We read with great interest the study by Quiles-Jiménez et al., showing that severely ill COVID-19 patients have altered circulating levels of proteins controlling the epitranscriptome.1Quiles-Jiménez A. Sousa M.M.L. Huse C. Dyrhol-Riise A.M. Holter J.C. Christensen E.E. et al.Severely-ill COVID-19 patients have altered circulating levels of proteins controlling the epitranscriptome.J Infect. 2023; S0163-4453: 00132-00139https://doi.org/10.1016/j.jinf.2023.03.002Abstract Full Text Full Text PDF Scopus (1) Google Scholar While severe COVID-19 can occur in otherwise healthy individuals of any age, it predominantly occurs in adults with advanced age or certain underlying medical comorbidities.2Zhou F. Yu T. Du R. Fan G. Liu Y. Liu Z. et al.Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.Lancet. 2020; 395: 1054-1062https://doi.org/10.1016/S0140-6736(20)30566-3Abstract Full Text Full Text PDF PubMed Scopus (17813) Google Scholar However, during the early stages of the pandemic, it was already noted that these risk factors did not fully explain the clinical variability of COVID-19 with reports of severe and fatal illness among otherwise healthy individuals, sometimes clustering in families, suggesting a role for human genetics as a risk factor for disease severity. This study used whole exome sequencing (WES) to explore whether genetic variants could be identified in a family that was severely affected by COVID-19 with four members succumbing to COVID-19 and two others suffering from severe and near-fatal infection. We included 23 members belonging to a family of Arabic origin (8 males and 15 females) of which there were 11 siblings (8 females and 3 males) (see pedigree chart in Fig. 1). Exome sequencing results were analyzed using 2 panels; a customized COVID-19 gene panel which included 46 gene loci that were associated with SARS-CoV-2 infection susceptibility or COVID-19 severity based on recent large-scale population-based association studies.3Pairo-Castineira E. Clohisey S. Klaric L. Bretherick A.D. Rawlik K. Pasko D. et al.Genetic mechanisms of critical illness in COVID-19.Nature. 2021; 591: 92-98https://doi.org/10.1038/s41586-020-03065-yCrossref PubMed Scopus (712) Google Scholar Second, through immune deficiency gene panel that includes genes that were previously associated with abnormal immune response (for more details, see Supplementary materials). The family analyzed in this study was severely affected by the pandemic. Four members suffered from critical illness and died from COVID-19-related complications (mother and three siblings, members; I-1, II-6, II-10, II-12), two siblings suffered from severe COVID-19 (members; II-4, II-5), and two other members of the extended family suffered from severe near-fatal disease (members II-14 and III-1) (Fig. 1). Three members died prior to the introduction of SARS-CoV-2 vaccines (siblings II-6, II-10, II-12) and one received two immunizations one year prior to her fatal illness (member I-1). Segregation analysis using the COVID-19 gene panel and immune deficiency gene panel did not show any segregation among the severely affected family members. However, by analyzing all coding genes, a potential pathogenic variant: c.5302+1G>A in CR1 gene (complement receptor 1, CD35) [NM_000651.6, chr1:207,755,349G>A, rs756221326, (GRCh37)] was detected. The CR1 gene encodes complement receptor 1 (CD35), the receptor for C3b/C4b complement peptides. CR1 has been identified as an inhibitor of the complement cascade by promoting the dissociation of the alternative pathway C3 convertase C3b,Bb and the cleavage of C3b by C3b/C4b inactivator. CR1 also inactivates the C3 and C5 convertases of the classical pathway and inhibits the consumption of C3 by C3 convertase EAC142 and enhances the decay of C4b,2a sites.4Iida K. Nussenzweig V. Complement receptor is an inhibitor of the complement cascade.J Exp Med. 1981; 153: 1138-1150https://doi.org/10.1084/jem.153.5.1138Crossref PubMed Scopus (191) Google Scholar Given the regulatory role of CR1 in the complement system we hypothesized that the identified variant in CR1 gene may provide insights into the catastrophic outcome of the affected family members. Therefore, we completed Sanger sequencing and segregation analysis for the rest of the family. We found a high correlation between severely affected individuals and heterozygote alteration. The variant c.5302+1G>A is an extremely rare variant in the general population (<0.01%), absent from in-house database (1320 alleles), and very low (<0.001%) in the Genome Aggregation Database (gnomAD). In silico analysis predicted dramatic decrease of donor splice-site strength. CR1 gene expression analysis identified two isoforms expressed for carries: one with full exon 32 inclusion (wild-type allele) and second with exon skipping (without exon 32). A major outcome of exon skipping is abolishing normal reading frame and creating early stop gain, leading to truncated protein (31 exons compared to a wild-type protein that includes 47 exons). (Fig. 2). Quantitative allele expression by qPCR of the wild-type allele, using primers targeting exon 32, among carriers and wild-type samples revealed significantly decreased levels of the wild-type allele (see Supplementary material). Patient I-1, who was a heterozygous of the variant c.5302+1G>A in CR1 gene, died from complications of severe COVID-19 during January 2022. We had obtained blood samples from the patient prior to that admission as part of the workup that was carried out to investigate the clustering of several COVID-19 related deaths in the family early in the pandemic (August 2020). During the patient's admission with severe COVID-19, we obtained weekly blood samples and compared mRNA CR1 expression to preadmission levels and to other patients (wild-type controls) with severe COVID-19. The relative expression of mRNA CR1 of the heterozygous carrier during severe COVID-19 was ∼ fourfold higher compared to preadmission levels but not significantly different from wild-type carriers admitted with severe COVID-19 (see Supplementary material). To our knowledge, the variant identified in this case series has not been described previously. This genetic variant impaired CR1 expression; however, a considerable upregulation of CR1 gene expression occurred during severe infection. To date, there are no known individuals with innate CR1 deficiency. Acquired CR1 deficiency, demonstrated by low expression of CR1 on erythrocytes, has been described in pregnancy and in acute or chronic infectious and inflammatory conditions.5Ghiran I. Nicholson-Weller A. CR1.in: Barnum S. Schein T. The complement FactsBook. 2nd ed. Academic Press, 2018: 295-308https://doi.org/10.1016/B978-0-12-810420-0.00028-6Crossref Scopus (3) Google Scholar In addition, temporary decrease in CR1 levels has been reported during the acute phase of COVID-19 with normalization during recovery.6Kisserli A. Schneider N. Audonnet S. Tabary T. Goury A. Cousson J. et al.Acquired decrease of the C3b/C4b receptor (CR1, CD35) and increased C4d deposits on erythrocytes from ICU COVID-19 patients.Immunobiology. 2021; 226152093https://doi.org/10.1016/j.imbio.2021.152093Crossref PubMed Scopus (9) Google Scholar, 7Wang F.S. Chu F.L. Jin L. Li Y.G. Zhang Z. Xu D. et al.Acquired but reversible loss of erythrocyte complement receptor 1 (CR1, CD35) and its longitudinal alteration in patients with severe acute respiratory syndrome.Clin Exp Immunol. 2005; 139: 112-119https://doi.org/10.1111/j.1365-2249.2005.02681.xCrossref PubMed Scopus (19) Google Scholar Emerging data indicate that complement activation plays a critical role in pathogenesis and disease severity of coronavirus infections.8Holter J.C. Pischke S.E. de Boer E. Lind A. Jenum S. Holten A.R. et al.Systemic complement activation is associated with respiratory failure in COVID-19 hospitalized patients.Proc Natl Acad Sci USA. 2020; 117: 25018-25025https://doi.org/10.1073/pnas.2010540117Crossref PubMed Scopus (228) Google Scholar, 9Gralinski L.E. Sheahan T.P. Morrison T.E. Menachery V.D. Jensen K. Leist S.R. et al.Complement activation contributes to severe acute respiratory syndrome coronavirus pathogenesis.mBio. 2018; 9https://doi.org/10.1128/mBio.01753-18Crossref PubMed Scopus (504) Google Scholar Given that CR1 plays a critical role in controlling complement activity by acting on all three complement pathways as a membrane-bound receptor of C3b and C4b, a decay accelerator for C3/C5, and a cofactor for factor I-mediated cleavage of C3b and C4b, it is intriguing to speculate that decreased CR1 expression among heterozygotes of the genetic variant may have contributed to the evolution of severe and fatal COVID-19 in this family. In conclusion, in this family that was tragically affected by COVID-19, we detected a unique genetic variant in CR1 gene that impaired CR1 expression. Our findings suggest a significant role for CR1 in the pathogenesis of COVID-19. Future research will focus on direct mechanisms by which CR1 affects the complement system in COVID-19. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

PURPOSE:Urinary tract infection (UTI) is one of the most common bacterial infections, with Escherichia coli causing up to 80 % of community-acquired bacteriuria (CA-Bu). The epidemiology and pathogenesis of E. coli have been intensively studied, yet, less is known about risk factors for CA-Bu due to other uropathogens. The purpose of this study was to clarify the latest knowledge.METHODS:A clinical epidemiological study among adult ambulatory patients was conducted. During November 2009, all urine cultures sent to our Microbiology Laboratory were evaluated, including demographic characteristics of the patients, underlying diseases and antibiotic treatment. Data were analysed by the SPSS statistical package.RESULTS:During the study period, 4,653 cultures were sent for evaluation. Of the 1,047 (22.5 %) that were positive, 838 were included in the study; 82.5 % were from females. E. coli was the most common pathogen, comprising 58.6 % of all positive cultures. By multivariate analysis, five independent risk factors were associated with non-E. coli CA-Bu: presence of foreign body in the urinary tract [odds ratio (OR) 5.8], nitrite urine test negative (OR 3.2), male gender (OR 2.5), normal erythrocyte count in urine test (OR 1.5) and recurrent UTI in the past year (OR 1.5).CONCLUSIONS:For adult outpatients presenting with CA-Bu, five independent factors suggesting the involvement of uropathogens other than E. coli were identified. These should be taken into consideration when empiric antibiotic treatment is prescribed.

Background There are no established data on the prevalence of bacterial colonization of lesional skin, nares and perineum in Darier's disease (DD), or its contribution to the clinical manifestations of the disease. Objective To determine the prevalence of bacterial colonization of lesional skin and Staphylococcus aureus (S. aureus) in nares and perineum in 75 patients with DD, the association of these parameters with disease and patient characteristics, and the features of the bacterial skin infection in this group. Methods Medical interviews and physical examinations were performed. Bacteria were isolated from swabs taken from lesional skin, nares and perineum. ResultsS. aureus was isolated in 68%, 47% and 22% of lesional skin, nares and perineum cultures respectively. Subjects with positive S. aureus culture from lesional skin and/or nares had a statistically significant higher percentage of skin area affected and a more severe disease than patients with negative culture. Thirty of the 75 patients (40%) recalled bacterial skin infection, most often on the chest. Conclusions Patients with DD have high prevalence of S. aureus colonization in lesional skin and nares, with a correlation between disease severity and extent of the colonization. Further studies examining the consequences of S. aureus eradication in those sites may establish the need for S. aureus lesional skin and nares colonization screening and eradication as part of the treatment of DD exacerbations.

Background: Resistant pathogens are an increasing threat affecting millions of people globally. More complicated patients are presented with pathogens harboring new resistance mechanisms, while the pipeline of new antimicrobials hardly proposes solutions. In such a scenario, more severely ill patients remain with no adequate treatment to offer. In addition, massive misuse of antimicrobials, including excessive length of treatment or wrong dosage, also contributes to increasing the rate of pathogens resistance to antimicrobials. Isolation of Streptococcus pyogenes (Group A StreptococcusGAS) is the main indication for antibiotic treatment to patients diagnosed with acute tonsillitis. Hence, GAS resistance to antibiotics requires periodic monitoring. Objectives: To assess susceptibility rates of GAS to penicillin, macrolides, clindamycin, and tetracycline in northern Israel and to compare the findings to the high antimicrobial susceptibility of GAS isolates reported in the same region in 2004 and to other geographical areas. Methods: Throat samples from 300 outpatients were collected and cultured at the regional laboratory of Emek Medical Center during September to October 2011. Results: In 300 samples, the susceptibility rates of GAS to penicillin, erythromycin, azithromycin, clindamycin, and tetracycline in northern Israel still remain very high. Conclusions: Continuous control of antimicrobials usage and periodic surveillance of susceptibility rates, together with educational programs and appropriate and targeted treatment protocols, are essential and highly recommended to keep these high susceptibility rates for as long as possible.

Mannose-binding lectin (MBL) comprises an oligomeric serum protein that is a member of the collectin class of the C-type lectin superfamily. Its deficiency is genetically determined and confers predisposition to recurrent infections as well as increased infection severity. This correlation has been demonstrated in recurrent furunculosis caused by Staphylococcus aureus, and in pneumococcal and Candida infections. The present study aimed to determine whether there is a correlation between MBL serum levels and recurrent urinary tact infections (UTI) in pre-menopausal women. The present aged-matched double-blind controlled study was conducted in 100 pre-menopausal adult women: 50 who suffered from recurrent UTI and 50 without UTI. The MBL concentration was measured in a single serum sample from each patient using an enzyme-linked immunosorbent assay. MBL serum levels [median (range)] were 2500 (4-12,000) ng/mL and 2105 (4-22,800) ng/mL for the research and control groups, respectively. The results from the two groups were compared and were not statistically different (p 0.4). According to these results, MBL serum levels are not associated with an increased risk for recurrent UTI in pre-menopausal women.

Background: Prostate cancer is the most common malignancy in men, and has been increasing in incidence in the Western world. The gold standard for diagnosing prostate cancer is a transrectal US-guided biopsy. One of the complications of this procedure is the development of urinary tract infections. It has been shown that treatment with prophylactic antibiotics prior to the procedure reduces the rate of infections. The widespread use of quinolones for this and other reasons has led to an increase in resistant bacteria. Aims of this study: to evaluate the efficacy of single-dose gentamicin in comparison with single dose of ofloxacin in patients underwent transrectal ultrasound guided biopsy of prostate. Methods: 109 patients undergoing a prostate biopsy were randomly assigned to two groups: the first group was treated with a single dose of ofloxacin (400 mg) prior to the biopsy and the second with a single dose of gentamicin (3 mg/kg). Clinical signs and symptoms, and urine tests and cultures were followed 2 and 7 days after procedure. Results: 57 patients received Ofloxacin and 52 Gentamicin. 3 patients in the Ofloxacin group (5.2%) and 4 in the gentamicin group (7.6%) developed urinary tract infections (N.S). No diferences were seen in the clinical outcome between the groups. Conclusion: The development of quinolone resistant bacteria has led us to examine alternative options for prophylactic treatment before prostate biopsies. Gentamicin, was as efficient as quinolones in the prevention of urinary tract infections. A single dose prior to the procedure is sufficient and longer treatment duration is unnecessary. Abstracts for SupplementInternational Journal of Infectious DiseasesVol. 14Preview Full-Text PDF Open Archive

Seasonal variation in the infection rate with certain Gram-negative organisms has been previously described, but few studies have been published regarding Escherichia coli. The aim of this study was to investigate the incidence rate of E. coli bloodstream infection (BSI) and the association with temperature in different seasons in the Yizrael Valley. Positive blood cultures sent to the microbiology laboratory of Ha'Emek Medical Centre over a period of 8 years (January 2001 to December 2008) were included. The mean monthly temperature in the Yizrael Valley in the same period was compared with the monthly E. coli BSI rate. We divided the year into three periods: winter (December to February: mean temperature <15°C), transitional (March, April and November: mean temperature 15-19°C) and summer (May to October: mean temperature ≥20°C). In addition, we correlated the mean monthly antibiotic use in the same period measured as total defined daily doses for the whole regional population with E. coli BSI. During the study period, 2810 BSIs were recorded (35%E. coli). In 67.4% of the cases of E. coli bacteraemia, the source was urinary tract infection. The crude incidence of E. coli BSI was 4.1/1000 admissions. There was no difference in the number of cultures/month (mean: 29 ± 6). However, E. coli BSI was 19% and 21% more frequent in summer than in the transitional and winter seasons, respectively (p 0.01). The antibiotic consumption was significantly higher in the winter period. We found significantly higher rates of E. coli BSI in the summer period. Host, bacterial and ecological factors, together with high consumption of antibiotics during the winter season, could partially explain these findings.

Pasteurella multocida is the commonest organism infecting pet bites. Anecdotal reports tend to overemphasize dramatic outcomes. We aimed to study a large database of P. multocida infections. This retrospective survey of P. multocida infections in Israeli hospitals refers to the y 2000-2005. Clinical microbiologists were contacted by email and asked to perform a back-search of their hospital's records for isolates of P. multocida. The charts of patients growing P. multocida were abstracted into a structured questionnaire. 77 cases were identified in 12 hospitals, yielding an annual incidence of 0.19/100,000. The mean age was 49.2+/-26.5 y and the mortality rate was 2.6%. Those who died were >65 y of age, had diabetes mellitus or cirrhosis and were bacteraemic. One-third of the cases occurred in people aged > or =65 y. Cats caused most of these infections (54%). Surgery for debridement was common (53.7%), but no-one required amputation; a second- and third-look operation was necessary for these patients. Bacteraemia was found in 32.5% of patients and was significantly more common among those aged >60 y (p =0.044). Hospitalized patients with P. multocida have a favourable prognosis, apart from elderly and bacteraemic patients with comorbidities. Surgery and reoperations may be required in about half of the patients.

Hospital-acquired candiduria (HAC) is a well-known finding, related to severely ill patients, prolonged antibiotic treatment, use of catheters, and invasive procedures. However, the risk factors and clinical significance of community-acquired candiduria (CAC) has not yet been described. In this study, the prevalence and clinical characteristics of CAC and HAC were compared. Demographic and clinical data from all patients with positive urinary cultures sent to the bacteriology laboratory of the Haemek Medical Center, Israel, between May 2005 and October 2006 which grew Candida spp. were collected and analyzed. A total of 100,522 urine samples were received, 19,611 (19.5%) of which grew uropathogens. Among them, 204 (125 community-acquired and 79 hospital-acquired) grew Candida spp. (1% of all positive and 0.2% of all samples). Patients with CAC were younger than those with HAC (mean 50.5 years vs. 68.3 years). Pregnant women and bed-ridden patients were more prevalent in CAC (22.5% vs. 1.9% and 46.8% vs. 18.55%, respectively). More patients with HAC suffered from renal failure (27.8% vs. 11.2%) and fever (62.0% vs. 25.6%), had urinary catheters (32.9% vs. 15.2%), and received antibiotic or immunosuppressive therapy in the last month (73.4% vs. 46.4% and 10.1% vs. 3.2%). Most candiduria cases were not treated medically and no further investigation was conducted. Significant differences between patients with CAC and HAC were found. Our results confirm that candiduria (nosocomial as community-acquired) infrequently requires intervention. However, the identification of high-risk patients is desirable and questions regarding the management of candiduria, both CAC and HAC, still remain unresolved.

BACKGROUND:In October 2002, guidelines for empiric antibiotics in emergency room (ER) were introduced.AIMS:To evaluate physician's compliance with guidelines and their utility in improving patient care.METHODS:Reviewing charts of patients admitted to ER during October 4, 2004 to February 14, 2005 with suspected infection, subsequently hospitalized to internal medicine ward. Along with demographic data, the following parameters were recorded: Initiating antibiotics in ER, according-to-guidelines treatment (ATGT), lag-time between admittance and first antibiotic dose, diagnosis, proper coverage of pathogens by treatment (PCPT), and outcome.RESULTS:A total of 534 patients were admitted to ER with a suspected infection, 481 (90.1%) of them were managed according to guidelines, and from the 431 patients (80.7%) who received antibiotics, 381 (88.4%) were given ATGT. In 105 cases (19.7%), positive cultures (urine or blood) were obtained: 23.6% and 30.0% of the patients who received ATGT and not-ATGT, and the given antibiotic ensured proper coverage of the pathogen which grew in 73.3% and 46.7% of the cases, respectively. Percentages of good outcome (staying alive) for ATGT, non-ATGT, PCPT, and not-PCPT were 92.1%, 76.0%, 89.0%, and 69.0%, respectively. By multivariate analysis, early ATGT proved to be related to good outcome.CONCLUSIONS:Physicians' compliance with hospital guidelines to empiric antibiotics in ER was high. Adherence to guidelines was associated with a better outcome. Local susceptibility patterns to antibiotics need to be actively monitored. Prompt administration of antibiotics in the ER is likely to have a favorable outcome on survival, yet larger studies are required to establish this conclusively.

BACKGROUND:Resistance to fluoroquinolone drugs is emerging among E. coli causing community acquired urinary tract infections (COMA-UTI).OBJECTIVES:To evaluate demographic and clinical risk factors associated with COMA-UTI due to quinolone-resistant E. coli (QREc).METHODS:In this case-control study, clinical and demographic data from 300 COMA-UTI due to E. coli (including 150 QREc) were analyzed.RESULTS:By univariate analysis QREc was associated to males, older patients, nursing home residents, functionally dependent, dementia, diabetes, cardiovascular diseases, immunosupression, nephrolithiasis, recurrent UTI, invasive procedures, hospitalization, and antibiotic use within previous 6 months. By multivariate analysis, use of ciprofloxacin (OR 20.6 [CI 2.3-179.2], p=0.006) or ofloxacin (OR 7.5 [CI 2.9-19.4], p<0.0001), previous invasive procedure (OR 6.6 [CI 3.0-14.7], p<0.0001), recurrent UTI (OR 4.7 [CI 2.3-9.3], p<0.0001), and previous hospitalization (OR 2.9 [CI 1.4-6], p=0.003) were identified as independent risk factors for COMA-UTI due to QREc.CONCLUSION:In patients with one or more of the risk factors identified here, the empiric use of quinolones should be reconsidered.

Shigellosis is an acute infection of the intestine caused by bacteria in the genus Shigella and also an important cause of diarrhea in developing countries. This study was carried out to find the extent and nature of the emerging resistance in north part of Karnataka, India, and surrounding region with huge population, and also focused on the molecular mechanism of development of resistance against different generations of fluoroquinolones and explored the diversity of restriction endonucleases; we also tried to establish the significance of reduced minimal inhibitory concentrations (MIC) values.A total of 32 multidrug-resistant Shigella species (isolated from infants’ stools) were subjected to MICs of fluoroquinolone-resistant isolates done by both broth dilution and E-test method. The genes implicated in resistance to fluoroquinolone generations ciprofloxacin, ofloxacin, and gatifloxacin (gyrA, gyrB, parC, and parE) were amplified using polymerase chain reaction (PCR) method and restriction digestion analysis of PCR product were performed using PvuI and HaeII enzymes.Fluoroquinolone-resistant Shigella species (n = 32) comprising S dysenteriae, S flexneri, and S sonnei were selected for MIC; 90.6% (29/32), 93.75% (30/32), and 93.75% (30/32) of isolates were ciprofloxacin, ofloxacin, and gatifloxacin resistant and showed the MIC range from 4-128 μg/mL. The PCR amplification results were positive for all species and asserted the presence of gyrA, gyrB, parC, and pare and sizes of the amplified products. The restriction banding patterns of amplified resistant genes were employed to detect differences among the Shigella species.The present study found that the genetic basis and its characterization of fluoroquinolone resistance in Shigella isolates was considered for the common resistant genes, namely, gyrA, gyrB, parC, and pare, and had mutations at position 83 of gyrA and at position 80 of parC of the quinolone-resistant determining regions and associated molecular mechanism. Our study beneficial in identification of the causative agents of the infections, careful control and cautions use of antibiotics must be promoted, particularly to monitor the emergence of isolates that are fully resistant to fluoroquinolones.

A 48-year-old man presented with severe pain in the scrotum and right gluteal area. Three days earlier he had noted a small perianal abscess. The patient was a bike rider, smoker, and hypertensive with no alcohol consumption or diabetes and could recall no local trauma. On admission he was febrile (38 °C), tachycardic (115 bpm), and hypotensive (98/66 mmHg). Examination of the genitalia revealed swelling, redness, pain on palpating the right gluteal and perianal areas, crepitations (subcutaneous gas), a foul smell, and dark fluid droplets on the scrotal skin. Laboratory results showed a white blood cell count of 18,740 cells/mL (88% neutrophils); his coagulation, liver and kidney functions were normal. Physical examination and chest X-rays were normal. He was immediately treated with intravenous penicillin, clindamycin, and ofloxacin. A total scrotectomy, with wide resection of the necrotic fascias, tissues, and skin of the right gluteal and inguinal region was performed. The patient deteriorated abruptly developing septic shock; the necrotic and infectious process rapidly advanced through the retroperitoneal space. Despite intensive supportive care and repeated extensive surgical debridement, the patient died 36 h after admission. The resected tissue cultures showed aerobic and anaerobic bacteria. Blood and urine cultures were negative. Pathology showed necrotic skin, subcutaneous tissues, and abscess formation. Blood vessels within the specimen were partially obstructed by fibrin and thrombi. A positive HIV-test result (ELISA) and Western Blot was received after the patient died. Fournier's gangrene (FG) is a necrotizing fasciitis of the genitalia and scrotal region due to a mixed aerobic–anaerobic infection and was first described in 1883.1Roca B. Cunat E. Simon E. HIV infection presenting with Fournier's gangrene.Neth J Med. 1998; 53: 168-171Crossref PubMed Scopus (14) Google Scholar Predisposing illnesses are diabetes (60%), hypertension (55%), obesity, smoking, alcoholism, renal failure, and immunosuppression.2Ayumba B.R. Magoha G.A. Epidemiological aspects of Fournier's gangrene at Kenyatta National Hospital.Nairobi. East Afr Med J. 1998; 75: 586-589PubMed Google Scholar, 3Yeniyol C.O. Suelozgen T. Arslan M. Ayder A.R. Fournier's gangrene: experience with 25 patients and use of Fournier's gangrene severity index score.Urology. 2004; 64: 218-222Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar It has rarely been associated with HIV infection,1Roca B. Cunat E. Simon E. HIV infection presenting with Fournier's gangrene.Neth J Med. 1998; 53: 168-171Crossref PubMed Scopus (14) Google Scholar yet the relationship between them is questionable. Ayumba and Magoha2Ayumba B.R. Magoha G.A. Epidemiological aspects of Fournier's gangrene at Kenyatta National Hospital.Nairobi. East Afr Med J. 1998; 75: 586-589PubMed Google Scholar reported HIV as a comorbidity in 4% of FG patients. In addition, Elem and Ranjan4Elem B. Ranjan P. Impact of immunodeficiency virus (HIV) on Fournier's gangrene: observations in Zambia.Ann R Coll Surg Engl. 1995; 77: 283-286PubMed Google Scholar assumed that the presence of HIV infection does not affect the progression of FG. Our patient was a smoker and hypertensive; his HIV status was unknown on admission CD4 and viral-load were not measured. Most patients present later than 48 h after the onset of symptoms2Ayumba B.R. Magoha G.A. Epidemiological aspects of Fournier's gangrene at Kenyatta National Hospital.Nairobi. East Afr Med J. 1998; 75: 586-589PubMed Google Scholar with a fulminant progression causing multi-organ failure and death.1Roca B. Cunat E. Simon E. HIV infection presenting with Fournier's gangrene.Neth J Med. 1998; 53: 168-171Crossref PubMed Scopus (14) Google Scholar, 3Yeniyol C.O. Suelozgen T. Arslan M. Ayder A.R. Fournier's gangrene: experience with 25 patients and use of Fournier's gangrene severity index score.Urology. 2004; 64: 218-222Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar Histologic examination of FG suggests an ischemic necrosis, obliterative endarteritis, and thrombosis of pudendal arteries. Hemodynamic stabilization, empiric broad-spectrum antimicrobial therapy, and urgent aggressive surgical debridement remain the hallmarks of treatment.1 Hyperbaric oxygen therapy may decrease the extent of tissue destruction as an adjunctive therapy but could not be a substitute for surgery or antimicrobial therapy.1Roca B. Cunat E. Simon E. HIV infection presenting with Fournier's gangrene.Neth J Med. 1998; 53: 168-171Crossref PubMed Scopus (14) Google Scholar, 3Yeniyol C.O. Suelozgen T. Arslan M. Ayder A.R. Fournier's gangrene: experience with 25 patients and use of Fournier's gangrene severity index score.Urology. 2004; 64: 218-222Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar Our hospital does not have this technology, and a transfer was impossible since patient was hemodyanamically unstable and in need of urgent repeated surgeries. A patient's metabolic status, the extent of the disease at presentation, and the need for cystostomy/colostomy are important factors in the prognosis of FG;3Yeniyol C.O. Suelozgen T. Arslan M. Ayder A.R. Fournier's gangrene: experience with 25 patients and use of Fournier's gangrene severity index score.Urology. 2004; 64: 218-222Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar global mortality is still high (20–30%).1Roca B. Cunat E. Simon E. HIV infection presenting with Fournier's gangrene.Neth J Med. 1998; 53: 168-171Crossref PubMed Scopus (14) Google Scholar, 2Ayumba B.R. Magoha G.A. Epidemiological aspects of Fournier's gangrene at Kenyatta National Hospital.Nairobi. East Afr Med J. 1998; 75: 586-589PubMed Google Scholar, 3Yeniyol C.O. Suelozgen T. Arslan M. Ayder A.R. Fournier's gangrene: experience with 25 patients and use of Fournier's gangrene severity index score.Urology. 2004; 64: 218-222Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar Perineal arterial compression has been demonstrated in long distance cyclists;5Sommer F. Konig D. Graft C. Schwarzer U. Bertram C. Klotz T. et al.Impotence and genital numbness in cyclists.Int J Sports Med. 2001; 22: 410-413Crossref PubMed Scopus (80) Google Scholar our patient was a frequent bike rider. However, the relationship between bike riding and FG has not been established as a risk factor, so far. We speculate that repeated trauma to the perineum with an HIV-positive immunocompromised status could have been factors provoking a local trauma that led to a fatal infection. Conflict of interest: No conflict of interest to declare.

BACKGROUND:Staphylococcus saprophyticus is a leading cause of lower urinary tract infections (UTI) in young women in the USA, Canada and Scandinavian countries, but seems to be very rare in other countries like Israel. The goal of this study was to investigate the incidence of S. saprophyticus in Northern Israel and to compare demographic and clinical characteristics of patients with S. saprophyticus and Escherichia coli bacteriuria.PATIENTS AND METHODS:Data from all patients with S. saprophyticus bacteriuria isolated in two major laboratories in northern Israel during a 1-year period were analyzed and clinical and epidemiological findings from 129 patients with S. saprophyticus bacteriuria were compared to that of 129 patients with E. coli bacteriuria.RESULTS:The incidence of S. saprophyticus in our region was 0.09% among all urine cultures requested. Patients with S. saprophyticus bacteriuria are mainly young women, more likely suffering asymptomatic bacteriuria, complain less of dysuria and burning and are less hospitalized than those infected with E. coli. Reported risk factors associated to S. saprophyticus bacteriuria such us seasonal variation, occupation in meat products industry, use of contraceptives, or sexual activity were not found by us. No nasal, vaginal, or rectal carriage was demonstrated.CONCLUSION:S. saprophyticus is a very uncommon urinary pathogen in Northern Israel. The natural reservoir of this uropathogen in our region remains unknown.

Cylindrocarpon is a cosmopolitan soil fungus, which rarely causes human disease. It has infrequently been reported as causing keratitis, mycetoma, osteomyelitis and peritonitis in chronic peritoneal ambulatory dialysis patients and disseminated infection in leukemic neutropenic hosts. This report describes a case of invasive infection caused by Cylindrocarpon lichenicola, localized in the right foot of an otherwise immunocompetent traveler.

The clinical significance of low counts of enterococci in urine cultures remains unclear. The goal of this study was to investigate the clinical significance of enterococci growing in numbers lower than 100,000 colony-forming units per milliliter (cfu/ml) in urine samples. Clinical parameters were collected from patients whose midstream clean-catch urine samples grew Enterococcus spp. in amounts between ≥10,000 and 100,000 cfu/ml and who were not previously treated with antibiotics. Only those patients who had leukocyturia in addition to positive culture were considered to have true urinary tract infection (UTI). Of the 208 patients included in the study, 54% were diagnosed with true UTI. Patients with true UTI were older by 6 years (p=0.03), were more likely to be hospitalized (p=0.016), had higher rates of dysuria (p=0.0001), urgency (p=0.0001), and frequency (p=0.0001), and had more solid tumors (p=0.03). By multivariate analysis, urgency (OR=7.1) and hospitalization (OR=4.4) were identified as independent risk factors for true UTI with enterococci in low counts. Enterococcal counts in patients with true UTI were randomly distributed all along the scale between 10,000 and 100,000 cfu/ml, and no differential cutoff could be determined. In conclusion, more than half of the patients whose urine cultures grow Enterococcus spp. in counts lower than 100,000 cfu/ml may have true UTI, especially if they are hospitalized and have symptoms of dysuria, urgency, or frequency. Microbiology laboratories should perform a complete work-up on samples containing low counts of enterococci, and the final interpretation should be done by physicians, using additional clinical information.

Journal of the European Academy of Dermatology and VenereologyVolume 19, Issue 6 p. 763-764 Bullous haemorrhagic cellulitis caused by Enterobacter cloacae P Dyachenko, Corresponding Author P Dyachenko Department of Dermatology, Ha’emek Medical Center, Afula, * Corresponding author: Haagana 60, Afula-Ilit, Israel, 18580, tel. +972 4 6421472, fax +972 4 6494255; E-mail: pavela4@hotmail.comSearch for more papers by this authorM Ziv, M Ziv Department of Dermatology, Ha’emek Medical Center, Afula, Search for more papers by this authorS Kamil, S Kamil Department of Dermatology, Ha’emek Medical Center, Afula, Search for more papers by this authorR Dodiuk-Gad, R Dodiuk-Gad Department of Dermatology, Ha’emek Medical Center, Afula, Search for more papers by this authorB Chazan, B Chazan Infectious Diseases Unit, Ha’emek Medical Center, Afula, Israel. Search for more papers by this authorD Rozenman, D Rozenman Department of Dermatology, Ha’emek Medical Center, Afula, Search for more papers by this author P Dyachenko, Corresponding Author P Dyachenko Department of Dermatology, Ha’emek Medical Center, Afula, * Corresponding author: Haagana 60, Afula-Ilit, Israel, 18580, tel. +972 4 6421472, fax +972 4 6494255; E-mail: pavela4@hotmail.comSearch for more papers by this authorM Ziv, M Ziv Department of Dermatology, Ha’emek Medical Center, Afula, Search for more papers by this authorS Kamil, S Kamil Department of Dermatology, Ha’emek Medical Center, Afula, Search for more papers by this authorR Dodiuk-Gad, R Dodiuk-Gad Department of Dermatology, Ha’emek Medical Center, Afula, Search for more papers by this authorB Chazan, B Chazan Infectious Diseases Unit, Ha’emek Medical Center, Afula, Israel. Search for more papers by this authorD Rozenman, D Rozenman Department of Dermatology, Ha’emek Medical Center, Afula, Search for more papers by this author First published: 05 May 2005 https://doi.org/10.1111/j.1468-3083.2005.01246.xCitations: 4Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume19, Issue6November 2005Pages 763-764 RelatedInformation