Adherence to guidelines on empiric use of antibiotics in the emergency room.

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

A predictive model for the management of community-acquired pneumonia.

BACKGROUND: Understanding what determines the prognosis of community-acquired pneumonia (CAP) is especially important for decisions on hospitalization and antimicrobial therapy. The objective of the present study was to compare the predictability of mortality in our patients to that of the pneumonia patient outcomes research team (PORT) study. PATIENTS AND METHODS: Data of 320 patients admitted with CAP were retrospectively evaluated and classified according to the published scheme. RESULTS: One-month mortality was 14.4%; 1-year mortality was 27.8%, two-thirds from new episodes. Univariate logistic regression risk factors for the 1-month mortality rate included leukocytosis, anemia, hypoalbuminemia, elevated blood urea nitrogen, >or= two comorbidities, tachycardia, tachypnea, acidosis, stupor, age > 65 years and high serum lactic dehydrogenase. These variables, except the last two, plus pleural effusion and bilateral infiltration were also risk factors for 1-year mortality. In the multivariate models, eight of these factors were significant risk factors, four for 1-month mortality and six for 1-year mortality. Our model for prediction of 1-month mortality had a sensitivity of 65%, specificity of 95% and accuracy of 91%. CONCLUSION: Agreement between predictions by our model and the published model was considerable, showing that most patients in the low score groups should not have been hospitalized.

Home intravenous antibiotic therapy programme, 1999.

OBJECTIVES: To evaluate the cost-effectiveness and safety of the Home Intravenous Antibiotic Therapy (HIAT) program in the district of Haifa and Western Galilee in Northern Israel. METHODS: We checked all the medical records of all the patients who had been treated at home with intravenous antibiotics during 1999. We reviewed the mean clinical diagnosis, aetiological agent, type of antibiotic given, complications and cost evaluation. RESULTS: During 1999, 250 patients received 284 courses of HIAT. The total duration of treatments was 3404 days; 61% of the patients were referred from clinical departments from one of the medical centres in our area. Soft-tissue infections and osteomyelitis were the most common clinical diagnoses at 40%. Pseudomonas aeruginosa was the most frequent pathogen presented and Ceftazidine the most common antimicrobial agent prescribed. The HIAT program saved $815 000 during 1999. Only minor complications were present. CONCLUSIONS: HIAT is effective, safe, comfortable for the patients, and has an important economical impact.

Risk factor clustering in hypertensive patients: impact of the reports of NCEP-II and second joint task force on coronary prevention on JNC-VI guidelines.

INTRODUCTION: Although the association of hypertension with established risk factors has been noted in several population studies, the recent redefinition of dyslipidaemia, hypertension and diabetes calls for reassessment of the prevalence and pattern of risk factor clusters in essential hypertension. OBJECTIVE: To analyse the risk factor profile of Israeli patients with essential hypertension seen by primary care physicians and in hypertension specialty clinics, based on current definitions of dyslipidaemia hypertension and diabetes and JNC-VI guidelines for the assessment of risk factors. DESIGN AND SETTING: We analysed the risk profile of 324 Israeli hypertensive subjects using the JNC-VI risk table and risk grouping. A total of 122 consecutive patients were recruited from primary care clinics and 212 consecutive patients were recruited from a hospital based hypertension clinic. RESULTS: Amongst hypertensive individuals with no known target organ damage, only 1.5% had no risk factors other than hypertension, whereas all hypertensives with coronary artery disease had additional risk factors. Of the six listed major JNC-VI risk factors (smoking, dyslipidaemia, diabetes, age, sex, family history of cardiovascular disease), hypertensive subjects without coronary artery disease (coronary artery disease-negative) had 3.02 +/- 0.10 risk factors, whereas hypertensive subjects with coronary artery disease (coronary artery disease positive) had 3.6 +/- 0.07 risk factors other than hypertension (P < 0.01). Dyslipidaemia defined by NCEP-II criteria was the most common associated risk factor identified in 93% of coronary artery disease-positive and 77% of the coronary artery disease-negative hypertensive subjects. The most common dyslipidaemic abnormality was an increased LDL cholesterol (79.2% of the cohort), followed by hypertriglyceridaemia (31.7%) and low HDL cholesterol (22.3%). Nevertheless, in nearly half of the coronary artery disease-negative patients, LDL cholesterol concentrations were within 30 mg dL-1 of the target levels. The most common dyslipidaemic variant was isolated hypercholesterolaemia (42%), whereas the syndrome X dyslipidaemic combination of hypertriglyceridaemia and low HDL was strikingly uncommon, observed in 2.8% of the coronary artery disease-positive and 0.8% of the coronary artery disease-negative patients. CONCLUSIONS: (i) JNC-VI group risk A patients (no risk factors) comprise a very small minority in this cohort (< 5%); (ii) dyslipidaemia is exceedingly common with mild hypercholesterolaemia being the most prevalent variant and hypertriglyceridaemia with low HDL the least common form.

Prevalence of hypothyroidism and diabetes mellitus in elderly kibbutz members.

UNLABELLED: The aim of this study was to determine the prevalence of hypothyroidism and diabetes mellitus (DM) in elderly (aged 65-92 years) kibbutz members in Northern Israel. METHOD: The medical records of 1096 elderly (642 females and 454 males) residing in 11 kibbutzim were reviewed for data regarding thyroid function tests (TSH and FT4) and fasting blood glucose. Fasting blood glucose levels above 7.8 mmol/l was considered diagnostic for diabetes mellitus. RESULTS: The prevalence of hypothyroidism was 14% (9.7% in males and 18.2% in females) and that of DM was 11.5% (12.1% in males and 11.1% in females). In 74% of the diabetics the diagnosis was made after the age of 60 years. Distribution of treatment modalities in diabetics was as follows: diet only 42%. oral hypoglycemic agents 52% and Insulin 6%. Subclinical hypothyroidism (serum TSH levels above 4.5 mU/L with normal FT4 levels) was detected in 38% of all the hypothyroid subjects. CONCLUSION: The data suggest that diabetes mellitus and primary hypothyroidism are common disorders in elderly subjects. DM in the elderly can usually be handled with diet and oral hypoglycemic drugs. Since the clinical features of hypothyroidism in the elderly are often atypical, we suggest that elderly subjects should be screened for hypothyroidism.

Malaria and Borrelia co-infection.

Severe anemia requiring blood transfusion may complicate falciparum malaria, but is rare in nonfalciparum malaria. We present a case of a young man with high fever, severe hemolytic anemia, and a blood film containing massive co-infection with Plasmodium vivax and with Borrelia. The possible importance of the co-infection on the magnitude of hemolysis will be discussed.

[Brucellosis presenting as acute abdomen].

Usually symptoms of brucellosis are nonspecific and characterized by a wide range of complaints. Although the disease in Israel is almost exclusively food borne (caused by Brucella melitensis in unpasteurized goat milk products) so the main route of infection is the gastrointestinal tract, but gastrointestinal complications are rare, and only sporadic cases of ileitis or colitis have been described. We present a 43-year-old woman with an acute abdomen, probably due to diverticulitis. It was diagnosed only after blood cultures were positive for Brucella melitensis. We believe that its protean manifestations should be considered in addition to the other bizarre presentations of this disease, important in our region.

[Cryptococcal meningitis following cryptococcal pneumonia in an immunocompetent].

Cryptococcal meningitis (CM) is common in the immunocompromised (especially due to AIDS), but also occurs in immunocompetent subjects. CM can complicate cryptococcal pneumonia (CP) not only in the immunocompromised but also in the immunocompetent. We describe a healthy 26-year-old man who developed a prolonged lung infection. Diagnosis of cryptococcal pneumonia was established from bronchoscopic washings. He recovered spontaneously, so no antifungal treatment was given. 4 months later he was admitted with cryptococcal meningitis and was treated successfully with amphotericin B. An extensive immunologic study revealed no abnormalities. Since CM can complicate cryptococcal pneumonia, it is recommended that patients with CP be followed, even if recovery is apparently complete.

[Ferritin levels in adult Still's disease].

Adult-onset Still's disease (AOSD) is characterized by a spiking fever and diverse clinical findings; the diagnosis is often delayed for months or even years. The only positive laboratory finding is neutrophilic leukocytosis. Since 1987, the diagnostic importance of elevated serum ferritin levels has been discussed in numerous papers, but is not yet among the diagnostic criteria for AOSD. We describe a case in which the finding of extreme hyperferritinemia enabled prompt diagnosis and treatment.

Familial pattern of infection with hepatitis B virus among immigrating Ethiopian Jews in Israel.

Seventy-eight families (506 members) of recently immigrating Ethiopian Jews to Israel, were tested for the presence of HBV serological markers to evaluate the intrafamilial horizontal transmission of the virus. Eighty-four members (16.6%) were carriers and 20.2% were HBeAg positive, the overall infection rate was 67.8%. In 40 families (51.3%) at least one family member was HBsAG positive, and in 19 families (24.4%) two or more family members were HBsAg positive. Thirty-six carriers (42.8%) were children under the age of 10, by one year of age 30% have contracted the virus, and by the age of 5 and 10 years 43.5% and 57.1% have had serological markers for past HBV infection, respectively. Our data correlate with other studies regarding the importance of horizontal spread of HBV among Sub-Saharan Africans.

[Purpura--an unusual presentation of Takayasu arteritis].

Takayasu arteritis is an uncommon vasculitis, often referred to as aortic arch syndrome. It is most prevalent in young women. Physical findings such as the combination of pulseless arms and carotid bruits suggest the diagnosis. Associated skin manifestations such as pyoderma gangrenosum and erythema nodosum have been described. We present a 27-year-old woman with diffuse purpuric eruption and Takayasu arteritis. This appears to be the first description of such an association.

[Acute effusive-constrictive pericarditis in influenza A].

Constrictive pericarditis may complicate the course of several viral infections, mainly Coxsackie virus group B, as well as in rheumatoid disease, radiation and neoplasm. Perimyocardial involvement during influenzal infections is usually mild and does not progress to constriction or tamponade. A single case of cardiac tamponade caused by influenza A was reported in 1986. We report a case of acute effusive-constrictive pericarditis due to influenza A infection. Corticosteroids resulted in some benefit, but did not relieve constriction, which required extensive pericardiectomy.

Prevalence of cognitive dysfunction and hypothyroidism in an elderly community population.

Cognitive function was assessed in 801 elderly subjects (aged 65-92 years) using the Mini Mental State Examination (MMSE). The mean (+/- SD) MMSE score in the age group 65-70 years was 27.8 +/- 5.6, and the score declined to 22.3 +/- 7.8 at the age 85-90 (P = 0.001). Abnormal MMSE scores (less than 24) were found in 5.2% of the subjects aged 65-70 and gradually increased with age to 35.5% in the age group of 85-90. Serum thyroid-stimulating hormone (TSH) levels were determined in 751 subjects. Elevated TSH (> 4.5 mIU/l) were detected in 112 people (14%). The prevalence of hypothyroidism was higher in females (18.2%) than in males (9.7%). MMSE scores in 39 patients (14 males and 25 females) with untreated hypothyroidism were compared to the scores of 570 euthyroid elderly controls (235 males and 335 females). The mean +/- SD MMSE scores were 27.0 +/- 2.1 in hypothyroid males vs. 26.0 +/- 4.7 in male controls and 25.0 +/- 7.7 in hypothyroid females vs. 25.0 +/- 6.6 in female controls. The scores in the hypothyroid patients were not significantly different from the controls. Our data suggest that: a) the average cognitive performance declines with age; b) the percentage of subjects with abnormal MMSE scores increases with age, and is higher in females than in males; c) the prevalence of hypothyroidism in the elderly population is 14% and is higher in females (18%) than in males (10%); and d) mild untreated hypothyroidism is not associated with cognitive impairment.

[Prevalence of diabetes mellitus and glucose intolerance in adult Ethiopian immigrants].

339 adult immigrants from Ethiopia were surveyed 1 year after arrival. They were screened for diabetes mellitus and impaired glucose tolerance by measurement of serum HgbA1C levels. The levels were higher than normal in 35 subjects (10.3%), and were significantly higher in immigrants consuming the Israeli diet, which is richer in proteins and carbohydrates, than in those on the Ethiopian diet. Oral glucose load was abnormal in 7 subjects. 3 had overt diabetes mellitus with absent serum insulin response to glucose load. 4 had glucose intolerance with normal insulin secretion. However, clinical appearance of diabetes was incidental and diabetes ketoacidosis was not detected. The overall prevalence of diabetes mellitus and glucose intolerance in this ethnic group (2.1%) is similar to that in the general population of Israel. Longitudinal studies would indicate the exact prevalence and type of diabetes mellitus among the Ethiopian immigrants.

Goiter prevalence in children immigrating from an endemic goiter area in Ethiopia to Israel.

A survey study was performed to assess the prevalence of goiter and thyroid dysfunction in a population of 534 Ethiopian children, one year after arrival in Israel. The overall prevalence of goiter was 43.6%. Children in the age group 1-2 years had the lowest prevalence of goiter (6.7%). A progressive increase in goiter prevalence and size with age was observed, with peak occurrence around puberty for both boys (56.7%) and girls (72.2%). Serum FT4 levels were elevated in 4 children; elevated serum TSH levels (above 4.5 mIU/l) were found in 11 children, all of them had normal FT4 levels. Thus the prevalence of hypothyroidism and hyperthyroidism was 2% and 0.8%, respectively, with an even distribution across the various age groups. All the children were clinically normal. The high prevalence of goiter in this group of Ethiopian children with the low frequency of hypothyroidism may be attributed to the combined effects of food goitrogens and iodine deficiency prevailing in Ethiopia. The standard Israeli diet seems to be adequate in respect to iodine requirements, and no iodine enrichment is needed for children immigrating from Ethiopia.

[Thyroid dysfunction and goiter among immigrants from Ethiopia].

1131 immigrants from Gonder, Ethiopia were surveyed a year after arrival in Israel. The overall prevalence of goiter was 46.1%; the lowest rates (6.7%) were in infants (aged 1-2 years) and the peak prevalence in males was 56.7% (in those aged 12-14 years) and in females, 77.7% (in those aged 35-40). A significant decrease in goiter prevalence was observed after the age of 60 for both men (7.2%) and women (35%). The prevalence of hypothyroidism was 1.1%, 2% in children and 0.2% in adults. That of hyperthyroidism was 1.7%, 0.8% in children and 2.4% in adults. The high prevalence of goiter and hyperthyroidism with low prevalence of hypothyroidism probably resulted from the combined effects of food goitrogens and iodine deficiency in Ethiopia, with the latter playing only a minor role. Neither factor was in effect after arrival in Israel. Genetic and hormonal factors may contribute to the low prevalence of both goiter and hypothyroidism in the adult males. In view of the high prevalence of hyperthyroidism, iodine enrichment is not recommended for Ethiopian immigrants.

Recurrent nephrotic syndrome associated with Kimura's disease in a young non-Oriental male.

Kimura's disease (KD) is an angiolymphoid proliferative disorder of soft tissue with eosinophilia, with a predilection for head and neck regions in young Oriental men. Renal disease is rarely associated with it. We describe a young non-Oriental male with KD and relapsing steroid-responsive minimal-change nephrotic syndrome. This case of KD associated nephrotic syndrome is unique in the relapsing nature of the nephropathy and the non-Oriental origin of the patient. We comment on KD and nephrotic syndrome and on treatment strategy.