SAR project)--coordinated by the University of Groningen in the Netherlands and run in 19 European countries and Israel.

OBJECTIVES

To estimate self-medication with antibiotics by a population in northern Israel.

METHODS

We sent by post a questionnaire on antibiotic usage to 2,615 adults, both Jewish and Arab, living in northern Israel.

RESULTS

The overall response rate was low (17.9%), particularly among the Arab population (9.4% of respondents). Among the 467 respondents, 169 (36.2%) reported 215 antibiotic courses within the last year. Amoxicillin was the antibiotic most commonly used (32.7% of courses); 89.4% of antibiotics were obtained via a physician's prescription; 114 respondents (24.4%) stored leftover antibiotics at home, and 81 (18.7%) would consider self-medication with antibiotics without a medical consultation.

CONCLUSIONS

Over-the-counter acquisition of antibiotics is rare in Israel. However, the storage of leftover antibiotics in the home constitutes an alternative potential source of self-medication that can have untoward consequences, not only for the individual patient but also for the general population since inappropriate antibiotic usage contributes to the increasing rates of antimicrobial resistance.

[Incidence of influenza among patients admitted to the department of internal medicine during the winter season]

BACKGROUND

Influenza is a common disease, especially in the winter season. Influenza virus causes symptoms of acute viral illness, development of complications and worsening of chronic diseases. Vaccination may prevent influenza illness.

OBJECTIVES

1. To determine the rate of vaccination against influenza. Furthermore, in the immunized patients--the study aimed to determine the efficiency of the vaccination. 2. To determine the incidence of influenza illness among patients admitted to a Department of Internal Medicine during the winter season.

METHODS

We performed a prospective screening of 124 consecutive patients hospitalized in the Department of Internal Medicine during February 1998. Demographic parameters (age, sex) and admission diagnosis were collected. All patients were asked about influenza vaccination in the last fall. Blood samples were collected on admission and 10-30 days later. Three relevant virus subtypes were examined. Virus subtype was determined in all patients with evidence of influenza illness.

RESULTS

Eleven patients (8.9%) were found with evidence of acute influenza illness at the time of hospitalization. The rate of patients with chronic pulmonary disease was higher in this group than in the group without evidence of influenza (p = 0.03). Forty-four out of 124 patients (35.5%) had been vaccinated against influenza. In the vaccinated patients, the protective antibody level for all 3 subtypes developed in 27.3% of cases and for one or two subtypes in 50% of cases. In 22.7% of patients no protective level of antibody was detected for any subtype.

CONCLUSIONS

It is necessary to encourage vaccination in the high-risk group patient, especially those with chronic pulmonary disease. It is essential to develop new vaccination strategies and prophylactic antiviral medications.

Distribution and characteristics of Escherichia coli clonal group A

Among 1,102 recent Escherichia coli clinical isolates, clonal group A was identified in 17 of 20 (U.S. and non-U.S.) geographic locales, mainly among U.S. isolates (9% vs. 3%; p < 0.001) and those resistant to trimethoprim-sulfamethoxazole (10% vs. 1.7%; p < 0.001). The extensive antimicrobial resistance and virulence profiles of clonal group A may underlie its recent widespread emergence.

Pharyngotonsillitis due to Arcanobacterium haemolyticum in northern Israel

BACKGROUND

Arcanobacterium haemolyticum is a well-recognized but uncommon cause of pharyngitis and skin rash in adolescents and young adults. To date, no data regarding its frequency in Israel have been published.

OBJECTIVE

To establish the frequency of A. haemolyticum in throat cultures in a northern Israeli population and to estimate the clinical significance of this pathogen in patients with sore throat.

METHODS

We examined suspected colonies for A haemolyticum by gram stain, catalase test and reverse CAMP test in 518 throat cultures sent to the microbiologic laboratory of HaEmek Medical Center.

RESULTS

Of the throat cultures tested, A. haemolyticum was recovered from one patient (0.2%). In contrast, group A Streptococcus (Streptococcus pyogenes) was recovered from 135 patients (26%).

CONCLUSION

A hemolyticum is an uncommon pathogen implicated in acute pharyngitis, therefore routine screening in throat swabs is not required.