F. Schlaeffer

Nosocomial multi-drug resistant Acinetobacter baumannii bloodstream infection: risk factors and outcome with ampicillin-sulbactam treatment

The emergence of multidrug-resistant (MDR) Acinetobacter baumannii poses a therapeutic problem. The aim of this study was to assess the risk factors for nosocomial MDR-A. baumannii bloodstream infection (BSI) and the efficacy of ampicillin-sulbactam (A/S) in its treatment. Of 94 nosocomial A. baumannii BSI during the year 2000, 54% involved MDR strains, 81% of which were genetically related. Various risk factors for MDR-A. baumannii were found, of which intensive-care unit admission and prior aminoglycoside therapy were independently associated with MDR-A. baumannii acquisition on multivariate analysis. Of MDR-A. baumannii BSI cases, 65% received A/S and 35% inadequate antibiotic therapy, whereas of 43 non-MDR cases, 86% were treated according to susceptibility and 14% inappropriately with antibiotics to which these organisms were resistant. Crude mortality was comparable in the adequately treated groups. Respective mortalities among patients treated adequately and inadequately were 41.4 and 91.7% (p<0.001). Among severely ill patients, A/S therapy significantly decreased the risk of death (P=0.02 OR=7.64). MDR-A. baumannii has become highly endemic in our institution. A/S appears to be one of the last effective and safe empirical resorts for treatment of MDR A. baumannii BSI.

The epidemiology of community-acquired pneumonia among hospitalized adults

OBJECTIVE To identify and characterize the aetiological agents of community-acquired pneumonia (CAP) among hospitalized patients, as an aid in therapeutic decision-making. METHOD A prospective 1 year study of all patients hospitalized with CAP in the Negev region of Israel. The aetiology was determined by blood and pleural fluid cultures, and specific serological testing for pathogenic agents. Eighty-nine percent of the patients underwent follow-up for a month after discharge. RESULTS The study included 346 patients (53% males, mean age 49.3 +/- 19.5, range 17-94). A single aetiologic agent was identified in 146 patients (42.2%), multiple agents were found in 133 (38.4%), and no agent was identified in 67 (19.4%). Among the common pathogens were Pneumococcus sp. in 148 patients (42.8%). Mycoplasma pneumoniae (101, 29.2%), Chlamydia pneumoniae (62, 17.9%), Legionella sp. (56, 16.2%), viruses (35, 10.1%), Coxiella burnetti (20, 5.8%). Haemophilus influenzae (19, 5.5%), and other bacteria (21, 6.1%). Approximately 70% of the patients infected with M. pneumoniae and C. burnetti were younger than 45 years (P < 0.05). In contrast, about 50% of the patients with C. pneumoniae (TWAR) were over the age of 65 (P = 0.03). The presence of comorbidity was associated with a greater frequency of bacterial aetiologies (57% vs. 44%, P = 0.02), and fewer infections with M. pneumoniae (15% vs. 36%, P = 0.0004), or C. burnetii (2% vs. 8%, P = 0.02). Specific causative agents were associated with specific seasons: viruses between December and April (P = 0.03), and Legionella sp. from July to October (P = 0.003). In contrast, no seasonal variation was associated with pneumococcus, M. pneumoniae, or C. pneumoniae (TWAR). CONCLUSIONS Patients are hospitalized with CAP throughout the year. Since the pathogen is usually unknown at hospitalization, epidemiological data is important for choosing medication. The findings of this study point to the importance of macrolides alone or in combination with cephalosporins, as the treatment of choice for patients in our region.

Chlamydia pneumoniae community-acquired pneumonia: A review of 62 hospitalized adult patients

SummaryIn a prospective study,Chlamydia pneumoniae was identified as the etiological agent in 62 (17.9%) of 346 adult patients hospitalized over the course of one year for community-acquired pneumonia at the Soroka Medical Center in Beer-Sheva, Israel. The diagnosis ofC. pneumoniae infection was based on serological testing of antibodies by the MIF technique. In 43 of these patients (69.4%), at least one other etiological agent, in addition toC. pneumoniae for community-acquired pneumonia was identified.Streptococcus pneumoniae was identified in 34 patients withC. pneumoniae (54.8%), as an additional causative factor in infection. Community-acquired pneumonia patients withC. pneumoniae were significantly older than non-C. pneumoniae patients (p=0.03), had a higher APACHE II score on admission (p<0.05), a higher rate of positive blood cultures (p=0.02), and longer periods of hospitalization (p=0.022). Seven patients with pureC. pneumoniae infection recovered, despite treatment which is not considered to be specific forC. pneumoniae. It was concluded thatC. pneumoniae is a common etiological agent for community-acquired pneumonia in our region, particularly in the elderly, and is characterized by a high rate of concomitant infections with other pulmonary pathogens. No specific clinical or radiological pattern was discerned that could distinguish betweenC. pneumoniae community-acquired pneumonia and non-C. pneumoniae community-acquired pneumonia.ZusammenfassungUnter 346 im Rahmen einer prospektiven Studie erfaßten Patienten mit ambulant erworbener Pneumonie fanden sich 62 Fälle (17,9%), bei denenChlamydia pneumoniae als der verantwortliche Erreger identifiziert wurde. Die Studie lief über einen Zeitraum von einem Jahr am Soroka Medical Center in Beer-Sheva, Israel. Die Diagnose basierte auf dem serologischen Nachweis von anti-C. pneumoniae Antikörpern mit der MIF-Technik. Bei 43 dieser Patienten fand sich mindestens noch ein zusätzlicher Erreger (69,4%). Bei 34 Patienten wurdeStreptococcus pneumoniae isoliert (54,8%). Patienten mit einerC. pneumoniae-Infektion waren signifikant älter als Patienten, bei denenC. pneumoniae nicht der Erreger war (p=0,03), diese Patienten hatten außerdem bei Einweisung einen höheren APACHE Score (p<0,05), häufiger positive Blutkulturen (p=0,02) und mußten länger stationär behandelt werden (p=0,022). Obwohl keine erregerspezifische Behandlung vorgenommen worden war, erholten sich 7 Patienten, die an einerC. pneumoniae Pneumonie erkrankt waren. Wir schließen aus den Daten, daßC. pneumoniae in unserer Region ein häufiger Pneumonieerreger ist, der vorwiegend ältere Personen befällt. Typischerweise besteht eine hohe Rate an Begleitinfektionen mit anderen Pneumonieerregern. Wir fanden kein spezifisches radiologisches Muster oder klinische Konstellationen, die eine Unterscheidung zwischenC. pneumoniae-Pneumonie und Pneumonien anderer Ätiologie ermöglichen würden.

Urinary Tract Infections Caused by Multi-Drug Resistant Proteus mirabilis: Risk Factors and Clinical Outcomes

Background:Proteus mirabilis (PM) as well as other membersof the Enterobacteriaceae family are a leading cause ofinfectious diseases in both the community and acute caresettings. The prevalence of multi-drug resistant (MDR) bacterialisolates have increased in the last few years, affectingthe prognosis and survival of hospitalized patients. The aimof our study was to determine the risk factors and clinicaloutcomes of urinary tract infections (UTIs) caused by MDR PMin patients hospitalized in our institution.Methods:This was a retrospective matched case-controlstudy. Records of patients with PM-positive urine culturewere reviewed, and data were included for analysis.Results:Univariate analysis revealed that the variablessignificantly associated with acquisition of MDR PM vs non-MDR PM UTI were younger age ([in years] median 77.5,range 20–94 vs median 78, range 40–94, p = 0.04), otherconcomitant infectious diseases (57.1 vs 35.7%, p = 0.037),number of prior infectious diseases (mean 0.95 ± 0.99 vs0.57 ± 0.85, p = 0.035), diagnosis of infection at hospitaladmission (67.9 vs 42.9%, p = 0.008), and prior therapywith antipseudomonal penicillin (17.9 vs 1.8%, p = 0.004),respectively. Mean length of hospitalization was 29.95 daysfor the MDR group and 30.04 days for the non-MDR group(p = non-significant [NS]). The crude mortality rate followinghospital admission was 19/56 (33.9%) vs 14 (25%)in the MDR PM and non-MDR PM groups, respectively(p = 0.300, odds ratio [OR] 1.54, 95% confidence interval[CI] 0.63–3.82). The production of extended-spectrum betalactamases(ESBL) was found in 100% of MDR-PM vs 31.5%of non-MDR-PM urine isolates (p < 0.001). All variablesfound to be significantly associated with MDR-PM UTI wereincluded in a logistic regression model. Independent riskfactors for MDR-PM UTI were empiric cephalosporin therapy(OR 4.694, 95% CI 1.76–12.516, p = 0.002) and prior antipseudomonalpenicillin (piperacillin/tazobactam) therapyduring the last year (OR 11.175, 95% CI 1.09–114.2,p = 0.04).Conclusions:Prior piperacillin/tazobactam and empiriccephalosporin use were the independent risk factors ofMDR-PM strains. All MDR-PM urinary isolates at our institutionwere ESBL producers. Therefore, carbapenem useremains the only available treatment option for MDR-PMisolates in our institution.

Fatal Clostridium sordellii ischio-rectal abscess with septicaemia complicating ultrasound-guided transrectal prostate biopsy

Clostridium sordellii is a Gram-positive spore-forming anaerobic bacillus rarely encountered in human infection. A case of C. sordellii ischio-rectal abscess with rapidly fatal septicaemia is described which complicated ultrasound-guided transrectal biopsy of the prostate, despite ciprofloxacin prophylaxis. Neither C. sordellii ischio-rectal abscess nor ischio-rectal abscess complicating transrectal biopsy have been reported previously. Judging from our experience and the reviewed literature, the addition of prophylactic anti-anaerobe drugs should be strongly considered until an optimal prophylactic regimen will be defined by randomized controlled trials.

IL-1β and IL-6 in community-acquired pneumonia: Bacteremic pneumococcal pneumonia versusMycoplasma pneumoniae pneumonia

Interleukin-1β (IL-1β) and interleukin-6 (IL-6) levels in 20 patients with bacteremicStreptococcus pneumoniae community-acquired pneumonia (CAP) were compared with these cytokine levels in 20 patients withMycoplasma pneumoniae CAP. All 40 patients survived hospitalization and underwent a follow-up examination one month later. Serum IL-1β and IL-6 levels were determined by the enzyme immunoassay (EIA) method using commercial kits. In the acute phase of CAP, IL-6 levels were significantly higher in theS. pneumoniae group (p=0.014), while IL-1β levels were higher in theM. pneumoniae group (p=0.046). In the convalescence phase, the two cytokines were detected in a considerable number of patients in both groups. In this phase, only the level of IL-1β was significantly higher in theM. pneumoniae group than in theS. pneumoniae group (p=0.03). We conclude that the levels of IL-1β and IL-6 are different between patients withS. pneumoniae-CAP andM. pneumoniae-CAP during the acute phase. In the convalescence phase, cytokine levels remain high in some of the CAP patients, but a significant difference between the groups exists only for IL-1β. Further studies are required.SummaryInterleukin-1β (IL-1β) and interleukin-6 (IL-6) levels in 20 patients with bacteremicStreptococcus pneumoniae community-acquired pneumonia (CAP) were compared with these cytokine levels in 20 patients withMycoplasma pneumoniae CAP. All 40 patients survived hospitalization and underwent a follow-up examination one month later. Serum IL-1β and IL-6 levels were determined by the enzyme immunoassay (EIA) method using commercial kits. In the acute phase of CAP, IL-6 levels were significantly higher in theS. pneumoniae group (p=0.014), while IL-1β levels were higher in theM. pneumoniae group (p=0.046). In the convalescence phase, the two cytokines were detected in a considerable number of patients in both groups. In this phase, only the level of IL-1β was significantly higher in theM. pneumoniae group than in theS. pneumoniae group (p=0.03). We conclude that the levels of IL-1β and IL-6 are different between patients withS. pneumoniae-CAP andM. pneumoniae-CAP during the acute phase. In the convalescence phase, cytokine levels remain high in some of the CAP patients, but a significant difference between the groups exists only for IL-1β. Further studies are required.

Enterococcus hirae septicemia in a patient with end-stage renal disease undergoing hemodialysis.

Enterococcus hirae, member of theEnterococcus genus known to cause infection in animals, is rarely encountered in clinical practice. There are no published reports describing clinical features ofEnterococcus hirae infection in humans. A case ofEnterococcus hirae septicemia in a 49-year-old patient with end-stage renal disease undergoing hemodialysis is reported here. A review of the available literature regarding the clinical spectrum ofEnterococcus hirae infection in humans and the antimicrobial susceptibility ofEnterococcus hirae is also included.

Appropriateness of Hospitalization of Patients With Community-Acquired Pneumonia

STUDY OBJECTIVE To investigate the association between the appropriateness of hospitalization and the course of hospitalization in patients with community-acquired pneumonia (CAP). METHODS We carried out a prospective study of 346 adult patients hospitalized with community-acquired pneumonia (CAP). Appropriateness of hospitalization was assessed with a modified appropriateness evaluation protocol (AEP) based on vital signs and laboratory tests. Hospitalizations that ended in death, lasted more than 4 days, or involved resuscitation, incubation, monitoring, or supplemental oxygen therapy were considered complicated. RESULTS According the AEP protocol, hospitalization was not appropriate for 210 of the 346 patients (61%). However, AEP proved to be an insensitive tool for the identification of patients with complicated hospital courses. Half of the 346 patients had complicated courses, including 82 of the 210 patients with inappropriate hospitalization (39%), according to the AEP. Four independent factors, age greater than 50 years, female sex, no antibiotic treatment before hospitalization, and more than 4 days of illness before admission predicted a complicated course in patients with inappropriate hospitalization as determined with the AEP criteria. CONCLUSION It is important to avoid the unnecessary hospitalization of patients with CAP. However, this should not be achieved at the expense of unjustified discharge from the emergency department. In the decision to hospitalize, additional prognostic factors, such as those presented here, should be taken into consideration to improve the admission process. This is particularly relevant for cases in which the AEP is invalid and indications for hospitalization are not clear cut. In these patients, a simpler and more precise scoring system should be developed.

Q-fever pneumonia in the Negev Region of Israel: A review of 20 patients hospitalised over a period of one year

BACKGROUND Three-hundred and forty-six patients with community acquired pneumonia were included in a prospective study of patients hospitalised over a 12-month period in the Soroka Medical Center in Beer-Sheva, Israel. Q-fever pneumonia (QFP) was diagnosed in 20 patients (5.8%). A detailed epidemiological and clinical description of this disease, is presented. METHODS QFP was diagnosed by conventional criteria using a commercial immunofluorescent assay. RESULTS The age of patients was 41 +/- 14 years (mean +/- S.D., range 20-69). Twelve of the patients were males. No concomitant or chronic disease was present in 16 patients. Chest radiograms revealed alveolar or air space pneumonia in 10 patients, bronchopneumonia in nine and interstitial pneumonia in one patient. The mean febrile period was 10.5 +/- 5.3 days. There was serological evidence of co-infection with Mycoplasma pneumonia in six patients, and with Legionella pneumophila in one patient. Patients treated with beta-lactam antibiotics recovered as quickly as those treated with tetracyclines or erythromycin. CONCLUSIONS The Negev region of Israel is an endemic area for Q-fever. The diagnosis of QFP can be made only on the basis of a specific serological test. Clinical, radiologic or laboratory findings are not diagnostically definitive. The importance of specific therapy is unclear.

Infective endocarditis due to Fusobacterium nucleatum in an intravenous drug abuser.

Abstract Infective endocarditis due to anaerobic non-spore-forming gram-negative bacilli in intravenous drug abusers is exceedingly rare, with only two cases being previously reported in the literature. A case of endocarditis due to Fusobacterium nucleatum in an intravenous drug abuser is reported, accompanied by a review of the literature.