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.

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.

International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases.

A Panel of International Experts was convened by the Infectious Diseases Society of America (IDSA) in collaboration with the European Society for Microbiology and Infectious Diseases (ESCMID) to update the 1999 Uncomplicated Urinary Tract Infection Guidelines by the IDSA. Co-sponsoring organizations include the American Congress of Obstetricians and Gynecologists, American Urological Association, Association of Medical Microbiology and Infectious Diseases-Canada, and the Society for Academic Emergency Medicine. The focus of this work is treatment of women with acute uncomplicated cystitis and pyelonephritis, diagnoses limited in these guidelines to premenopausal, non-pregnant women with no known urological abnormalities or co-morbidities. The issues of in vitro resistance prevalence and the ecological adverse effects of antimicrobial therapy (collateral damage) were considered as important factors in making optimal treatment choices and thus are reflected in the rankings of recommendations.

Etiology of community-acquired pneumonia in hospitalized patients in northern Israel.

BACKGROUND: Community-acquired pneumonia is a common infection and is associated with high rates of morbidity and mortality. Most patients with CAP are treated empirically. OBJECTIVES: To identify common pathogens causing CAP in hospitalized patients in northern Israel and to evaluate the correlation between etiology and disease severity. METHODS: We conducted a prospective study of patients with CAP hospitalized at HaEmek Medical Center, Afula. We collected demographic, clinical and laboratory data (blood and sputum cultures, serology, pneumococcal urinary antigen test, and respiratory multiplex-polymerase chain reaction from nasopharyngeal swab). Radiologic evaluation was performed. RESULTS: A total of 126 patients and 24 controls were enrolled. At least one pathogen was identified in 84 cases (66.7%), more than one in 43 patients (34.1%), and no pathogens in 42 (33.3%). Typical bacteria were found in 23 (18.3%), atypical bacteria in 66 (52.4%), and viruses in 42 (33.3%). The number (%) of patients with pathogens isolated was: Chlamydophila pneumoniae 26 (20.6%), Streptococcus pneumoniae 23 (18.3%), Mycoplasma pneumoniae 23 (18.3%), influenza virus A-B 20 (15.9%), Coxiella burnetti 8 (6.3%), and parainfluenza and adenovirus 13 (10.3%) each. A correlation was found only between a high PORT score on admission and S. pneumoniae, although atypical pathogens did not show class predominance. CONCLUSIONS: S. pneumoniae, M. pneumoniae and C. pneumoniae were the most common pathogens isolated, while co-infection was very frequent. PORT score did not predict any of the pathogens involved. The choice of empiric antimicrobial treatment for CAP should be made according to local epidemiologic data.

Nail puncture wound through a rubber-soled shoe: a retrospective study of 96 adult patients.

Nail punctures through rubber-soled shoes expose the foot to the possibility of deep infection and foreign body retention. In this article, we describe characteristics of adult patients who sustained nail puncture wounds through a rubber-soled shoe and were treated at our institution from January 1, 2000, to January 8, 2008. Of the 96 patients, 36 (37.5%) were treated conservatively and 60 (62.5%) were treated surgically in the operating room. Of those treated surgically, 15 (25%) had a foreign body extracted during the operation. The operated group had a longer duration of time from injury to hospital admission than did the nonoperated group (5.0 +/- 6.8 days versus 2.7 +/- 3.8 days, P < .05). Treatment success was observed in 91 (94.8%) of the patients, and the median lag time before admission for the less successfully treated group was longer than that for the successfully treated group (10 days versus 2 days, P < .002); and, the less successfully treated group was more likely to receive antibiotics in the community before hospitalization (100.0% versus 47.2%, P < .06), and was more likely to be diabetic (40.0% versus 9.9%, P < .10). Fever, white blood cell count, and erythrocyte sedimentation rate were not significantly associated with treatment outcome. Success of the treatment did not depend on white blood cell count, erythrocyte sedimentation rate, or fever. Ultrasonography was useful in detecting the presence of a foreign body.

Epidemiology and susceptibility to antimicrobials in community, hospital and long-term care facility bacteremia in northern Israel: a 6 year surveillance.

BACKGROUND: Identification of pathogens and their susceptibility to antimicrobials is mandatory for successful empiric antibiotic treatment. OBJECTIVES: To compare the clinical characteristics of patients with bacteremia, as well as the bacterial distribution and antimicrobial susceptibility in community, hospital and long-term care facilities during two periods (2001-2002 and 2005-2006). METHODS: The study was conducted at the HaEmek Medical Center, a community 500-bed teaching hospital in northern Israel serving a population of approximately 500,000 inhabitants. All episodes of bacteremia (n = 1546) during two 2 year periods (2001-2 and 2005-6) were prospectively recorded, evaluated and compared (755 in 2001-2 and 791 in 2005-6). RESULTS: In both periods the urinary tract was the main port of entry in community and long-term care facility bacteremia, while the urinary tract--primary and catheter-related--were similar in frequency as sources of hospital bacteremia. Escherichia coli was the most frequent pathogen isolate. No significant changes in the frequency of methicillin-resistant Staphylococcus aureus and extended-spectrum beta-lactamase-producing bacteria were seen between the two 2 year periods (2001-2 and 2005-6). The susceptibility of non-ESBL-producing E. coli decreased for some antibiotics while non-ESBL-producing Klebsiella pneumoniae susceptibility profile improved in the same period. A non-statistically significant trend of increased resistance in gram-negative isolates to quinolones, piperacillin and piperacillin-tazobactam was observed, but most isolates still remained highly susceptible to carbapenems. There was a small increase in mortality rate in hospital bacteremia during the second period. CONCLUSIONS: Continuous surveillance is imperative for monitoring the local epidemiology and for developing local treatment guidelines.

Association between urinary community-acquired fluoroquinolone-resistant Escherichia coli and neighbourhood antibiotic consumption: a population-based case-control study.

BACKGROUND: It is unknown whether increased use of antibiotics in a community increases the risk of acquiring antibiotic resistance by individuals living in that community, regardless of prior individual antibiotic consumption and other risk factors for antibiotic resistance. METHODS: We used a hierarchical multivariate logistic regression approach to evaluate the association between neighbourhood fluoroquinolone consumption and individual risk of colonisation or infection of the urinary tract with fluoroquinolone-resistant Escherichia coli. We did a population-based case-control study of adults (aged ≥22 years) living in 1733 predefined geographical statistical areas (neighbourhoods) in Israel. A multilevel study design was used to analyse data derived from electronic medical records of patients enrolled in the Clalit state-mandated health service. FINDINGS: 300 105 events with E coli growth and 1 899 168 cultures with no growth were identified from medical records and included in the analysis. 45 427 (16·8%) of 270 190 women and 8835 (29·5%) of 29 915 men had fluoroquinolone-resistant E coli events. We found an independent association between residence in a neighbourhood with higher antibiotic consumption and an increased risk of bacteriuria caused by fluoroquinolone-resistant E coli. Odds ratios (ORs) for the quintiles with higher neighbourhood consumption (compared with the lowest quintile) were 1·15 (95% CI 1·06-1·24), 1·31 (1·20-1·43), 1·41 (1·29-1·54), and 1·51 (1·38-1·65) for women, and 1·17 (1·02-1·35), 1·24 (1·06-1·45), 1·35 (1·15-1·59), and 1·50 (1·26-1·77) for men. Results remained significant when the analysis was restricted to patients who had not consumed fluoroquinolones themselves. INTERPRETATION: These data suggest that increased use of antibiotics in specific geographical areas is associated with an increased personal risk of acquiring antibiotic-resistant bacteria, independent of personal history of antibiotic consumption and other known risk factors for antimicrobial resistance. FUNDING: None.

Antibiotic use in 26 departments of internal medicine in 6 general hospitals in Israel: variability and contributing factors.

OBJECTIVES: Increased antibiotic consumption is associated with increased bacterial resistance worldwide. We aimed to analyse antibiotic consumption and potential contributory factors in internal medicine departments in Israel. METHODS: Data (2003-04) from 26 departments in 6 hospitals were retrieved. Defined daily doses (DDD)/100 bed-days were calculated for total antibiotic use and by antibiotic class. Patterns identified were correlated with 15 patients' and departmental variables by univariate and multivariate analyses. RESULTS: Total antibiotic consumption differed by a factor of 2.3 (115 DDD/100 bed-days to 49.1 DDD/100 bed-days) between the highest and lowest consuming departments. Antibiotic classes differed by a factor of 22.8 for macrolides, a factor of 20 for piperacillin/tazobactam, a factor of 17 for carbapenems, a factor of 13.3 for quinolones, a factor of 9 for vancomycin, a factor of 6.8 for amoxicillin/clavulanate, a factor of 6.6 for aminoglycosides, a factor of 5.3 for penicillins and a factor of 2.8 for cephalosporins. Even among departments within hospitals, there was a difference of up to 1.5-fold for total use and antibiotic class differences ranged between 2.5- and 7.2-fold for third- and fourth-generation cephalosporins, despite similar Charlson scores and other patient variables. In the multivariate analysis, hospital affiliation and rate of 1 day hospitalization were the only significant variables predicting total antibiotic use, contributing 43% and 7.3%, respectively, to the variance. By antibiotic class, controlling for hospital affiliation, patients with neutropenia, lower respiratory tract infections and assisted ventilation were the most common significant contributors, ranging from 3.5% for quinolones to 7.7% for piperacillin/tazobactam. CONCLUSIONS: Patterns of antibiotic use vary widely among internal medicine departments in Israel, which cannot be explained by objective parameters related either to patients or wards. Ongoing monitoring and guideline formulation are needed to regulate antibiotic prescription.

Nontuberculous mycobacterial infections of the skin: A retrospective study of 25 cases.

BACKGROUND: Absence of a pathognomonic clinical picture and variable histologic findings often delay diagnosis of nontuberculous mycobacteria (NTM)-induced cutaneous infections, and antimicrobial therapy varies. OBJECTIVE: We sought to investigate the clinical, microbiologic, and pathological findings of cutaneous NTM infections and response to different treatments. METHODS: Records of patients with NTM infections of the skin confirmed by positive cultures or histologic findings were reviewed. Clinical, microbiologic, and epidemiologic data were collected and skin biopsy specimens were reassessed. RESULTS: The series included 25 cases, one diagnosed by histology and 24 by positive culture: 16 cases with Mycobacterium marinum, 3 of atypical Mycobacterium without species identification, and one each with M chelonae, M xenopi, M abscessus, M gordonae, and M fortuitum. One of 16 patients with M marinum developed tenosynovitis. Mean interval between clinical presentation and diagnosis was 7.1 months (range: 1-27.3 months). All isolates analyzed for antimicrobial susceptibility pattern were sensitive to clarithromycin. LIMITATIONS: Limitations include methods of case collection, retrospective study, and relatively small number of patients. CONCLUSIONS: Diagnosis of NTM should be confirmed by histology and bacteriology studies of tissue cultures. Strong clinical suggestion of M marinum infection warrants initial empirical treatment to prevent progression to deep infection. The recommended treatment as indicated by the results of the in vitro susceptibility and clinical response is clarithromycin.

Ten years surveillance of antimicrobial susceptibility of community-acquired Escherichia coli and other uropathogens in northern Israel (1995-2005).

BACKGROUND: In an era of increasing antimicrobial resistance, knowledge of local antimicrobial susceptibility patterns of common uropathogens is essential for prudent empiric therapy of community-acquired urinary tract infections. OBJECTIVES: To define antimicrobial susceptibility of Gram-negative uropathogens in northern Israel over a 10 year period and to compare it with patterns of antibiotic use in the same community. METHODS: We tested the susceptibility of all Gram-negative urinary isolates from outpatients at HaEmek Medical Center over the years 1995, 1999, 2002 and 2005 to common antimicrobial agents. MIC90 of Escherichia coli to some of these agents was determined and antibiotic consumption data over the years 2000-2005 (DDD/1000/day) were obtained. RESULTS: We observed a rise in susceptibility rates of E. coli to amoxicillin-clavulanate, trimethoprim-sulfamethoxazole and nitrofurantoin and of other Gram-negative isolates to amoxicillin-clavulanate, ceftriaxone and cephalothin. Susceptibility rates of all Gram-negative uropathogens to ciprofloxacin decreased significantly. MIC90 of E. coli for all drugs tested remained stable. There was a significant decrease in the use of nitrofurantoin and TMP-SMX and a significant increase in the use of ampicillin, cephalothin and ceftriaxone. CONCLUSIONS: Antibiotic resistance patterns mostly remained unchanged or improved slightly. There was, however, a constant decrease in susceptibility of all Gram-negative uropathogens to ciprofloxacin. Antibiotic use patterns could not explain the changes seen in antibiotic susceptibility patterns.

Antibiotic consumption successfully reduced by a community intervention program.

BACKGROUND: The association between antibiotic use in the community and antimicrobial resistance is known. Attention has recently focused on the type of agents being prescribed. OBJECTIVES: To implement, evaluate and compare the efficacy of two community intervention programs--continuous versus seasonal medical education--oriented to primary care physicians with emphasis on the appropriate use of antimicrobial drugs. METHODS: From October 2000 to April 2003 we conducted two interventions: a) a monthly educational campaign in selected clinics promoting appropriate diagnosis of common infectious diseases and prudent antibiotic use (continuous intervention group); and b) a massive educational campaign, conducted before two consecutive winters, promoting the judicious use of antibiotics for treating respiratory infections (continuous intervention group and seasonal intervention group). Sixteen similar clinics were randomized (8 to each group). The total antibiotic use was measured as defined daily dose/1000 patients/day, and compared between the groups. RESULTS: The total use of antibiotics decreased between 1999-2000 and 2002-2003 in both groups, but slightly more significantly in the continuous intervention group. The DDD/1000 patients/day for the seasonal group in 1999-2000 was 27.8 vs. 23.2 in 2002-2003; and for the continuous group 28.7 in 1999-2000 vs. 22.9 in 2002-2003, a reduction of 16.5% and 20.0% respectively (P < 0.0001). The main change in antibiotic use was noted for broad-spectrum antibiotics. CONCLUSIONS: We present a successful community intervention program aimed to reduce unnecessary antibiotic use. Amplification of this type of intervention is imperative to stop the increase in antimicrobial resistance.

Efficacy and safety of ertapenem versus piperacillin-tazobactam for the treatment of intra-abdominal infections requiring surgical intervention.

Complicated intra-abdominal infections usually mandate prompt surgical intervention supplemented by appropriate antimicrobial therapy. The aim of this study was to demonstrate that ertapenem was not inferior to piperacillin-tazobactam for the treatment of community-acquired intra-abdominal infections. A randomized open-label active-comparator clinical trial was conducted at 48 medical centers on four continents from December 2001 to February 2003. Adult patients with intra-abdominal infections requiring surgery were randomized to receive either ertapenem 1 g daily or piperacillin/tazobactam 13.5 g daily in 3-4 divided doses. The primary analysis of efficacy was the clinical response rate in clinically and microbiologically evaluable patients at the test-of-cure assessment 2 weeks after completion of therapy. All treated patients were included in the safety analysis. Patient demographics, disease characteristics, and treatment duration in both treatment groups were generally similar. The most commonly isolated pathogens at baseline were E coli (greater than 50% of cases in each group) and B fragilis ( approximately 9%). Favorable clinical response rates were 107/119 (90%) for ertapenem recipients and 107/114 (94%) for piperacillin/tazobactam recipients. The frequencies of drug-related adverse events, most commonly diarrhea and elevated serum alanine aminotransferase levels, were similar in both treatment groups. Six of 180 ertapenem recipients (3%) and two of 190 piperacillin/tazobactam recipients (1%) had serious drug-related adverse experiences. In this study, ertapenem and piperacillin/tazobactam were comparably safe and effective treatments for adult patients with complicated intra-abdominal infections.

Who are you--Staphylococcus saprophyticus?

Staphylococcus saprophyticus is a leading cause of cystitis in young women. S. saprophyticus shares many clinical features of urinary tract infection caused by Escherichia coli, but differs in pathogenesis, seasonal variation, and geographic distribution. This review summarizes what is known and what still needs to be learned about this microorganism.

Pharyngotonsillitis due to Arcanobacterium haemolyticum in northern Israel.

BACKGROUND: Arcanobacterium haemolyticum is a well-recognized but uncommon cause of pharyngitis and skin rash in adolescents and young adults. To date, no data regarding its frequency in Israel have been published. OBJECTIVE: To establish the frequency of A. haemolyticum in throat cultures in a northern Israeli population and to estimate the clinical significance of this pathogen in patients with sore throat. METHODS: We examined suspected colonies for A haemolyticum by gram stain, catalase test and reverse CAMP test in 518 throat cultures sent to the microbiologic laboratory of HaEmek Medical Center. RESULTS: Of the throat cultures tested, A. haemolyticum was recovered from one patient (0.2%). In contrast, group A Streptococcus (Streptococcus pyogenes) was recovered from 135 patients (26%). CONCLUSION: A hemolyticum is an uncommon pathogen implicated in acute pharyngitis, therefore routine screening in throat swabs is not required.

Self-medication with antibiotics by a population in northern Israel.

BACKGROUND: The current study is part of a larger study--Self-Medication with Antibiotics and Resistance Levels in Europe (SAR project)--coordinated by the University of Groningen in the Netherlands and run in 19 European countries and Israel. OBJECTIVES: To estimate self-medication with antibiotics by a population in northern Israel. METHODS: We sent by post a questionnaire on antibiotic usage to 2,615 adults, both Jewish and Arab, living in northern Israel. RESULTS: The overall response rate was low (17.9%), particularly among the Arab population (9.4% of respondents). Among the 467 respondents, 169 (36.2%) reported 215 antibiotic courses within the last year. Amoxicillin was the antibiotic most commonly used (32.7% of courses); 89.4% of antibiotics were obtained via a physician's prescription; 114 respondents (24.4%) stored leftover antibiotics at home, and 81 (18.7%) would consider self-medication with antibiotics without a medical consultation. CONCLUSIONS: Over-the-counter acquisition of antibiotics is rare in Israel. However, the storage of leftover antibiotics in the home constitutes an alternative potential source of self-medication that can have untoward consequences, not only for the individual patient but also for the general population since inappropriate antibiotic usage contributes to the increasing rates of antimicrobial resistance.

[Incidence of influenza among patients admitted to the department of internal medicine during the winter season].

BACKGROUND: Influenza is a common disease, especially in the winter season. Influenza virus causes symptoms of acute viral illness, development of complications and worsening of chronic diseases. Vaccination may prevent influenza illness. OBJECTIVES: 1. To determine the rate of vaccination against influenza. Furthermore, in the immunized patients--the study aimed to determine the efficiency of the vaccination. 2. To determine the incidence of influenza illness among patients admitted to a Department of Internal Medicine during the winter season. METHODS: We performed a prospective screening of 124 consecutive patients hospitalized in the Department of Internal Medicine during February 1998. Demographic parameters (age, sex) and admission diagnosis were collected. All patients were asked about influenza vaccination in the last fall. Blood samples were collected on admission and 10-30 days later. Three relevant virus subtypes were examined. Virus subtype was determined in all patients with evidence of influenza illness. RESULTS: Eleven patients (8.9%) were found with evidence of acute influenza illness at the time of hospitalization. The rate of patients with chronic pulmonary disease was higher in this group than in the group without evidence of influenza (p = 0.03). Forty-four out of 124 patients (35.5%) had been vaccinated against influenza. In the vaccinated patients, the protective antibody level for all 3 subtypes developed in 27.3% of cases and for one or two subtypes in 50% of cases. In 22.7% of patients no protective level of antibody was detected for any subtype. CONCLUSIONS: It is necessary to encourage vaccination in the high-risk group patient, especially those with chronic pulmonary disease. It is essential to develop new vaccination strategies and prophylactic antiviral medications.

Susceptibility of Group A Streptococcus to Antimicrobial Agents in Northern Israel: A Surveillance Study.

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 Streptococcus-GAS) 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.

Long-term follow-up of women hospitalized for acute pyelonephritis.

Long-term outcome of acute pyelonephritis (AP) in adults is unknown. We evaluated the frequency of renal damage 10-20 years after hospitalization for AP in adult women and the utility of technetium Tc 99m-labeled dimercaptosuccinic acid (Tc 99m-DMSA) scanning for detection of renal scars; 63 of 203 women hospitalized with AP during 1982-1992 were included in the study. Tc 99m-DMSA scanning detected renal scarring in 29 women (46%). Multivariate analysis showed that pregnancy and hypoalbuminemia (albumin level, <3.2 g/dL) at hospitalization were independent risk factors for subsequent development of renal scars. At follow-up, hypertension was observed in approximately one-fifth of patients, regardless of renal scarring status. Four women with scars had a glomerular filtration rate of < or =75 mL/min; none of them developed severe renal impairment. In conclusion, the risk of developing renal scarring after AP in adult women is high. However, clinically relevant renal damage is rare 10-20 years after AP. Tc 99m-DMSA scanning is useful for detecting renal scars in adults but is not routinely needed in practice.

Asymptomatic bacteriuria. Clinical significance and management.

The clinical significance and management of asymptomatic bacteriuria (ASB) differs according to different groups of patients. ASB requires antibiotic treatment in pregnant women, children aged 5-6 years and prior to invasive genitourinary procedures. However, there is a consensus that ASB in the elderly, healthy school girls and young women, diabetic women and patients with indwelling catheters or intermittent catheterization has no clinical significance and antibiotic prescription is not indicated.