The impact of the early onset neonatal sepsis calculator on antibiotic initiation: a single center study in Israel

To evaluate the effect of implementation of the Kaiser Permanente (KP) early onset sepsis (EOS) calculator in infants born at 34 week's gestation or more on antibiotic utilization and length of hospitalization. A single center, retrospective cohort study included all neonates born in Soroka Medical Center at 34 weeks gestation or more between January 1^st, 2015, and January 1^st, 2019, with a predefined maternal risk factor for EOS. Two cohorts of neonates were compared during two time periods, before and after the implementation of the KP calculator. Multivariable logistic and linear regressions were performed to assess the effect of the KP calculator on antibiotic treatment and length of hospitalization. Also, an interrupted time series (ITS) analysis was used to assess the time trends of the two periods. The study included 3858 neonates in the pre-implementation period and 3081 neonates in the post-implementation cohort. The use of the calculator resulted in a significant reduction (46%) in antibiotics treatment for suspected EOS (5.1 vs. 9.4%, P < 0.001). The ITS analysis demonstrated a sharp decline in the slope of antibiotic treatment in the post intervention period: (b = -0.14, p-value = 0.08). The length of hospitalization was significantly reduced in the post-implementation cohort from 62 to 60 h (p-value < 0.001) with no clinical significance. The incidence of EOS was similar in both groups.    Conclusion: A significant reduction in antibiotic treatment was demonstrated after the implementation of the KP calculator without an increase incidence of EOS. The calculator is a powerful accessory decision-making tool that can be used safely in combination with, but not replacing, thorough clinical assessment. What is Known: • The EOS calculator is a useful tool that leads to a significant reduction in preemptive antibiotic utilization. What is New: • The EOS calculator is sensitive when applied to the whole-nursery. • The calculator is useful in different populations, also when women are not routinely screened for GBS.

P-503 The role of the duration of infertility on the of quality of life and psychological health in infertile couples

Study question

Is the quality of life (QoL) and psychological health affected by the duration of infertility in infertile women?

Summary answer

The duration of infertility negatively impacts infertile women's QoL and psychological health.

What is known already

Infertility is a deeply distressing experience. The process, from suspicion to received diagnosis and treatments often endures over a long period of time and usually involves repeated oscillations between hope and delusion, perception of loss of control, loss of self-esteem, inability to plan future, changes in identity and worldviews and difficulties in social interactions. Therefore, being infertile and undergoing fertility treatments is a condition which affects all infertile couple’s QoL. Whether QoL of these individuals is affected by the duration of infertility should be the focus of further investigation, to define psychological care interventions with patients dealing with infertility.

Study design, size, duration

This transversal study enrolled 442 female infertile patients that completed a modified non-validated Fertility Quality of Life Questionnaire (FertiQoL) between August and November 2021, containing multiple choice questions, which were evaluated in an ordinal manner (from one to five, being five the reference category associated with best QoL parameter).

Participants/materials, setting, methods

The FertiQoL questionnaire was conducted through an online-platform and consisted of 24 items derived from four subscales (mind-body, emotional, social, and relational), 10 treatment-related items, and two overall life and physical wellness items. Additionally demographic infertility-related characteristics were answered by the participants. Generalized Linear Models were performed to assess the association between FertiQoL scores and duration of infertility. Results are described by B coefficient and the p value.

Main results and the role of chance

A negative association between duration of infertility and FertiQoL scores were observed. With one unit increase in duration of infertility, the log of odds of having a positive perception about: (i) one’s own health decreases by -2.07 to -5.49, p &lt; 0.001, (ii) one’s satisfaction with the quality of life decreases by -0.981 to -3.90, p &lt; 0.001, (iii) ability to handle other life plans and goals while dealing with infertility decreases by -0.59 to -2.77, (iv) ability to deal with one's fertility issues decreases by-1.38 to -4.00, p &lt; 0.001, (v) experience of envy feelings increases by 0.10 to 2.71, p &lt; 0.001, (vi) experience oscillations of hope and hopelessness feelings increases by 0.25 to 0.97, p &lt; 0.001, (vii) experience of social isolation due to infertility increases by 0.92 to 3.12, p &lt; 0.001, (viii) loving to one's partner despite fertility problems decreased by -0.54 to -5.99 p &lt; 0.001, (ix) feeling discomfort in social situations increases by 0.80 to 2.73, p &lt; 0.001, (x) feeling of inferiority in relation to people who have children increases from 0.48 to 1.29, p &lt; 0.001, (xi) feeling of anger due to infertility increases from -0.20 to -1.56, p &lt; 0.001, and (xii) unpleasant effects of infertility treatment increases from 0.217 to 1.97, p &lt; 0.001.

Limitations, reasons for caution

Lack of adequate opportunities to conduct face to face interview and lack of knowledge of the real state of the participants, concerning infertility or when involved in an assisted reproduction treatment (ART), knowledge of which treatment.

Wider implications of the findings

Long infertility duration is a significant risk factor affecting women's QoL and psychological health. It can be hypothesized that, besides the duration of infertility itself, repeated ART treatments related to longer infertility may compromise QoL, highlighting the importance of the psychological counseling for infertile patients, especially those with longer infertility.

Trial registration number

Not applicable

Early versus late-onset necrotizing enterocolitis in very low birth infants in the neonatal intensive care unit

BACKGROUND

Necrotizing enterocolitis (NEC), one of the most severe emergencies in neonates, is a multifactorial disease with diverse risk factors.

OBJECTIVES

To compare between the clinical and laboratory characteristics of premature infants diagnosed with early-onset NEC (EO-NEC) and those with late-onset NEC (LO-NEC).

PATIENTS AND METHODS

Enrolled infants were identified from prospective local data collected for the Israel National very low birth weight (VLBW, < 1500 g) infant database and from the local electronic patient files data base for the period 1996-2017.

RESULTS

Overall, 95 VLBW infants (61, 64.21% EO-NEC and 34, 35.87% LO-NEC) were enrolled. EO-NEC infants had higher rate of IVH grade 3 and 4 (26.2% vs 2.9%, p = 0.005) and were more likely to undergo surgery (49.2% vs 26.5%, p = 0.031). LO-NEC infants had a higher incidence of previous bloodstream infections (35.3% vs 8.2%, p = 0.002) compared to EO-NEC. In multivariable analysis models, surgical intervention was associated with EO-NEC (OR: 4.627, p = 0.013) as well as PDA and positive blood culture prior to the NEC episode.

CONCLUSIONS

Our data support the hypothesis that EO-NEC has significant different clinical and microbiological attributes compared to LO-NEC.

P–477 The child’s right to know vs. the parents’ right not to tell: the attitudes of couples undergoing fertility treatments towards identity-release gamete donation

Study question

Do couples undergoing assisted reproduction treatments (ART) have a different perception of anonymous vs identity-release gamete donation than a population interested in the subject?

Summary answer

Compared with a population interested in the subject, more couples undergoing ART believed the child shouldn’t be given information that would identify the gamete-donor.

What is known already

Recent research has investigated the psychological well-being of parents and children born through gamete donation, focusing on the possibility of having the donor’s identity revealed. Gamete donors have traditionally been anonymous to recipients and offspring; however, there is a global trend towards programs using donors that are identifiable to the resulting offspring at maturity. While some countries only allow the use of identity-release egg donation, others only allow anonymous-donation, and in some countries both types of donation are practiced. However, the attitudes concerning anonymous vs identity-release gamete donation, in a country where only anonymous donation is allowed, are still unknown.

Study design, size, duration

This cross-sectional study was performed from 01/Sep/2020 to 15/Dec/2020. For that, surveys through online-platforms were conducted, including either patients undergoing ART, (ART-group, n = 358) or those interested in the subject, who accessed the website of a university-affiliated IVF-center (interested-group, n = 122). Participants in the ART-group were invited via e-mail, with a cover-letter outlining the survey and a link to access it and participants in the interested-group accessed the questionnaire via website.

Participants/materials, setting, methods

The survey collected information on demographic characteristics and the participant’s attitudes towards anonymity of gamete donors. The questions were: (i) In the case of children conceived through ART, do you believe that revealing the method of conception may affect the relationship between children and their parents? (ii) Once the method of conception is revealed, do you believe that the child has the right to know the gamete donor? (iii) If yes, when?

Main results and the role of chance

Most of the participants answered that the relationship between children and parents wouldn’t be affected by the child’s knowledge of the origin of their conception, regardless of the group (83.6% vs 82.7%, for ART-group and interested-group, respectively, p = 0.868). Most participants in the ART-group answered that the sperm donor identity shouldn’t be revealed to the child, while only half of the interested-group stated the same (65.4% vs 50.8%, p = 0.044). The same result was observed when participants were asked if the oocyte donor should be identifiable (64.8% vs 50.8%, p = 0.050). When asked when the donor’s identity should be revealed to the child, no significant differences were noted in the responses among the groups (p = 0.868). Most of the participants who believe that the child has the right of learning the donor’s identity, stated that “the donor’s identity should be revealed if the child questions its biological origin” (67.2% vs 67.5%, for ART-group and interested-group, respectively). “Since birth” was the second most common response, (21.0% vs 19.7%, for ART-group and interested-group, respectively), while “when the child turns 18 years-old” (9.2% vs 11.2%, for ART-group and interested-group, respectively), and “sometime during teenage years” (2.5% vs 2.4%, for ART-group and interested-group, respectively) were less common answers.

Limitations, reasons for caution

Lack of adequate opportunities to conduct face to face interview and lack of knowledge of the real state of the website participants, concerning infertility or being involved in ART. The retrospective nature of the study and the small sample size may also be reasons for caution,

Wider implications of the findings: It has been discussed that, whether or not children or parents are harmed by knowing their biological origins, donor offspring have the right to know. However, when facing the situation, couples undergoing ART would argue that in case of gamete donation, there are reasons for not telling the child.

Trial registration number

Not applicable

Cat Scratch Disease Presenting as Fever of Unknown Origin Is a Unique Clinical Syndrome

BACKGROUND

Fever of unknown origin (FUO) is a rare manifestation of cat scratch disease (CSD). Data regarding CSD-associated FUO (CSD-FUO), particularly in adults, are limited. We aimed to study disease manifestations and long-term clinical outcome.

METHODS

A national CSD surveillance study has been conducted in Israel since 1991. Data are obtained using questionnaires, review of medical records, and telephone interviews. FUO was defined as fever of ≥14 days without an identifiable cause. CSD-FUO patients were identified in the 2004-2017 CSD national registry. Follow-up included outpatient clinic visits and telephone/e-mail surveys.

RESULTS

The study included 66 CSD-FUO patients. Median age was 35.5 years (range, 3-88). Median fever duration was 4 weeks (range, 2-9). Relapsing fever pattern was reported in 52% of patients, weight loss in 57%, and night sweats in 48%. Involvement of ≥1 organs occurred in 59% of patients; hepatosplenic space-occupying lesions (35%), abdominal/mediastinal lymphadenopathy (20%), ocular disease (18%), and multifocal osteomyelitis (6%) were the most common. Malignancy, particularly lymphoma, was the initial radiological interpretation in 21% of patients; 32% underwent invasive diagnostic procedures. Of the 59 patients available for follow-up (median duration, 31 weeks; range, 4-445), 95% had complete recovery; 3 patients remained with ocular sequelae.

CONCLUSION

This is the first attempt to characterize CSD-FUO as a unique syndrome that may be severe and debilitating and often mimics malignancy. Relapsing fever is a common clinical phenotype. Multiorgan involvement is common. Recovery was complete in all patients except in those with ocular disease.

A global point prevalence survey of antimicrobial use in neonatal intensive care units: The no-more-antibiotics and resistance (NO-MAS-R) study

BACKGROUND

Global assessment of antimicrobial agents prescribed to infants in the neonatal intensive care unit (NICU) may inform antimicrobial stewardship efforts.

METHODS

We conducted a one-day global point prevalence study of all antimicrobials provided to NICU infants. Demographic, clinical, and microbiologic data were obtained including NICU level, census, birth weight, gestational/chronologic age, diagnoses, antimicrobial therapy (reason for use; length of therapy), antimicrobial stewardship program (ASP), and 30-day in-hospital mortality.

FINDINGS

On July 1, 2019, 26% of infants (580/2,265; range, 0-100%; median gestational age, 33 weeks; median birth weight, 1800 g) in 84 NICUs (51, high-income; 33, low-to-middle income) from 29 countries (14, high-income; 15, low-to-middle income) in five continents received ≥1 antimicrobial agent (92%, antibacterial; 19%, antifungal; 4%, antiviral). The most common reasons for antibiotic therapy were "rule-out" sepsis (32%) and "culture-negative" sepsis (16%) with ampicillin (40%), gentamicin (35%), amikacin (19%), vancomycin (15%), and meropenem (9%) used most frequently. For definitive treatment of presumed/confirmed infection, vancomycin (26%), amikacin (20%), and meropenem (16%) were the most prescribed agents. Length of therapy for culture-positive and "culture-negative" infections was 12 days (median; IQR, 8-14) and 7 days (median; IQR, 5-10), respectively. Mortality was 6% (42%, infection-related). An NICU ASP was associated with lower rate of antibiotic utilization (p = 0·02).

INTERPRETATION

Global NICU antibiotic use was frequent and prolonged regardless of culture results. NICU-specific ASPs were associated with lower antibiotic utilization rates, suggesting the need for their implementation worldwide.

FUNDING

Merck & Co.; The Ohio State University College of Medicine Barnes Medical Student Research Scholarship.

Targeted and universal screen in term and preterm infants for congenital CMV infection

Background: The aims of this study were to evaluate the incidence of congenital cytomegalovirus (CMV) in term and near-term infants who fail hearing screen (target screening), the incidence of congenital CMV infections in infants born before 33 weeks of gestation (universal screening) and the incidence of infants who need pharmacologic treatment for congenital CMV associated sensorineural hearing loss (SNHL).Methods: This was a retrospective cohort study that assessed two groups of infants born between 2014 and 2017. The first group consisted of infants born between 33 and 42 weeks gestation and the second group, of infants born before 33 weeks gestation. Targeted CMV screening was performed in the first group who either failed neonatal hearing screen or were growth retarded. Universal screen was performed in the second group of infants. CMV DNA was tested in urine samples using real time PCR soon after birth.Results: In the first group, 2078 infants were assessed, 19 (0.9%) were found to be CMV positive and in 9 (42%) valganciclovir treatment was initiated. In the second group, out of 549 urine samples/infants, none was positive for CMV DNA soon after birth.Conclusions: A joint strategy of targeted CMV screening in infants who fail hearing screen test with universal screen of premature infants can select infants at risk of hearing impairment due to congenital CMV soon after birth, allows for timely initiation of treatment and prevents dilemmas regarding congenital CMV diagnosis in infants who fail hearing screen in a later age until universal screen will be widely adopted.

Nationwide epidemiology of early-onset sepsis in Israel 2010-2015, time to re-evaluate empiric treatment

AIM

Early-onset neonatal sepsis (EOS) may lead to significant morbidity and mortality, yet the recommended antimicrobials have not changed for many years. We aimed to optimise EOS treatment by examining EOS pathogens, resistance rates and resistance risk factors.

METHODS

A retrospective, nationwide cohort study analysing 2010-2015 EOS data in Israel.

RESULTS

The 21 participating centres constitute 92% of the total birth cohort (around 180 000 live births/year). Of 549 EOS neonates (0.57/1000 live births), 306 (56%) and 243 (44%) were full-term and preterm, respectively (0.35 vs. 2.94 per/1000 live births). Gram-negative pathogens predominated, especially in preterms. Escherichia coli and Streptococcus agalactiae were most common pathogens (0.2 and 0.19 per 1000 live births, respectively). In 277 Gram-negatives, 16%, 14%, 8% and 3% were gentamicin-resistant, extended-spectrum beta-lactamase (ESBL)-positive, gentamicin-resistant and ESBL-positive, and amikacin-resistant, respectively; preterms had higher resistance rates. No risk factors for antimicrobial resistance were identified. Mortality was reported in 21% of Gram-negative EOS versus 7% of Gram-positive EOS [OR 3.4 (95% CI 1.8-6.2), p < 0.01].

CONCLUSION

In this nationwide study, EOS was caused predominantly by Gram-negatives, with high gentamicin resistance and ESBL phenotype rates, without identifiable resistance risk factors. As EOS is life-threatening, modification of empiric therapy for amikacin-based regimens should be considered, mainly in preterms.

Urinary tract infection in young infants discharged from the emergency room with normal urinalysis

AIM

We describe the clinical, microbiologic, therapeutic, and outcome characteristics of infants under three months of age with a positive urine culture reported after discharge from emergency department with normal urinalysis.

METHODS

We enrolled all infants with a urine culture obtained during an emergency room visit during 2004-2012, discharged without antibiotic therapy and subsequently reported with a positive urine culture.

RESULTS

Three hundred and ninety-three positive urine cultures were reported; 46/393 (11.7%, 42 in patients under two months of age) had positive urine cultures following normal urinalysis at first visit. Fifteen (33%) had positive urine cultures at second visit; 11/15 (73%) infants with second positive urine culture were under one month of age, eight were asymptomatic and seven had mild symptoms at second visit. Pathogens isolated in all 15 infants were identical between first and second visit. All 27 infants re-examined at second visit at the emergency room were hospitalised, completed sepsis work/up and received antibiotic treatment. None developed serious bacterial infections.

CONCLUSION

We propose a new management approach for young infants with normal urinalysis and positive urine culture and suggest restricting the management option including hospitalisation, sepsis work/up and antibiotic treatment at second visit only to infants under one month of age.

Late onset sepsis: comparison between coagulase-negative staphylococci and other bacteria in the neonatal intensive care unit

OBJECTIVE

To compare demographic and clinical features of neonates with late-onset sepsis due to coagulase-negative-staphylococcus with those due to other bacterial pathogens.

STUDY DESIGN

Retrospective, population-based cohort study. Data on infants less than 90 days old diagnosed with late-onset bacterial sepsis in the neonatal intensive care unit were reviewed. Univariable and multivariable analysis were performed.

RESULTS

Two hundred and sixteen sepsis episodes were identified: coagulase-negative-staphylococcus caused 113 (52.3%) and other pathogen 103 (47.7%). Patients with coagulase-negative-staphylococcus sepsis had lower gestational age and younger age at onset, higher rates of parenteral nutrition exposure and normal temperature, lower rates of necrotizing enterocolitis, meningitis and neutropenia than patients with sepsis caused by other pathogens. In multivariable analysis, parenteral nutrition was the only independent risk factor for coagulase-negative-staphylococcus sepsis (odds ratio: 3.5, 95% confidence interval: 1.4-8.6).

CONCLUSIONS

Initial empiric treatment for suspected sepsis should be targeted for other pathogens than coagulase-negative-staphylococci and vancomycin treatment should be reserved for infants with specific risk factors and according to local antimicrobial susceptibility.

Neonatal Risk Factors for Colonization with Extended-Spectrum Beta-Lactamase-Producing Bacteria in the Neonatal Intensive Care Unit

BACKGROUND

Extended-spectrum beta-lactamase (ESBL) production is the most common antimicrobial resistance mechanism in the neonatal intensive care unit (NICU), with colonization and blood stream infections being a major threat to this population. Since 2013, all NICU admissions at our facility were screened twice weekly for ESBL colonization.

OBJECTIVES

To determine independent risk factors for colonization of infants with ESBL-producing bacteria in the NICU.

METHODS

A retrospective case study of ESBL-colonized infants vs. controls (matched by date of birth and gestational age) was conducted in the NICU of Soroka University Medical Center, Israel, between 2013 and 2014. Epidemiological, laboratory, and clinical data were extracted from medical files. Univariable and multivariable analyses were used to assess associations between ESBL colonization and possible clinical risk factors.

RESULTS

Of 639 admissions during the study period, 87 were found to be ESBL-colonized (case infants) and were matched to 87 controls. Five case infants became infected (5.7%) with ESBL strains. Klebsiella pneumoniae was the most common isolated bacteria. The mean time from admission to colonization was 15 days. Univariable analysis showed an association of male gender and highest Apgar score at 1 and 5 minutes with ESBL colonization (P < 0.05). Multivariable analysis yielded only a possible association of higher Apgar score at 1 and 5 minutes (hazard ratio [HR] 1.515, 95% confidence interval [95%CI] 0.993-2.314; HR 1.603, 95%CI 0.958-2.682, respectively) with ESBL colonization.

CONCLUSIONS

Future studies should focus on maternal colonization and possible strategies for preventing vertical transmission of ESBL strains to high-risk neonates.

Performance of risk stratification criteria in the management of febrile young infants younger than three months of age

AIM

We evaluated the diagnosis, risk stratification and management of febrile infants under three months of age who presented to an Israeli paediatric emergency room (ER).

METHODS

This retrospective study enrolled all febrile infants examined in the paediatric ER of Soroka Medical Center during 2010-2013. The patients were classified into low-risk and high-risk subgroups and compared by age and ethnicity.

RESULTS

Overall, 2251 febrile infants (60.5% of Bedouin and 34.4% of Jewish ethnicity) were enrolled. Hospitalisation rates were higher among Bedouin vs. Jewish infants (55 vs. 39.8%, p < 0.001). Fever without localising signs was diagnosed in 1028 (45.6%) infants and 499 (48.5%) were hospitalised; 26% were stratified as high-risk and 74% as low-risk. Bedouin infants rates were more likely to be at high-risk (p = 0.001) and hospitalised (p < 0.001) than Jewish infants. With regard to low-risk infants, the incidence rates were higher before two months than two to three months of age (73.3 vs. 59%, p < 0.001), as were the hospitalisation rates (46.3 vs. 20.1%, p < 0.001). No differences were recorded for the hospitalisation rates of Bedouin and Jewish infants between the three daily shifts.

CONCLUSION

Major differences were recorded in hospitalisation rates, risk stratification and management of Bedouin and Jewish infants with fever without localising signs.

Case-Control Assessment of the Roles of Noroviruses, Human Bocaviruses 2, 3, and 4, and Novel Polyomaviruses and Astroviruses in Acute Childhood Diarrhea

BACKGROUND

The etiology of acute childhood diarrhea often eludes identification. We used a case-control study-stool archive to determine if nucleic acid tests for established and newly identified viruses diminish our previously published 32% rate of microbiologically unexplained episodes.

METHODS

Using polymerase chain reaction, we sought to detect noroviruses GI and GII, classic and novel astroviruses, and human bocaviruses (HBoVs) 2, 3, and 4 among 178 case and 178 matched control stool samples and St. Louis and Malawi polyomaviruses among a subset of 98 case and control stool samples. We calculated adjusted odds ratios and 95% confidence intervals using conditional logistic regression.

RESULTS

Noroviruses were more common in cases (GI, 2.2%; GII, 16.9%) than in controls (GI, 0%; GII, 4.5%) (adjusted odds ratio, 5.2 [95% confidence interval, 2.5-11.3]). Astroviruses and HBoVs 2, 3, and 4 were overrepresented among the cases, although this difference was not statistically significant. Malawi polyomavirus was not associated with case status, and St. Louis polyomavirus was identified in only 1 subject (a control). When identified in cases, HBoVs 2, 3, and 4 were frequently (77%) found in conjunction with a bona fide diarrheagenic pathogen. Thirty-five (20%) case and 3 (2%) control stool samples contained more than 1 organism of interest. Overall, a bona fide or plausible pathogen was identified in 79% of the case stool samples. Preceding antibiotic use was more common among cases (adjusted odds ratio, 4.5 [95% confidence interval, 2.3-8.5]).

CONCLUSION

Noroviruses were found to cause one-third of the diarrhea cases that previously had no identified etiology. Future work should attempt to ascertain etiologic agents in the approximately one-fifth of cases without a plausible microbial cause, understand the significance of multiple agents in stools, and guide interpretation of nonculture diagnostics.

Comparison of early onset sepsis and community-acquired late onset sepsis in infants less than 3 months of age

Background

We compared demographic and clinical characteristics of early-onset sepsis (EOS) and community-acquired late onset sepsis (CA-LOS) in infants.

Methods

Our medical center is the sole hospital in southern-Israel, enabling incidence calculations. EOS (<7 days) and CA-LOS (7–90 days) episodes recorded between 2007 and 2013 were reviewed. Univariate and multivariate analyses were performed.

Results

70 EOS and 114 CA-LOS episodes were recorded. The respective mean ± SD annual rates per 1,000 live-births were 0.66 ± 0.16 and 1.03 ± 0.23. Prematurity (42.9 % vs. 17.0 %), premature rupture of membranes (PROM; 22.9 % vs. 1.9 %), leukopenia (29.0 % vs. 11.6 %), thrombocytopenia (44.9 % vs. 14.3 %) and Streptococcus agalactiae infections (22.7 % vs. 8.1 %) were more common in EOS. Fever (25.4 % vs. 79.1 %) and Streptococcus pneumoniae infections (1.3 % vs. 12.9 %) were less common in EOS. In both groups, Gram-negative bacteria predominated (~60 %). Longer hospitalization duration (23.3 ± 25.1 vs. 10.3 ± 8.6 days) and higher case fatality rate (20.0 % vs. 5.3 %) were noted in EOS. Antibiotic resistance rates to empiric EOS and CA-LOS treatments were 0.0 % and 1.2 %, respectively.

In multivariate analysis, adjusting for prematurity and ethnicity, PROM, central line, low Apgar-score, low birth-weight, ventilation support and non-vaginal delivery were risk factors for EOS. Normal temperature, thrombocytopenia and leukopenia characterized EOS.

Conclusion

EOS and CA-LOS rates were low in Jewish compared with Bedouin infants. EOS was characterized by higher rates of perinatal risk factors, S. agalactiae infections, normal temperature, thrombocytopenia, leukopenia and mortality, while fever and S. pneumoniae infections were common in CA-LOS. Current initial antibiotic regimens seem adequate, considering the susceptibility patterns of the isolated pathogens

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-016-0618-6) contains supplementary material, which is available to authorized users.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PGE2 suppresses NK activity in vivo directly and through adrenal hormones: effects that cannot be reflected by ex vivo assessment of NK cytotoxicity

Surgery can suppress in vivo levels of NK cell cytotoxicity (NKCC) through various mechanisms, including catecholamine-, glucocorticoid (CORT)-, and prostaglandin (PG)-mediated responses. However, PGs are synthesized locally following tissue damage, driving proinflammatory and CORT responses, while their systemic levels are often unaffected. Thus, we herein studied the role of adrenal factors in mediating in vivo effects of PGs on NKCC, using adrenalectomized and sham-operated F344 rats subjected to surgery or PGE(2) administration. In vivo and ex vivo approaches were employed, based on intravenous administration of the NK-sensitive MADB106 tumor line, and based on ex vivo assessment of YAC-1 and MADB106 target-line lysis. Additionally, in vitro studies assessed the kinetics of the impact of epinephrine, CORT, and PGE(2) on NKCC. The results indicated that suppression of NKCC by epinephrine and PGE(2) are short lasting, and cannot be evident when these compounds are removed from the in vitro assay milieu, or in the context of ex vivo assessment of NKCC. In contrast, the effects of CORT are long-lasting and are reflected in both conditions even after its removal. Marginating-pulmonary NKCC was less susceptible to suppression than circulating NKCC, when tested against the xenogeneic YAC-1 target line, but not against the syngeneic MADB106 line, which seems to involve different cytotoxicity mechanisms. Overall, these findings indicate that elevated systemic PG levels can directly suppress NKCC in vivo, but following laparotomy adrenal hormones mediate most of the effects of endogenously-released PGs. Additionally, the ex vivo approach seems limited in reflecting the short-lasting NK-suppressive effects of catecholamines and PGs.

Hospital-acquired conjunctivitis in a neonatal intensive care unit: Bacterial etiology and susceptibility patterns

Our study investigates the causative pathogens of hospital-acquired conjunctivitis in our neonatal intensive care unit and their susceptibility patterns. Coagulase-negative Staphylococcus was the most common bacterium, 22.1% of all isolates. The frequency of the pathogens changed during neonates' stay; Klebsiella pneumoniae (from 18% to 6.9%) and Escherichia coli (from 16% to 4.8%) decreased, whereas methicillin-susceptible Staphylococcus aureus (from 4% to 12.7%) and Enterococcus spp (from 1% to 5.3%) increased. Gram-positive cocci showed high resistant patterns. Our study indicates that the distribution of bacteria causing hospital-acquired conjunctivitis in our neonates shifted from gram-negative to gram-positive microorganisms during their neonatal intensive care unit stay. The resistance patterns are worrisome among gram-positive cocci.

Risk factors for early sepsis in very low birth weight neonates with respiratory distress syndrome

AIM

To identify maternal and neonatal factors that increase suspicion of early sepsis in Very Low Birth Weight neonates with respiratory distress syndrome.

METHODS

The cohort included 282 neonates born at Soroka Medical Centre 1996-2000. Definitions of 'high' and 'low'-suspicion groups for early sepsis were based on comparison between neonates with early sepsis and the remaining cohort. Univariate analysis and logistic regression were used to compare between groups.

RESULTS

The incidence of early sepsis in the cohort was 1.8%, and 94% received antibiotics following delivery. Comparing with the remaining cohort, the five neonates with early sepsis had increased incidence of positive maternal cultures, use of antenatal antibiotics, lower 1 min Apgar scores and tendency to leucopenia. A 'low-suspicion' group comprised 38% of the cohort and did not include any neonates with early sepsis. This group were more frequently treated with antenatal steroids and delivered by Caesarean section compared to the 'high-suspicion' group, but otherwise there were no clinical and laboratory differences.

CONCLUSION

Although the incidence of early sepsis is low almost all neonates received antibiotics. A 'low-suspicion' group was defined and the role of antibiotic treatment in this group needs to be determined.

Clonal variability of group B Streptococcus among different groups of carriers in southern Israel

A high prevalence of maternal group B Streptococcus (GBS) carriage and an extremely low incidence of invasive neonatal disease have been reported from southern Israel. In order to obtain insight into this discrepancy, this study was performed to determine the population structure of GBS from asymptomatic pregnant women living in this area. Seventy-two strains from maternal GBS carriers were characterized using multilocus sequence typing (MLST). Epidemiologic characteristics of the carriers and their newborns, including demographic variables, obstetric status, and general health parameters, were collected by means of a postpartum interview and a review of the relevant medical records. The MLST analysis grouped the bacteria into six different lineages (clonal complexes). Lineage ST-2 was prevalent among Bedouin-Arabs (p=0.01) and lineage ST-22 among Jews (p=0.001). Lineage ST-17 was prevalent among carriers who emigrated after 1997 from western nations of the former USSR (p<0.001). Lineage ST-22 was associated with carriage of surface-protein C (p=0.01) and lineage ST-17 with surface-protein R (p<0.01). Lineage ST-2 was prevalent among consumers of antibiotics (p=0.02) and was associated with erythromycin-resistant strains (p<0.001). Each subgroup of the southern Israeli maternal population has a different distribution of GBS clones. The clones prevalent among the Bedouin-Arabs and the Jews are known to be of low virulence. Lineage ST-17, which is associated with invasive disease, is prevalent among women who emigrated from western Soviet nations. Therefore, a different policy of GBS prophylaxis, resembling the one executed in endemic areas, should be considered in this population.

Superficial skin infection caused by Streptococcus pneumoniae in children

Pneumococcal superficial skin infections are rarely described. We present 3 cases of Streptococcus pneumoniae superficial skin infections in previously healthy children. In 2 cases, lesions occurred on facial skin; in the third case they occurred on the scrotal raphe. One isolate was fully penicillin-resistant.

Interleukin-12 receptor beta1 deficiency presenting as recurrent Salmonella infection

We describe a child with interleukin-12 receptor beta1 (IL-12Rbeta1) deficiency caused by a homozygous IL12RB1 large deletion who presented at the age of 1 year with recurrent, often asymptomatic episodes of bacteremia caused by group D Salmonella species. No mycobacterial disease or other unusual infection was present. The episodes of salmonellosis were caused by an identical serovar during a period of 18 months. This is the first case of inherited IL-12Rbeta1 deficiency diagnosed after isolated, recurrent salmonellosis.

Shigella bacteremia: a retrospective study

The aims of this study were to determine the risk factors in, and the clinical and laboratory characterizations of, Shigella bacteremia, as well as the subspecies of Shigella, and the antibiotic susceptibility. A retrospective study of all patients younger than 18 years of age with documented Shigella bacteremia from January 1989 through December 2001 was conducted. Fifteen children with Shigella bacteremia were treated at our center. The mean age (+/- SD) was 20.5 months (+/- 34.2), median 7 months. Thirteen (87%) patients failed to gain weight. The mean duration of diarrhea was 14.7 days. Patients were hospitalized for a mean (+/- SD) of 13.5 days (+/- 9.2). There were no fatalities in our study sample. The vast majority (86.7%) of the Shigella isolates were flexneri. Most isolates were susceptible to ceftriaxone, ciprofloxacine, and gentamicin but resistant to ampicillin and trimethoprim/sulfamethoxazole.

Neonatal nosocomial pneumococcal infections acquired by patient-to-patient transmission

A case of neonatal nosocomial pneumococcal sepsis acquired by patient-to-patient transmission and confirmed by phenotypic and genotypic typing is documented. To the best of our knowledge this is the first documented case of neonatal nosocomial person-to-person transmission.

Successful control of an Acinetobacter baumannii outbreak in a neonatal intensive care unit

We describe an outbreak of Acinetobacter baumannii in a neonatal intensive care unit (NICU), and our investigation to determine the source and mode of transmission and identify the population at risk. A case (infected infant) was defined as a patient hospitalized in the NICU during the outbreak period, with clinical signs of sepsis and isolation of A. baumannii. In colonized infants, A. baumannii was isolated from body surfaces without signs of infection. Infected infants were separated and treated by a different medical team. Cultures were taken from working surfaces and along the infant's admission passage from the delivery room to the NICU. The outbreak strain was identified by pulsed-field gel electrophoresis (PFGE). Nine cases and eight colonized infants met the definition criteria. Cases were younger than colonized infants with regard to gestational age and age of diagnosis and had lower birthweights (P<0.01). The outbreak strain was only isolated from hygroscopic bandages used on skin under the ventilation tube and umbilical catheters. Discontinuing the use of the bandages put an end to the outbreak. We conclude that a rapid and thorough investigation of the environment during an outbreak of A. baumannii is essential to finding the source of the infection, and that hygroscopic bandages may be a source of such outbreaks.

Attenuation of the tumor-promoting effect of surgery by spinal blockade in rats

BACKGROUND

The perioperative period is characterized by a state of immunosuppression, which was shown in animal studies to underlie the promotion of tumor metastasis by surgery. As this immunosuppression is partly ascribed to the neuroendocrine stress response, the authors hypothesized that spinal blockade, known to attenuate this response, may reduce the tumor-promoting effect of surgery.

METHODS

Fischer-344 rats were subjected to a laparotomy during general halothane anesthesia alone or combined with either systemic morphine (10 mg/kg) or spinal block using bupivacaine (50 microg) with morphine (10 microg). Control groups were either anesthetized or undisturbed. Blood was drawn 5 h after surgery to assess number and activity of natural killer cells, or rats were inoculated intravenously with MADB106 adenocarcinoma cells, which metastasize only to the lungs. Metastatic development was assessed by quantifying lung retention of tumor cells 24 h after inoculation or by counting pulmonary metastases 3 weeks later.

RESULTS

Laparotomy conducted during general anesthesia alone increased lung tumor retention up to 17-fold. The addition of spinal block reduced this effect by 70%. The number of metastases increased from 16.7 +/- 10.5 (mean +/- SD) in the control group to 37.2 +/- 24.4 after surgery and was reduced to 10.5 +/- 4.7 during spinal block. Systemic morphine also reduced the effects of surgery, but to a lesser degree. Natural killer cell activity was suppressed to a similar extent by surgery and by anesthesia alone.

CONCLUSIONS

The addition of spinal blockade to general halothane anesthesia markedly attenuates the promotion of metastasis by surgery.

Timing within the oestrous cycle modulates adrenergic suppression of NK activity and resistance to metastasis: possible clinical implications

Clinical observations suggest that the rate of metastatic development and long-term mortality following surgery in breast cancer patients is influenced by the menstrual phase during which surgery is conducted. The menstrual cycle is known to modulate various physiological responses and medical conditions that involve adrenergic mechanisms (e.g., asthma). Natural killer activity (NKA), an immune function controlling metastasis, is suppressed following surgery, and in vitro by adrenaline. We therefore hypothesize that the clinical observation may be partly attributable to surgery-induced adrenergic suppression of NK-dependent resistance to metastasis, a suppression that depends on menstrual phase during surgery. To test this hypothesis in rats, 140 F344 females at different phases of their oestrous cycle were injected with a beta-adrenergic agonist, metaproterenol (MP) (0.4 or 0.8 mg kg(-1), s.c.), or with vehicle, before i.v. inoculation with MADB106 tumour cells. This syngeneic mammary adenocarcinoma line metastasizes only to the lungs, and is highly sensitive to NKA. In a second experiment, the suppression of NKA by MP was studied in vitro in blood drawn at different phases of the oestrous cycle (n = 36). Finally, the effects of stress on the number and activity of NK cells were assessed along the oestrous cycle (n = 71). The findings indicate that the suppressive effects of MP on resistance to metastasis and on NKA, are significantly greater during the oestrous phase characterized by high oestradiol levels (D3/proestrus/oestrus). Similarly, NKA per cell was suppressed by stress only during this phase. In untreated animals, in which inadvertent stress was minimized, no effects of the oestrous cycle on NKA or on resistance to metastasis were evident. These findings indicate that the oestrous cycle modulates adrenergic suppression of NKA and of resistance to metastasis. The relevance of these findings to the above clinical observation, as well as that of our related findings in women from a parallel study, is discussed.

Application of physico-chemical amendments for the counteraction of mercury pollution

In order to counteract mercury pollution, due to gold recovery practices, in situ strategies are required. In this study, some physico-chemical additions were tested, in different environmental compartments, to verify their potential to mitigate mercury contamination. Results indicate that the addition of sulfide reduces chemical methylation of Hg(II), but enhances the solubility of Hg0. The use of oxides, phosphate, and organic matter may be effective in the immobilization of Hg(II), depending upon Hg speciation. Calcium was effective in counteracting the solubility enhancement of Hg0 promoted by the presence of Aldrich humic acid.

Successful non-surgical treatment of Candida tropicalis endocarditis with liposomal amphotericin-B (AmBisome)

Fungal endocarditis in children is most commonly a complication of palliative or curative surgery for congenital heart disease, rheumatic valvulitis and prolonged indwelling central venous and umbilical catheters. We describe here the case of a 3-y-old patient with chronic diarrhoea and prolonged total parenteral alimentation who developed severe C. tropicalis endocarditis and was treated successfully using a liposomal preparation of amphotericin-B (AmBisome) without surgical intervention.

Safety and immunogenicity of a combined pentavalent diphtheria, tetanus, acellular pertussis, inactivated poliovirus and Haemophilus influenzae type b-tetanus conjugate vaccine in infants, compared with a whole cell pertussis pentavalent vaccine

BACKGROUND

We compared the safety and immunogenicity of two combined diphtheria-tetanus-pertussis-inactivated poliovirus vaccines containing either acellular (Pa, SmithKline Beecham Biologicals) or whole cell (Pw, Pasteur Merieux Connaught) pertussis components, mixed with a Haemophilus influenzae type b polysaccharide polyribosylribitol phosphate-tetanus conjugate vaccine in an open, randomized study in healthy infants.

DESIGN

The combined vaccines were given at 2, 4, 6 and 12 months of age, and serum samples were obtained at ages 2, 6, 7, 12 and 13 months. Adverse events were obtained by diary cards.

RESULTS

The Pa group (n = 101) had a clearly lower incidence of both local and systemic adverse events than the Pw group (n = 100). Immunogenicity was comparable for the diphtheria and tetanus components, but significantly superior for pertussis toxin, filamentous hemagglutinin, pertactin and polioviruses 1, 2 and 3 in the Pa group. Both groups had an appropriate response with regard to H. influenzae type b polysaccharide polyribosylribitol phosphate, but the dynamics of the response were significantly different: geometric mean concentrations (micrograms per ml) after the second, third and booster doses were 1.27, 5.06 and 23.12 in the Pa group and 2.72, 6.66 and 13.59 in the Pw group, respectively (P = 0.0002 after second dose; P = 0.0005 after booster).

CONCLUSION

The presently studied diphtheria, tetanus, acellular pertussis-H. influenzae b vaccine conjugated to tetanus toxoid combination was at least as immunogenic as the diphtheria, tetanus, whole cell pertussis-H. influenzae b vaccine conjugated to tetanus toxoid combination, with a significantly better safety profile. This is of obvious importance in countries where inactivated poliovirus vaccine is part of the routine infant immunization programs.

Safety and immunogenicity of tetravalent pneumococcal vaccines containing 6B, 14, 19F and 23F polysaccharides conjugated to either tetanus toxoid or diphtheria toxoid in young infants and their boosterability by native polysaccharide antigens

BACKGROUND

New vaccines against pneumococcal infections in infancy are needed. We assessed in young infants the safety and immunogenicity of two tetravalent vaccines containing pneumococcal 6B, 14, 19F and 23F polysaccharides conjugated to either tetanus toxoid (Pnc-T) or diphtheria toxoid (Pnc-D).

METHODS

Pnc-T or Pnc-D containing 3 microg of polysaccharide of each of the four pneumococcal polysaccharides or placebo were given intramuscularly in a double blinded fashion (25 infants per group) at 2, 4 and 6 months of age. At 12 months of age all 75 children were boosted with a 23-valent nonconjugate polysaccharide pneumococcal vaccine. Serum type-specific anticapsular antibody concentrations were measured at 2, 4, 6, 7, 12 and 13 months of age. Adverse events occurring within 72 h after each injection were recorded.

RESULTS

Both Pnc-T and Pnc-D were well-tolerated. Pnc-T and Pnc-D had higher antibody concentrations compared with placebo after primary immunity (type 6B, 1.66, 1.40 and 0.60 microg/ml, respectively; type 14, 4.81, 2.65 and 2.22 microg/ml, respectively; type 19F, 2.40, 3.48 and 0.83 microg/ml, respectively; type 23F, 0.96, 0.44 and 0.35 microg/ml, respectively). Proportions of infants with concentrations above 1.0 microg/ml were also higher in the vaccine recipients than in those given placebo. After booster with the nonconjugate polysaccharide vaccine, both geometric antibody concentration and proportion with concentrations > or =1.0 microg/ml were significantly higher among either Pnc-T or Pnc-D recipients than among placebo recipients.

CONCLUSIONS

Both Pnc-T and Pnc-D were well-tolerated, induced serotype-specific anticapsular antibodies and induced immunologic memory.

Reduction of pneumococcal nasopharyngeal carriage in early infancy after immunization with tetravalent pneumococcal vaccines conjugated to either tetanus toxoid or diphtheria toxoid

BACKGROUND

Pneumococcal nasopharyngeal colonization is important for transmission of the organisms. We assessed the ability of two tetravalent conjugate vaccines administered in early infancy to prevent carriage of vaccine-related pneumococci.

METHODS

A vaccine containing pneumococcal type 6B, 14, 19F and 23F polysaccharide conjugated to tetanus toxoid (Pnc-T) and a vaccine containing the same four polysaccharides conjugated to diphtheria toxoid (Pnc-D) were compared with placebo, in a double blinded study (25 infants per group). Vaccines (or placebo) were injected at 2, 4 and 6 months of age. At 12 months of age a native (nonconjugate) polysaccharide vaccine was administered as a booster. Serum type-specific anticapsular antibody concentrations were measured and nasopharyngeal cultures were obtained at 2, 4, 6, 7, 12 and 13 months of age.

RESULTS

In general carriage of all pneumococci (vaccine- and non-vaccine-related) was low at age 2 months and increased with age. However, for the vaccine-related serotypes (6A, 6B, 14, 19F and 23F) carriage was not increased with age in Pnc-D or Pnc-T recipients. Of all cultures obtained after the full primary series, 7 of 72 (10%), 3 of 62 (5%) and 19 or 70 (27%) were positive for the vaccine-related pneumococcal serotypes among the Pnc-D, Pnc-T and placebo recipients, respectively (P = 0.001 for Pnc-D vs. placebo; P = 0.014 for Pnc-T vs. placebo). Most of the antibiotic-resistant isolates belonged to the vaccine-related serotypes.

CONCLUSIONS

A significant reduction in the carriage of vaccine-related strains after administration of conjugate vaccines was observed. These preliminary results suggest that transmission of specific pneumococcal serotypes most often associated with disease and antibiotic resistance may at least partially be controlled by immunization.

Immunogenicity and safety of a liquid combination of DTP-PRP-T [corrected] vs lyophilized PRP-T reconstituted with DTP

The immunogenicity and safety of a combined diphtheria, tetanus, pertussis and Haemophilus influenzae type b-tetanus conjugate vaccine (DTP-PRP-T) was compared to the same combination obtained by the reconstitution of H. influenzae type b-tetanus conjugate vaccine lyophilized (PRP-T) with liquid diphtheria-tetanus-pertussis vaccine (DTP). Two hundred and sixty-two healthy infants were randomized to receive a intramuscular injection of 0.5 ml of one of the above combination vaccines at 2, 4 and 6 months of age, and a subgroup of 134 infants received a booster dose at 12 months. Serum antibody levels to each vaccine component were measured at ages 2, 6, 7, 12 and 13 months. Systemic and local reactions were assessed during the first 3 days after each injection by diary cards distributed to the parents. After the third dose and booster administered at 12 months of age, significant equivalence between the groups was observed, and the geometric mean titer of anti H. influenzae type b capsular polysaccharide (Hib-CP) antibodies were 5.9 and 32.6 micrograms ml-1 for the liquid combination group and 5.8 and 19.4 for the lyophilized group, respectively. After the third dose, anti-Hib-PC antibody levels of > or = 1.0 microgram ml-1 and 0.15 microgram ml-1 were seen in 94% and 100%, respectively, of the liquid combination group and 90 and 99%, respectively of the lyophilized group. After the booster dose, levels of > or = 1.0 microgram ml-1 were observed in 100% and 93.5% of the liquid combination group and the lyophilized combination group, respectively. Systemic and local reactions to the vaccination were generally mild and did not differ significantly between the groups. We conclude that the liquid combination of DTP-PRP-T is safe and at least as immunogenic as the lyophilized preparation. This liquid preparation, like other combined vaccines may be helpful for planning vaccination programs with a reduced number of injections.

Reduction of nasopharyngeal carriage of pneumococci during the second year of life by a heptavalent conjugate pneumococcal vaccine

Children 12-18 months old were randomized to receive one dose of a conjugate heptavalent pneumococcal vaccine, two doses of the same vaccine, or one dose of a 23-valent native polysaccharide vaccine. Before immunization, pneumococci included in the conjugate vaccine were isolated from 24% of the children, and an antibiotic-resistant pneumococcus was isolated from 22% of the children. The vaccines had no effect on carriage of non-vaccine-type pneumococci. In contrast, there was a significant reduction in carriage of vaccine-type pneumococci 3 months after one dose and 1 month after a second dose of conjugate vaccine (from 25% to 9% and 7%, respectively; P < .001). No effect was seen after vaccination with the nonconjugate vaccine. One year after immunization, carriage of antibiotic-resistant vaccine-type pneumococci in children receiving conjugate vaccine was lower than that in children receiving the nonconjugate vaccine (4% vs. 14%, P = .042). Conjugate pneumococcal vaccines may reduce spread of pneumococci in the community.

Nasopharyngeal colonization in southern Israel with antibiotic-resistant pneumococci during the first 2 years of life: relation to serotypes likely to be included in pneumococcal conjugate vaccines

Nasopharyngeal carriage of Streptococcus pneumoniae was studied in 162 healthy infants at ages 2, 4, 6, 7, 12, and 13 months and in an additional 352 healthy children at ages 12, 15, 18, 21, and 24 months. Carriage was 26%, 39%, and 62% at 2, 12, and 24 months, respectively, and the respective resistance to > or = 1 antibiotic was 11%, 19%, and 27%. The presence of an older sibling or antibiotic treatment during the month preceding the culture was associated with carriage of resistant pneumococci in infants, whereas attendance at large day care centers was associated with carriage during the second year of life. Antibiotic resistance was detected in all 7 serotypes included in the candidate pediatric conjugate vaccines and was significantly more prevalent among vaccine-type pneumococci than among non-vaccine-type pneumococci. The use of conjugate vaccines may reduce the spread of resistant pneumococci.

[A national qualifying internal medicine examination for Israeli medical students]

In 1991 the deans of the 4 medical schools in Israel decided to institute a national qualifying examination in internal medicine. This marked the beginning of the process of unifying the qualifying examinations in all major medical fields. We describe the development of the examination, experience with its administration to 720 students in 1992-1994, and the outcome of this initial effort. The examinations were prepared by a committee of senior faculty from the 4 schools, representing all the relevant clinical areas. Professional consultation was provided by the Unit for Medical Education of Tel Aviv University. Each examination consisted of 180 multiple choice items, reflecting an agreed representation of the various medical specialties, and was designed to test both comprehension and problem-solving ability. A syllabus was published by the committee and distributed to students and faculty in preparation for the examination. In composing the examination, the committee took into consideration differences in general policy and varying emphases in the curricula of the 4 schools. Analysis of the results of the 3 annual examinations showed both a high level of reliability and high quality of the majority of the individual test items. There was a trend with time to slightly lower average scores, and fewer passed the exam last year. There was improvement in the results after the first 2 years in the area of problem-solving related to interpretation of imaging, blood smears and clinical photographs, but this trend did not continue into 1994. The introduction of a high level examination based on a common syllabus provided important feedback, improving both student motivation and clinical teaching. For all schools, the outcome of the examination served as an important external indicator of teaching standards. Following this positive experience, uniform examinations in surgical subjects and pediatrics were introduced for the first time in 1993. The committee recommends that Israeli medical schools gradually introduce a comprehensive qualifying examination based on a mutually agreed list of objectives and syllabus.

Pregnancy in a homozygous familial hypercholesterolemic patient treated with long-term plasma exchange

We describe the first pregnancy in a homozygous familial hypercholesterolemic woman who started plasma exchange therapy 3 years before she became pregnant. We especially studied the effects of plasma exchange on lipid profile, uteroplacental circulation, and pregnancy course.

A collaborative study of the analysis of doxycycline hyclate by high-performance liquid chromatography on polystyrene-divinylbenzene packing materials

An improved method for the analysis of doxycycline hyclate by high-performance liquid chromatography using polystyrene-divinylbenzene column packings is described. The separation obtained with this method was compared with that of other, recently described methods. The improved method was examined in a collaborative study involving five separate laboratories, using 11 different columns and four discrete samples. The main component and impurities were determined. An analysis of variance showed absence of consistent laboratory bias and presence of significant laboratory-sample interaction. Estimates for the repeatability and reproducibility of the method, expressed as relative standard deviations (RSD) of the result of the determination of doxycycline, were found to be 0.9 and 1.2%, respectively.

Identification of a factor IX/IXa binding protein on the endothelial cell surface

Endothelium provides a specific binding site for Factor IX/IXa which can propagate activation of coagulation by promoting Factor IXa-VIII-mediated activation of Factor X. In this report the endothelial cell Factor IX/IXa binding site has been identified and the coagulant function of the receptor blocked. Studies using [3H]Factor IX derivatized with the photoaffinity labeling agent N-succinimidyl-6-(4'-azido-2'-nitrophenylamino)hexanoate (SANPAH) and cultured bovine endothelial cells demonstrated cross-linking to a trypsin-sensitive cell surface protein of Mr approximately equal to 140,000. Immunoprecipitation of metabolically labeled endothelium with Factor IX derivatized with the cleavable cross-linking agent N-succinimidyl(4-azidophenyl)-1,3'-dithiopropionate and antibody to Factor IX demonstrated the endothelial cell origin of the Mr 140,000 cell surface protein. Blockade of the Factor IX/IXa binding protein by covalently linking SANPAH-5-dimethylaminonaphthalene-1-sulfonyl-Glu-Gly-Arg-Factor IXa or SANPAH-Factor IX prevented both specific Factor IXa binding and effective Factor IXa-VIII-mediated activation of Factor X on endothelium. Following extraction of endothelium with detergents, Factor IX/IXa binding activity was solubilized and could be assayed using a polyvinyl chloride plate binding assay. Western blots of cell extracts demonstrated binding of 125I-Factor IX at Mr approximately equal to 140,000 which was blocked by excess Factor IX, but not antisera to Factor VIII, von Willebrand factor, alpha 2-macroglobulin, or epidermal growth factor receptor. These data indicate that endothelium provides a distinct binding site for Factor IX/IXa consisting, at least in part, of a membrane protein which can modulate the coagulant activity of Factor IXa on the cell surface.

Anomalous origin of the coronary arteries

The incidence and the clinical significance of various forms of anomalous aortic origin of coronary arteries are not well known. Among 2,000 consecutive patients who underwent selective coronary aretriography, 11 had such anomalies (0.55%). Two patients with atresia of the left main ostia developed ischemic symptoms at the ages of thirty-five and fifty-two, and both benefitted from coronary bypass graft operation. In other forms of anomalies the presence of ischemic symptoms was also associated with atherosclerotic stenosis (7 patients) or with constricting muscle bridge (1 patient).

Intraoperative nerve fascicle identification using choline acetyltransferase: a preliminary report

One reason for failure of nerve recovery after suture or nerve grafting is the inappropriate matching of motor and sensory fibers. Methods used in attempting to solve this problem have either been unprecise, too time consuming, or unpleasant to the patient. Both experimentally and on cadaver samples, the level of choline acetylase activity is eight times higher in motor nerve fascicles than in sensory fascicles. In experimentally cut nerves, the ChAC activity remained high even after a period of 45 days. Thus it was possible to identify both ends of the motor and sensory fascicles in fresh injuries, and the proximal parts in old injuries. We have since used this method of intraoperative nerve identification in three patients. It has proved to be a rapid (70-80 minutes), viable technique for the immediate differentiation between proximal parts of motor and sensory nerve fascicles in cases of old nerve injuries. In contrast to our animal studies we found that the ChAC activity in the distal segment was still different for the various fascicles five months after transection. Presumably the present need for distal exploration to identify the "target organ" can be avoided.

Concealed pentageminy

Concealed pentageminy was observed during 10 h of Holter monitoring in a 27-year-old woman without apparent heart disease. In a continuous electrocardiographic recording the number of sinus beats within 114 consecutive interectopic intervals complied with the formula of S = 5n-1. The probability of this occurring by chance alone is infinitesimally small (p = 2(-114).

Choline acetyltransferase nerve identification method in early and late nerve repair

Choline acetyltransferase (ChAC) measurement after complete transection of the sciatic nerve in rats revealed a steady increase in ChAC in the proximal nerve stump and a rapid drop in ChAC in the distal nerve stump. Ninety-six hours following transection no appreciable ChAC activity could be detected in the distal segment. The increase in the proximal segments was followed by a slight decline and leveling off at about twice the normal level. End-to-end nerve anastomosis, using the enzymatic nerve differentiation technique, could therefore be performed up to the first 96 hours. Nerve grafts could be used, with markedly improved results, up to the forty-fifth day following transection.

Choline acetyltransferase for differentiation between human motor and sensory nerve fibers

A rapid and precise nerve fascicle identification method based on the enzymatic activity of choline acetyltransferase (choline acetylase, or ChAC) is described. Motor nerve facicles demonstrated significantly higher ChAC activity in comparison to sensory nerve facicles. Based on this difference in activity, matching of nerve fascicle cut ends is possible in cases of recent trauma.

Segmental transit time in coronary arteries with varying degrees of stenosis

The transit time of contrast material through a proximal segment of right coronary and anterior descending arteries were measured from cineangiograms by means of a projector-linked frame counter. The time required for the contrast material to traverse a 15-cm segment from the ostia was more than 800 msec in 58 out of 80 vessels with more than 85% stenosis and only in 12 of 129 vessels with up to 85% stenosis. This simple measurement during routine interpretation of cineangiograms may add valuable information.

False aneurysm of the left ventricle. Surgical treatment

The clinical and pathological features in three cases of false aneurysm of the left ventricle are reported. In two instances the condition developed after myocardial infarction, and in the third case a mycotic pseudoaneurysm developed after purulent pericarditis. All three patients were in intractable heart failure before urgent operation. The correct diagnosis was established preoperatively by angiography. In all three cases the aneurysms were successfully resected and the left ventricle reconstructed. An aggressive surgical approach is warranted in the management of this lesion.