Recent trends in the epidemiology of shigellosis in Israel.

We provide an update on the epidemiology of shigellosis in Israel using data generated by a sentinel laboratory-based surveillance network for the period 1998-2012. The average annual incidence of culture-proven shigellosis was 97/100 000. We estimated that each case of shigellosis accounted for 25 cases in the community indicating the high burden of disease. Orthodox Jewish communities, living in highly crowded conditions and with a high number of children aged <5 years were the epicentre of country-wide biennial propagated epidemics of S. sonnei shigellosis. S. flexneri was the leading Shigella serogroup in Israeli Arabs. S. flexneri 2a and S. flexneri 6 alternated as the most common serotypes. Both S. sonnei and S. flexneri isolates showed high rates of resistance to ampicillin and trimethoprim/sulfamethoxazole and very low rates of resistance to quinolones and third-generation cephalosporins. Shigellosis due to S. sonnei conferred 81% (95% confidence interval 69-89) protection against the homologous Shigella serotype when epidemic exposure re-occurred 2 years later. These data are of value in the process of Shigella vaccine development.

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.

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.

Increasing incidence of gonorrhea in Israel associated with countrywide dissemination of a ciprofloxacin-resistant strain.

The annual incidence of gonorrhea in Israel has sharply increased during the past 2 years. At the end of 1999, high-level ciprofloxacin-resistant strains of Neisseria gonorrhoeae (MIC90, > or =32 mcg/ml) also exhibiting decreased susceptibility to penicillin and tetracycline were isolated for the first time in southern Israel, as well as in other regions of the country. The incidence of male gonococcal urethritis in the south increased in a 1.5-year period from 3/100,000 to 12/100,000 ( P<0.05) in correlation with increased isolation of ciprofloxacin-resistant organisms. A marked increase in the incidence of gonorrhea was also encountered in Jerusalem, where ciprofloxacin resistance affected 54.5% of the isolates in 2000. Pulsed-field gel electrophoresis typing of gonococci from different areas of Israel indicated that all of the ciprofloxacin-resistant isolates belonged to identical or related strains. Since fluoroquinolone-resistant gonococci may emerge and disseminate extensively over a short period of time, continuous surveillance of antibiotic susceptibility among gonococcal isolates should be performed to guide empiric therapy.

Unusual portal of entry of Vibrio vulnificus: evidence of its prolonged survival on the skin.

Vibrio vulnificus biotype 3 is an emerging pathogen isolated from cultures of skin and blood samples obtained from patients who were directly injured by the fins of tilapia fish bred in artificial ponds. We describe a patient infected with this pathogen after being punctured by a wire. Meticulous anamnestic investigation demonstrated for the first time that this pathogen can survive on the skin for at least 24 hours.

Antimicrobial susceptibility of community-acquired uropathogens in northern Israel.

In order to study the trends in resistance to first line antimicrobial agents, the susceptibility patterns of 8338 community urinary isolates collected during 1995 were compared with 6692 isolates from 1999. Our data shows that community-acquired Gram-negative uropathogens remained highly susceptible to ciprofloxacin, cefuroxime and amoxycillin/clavulanate with sensitivities of 94, 89 and 83% respectively. Nitrofurantoin was shown to be suitable (99% susceptibility rate) only for Escherichia coli urinary tract infections. Ampicillin, first generation cephalosporins and sulphamethoxazole/trimethoprim could no longer be considered first line drugs for empirical treatment of clinically evident urinary tract infection because of very high resistant rates. Ampicillin remained a good choice for urinary infections caused by enterococci, 98% of the strains being susceptible. It was found that 1.25% of the Gram-negative uropathogens isolated during 1999 were extended spectrum beta-lactamase producers which suggests that this plasmid-encoded trait is finding its way into the community.

Evaluation of DipStreak containing CNA-MacConkey agar: a new bedside urine culture device.

BACKGROUND: Many bedside urine culture devices have been developed with the aim of reliability, simplicity and use in both the physician's office and the clinical laboratory. OBJECTIVE: To compare a novel bedside urine culture device (DipStreak, Novamed Ltd., Israel) comprising a combination of MacConkey and Columbia CNA blood agar with conventional seeding on the same culture media. METHODS: A total of 1,000 urine specimens sent to our microbiology laboratory were simultaneously processed by both methods. Results were evaluated after 24 and 48 hours incubation at 37 degrees C. RESULTS: Altogether, 171 (17.1%) and 124 (12.4%) specimens were defined as positive by the conventional method using cutoff values of 10(4) colony-forming units/ml and 10(5) CFU/ml respectively; 178 specimens (17.8%) were defined as contaminated. The sensitivity, specificity, positive and negative predictive values of DipStreak for urinary tract infection were 98.8%, 98.6%, 96% and 99.6% respectively, using a cutoff value of 10(4) CFU/ml, and 99.3%, 99.2%, 96% and 99.8% respectively, using cutoff value of 10(5) CFU/ml. Full agreement between both techniques was 95%. CONCLUSIONS: The agreement rate between DipStreak and conventional seeding was remarkably high. These results suggest that DipStreak in the agar combination tested in this study is a useful and precise tool for diagnosing urinary tract infections.

Duration of antibacterial effectiveness of gentamicin ear drops in external otitis.

The recommendation of Anderson and Steele, for the use of ear drops four times a day, has not been changed since 1948. In order to re-evaluate the frequency of using ear drops, we examined the duration of the effectiveness of the antibacterial activity of gentamicin ear drops in external otitis. Seventeen patients (25 ears) with external otitis were studied. We took 18 samples from each ear at 0, 1, 2, 3, 6, 8, 10, 12 and 14 hours and measured the concentration of gentamicin on the wick and in the ear canal. We found that the concentration of gentamicin began to decrease only after 12 hours and a more significant decrease was detected after 14 hours of treatment. We have shown that the antibiotic used on the wick is effective for 12 hours. In conclusion, we recommend using ear drops twice a day on a wick as routine therapy for external otitis.

[Isolated susceptibility of Streptococcus pyogenes to 3 macrolides].

Erythromycin is considered the drug of choice in the treatment of streptococcal pharyngitis in patients allergic to penicillin. However, in recent years several publications, especially in Finland and Italy, showed high resistance rates of S. pyogenes isolates to erythromycin and other new macrolides. To evaluate the situation in Israel, we checked the MIC of isolates from patients with tonsillitis during 1996. E-test results showed an MIC-50 of 0.23, 0.13 and 0.47 mcg/ml for erythromycin, clarithromycin and roxithromycin, respectively and a MIC-90 of 0.37, 0.23 and 0.78 mcg/ml. Only 2 isolates (2.1%) were partially or completely resistant to all 3 antibiotics. We conclude that empiric therapy with macrolides in Israel is still a viable option and can be recommended in S. pyogenes tonsillitis for patients allergic to penicillin.

Ingestion of yogurt containing Lactobacillus acidophilus compared with pasteurized yogurt as prophylaxis for recurrent candidal vaginitis and bacterial vaginosis.

To compare and assess ingestion of yogurt that contained live Lactobacillus acidophilus with pasteurized yogurt as prophylaxis for recurrent bacterial vaginosis (BV) and candidal vaginitis, we designed a crossover trial during which patients were examined monthly for candidal infection and BV while they were receiving either a pasteurized yogurt or a yogurt that contained live L acidophilus. Forty-six patients in 2 groups of 23 were randomly assigned to each of the study groups. At least 28 (61%) participated during the first 4 months of the study. Seven patients completed the entire study protocol. We concluded that daily ingestion of 150 mL of yogurt, enriched with live L acidophilus, was associated with an increased prevalence of colonization of the rectum and vagina by the bacteria, and this ingestion of yogurt may have reduced episodes of BV.

[Association of bacterial vaginosis in pregnancy with preterm delivery].

In a prospective study we examined the correlation between bacterial vaginosis (BV) during pregnancy and preterm labor. Direct vaginal smears were obtained during the 15th to 20th gestational weeks, and the subsequent delivery records were evaluated for the occurrence of preterm labor. BV was found in 15% of pregnant women at 15-20 gestational weeks, and in 8% at 27-32 gestational weeks. No correlation was found between BV and preterm labor.

A 1-year trial of nasal mupirocin in the prevention of recurrent staphylococcal nasal colonization and skin infection.

BACKGROUND: The usefulness of nasal mupirocin in preventing recurrent staphylococcal nasal colonization and skin infection has been examined in immunodeficient patients and in healthy staphylococcal carriers but not in immunocompetent staphylococcal carriers who experience recurrent skin infections. We studied 34 such patients. METHODS: After an initial 5-day course of nasal mupirocin ointment for all patients, 17 patients continued to apply a 5-day course of nasal mupirocin every month for 1 year, and the other 17 patients applied a placebo ointment. Nasal cultures were obtained monthly, and all episodes of skin infection were recorded. RESULTS: The overall number of positive nasal cultures was 22 in the mupirocin group and 83 in the placebo group (P < .001), and the number of skin infections was 26 and 62, respectively (P < .002). Eight of the 17 mupirocin-treated patients but only 2 in the placebo group remained free of positive staphylococcal nasal cultures. One of the 10 patients who were free of colonization during the 12-month treatment period had skin infections, in contrast to all 24 of the patients with positive cultures (P < .01). Staphylococci resistant to mupirocin were observed in 1 patient. No adverse effects were reported. CONCLUSIONS: A monthly application of mupirocin ointment in staphylococcal carriers reduces the incidence of nasal colonization, which in turn lowers the risk of skin infection.