Matan J. Cohen

Vancomycin-resistant enterococci in long-term care facilities.

Knowledge of the prevalence rates and associated risk markers of vancomycin-resistant enterococci (VRE) colonization among long-term care facility (LTCF) residents could be used to improve screening policies among newly admitted hospital inpatients. In a cross-sectional survey among 1,215 residents of LTCFs in Jerusalem, the VRE carriage rate was 9.6%. Previous hospitalization and antibiotic treatment were associated with elevated VRE colonization rate. In contrast, moderate and severe levels of dependency and prolonged stay in an LTCF were associated with a decrease in the VRE colonization rate.

Institutional Control Measures to Curtail the Epidemic Spread of Carbapenem-Resistant Klebsiella pneumoniae: A 4-Year Perspective

OBJECTIVEnTo describe the implementation of an institution-wide, multiple-step intervention to curtail the epidemic spread of carbapenem-resistant Klebsiella pneumoniae (CRKP).nnnDESIGNnConsecutive intervention analyses.nnnPATIENTS AND SETTINGnAll patients admitted to a 775-bed tertiary care medical center in Jerusalem, Israel, from 2006 through 2010.nnnINTERVENTIONSnThe effects of 4 interventions were assessed: (1) a policy of isolation for patients colonized or infected with CRKP in single rooms, which was started in March 2006; (2) cohorting of CRKP patients with dedicated nursing staff and screening of patients neighboring a patient newly identified as a carrier of CRKP, which was started in March 2007; (3) weekly active surveillance of intensive care unit patients, which was started during August 2008; and (4) selective surveillance of patients admitted to the emergency department, which was started in March 2009. Interrupted regression analysis and change-point analysis were used to assess the effect of each intervention on the CRKP epidemic.nnnRESULTSnPatient isolation alone failed to control the spread of CRKP, with incidence increasing to a peak of 30 new cases per 1,000 hospital beds per month. Institution of patient cohorting led to a steep decline in the incidence of CRKP acquisition (P < .001). Introduction of active surveillance interventions was followed by a decrease in the incidence of CRKP-positive clinical cultures but an increase in the incidence of CRKP-positive screening cultures. The mean prevalence of CRKP positivity for the period after cohorting began showed a statistically significant change from the mean prevalence in the preceding period (P < .001).nnnCONCLUSIONSnThe cohorting of patients with dedicated staff, combined with implementation of focused active surveillance, effectively terminated the epidemic spread of CRKP. Cohorting reduced cross-infection within the hospital, and active surveillance allowed for earlier detection of carrier status. Both interventions should be considered in attempts to contain a hospital epidemic.

Antibiotic prophylaxis for spontaneous bacterial peritonitis in cirrhotic patients with ascites, without gastro‐intestinal bleeding

BACKGROUNDnSpontaneous bacterial peritonitis is frequent among cirrhotic patients, associated with significant morbidity and mortality. Selective intestinal decontamination employing antibiotics is a proposed prophylactic measure. While data regarding this modality among cirrhotic patients with gastrointestinal bleeding exist, there is insufficient data synthesis regarding cirrhotic patients with ascites and no gastrointestinal bleeding.nnnOBJECTIVESnTo assess whether antibiotic prophylaxis decreases spontaneous bacterial peritonitis and mortality among cirrhotic patients with ascites and no gastrointestinal bleeding.nnnSEARCH STRATEGYnWe identified relevant randomised trials by searching trial registries of The Cochrane Hepato-Biliary Group and The Cochrane Collaboration, medical literature search engines, and reviewing all literature we found on the topic until February 2009.nnnSELECTION CRITERIAnWe searched for randomised clinical trials assessing prophylactic treatment among adult cirrhotic patients with ascites and no gastrointestinal bleeding, comparing antibiotic therapy with no intervention, placebo, or with another antibiotic regimen.nnnDATA COLLECTION AND ANALYSISnThree independent authors searched for and collected the trials and extracted relevant data. Four other independent authors validated the findings and assessed them. The studies were assessed for design, patient and intervention characteristics, and quality. A meta-analysis was performed to estimate measures of association between antibiotic prophylaxis and spontaneous bacterial peritonitis or mortality.nnnMAIN RESULTSnNine trials were included in the review. Seven trials, comparing antibiotics to placebo or no treatment, were meta-analysed. Systematic bias in design or publication is suggested by trial results. The randomisation results suggest that the probability that true randomisation took place in all trials is very small and the report of most trials regarding design was poor. The proportion of participants with spontaneous bacterial peritonitis varied between the trials from 15% to 50%. The calculated relative risks (95% confidence interval) of spontaneous bacterial peritonitis and mortality among patients treated with antibiotics compared with no treatment/placebo were 0.20 (0.11 to 0.37) and 0.61 (0.43 to 0.87). There were very few reports of adverse events.nnnAUTHORS CONCLUSIONSnThe pooled estimates suggest that antibiotic prophylaxis might be prudent among cirrhotic patients with ascites and no gastrointestinal bleeding. However, poor trial methodology and report coupled with findings suggesting systematic bias in publication and design reflect the fragility of these findings. Potential hazard to society and the patients themselves from resistant pathogens should be considered when promoting long-lasting antibiotic prophylaxis. It seems that recommending antibiotic prophylaxis is still far from being a substantiated prevention strategy. Trials of better design, well reported, and of longer follow-up are greatly needed.

Continuous surveillance to reduce extended-spectrum β-lactamase Klebsiella pneumoniae colonization in the neonatal intensive care unit.

Background: Clinical illness caused by resistant bacteria usually represents a wider problem of asymptomatic colonization. Active surveillance with appropriate institution of isolation precautions represents a potential mechanism to control colonization and reduce infection. The neonatal intensive care unit (NICU) is an environment particularly appropriate for such interventions. Neonates are rarely colonized by resistant bacteria on admission and staff enthusiasm for infection control is high. Objective: To reduce extended-spectrum β-lactamase-producing Klebsiella pneumoniae (ESBL-KP) acquisition amongst neonates through a continuous active surveillance intervention. Methods: Fecal ESBL-KP cultures were performed weekly on all neonates over 4 years. Neonates with positive cultures were managed with contact precautions by dedicated nurses separately from other neonates. ESBL-KP acquisition amongst neonates staying >7 days was compared for the consecutive years. A subset of ESBL-KP isolates was typed with pulsed-field gel electrophoresis (PFGE). Results: Surveillance cultures were obtained from 1,482/1,763 (84%) neonates over 4 years. ESBL-KP acquisition decreased continuously from 94/397 (24%) neonates in 2006 to 33/304 (11%) in 2009 (p < 0.001, hazard ratio 0.75, 95% confidence interval 0.66–0.85, p < 0.001 for comparison of years). Hospital-wide ESBL-KP acquisition did not decrease outside the NICU. PFGE identified identical ESBL-KP strains from multiple neonates on six occasions and different strains from single neonates on seven occasions. Conclusions: ESBL-KP is probably both imported into and spread within the NICU. Continuous long-term surveillance with cohorting was associated with a decrease in ESBL-KP acquisition within the NICU. This low-risk intervention should be considered as a means to decrease neonatal acquisition of resistant bacteria.

Insoles for prevention and treatment of back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group.

Study Design. A systematic review of randomized controlled trials. Objective. To determine the effectiveness of shoe insoles in the prevention and treatment of nonspecific back pain compared with placebo, no intervention, or other interventions. Summary of Background Data. There is lack of theoretical and clinical knowledge of the use of insoles for prevention or treatment of back pain. Methods. We searched electronic databases from inception to October 2008. We reviewed reference lists in review articles, guidelines, and in the included trials; conducted citation tracking; and contacted individuals with expertise in this domain. One review author conducted the searches and blinded the retrieved references for authors, institution, and journal. Two review authors independently selected the relevant articles. Two different review authors independently assessed the methodological quality and clinical relevance and extracted the data from each trial using the criteria recommended by the Cochrane Back Review Group. Results. Six randomized controlled trials met inclusion criteria: 3 examined prevention of back pain (2061 participants) and 3 examined mixed populations (256 participants) without being clear whether they were aimed at primary or secondary prevention or treatment. No treatment trials were found. There is strong evidence that the use of insoles does not prevent back pain. There is limited evidence that insoles alleviate back pain or adversely shift the pain to the lower extremities. Conclusion. There is strong evidence that insoles are not effective for the prevention of back pain. The currentevidence on insoles as treatment for low back pain does not allow any conclusions.

Delayed fecal incontinence following surgery for anal fissure

PurposeThe surgical treatment of chronic anal fissure is basically done by therapeutic controlled damage to the internal anal sphincter. While fecal incontinence is a well-documented early complication of anal fissure surgery, few data are available about delayed incontinence. The aim of the present study was to assess whether surgical treatment of anal fissures may contribute to the development of delayed anal incontinence.MethodsA retrospective review of patients referred to the Pelvic Floor Laboratory for physiological evaluation of anal incontinence between 1992 and 2009. All patients, diagnosed with anal fissures, who underwent anal dilatation or partial lateral internal sphincterotomy and developed incontinence at least 4xa0years after the surgery were included. Controls were patients with delayed anal incontinence after obstetric injury.ResultsA total of 21 patients with delayed post-anal fissure surgery incontinence (nine women and 12 men) were identified. The mean (SE) age of incontinence onset in this group of patients was 51.5 (±2), which was 8xa0years younger than the rest of the 363 incontinent patients (pu2009<u20090.001). Time from presumed anal sphincter damage to the onset of incontinence was significantly shorter in the group of past anal-fissure-surgery patients compared to post-obstetric trauma patients (mean difference 15xa0years, pu2009<u20090.001). The severity of incontinence was higher in post-obstetric trauma patients.ConclusionsFecal incontinence may present as a late complication of anal fissure surgery. Incontinence may be associated with other cofactors accumulating over time or, more likely, anal fissure surgery may accelerate the physiologic age-related weakening of the anal sphincter mechanism. Candidates for anal fissure surgery should be informed regarding this possible outcome.

Uterine abnormalities and embryo implantation: clinical opinion altered by peer debate.

Medical professionals often hold different views on patient treatment. This study assessed the degree to which these views differ and the degree to which these opinions changed following peer debate. The authors used an audience response system at an Israeli Fertility Association symposium. Clinical cases in the field of reproductive surgery were presented and the favoured management approach was recorded from each participant before and after holding peer debates. The cases presented were: endometrial assessment prior to artificial reproductive treatment, the management of thin endometrium, endometrial septum, intramural fibroid and hydrosalpinx. All audience responses were analysed. There was variability in answers in all five clinical scenarios. Before and after debates, the proportions of physicians preferring referral to prophylactic surgery due to endometrial septum, intramural fibroid and hydrosalpinx were 61% versus 59%, 12% versus 10% and 41% versus 37%, respectively. While these overall proportions remained similar, significantly more clinicians changed their approach regarding septum and hydrosalpinx management, compared with fibroid management (18%, 18% and 8% respectively, P = 0.03). Medical professionals are likely to change their approach in some clinical cases more than others. It is postulated that treatment risk and lack of good evidence account for these differences.

Vitamin D levels, vitamin D supplementation, and prognosis in patients with chronic kidney disease .

BACKGROUNDnVitamin D (Vit D) deficiency plays a central role in the pathogenesis of chronic kidney disease (CKD) complications, both skeletal and nonskeletal. The purpose of this study was to examine whether 25(OH)D levels and supplementation with oral cholecalciferol (Vitamin D3 (Vit D3)) are associated with morbidity and mortality among patients with significant CKD.nnnMETHODSnCKD patients attending the nephrology clinic at Shaare Zedek Medical Center between July 1, 2008 and January 31, 2012, tested at least twice for 25(OH)D levels, were enrolled. Primary endpoints included death, end-stage renal disease (ESRD) requiring start of dialysis, a rise of at least 50% in serum creatinine, or composite endpoints of the above.nnnRESULTSnA total of 516 patients were studied, of whom 178, 257, and 81 patients had baseline vitamin D levels <xa05xa0ng/mL, 15 - 30xa0ng/mL, and >xa030xa0ng/mL, respectively. We found an association between baseline 25(OH)D level below 15xa0ng/mL and renal outcomes (start of dialysis or a rise of at least 50% in serum creatinine) in both crude and multivariate analyses (hazard ratio (HR) 3.17, 95% CI 1.12 - 8.94). Vit D3 supplementation demonstrated beneficial effects on combined renal outcomes and death in univariate analyses (pxa0=xa00.02). Moreover, an increment of 10xa0ng/mL in 25(OH)D levels was associated with a 25% reduction in mortality (HR 0.755 (95% CI 0.54xa0-xa01.00), in crude but not adjusted analyses.nnnCONCLUSIONSnSignificant Vit D deficiency in CKD can serve as a biological marker indicating patients in whom adverse renal outcomes can be anticipated. Moreover, Vit D3 supplementation and rise of serum 25(OH)D levels may have beneficial influence on hard renal outcomes.u2029.

A Practical Tool for Surveillance of Surgical-Site Infections: A 5-Year Experience in Orthopedic Surgeries

Continuous surveillance of surgical-site infection (SSI) is labor intensive. We developed a semiautomatic surveillance system partly assisted by surgeons. Most patients who developed postdischarge SSI were readmitted, which allowed us to limit postdischarge surveillance to this group. This procedure significantly reduced workload while maintaining high sensitivity and specificity for SSI diagnosis. Infect Control Hosp Epidemiol 2017;38:610-613.

The Incidence and Prognosis of Renal Dysfunction following Cardioversion of Atrial Fibrillation

Objective: Limited data are available regarding the incidence and clinical impact of renal dysfunction following cardioversion of atrial fibrillation. The objective of this study was to assess the incidence and implications of renal dysfunction following cardioversion of atrial fibrillation. Methods: We conducted a nested case-control study to determine the incidence, timing, risk factors and outcome of atrial fibrillation cardioversion associated with renal dysfunction (AFCARD) in a tertiary medical center. Consecutive patients undergoing direct current cardioversion (DCCV) for atrial fibrillation in our institution during 2008-2009 with measurements of creatinine before and following cardioversion were included. AFCARD was defined as a rise in serum creatinine greater than 25% from baseline within a week following DCCV. Results: One hundred and twelve patients were included in the study, of whom 19 (17%) developed AFCARD. One patient required hemodialysis. Patients with AFCARD had a higher incidence of advanced heart failure, diabetes mellitus and were more frequently treated with digoxin and enoxaparin. Patients with AFCARD had a significantly decreased survival rate at 1 year (63 vs. 92%; p < 0.001). Conclusions: AFCARD is relatively common and is associated with increased mortality. These findings suggest a role for close surveillance of renal function following DCCV.