Zvi Shimoni

Pregnancy-Associated Listeriosis: Clinical Characteristics and Geospatial Analysis of a 10-Year Period in Israel

BACKGROUND Listeria monocytogenes is a foodborne pathogen that causes life-threatening infections in elderly, immunocompromised, and pregnant women. In pregnancy it may cause fetal loss or a preterm delivery, and the neonate is prone to neonatal sepsis and death. METHODS We created a cohort of all L. monocytogenes cases during 10 years (1998-2007) in Israel, by a comprehensive review of cases in hospitals throughout the country and cases reported to the Ministry of Health. RESULTS One hundred sixty-six pregnancy-related listeriosis cases were identified, resulting in a yearly incidence of 5-25 cases per 100 000 births. Presentation associated with fetal demise was more common in the second trimester (55.3%), and preterm labor (52.3%) and abnormal fetal heart rate monitoring (22.2%) were more common in the third trimester (P = .001). Fetal viability was low in the second trimester (29.2%) and much higher (95.3%) in the third trimester. Each additional week of pregnancy increased the survival chance by 33% (odds ratio, 1.331 [95% confidence interval, 1.189-1.489]). A single case of maternal mortality was identified. Listeria monocytogenes serotype 4b was more common in pregnancy-related than in non-pregnancy-related cases (79.5% vs 61.3%, P = .011). Pulsed-field gel electrophoresis analysis suggested that 1 pulsotype is responsible for 35.7% of the pregnancy cases between 2001 and 2007. This clone is closely related to the Italian gastroenteritis-associated HPB2262 and the invasive US Scott A L. monocytogenes strains. CONCLUSIONS Our survey emphasizes the high rate of pregnancy-related listeriosis in Israel and shows that specific clones might account for this.

Will more restrictive indications decrease rates of urinary catheterisation? An historical comparative study

Objectives To determine if more restrictive indications for urinary catheterisation reinforced by daily chart review will lower catheterisation rates. Design An historical comparative observational study. Setting An internal medicine department in a regional hospital in Israel. Participants The authors compared 882 patients hospitalised after a change in policy to an historical cohort of 690 hospitalised patients. Exclusions included patients less than age 30 and those with bladder outlet obstruction. Intervention Emergency and internal medicine department physicians received instruction on a more restricted urinary catheterisation policy. During daily chart rounds, admissions were discussed with an emphasis on the appropriateness of all new urinary catheter insertions. Main outcome measures The primary outcome measure was catheterisation rate by admission diagnosis. Secondary outcome measures were the need for post-admission in hospital catheterisations and the rate of indwelling catheters 14 or more days after discharge. Results There was a reduction in catheterisation rate in patients with congestive heart failure from 30/106 (29.3%) to 3/107 (2.8%) (p<0.001), in patients with an admission diagnosis of fever unable to provide a urine sample for culture from 35/132 (26.5%) to 12/153 (7.8%) (p<0.001) and in patients admitted for palliative care from 51.7% (15/29) to 12.0% (3/25) (p=0.002). The overall rate of catheterisation decreased from 17.5% (121/690) to 6.6% (58/882) (p<0.001). There was only one indicated catheterisation after admission due to the change in policy, and the proportion of patients discharged with catheters decreased. Conclusion The use of more restrictive indications for urinary catheterisation along with daily chart rounds can reduce the rate of urinary catheterisation in an internal medicine department without adverse consequences.

Increased complaints of fever in the emergency room can identify influenza epidemics

BACKGROUND In developing countries, it may be easier to use the reasons why patients come to the emergency room (ER) instead of sentinel practices to identify influenza epidemics. METHODS We studied the reasons why adult patients present to the ER in order to attempt to predict increased hospital activity as a result of influenza. The daily frequency of presenting symptoms during the 30 days of maximal influenza activity was compared to the other days of the study period (335 days). RESULTS During the influenza period, more patients presented with fever, syncope or near syncope, cough, asthma attack, and paralysis than on the days outside of this period. On 50% of the days, eight or more patients presented with fever, an 8.36 (95% CI=4.6-15.19) higher frequency than during the rest of the year. During the subsequent year, days with excess presentations by patients with a principal complaint of fever predicted increased hospital activity due to influenza with no false-positive periods. CONCLUSIONS We conclude that an increase in the number of patients presenting to the ER complaining of fever can identify increased hospital influenza activity.

The addition of fiber and the use of continuous infusion decrease the incidence of diarrhea in elderly tube-fed patients in medical wards of a general regional hospital: a controlled clinical trial.

Goals To determine if feeds high in fiber continuously administered might minimize diarrhea. Background The addition of soluble fiber to enteral feedings has not consistently decreased diarrhea in controlled clinical trials, and the effect of the use of intermittent or continuous infusions on the rate of diarrhea is similarly controversial. Study We studied 148 of 160 selected elderly well-nourished patients with acute disease prohibiting oral intake in a controlled clinical trial in the setting of an internal medicine departments in a regional hospital who were divided into 4 groups and fed according to combinations of intermittent or continuous systems, with fiber-free or fiber rich formulas. The 5-day rate of diarrhea was defined as 2 liquid stools or 3 or more semisolid or liquid bowel movements during a 24-hour period. Other outcome variables included mortality, hospital days, prolonged hospitalization (over 20 d), fever, and stools positive for Clostridium difficile cytotoxin A/B. Results The increased relative risk of the continuous/fiber-free, intermittent/fiber, and intermittent/fiber-free groups compared with the continuous/fiber group was 2.8 [95% confidence interval (CI)=1.0-8.1], 2.5 (95% CI=0.9-7.1), and 5.0 (95% CI=1.9-13.2), respectively. These findings were independent of age (>80 y), female sex, being treated with antibiotics for respiratory or urinary infections, receiving respiratory support, or being fully conscious. There were no significant differences in the other outcomes. Conclusions We conclude that in elderly well-nourished hospitalized patients with acute diseases prohibiting oral intake, continuous and closed enteral feedings with the addition of fiber is effective in reducing the rate of diarrhea.

Tricuspid Valve Endocarditis in Adult Patients Without Known Predisposing Factors

Abstract Four patients with no known predisposing conditions developed tricuspid valve endocarditis. All patients had community-acquired infection with a rapidly progressive course that was complicated by right heart failure and respiratory insufficiency. Pulmonary involvement was prominent in all cases. The infectious process was due to Staphylococcus aureus in three patients and to Streptococcus intermedius in one patient. Three patients underwent early surgical intervention; the outcome was favourable in all cases. It is clear that tricuspid valve endocarditis can occur in the absence of known predisposing factors, and when Staphylococcus aureus is involved, the course of the disease may be acute and rapidly progressive.

The clinical response of West Nile virus neuroinvasive disease to intravenous immunoglobulin therapy

The aim of the study was to determine whether intravenous gamma globulin (IVIG) treatment is effective in patients with West Nile Virus (WNV) neuroinvasive disease. We contacted hospital based infectious disease experts in Israeli hospitals to identify patients with WNV neuroinvasive disease who were treated with IVIG. The main outcome measure was neurological response after treatment. There were 12 patients who received IVIG and four improved within 48 h. Three patients died, 6 had partial recovery, and 3 recovered completely. Eleven of the 12 patients were infected with Israeli genotypes that are highly homologous to Europe/Africa viruses. The rapid response in some patients suggests that IVIG is effective, and might be used to treat patients with WNV neuroinvasive disease with IVIG.

Symptomatic Hypocalcemia Precipitated by Small-Volume Blood Transfusion

We present 2 cases in which the transfusion of small volumes of packed RBC was sufficient to precipitate symptomatic hypocalcemia. Subsequent inquiry revealed that both of the patients had preexisting, untreated, and asymptomatic hypocalcemia, 1 following partial thyroidectomy many years earlier and the other with documented hypocalcemia but without a definitive diagnosis.

The Effect of Urinary Bladder Catheterization on Patient Care in an Internal Medicine Department

Introduction:Recommendations for urinary catheterization in newly hospitalized patients are inconsistent and unclear. Methods:The authors studied prospectively consecutive patients who were catheterized in an internal medicine department over a 3-month period, with follow-up for 6 months or until the catheter was removed. Patient records were reviewed to determine if catheterization was definitely not indicated by commonly accepted criteria. After chart review, a category of possibly not indicated was defined as having no demonstrable effect on patient care. Results:There were 17.7% patients (122/691) catheterized during their admission. According to accepted criteria, definite inappropriate catheterization occurred in 18 patients (14.7%). There were an additional 69 patients (56.6%) with unclear clinical benefits, hospitalized because of fever, acute congestive heart failure, a cerebral vascular accident or respiratory insufficiency due to exacerbation of chronic obstructive lung disease. During hospitalization, attempts to remove the catheter failed in 13 patients, 4 of who remained with the catheter permanently, complicated by urosepsis in 1 patient. Conclusion:Over 50% of the patients had acceptable indications for catheterization but no demonstrable benefit from the procedure. In such patients, the uncertain benefits of catheterization should be balanced by potential complications. Additional studies are warranted to determine the effect of acute urinary catheterization on patient care.

Treatment of febrile geriatric patients with suspected urinary tract infections in a hospital with high rates of ESBL producing bacteria: a cohort study

Purpose To determine the consequences of treating febrile geriatric patients with a suspected urinary tract infection (UTI) with antibiotics that have high resistance rates due primarily to extended-spectrum β-lactamase (ESBL) producing bacteria. Methods In this cohort study, we selected 257 consecutive hospitalised patients aged ≥70 years with a chief symptom of fever, possibly due to a UTI and initially treated with antibiotics with rates in our hospital of urinary culture resistance >20%. Patients with severe sepsis were excluded. The main outcomes measures were in vitro bacterial resistance to initial antibiotic therapy (BRIAT), response to therapy, hospitalisation days and mortality. Results Urine cultures were positive in 64.2% (165 of 257) of the patients and BRIAT occurred in 28.0% (72 of 257). Response rates were 100% (93 of 93) in those with bacteria sensitive to initial antibiotic therapy, 95.7% (88 of 92) in the culture negative patients, and 66.7% (48 of 72) in those with BRIAT (p<0.001). There were no deaths due to deterioration during the initial treatment period because of BRIAT. In the patients with BRIAT, the median length of hospitalisation was 3 days longer than that in the other patients (7 and 4 days, respectively, p<0.001). Conclusions We conclude that initial broad spectrum antibiotic treatment could potentially lower the median length of hospitalisation by 3 days in many hospitalised geriatric patients without an extra-urinary tract source for their fever. This benefit needs to be balanced against the risk to the individual patient and to the general public of increasing bacterial resistance rates to broader spectrum antibiotics often held in reserve.

Sensitivity of the dipstick in detecting bacteremic urinary tract infections in elderly hospitalized patients

Background The sensitivity of the dipstick in elderly patients with a suspected urinary tract infection (UTI) is unclear because of the inclusion of patients with urine contamination or asymptomatic bacteriuria in previous studies. Methods We selected consecutive patients aged 65 years or older hospitalized in internal medicine departments with bacteremic UTI (same organism in blood and urine cultures) minimizing misclassifications. The false positive rate was determined in consecutive patients with negative culture results. A positive dipstick was a test result with a trace leukocyte esterase and/or nitrite positivity. Bacteriuria was the growth of at least 105 colony-forming units per milliliter of urine. Results Of 20,555 consecutive patients, 228 had a bacteremic UTI, and 4069 a negative culture result. The sensitivity of the dipstick was 96.9% (95% CI—93.7–98.6) with a false positive rate of 42.4% (95% CI, 41.0–43.8) in those with a negative culture result. Conclusions In elderly hospitalized patients with a bacteremic UTI, the dipstick urinalysis is highly sensitive, much higher than reported previously in studies of UTIs in the elderly. It is unclear whether the observed high sensitivity of the dipstick was due to the exclusion of patients with asymptomatic bacteriuria or to spectrum bias. Studies of the clinical utility/disutility of using a negative dipstick to rule out a urinary tract infection are warranted.