Orna Nitzan

Antimicrobial susceptibility of Clostridium difficile isolates in Israel

OBJECTIVES An increase of Clostridium difficile isolates with reduced susceptibility to various antimicrobial agents has been observed, including isolates that are non-susceptible to antibiotics that are routinely used for treatment of C. difficile, such as vancomycin and metronidazole. We determined the susceptibility rates of C. difficile isolates from hospitals in northern Israel to various antibiotics including tigecycline, which was not previously reported from Israel. METHODS A total of 81 stool samples were collected from three hospitals in northern Israel from patients with C. difficile infection. Specimens were screened for BI/NAP1/027 ribotype, cultured, and sensitivity tests were performed for vancomycin, metronidazole, moxifloxacin, and tigecycline. Statistical tests were applied for analysing the differences in distribution of resistance between the different antibiotics and between BI/NAP1/027 and resistance of antibiotics. RESULTS Reduced susceptibility was found among 6/81 isolates for vancomycin, 4/81 for metronidazole, and 17/81 for moxifloxacin. Only 1 isolate had reduced susceptibility to tigecycline, with a mean MIC of 0.05μg/mL. Reduced susceptibility to moxifloxacin was significantly associated with reduced susceptibility to vancomycin (p=0.016) and to metronidazole (p=0.0276), and reduced susceptibility to metronidazole was associated with reduced susceptibility to vancomycin (p=0.0259). Eight of 81 isolates (9.9%) were positive for BI/NAP1/027 ribotype and had significantly higher non-susceptibility rates to moxifloxacin and vancomycin compared with BI/NAP1/027 negative isolates (p<0.0001 and p=0.0113, respectively). CONCLUSIONS We found higher non-susceptibility rates to vancomycin and metronidazole than most previous studies, while tigecycline resistance rates are very low in northern Israel, rendering it a potential agent for treating CDI.

Clostridium difficile infection: Associations with chemotherapy, radiation therapy, and targeting therapy treatments

BACKGROUND Although mucositis, diarrhea, and constipation as well as immunosuppression are well recognized side-effects of cancer treatment, the underlying mechanisms including changes in the composition of gut microbiota and Clostridium difficile infection have not yet been thoroughly reviewed. OBJECTIVE We herein set out to review the literature regarding the relations between cancer chemotherapy, radiation treatment, and Clostridium difficile-associated colitis. METHOD Review of the English language literature published from 2008 to 2015 on the association between cancer chemotherapy, radiation treatment, and C. difficile-associated colitis. RESULTS Certain chemotherapeutic combinations, mainly those containing paclitaxel, are more likely to be followed by C. difficile infection (CDI), while some tumor types are more likely to be complicated by CDI following chemotherapy. CDI following irradiation occurs mostly in patients who were treated for cancer in the head and neck area. Risk factors found were proton pump inhibitors, antibiotics, cytostatic agents, and tube feeding. The drug of choice for an initial episode of mild-to-moderate CDI is metronidazole, whereas vancomycin is reserved for an initial episode of severe CDI. Fidaxomycin is another option for treatment of severe CDI, with fewer recurrences. CONCLUSION The influence of CDI on the treatment of oncological patients is not fully acknowledged. Infection with C. difficile is more frequent in those patients treated by antibiotics simultaneously with chemotherapy. Aggressive supportive care with intravenous hydration, antibiotics, and close surgical monitoring for selective intervention can significantly decrease the morbidity and life-threatening complications associated with this infection.

Case Report: Infectious Diseases in Pilgrims Visiting the Holy Land

Every year Christian pilgrims from around the world visit the holy sites located around the Sea of Galilee. Some become ill during their stay with infectious diseases that were acquired in their country of origin, and are hospitalized at Poriya Medical Center. They pose a diagnostic challenge due to language barriers, the rarity of these infections in Israel, and the fact that diagnostic tests are not readily available. All patient records from 2015 of Holy Land tourists hospitalized at Poriya Medical Center were screened for the diagnosis of imported zoonotic diseases that are not commonly diagnosed in Israel. Three patients who were on a Holy Land tour were hospitalized during 2015 with laboratory-confirmed diagnostically challenging zoonotic infectious diseases: a 91-year-old priest from Ethiopia diagnosed with relapsing fever due to Borrelia recurrentis, an 85-year-old retired mountaineer from New Hampshire diagnosed with human granulocytic anaplasmosis, and a 57-year-old farmer from central Brazil diagnosed with leptospirosis. These case reports emphasize the importance of considering imported zoonotic infectious diseases and obtaining appropriate diagnostic tests when treating Holy Land travelers to Israel.

A comparison of enriched culture and Xpert polymerase chain reaction assay of Group B streptococcus carrier status at 35–37-week gestation to labor onset: a prospective controlled study

Abstract Objectives: (1) To compare the accuracy of vagino-rectal enriched culture (EC) and a rapid polymerase chain reaction (PCR) test for the detection of Group B streptococcus (GBS) carrier status at 35–37-week gestation and at onset of labor. (2) To assess the conversion rate of GBS carrier status between 35–37 weeks to the onset of labor according to the EC/PCR tests. A prospective study was performed at a women’s health clinic, referred to give birth at one medical center. Study population: Low risk pregnant women at 35–37-week gestation who did not know their GBS carrier status. Methods: Participants were evaluated for GBS status both at 35–37 weeks and at labor onset. Correlation between tests was calculated by Spearman correlation. Results: One hundred and ten specimens were analyzed. Correlations: EC-PCR: 35–37 weeks – very high (r = 0.8), at labor – high (r = 0.5). EC-EC: 35–37 weeks and at labor – high (r = 0.39); PCR-PCR: 35–37 weeks and at labor- high (r = 0.7). Conclusions: Both the EC and Xpert PCR tests are accurate for detecting GBS carrier, both at 35–37 weeks and at labor onset. We did not detect a significant conversion of the GBS status from negative at 35–37 weeks to positive at onset of labor.

In Vitro Activity of Tedizolid, Dalbavancin, and Ceftobiprole Against Clostridium difficile.

Background: Clostridium difficile (C. difficile) is a major nosocomial pathogen that colonizes in the human gut. Recently, the U.S. FDA approved three new antimicrobial agents against gram-positive bacteria: Tedizolid, Dalbavancin, and Ceftobiprole. The efficacy of these antibiotics for treatment of C. difficile infection has not been thoroughly examined. The current study aimed to examine the in vitro activity of these antibiotics against C. difficile. In addition, to compare between Dalbavancin and Ceftobiprole to antibiotics from the same class: Vancomycin and Ceftriaxone, respectively. Methods: Eighty-four C. difficile isolates were tested for susceptibility to Tedizolid, Dalbavancin, Ceftobiprole, Vancomycin, and Ceftriaxone by Etest technique in order to determine the minimum inhibitory concentration (MIC). Results: Upon comparison of the novel antibiotic agents, Dalbavancin demonstrated the lowest MIC values and ceftobiprole the highest at MIC50 (0.016, 0.38, and 1.5 μg/mL, for Dalbavancin, Tedizolid, and Ceftobiprole, respectively) and MIC90 (0.03, 0.78, and 3.17 μg/mL, respectively). Dalbavancin demonstrated significantly lower MIC50 and MIC90 values compared to Vancomycin (0.016 vs. 0.38 and 0.03 vs. 3.5, respectively) (p < 0.001) and ceftobiprole had significantly lower MIC values compare to ceftriaxone (1.5 vs. 32 and 3.17 vs. 28.8, respectively) (p < 0.001). Conclusion: Dalbavancin and Tedizolid may play a role as potential therapeutic agents for treatment of C. difficile infection. Examination of antibiotic effect on the intestinal microbiome and clinical trials are needed for more accurate results.

Infectious disease burden and antibiotic prescribing in primary care in Israel

BackgroundAntibiotics are frequently prescribed at many of the visits to primary care clinics, often for conditions for which they provide no benefit, including viral respiratory tract infections.ObjectivesThe aim was to evaluate primary care visits due to infectious diseases, and to estimate antibiotic prescribing and antibiotic dispensing by pharmacies.MethodsDiagnosis of infectious disease, antibiotic prescribing and dispensing data at the individual patient level were extracted for 2015 from Clalit Health Services’ electronic medical records and linked to determine the condition for which the antimicrobial was prescribed.ResultsThere were 6.6 million visits due to infections, representing 22% of all primary care visits. The most common events were upper respiratory tract infections (38%) and pharyngitis (10%). Highest prescription rates were for urinary tract infections (80%), otitis media (64%), pharyngitis (71%), sinusitis (63%), and lower respiratory tract infections (76%). The highest rates of undispensed prescriptions were for acute gastroenteritis, urinary tract infections, and pharyngitis (24, 23, and 16%, respectively).ConclusionsInfectious diseases constitute a heavy burden on primary care, with overprescribing of antibiotics. Intervention to reduce unwarranted antibiotic use is needed. In pediatric care, interventions should focus on better controlling antibiotic consumption and encouraging adherence to guidelines for upper respiratory tract infections, pharyngitis, and otitis media. In adults interventions should aim to monitor antibiotic prescribing for upper respiratory tract infections and improve adherence to guidelines for urinary tract infections.

Tinea capitis-like infection caused by Rhodotorula mucilaginosa in a shelter for African Refugee Children in Northern Israel

Rhodotorula is a genus of unicellular pigmented yeasts, part of the division Basidiomycota. In this article, we report three cases of refugee children in a day care shelter in northern Israel who were clinically diagnosed and treated empirically as with ringworm infection but with clean and exclusive growth of Rhodotorula mucilaginosa in repeated cultures of several skin samples. Skin infections caused by this yeast are rare and there are few reports in the literature, mainly in patients who are immunocompromised. Here we report an infectious process of the scalp in immunocompetent children, caused by Rhodotorula mucilaginosa mimicking tinea capitis.

Role of Single Procalcitonin Test on Admission as a Biomarker for Predicting the Severity of Clostridium difficile Infection

Objective: To evaluate whether serum Procalcitonin (PCT) at the early stage of infection can serve as a potential biomarker for determining Clostridium difficile infection (CDI) severity. Methods: Fifty-four patients diagnosed with CDI were enrolled in the study. Serum samples were obtained within a median time of 24–48 h of the lab result for presence of C. difficile. PCT levels were measured by chemiluminescence immunoassay. Demographic, clinical, and prognostic data concerning the patients were retrospectively collected from medical records. The illness severity score was determined according to “Score indices for C. difficile infection severity.” Results: We found that serum PCT levels were significantly higher in patients with moderate disease, compared to patients with mild disease (p = 0.0032). Additionally, PCT was correlated with mortality (p = 0.0002), white blood cell count (p = 0.019), and community-acquired disease (p = 0.0345). Conclusion: Early measurement of PCT may serve as a biomarker for early prediction of CDI severity, which is of great importance due to the high risk of complications and death.

Destruction of Clostridium difficile spores colitis using acidic electrolyzed water

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Is One Colony Enough

Carbapenem-resistant enterobacteriaceae (CRE) have emerged as important health care-associated pathogens that cause significant morbidity and mortality ([1][1]). CRE with carbapenemase production (CP-CRE) possess a more stable and transferable resistance mechanism. Detection of CP-CRE is performed