The correlation between Clostridium-difficile infection and human gut concentrations of Bacteroidetes phylum and clostridial species.

We aimed to assess differences in bacterial intensities of Bacteroidetes phylum and different clostridial species in the human intestines with respect to C. difficile infection. Patients with a stool assay for C. difficile toxin were identified via the microbiology laboratory in our institute. Bacterial populations were quantified from stool samples of four groups of patients: Group I-patients with C. difficile associated diarrhea (CDAD); Group II-asymptomatic C. difficile carriers; Group III-patients with non-C. difficile diarrhea; Group IV-patients with no diarrhea and negative stool samples for the C. difficile toxin (control group). Stool was examined for three genes-C. difficile toxin A gene, 16S rRNA gene from Clostridium thermocellum representing other clostridial species, and 16S rRNA gene from Bacteroides fragilis representing the Bacteroidetes phylum. Fifty-nine patients underwent analysis of the stool (CDAD group 14, carriers group 14, non-C. difficile diarrhea group 16, control group 15). C. difficile concentration was highest in the CDAD group, followed by the carriers group. Higher concentrations of both clostridial species and Bacteriodetes were observed in the control and non-C. difficile diarrhea groups compared to the CDAD and carriers groups. We demonstrated an inverse association between infection with C. difficile and the abundance of Bacteroidetes phylum and other clostridial species in human intestines. Studies with larger samples and broader diagnostic procedures are needed in order to better explore and understand this association.

Mortality of patients with antibiotic-associated diarrhoea: the impact of Clostridium difficile.

Previous studies have shown conflicting results concerning mortality related to Clostridium difficile infection. The objective of this study was to determine the impact of C. difficile infection on short- and long-term mortality in hospitalised patients with antibiotic-associated diarrhoea. We therefore undertook a prospective case-control study of 217 hospitalised patients who received antibiotics, developed diarrhoea and underwent stool enzyme immunoassay for C. difficile TOX A/B. The Kaplan-Meier and the log-rank test were used to determine univariate survival analysis and a Cox regression model for multivariate analysis of 28 day and long-term mortality. Fifty-two (24%) of the 217 patients who met the study criteria were positive for C. difficile TOX A/B. The crude 28 day and long-term mortality rates of the entire cohort were 12.4% and 56%, respectively. On Cox regression analysis, hypoalbuminaemia, impaired functional capacity and elevated serum urea levels were found to be the only independent and statistically significant variables associated with long-term mortality. C. difficile toxin positivity per se was not associated with increased short- or long-term mortality rates. In conclusion, hypoalbuminaemia, renal failure, and impaired function capacity predict mortality due to antibiotic-associated diarrhoea, but C. difficile involvement by itself does not further increase the risk of death in these patients.

Soluble triggering receptor expressed on myeloid cells-1 for distinguishing bacterial from aseptic meningitis in adults.

The aim of the present study was to evaluate whether soluble triggering receptor expressed on myeloid cells (sTREM-1) is present in the cerebrospinal fluid (CSF) of patients with acute meningitis and if its presence can predict bacterial infection. We found elevated levels of sTREM-1 in the CSF of seven of the nine (78%) patients with culture-positive specimens and in none of 12 (0%) patients with culture-negative specimens (sensitivity: 78%; specificity: 100%). The area under the receiver operating characteristic curve for sTREM-1 in the CSF as a predictor for bacterial meningitis was 0.889. This suggests that sTREM-1 is upregulated in the CSF of patients with bacterial meningitis with high specificity and that its presence can potentially assist clinicians in the diagnosis of bacterial meningitis.

An outbreak of Mycobacterium jacuzzii infection following insertion of breast implants.

BACKGROUND: Surgical wound infections caused by rapidly growing mycobacteria developed in 15 women after insertion of breast implants from August to November 2003 at a single medical center. METHODS: A case-control study was conducted that included the identified patients, as well as women who underwent breast operations at the same center who did not develop infections. The study was accompanied by an extensive environmental investigation. Isolates were identified by standard bacteriological methods and by comparison of their 16S rRNA, HSP65, RPOB, SODA, and RECA gene sequences. Isolates were compared by random amplified polymorphic DNA analysis and by pulsed-field gel electrophoresis. RESULTS: The risk factors for infection included surgery performed by 1 specific surgeon (odds ratio, 21.3; 95% confidence interval, 3.64-125.6). Identical strains of mycobacteria were isolated from the infected wounds of the patients; from the eyebrows, hair, face, nose, ears, and groin of this particular surgeon; and from this surgeon's outdoor whirlpool. The isolates exhibited a biochemical profile overlapping that of Mycobacterium wolinskyi, but their sequences of 16S rRNA and HSP65, RPOB, SODA, and RECA genes differed. We propose the name "Mycobacterium jacuzzii" for this new species. DNA fingerprints of cultured isolates from the surgical wounds, areas of the surgeon's body that grow hair, and the surgeon's whirlpool were identical. When the surgeon discontinued his use of the whirlpool and began cleaning the hairy areas of his body with a shampoo containing triclosan, the outbreak ended. CONCLUSIONS: This outbreak brings to light the possibility of the colonization of human skin and human-to-human transmission of environmental mycobacteria during surgery that involves implant insertion.

The significance of Acinetobacter baumannii bacteraemia compared with Klebsiella pneumoniae bacteraemia: risk factors and outcomes.

Risk factors and outcomes for patients with nosocomial Acinetobacter baumannii bacteraemia were compared with those for patients with nosocomial Klebsiella pneumoniae bacteraemia in a single centre in Israel between 2000 and 2003. Data were collected retrospectively through patient chart review. In total, 112 patients with A. baumannii bacteraemia and 90 patients with K. pneumoniae bacteraemia were identified. A. baumannii was significantly associated with poorer performance status, mechanical ventilation, presence of devices, prior treatment with carbapenems, pneumonia as the source of infection and inappropriate empirical antibiotic treatment. All-cause 30-day mortality was higher for A. baumannii bacteraemia compared with K. pneumoniae bacteraemia (61.6% vs 38.9%, P=0.001). Variables significantly associated with mortality at the univariate level (P<0.1) were entered into a multi-variable logistic regression model for mortality. A. baumannii remained significantly associated with mortality when adjusted for all other risk factors (odds ratio 3.61, 95% confidence interval 1.55-8.39). This result did not change when the analysis was repeated for subgroups of less severely ill patients, i.e. those who were not ventilated and those who did not present with septic shock. These results support the view that nosocomial bacteraemia due to A. baumannii is associated with increased mortality.

Isolated endogenous endophthalmitis due to a sporodochial-forming Phialemonium curvatum acquired through intracavernous autoinjections.

We report a case of endogenous endophthalmitis due to a sporodochial-forming species of Phialemonium curvatum. The infection led to the enucleation of the affected eye, but there was no evidence of systemic dissemination. The isolated P. curvatum produced aggregates of phialides, many occurring on coils or in verticils, which eventually develop into sporodochia. The initial and post-enucleation isolates revealed they were identical to strains of P. curvatum from Israel causing disseminated disease in patients practicing intracavernous autoinjections for the treatment of erectile dysfunction. The reported case had unusual clinical and microbiological features. Despite the route of acquisition and the lack of systemic antifungal therapy, the infection did not spread beyond the eye. The morphology of the phialides aggregates was also unique, and the distinction between Volutella and Acremonium is discussed. This case expands the spectrum of infections due to Phialemonium species, and reveals a novel way of developing fungal endophthalmitis.

Characteristics of candidaemia with Candida-albicans compared with non-albicans Candida species and predictors of mortality.

Candidaemia due to non-albicans Candida species is increasing in frequency. We describe 272 episodes of candidaemia, define parameters associated with Candida albicans and other Candida species, and analyse predictors associated with mortality. Patients with C. albicans (55%) had the highest fatality rate and frequently received immunosuppressive therapy, while patients with Candida parapsilosis (16%) had the lowest fatality and complication rates. Candida tropicalis (16%) was associated with youth, severe neutropenia, acute leukaemia or bone marrow transplantation, Candida glabrata (10%) was associated with old age and chronic disease, and Candida krusei (2%) was associated with prior fluconazole therapy. The overall fatality rate was 36%, and predictors of death by multi-variate analysis were shock, impaired performance status, low serum albumin and congestive heart failure. Isolation of non-albicans Candida species, prior surgery and catheter removal were protective factors. When shock was excluded from analysis, antifungal therapy was shown to be protective. Unlike previous concerns, infection with Candida species other than C. albicans has not been shown to result in an increased fatality rate.

Acinetobacter baumannii: emergence and spread in Israeli hospitals 1997-2002.

The incidence of multi-drug-resistant Acinetobacter baumannii bloodstream infections (BSIs) increased two- to four-fold in three Israeli hospitals between 1997 and 2002, accounting for 3.5-18% of all hospital-acquired BSIs. This was associated with increasing carbapenem resistance reaching 35-54%, and by a dramatic increase in carbapenem consumption. In-hospital fatality rates ranged between 47% and 58% and were significantly higher than those seen with other nosocomial Gram-negative pathogens. A. baumannii was not restricted to intensive care units, but had spread to all hospital wards. Multi-drug-resistant A. baumannii has the potential to reach endemicity in hospitals and warrants more vigorous and innovative efforts to limit its spread.

Blood invasiveness of Salmonella enterica as a function of age and serotype.

We explored the dual influence of the patient's age and the infecting serotype on the blood invasiveness patterns of non-Typhi Salmonella enterica (NTS). Blood invasiveness ratio (BIR) was calculated as the ratio between the number of blood and blood + stool isolates. Analysis of 14,951 NTS isolates showed that the BIR increased drastically above the age of 60 years, reaching levels 3.5-7 times higher compared to age group < 2 years. Different patterns of age-related invasiveness were observed for the five most common NTS serotypes (Enteritidis, Typhimurium, Virchow, Hadar, Infantis). Among children < 2 years, the BIR was highest for serotype Virchow and lowest for serotype Hadar, while in persons > or = 60 years it was highest for serotypes Enteritidis and lowest for serotype Infantis. The tendency of NTS serotypes to invade the bloodstream was significantly influenced by the patient's age, however the impact of age differed for various NTS serotypes.

Persistent bacteremia in the absence of defined intravascular foci: clinical significance and risk factors.

The clinical significance of and the risk factors for persistent bacteremia were assessed in 299 episodes. Persistent bacteremia was defined as at least two positive blood cultures obtained on different calendar days during the same infectious episode. Short-term bacteremia was defined as positive blood cultures solely on the first day of the infectious episode. A total of 4,277 episodes of bloodstream infections were detected, of which 299 episodes (7%) were persistent bacteremia. The following were independent risk factors were for persistent bacteremia: burns, presence of a central vascular catheter, cirrhosis, infections caused by Salmonella spp., polymicrobial infections, and inappropriate empirical antibiotic treatment. Irrespective of the source of infection, the presence of a central vascular catheter was correlated with an increased risk for persistent bacteremia. Mortality among patients with persistent bacteremia was 50%, compared to 35% among patients with short-term bacteremia. Because of the high mortality associated with persistent bacteremia, a thorough search for the source of infection is essential to ensure timely and appropriate therapy.

Clinical and laboratory presentation of EBV positive infectious mononucleosis in young adults.

Clinical descriptions of Epstein-Barr virus (EBV) positive infectious mononucleosis (IM) are rare and their results are inconsistent. Over a 4-year period, we prospectively studied 590 young adults with clinically suspected IM, all of whom were tested for the presence of EBV IgM antibodies. We investigated the demographical, clinical and laboratory features of subjects with positive EBV IgM serology and heterophile antibodies. Contrary to previous studies, we found a seasonal disease pattern with a peak incidence during summer months, and a lower-than-expected prevalence of lymphadenopathy (88.9%), leucocytosis (46.2%), atypical lymphocytosis (89.2%) and elevated liver enzymes (57.9%). The prevalence of hyperbilirubinemia was relatively high (14.9%). The classic triad of fever, sore throat and lymph-adenopathy had relatively low sensitivity (68.2%) and specificity (41.9%) for EBV infection. Our study provides a complete and updated description of the clinical and laboratory presentation of laboratory confirmed IM, which is important for both clinicians and epidemiologists.

Failure to detect Chlamydia pneumoniae by cell culture and polymerase chain reaction in major arteries of 93 patients with atherosclerosis.

To detect Chlamydia pneumoniae in punch specimens of the aortic wall of 61 patients undergoing coronary-aortic bypass graft, and carotid atheromas of 32 patients undergoing carotid endarterectomy, cell culture (HEp-2 cells) and two polymerase chain reaction assays in two different laboratories were used. All cultures and polymerase chain reaction tests for Chlamydia pneumoniae were negative. Further studies are required to explore the complex relationship between Chlamydia pneumoniae and atherosclerosis.

Correlation between candiduria and departmental antibiotic use.

The incidence of candiduria is increasing in teaching hospitals. We examined the hypothesis that this trend was correlated with the amount of departmental antibiotic consumption. In the setting of a large teaching hospital in Israel, the correlation coefficient between departmental intravenous antibiotic consumption (expressed as daily defined dose (DDD)/1000 patient-days) and the incidence of candiduria per 1000 patient-days was 0.47 (P=0.03). For broad-spectrum antibiotics, the corresponding correlation coefficient was 0.66 (P=0.001). The strongest correlation with candiduria was shown for the use of meropenem (r=0.79, P<0.001) and ceftazidime (r=0.66, P=0.001). This is the first time that departmental habits of antibiotic use have been shown to be strongly correlated with the incidence of candiduria in hospitalized patients. These results add an important new dimension to the strategy of restricting broad-spectrum antibiotics.

Possible benefit of intravenous immunoglobulin therapy in a lung transplant recipient with West Nile virus encephalitis.

During the summer of 2000, a countrywide epidemic of West Nile fever (WNF) occurred in Israel, with 417 confirmed cases and 35 deaths. Immunosuppressed patients had a 31% case-fatality rate, which was significantly higher compared to non-immunosuppressed patients (13%). We describe a 42-year-old male lung-transplant recipient with serologically confirmed West Nile virus (WNV) encephalitis and deteriorating level of consciousness. He was treated with 0.4 g/kg intravenous immunoglobulin preparation from Israeli donors that contained a high titer of anti-WNV antibodies (1 : 1600). The patient showed rapid improvement within 24 h and complete disappearance of signs and symptoms within 48 h. This is the second case of an immunosuppressed patient responding to the same preparation of intravenous immunoglobulins. Larger studies are required in order to establish the therapeutic role of immunoglobulins in patients with WNF.

Changing distribution of Candida species isolated from sterile and nonsterile sites in Israel.

To determine if the prevalence of non- albicans Candida spp. has increased at two institutions in Israel, the distribution of 6,954 Candida isolates obtained from sterile and nonsterile sites during the periods 1995-1996 and 1999-2000 were compared. In the latter period, a slight decrease was observed in the prevalence of non- albicans Candida spp. isolated from sterile sites (from 39% to 37%) and nonsterile sites (from 38% to 35%). Specifically, the prevalence of Candida glabrata increased significantly in sterile sites, from 26% to 35% (P=0.0095), and in nonsterile sites, from 18% to 27% (P<0.0001), and the prevalence of Candida krusei increased significantly in sterile sites, from 2% to 7% (P=0.0072). The prevalence of Candida parapsilosis decreased significantly in nonsterile sites, from 31% to 23% (P=0.0002). Continuous surveys of the distribution of Candida spp. and analysis of the clinical significance of changes are warranted.

Urinary soluble VCAM-1 in systemic lupus erythematosus: a clinical marker for monitoring disease activity and damage.

OBJECTIVE: To determine the urinary levels of soluble vascular cell adhesion molecule-1 (VCAM-1) and intercellular adhesion molecule-1 (ICAM-1) in patients with systemic lupus erythematosus (SLE) and to assess their relationship with clinical and laboratory features and the degree of activity and damage associated with the disease. METHODS: The study sample included 24 consecutive patients with SLE. 24-hour urine samples were collected for the determination of soluble VCAM-1 and ICAM-1 levels by ELISA. Disease activity was defined by the SLE Disease Active Index (SLEDAI) and disease outcome by the Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ ACR) damage index. RESULTS: The urinary soluble VCAM-1 level was significantly higher in patients with SLE compared to normal controls (32.35+/-34.27 vs. 4.66+/-3.8 ng/mg creatinine, p = 0.0005) and statistically significantly correlated with disease activity (SLEDAI), a low serum C3 level, decreased creatinine clearance and albuminuria, as well as with disease damage (SLICC/ACR damage index). In contrast, the urinary soluble ICAM-1 level was not significantly higher in the patients' group compared with the controls (4.5+/-5.19 vs. 2.72+/-2.31 ng/mg creatinine, p=0.2), but was statistically significantly correlated with hematuria and albuminuria. CONCLUSION: Our data suggest that the urinary level of soluble VCAM-1 significantly correlates with overall disease activity and damage scores, but not with nephritis in SLE.