Yardena Siegman-Igra

Pseudomonas aeruginosa Bacteremia: An Analysis of 123 Episodes, with Particular Emphasis on the Effect of Antibiotic Therapy

OBJECTIVES To review current experience with Pseudomonas aeruginosa bacteremia and compare outcome of patients treated with single-drug, versus combination therapy. METHODS The charts of all patients with P. aeruginosa bacteremia between 1990 and 1992 were reviewed, and pertinent demographic, clinical, and bacteriologic data were retrieved. In addition, similar data were collected from a series of patients with P. aeruginosa bacteremia from the literature of the past 20 years. RESULTS One hundred and twenty-three episodes of P. aeruginosa bacteremia in 121 patients were identified. Most patients were older than 70 years, had at least one underlying condition, and had acquired the infection in the hospital. Attributable mortality was 34%. After exclusion for early mortality and inappropriate therapy, 57 patients remained eligible for comparison of outcome according to therapy protocol. Mortality from infection was equal between the group of 42 patients who received monotherapy and the 15 patients who received combination therapy (14% and 13%, respectively). The literature review revealed eight articles describing 21 to 410 episodes of Pseudomonas bacteremia. The clinical characteristics of these series did not differ significantly from those of the present series. CONCLUSIONS Incidence, epidemiology, clinical characteristics, and outcome of pseudomonas sepsis did not change significantly over the past 2 decades. Appropriate monotherapy was as effective as combination drug therapy for individuals with pseudomonas bacteremia surviving the first 2 days of infection.

Q fever endocarditis in Israel and a worldwide review.

The worldwide epidemiology and population-based incidence of Q fever endocarditis (QFE) have been less well studied than those for uncomplicated Q fever. An exhaustive literature review revealed 408 patients with QFE reported between 1949 and 1994, mostly from 3 large geographic areas. Underlying valvular heart disease was almost invariably present, and 38% had prosthetic valves. The most common clinical manifestations were fever and congestive heart failure. The mortality rate dropped over the years from 65% to 25%, but a meta-analysis of published data showed the death rate to be significantly lower among patients receiving combination therapy (12/65, 18%), as compared to patients treated with tetracycline alone (18/41, 44%, p = 0.005). A 10-year (1983-1992) retrospective nationwide survey of QFE in Israel revealed 35 patients with QFE, representing an annual incidence of 0.75 cases per 1 million population. Underlying heart disease, clinical manifestations and outcome in the Israeli group were not substantially different from those described in the world literature. The current state-of-the-art clinical approach includes early diagnosis, prompt initiation of combination therapy for at least 3 years, and long-term clinical and serologic follow-up. Adherence to these rules might have contributed to the improved prognosis in recent years.

Polymicrobial and monomicrobial bacteraemic urinary tract infection

Polymicrobial blood or urine cultures in bacteraemic urinary tract infection (UTI) are relatively common. There is, however, very little information available on the clinical and bacteriological features that distinguishes between monomicrobial and polymicrobial urosepsis. During 1980-84, 68 of 198 episodes (34%) of urosepsis with at least one identical organism in blood and urine, had multiple growth in either one or the other. Comparison between monomicrobial and polymicrobial infectious episodes showed that the latter were more often hospital-acquired and more frequently associated with urinary catheters. Pseudomonas aeruginosa was more often associated with polymicrobial than with monomicrobial infections, whereas Escherichia coli was more common in monomicrobial infections. Mortality was higher in polymicrobial infections, and was further increased if multiple organisms grew from blood rather than from urine. Thus, there are clinical, microbiological and prognostic characteristics that distinguish polymicrobial from monomicrobial bacteraemic UTIs.

Retinal Lesions in Septicemia

We explored the association between septicemia and specific retinal lesions in a prospective controlled study. Hemorrhages, cotton-wool spots, or Roths spots were found in 24 of 101 septicemic patients (24%), compared to four of 99 age- and gender-matched control patients (4%) (P = .0002). There was no significant association between types of organisms or focus of infection and the presence of specific lesions. Histologic examination of affected eyes disclosed cytoid bodies in the nerve fiber layer without inflammation. A definite association between septicemia and retinal lesions was found and indicates the need for routine ophthalmoscopy in septicemic patients.

The Significance of Polymicrobial Growth in Urine: Contamination or True Infection

Urine growing more than one organism is usually considered contaminated. During 1980-1984, among 198 episodes of urosepsis with at least one identical organism in blood and urine, there were 62 with polymicrobial growth from urine. The significance of the multiple growth from urine was confirmed in 12 episodes by the growth of more than one identical organism in blood and urine and in 21 episodes by repeated growth of the same mixture of organisms in multiple urine specimens. Escherichia coli had a higher tendency to invade blood stream than other Gram-negative organisms, such as pseudomonas and proteus. In specific populations with high risk of polymicrobial infection, multiple growth in urine should be carefully evaluated with appropriate colony count and identification of each isolate.

Infective endocarditis following gastrointestinal and genitourinary procedures: An argument in favour of prophylaxis

Abstract In the 2007 American Heart Association guidelines, gastrointestinal (GI) and genitourinary (GU) procedures were removed from the indications for infective endocarditis (IE) prophylaxis. The purpose of this study was to estimate the contribution of GI and GU procedures to the occurrence of IE in order to appreciate whether this removal was justified. Among 212 episodes of IE prospectively collected during 7 y, 20 cases (9%) had invasive GI and GU procedures and 17 (8%) had dental interventions within 3 months before IE diagnosis. Enteric organisms (predominantly Enterococcus faecalis) were significantly more common in the GI and GU group than in all other patients, whereas viridans streptococci, the most common pathogen in the dental group, were absent from the GI and GU group. This unique combination of pathogens in the GI and GU group is highly suggestive of a true association between the procedure and IE. Hence, GI and GU procedures pose a non-negligible risk of acquisition of IE. Consequently, it is proposed here, that adults at high risk of IE who undergo surgical GI and GU procedures, receive prophylaxis that includes an anti-enterococcal agent.

Streptococcus bovis Revisited: A Clinical Review of 81 Bacteremic Episodes Paying Special Attention to Emerging Antibiotic Resistance

Following 2 cases of Streptococcus bovis endocarditis with a high level of resistance to clindamycin during 2002, the authors reviewed their clinical experience with S. bovis bacteremia during 2 periods, starting in 1980. 81 episodes of S. bovis bacteremia represented approximately 1% of all episodes of bacteremia. In 32 (40%) cases the bacteremia represented endocarditis, in 15 (19%) the bacteremia originated from sick bowel, 11 (14%) were suspected to arise from urinary tract infection, 10 (12%) originated from biliary or peritoneal infection, and 13 from other or unknown sources. 25 (31%) of the bacteremias were polymicrobial. All of the isolates were highly susceptible to penicillin and clindamycin, with the following exceptions: 2 isolates had a minimal inhibitory concentration (MIC) of 0.5 mg/l to penicillin (in 1997) and 5 isolates had an MIC of >2 mg/l to clindamycin (in 1997, 1998, 2000 and 2002). The 2 most recent of these 5 had high-level resistance to clindamycin of >256 mg/l. It seems that clindamycin resistance in S. bovis is an emerging phenomenon, in contrast to penicillin resistance, high levels of which have not yet been described in S. bovis.

Prevalence of hepatitis B virus markers among hospital personnel in Israel: correlation with some risk factors

During 1986-1987, 480 employees of the Tel-Aviv Medical Center were screened for hepatitis B virus (HBV) markers as a preliminary step in a vaccination campaign. One hundred and seventeen (24.4%) had evidence of previous infection, including nine (1.9%) carriers. The effect of potential risk factors on seropositivity was evaluated by multiple logistic regression analysis, which enabled assessment of the individual contribution of each risk factor under the specific environmental conditions. The following risk factors were found to influence seropositivity: origin from Third World countries as opposed to the Western World, employment as sanitary workers, age over 40 years, and history of accidental needle punctures. In the heterogeneous Israeli population, hospital workers had a relatively high prevalence of HBV markers, probably resulting from occupational exposure.