The Prognostic Value of Serology in Persistent Q Fever Infection.

Background: Q fever has significant consequences for patients with persistent localized infection. A combination of doxycycline with hydroxychloroquine, for at least 18-24 months, is the first-line therapy. The use of serology as a prognostic marker during therapy is controversial. Methods: A retrospective, observational cohort study in two outpatient clinics in northern Israel. All adults with persistent Q fever (2015-2021) were included in the study. Clinical failure was defined as relapse or death related to Q fever after end of treatment (EOT). Serological cure was defined as phase 1 IgG ≤800 or a four-fold decrease at EOT. Results: Twenty-two patients were included in the study, with a median follow up of 40 months (IQR = 28.5-63.5), and median treatment duration of 28.5 months (IQR = 21.8-50.5). Clinical cure occurred in 18 patients (82%), serological cure in 10 (45%). Phase 1 IgG at presentation was significantly higher in the clinical failure group (median 9600 vs. 3200 in the clinical cure group, p = 0.019), and at 6-12 months after EOT (median 6400 vs. 800 respectively, p = 0.03). Phase 1 IgG levels at 1 year and EOT were similar in both groups. Positive phase 2 IgM after one year of therapy correlated with clinical failure (p = 0.038), but not at EOT or after EOT. Conclusion: Phase 1 IgG levels at presentation, phase 2 IgM at 1 year, and Phase 1 IgG 6-12 months after EOT were associated with clinical failure in patients with persistent Q fever.

An emergency department intervention to improve earlier detection of community-onset bloodstream infection among hospitalized patients.

BACKGROUND: Blood cultures (BCs) are essential microbiologic tests, but blood culturing diagnostic stewardship is frequently poor. We aimed to study the process-related failures and to evaluate the effect of an emergency department (ED) intervention on BCs collection practices and yield. METHODS: We implemented an ED-quality improvement intervention including educational sessions, phlebotomists addition, promoting single-site strategy for BC-collection and preanalytical data feedback. BC-bottles collected, positive BCs, blood volumes and documentation of collection times were measured, before (December 2021-August 2022) and after (September 2022-July 2023) intervention. Results were corrected to hospitalizations admissions or days. We used interrupted-time series analyses for comparisons. RESULTS: A total of 64,295 BC bottles were evaluated, 26,261 before and 38,034 postintervention. The median ED-BCs collected and week increased from 88 to 105 BCs (P < .0001), resulting from increased early sampling (P = .0001). Solitary BCs decreased (95%-28%), documented times increased (2.8%-25%), and average blood volume increased (3 mL to 4.5 mL) postintervention. Community-onset Bloodstream infections (BSIs) increased (39.6-52 bottles/1,000 admissions, P = .0001), while Health care-associated BSIs decreased (39-27 bottles/10,000 days, P = .0042). Contamination rates did not change. CONCLUSIONS: An ED-focused intervention based on the education sessions and single-site strategy improved culturing stewardship and facilitated the early identification of BSI without an increase in contamination.

Audit and feedback as a tool to increase compliance with carbapenemase-producing Enterobacteriaceae (CPE) screening and decrease CPE transmission in the hospital.

OBJECTIVE: To increase compliance with carbapenemase-producing Enterobacteriaceae (CPE) screening through real-time audit and feedback in our hospital and decrease CPE transmissions. DESIGN: A before-and-after trial, using active enhanced surveillance of CPE carriers. SETTING: A 500-bed, secondary, university-affiliated hospital that serves a population of 450,000 in a northern district in Israel. METHODS: The study was conducted during 2016-2019 and included patients who were admitted to the hospital and fulfilled CPE screening criteria upon admission and during prolonged hospitalizations. On January 1, 2017, the infection control team implemented a new strategy of real-time feedback toward compliance with in-hospital screening guidelines. Other infection control measurements were performed without interventions. The primary outcome was compliance with appropriate CPE screening. Secondary outcomes included CPE acquisition and compliance with hand hygiene and contact precaution practices. Data were analyzed to calculate differences between compliance with CPE screening during the study period and to test the correlation between contact precautions and hand hygiene practices according to compliance with CPE screening. RESULTS: During the study period, 3,131 patients were eligible for CPE screening. We detected a statistically significant increase in compliance to CPE screening from 74% during 2017 to 92% in 2018 and 95% in 2019 (P < .0001 for both comparisons). We detected a decrease in CPE transmission from 12% in 2017 to 2% in 2019 (P < .0001). We did not find any correlation between other infection control interventions and CPE screening and acquisition. CONCLUSION: Audit and feedback can improve appropriate CPE screening and may reduce CPE transmission in the hospital.

Invasive Fungal Diseases in Hospitalized Patients with COVID-19 in Israel: A Multicenter Cohort Study.

Highly variable estimates of COVID-19-associated fungal diseases (IFDs) have been reported. We aimed to determine the incidence of clinically important fungal diseases in hospitalized COVID-19 patients during the first year of the pandemic. We performed a multicenter survey of IFDs among patients hospitalized with COVID-19 in 13 hospitals in Israel between February 2020 and May 2021. COVID-19-associated pulmonary mold disease (PMD) and invasive candidiasis (IC) were defined using ECMM/ISHAM and EORTC/MSG criteria, respectively. Overall rates of IC and PMD among patients with critical COVID-19 were 10.86 and 10.20 per 1000 admissions, respectively, with significant variability among medical centers. PMD rates were significantly lower in centers where galactomannan was a send-out test versus centers with on-site testing (p = 0.035). The 30-day mortality rate was 67.5% for IC and 57.5% for PMD. Treatment with an echinocandin for IC or an extended-spectrum azole for PMD was associated with significantly lower mortality rates (adjusted hazard ratio [95% confidence interval], 0.26 [0.07-0.91] and 0.23 [0.093-0.57], respectively). In this multicenter national survey, variable rates of PMD were associated with on-site galactomannan testing, suggesting under-detection in sites lacking this capacity. COVID-19-related IFDs were associated with high mortality rates, which were reduced with appropriate antifungal therapy.

Spotted Fever Group Rickettsioses in Israel, 2010-2019.

In a multicenter, nationwide, retrospective study of patients hospitalized with spotted fever group rickettsiosis in Israel during 2010-2019, we identified 42 cases, of which 36 were autochthonous. The most prevalent species was the Rickettsia conorii Israeli tick typhus strain (n = 33, 79%); infection with this species necessitated intensive care for 52% of patients and was associated with a 30% fatality rate. A history of tick bite was rare, found for only 5% of patients; eschar was found in 12%; and leukocytosis was more common than leukopenia. Most (72%) patients resided along the Mediterranean shoreline. For 3 patients, a new Rickettsia variant was identified and had been acquired in eastern, mountainous parts of Israel. One patient had prolonged fever before admission and clinical signs resembling tickborne lymphadenopathy. Our findings suggest that a broad range of Rickettsia species cause spotted fever group rickettsiosis in Israel.

[DELAYED PERSISTENT BREAST IMPLANT INFECTION WITH MYCOBACTERIUM FORTUITUM].

INTRODUCTION: Non-Tuberculous Mycobacteria (NTM) are opportunistic environmental pathogens that can produce a wide range of diseases, including infection of the skin and soft tissues. Mycobacterium fortuitum is a predominant causative agent of postsurgical wound infection, especially in breast surgery. Peri-prosthetic infection due to Mycobacterium fortuitum are uncommon, but increasingly reported. This report summarizes the case of a young healthy female who underwent bilateral breast mastopexy with insertion of silicone implants. Shortly after the procedure she presented with clinical signs of wound infection that failed to heal completely in spite of repeated drainage and empiric antibiotic therapy. Additional microbiological investigation allowed for a diagnosis of Mycobacterium fortuitum. A prolonged course of anti-mycobacterial therapy, combined with removal of the implants initiated eradication of the infection and enabled re-implantation of the prosthesis. This case report underscores the importance of awareness to this type of pathogen especially in cases of exudative infection with sterile cultures. Timely identification can lead to prompt therapy of patients preventing further complications, costs and remaining aesthetic damage.

Time above the MIC of Piperacillin-Tazobactam as a Predictor of Outcome in Pseudomonas aeruginosa Bacteremia.

Pseudomonas aeruginosa bacteremia is an infection associated with a high mortality rate. Piperacillin-tazobactam is a ß-lactam-ß-lactamase inhibitor combination that is frequently used for the management of Pseudomonas aeruginosa infections. The pharmacokinetic-pharmacodynamic index associated with in vitro maximal bacterial killing for piperacillin-tazobactam is the percentage of the time between doses at which the free fraction concentration remains above the MIC (%fT >MIC). However, the precise %fT >MIC target associated with improved clinical outcomes is unknown. The aim of this study was to investigate the correlation between the survival of patients with Pseudomonas aeruginosa bacteremia and the threshold of the piperacillin-tazobactam %fT >MIC This retrospective study included all adult patients hospitalized over an 82-month period with Pseudomonas aeruginosa bacteremia and treated with piperacillin-tazobactam. Patients with a polymicrobial infection or those who died within 72 h of the time of collection of a sample for culture were excluded. The %fT >MIC of piperacillin-tazobactam associated with in-hospital survival was derived using classification and regression tree analysis. After screening 270 patients, 78 were eligible for inclusion in the study; 18% died during hospitalization. Classification and regression tree analysis identified a %fT >MIC of >60.68% to be associated with improved survival, and this remained statistically significant after controlling for clinical covariates (odds ratio = 7.74, 95% confidence interval = 1.32 to 45.2). In conclusion, the findings recommend dosing of piperacillin-tazobactam with the aim of achieving a pharmacodynamic target %fT >MIC of at least 60% in these patients.

Timing of antimicrobial initiation and reduced infection risk in open limb fractures: a cohort study.

To assess whether early administration of antimicrobials in open fractures of the limbs reduces infection risk. A historical cohort study included all adult patients admitted with an open fracture of the limbs, between January 1, 2012, and December 31, 2016. Epidemiological, clinical, and microbiological data was collected and analyzed. Microbiological infection was defined by positive wound cultures during the first 30 days, and clinical infection as defined by the treating physician. Of 167 patients, microbiological infection was identified in 12 (7%) patients, and clinical infection in 27 (16%) patients. All patients received the first dose of antimicrobials within 15 h of admission (median 1.29 h). Very early administration of the first dose did not reduce the risk of infection (median of 1.06 h and 1.31 h for patients that did vs. did not develop infection, respectively P = 0.58). In multivariate logistic regression, location of fracture in the lower limbs was associated with an increased risk of infection (OR 4.654, CI 1.407-15.398), and Gustilo-Anderson classification grade 1 or 2 was associated with a decreased risk of infection (OR 0.301, CI 0.104-0.872). Very early administration of antimicrobials did not reduce risk of infection in open limb fractures.

Screening for Q Fever during Other Bacterial Endocarditis in Endemic Areas: Our Experience with Three Patients.

Endocarditis is not a usual manifestation of acute Q fever. There is an ongoing debate about the need to screen patients for valvular diseases after acute Q fever. We present, for the first time, three patients with bacterial endocarditis from different aetiologies and a simultaneous diagnosis of acute Q fever. All were treated with prolonged antimicrobial treatment, and none of them developed a persistent Q infection. We suggest screening patients with endocarditis from other aetiologies to Q fever.

Antibiotic misuse in respiratory tract infections in children and adults-a prospective, multicentre study (TAILORED Treatment).

Respiratory tract infections (RTI) are more commonly caused by viral pathogens in children than in adults. Surprisingly, little is known about antibiotic use in children as compared to adults with RTI. This prospective study aimed to determine antibiotic misuse in children and adults with RTI, using an expert panel reference standard, in order to prioritise the target age population for antibiotic stewardship interventions. We recruited children and adults who presented at the emergency department or were hospitalised with clinical presentation of RTI in The Netherlands and Israel. A panel of three experienced physicians adjudicated a reference standard diagnosis (i.e. bacterial or viral infection) for all the patients using all available clinical and laboratory information, including a 28-day follow-up assessment. The cohort included 284 children and 232 adults with RTI (median age, 1.3 years and 64.5 years, respectively). The proportion of viral infections was larger in children than in adults (209(74%) versus 89(38%), p < 0.001). In case of viral RTI, antibiotics were prescribed (i.e. overuse) less frequently in children than in adults (77/209 (37%) versus 74/89 (83%), p < 0.001). One (1%) child and three (2%) adults with bacterial infection were not treated with antibiotics (i.e. underuse); all were mild cases. This international, prospective study confirms major antibiotic overuse in patients with RTI. Viral infection is more common in children, but antibiotic overuse is more frequent in adults with viral RTI. Together, these findings support the need for effective interventions to decrease antibiotic overuse in RTI patients of all ages.

[CHRONIC Q FEVER IN PATIENTS AT THE HILLEL YAFFE MEDICAL CENTER - THREE YEARS OF FOLLOW UP].

INTRODUCTION: Q fever is an acute zoonotic infection, which in some cases is complicated by a chronic disease. Diagnosis is based on serology, and in patients with a chronic disease, the source of infection must be investigated. AIMS: To describe patients with chronic Q fever, who were treated at the Hillel Yaffe Medical Center: risk factors, course of the disease, and serological findings. METHODS: This was an observational study; patients with chronic Q fever who were treated in the Infectious Diseases Clinic during the period 5/2015 - 1/2018 were included. The diagnosis was based on clinical findings and results of phase 1 IgG ≥ 800. Clinical, laboratory and imaging data from diagnosis to the end of treatment were collected. RESULTS: Sixteen patients were included in the study; all these patients were treated with antibiotics, and three also underwent operations. Risk factors for a chronic infection were a significant valvular disease in 11 patients (69%) and vascular diseases in five (31%). Trans-esophageal echocardiogram (TEE) was performed in 13 patients (81%), and a 18F-FDG/PET-CT was performed in eight patients (50%). The source of infection was found in seven patients, four with endocarditis and three with vascular infection. CONCLUSIONS: Endocarditis was more common than vascular infection. In 56% of the patients, the source of the infection was not found. DISCUSSION: We presented patients with chronic Q fever who were treated in a unique clinic in Israel. Diagnosing the source of the infection is challenging; the increasing use of 18F-FDG/PET-CT allowed accurate diagnosis in some patients in which TEE results were negative.

Clinical, diagnostic, and therapeutic features of patients admitted to acute care hospitals with trunk compared to lower limb cellulitis.

The objective of this study is to report the clinical course and risk factors of trunk cellulitis, to identify diagnostic and therapeutic approaches, and compare them to patients with lower limb cellulitis. Medical records of adult patients with trunk cellulitis were reviewed and compared to an equal number of randomly selected patients with lower limb cellulitis. Demographic, clinical, and laboratory data were collected and analyzed using binary univariate and multivariate logistic regression analyses. Primary outcome was surgical drainage. Secondary outcomes were use of imaging studies, length of stay, readmission within 30 days, and 30-day mortality. During the study period, 74 patients were diagnosed with trunk cellulitis. Compared to patients with lower limb cellulitis, there are more women (57 vs. 39%, p = 0.032) and they are younger (mean age 59.7 vs. 68.4 years, p = 0.005). The only co-morbidity found as a significant risk factor for trunk cellulitis is malignancy (p = 0.017). These variables remain independent risk factors for trunk cellulitis after multivariate regression analysis. There is a trend toward more surgical interventions in the study group [6 (8%) patients vs. 1 (1%) with leg cellulitis, p = 0.116], and a longer hospital stay (5.8 days in the study group vs. 4.3 days in the control group, p = 0.025). Laboratory data are similar in both groups. There are risk factors for trunk cellulitis compared to lower limb cellulitis. However, diagnostic and therapeutic approaches are similar, except for a trend for more surgical interventions.

Characteristics of SCCmec IV and V Methicillin-Resistant Staphylococcus aureus (MRSA) in Israel.

BACKGROUND: Isolation of methicillin-resistant Staphylococcus aureus (MRSA) in healthy individuals is not common in Israel. In our hospital, about 30% of MRSA isolates were SCCmec types IV and V. OBJECTIVES: To identify the demographic and clinical characteristics of patients carrying MRSA SCCmec type IV or V, and to compare them with each other and with those of patients with SCCmec types I-III. METHODS: We conducted a case-control study that included 501 patients from whom MRSA was isolated: 254 with SCCmec type I, II, or III, and 243 isolates from SCCmec types IV or V. RESULTS: MRSA was isolated from surveillance cultures in 75% of patients and from a clinical site in 25%. The majority of our study population was elderly, from nursing homes, and with extensive exposure to health care. First, we compared characteristics of patients identified through screening. Statistically significant predictors of SCCmec V vs. IV were Arab ethnicity (OR 7.44, 95% CI 1.5-37.9) and hospitalization in the year prior to study inclusion (OR 5.7, 95% CI 1.9-16.9). No differences were found between patients with SCCmec types I-III and patients with SCCmec type IV or V. Analysis of the subset of patients who had clinical cultures yielded similar results. CONCLUSIONS: SCCmec types IV and V were common in the hospital setting although rare in the community. It seems that in Israel, SCCmec IV and V are predominantly health care-associated MRSA.

Polymicrobial Q Fever and enterococcal aortic prosthetic valve endocarditis with aortic root abscess.

Polymicrobial endocarditis is uncommon. We present a case of polymicrobial endocarditis caused by Enterococcus faecalis and Coxiella burnetii and review previous cases of polymicrobial endocarditis involving Coxiella burnetii. Testing for Q fever should be considered in any patient with endocarditis living in an endemic area.

[Metabolic bone disorders in HIV patients].

The life expectancy of HIV patients has increased dramatically since the introduction of combination antiretroviral therapy. This led to an increase in the incidence of non-AIDS related diseases, such as liver diseases, malignancies and metabolic disorders. Increased incidence of osteoporosis and bone fractures was found in HIV patients compared to the general population. The causes were multifactorial, combining traditional risk factors (such as age, sex, low weight, smoking, steroid treatment, vitamin D deficiency), with risk factors associated with the viral infection itself (increased bone loss and decreased bone formation), and to a lesser extent from the antiretroviral treatment itself. An association between bone density loss and antiviral drugs such as Tenofovir, and different protease inhibitors, was found in several studies, but no definite evidence of an increased risk of bone fractures was found. Current American guidelines recommend screening for low bone density only HIV patients who are over 50 years of age with a risk factor for osteoporosis. European guidelines recommend screening all HIV patients older than 50 years. HIV patients at risk for fractures should be treated according to local guidelines in the general population. Currently, no recommendations exist to change any specific antiretroviral therapy in case of osteoporosis, unless there are specific circumstances.

Management of patients with known drug hypersensitivity in an emergency department in Israel.

BACKGROUND: Drug hypersensitivity (DH) is potentially life threatening. Its management in the emergency department (ED) is not always satisfactory. Previous studies have evaluated the management of allergic reactions in the ED, but none has specifically addressed patients with known DH. In this study we aimed to analyze the treatment offered to patients with DH presenting to the ED in a hospital in Israel for any reason. METHODS: Records of patients discharged from the ED on 19 randomly chosen dates between February 2004 and September 2005 were retrospectively reviewed. Data included demographics, diagnosis, previous drug allergies, training of the ED physician, time and day of the week, management, and discharge instructions. RESULTS: Of 3,996 admissions to the ED, 436 (11%) patients reported 531 hypersensitivities, 45 (10%) of which were treated incorrectly. Trainees in internal medicine made significantly fewer errors than did trainees in surgery (p < 0.0005). Most errors involved NSAID hypersensitivity. CONCLUSION: A known DH was overlooked in 45 patients admitted to the ED. The specialty of the treating physician was the only significant factor found to affect patient management. Physicians, especially surgeons, should receive guidance concerning the correct management of patients with DH. All physicians should be aware of the optimal management of these patients.