Bibiana Chazan

Risk Factors for the Development of Extended-Spectrum Beta-Lactamase-Producing Bacteria in Nonhospitalized Patients

Although the risk factors for acquiring infection by extended-spectrum beta-lactamase (ESBL)-producing bacteria have been investigated in hospitalized patients, such risk factors have not been defined in the community setting. In this study, clinical data from a total of 311 nonhospitalized patients with community-acquired urinary tract infection (128 with ESBL-positive strains and 183 with ESBL-negative strains) were obtained. According to a multivariate analysis, the following were identified as independent risk factors: previous hospitalization in the past 3 months (OR=8.95, 95%CI, 3.77–21.25), antibiotic treatment in the past 3 months (OR=3.23, 95%CI, 1.76–5.91), age over 60 years (OR=2.65, 95%CI, 1.45–4.83), diabetes (OR=2.57, 95%CI, 1.20–5.51), male gender (OR=2.47, 95%CI, 1.22–5.01), Klebsiella pneumoniae infection (OR=2.31, 95%CI, 1.17–4.54), previous use of third-generation cephalosporins (P=0.014, OR=15.8, 95%CI, 1.7–143), previous use of second-generation cephalosporins (P<0.0001, OR=10.1, 95%CI, 4.2–24), previous use of quinolones (P=0.001, OR=4.1, 95%CI, 1.8–9.0), and previous use of penicillin (P=0.003, OR=4.0, 95%CI, 1.6–9.0).

Empiric use of trimethoprim-sulfamethoxazole (TMP-SMX) in the treatment of women with uncomplicated urinary tract infections, in a geographical area with a high prevalence of TMP-SMX-resistant uropathogens

This study evaluated whether trimethoprim-sulfamethoxazole (TMP-SMX) is effective for treatment of uncomplicated urinary tract infections (UTIs) due to TMP-SMX-resistant (TMP-SMX-R) pathogens. Healthy nonpregnant premenopausal women with symptomatic lower UTI were assessed for the presence of pyuria and bacteriuria; if either was present, a urine sample was cultured and TMP-SMX was prescribed. Clinical and microbiologic cure was assessed at days 5-9 and 28-42 after cessation of therapy. For 71%, of patients, cultures grew TMP-SMX-susceptible (TMP-SMX-S) microorganisms, and for 29%, cultures grew TMP-SMX-R organisms. Escherichia coli remained the predominant bacteria in both groups of cultures. At visit 2, microbiological cure had been achieved in 86% of the patients in the TMP-SMX-S group and 42% of those in the TMP-SMX-R group. Similar differences were found at visit 3 by clinical evaluation. Treatment with TMP-SMX of uncomplicated UTI caused by TMP-SMX-R microorganisms results in microbiologic and clinical failure. In high-resistance areas, TMP-SMX should not be the empiric drug of choice for uncomplicated UTI.

Cranberry Juice and Urinary Tract Infection

Cranberries have long been the focus of interest for their beneficial effects in preventing urinary tract infections (UTIs). Cranberries contain 2 compounds with antiadherence properties that prevent fimbriated Escherichia coli from adhering to uroepithelial cells in the urinary tract. Approximately 1 dozen clinical trials have been performed testing the effects of cranberries on the urinary tract. However, these trials suffer from a number of limitations. Most importantly, the trials have used a wide variety of cranberry products, such as cranberry juice concentrate, cranberry juice cocktail, and cranberry capsules, and they have used different dosing regimens. Further research is required to clarify unanswered questions regarding the role of cranberries in protecting against UTI in general and in women with anatomical abnormalities in particular.

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.

Antibiotic Exposure as a Risk Factor for Fluconazole-Resistant Candida Bloodstream Infection

ABSTRACT Recent exposure to azoles is an important risk factor for infection with fluconazole-resistant Candida spp., but little is known about the role of antibacterial drug exposure in the emergence of drug-resistant Candida. We did a prospective nationwide surveillance study of candidemia in Israel and analyzed the propensity score-adjusted association between antifungal and antibacterial drug exposure and bloodstream infection with C. glabrata and fluconazole-resistant Candida isolates. Four hundred forty-four episodes of candidemia (450 Candida isolates, 69 [15%] C. glabrata isolates, and 38 [8.5%] fluconazole-resistant isolates) from 18 medical centers in Israel were included. C. glabrata bloodstream infection was strongly associated with recent metronidazole exposure (odds ratio [OR], 3.2; P < 0.001). Infection with a fluconazole-resistant isolate was associated with exposure to carbapenems, trimethoprim-sulfamethoxazole, clindamycin, and colistin (odds ratio, 2.8; P = 0.01). The inclusion of antibacterial drug exposure in a multivariable model significantly enhanced the models predictive accuracy for fluconazole-resistant Candida bloodstream infection. Our findings may be relevant to the selection of empirical antifungal treatment and broaden the scope of antibiotic-associated collateral damage.

Clostridium difficile and inflammatory bowel disease: Role in pathogenesis and implications in treatment

Clostridium difficile (C. difficile) is the leading cause of antibiotic associated colitis and nosocomial diarrhea. Patients with inflammatory bowel disease (IBD) are at increased risk of developing C. difficile infection (CDI), have worse outcomes of CDI-including higher rates of colectomy and death, and experience higher rates of recurrence. However, it is still not clear whether C. difficile is a cause of IBD or a consequence of the inflammatory state in the intestinal environment. The burden of CDI has increased dramatically over the past decade, with severe outbreaks described in many countries, which have been attributed to a new and more virulent strain. A parallel rise in the incidence of CDI has been noted in patients with IBD. IBD patients with CDI tend be younger, have less prior antibiotic exposure, and most cases of CDI in these patients represent outpatient acquired infections. The clinical presentation of CDI in these patients can be unique-including diversion colitis, enteritis and pouchitis, and typical findings on colonoscopy are often absent. Due to the high prevalence of CDI in patients hospitalized with an IBD exacerbation, and the prognostic implications of CDI in these patients, it is recommended to test all IBD patients hospitalized with a disease flare for C. difficile. Treatment includes general measures such as supportive care and infection control measures. Antibiotic therapy with either oral metronidazole, vancomycin, or the novel antibiotic-fidaxomicin, should be initiated as soon as possible. Fecal macrobiota transplantation constitutes another optional treatment for severe/recurrent CDI. The aim of this paper is to review recent data on CDI in IBD: role in pathogenesis, diagnostic methods, optional treatments, and outcomes of these patients.

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.

Long-Term Follow-Up of Women Hospitalized for Acute Pyelonephritis

Long-term outcome of acute pyelonephritis (AP) in adults is unknown. We evaluated the frequency of renal damage 10-20 years after hospitalization for AP in adult women and the utility of technetium Tc 99m-labeled dimercaptosuccinic acid (Tc 99m-DMSA) scanning for detection of renal scars; 63 of 203 women hospitalized with AP during 1982-1992 were included in the study. Tc 99m-DMSA scanning detected renal scarring in 29 women (46%). Multivariate analysis showed that pregnancy and hypoalbuminemia (albumin level, <3.2 g/dL) at hospitalization were independent risk factors for subsequent development of renal scars. At follow-up, hypertension was observed in approximately one-fifth of patients, regardless of renal scarring status. Four women with scars had a glomerular filtration rate of < or =75 mL/min; none of them developed severe renal impairment. In conclusion, the risk of developing renal scarring after AP in adult women is high. However, clinically relevant renal damage is rare 10-20 years after AP. Tc 99m-DMSA scanning is useful for detecting renal scars in adults but is not routinely needed in practice.

Cutaneous nocardiosis: report of two cases and review of the literature.

Background  Cutaneous nocardiosis is an uncommon infectious disease that presents as a primary cutaneous infection or as a disseminated disease. It is often misdiagnosed because of its rarity and nonspecific clinical picture.

Urinary tract infections in patients with type 2 diabetes mellitus: review of prevalence, diagnosis, and management

Urinary tract infections are more common, more severe, and carry worse outcomes in patients with type 2 diabetes mellitus. They are also more often caused by resistant pathogens. Various impairments in the immune system, poor metabolic control, and incomplete bladder emptying due to autonomic neuropathy may all contribute to the enhanced risk of urinary tract infections in these patients. The new anti-diabetic sodium glucose cotransporter 2 inhibitors have not been found to significantly increase the risk of symptomatic urinary tract infections. Symptoms of urinary tract infection are similar to patients without diabetes, though some patients with diabetic neuropathy may have altered clinical signs. Treatment depends on several factors, including: presence of symptoms, severity of systemic symptoms, if infection is localized in the bladder or also involves the kidney, presence of urologic abnormalities, accompanying metabolic alterations, and renal function. There is no indication to treat diabetic patients with asymptomatic bacteriuria. Further studies are needed to improve the treatment of patients with type 2 diabetes and urinary tract infections.