Background: The worldwide introduction of pneumococcal conjugate vaccines (PCV) into National Immunization Programs resulted in rapid and substantial reduction of invasive pneumococcal disease (IPD) rates in children. However, the reduction of meningitis vs. non-meningitis IPD (nm-IPD) was not yet fully elucidated. We compared 7-valent and 13-valent PCV (PCV7 and PCV13) impact on pneumococcal-meningitis vs. nm-IPD in Israeli children <5 years.Methods: We conducted an ongoing nationwide, prospective, population-based, active surveillance. PCV7 and PCV13 were implemented in Israel in July 2009 and November 2010, respectively. All pneumococcal isolates (blood and/or CSF) from IPD episodes in children <5 years from July 2000 through June 2015 were included. Extrapolation for missing serotypes (34.7% of all isolates) was conducted.Results: 4163 IPD cases were identified; 3739 nm-IPD (89.8%) and 424 meningitis (10.2%). During the pre-PCV period (2000-2008), children <12 months constituted 52.1% and 33.7% of meningitis and nm-IPD, respectively (p < 0.001). The respective proportions of non-PCV13 serotypes (non-VT) were 18.2% vs. 10.1%, (p < 0.001).Comparing the last study year (2014-2015) to the mean of pre-PCV period, meningitis incidence in children <5 years decreased non-significantly by 27%, while nm-IPD decreased significantly by 69%. Dynamic rates of meningitis and nm-IPD caused by PCV13 serotypes were similar, with 93% and 95% overall reductions, respectively. However, non-VT increased in meningitis relatively to nm-IPD, mainly in children <24 months. Serotype 12F rose sharply and significantly since 2009-2010 through 2014-2015 (28.6% of all non-VT meningitis in children <24 m).Conclusions: The overall impact of PCV7/PCV13 in children <5 years in Israel was less prominent in meningitis than in nm-IPD. This could be attributed to the younger age of children with meningitis and differences in causative serotypes between the two groups, as the decline of the incidence of meningitis and nm-IPD caused by vaccine-serotypes is similar. Continuous monitoring of meningitis and nm-IPD is warranted. (C) 2016 Elsevier Ltd. All rights reserved.

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.

During a national outbreak of carbapenem-resistant Klebsiella pneumoniae (CRKP) in Israel, we conducted a point prevalence survey to determine the extent of asymptomatic carriage. Subsequently, a retrospective case-control study was done, comparing carriers of CRKP with non-carriers, in order to detect risk factors for carriage. Oral, perianal and rectal swabs were obtained from all hospitalised eligible and consenting patients. Selective media for carbapenem-resistant Gram-negative bacteria were used and pulsed-field gel electrophoresis (PFGE) helped to determine clonal source. Culture was obtained from 298 patients. Sixteen (5.4%) were carriers of CRKP, with a higher carriage rate in medical and surgical wards. Only 18% of carriers were treated with any carbapenem prior to the survey. Five of the 16 carriers had a positive clinical specimen for CRKP, hence a clinical infection versus asymptomatic carriage ratio of 1:3. The rectum was the most sensitive site sampled, detecting 15/16 carriers, and the overall sensitivity of the method was 94% with a negative predictive value of 99.6%. In a multivariate analysis of risk factors for CRKP carriage, three variables were significantly related to carriage state: diaper use, longer duration of hospital stay and vancomycin use. PFGE demonstrated that all 16 isolates were identical, confirming clonal origin. A point prevalence survey performed at a single medical centre during an outbreak of CRKP demonstrated a carriage rate of 5.4%. The clonal origin of these isolates suggests that strict adherence to isolation procedure may contain this outbreak.

Objective: To examine the reliability of "low-risk" criteria (LRC) to exclude serious bacterial infection (SBI) in febrile neonates (<= 28 days), according to age in weeks.Design: Epidemiological and clinical data and final diagnosis of all febrile neonates presenting to the emergency room from June 1997 to May 2006 were reviewed. Neonates who fulfilled specific LRC for the presence of SBI were classified as LRC+. The prevalence of SBI and the percentage of LRC+ neonates who had SBI were calculated for each of the first 4 weeks of life.Results: A total of 449 neonates were evaluated. Eighty-seven (19.4%) neonates had an SBI. The prevalence of SBI among infants 3-7, 8-14, 15-21 and 22-28 days of age was 21.6%, 26.1%, 17.9% and 12.1%, respectively (p = 0.007 for linear trend after second week of life). Of the 226 LRC+ neonates, 14 (6.2%) had an SBI, including one case of bacteraemia and meningitis and 13 cases of urinary tract infection (UTI). The negative predictive value (NPV) of the LRC for SBI was 93.8% (95% CI 90.1% to 96.4%). The prevalence of SBI among LRC+ infants 3-7, 8-14, 15-21 and 22-28 days of age was similar, with rates of 15%, 6.3%, 3.0% and 6.7%, respectively.Conclusion: LRC are not sufficiently reliable to exclude the presence of SBI, including bacteraemia and meningitis in febrile neonates of all ages. All febrile neonates should therefore be hospitalised, undergo a full "sepsis evaluation" and receive empirical intravenous antibiotic therapy.

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.

BACKGROUND:Cefepime, piperacillin-tazobactam and meropenem are among the broadest-spectrum and most expensive antimicrobials.AIM:To evaluate guidelines for appropriate use of these drugs.METHODS:We developed guidelines for use of these antibiotics, and conducted a two-phase drug utilization evaluation. We included all patients who received one of the study drugs during two 3-month periods, with an educational intervention in the intervening period. Appropriateness was determined for initiation of treatment, and for adaptation or continuation of established treatment.RESULTS:Overall, 205 patients received 271 courses with one of these antibiotics, for a total of 709 defined daily doses (DDD) of cefepime, 543 of piperacillin-tazobactam, and 680 of meropenem (8.3, 6.3 and 7.9 DDD/1000 admission days, respectively). Of these 271 courses, 234 were appropriate (86%). Treatment was continued for > or =5 days in 60%, of which 88% were appropriate (NS). Of the 271 courses, 210 (77%) were empirical (83% appropriate), while 61 (23%) were based on a relevant culture result (97% appropriate) (p < 0.001). Appropriateness differed significantly between departments (p < 0.001), and between the two phases (p < 0.001). The major difference between the two surveys was a decrease in meropenem usage (p < 0.05).DISCUSSION:The vast majority of courses with cefepime, piperacillin-tazobactam and meropenem are empirically selected and continued, underlying the importance of an optimal initial choice. Antibiotic guidelines, in conjunction with formal infectious disease consultation, can contribute to more appropriate use of these drugs.

Group A streptococcus (GAS) bacteraemia is often associated with soft-tissue infection, with significant morbidity and mortality. Little is known concerning the differences between adults and children with GAS bacteraemia. Records for 98 of 116 cases of GAS bacteraemia (60 adults and 38 children, aged 7 days to 96 years) occurring during a 10-year period (1993-2002) were located and reviewed. GAS bacteraemia comprised 0.6% of all bacteraemias in adults, compared to 3.3% in children (p < 0.001). The rate of adult GAS bacteraemia was two cases/1000 hospitalisations, compared to 13/1000 in children (p < 0.001). Seventy-six (78%) patients had concomitant tissue involvement, with skin or soft-tissue infection being the most common (62%). Fifty-three (88%) of 60 adults and five (13%) of 38 children had underlying conditions (p < 0.001). Twelve patients died, only one of whom was a child. Parameters associated with mortality were older age, lower temperature, hypotension, a need for surgical intervention, toxic shock syndrome, disseminated intravascular coagulation, thrombocytopenia, lymphopenia, hypocalcaemia, renal failure and acidosis (p < 0.05).

We conducted a retrospective, cohort-controlled study to evaluate the effect of extended-spectrum β-lactamase (ESBL) production by Enterobacteriaceae isolated from blood cultures, and of third or fourth generation cephalosporin treatment, on outcome.

The breached skin of most patients with atopic dermatitis is heavily colonized with Staphylococcus aureus.1Leung D.Y.M. Role of Staphylococcus aureus in atopic dermatitis.in: Leung D.Y.M. Bieber T. Atopic dermatitis. Marcel Dekker, Inc, New York2002: 401-418Google Scholar We present two cases of S. aureus bacteremia in patients with atopic dermatitis and review 17 other published cases of invasive S. aureus infections associated with atopic dermatitis. A 17-year-old male patient was admitted to our hospital with severe right shoulder pain, high fever, and chills. His medical history was significant only for atopic dermatitis, which he had since childhood. The leukocyte count was 19 500/mm3 with 95% granulocytes. A computed tomography scan of the shoulder was noncontributory. After blood cultures were taken, antibiotic treatment with intravenous ceftriaxone was started. Blood cultures yielded methicillin-sensitive S. aureus, and treatment was changed to intravenous cloxacillin. Bone scan with technetium99 showed no increased uptake, and transesophageal echocardiography revealed no pathology. On the eighth day of antibiotic treatment, a fluctuation was noted above the right shoulder; approximately 100 mL of pus was drained from a subcutaneous abscess, and S. aureus with identical antibiogram was isolated from this specimen. The patient was discharged to complete 4 weeks of intravenous home antibiotic therapy, and he subsequently completely recovered. A 36-year-old woman was brought to the emergency department after sudden onset of confusion and high fever. In the year before admission she began to have itching skin lesions on her extremities fulfilling the criteria for atopic dermatitis. The patient appeared confused with a systolic blood pressure of 80 mm Hg, nuchal rigidity, and few petechial lesions on her trunk and extremities. The white blood cell count was 18 000/mm3, and the platelet count was 64 000/mm3. A lumbar puncture yielded 850 white blood cells with 90% granulocytes and 250 red blood cells. The patient was intubated and admitted to the intensive care unit; intravenous ceftriaxone and acyclovir were initiated. Transesophageal echocardiography revealed large sessile vegetation on the posterior leaflet of the mitral valve. Cerebrospinal fluid and blood cultures yielded methicillin-sensitive S. aureus, and antibiotic treatment was changed to intravenous cloxacillin. After 4 weeks of antibiotic treatment, the patient successfully underwent mechanical mitral valve replacement and completely recovered. A MEDLINE search of articles published between 1966 and 2003 yielded an additional 12 cases of bacteremia2Pike M.G. Warner J.O. Atopic dermatitis complicated by acute bacterial endocarditis.Acta Pediatr Scand. 1989; 78: 463-464Crossref PubMed Scopus (17) Google Scholar, 3Grabczynska S.A. Cerio R. Infective endocarditis associated with atopic eczema.Br J Dermatol. 1999; 140: 1193-1194PubMed Google Scholar, 4Kobayashi H. Sugiuchi R. Tabata N. et al.Guess what! Acute infectious endocarditis with Janeway lesions in a patient with atopic dermatitis.Eur J Dermatol. 1999; 9: 239-240PubMed Google Scholar, 5Harada M. Nishi Y. Tamura S. et al.Infective endocarditis with a huge vegetation related atopic dermatitis and high serum level of infection-related antiphospholipid antibody a case report.J Cardiol. 2003; 42: 135-140PubMed Google Scholar, 6Conway D.S. Taylor A.D. Burrell C.J. Atopic eczema and staphylococcal endocarditis time to recognize an association?.Hosp Med. 2000; 61: 356-357PubMed Google Scholar, 7Onoda K. Mizutan H. Komada T. et al.Atopic dermatitis as a risk factor for acute native valve endocarditis.J Heart Valve Dis. 2000; 9: 469-471PubMed Google Scholar, 8Satchell A.C. Barnetson R.S. Staphylococcal septicaemia complicating treatment of atopic dermatitis with mycophenolate.Br J Dermatol. 2000; 143: 202-203Crossref PubMed Scopus (30) Google Scholar, 9Hoeger P.H. Ganschow R. Finger G. Staphylococcal septicemia in children with atopic dermatitis.Pediatr Dermatol. 2000; 17: 111-114Crossref PubMed Scopus (28) Google Scholar (Table 1) and 6 cases of musculoskeletal infections10Kitamura S. Nakayama Y. Shirai Y. et al.Septic arthritis of the hip associated with atopic dermatitis. A case report.J Nippon Med Sch. 2000; 67: 464-467Crossref PubMed Scopus (13) Google Scholar, 11Boiko S. Kaufman R.A. Lucky A.W. Osteomyelitis of the distal phalanges in three children with severe atopic dermatitis.Arch Dermatol. 1988; 124: 418-423Crossref PubMed Scopus (26) Google Scholar, 12Sharma A.K. Atopic dermatitis and Staphylococcus aureus-induced osteomyelitis-a peculiar association in a case.Pediatr Dermatol. 1997; 14: 453-455Crossref PubMed Scopus (10) Google Scholar, 13Nassif A. Smith D.L. Hanifin J.M. Olecranon and pretibial bursitis in atopic dermatitis coincidence or association?.J Am Acad Dermatol. 1994; 30: 737-742Abstract Full Text PDF PubMed Scopus (6) Google Scholar (Table 2) in patients with atopic dermatitis. Most of the cases with AD-associated invasive S. aureus infections involved children and adolescents who had severe atopic dermatitis since childhood.Table 1Case reports of patients with atopic dermatitis and bacteremiaCaseAuthor (reference)Age (y)/sexPreexisting heart diseaseAD characteristicsWBC per mm3 (neutrophils %)Fever (°C)Blood cultureDiagnosisSurgical treatment1Pike et al (2Pike M.G. Warner J.O. Atopic dermatitis complicated by acute bacterial endocarditis.Acta Pediatr Scand. 1989; 78: 463-464Crossref PubMed Scopus (17) Google Scholar)3.5/MVSDSevereNANAS. aureusIE – tricuspid v.Vegetectomy, VSD repair2Grabczynska et al (3Grabczynska S.A. Cerio R. Infective endocarditis associated with atopic eczema.Br J Dermatol. 1999; 140: 1193-1194PubMed Google Scholar)24/MPrevious IERecent flareNANAMSSAIE—3Kobayashi et al (4Kobayashi H. Sugiuchi R. Tabata N. et al.Guess what! Acute infectious endocarditis with Janeway lesions in a patient with atopic dermatitis.Eur J Dermatol. 1999; 9: 239-240PubMed Google Scholar)33/M—Adult onset18 300 (92)39.9MSSAIE – aortic v.Valve replacement4Harada et al (5Harada M. Nishi Y. Tamura S. et al.Infective endocarditis with a huge vegetation related atopic dermatitis and high serum level of infection-related antiphospholipid antibody a case report.J Cardiol. 2003; 42: 135-140PubMed Google Scholar)24/F—NANAFebrileMSSAIE – mitral v.Vegetectomy5Conway et al (6Conway D.S. Taylor A.D. Burrell C.J. Atopic eczema and staphylococcal endocarditis time to recognize an association?.Hosp Med. 2000; 61: 356-357PubMed Google Scholar)18/M—Moderate11 700 (89)39.0MSSAIE – mitral v.Valve replacement6Conway et al (6Conway D.S. Taylor A.D. Burrell C.J. Atopic eczema and staphylococcal endocarditis time to recognize an association?.Hosp Med. 2000; 61: 356-357PubMed Google Scholar)45/MMRRecent flareNANAMSSAIE – mitral v.Valve replacement7Onoda et al (7Onoda K. Mizutan H. Komada T. et al.Atopic dermatitis as a risk factor for acute native valve endocarditis.J Heart Valve Dis. 2000; 9: 469-471PubMed Google Scholar)16/M—Severe23 800 (90)39.5MRSAIE – aortic v.Valve replacement, annulus repair8Onoda et al (7Onoda K. Mizutan H. Komada T. et al.Atopic dermatitis as a risk factor for acute native valve endocarditis.J Heart Valve Dis. 2000; 9: 469-471PubMed Google Scholar)14/M—Severe13 80039.9S. aureusIE – mitral v.Vegetectomy, commissure repair9Satchell et al (8Satchell A.C. Barnetson R.S. Staphylococcal septicaemia complicating treatment of atopic dermatitis with mycophenolate.Br J Dermatol. 2000; 143: 202-203Crossref PubMed Scopus (30) Google Scholar)50/F—SevereNANAS. aureusIE – mitral v.Valve repair10Hoeger et al (9Hoeger P.H. Ganschow R. Finger G. Staphylococcal septicemia in children with atopic dermatitis.Pediatr Dermatol. 2000; 17: 111-114Crossref PubMed Scopus (28) Google Scholar)2/M—Severe15 000 (60)40.5MSSABacteremia, cellulitis—11Hoeger et al (9Hoeger P.H. Ganschow R. Finger G. Staphylococcal septicemia in children with atopic dermatitis.Pediatr Dermatol. 2000; 17: 111-114Crossref PubMed Scopus (28) Google Scholar)4/FVSDSevere17 300 (69)40.1MSSABacteremiaVSD repair12Current case 117/M—Moderate19 500 (95)38.0MSSABacteremia, skin abscessAbscess drainage13Current case 236/F—Adult onset18 100 (85)39.5MSSAIE, meningitisValve replacementAD, atopic dermatitis; WBC, white blood cell; VSD, ventricular septal defect; IE, infective endocarditis; MR, mitral regurgitation; NA, not available; V, valve; S. aureus, Staphylococcus aureus (antibiotic sensitivity not revealed); MSSA/MRSA, methicillin-sensitive/resistant Staphylococcus aureus. Open table in a new tab Table 2Case reports of patients with atopic dermatitis and musculoskeletal infectionsCaseAuthor (reference)Age (y)/sexAD characteristicsWBC per mm3 (neutrophils %)Fever (°C)Culture (joint, bone, bursa)DiagnosisSurgical treatment1Kitamura et al (10Kitamura S. Nakayama Y. Shirai Y. et al.Septic arthritis of the hip associated with atopic dermatitis. A case report.J Nippon Med Sch. 2000; 67: 464-467Crossref PubMed Scopus (13) Google Scholar)15/FRecent flare11 300 (72)38Staphylococcus aureusSeptic arthritis — hipJoint irrigation2Boiko et al (11Boiko S. Kaufman R.A. Lucky A.W. Osteomyelitis of the distal phalanges in three children with severe atopic dermatitis.Arch Dermatol. 1988; 124: 418-423Crossref PubMed Scopus (26) Google Scholar)3/MSevere11 900 (16)AfebrileMRSA, Streptococcus viridansOsteomyelitis — distal phalanxDebridement3Boiko et al (11Boiko S. Kaufman R.A. Lucky A.W. Osteomyelitis of the distal phalanges in three children with severe atopic dermatitis.Arch Dermatol. 1988; 124: 418-423Crossref PubMed Scopus (26) Google Scholar)4/FSevere14 000 (28)AfebrileMSSA, Streptococcus viridansOsteomyelitis — distal phalanxDebridement4Boiko et al (11Boiko S. Kaufman R.A. Lucky A.W. Osteomyelitis of the distal phalanges in three children with severe atopic dermatitis.Arch Dermatol. 1988; 124: 418-423Crossref PubMed Scopus (26) Google Scholar)2/FSevere12 500 (29)AfebrileMSSA, β hemolytic group B StreptococcusOsteomyelitis — nail plateDebridement5Sharma et al (12Sharma A.K. Atopic dermatitis and Staphylococcus aureus-induced osteomyelitis-a peculiar association in a case.Pediatr Dermatol. 1997; 14: 453-455Crossref PubMed Scopus (10) Google Scholar)4/MSevereNAAfebrileMSSAOsteomyelitis — fibulaDebridement6Nassif et al (13Nassif A. Smith D.L. Hanifin J.M. Olecranon and pretibial bursitis in atopic dermatitis coincidence or association?.J Am Acad Dermatol. 1994; 30: 737-742Abstract Full Text PDF PubMed Scopus (6) Google Scholar)60/MSevereNANAMRSASeptic bursitis — mid-tibial, olecranon—AD, atopic dermatitis; WBC, white blood cell; NA, not available; MSSA/MRSA, methicillin-sensitive/resistant Staphylococcus aureus. Open table in a new tab AD, atopic dermatitis; WBC, white blood cell; VSD, ventricular septal defect; IE, infective endocarditis; MR, mitral regurgitation; NA, not available; V, valve; S. aureus, Staphylococcus aureus (antibiotic sensitivity not revealed); MSSA/MRSA, methicillin-sensitive/resistant Staphylococcus aureus. AD, atopic dermatitis; WBC, white blood cell; NA, not available; MSSA/MRSA, methicillin-sensitive/resistant Staphylococcus aureus. The skin has been shown to be the portal of entry of S. aureus to the bloodstream,14Jensen A.G. Wachmann C.H. Espersen F. et al.Treatment and outcome of Staphylococcus aureus bacteremia a prospective study of 278 cases.Arch Intern Med. 2002; 162: 25-32Crossref PubMed Scopus (218) Google Scholar and S. aureus carriers are at higher risk for invasive S. aureus infections once the skin is breached.15Moreillon P. Que Y. Glauser M.P. Staphylococcus aureus.in: Mandell G.L. Bennett J.E. Dolin R. Principles and practice of infectious diseases. 6th ed. Churchill Livingstone, Philadelphia2005: 2321-2351Google Scholar In contrast with healthy subjects, in whom the skin is colonized with S. aureus in less than 5%,16Noble W.C. Valkenburg H.A. Wolters C.H. Carriage of Staphylococcus aureus in random samples of a normal population.J Hyg (Lond). 1967; 65: 567-573Crossref PubMed Scopus (135) Google ScholarS. aureus can be isolated from skin lesions of most patients with atopic dermatitis.1Leung D.Y.M. Role of Staphylococcus aureus in atopic dermatitis.in: Leung D.Y.M. Bieber T. Atopic dermatitis. Marcel Dekker, Inc, New York2002: 401-418Google Scholar Moreover, when this organism is present on intact skin, its density is usually low, whereas the density of S. aureus on acute exudative atopic dermatitis skin lesions can reach 107Onoda K. Mizutan H. Komada T. et al.Atopic dermatitis as a risk factor for acute native valve endocarditis.J Heart Valve Dis. 2000; 9: 469-471PubMed Google Scholar colony-forming units per cm2.17Leyden J.J. Marples R.R. Kligman A.M. Staphylococcus aureus in the lesions of atopic dermatitis.Br J Dermatol. 1974; 90: 525-530Crossref PubMed Scopus (703) Google Scholar Once attached to the skin, S. aureus secretes exotoxins with superantigenic properties that worsen atopic dermatitis.18Bunikowski R. Mielke M.E. Skarabis H. et al.Evidence for a disease-promoting effect of Staphylococcus aureus-derived exotoxins in atopic dermatitis.J Allergy Clin Immunol. 2000; 105: 814-819Abstract Full Text Full Text PDF PubMed Scopus (271) Google Scholar A deficiency in the expression of endogenous antimicrobial peptides in the skin of patients with atopic dermatitis, causing localized immunodeficiency, may account for the susceptibility of these patients to skin invasion with S. aureus.19Ong P.Y. Ohtake T. Brandt C. et al.Endogenous antimicrobial peptides and skin infections in atopic dermatitis.N Engl J Med. 2002; 347: 1151-1160Crossref PubMed Scopus (1611) Google Scholar Therefore, atopic skin provides a favorable environment for the colonization, proliferation, and invasion of S. aureus. A possible causal relationship between atopic dermatitis and invasive S. aureus infection is likely because in most of the reviewed cases atopic dermatitis was present in a severe form, thus facilitating a breach of the natural cutaneous barrier and increasing the risk for S. aureus penetration and spread. Moreover, the median age of patients with bacteremia was 22 years, which was much younger than that reported in other series of S. aureus bacteremia or endocarditis (55–70 years).14Jensen A.G. Wachmann C.H. Espersen F. et al.Treatment and outcome of Staphylococcus aureus bacteremia a prospective study of 278 cases.Arch Intern Med. 2002; 162: 25-32Crossref PubMed Scopus (218) Google Scholar, 20Chang F.Y. MacDonald B.B. Peacock Jr, J.E. et al.A prospective multicenter study of Staphylococcus aureus bacteremia incidence of endocarditis, risk factors for mortality, and clinical impact of methicillin resistance.Medicine. 2003; 82: 322-332Crossref PubMed Scopus (290) Google Scholar Extrapolating the risk for developing invasive S. aureus disease from other conditions in which S. aureus carriage is common, we hypothesize that atopic dermatitis is an underestimated risk factor for invasive S. aureus infection. Atopic dermatitis-associated invasive S. aureus infection is probably an underreported situation rather than an uncommon disease. We suggest that in patients with known atopic dermatitis who present with acute febrile illness without an apparent source or with localized pain, the diagnosis of invasive S. aureus infection should be sought.

We conducted surveys in 1997 and 2002 to determine the rate, underlying sources and outcome of nosocomial bacteraemia. Blood culture results were reviewed daily. All patients with positive cultures drawn >or=48 h after hospitalization were included in the study and their charts were reviewed. The underlying source of infection was determined by pre-defined clinical and/or microbiological criteria. Patients were followed until discharge or death. In 1997 and 2002, 851 and 857 patient-unique cases of bacteraemia were diagnosed, respectively, excluding contaminants; of these, 228 (27%) and 277 (32%) cases, respectively, were hospital acquired (P<0.05). The overall rate decreased from 7.5 to 7.0 per 1,000 admissions (P<0.001). The sources of bacteraemia in 1997 and 2002, respectively, were: intravascular catheters (36% and 27%, P<0.05), urinary tract (8% and 15%, P<0.05), respiratory tract (5% and 13%, P<0.01) and surgical sites (14% and 4%, P<0.001). In one-third of patients, the source of bacteraemia could not be determined. Only 52% and 54%, respectively, of these patients were discharged alive (difference was not significant). In 1997, Staphylococcus aureus was the most frequent isolate (26%), followed by coagulase-negative Staphylococcus (13%) and Klebsiella pneumoniae (11%). By 2002, the incidence of S. aureus had fallen to 11% (P<0.001), acinetobacter was the single most frequently isolated organism (increased from 6% to 17%) (P<0.001). In-hospital mortality associated with acinetobacter bacteraemia (57%) was significantly higher than that for other organisms (31-43%) (P<0.05). In conclusion, prospective surveys of nosocomial bacteraemias provide valuable information, facilitating the pursuit of successful interventions.

The records of children with Salmonella gastroenteritis only (n = 97), and those with associated bacteraemia (n = 64), seen in one medical centre during a 12-year period, were analysed retrospectively. Mean patient age was 2.24 +/- 2.8 years (range, 0.05-16 years), and 49% were male. Children with bacteraemia presented after a longer duration of symptoms (7.0 +/- 6.9 vs. 3.9 +/- 4.6 days, p 0.0002), and had higher erythrocyte sedimentation rates (45 +/- 22 vs. 33 +/- 22 mm/h, p < 0.02) and lactate dehydrogenase values (924 +/- 113 vs. 685 +/- 165 IU/L, p 0.001). There was a trend in bacteraemic children towards immunosuppression (6.3% vs. 1.0%, p 0.08) and a lower number of siblings (2.9 +/- 1.9 vs. 3.8 +/- 2.7, p 0.063). Non-bacteraemic children had a more severe clinical appearance, and a higher percentage had a moderate to bad general appearance (51.5 vs. 29.7%, p < 0.01), with dehydration (37.1 vs. 18.8%, p 0.02) and vomiting (58.8 vs. 39.0%, p 0.02). Laboratory dehydration indicators were also markedly worse in non-bacteraemic children, with urine specific gravity of 1020 +/- 9.4 vs. 1013 +/- 9.0 (p 0.0002), base excess of - 4.2 +/- 3.0 vs. - 2.5 +/- 3.4 mEq/L (p 0.01), and blood urea nitrogen of 10.1 +/- 7.0 vs. 7.4 +/- 4.5 mg% (p 0.002). Thus, the clinical presentation of bacteraemic children was more gradual, and associated gastroenteritis and dehydration was less pronounced. These findings may contribute in part to the inadvertent discharge of bacteraemic children from the emergency department.

Background: The incidence of congenital cytomegalovirus in Israel has never been determined, either in general or in relation to various population subgroups. We recently proved the utility of newborn urine polymerase chain reaction as a screening tool for congenital CMV.Objectives: To define the incidence of congenital CMV infection in two different subpopulations, as a model for the entire population of Israel.Methods: Urine specimens were randomly collected from 2,000 newborns in Shaare Zedek Medical Center, Jerusalem, and HaEmek Medical Center, Afula (1,000 specimens each). These hospitals have many characteristic differences, presumably representing the diverse population of Israel. Urine specimens were subjected to a CMV PCR reaction and positive specimens were validated by urine viral culture. Maternal seroprevalence was determined in a representative sample of the mothers in each hospital. Epidemiologic characteristics of the mothers were extracted from hospital records and compared.Results: The population in Shaare Zedek Medical Center was mostly Jewish (97.7%) and urban (87.0%), as compared to that of HaEmek Medical Center (49.2% and 61.0%, respectively, P < 0.01). Nevertheless, CMV seroprevalence was similar: 81.5% and 85%, respectively. Ten (1.0%) and 4 (0.4%) newborns, respectively, were found to have congenital CMV infection (not significant).Conclusions: The combined incidence of congenital CMV infection in the study population was 0.7% (95% confidence interval 0.3-1.0%). If this rate is extrapolated to the entire population of Israel, then a total of 945 cases of congenital CMV can be expected among the 135,000 annual deliveries. A nationwide screening program for congenital CMV should be considered.

A 1-year prospective study of patients with a positive blood culture and admitted through the emergency department (ED), was conducted to detect incidence and risk factors for resistance of Enterobacteriaceae to gentamicin and ciprofloxacin. A total of 245 emergency department-admitted patients had positive blood cultures, of which 131 (54%) grew Enterobacteriaceae. Of these 131 isolates, 32 (24%) were resistant to gentamicin and 37 (28%) to ciprofloxacin. Risk factors, by multivariate analysis, for gentamicin and ciprofloxacin resistance were: male gender (P<0.05 and P<0.01, respectively), nursing home residence (P<0.001), diabetes mellitus (P<0.05) and presence of a foreign body (P<0.05 and P<0.005). An additional risk factor for ciprofloxacin resistance was recent hospitalisation (P<0.05). These data facilitate optimal selection of empirical antibiotic treatment of suspected Gram-negative infections, and may contribute to improved patient outcome and optimal use of antibiotics.

Moraxella is an aerobic, oxidase-positive, Gram-negative coccobacillus, which is rarely associated with serious and invasive infections. We describe 4 cases of Moraxella lacunata endocarditis and review 12 previously published cases of Moraxella endocarditis, including 1 further case with M. lacunata, 5 with M. catarrhalis, 2 with M. phenylperuvica and the remainder consisting of 1 case each of M. liquefaciens, M. osloensis, M. nonliquefaciens and 1 non-specified. Of these 16 patients, 5 had prosthetic valves, 5 suffered from an underlying heart abnormality, and the other 6 had normal hearts. Therapy consisted of a beta-lactam antimicrobial and, in several instances, an aminoglycoside as well. The mean duration of antibiotic treatment was 35+/-13 d. Four patients (25%) underwent surgery and 4 out of 16 (25%) died. Moraxella should be added to the growing list of organisms which may occasionally cause infective endocarditis, even in patients without preexisting valvular abnormality.

Journal of Pediatric Gastroenterology and NutritionVolume 39, Issue S1 p. S49-S50 ABSTRACTS: Oral Presentation Abstracts O0108 THE COMBINATION OF HELICOBACTER PYLORI STRAIN AND TNF ALPHA POLYMORPHISM OF THE HOST INCREASES THE RISK OF PEPTIC ULCER DISEASE IN CHILDREN M. Wilschanski, M. Wilschanski Pediatric Gastroenterology, Hadassah University Hospital, Jerusalem, IsraelSearch for more papers by this authorY. Schlesinger, Y. Schlesinger Pediatric Infectious Diseases, Jerusalem, IsraelSearch for more papers by this authorB. Rudensky, B. Rudensky Microbiology Laboratory, Shaare Zedek Medical Center, Jerusalem, IsraelSearch for more papers by this authorJ. Faber, J. Faber Pediatric Gastroenterology, Shaare Zedek Medical Center, Jerusalem, IsraelSearch for more papers by this authorF. Ohnona, F. Ohnona Pediatric Infectious Diseases, Jerusalem, IsraelSearch for more papers by this authorS. Refael, S. Refael Pediatric Gastroenterology, Shaare Zedek Medical Center, Jerusalem, IsraelSearch for more papers by this authorS. Freier, S. Freier Pediatric Gastroenterology, Shaare Zedek Medical Center, Jerusalem, IsraelSearch for more papers by this authorD. Branski, D. Branski Pediatric Gastroenterology, Hadassah University Hospital, Jerusalem, IsraelSearch for more papers by this authorD. Halle, D. Halle Pediatric Gastroenterology, Shaare Zedek Medical Center, Jerusalem, IsraelSearch for more papers by this author M. Wilschanski, M. Wilschanski Pediatric Gastroenterology, Hadassah University Hospital, Jerusalem, IsraelSearch for more papers by this authorY. Schlesinger, Y. Schlesinger Pediatric Infectious Diseases, Jerusalem, IsraelSearch for more papers by this authorB. Rudensky, B. Rudensky Microbiology Laboratory, Shaare Zedek Medical Center, Jerusalem, IsraelSearch for more papers by this authorJ. Faber, J. Faber Pediatric Gastroenterology, Shaare Zedek Medical Center, Jerusalem, IsraelSearch for more papers by this authorF. Ohnona, F. Ohnona Pediatric Infectious Diseases, Jerusalem, IsraelSearch for more papers by this authorS. Refael, S. Refael Pediatric Gastroenterology, Shaare Zedek Medical Center, Jerusalem, IsraelSearch for more papers by this authorS. Freier, S. Freier Pediatric Gastroenterology, Shaare Zedek Medical Center, Jerusalem, IsraelSearch for more papers by this authorD. Branski, D. Branski Pediatric Gastroenterology, Hadassah University Hospital, Jerusalem, IsraelSearch for more papers by this authorD. Halle, D. Halle Pediatric Gastroenterology, Shaare Zedek Medical Center, Jerusalem, IsraelSearch for more papers by this author First published: 01 June 2004 https://doi.org/10.1002/j.1536-4801.2004.tb12416.x Submitted by: [email protected] Read 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 onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Reference(S): (1)J Pediatr Gastro Nutr 35: 680–684; 2002. 10.1097/00005176-200211000-00018 PubMedWeb of Science®Google Scholar Volume39, IssueS1June 2004Pages S49-S50 ReferencesRelatedInformation

Background: Treatment regimens for Helicobacter pylori have variable success rates, and data comparing effectiveness with respect to strain sensitivity are relatively scarce.Objective: To evaluate the efficacy of two treatment regimens for eradication of H. pylori and the impact of bacterial susceptibility testing. Study Design: 265 children endoscopically diagnosed with H. pylori infection were randomly assigned to receive omeprazole + amoxicillin with clarithromycin or omeprazole + amoxicillin with metronidazole. Bacterial culture and susceptibility was performed in a subgroup. Eradication was assessed by C-13-urea breath test.Results: Eradication was achieved in 73.4% by omeprazole + amoxicillin with metronidazole and in 62.6% by omeprazole + amoxicillin with clarithromycin (P = 0.078). H. pylori was cultured successfully in 105 patients. Resistance to metronidazole was detected in 31.4% of the isolates and resistance to clarithromycin in 15%. Eradication rate by omeprazole + amoxicillin with metronidazole for metronidazole-susceptible bacteria (N = 38) was 90%, and for resistant bacteria (N = 19) it was 42%. Only 75% of clarithromycin-sensitive strains were successfully treated by omeprazole + amoxicillin with clarithromycin, and none of the cases with clarithromycin-resistant strains responded to omeprazole + amoxicillin with clarithromycin treatment.Conclusion: There is a trend of greater efficacy of eradication with omeprazole + amoxicillin with metronidazole versus omeprazole + amoxicillin with clarithromycin therapy. Although resistance negatively influences eradication, first-line sensitivity-based treatment would be expected to improve this rate only slightly. Susceptibility testing should probably be reserved only for treatment failures. (c) 2005 Lippincott Williams & Wilkins.

Background: Nasal colonization with methicillin-resistant Staphylococcus aureus in the community is being increasingly reported, but there is a general lack of data on MRSA colonization in children in chronic care institutions and on colonization rates in Israeli children.Objectives: To define the rate of MRSA nasal colonization in a generally healthy pediatric population in Jerusalem, to compare it with that of children in chronic care institutions, to define risk factors for colonization, and to compare community and hospital-acquired MRSA strains.Methods: Anterior nares culture for the presence of methicillin-sensitive and methicillin-resistant S. aureus was taken from 831 healthy children attending primary pediatric clinics or emergency departments and from 118 children hospitalized in three chronic care institutions in Jerusalem.Results: Of the 831 healthy children, 195 (23.5%) were colonized with S. aureus, as compared to 43 of 118 (36.4%) chronically institutionalized children (P < 0.005). Five of the 195 S. aureus isolates from healthy children (2.6%) were MRSA, as compared to 9 of 43 (21%) from chronically institutionalized children (P < 0.001). Older age and a family member who is a healthcare worker were associated with S. aureus colonization in the population of healthy children, and older age was associated with MRSA colonization in the chronically institutionalized children. The antibiotic susceptibility pattern was similar for both groups, and pulsed field gel electrophoresis of the isolates showed a wide and random distribution in both groups.Conclusions: MRSA colonization in the studied pediatric community in Jerusalem was very low, whereas that of patients hospitalized in chronic rare institutions was significantly higher. In the small number of isolates detected, no significant differences were found in antibiotic susceptibility or PFGE pattern between hospital-acquired and community-acquired strains.

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.

Objectives: To define the incidence of congenital cytomegalovirus (CMV) infection in a defined population in Israel as diagnosed by urine polymerase chain reaction (PCR), and to assess the utility of this method for screening for congenital CMV infection. Design: A convenient sample of urine specimens from asymptomatic newborns were subjected to CMV PCR. Positive results were validated by urine tube culture and by determination of serum CMV IgM antibodies. Maternal CMV IgG was determined in a representative sample of mothers. Newborns with positive urine specimens underwent full clinical evaluation. Epidemiological characteristics of the mothers were extracted from the medical records. Settings: Two medical centres in Israel with different population characteristics. Patients: A total of 2000 newborns (1000 in each medical centre). Main outcome measure: Presence of CMV DNA in the urine. Results: Despite significant epidemiological differences between the populations in the two hospitals, the CMV seroprevalence was similar, 80.5% and 85%. Fourteen of the 2000 newborns screened (0.7%) were PCR positive. Urine culture was positive in nine of 10 specimens; IgM was positive in only two of 13 newborns with positive PCR. Eleven newborns underwent full or partial evaluation, and only one (9%) was symptomatic. Conclusions: The incidence of congenital CMV infection in the study population was 0.7%; over 90% were asymptomatic. Urinary CMV PCR is a reliable, rapid, and convenient method, and thus may serve as a screening tool for the detection of congenital CMV infection.