Yechiel Schlesinger

Surveillance of antimicrobial prophylaxis for surgical procedures.

OBJECTIVEnTo assess the practice of antimicrobial prophylaxis for surgical procedures in eight surgical departments in a 550-bed teaching hospital.nnnMETHODSnA list of all major procedures performed in our hospital, with recommendations for prophylaxis based upon the literature, has been distributed since 1993 and is updated periodically. The practice of surgical prophylaxis between January 1 and March 31, 1996, was examined by assessing four variables: (1) Did the particular procedure justify prophylaxis, and was it provided? (2) Was timing optimal, ie, within 1 hour prior to surgery? (3) Was the appropriate antimicrobial selected? (4) Was duration optimal, ie, < or =24 hours?nnnRESULTSnDuring the study period, 2,117 operations were performed, of which 1,631 (77%) were reviewed. Sixty-six percent were clean surgery, 28% clean-contaminated, and 6% contaminated; 72% of procedures were elective, 28% emergencies. Of 1,631 operations requiring prophylaxis, 1,142 (70%) received it, 489 (30%) did not. Of 1,631 patients, 1,392 (85%) received appropriate care: 929 (67%) appropriately received prophylaxis, and 463 (33%) appropriately did not receive prophylaxis. Of 955 patients who received prophylaxis, 26 (3%) did so inappropriately. Of 1,142 patients who should have received prophylaxis, 213 (19%) did not receive it. Female gender, clean surgery, elective operations, and infrequently performed procedures were all significant indicators of inappropriately withheld prophylaxis (P<.001). In addition, the rate of appropriately provided prophylaxis varied between departments from 71% to 97% (P<.001). Assessment of the 929 procedures for which prophylaxis was justified and given revealed that 100% of patients received it on time, the choice of antimicrobial was appropriate in 95% of cases, and duration was < or =24 hours in 91%.nnnCONCLUSIONSnAudits of surgical prophylaxis are expected to detect different errors in different institutions. Conducting audits of surgical prophylaxis probably should be part of the routine activity of infection control teams. Feeding the information back to surgeons could improve adherence to recommended guidelines and might contribute to reduced wound infection rates.

Incidence and Clinical Manifestations of Breast Milk-Acquired Cytomegalovirus Infection in Low Birth Weight Infants

OBJECTIVES:To determine the incidence and clinical manifestations of human breast milk (HMB)-associated acquired cytomegalovirus (CMV) infection in small premature infants.STUDY DESIGN:A prospective study of premature infants born at or prior to 32 weeks gestation, and or infants weighing 1500u2009g or less at birth. The babies were divided into two groups: Group 1 included babies of CMV seropositive mothers who received HBM throughout the study period. Group 2 included babies of seronegative mothers or babies that did not receive HBM at all. Urine sample were obtained once weekly from birth until the age of 8 weeks or until discharge and were tested for the presence of CMV-DNA by PCR.RESULTS:Four of 70 infants from group 1 (5.7%, 95% CI, 0 to 11%) acquired CMV infection between the ages of 3 and 7 weeks as compared to none of 26 babies in group 2. Only one infected baby had severe CMV disease with complete recovery.CONCLUSION:The relative incidence of HBM-associated CMV infection and the severity of HBM-associated CMV disease in premature infants are low.

Prevalence and predictive features of bacteremic urinary tract infection in emergency department patients

The aim of this study was to determine the prevalence and predictive features of bacteremia among patients evaluated in the emergency department for urinary tract infection. Of the 350 patients with symptomatic urinary tract infection included in this retrospective study, 53 (15%; 95%CI 11.6–19.4%) were bacteremic. Five variables were independently associated with bacteremia: residence at home rather than in an institution (OR 4; 95%CI 1.5–10.7), presence of an indwelling urinary catheter (OR 3.3; 95%CI 1.3–8.8), presence of band forms in the blood count (OR 3.3; 95%CI 1.5–7.2), shaking chills (OR 2.3; 95%CI 1.1–4.8), and neutrophilia (OR 1.1; 95%CI 1.04–1.15). These easily assessable parameters may assist in the diagnosis of bacteremic urinary tract infection and the selection of empiric antibiotic treatment, thus potentially improving a patient’s prognosis.

Susceptibility trends in bacteraemias: analyses of 7544 patient-unique bacteraemic episodes spanning 11 years (1990-2000).

The aim of the present study was to design more accurate tools for the selection of appropriate antimicrobial therapy for hospitalized patients with suspected sepsis. We created a large database comprising data on all patient-unique blood cultures obtained over an 11 year period (1 January, 1990 through 31 December, 2000). Improved statistical tools were applied to assess the trends in in vitro activity of individual antibiotic agents against various bacteria over time, and to calculate susceptibility rates of subsets of organisms. During the 11 year study period, 173571 blood cultures were obtained, of which 17703 (10.2%) were positive, with 7544 patient-unique blood cultures (4.3%). The mean annual number of positive, patient-unique cultures was 686 (standard deviation=79). The 10 most frequently isolated organisms were: Escherichia coli (1494), Staphylococcus aureus (1240), Klebsiella pneumoniae (779), Enterococcus spp. (631), Pseudomonas aeruginosa (488), Streptococcus pneumoniae (447), Enterobacter spp. (338), Acinetobacter spp. (298), Proteus mirabilis (260) and Candida spp. (254). No significant change was detected in the annual rates (means, standard deviations) per 1000 admissions of these organisms: the highest was E. coli (5.5, 1), the lowest was Candida (1, 0.3). Forty percent of organisms (N=2943) were obtained from patients in the emergency department (ED), 23% (1744) in medical departments, 15% (1134) in paediatric units, 13% (998) on surgical wards and 9% (709) in intensive care units (ICUs). Trend statistical analysis revealed a significant decrease in susceptibility in ED Enterobacteriaceae to eight of 15 (53%) tested antimicrobials, with a mean annual decrease of 1.6%+/-0.6%, in the ICU isolates, a significant decrease was detected in only five (33%) of the tested antimicrobials, with a mean annual decrease of 2.5%+/-1.3%. The difference in susceptibility between ED and ICU isolates was significant for all antimicrobials (P<0.001). A significant decrease in the susceptibility of E coli to nine of 15 drugs (60%) was detected, ranging from 0.7% to 2.7% annually. In K. pneumoniae a significant decrease in susceptibility of K. pneumoniae was detected with only two agents. Pseudomonas spp. isolates remained highly sensitive to all traditional anti-pseudomonal agents, without significant decay in sensitivity rates over time. Susceptibility of S. aureus to methicillin decreased significantly for several subsets of patients (P<0.001). Marked differences in susceptibility rates between the departments were detected. Trend statistical analyses, when appropriately applied to multi-year databases of microbial susceptibilities, may yield susceptibility tables that are significantly more accurate than traditional semi-annual or annual tables.

Clinical characteristics of patients with psoas abscess due to non-typhi Salmonella

Infections due to Salmonella spp. are common and their incidence appears to be increasing in many countries [1, 2]. Non-typhoidal Salmonella infections are usually associated with contaminated food products [3]. Salmonellosis may present in five forms: asymptomatic chronic carrier state, gastroenteritis, enteric fever, bacteremia and extraintestinal localized complications, of which endovascular infection is one of the most serious [4, 5, 6]. Psoas abscess has been reported only very rarely. Between 1990 and 2000, 7,544 patients were diagnosed in our hospital with bacteremia. Of these patients, 120 (1.6%) had Salmonella bacteremia [7]. Eight of these patients (7%) had Salmonella typhi, and of the 112 patients with non-typhi Salmonella bacteremia, 68 (61%) were children and 44 (39%) were adults. None of the children nor any of the eight adults younger than 50 years old were diagnosed with psoas abscess. However, of the 36 adults older than 50 years who had non-typhi Salmonella bacteremia, two patients (5.5%) had a psoas abscess. It is not unlikely that bacteremia in these patients was secondary to the psoas abscess, which may have formed weeks or months earlier after primary bacteremia or direct extension from an adjacent site. The association of Salmonella bacteremia and localized symptoms led to the conduction of appropriate tests and the eventual diagnosis of psoas abscess. Patient No. 1, a 75-year-old woman with an 18-month history of idiopathic thrombocytopenic purpura (ITP) was seen in March 2000 for relapse of ITP. She had been previously treated with steroids, which were tapered and discontinued 3 months earlier. Treatment with steroids was resumed and intravenous gammaglobulin was added. Several days later she complained of a sudden onset of severe pain in her left hip, accompanied by a low-grade fever (37.5–37.8 C). A bone scan was suggestive of avascular necrosis of the neck of the left femur. A radiogram of the joint was negative. Two blood cultures and a urine culture grew Salmonella enteritidis. She was started on ampicillin 8 g/day in four divided doses. A computerized tomographic (CT) scan of the abdomen revealed multiple abscesses in the left iliopsoas muscle. Oral ciprofloxacin, 750 mg twice daily, was added. A drain was inserted into the left iliac fossa and pus was drained, from which Salmonella enteritidis was isolated. After prolonged percutaneous drainage and antibiotic treatment, cultures of the drained material became negative, and the patient made a complete recovery. Patient No. 2, a 74-year-old woman, was admitted to hospital in May 2000 with a 2-month history of rightsided groin pain radiating to the right hip and upper thigh without trauma, and a temperature of 38.8 C that had started the day before. An orthopedic surgeon had examined her a month previously and had ascribed her symptoms to discopathy. A bone scan, performed 1 month prior to her admission, was reported as demonstrating an increased uptake in the spine and right hip joint, which was ascribed to arthritic changes. Her past medical history included myasthenia gravis for which she had undergone Y. Schlesinger · A. M. Yinnon ()) · D. Raveh Infectious Disease Unit, Shaare Zedek Medical Center, P.O. Box 3235, 91031 Jerusalem, Israel e-mail: Yinnon@SZMC.org.il Tel.: +972-2-6555076 Fax: +972-2-6555076

Acute human parvovirus B-19 infection in hospitalized children: A serologic and molecular survey.

Background: The extent and clinical manifestations of acute human parvovirus B19 (B19) infection were assessed in previously healthy hospitalized children admitted with clinical syndromes potentially associated the virus. Patients and Methods: The study was prospective and was conducted between October 2002 and August 2004 in the pediatric departments of 3 hospitals in Israel. The survey included previously healthy children who were hospitalized with 1 or more of the following acute diseases: acute nonallergic exanthema, fever for >1 week, aplastic anemia or pancytopenia, acute nonbacterial arthropathy, immune thrombocytopenic purpura (ITP), Henoch-Schönlein purpura (HSP) and aseptic meningitis. A control group of children with a proven, non-B19 infection was also studied. Serum samples obtained from each child on admission were tested for B19 DNA by real-time PCR and B19 IgM by ELISA. Acute B19 infection was defined by the following criteria: positive serum B19-DNA and/or B19 IgM, negative serum B19 IgG, and no other proven infection. Results: Overall, 167 children were included in the study. The mean age was 5.5 ± 4.6 years (range, 0.5–17), males and females equally divided. Acute B19 infection was demonstrated in 12.6% (n = 21) of the children. Both tests were performed in 19 children and were positive in 10 (53%). In 7 and 2 children, only B19-DNA or B19 IgM, respectively, was positive. Acute B19 infection was documented in 27% (10/39) of children who presented with a variety of acute exanthema diseases; 9% (5/57) of children with acute arthropathy (all 5 had transient synovitis); 10% (2/21) of children with fever >1 week, both presented as mononucleosis syndrome; and in 44% (4/9) of children with transient pancytopenia or aplastic anemia. No acute B19 infection was demonstrated in 15 children with ITP, 9 with HSP, and 6 with aseptic meningitis and among 70 children in the control group. By logistic regression analysis, manifestations significantly associated with acute B19 infection were exanthema (OR 2.9; 95% CI = 1.1–7.5), anemia (OR 6.35; 95% CI = 2.2–18.2) and leucopenia (OR 4.14; 95% CI =1.2–14.2). Conclusions: Acute B19 infection was documented among 12.6% of children hospitalized with clinical syndrome potentially associated with the virus. Clinical and laboratory features associated with acute B19 infection were exanthema, anemia and leucopenia. Determination of both serum B19-DNA and serum B19 IgM should be performed for the accurate diagnosis of acute B19 infection.

Q fever endocarditis; not always expected

Q fever endocarditis is a chronic disease with protean manifestations. The clinical and serological manifestations of nine patients diagnosed as having Q fever endocarditis during a 19-year period are reviewed. Four patients (44%) required valve replacement due to congestive heart failure. Three of these four patients were diagnosed as having Q fever endocarditis only after elective valve surgery, by histopathological examination of the valve and subsequent serological tests. Prior to surgery they were afebrile and had no other symptom or sign indicative of endocarditis. The antibiotic treatment and the decreasing titres of Q fever antibodies of all nine patients during several years of follow-up are summarized. Careful assessment of heart valves for histopathological evidence of inflammation is suggested, even after elective replacement. If found, clinical and laboratory evaluation should include determination of anti-Coxiella burnetti antibodies.

Cytomegalovirus myocarditis in a healthy infant: Complete recovery after ganciclovir treatment.

Objectives To report a case of acute myocarditis caused by cytomegalovirus infection in a 15-month-old immunocompetent infant completely recovered with ganciclovir treatment. Design Descriptive case report. Setting Pediatric intensive care unit in a general hospital. Patient A 15-month-old healthy girl with acute, severe myocarditis. Intervention General supportive intensive care and mechanical ventilatory support, iv immunoglobulin, and iv ganciclovir. Measurements and Main Results Intensive supportive care including iv fluids, mechanical ventilatory support, diuretics (furosemide, spironolactone), digoxin, dobutamine, captopril, methylprednisolone, and iv immunoglobulin. Despite clinical stabilization, shortening fraction remained very poor at 17%. Addition of iv ganciclovir resulted in prompt and complete recovery of the cardiac muscle contractility with a shortening fraction of 35% that remained normal during a long follow-up period. Conclusions Cytomegalovirus should be considered as a causative agent in acute myocarditis even in the normal, immunocompetent host. In such cases, addition of ganciclovir treatment should be strongly considered.

Case 1: a 14‐month‐old infant with pericarditis

CASE PRESENTATION A 14-month-old male infant with three weeks of fever up to 39◦C and diarrhea, presented to our emergency department. He was well until three weeks before arrival. On arrival he was alert but appeared pale and ill. Rectal temperature was 39.2◦C, heart rate was 166 beats per minute, blood pressure was 103/74 mmHg and oxygen saturation on room air was 95%. On physical examination he had normal peripheral pulses, normal heart sounds with no additional sounds or murmurs, and good air entry. He did not have enlarged lymph nodes and the throat examination revealed no abnormalities. His liver was not palpable below the costal margin, and he had mild splenomegaly. The rest of the physical examination was unremarkable. Bacterial cultures of blood and stool were obtained and were negative. Blood tests revealed white blood cell count (WBC) 15,900/mm3 with 33% neutrophils, 54% lymphocytes and 13% monocytes, hemoglobin 9 g/dL, hematocrit 29%, mean corpuscular volume 72 fL and platelets 356,000/mm3. Serum electrolytes, glucose and liver function tests were normal. C-reactive protein (CRP) was 4.1 mg/dL. Chest radiograph revealed moderate cardiac enlargement and echocardiography was done (Fig. 1). Echocardiography demonstrated normal cardiac anatomy and function, moderate to large amount of pericardial effusion, and mild thickening (6 mm) of the right lateral superior atrial wall with no interruption of the superior vena cava (SVC) to the right atrium (RA) flow. No vegetations were seen. Electrocardiogram was normal except for sinus tachycardia. On the following morning there was an increase in the amount of the pericardial fluid with mild tamponade effect. An echocardiography-guided pericardiocentesis was performed, and a 6 Fr. Pigtail catheter was placed percutaneously into the pericardial sac. A 100 mL of fluid was drained, which contained 3000 red blood cells/ L, 800 WBC/ L of which 74% were neutrophils and 26% were lymphocytes, glucose was 81 mg/dL and LDH 1186 IU/L. No malignant cells were detected. Bacterial cultures of pericardial fluid were negative. Serology studies done on admission suggested recent EBV infection (positive anti EBV IgM antibodies and negative anti EBV IgG and EBNA antibodies). Workup for an underlying collagen disease was negative. The fluid was sent for PCR for enteroviruses and EBV.