Unmasking Myocardial Dysfunction in Patients Hospitalized for Community-Acquired Pneumonia Using a 4-Chamber 3-Dimensional Volume/Strain Analysis.

Lower respiratory infection was reported as the most common fatal infectious disease. Community-acquired pneumonia (CAP) and myocardial injury are associated; yet, true prevalence of myocardial injury is probably underestimated. We assessed the rate and severity of myocardial dysfunction in patients with CAP. Admitted patients diagnosed with CAP were prospectively recruited. All the patients had C-reactive protein (CRP), brain natriuretic peptide (BNP), and high-sensitivity cardiac troponin (hs-cTnl) tests added to their routine workup. 2D/3D Doppler echocardiography was done on a Siemens Acuson SC2000 machine ≤ 24 h of diagnosis. 3D datasets were blindly analyzed for 4-chamber volumes/strains using EchobuildR 3D-Volume Analysis prototype software, v3.0 2019, Siemens-Medical Solutions. Volume/strain parameters were correlated with admission clinical and laboratory findings. The cohort included 34 patients, median age 60 years (95% CI 55-72). The cohort included 18 (53%) patients had hypertension, 9 (25%) had diabetes mellitus, 7 (21%) were smokers, 7 (21%) had previous myocardial infarction, 4 (12%) had chronic renal failure, and 1 (3%) was on hemodialysis treatment. 2D/Doppler echocardiography findings showed normal ventricular size/function (LVEF 63 ± 9%), mild LV hypertrophy (104 ± 36 g/m2), and LA enlargement (41 ± 6 mm). 3D volumes/strains suggested bi-atrial and right ventricular dysfunction (global longitudinal strain RVGLS = - 8 ± 4%). Left ventricular strain was normal (LVGLS = - 18 ± 5%) and correlated with BNP (r = 0.40, p = 0.024). The patients with LVGLS > - 17% had higher admission blood pressure and lower SaO2 (144 ± 33 vs. 121 ± 20, systolic, mmHg, p = 0.02, and 89 ± 4 vs. 94 ± 4%, p = 0.006, respectively). hs-cTnl and CRP were not different. Using novel 3D volume/strain software in CAP patients, we demonstrated diffuse global myocardial dysfunction involving several chambers. The patients with worse LV GLS had lower SaO2 and higher blood pressure at presentation. LV GLS correlated with maximal BNP level and did not correlate with inflammation or myocardial damage markers.

The microbial diversity following antibiotic treatment of Clostridioides difficile infection.

BACKGROUND: Clostridioides difficile (C. difficile) is a major nosocomial pathogen that infects the human gut and can cause diarrheal disease. A dominant risk factor is antibiotic treatment that disrupts the normal gut microbiota. The aim of the study was to examine the correlation between antibiotic treatment received prior to C. difficile infection (CDI) onset and patient gut microbiota. METHODS: Stool samples were collected from patients with CDI, presenting at the Baruch Padeh Medical Center Poriya, Israel. Demographic and clinical information, including previous antibiotic treatments, was collected from patient charts, and CDI severity score was calculated. Bacteria were isolated from stool samples, and gut microbiome was analyzed by sequencing the 16S rRNA gene using the Illumina MiSeq platform and QIIME2. RESULTS: In total, 84 patients with CDI were enrolled in the study; all had received antibiotics prior to disease onset. Due to comorbidities, 46 patients (55%) had received more than one class of antibiotics. The most common class of antibiotics used was cephalosporins (n = 44 cases). The intestinal microbiota of the patients was not uniform and was mainly dominated by Proteobacteria. Differences in intestinal microbiome were influenced by the different combinations of antibiotics that the patients had received (p = 0.022) CONCLUSIONS: The number of different antibiotics administered has a major impact on the CDI patients gut microbiome, mainly on bacterial richness.

Tinea capitis in an immigrant pediatric community; a clinical signs-based treatment approach.

BACKGROUND: Tinea capitis is a common cutaneous infection of the scalp and hair follicles, typically diagnosed by direct examination and culture. Treatment with oral antifungals is usually withheld until mycology results are available. In Israel, African refugee children demonstrate higher susceptibility to Tinea capitis and generally fail to undergo follow-up evaluations. METHODS: This study aimed to identify the clinical characteristics and treatment responses of refugee children in Israel with Tinea capitis, in order to formulate a treatment plan for primary care physicians. To this end, demographic, clinical and laboratory data were extracted from the electronic medical records of 76 refugee children presenting with Tinea capitis during 2016-2017. All measured variables and derived parameters are presented using descriptive statistics. The correlation between background clinical and demographic data and Tinea capitis diagnosis was assessed using the chi-squared and Wilcoxon tests. Correlations between demographic/clinical/laboratory characteristics and other types of fungi or other important findings were assessed using a T-test. RESULTS: Scaling was the most common clinical finding. Cultures were positive in 64 (84%) and direct examination in 65 (85%) cases, with a positive correlation between the methods in 75% of cases. The most common fungal strain was T. violaceum. Fluconazole treatment failed in 27% of cases. Griseofulvin 50 mg/kg/day was administered to 74 (97%) children, and induced clinical responses. No side effects were reported. CONCLUSIONS: The key aim of this study was to emphasize the importance of diagnosis and treatment of these immigrant children by their primary pediatric doctor since it takes, an average of 4.3 months until they visit a dermatologist. During this critical time period, the scalp can become severely and permanently damaged, and the infection can become systemic or cause an outbreak within the entire community. In conclusion, we recommend to relate to scaly scalp in high-risk populations as Tinea capitis, and to treat with griseofulvin at a dosage of up to 50 mg/kg/day, starting from the first presentation to the pediatrician.

Detection of group a Streptococcus in pharyngitis by two rapid tests: comparison of the BD Veritor™ and the QuikRead go® Strep A.

We compared the performance of two rapid antigen tests-QuikRead go® Strep A test (Orion Diagnostica, Espoo, Finland) and BD Veritor™ system (Becton, Dickinson and Company, Sparks, MD) with throat culture. Our aim was to evaluate each assay's performance and agreement compared to throat culture in order to choose one of the assays as a point-of-care test in the emergency room. One hundred throat samples were collected in triplicates from patients with suspected pharyngitis admitted to the emergency room. One throat swab was seeded for a throat culture. The other two throat swabs from each patient were analyzed at the emergency room by the QuikRead go® Strep A test, and by the BD Veritor™ system, according to each manufacturer's instructions. Agreement level between BD Veritor™ test and throat culture was 79%; sensitivity and specificity of this test were 80% and 78.7%, respectively. QuikRead go® Strep A test had an agreement level of 75% with throat culture; sensitivity and specificity of this test were 80% and 73.3%, respectively. Both tests have a good diagnostic performance. Other characteristics such as costs, size of instrument, and ease of implementation should be taken into consideration when choosing a point-of-care test.

Cheap and rapid in-house method for direct identification of positive blood cultures by MALDI-TOF MS technology.

BACKGROUND: Rapid and accurate pathogen identification in blood cultures is very important for septic patients and has major consequences on morbidity and mortality rates. In recent years, matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS)-based technology has become useful for highly specific and sensitive identification of bacteria and yeasts from clinical samples including sterile body fluids. Additional in-house methods enabled direct identification from blood cultures following various preparation protocols. METHODS: Blood culture (5 ml) was harvested from each positive bottle following growth identification by BACTEC™ FX system and transferred into a VACUETTE® Z Serum Sep Clot Activator tube containing an inert gel, which following centrifugation separates microorganisms from the blood cells. We used MALDI-TOF MS analysis for identification of microorganisms collected from the gel surface. RESULTS: Positive blood culture bottles (186) were collected. In comparison with the routine method, 99% (184/186) and 90% (168/186) of the isolates were correctly identified by the SepsiTyper kit and the in-house method, respectively. We found high concordance (Pearson coefficient = 0.7, p <  0.0001) between our in-house method and the SepsiTyper kit. Additionally, high correlation was found in sub-groups of identified bacteria, with Pearson coefficients of 0.77 (p <  0.0001), 0.67 (p <  0.0001), and 0.73 (p <  0.007) for Gram negative, Gram positive, and anaerobic bacteria, respectively. CONCLUSIONS: Our in-house method was found to be in good agreement with the SepsiTyper kit. Considering the low costs and the rapid and easy implementation of this procedure, we propose our in-house method for the direct identification of bacteria from blood cultures.

Presence of anaerobic bacteria in the urinary tract of catheterized ICU patients.

The purpose of our study was to examine the extent of anaerobic bacteriuria in catheterized patients in the intensive care unit (ICU) and to search for risk factors for anaerobic bacteriuria. A urine culture was collected from each patient every 2 days during their ICU stay and incubated under aerobic and anaerobic conditions. Aerobic and anaerobic blood cultures were collected as well. Demographic, clinical, and laboratory data were collected from patient files. Ninety patients were included in this study, 32 women (35.6%) and 58 men (64.4%). A total of 663 cultures were obtained. Twenty-three patients (25.6%) had growth of anaerobic bacteria in a urinary culture at some point during ICU stay, with Bifidobacterium being the most common pathogen. Aerobic urinary cultures were positive in 38 patients (42.2%). A significant statistical correlation was found between the presence of aerobic and anaerobic bacteria in urine culture (p = 0.0004). Treatment with glycopeptides was found to be inversely associated with anaerobic bacteriuria (p = 0.0292), and treatment with imidazoles was associated with an increased risk of anaerobic bacteriuria (p = 0.0186). None of the patients developed bacteremia with the same anaerobic pathogen that was isolated from their urine. Anaerobic bacteriuria is a common phenomenon in catheterized patients in the ICU. Further studies are needed in order to define the clinical significance of these findings in such patients and in other patient groups as well as in healthy people.

Antimicrobial susceptibility of Campylobacter jejuni and Campylobacter coli: comparison between Etest and a broth dilution method.

BACKGROUND: Campylobacter is a leading cause of foodborne gasteroenteritis worldwide. Antimicrobial susceptibility testing for Campylobacter spp. is not routinely performed by most clinical laboratories. However, the emergence of resistant isolates strengthens the importance of antimicrobial susceptibility testing and the critical need for epidemiologic surveillance. The aim of this study was to compare the efficacy of Etest and Sensititre kit (a broth microdilution method) as methods for susceptibility tests and the critical need for epidemiologic surveillance. The aim of this study was to compare the efficacy of Etest and Sensititre kit (a broth microdilution method) as methods for susceptibility testing of Campylobacter spp. to tetracycline, erythromycin, and ciprofloxacin. METHODS: Sixty-six Campylobacter isolates were collected from feces samples and subjected to susceptibility testing by Etest and Sensititre, a broth microdilution kit for tetracycline, erythromycin, and ciprofloxacin. Minimal inhibitory concentration (MIC) results of each method were determined and compared. RESULTS: Similar MIC interpretations for tetracycline, erythromycin, and ciprofloxacin were found in 97%, 98.5%, and 100% of the isolates, respectively, indicating a good level of agreement between Etest and Sensititre (p < 0.0001); additionally, the correlation between the two methods was highly significant for the three tested antibiotics (p < 0.0001). CONCLUSIONS: Both the broth microdilution and the Etest are reliable and convenient methods for testing antimicrobial susceptibility of Campylobacter spp. The Sensititre kit has the advantages of high availability and the automation.

Infectious disease burden and antibiotic prescribing in primary care in Israel.

BACKGROUND: Antibiotics are frequently prescribed at many of the visits to primary care clinics, often for conditions for which they provide no benefit, including viral respiratory tract infections. OBJECTIVES: The aim was to evaluate primary care visits due to infectious diseases, and to estimate antibiotic prescribing and antibiotic dispensing by pharmacies. METHODS: Diagnosis of infectious disease, antibiotic prescribing and dispensing data at the individual patient level were extracted for 2015 from Clalit Health Services' electronic medical records and linked to determine the condition for which the antimicrobial was prescribed. RESULTS: There were 6.6 million visits due to infections, representing 22% of all primary care visits. The most common events were upper respiratory tract infections (38%) and pharyngitis (10%). Highest prescription rates were for urinary tract infections (80%), otitis media (64%), pharyngitis (71%), sinusitis (63%), and lower respiratory tract infections (76%). The highest rates of undispensed prescriptions were for acute gastroenteritis, urinary tract infections, and pharyngitis (24, 23, and 16%, respectively). CONCLUSIONS: Infectious diseases constitute a heavy burden on primary care, with overprescribing of antibiotics. Intervention to reduce unwarranted antibiotic use is needed. In pediatric care, interventions should focus on better controlling antibiotic consumption and encouraging adherence to guidelines for upper respiratory tract infections, pharyngitis, and otitis media. In adults interventions should aim to monitor antibiotic prescribing for upper respiratory tract infections and improve adherence to guidelines for urinary tract infections.

Bloodstream Infections Caused by Contaminants: Epidemiology and Risk Factors: A 10-Year Surveillance.

BACKGROUND: Skin colonization of microorganisms in blood cultures (BCs) are generally considered clinically non-significant and can be the source of a true infection, particularly in immunosuppressed patients. OBJECTIVES: To study the epidemiology and risk factors for bacteremia caused by contaminants. METHODS: This retrospective, descriptive study is based on adult BCs collected (2004-2013) and categorized as positive (True bacteremia [TrueB] or contamination) or negative. Clinical, demographic, and laboratory characteristics of BCs positive for the six most common potential contaminant pathogens (PCPs) that can cause TrueB and contamination (Coagulase-negative Staphylococcus [CoNS], Streptococcus viridans, Propionibacterium acnes, Corynebacterium spp., Bacillus spp., Clostridium spp.) were assessed. Ninety-two TrueB were identified vs. 196 contaminations (1:2 ratio). RESULTS: From 74,014 BCs, PCPs were found in 3735 samples, of which 3643 (97.5%) were contaminations and 92 (2.5%) were TrueB. The overall rate of BC contamination decreased during the study period from 6.7% to 3.8%. CoNS was the most common PCP. Bacillus spp. were only contaminants. Clostridium spp. and Streptococcus viridans were more often TrueB. In a multivariate model, predictors of TrueB included high creatinine levels, Streptococcus viridans in BC, and multiple positive BCs. A single culture of CoNS was strongly predictive of contamination. CONCLUSIONS: Ten years of data on BCs, focusing on six PCPs, demonstrates a significant, yet insufficient reduction in the rate of contamination. High creatinine level, isolation of Streptococcus viridans, and multiple positive BCs were predictors of TrueB, while growth of CoNS was strongly predictive of contamination. This model could assist in diagnostic and therapeutic decision making.

Correlation between fecal calprotectin levels, disease severity and the hypervirulent ribotype 027 strain in patients with Clostridium difficile infection.

BACKGROUND: Clostridium difficile is the most common infectious etiology of nosocomial diarrhea. Fecal calprotectin (fc) is a sensitive marker of intestinal inflammation, found to be associated with enteric bacterial infections and inflammatory bowel disease. METHODS: We evaluated fc levels using a Chemiluminescent immunoassay method, in hospitalized patients with C. difficile infection (CDI) diagnosed by molecular stool examination and assessed correlation with virulent ribotype 027 strain infection, antibiotic susceptibility by gradient Etest strip performed on C. difficile colonies and clinical and laboratory measures of disease severity. Statistical analysis was performed for correlation of fc levels with clinical and laboratory parameters, disease severity and patient outcomes. RESULTS: Overall 29 patients with CDI were admitted at the Poria medical center in northern Israel, during June 2014-May 2015. Resistance to metronidazole was found in 3 (10.3 %) isolates and to vancomycin in 5 (17.2 %) isolates. Regarding patient outcomes, within 30 days of CDI diagnosis, recurrence of disease occurred in 10 (34.5 %) patients and 2 patients (6.9 %) died. Seven (24.1 %) isolates were C. difficile ribotype 027. Mean fc level was 331.4 µg/g (21-932). Higher fc levels were found in patients with C. difficile ribotype 027 (p < 0.0005). Fc levels were also correlated with elevated peripheral blood white cell count (p = 0.0007). A trend for higher fc levels was found in patients with a higher clostridium severity score index (p = 0.0633). No correlation was found between fecal calprotectin levels and age, sex, functional status, community versus hospital acquired CDI, antibiotic susceptibility, fever, and creatinine levels. CONCLUSIONS: Our study highlights the fact that fc has a potential role as a biomarker of disease severity and binary toxin producing ribotype associated disease.

Seasonal Influenza Vaccination Effectiveness and Compliance among Hospital Health Care Workers.

BACKGROUND: Recent studies show that vaccination of health care workers (HCW) might reduce influenza transmission and mortality among hospitalized patients. No studies have compared the incidence of laboratory-proven influenza in vaccinated versus unvaccinated hospital HCW. OBJECTIVES: To evaluate the effectiveness of influenza vaccination among hospital HCW and to examine the attitudes of this population towards influenza vaccination. METHODS: We performed a prospective cohort study between 1 January and 30 April 2014 of 1641 HCW at our medical center; 733 were vaccinated and 908 were not. A random sample of 199 subjects was obtained: 97 vaccinated and 102 non-vaccinated. Participating individuals were contacted on a weekly basis during the flu season and were asked to report any respiratory or flu symptoms and, if positive, to undergo a polymerase chain reaction (PCR) test for influenza. Results: In the general HCW population vaccination was more frequent among physicians (298/498, 58%) than among nurses (324/862, 38%) and among males than females. Flu symptoms were reported by 20 of 199 participants, 13 in the non-vaccinated group (12.7%) and 7 in the vaccinated group (7.2%). A positive PCR test for influenza A virus was present in 4 of 20 people tested (20%). All positive cases were from the non-vaccinated group (P = 0.0953). CONCLUSIONS: Non-vaccinated HCW showed a higher, although not statistically significant, tendency for contracting laboratory-proven influenza than the vaccinated population. The main reasons for vaccination and non-vaccination were personal beliefs and habits. Education efforts are needed to improve compliance. Larger studies could further clarify this issue.

Chloramphenicol use and susceptibility patterns in Israel: a national survey.

BACKGROUND: Due to increasing antimicrobial resistance, there has been renewed interest in old drugs that have fallen into disuse because of toxic side effects. One such drug is chloramphenicol. Data on the use and susceptibility patterns to chloramphenicol in developed countries in recent years are limited. OBJECTIVES: To assess the susceptibility of bacteria to chloramphenicol, and evaluate the use of chloramphenicol in Israeli hospitals as influenced by infectious disease specialists' attitudes with regard to its potential harms. METHODS: A national survey was conducted in all Israeli hospitals. Questionnaires were sent to the directors of infectious disease units and included items on chloramphenicol susceptibility in clinical isolates, use of chloramphenicol for the treatment of inpatients, local recommendations for use of chloramphenicol, and concerns regarding side effects. RESULTS: Chloramphenicol is used in 83.3% of hospitals, mostly for the treatment of aspiration pneumonia. While 22.2% of infectious disease unit directors believe that chloramphenicol should be avoided because of dangerous side effects, 88.9% believe there is a place for chloramphenicol in the treatment of patients in this era of increasing antibiotic resistance. Chloramphenicol susceptibility is routinely assessed in 44.4% of hospitals, with high susceptibility rates found among gram-positive, gram-negative and anaerobic bacteria. CONCLUSIONS: In an era of increasing antibiotic resistance, many Israeli infectious disease unit directors believe that chloramphenicol has a role in the treatment of respiratory tract and other infections in hospitalized patients.

[Sarcoidosis presenting with recurrent aseptic meningitis and acute hearing loss].

Neurologic complications occur in 5% of patients with sarcoidosis. Neurosarcoidosis ranges from mild neurologic deficits to a destructive, life-threatening disease, and at times is the only presenting symptom of sarcoidosis, thus posing a diagnostic challenge for the doctor neurologic symptoms include cranial nerve palsies, with the vestibulocochlear nerve rarely being involved. We present a patient with neurosarcoidosis manifesting as recurrent episodes of aseptic meningitis, vertigo, and acute hearing loss.

Non-therapeutic anti-FXa levels are common among medical ward patients treated with enoxaparin.

Thromboembolism is treated with a weight-adjusted enoxaparin dose without the need for laboratory monitoring. This study aims to determine the prevalence of sub and supra-therapeutic anti-factor Xa (aFXa) levels among medical ward patients treated with enoxaparin, and to identify potential factors associated with non-therapeutic aFXa levels. aFXa levels were measured in a cohort of medical ward patients treated with curative enoxaparin regimen (1 mg/kg bid) in the Ha'emek Medical Center in the northeastern area of Israel. The relative risk (RR) ratio for sub and supra-therapeutic aFXa levels was estimated in demographic and clinical subgroups. Of the 294 included patients, only 78.6% had therapeutic aFXa levels, while 13.3% and 8.1% had sub and supra-therapeutic levels, respectively. On univariate analysis, females, smoking, BMI ≥ 30, and cancer were significantly associated with supra-therapeutic aFXa levels; fibrates and warfarin use were significantly associated with sub-therapeutic aFXa levels (P < 0.05). On multivariate analysis, females and patients with cancer were independently at increased risk for supra-therapeutic levels RR 3.35(95% CI 1.50, 7.48), RR 3.61(95% CI 1.50, 8.70), respectively. Fibrates and warfarin were associated with sub-therapeutic levels RR 2.99(95% CI 1.44, 6.20), RR 3.42(95% CI 1.73, 6.76), respectively. Standard curative enoxaparin regimen is associated with increased risk for supra-therapeutic aFXa levels in females and patients with cancer and sub-therapeutic levels in patients treated with fibrates and warfarin. This may suggest the need for anticoagulation monitoring in high-risk patients with these conditions.

IL-16 and BCA-1 Serum Levels Are Associated with Disease Severity of C. difficile Infection.

Clostridioides difficile infection (CDI) is associated with a high risk for complications and death, which requires identifying severe patients and treating them accordingly. We examined the serum level of six cytokines and chemokines (IL-16, IL-21, IL-23, IL-33, BCA-1, TRAIL) and investigated the association between them and patients' disease severity. Concentrations of six cytokines and chemokines were measured using the MILLIPLEX®MAP kit (Billerica, MA, USA) in serum samples attained from CDI patients within 24-48 h after laboratory confirmation of C. difficile presence. Demographic and clinical data were collected from medical records. The disease severity score was determined according to guidelines of the "Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America" (SHEA-IDSA). Out of 54 patients, 20 (37%) had mild to moderate disease and 34 (63%) had severe disease. IL-16 (p = 0.005) and BCA-1 (p = 0.012) were associated with a more severe disease. In conclusion, IL-16 and BCA-1, along with other cytokines and chemokines, may serve as biomarkers for the early prediction of CDI severity in the future. An improved and more accessible assessment of CDI severity will contribute to the adjustment of the medical treatment, which will lead to a better patient outcome.

Clinical and Demographic Characteristics of Patients With a New Diagnosis of Carriage or Clinical Infection With Carbapenemase-Producing Enterobacterales: A Retrospective Study.

Background: To examine the clinical, demographic, and microbiologic characteristics of new rectal carbapenemase-producing carbapenem-resistant Enterobacterales (CP-CRE) carriers vs. those with a clinical infection, hospitalized at Padeh-Poriya Medical Center between 2014 and 2017 and to examine the susceptibility profiles of isolates from clinical infections. Methods: In this retrospective, chart analysis, demographic and clinical data were collected from medical charts of 175 adult patients with either new- onset carbapenemase-producing Enterobacterales (CPE) carriage or clinical CPE infection. Collected data included age, ethnic group, place of residence, hospitalizations in the past 90 days, and 30-day mortality. Microbiological analyses considered bacterial genus, molecular resistance mechanism and antibiotic susceptibility. Results: A significantly higher percentage (42.4%) of CPE carriers were long-term care facility residents, and had been recently hospitalized (56.3%), as compared to patients with clinical CPE infection (29.2 and 45.9%, respectively). Additionally, we noted a high (58.3%) acquision of CPE in our hospital. The most common bacterial isolate was K. pneumoniae and the most common resistance mechanism was Klebsiella pneumoniae (K. pneumoniae) carbapenemases (KPC). High susceptibility rates to amikacin and chloramphenicol were also noted. Conclusions: This study reaffirmed the importance of CPE screening and infection control measures. The observed antibiotic susceptibility profile suggests amikacin and chloramphenicol as potential treatments for CPE infection.

Is chloramphenicol making a comeback?

BACKGROUND: Due to increasing antimicrobial resistance there has been renewed interest in old drugs that have fallen into disuse because of toxic side effects. OBJECTIVES: To evaluate the susceptibility profile, in our hospital, of Enterobacteriaceae and Streptococcus pneumoniae isolates to chloramphenicol and to compare them with the susceptibility to amoxicillin-clavulanate. METHODS: All isolates of Enterobacteriaceae and S. pneumoniae recovered in our lab during a one year period were tested for susceptibility to chloramphenicol and amoxicillin-clavulanate or penicillin, respectively. RESULTS: Of 413 Enterobacteriaceae isolates, 182 (44.1%) were resistant to amoxicillin-clavulanate, but only 76 (18.4%) were resistant to chloramphenicol. Of 189 isolates of S. pneumoniae, 4 (2.1%) were highly resistant to penicillin and 73 (38.8%) were partially resistant, while only 2 (1.1%) were resistant to chloramphenicol. None of the 24 S. pneumoniae isolates causing invasive diseases exhibited resistance to chloramphenicol CONCLUSIONS: In an era of increasing resistance to many antibiotic preparations, chloramphenicol might have a role in the treatment of intraabdominal and respiratory tract infections.