Ruth Lang

Listeria monocytogenes infection in Israel and review of cases worldwide.

Listeria monocytogenes, an uncommon foodborne pathogen, is increasingly recognized as a cause of life-threatening disease. A marked increase in reported cases of listeriosis during 1998 motivated a retrospective nationwide survey of the infection in Israel. From 1995 to 1999, 161 cases were identified; 70 (43%) were perinatal infections, with a fetal mortality rate of 45%. Most (74%) of the 91 nonperinatal infections involved immunocompromised patients with malignancies, chronic liver disease, chronic renal failure, or diabetes mellitus. The common clinical syndromes in these patients were primary bacteremia (47%) and meningitis (28%). The crude case-fatality rate in this group was 38%, with a higher death rate in immunocompromised patients.

Impaired bacteriologic response to oral cephalosporins in acute otitis media caused by pneumococci with intermediate resistance to penicillin.

BACKGROUND Penicillin resistance of Streptococcus pneumoniae, one of the most common causes of acute otitis media, has recently increased and is now highly prevalent in many regions. However, its contribution to clinical failure still must be proved. Because the role of antibiotics in acute otitis media is to eradicate the pathogens present in the middle ear fluid, we conducted a randomized controlled study to determine bacterial eradication of pathogens in acute otitis media by two commonly used oral cephalosporins, cefuroxime axetil (30 mg/kg/day) and cefaclor (40 mg/kg/day). METHODS Patients 6 to 36 months old with pneumococcal otitis media seen in the Pediatrics Emergency Room were studied. An initial middle ear fluid culture was obtained at enrollment, and a second culture was obtained on Day 4 or 5 during treatment. Follow-up was done also on Days 10, 17 and 42 after initiation of treatment. In cases of clinical relapse a third culture was obtained. RESULTS In total 78 patients were enrolled, 41 in the cefuroxime axetil group and 37 in the cefaclor group. Of the 78 S. pneumoniae isolates 31 (40%) were intermediately penicillin-resistant (MIC 0.125 to 1.0 microgram/ml). Of the 47 patients with penicillin-susceptible organisms 3 (6%) had bacteriologic failure vs. 4 of 19 (21%) and 7 of 11 (64%) of those with MIC of 0.125 to 0.25 microgram/ml and 0.38 to 1.0 microgram/ml, respectively (P < 0.001). For intermediately resistant pneumococci, in 7 of 12 (58%) of those receiving cefaclor the isolate was not eradicated vs. only 4 of 19 (21%) of those receiving cefuroxime axetil (P = 0.084). MIC to the administered cephalosporin of > 0.5 microgram/ml was associated with bacteriologic failure. Clinical failure was observed in 9 of 14 (64%) patients with bacteriologic failure vs. 10 of 52 (19%) patients with bacteriologic eradication (P = 0.003). CONCLUSION Intermediately penicillin-resistant S. pneumoniae is associated with an impaired bacteriologic and clinical response of acute otitis media to cefaclor and cefuroxime axetil. This effect was more pronounced with cefaclor than with cefuroxime axetil.

Angiotensin-Converting Enzyme Inhibitors and Cough: A Prospective Evaluation in Hypertension and in Congestive Heart Failure

Angiotensin‐converting enzyme inhibitors (ACE‐I) have become the mainstem of antihypertensive therapy and first‐choice agents for vasodilatation in congestive heart failure (CHF). A typical dry cough is the main cause for discontinuation of ACE‐I therapy. Data about the incidence, course, and clinical significance of this side effect are conflicting. This study determined the incidence of cough in ACE‐I treated patients with hypertension and with CHF and to appreciate its clinical significance; 268 ACE‐I treated patients, 164 with hypertension and 104 with CHF were prospectively followed for at least 1 year and specifically questioned about cough and other side effects. In those in whom cough developed, a second and then a third ACE‐I were tried. Cough developed in 50 (18.6%) of the 268 patients; 23 patients with hypertension (14%) had coughs 24.7 ± 17.1 (SD) weeks after initiation of therapy; 27 patients with CHF (26%) had coughs 12.3 ± 12 (SD) weeks after the start of ACE‐I therapy (P = 0.005). All but three patients had coughs also on the second and third ACE‐I. The time from the beginning of therapy to the onset of cough was significantly shorter with the second than the first drug. ACE‐I agents had to be discontinued in 50% of the patients in whom coughs developed, most of them in the CHF group. In the others, cough was well tolerated or disappeared during subsequent months. The incidence of cough, which necessitated discontinuation of ACE‐I treatment, was 4% among patients with hypertension and 18% among patients with CHF (P < 0.001). ACE‐I‐induced cough is common in patients with CHF and usually dictates the interruption of this treatment. In hypertension, ACE‐I therapy may be continued in most patients despite the cough, which will subsequently regress in intensity or disappear. Alternative ACE‐I agents should not be tried because cough will reappear.

CHILDHOOD BRUCELLOSIS IN ISRAEL

BACKGROUND Brucellosis has become a major medical problem in Israel particularly in the Muslim Arab population. METHODS Eighty-eight children with acute brucellosis are described. Sixty-seven were studied retrospectively during 1987 through 1988, and 21 children were studied prospectively during 1989 through 1992. Epidemiologic, clinical and laboratory features were evaluated, and the outcome of 4 antimicrobial regimens are compared. RESULTS Although the clinical manifestation varied, the classical triad of fever (91%), arthralgia or arthritis (83%) and hepato- and/or splenomegaly (63%) characterized most patients. Sixty-one percent of the children had elevated liver enzymes. Brucella melitensis was isolated from 61% of blood cultures. The relapse rate in patients who were treated with monotherapy (doxycycline) was 43% compared with 14% with regimens of combined therapy with rifampin and doxycycline, streptomycin and doxycycline or rifampin and trimethoprim-sulfamethoxazole (P < 0.049). Eleven children (33%) who were treated for 3 weeks had relapse compared with 1 patient (3.5%) treated for 4 weeks or longer. The total relapse or reinfection rate was 20%. All patients with relapse recovered after a second course of antibiotic therapy. During the 2 years of follow-up one child progressed to chronic osteomyelitis. CONCLUSIONS Combination therapy and extending treatment for 4 weeks or longer gave significantly better results than monotherapy or shorter courses of therapy and resulted in fewer relapses.

Human gastrin: A Helicobacter pylori–specific growth factor

Abstract Background & Aims: Helicobacter pylori resides within the gastric mucosa, a niche hostile to other microorganisms. Human gastrin levels are elevated after infection and return to normal after eradication. The aim of this study was to test the direct effect of gastrin on the growth of H. pylori. Methods: H. pylori and control bacteria were grown with gastrin or control peptides and growth rate was determined. 125 I-labeled gastrin was used to determine uptake. Results: Human gastrin stimulated H. pylori growth in a specific, dose-dependent manner. Gastrin shortened the lag time, increased growth rate in the logarithmic phase, and increased final bacterial concentration at the stationary phase. These effects were shown over a wide concentration range, including physiological luminal and serum levels. Labeled gastrin uptake was inhibited by unlabeled gastrin. Controls consisting of cholecystokinin and pentagastrin inhibited gastrin uptake but did not stimulate growth. In contrast, somatostatin and epidermal growth factor had no effect on either gastrin uptake or bacterial growth. These results suggest a structurally restricted, receptor-mediated, gastrin-specific effect. Conclusions: Human gastrin is a specific growth factor for H. pylori and may have a role in the adaptation of H. pylori to its unique habitat. GASTROENTEROLOGY 1999;117:1113-1118

Outcome of West Nile Fever in Older Adults

OBJECTIVES: To determine the effect of clinical presentation and cognitive changes on the postdischarge outcome in older adult patients with West Nile fever (WNF).

Fine needle aspiration biopsy in patients with diffusely enlarged spleens.

OBJECTIVE To evaluate the diagnostic value and potential risk of fine needle aspiration biopsy (FNAB) of the spleen in patients with diffuse splenomegaly due to an undetermined cause. STUDY DESIGN Retrospective evaluation of the medical records and cytologic material from 58 patients on whom FNAB was performed between 1967 and 1993. RESULTS Sixty-five FNABs were performed on 58 patients. Lymphoproliferative diseases were found in six; in four additional cases, metastatic adenocarcinoma, sarcoidosis, Candida albicans and enterococcal infection were demonstrated. The remaining 55 biopsies either showed normal splenic tissue or were nondiagnostic. No complications were recorded. CONCLUSION Splenic FNAB may be useful in some patients with diffuse splenomegaly. The diagnostic yield is rather low. The procedure, however, is simple, safe and well tolerated.

Once daily cefixime compared with twice daily trimethoprim/sulfamethoxazole for treatment of urinary tract infection in infants and children.

We conducted a randomized prospective multicenter study to compare the safety and efficacy of once daily oral cefixime (8 mg/kg) to twice daily oral trimethoprim/sulfamethoxazole (TMP/SMX) (8/10 mg/kg/day) for the treatment of acute urinary traet infection in children ages 6 months to 13 years. Seventy-six patients (38 in each group) were studied. Thirty-seven percent were younger than 3 years of age. Escherichia coli was the most common isolate in both groups (85%). Eighty-five percent of all Gramnegative organisms were susceptible to TMP/SMX and all were susceptible to cefixime. Seventy-two percent of all patients were febrile at the time of diagnosis. Both groups were treated for 7 to 10 days. Peripheral white blood cell

INFECTED URINE AS A RISK FACTOR FOR POSTPROSTATECTOMY WOUND INFECTION

OBJECTIVE To study the relation of preoperative infected urine and postprostatectomy wound infection in patients with and without indwelling bladder catheters. DESIGN Patients undergoing prostatectomy were evaluated for the presence of infected urine prior to prostatectomy and postoperative wound infection. They were further divided into patients with indwelling urinary catheter and catheter-free patients. All had received antibiotic prophylaxis. PATIENTS One hundred fifty consecutive patients undergoing open prostatectomy--mean age was 67 years; 100 patients with an indwelling catheter for a mean period of 50 days; 50 catheter-free patients. RESULTS Wound infection was found in 19 of 81 (23.5%) and in 6 of 69 (8.7%) patients with infected and sterile urine, respectively (p = .028). In patients with indwelling catheters prior to operation, wound infection was 22.4% when urine was infected and 8.3% when it was not. In patients without catheters, infected urine was associated with 40% of wound infections, as compared with 8.9% of wound infections in patients with sterile urine. Organisms obtained from infected wound and urine were identical in 84% of cases. These results were obtained despite antibiotic prophylaxis. CONCLUSIONS Wound infection has been demonstrated to be a postprostatectomy complication directly related to the presence of urinary infection at surgery; thus, elective prostatectomy should be deferred until urine becomes sterile.

Antibiotic for cesarean section: the case for ‘true’ prophylaxis

OBJECTIVES: To assess prospectively the efficiency and safety of two extended spectrum cephlosporins used as pre‐operative prophylaxis in nonelective cesarean sections, and compare the results to those of a third group of patients that received cefamezine post cord clamping. METHODS: Two hundred and forty one patients undergoing a nonscheduled cesarean section were assigned to receive either cefonicid or ceftriaxone prior to skin incision. These patients were followed prospectively for infectious and fetal complications. The outcome of these patients was also compared with another group of 194 patients that received cefamezine prophylaxis post cord clamping, and whose data were collected retrospectively. Chi‐square analysis of variance were performed with P < 0.05 considered significant. RESULTS: There were no significant differences in the febrile complications among the two groups of patients that received pre‐operative prophylaxis. However, these patients had significantly less wound infections (P = 0.008) and a significantly shorter hospital stay (P < 0.001) than the patients who received their prophylactic antibiotics post cord clamping. CONCLUSIONS: Extended‐spectrum cephalosporins, when given pre‐operatively, are both effective and safe, and may have an advantage over intra‐operative first generation cephalosporins in the reduction of post cesarean section infectious morbidity.