Risk factors for non-Escherichia coli community-acquired bacteriuria.

PURPOSE: Urinary tract infection (UTI) is one of the most common bacterial infections, with Escherichia coli causing up to 80 % of community-acquired bacteriuria (CA-Bu). The epidemiology and pathogenesis of E. coli have been intensively studied, yet, less is known about risk factors for CA-Bu due to other uropathogens. The purpose of this study was to clarify the latest knowledge. METHODS: A clinical epidemiological study among adult ambulatory patients was conducted. During November 2009, all urine cultures sent to our Microbiology Laboratory were evaluated, including demographic characteristics of the patients, underlying diseases and antibiotic treatment. Data were analysed by the SPSS statistical package. RESULTS: During the study period, 4,653 cultures were sent for evaluation. Of the 1,047 (22.5 %) that were positive, 838 were included in the study; 82.5 % were from females. E. coli was the most common pathogen, comprising 58.6 % of all positive cultures. By multivariate analysis, five independent risk factors were associated with non-E. coli CA-Bu: presence of foreign body in the urinary tract [odds ratio (OR) 5.8], nitrite urine test negative (OR 3.2), male gender (OR 2.5), normal erythrocyte count in urine test (OR 1.5) and recurrent UTI in the past year (OR 1.5). CONCLUSIONS: For adult outpatients presenting with CA-Bu, five independent factors suggesting the involvement of uropathogens other than E. coli were identified. These should be taken into consideration when empiric antibiotic treatment is prescribed.

Bacteriological aspects of Darier's disease.

BACKGROUND: There are no established data on the prevalence of bacterial colonization of lesional skin, nares and perineum in Darier's disease (DD), or its contribution to the clinical manifestations of the disease. OBJECTIVE: To determine the prevalence of bacterial colonization of lesional skin and Staphylococcus aureus (S. aureus) in nares and perineum in 75 patients with DD, the association of these parameters with disease and patient characteristics, and the features of the bacterial skin infection in this group. METHODS: Medical interviews and physical examinations were performed. Bacteria were isolated from swabs taken from lesional skin, nares and perineum. RESULTS: S. aureus was isolated in 68%, 47% and 22% of lesional skin, nares and perineum cultures respectively. Subjects with positive S. aureus culture from lesional skin and/or nares had a statistically significant higher percentage of skin area affected and a more severe disease than patients with negative culture. Thirty of the 75 patients (40%) recalled bacterial skin infection, most often on the chest. CONCLUSIONS: Patients with DD have high prevalence of S. aureus colonization in lesional skin and nares, with a correlation between disease severity and extent of the colonization. Further studies examining the consequences of S. aureus eradication in those sites may establish the need for S. aureus lesional skin and nares colonization screening and eradication as part of the treatment of DD exacerbations.

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.

Fosfomycin: an old--new antibiotic.

Fosfomycin is a broad-spectrum antibiotic discovered in Spain in 1969. It has bactericidal activity against a wide range of bacteria, including gram-negative micro-organisms and some gram-positive bacteria, such as staphylococci. Initially fosfomycin was administered parenterally and only to patients with severe infections. Today it is often dispensed as fosfomycin-trometamol, an oral formula recommended in the treatment of urinary tract infections. Fosfomycin-trometamol in a single dose is indicated for the treatment of women with uncomplicated urinary tract infections.

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.

Variability in outpatient antimicrobial consumption in Israel.

BACKGROUND: Antibiotic consumption has an important effect on microbial resistance. Nationwide data on the comparative use of antibiotics in outpatient settings in Israel have only been partially collected and published. The aim of our study was to analyze the use of antibiotics in the outpatient setting in Israel and assess a number of influencing factors. MATERIALS AND METHODS: Defined daily doses per 1,000 inhabitants per day (DID) of total antibiotic use, consumption in different age groups, and consumption of different antibiotic groups were calculated for the years 2003-2005 in the districts of Israel. The data was collected from prescription data compiled by the pharmaceutical services of "Clalit Health Services", the largest health maintenance organization (HMO) in Israel, covering 55% of the population.Trends in use and variables associated with antibiotic consumption were analyzed. RESULTS: There was a significant decrease in antibiotic use from 2003 to 2005, ranging from 1.8 to 8.2% in the different districts. The highest consumption was noted in the youngest age groups, with more than half of all antibiotics prescribed to children < or = 18 years of age. Antibiotic consumption was significantly different between the different regions in Israel. A multivariate analysis revealed that a higher prevalence of diabetes mellitus was the only significant variable associated with antibiotic use. Variability in the use of different antibiotics was also found; for example, amoxicillin comprised 19.5-33.4% of total antibiotic consumption in the different districts, while fluoroquinolone consumption ranged from 3.2 to 7.3%. CONCLUSIONS: Outpatient antibiotic use in the population insured by "Clalit Health Services" declined between 2003 and 2005. Children had the highest consumption rates. There were large differences in antibiotic use between geographic regions, and diabetes mellitus was the only variable significantly associated with antibiotic use. We therefore conclude that most of the differences in antibiotic use are likely due to doctor preferences, local routines, and patients' attitudes and expectations.

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.

Adherence to guidelines on empiric use of antibiotics in the emergency room.

BACKGROUND: In October 2002, guidelines for empiric antibiotics in emergency room (ER) were introduced. AIMS: To evaluate physician's compliance with guidelines and their utility in improving patient care. METHODS: Reviewing charts of patients admitted to ER during October 4, 2004 to February 14, 2005 with suspected infection, subsequently hospitalized to internal medicine ward. Along with demographic data, the following parameters were recorded: Initiating antibiotics in ER, according-to-guidelines treatment (ATGT), lag-time between admittance and first antibiotic dose, diagnosis, proper coverage of pathogens by treatment (PCPT), and outcome. RESULTS: A total of 534 patients were admitted to ER with a suspected infection, 481 (90.1%) of them were managed according to guidelines, and from the 431 patients (80.7%) who received antibiotics, 381 (88.4%) were given ATGT. In 105 cases (19.7%), positive cultures (urine or blood) were obtained: 23.6% and 30.0% of the patients who received ATGT and not-ATGT, and the given antibiotic ensured proper coverage of the pathogen which grew in 73.3% and 46.7% of the cases, respectively. Percentages of good outcome (staying alive) for ATGT, non-ATGT, PCPT, and not-PCPT were 92.1%, 76.0%, 89.0%, and 69.0%, respectively. By multivariate analysis, early ATGT proved to be related to good outcome. CONCLUSIONS: Physicians' compliance with hospital guidelines to empiric antibiotics in ER was high. Adherence to guidelines was associated with a better outcome. Local susceptibility patterns to antibiotics need to be actively monitored. Prompt administration of antibiotics in the ER is likely to have a favorable outcome on survival, yet larger studies are required to establish this conclusively.

Risk factors for community-acquired urinary tract infection due to quinolone-resistant E. coli.

BACKGROUND: Resistance to fluoroquinolone drugs is emerging among E. coli causing community acquired urinary tract infections (COMA-UTI). OBJECTIVES: To evaluate demographic and clinical risk factors associated with COMA-UTI due to quinolone-resistant E. coli (QREc). METHODS: In this case-control study, clinical and demographic data from 300 COMA-UTI due to E. coli (including 150 QREc) were analyzed. RESULTS: By univariate analysis QREc was associated to males, older patients, nursing home residents, functionally dependent, dementia, diabetes, cardiovascular diseases, immunosupression, nephrolithiasis, recurrent UTI, invasive procedures, hospitalization, and antibiotic use within previous 6 months. By multivariate analysis, use of ciprofloxacin (OR 20.6 [CI 2.3-179.2], p=0.006) or ofloxacin (OR 7.5 [CI 2.9-19.4], p<0.0001), previous invasive procedure (OR 6.6 [CI 3.0-14.7], p<0.0001), recurrent UTI (OR 4.7 [CI 2.3-9.3], p<0.0001), and previous hospitalization (OR 2.9 [CI 1.4-6], p=0.003) were identified as independent risk factors for COMA-UTI due to QREc. CONCLUSION: In patients with one or more of the risk factors identified here, the empiric use of quinolones should be reconsidered.

Community-acquired and hospital-acquired candiduria: comparison of prevalence and clinical characteristics.

Hospital-acquired candiduria (HAC) is a well-known finding, related to severely ill patients, prolonged antibiotic treatment, use of catheters, and invasive procedures. However, the risk factors and clinical significance of community-acquired candiduria (CAC) has not yet been described. In this study, the prevalence and clinical characteristics of CAC and HAC were compared. Demographic and clinical data from all patients with positive urinary cultures sent to the bacteriology laboratory of the Haemek Medical Center, Israel, between May 2005 and October 2006 which grew Candida spp. were collected and analyzed. A total of 100,522 urine samples were received, 19,611 (19.5%) of which grew uropathogens. Among them, 204 (125 community-acquired and 79 hospital-acquired) grew Candida spp. (1% of all positive and 0.2% of all samples). Patients with CAC were younger than those with HAC (mean 50.5 years vs. 68.3 years). Pregnant women and bed-ridden patients were more prevalent in CAC (22.5% vs. 1.9% and 46.8% vs. 18.55%, respectively). More patients with HAC suffered from renal failure (27.8% vs. 11.2%) and fever (62.0% vs. 25.6%), had urinary catheters (32.9% vs. 15.2%), and received antibiotic or immunosuppressive therapy in the last month (73.4% vs. 46.4% and 10.1% vs. 3.2%). Most candiduria cases were not treated medically and no further investigation was conducted. Significant differences between patients with CAC and HAC were found. Our results confirm that candiduria (nosocomial as community-acquired) infrequently requires intervention. However, the identification of high-risk patients is desirable and questions regarding the management of candiduria, both CAC and HAC, still remain unresolved.

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.

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.

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.

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.

Prevalence and risk factors of extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella pneumoniae in an Israeli long-term care facility.

The purpose of this study was to ascertain the prevalence of extended-spectrum beta-lactamases (ESBLs) among Escherichia coli and Klebsiella pneumoniae strains obtained from urine samples of residents of a long-term care facility and to determine the risk factors for acquisition of ESBL-producing strains. All urine samples collected from January 2003 to October 2003 that were positive for E. coli or K. pneumoniae were tested for the presence of ESBL. Records of patients with ESBL-positive (ESBL-P) samples were analyzed for clinical and demographic data. The records of a matched control group of patients whose urine samples were positive for E. coli or K. pneumoniae but were ESBL-negative (ESBL-N) were also analyzed. The overall rate of ESBLs among the E. coli and K. pneumoniae samples was 25.6%. Of 350 urine samples that grew E. coli, 77 (22%) were positive for ESBL; 34 of 84 (40.5%) samples that grew K. pneumoniae were ESBL-P. Male sex, treatment in the subacute care unit, recent antimicrobial treatment, pressure sores, (percutaneous endoscopic gastrostomy) PEG tube, anemia, hypoalbuminemia, permanent urinary catheter, and any recent invasive procedure were all associated with ESBL-P bacteria in the univariate analysis. The multivariate analysis revealed three independent risk factors for the presence of an ESBL-producing strain: anemia, permanent urinary catheter, and previous antibiotic use. Fluoroquinolones were most strongly associated with the development of ESBL-producing bacteria. The prevalence of ESBL-producing E. coli and K. pneumoniae in the long-term care facility investigated was unexpectedly high and corroborates the notion that long-term care facilities could be important reservoirs of resistant bacteria. Identification of the risk factors for ESBLs is the first step in formulating an effective strategy to curtail the spread of ESBL resistance in long-term care facilities.

Cytomegalovirus encephalitis in an immunocompetent pregnant woman.

Presented here is the case of an immunocompetent pregnant woman with probable cytomegalovirus encephalitis. The clinical picture was characterized by diffuse headache, drowsiness and the development of an acute confused state. Diagnosis was based on the documentation of recent cytomegalovirus seroconversion with low avidity for the immunoglobulin G class antibodies. Initially, the diagnosis of encephalitis was challenging due to the subtle findings in cerebrospinal fluid and the normal electroencephalograph results. However, repeated tests revealed findings compatible with the diagnosis of encephalitis. Due to the suspicion of herpes simplex encephalitis the patient was treated with acyclovir. Within a few days rapid resolution of the fever and complete recovery were observed. Cytomegalovirus encephalitis should be considered early in the evaluation of pregnant women if appropriate clinical symptoms are present.

Aging and vestibular system: specific tests and role of melatonin in cognitive involvement.

Balance disorders are frequent with aging. They are particularly important because they decrease social autonomy of the aged subjects and they often provoke falls. The cause is always multifactorial. There is evidence that aging affects multiple sensory inputs, as well as the muscoloskeletal system and central nervous system ability to perform sensorimotor integration. For the evaluation of decreased balance skills in elderly, a specific questionnaire has been prepared, in order to identify high risk of falling called falling risk inventory (FRI) questionnaire, and a complex psycho-sensory-motor test has been studied by means of posturography, in order to detect specific vestibular impairment. Regarding ethiopathogenesis of balance disorders in aged subjects, because the decline of behavioral and cognitive performances are due also to decline of biological rhythm control, the role of melatonin (the hormone regulating circadian rhythms, being strictly connected with cerebellar function, and it is well known that cerebellum acts in elderly both at motor and cognitive regulation. The goals of the present paper are: (i) To present a self-administered FRI questionnaire aimed at identifying possible causes of falls and quantifying falling risk in aged. (ii) To validate posturography as a specific test to investigate vestibular involvement in elderly in correlation with FRI. (iii) To present a complex behavioral test (NT) aimed at evaluating both spatial orientation and spatial memory in elderly, factors involved into the genesis of complex dizziness and unsteadiness. (iv) To evaluate the role of melatonin in cognitive involvement in dizzy, old subjects due to the functional correlations between circadian rhythms, cerebellum balance disturbances and cognitive disorders. General conclusions are: FRI correlates with falling risk. Posturography identifies specific vestibular impairments correlated to balance disorders and elderly falls. Spatial orientation is altered in about 40% of dizzy patients but no significant differences are revealed in melatonin rhythm. Spatial memory is highly altered only in subjects with inversion of circadian melatonin rhythm it is possible to hypothesize that the alteration of the normal circadian melatonin rhythm plays some role in the genesis of dizziness in a subpopulation of patients.