Amos M. Yinnon

Protective Efficacy of Combined Live Intranasal and Inactivated Influenza A Virus Vaccines in the Elderly

OBJECTIVE To evaluate the efficacy of adding intranasal live attenuated cold-adapted influenza A vaccine to inactivated influenza vaccine to prevent influenza A in elderly residents of long-term-care institutions. DESIGN Randomized, double-blind, placebo-controlled study conducted over 3 years. SETTING Three large nursing homes. PARTICIPANTS A total of 523 residents of nursing homes (mean age, 84.2 years). INTERVENTIONS All participants received trivalent inactivated influenza vaccine parenterally and were randomly assigned to receive either live attenuated influenza A (H3N2) virus vaccine or placebo intranasally. MEASUREMENTS Laboratory-documented influenza A was defined as a respiratory illness plus isolation of influenza A virus from nasal secretions, significant serologic response, or both. Participants were considered to have been exposed to influenza A if they resided in an institution in which cases of influenza A were documented. Outbreak-associated illnesses were defined as those occurring between the first and last isolation of influenza virus from within the institution, +/- 3 days. RESULTS Participants who received intranasal vaccine and were subsequently exposed to influenza A had significantly lower rates of laboratory-documented influenza A (9 of 162 vaccine recipients compared with 24 of 169 placebo recipients; vaccine protective efficacy, 60.6%; 95% CI, 18% to 82%), outbreak-associated respiratory illnesses (13 of 162 vaccine recipients compared with 34 of 169 placebo recipients; vaccine protective efficacy, 56.8%; CI 23% to 76%), and outbreak-associated influenza-like illnesses (6 of 162 vaccine recipients compared with 18 of 169 placebo recipients; vaccine protective efficacy, 65.0%; CI 17% to 86%). CONCLUSIONS Intranasal immunization with live attenuated influenza A virus vaccine provided additional protection against influenza A when added to parenteral trivalent inactivated influenza vaccine among elderly nursing home residents.

Surveillance of antimicrobial prophylaxis for surgical procedures.

OBJECTIVE To assess the practice of antimicrobial prophylaxis for surgical procedures in eight surgical departments in a 550-bed teaching hospital. METHODS A list of all major procedures performed in our hospital, with recommendations for prophylaxis based upon the literature, has been distributed since 1993 and is updated periodically. The practice of surgical prophylaxis between January 1 and March 31, 1996, was examined by assessing four variables: (1) Did the particular procedure justify prophylaxis, and was it provided? (2) Was timing optimal, ie, within 1 hour prior to surgery? (3) Was the appropriate antimicrobial selected? (4) Was duration optimal, ie, < or =24 hours? RESULTS During the study period, 2,117 operations were performed, of which 1,631 (77%) were reviewed. Sixty-six percent were clean surgery, 28% clean-contaminated, and 6% contaminated; 72% of procedures were elective, 28% emergencies. Of 1,631 operations requiring prophylaxis, 1,142 (70%) received it, 489 (30%) did not. Of 1,631 patients, 1,392 (85%) received appropriate care: 929 (67%) appropriately received prophylaxis, and 463 (33%) appropriately did not receive prophylaxis. Of 955 patients who received prophylaxis, 26 (3%) did so inappropriately. Of 1,142 patients who should have received prophylaxis, 213 (19%) did not receive it. Female gender, clean surgery, elective operations, and infrequently performed procedures were all significant indicators of inappropriately withheld prophylaxis (P<.001). In addition, the rate of appropriately provided prophylaxis varied between departments from 71% to 97% (P<.001). Assessment of the 929 procedures for which prophylaxis was justified and given revealed that 100% of patients received it on time, the choice of antimicrobial was appropriate in 95% of cases, and duration was < or =24 hours in 91%. CONCLUSIONS Audits of surgical prophylaxis are expected to detect different errors in different institutions. Conducting audits of surgical prophylaxis probably should be part of the routine activity of infection control teams. Feeding the information back to surgeons could improve adherence to recommended guidelines and might contribute to reduced wound infection rates.

Pneumococcal Bacteremia in Hospitalized Israeli Adults: Epidemiology and Resistance to Penicillin

In April 1993 a national survey of pneumococcal bacteremia in hospitalized Israeli adults was started, and this survey covered 23 of the 24 Israeli medical centers. During the first 2 years, 603 episodes of pneumococcal bacteremia were recorded. The overall annual incidence of pneumococcal bacteremia in Israeli adults was 14.5 episodes per 100,000 inhabitants, and the overall mortality rate was 27.8%. Pneumonia was the source of bacteremia in 70.8% of cases, primary bacteremia was the source in 17.5%, meningitis was the source in 7.5%, and otitis media/sinusitis was the source in 4.2%. Of the 258 pneumococcal isolates for which an MIC was determined, 88.8% were susceptible to penicillin, 9.3% were partially resistant, and only 1.9% were highly resistant. Twenty-four serogroups were identified from 398 strains tested. The highest percentage of penicillin-resistant strains belonged to serogroups 23, 19, 9, 4, and 6. Although only 13 of these 24 serogroups correspond to the serotypes included in the 23-valent pneumococcal vaccine, they accounted for 94% of all isolates.

Neutrophil CD64 expression as a diagnostic marker of bacterial infection in febrile children presenting to a hospital emergency department.

Background: The expression of CD64 (Fc&ggr; receptor) is increased in neutrophils from an almost negligible value to a marked level in patients with bacterial infections. CD64 expression on neutrophils might therefore be useful to differentiate between bacterial and viral infections in young children. We evaluated the usefulness of CD64 as a marker for the diagnosis of bacterial infections in children up to the age of 3 years and its ability to differentiate between bacterial and viral infections. Methods: Blood samples were drawn from 70 children aged 3 years or younger who presented to the pediatric emergency department with fever as their main complaint. Thirty-eight children were diagnosed as having bacterial infection and 32 as having viral infection. The control group included 39 healthy children. CD64, C-reactive protein (CRP), and procalcitonin levels were determined for each child. The sensitivity and specificity of these parameters were calculated. Results Neutrophil expression of CD64 was significantly higher in the bacterial infection group compared with the viral infection and the control groups (P < 0.0001). Raising the cutoff for diagnosis of bacterial disease lowered the sensitivity but improved the specificity. CD64 was found to have a very high sensitivity (94.7%), but its specificity was poor (46.5%). No significant differences were found between the diagnostic performance of CD64 and that of CRP: both have high sensitivity and low specificity (94.7% and 47.9%, respectively, for CRP). In contrast, procalcitonin had a betterspecificity (91%), but its sensitivity reached only 71.9%. CD64 expression was increased in patients with respiratory syncytial virus-related infections compared with that in patients with other viral infections and was similar to that found during bacterial illness. Conclusions: Neutrophil CD64 expression is a sensitive marker for diagnosing bacterial infection in young children, but as it is also raised in viral infection, it lacks specificity.

Susceptibilities of ESBL-Producing Enterobacteriaceae to Ertapenem, Meropenem and Piperacillin-Tazobactam with and without Clavulanic Acid

Background: Faced with the extended-spectrum β-lactamase (ESBL) pandemic, we compared the susceptibilities of ESBL-producing Enterobacteriaceae to ertapenem, meropenem and piperacillin-tazobactam with and without clavulanate. Methods: 121 strains of Escherichia coli and Klebsiella were studied. 70 strains were originally reported as resistant to ceftazidime based upon disk diffusion; 51 strains were originally reported as sensitive to ceftazidime based upon previous guidelines of the National Committee for Clinical Laboratory Standards, but subsequently shown to be ESBL producers. Minimal inhibitory concentrations (MICs) of the strains towards ertapenem, meropenem and piperacillin-tazobactam were determined by Etest. The effect of adding clavulanate on the MICs was determined by performing the Etest, using plates containing 2 µg/ml of clavulanate. Results: The MIC90 of all isolates was 0.094 and 0.25 µg/ml for ertapenem, 0.032 and 0.064 µg/ml for meropenem, and 16 and 256 µg/ml for piperacillin-tazobactam with and without clavulanate, respectively. Conclusions: ESBL-producing organisms were more susceptible to meropenem than to ertapenem, although the MICs to ertapenem were well within clinically achievable levels. Piperacillin-tazobactam was ineffective in a large percentage of isolates. The presence of clavulanate resulted in a 5-fold decrease in the MIC of ertapenem and in a drastic reduction in the MIC of piperacillin-tazobactam. The decrease observed with ertapenem is unlikely to be of clinical significance. Thus, in our hospital, ertapenem could be a good meropenem-sparing agent for infections due to ESBL-producing organisms. Piperacillin-tazobactam appeared to be a poor choice, as our isolates produce ESBLs which are not successfully inhibited by tazobactam.

Infective endocarditis due to Moraxella lacunata: report of 4 patients and review of published cases of Moraxella endocarditis.

Moraxella is an aerobic, oxidase-positive, Gram-negative coccobacillus, which is rarely associated with serious and invasive infections. We describe 4 cases of Moraxella lacunata endocarditis and review 12 previously published cases of Moraxella endocarditis, including 1 further case with M. lacunata, 5 with M. catarrhalis, 2 with M. phenylperuvica and the remainder consisting of 1 case each of M. liquefaciens, M. osloensis, M. nonliquefaciens and 1 non-specified. Of these 16 patients, 5 had prosthetic valves, 5 suffered from an underlying heart abnormality, and the other 6 had normal hearts. Therapy consisted of a beta-lactam antimicrobial and, in several instances, an aminoglycoside as well. The mean duration of antibiotic treatment was 35±13 d. Four patients (25%) underwent surgery and 4 out of 16 (25%) died. Moraxella should be added to the growing list of organisms which may occasionally cause infective endocarditis, even in patients without preexisting valvular abnormality.

Anaerobiospirillum succiniciproducens bacteremia in a young child

We report a case of Anaerobiospirillum succiniciproducens bacteremia in a young child who had no underlying disease. The case should alert microbiologists and physicians to an uncommon organism that is very often resistant to antibiotics normally prescribed empirically for infections caused by organisms of similar morphology and characteristics such as Campylobacter species.

Enterococcal Diskitis: Case Reports and Review of Reported Patients

AbstractWe describe 2 patients diagnosed with enterococcal vertebral spondylodiskitis, leading to the unsuspected diagnosis of endocarditis in one. Because of high-level aminoglycoside resistance, 1 patient received a 6-week course of ampicillin and ceftriaxone, whereas the other received standard a

Reducing blood culture contamination using a departmental report card

Approximately 50% of positive blood cultures represent contamination [1,2], requiring additional laboratory resources and resulting in unnecessary treatment and hospitalization days, costing approximately

Mortality due toblaKPCKlebsiella pneumoniaebacteraemia

4,385-