Infective endocarditis following gastrointestinal and genitourinary procedures: an argument in favour of prophylaxis.

In the 2007 American Heart Association guidelines, gastrointestinal (GI) and genitourinary (GU) procedures were removed from the indications for infective endocarditis (IE) prophylaxis. The purpose of this study was to estimate the contribution of GI and GU procedures to the occurrence of IE in order to appreciate whether this removal was justified. Among 212 episodes of IE prospectively collected during 7 y, 20 cases (9%) had invasive GI and GU procedures and 17 (8%) had dental interventions within 3 months before IE diagnosis. Enteric organisms (predominantly Enterococcus faecalis) were significantly more common in the GI and GU group than in all other patients, whereas viridans streptococci, the most common pathogen in the dental group, were absent from the GI and GU group. This unique combination of pathogens in the GI and GU group is highly suggestive of a true association between the procedure and IE. Hence, GI and GU procedures pose a non-negligible risk of acquisition of IE. Consequently, it is proposed here, that adults at high risk of IE who undergo surgical GI and GU procedures, receive prophylaxis that includes an anti-enterococcal agent.

[A revolutionary change in the recommendations for antimicrobial prophylaxis of infective endocarditis (ie)].

Prophylactic use of antibiotics to prevent infective endocarditis (IE) used to be a part of the routine care of patients with almost any type of cardiac abnormality for more than 50 years. However, in the absence of placebo-controlled, randomized, double-blinded studies to evaluate its efficacy, doubts have been raised concerning its utility. It was recently concluded that IE is much more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremias caused by invasive medical procedures; that only a small number of cases of IE are caused by bacteremia that follows dental procedure; and that prophylaxis may prevent an extremely small number of cases of IE. This led the American Heart Association (AHA) to initiate substantial changes in the recommendations for prophylaxis, the main points of which are as follows: 1. Good oral hygiene and eradicating dental disease is the most important tool for preventing IE. 2. Antibiotic prophylaxis should be limited only to patients at high risk for complications and mortality from IE. 3. Prophylaxis for GI or GU tract procedures is no longer recommended. It is most likely that this remarkable change in the guidelines will provoke a debate in the medical literature; moreover, for the first time, this change allows performing placebo-controlled, randomized, double-blinded studies to evaluate the efficacy of antibiotic prophylaxis of IE.

An outbreak of Phialemonium infective endocarditis linked to intracavernous penile injections for the treatment of impotence.

BACKGROUND: In March 2002, a patient in Tel Aviv, Israel, died of endocarditis caused by Phialemonium curvatum. As part of his therapy for erectile dysfunction, the patient had been trained to self-inject a compound of vasoactive drugs provided by an impotence clinic into his penile corpus cavernosous. METHODS: We identified the used prefilled syringes as the source of his infection. Similar cases were investigated as a putative outbreak of P. curvatum invasive disease among customers of this impotence clinic. P. curvatum isolates, cultured from samples obtained from the patients and from prefilled syringes, were compared by DNA sequencing of the nuclear ribosomal internal transcribed spacer. RESULTS: We identified 2 additional customers at the impotence clinic who had P. curvatum endocarditis. In addition, cultures of unused, prefilled syringes and bottles provided by the same clinic to 5 asymptomatic customers tested positive for pathogenic molds (P. curvatum in 4 cases and Paecilomyces lilacinus in 1). All P. curvatum isolates were of a single genetic type that is known only from this outbreak but is closely related to 3 other P. curvatum genotypes associated with pathogenicity in humans. CONCLUSIONS: P. curvatum is an emerging pathogen that can be readily isolated from blood. We identified an outbreak of P. curvatum endocarditis among men who had erectile dysfunction treated by intracavernous penile injections from contaminated prefilled syringes.

Endogenous Phialemonium curvatum endophthalmitis.

PURPOSE: To report a case of bilateral endogenous Phialemonium curvatum endophthalmitis, secondary to intrapenile injections for erectile dysfunction. DESIGN: Observational case report. METHODS: A 71-year-old man with P. curvatum endocarditis and bilateral decreased vision was diagnosed as having bilateral endogenous endophthalmitis. P. curvatum was identified in cultures that were performed on samples of the vitreous. Treatment consisted of bilateral vitrectomy and intraocular and systemic antifungals. RESULTS: Despite resolution of the systemic infection, the patient's postoperative visual acuity remained limited to hand movement, and the ophthalmic clinical picture remained unchanged. CONCLUSIONS: P. curvatum is a pathogen that can be readily isolated from the vitreous. The authors are unaware of previous reported cases of ocular infection that was caused by P. curvatum.

Malaria in travelers returning from short organized tours to holiday resorts in Mombassa, Kenya.

BACKGROUND: Short trips to holiday resorts in Mombassa, Kenya, have gained popularity among Israelis since the early 1990s. A cluster of cases of malaria among returned travelers raised concern that preventive measures were being neglected. OBJECTIVES: To characterize the demographic and clinical features of malaria acquired in Kenya, and to assess the adequacy of preventive measures. METHODS: Data were collected from investigation forms at the Ministry of Health. All persons who acquired malaria in Kenya during the years 1999-2001 were contacted by phone and questioned about use of chemoprophylaxis, attitudes towards malaria prevention, and disease course. Further information was extracted from hospital records. RESULTS: Kenya accounted for 30 (18%) of 169 cases of malaria imported to Israel and was the leading source of malaria in the study period. Of 30 malaria cases imported from Kenya, 29 occurred after short (1-2 weeks) travel to holiday resorts in Mombassa. Average patient age was 43 +/- 12 years, which is older than average for travelers to tropical countries. Only 10% of the patients were fully compliant with malaria chemoprophylaxis. The most common reason for non-compliance was the belief that a short trip to a holiday resort carries a negligible risk of malaria. Only 3 of 13 patients (23%) who consulted their primary physician about post-travel fever were correctly diagnosed with malaria. Twenty percent of cases were severe enough to warrant admission to an intensive care unit; one case was fatal. CONCLUSIONS: Measures aimed at preventing malaria and its severe sequelae among travelers should concentrate on increasing awareness of risks and compliance with malaria chemoprophylaxis.

Reappraisal of community-acquired bacteremia: a proposal of a new classification for the spectrum of acquisition of bacteremia.

In recent years, dramatic changes in health care systems have shifted much of the care of sick individuals from hospitals to the community. Consequently, infections traditionally classified as community-acquired or hospital-acquired infections cannot now be readily classified into either category. We thus propose a new classification based on a wider spectrum of acquisition. A total of 1028 episodes of bloodstream infection (BSI) were divided into 5 categories: true community-acquired infections (370 episodes [36%]), infections in recently discharged patients (110 [11%]), infections associated with invasive procedures performed just before or at the time of admission (56 [5%]), infections in patients admitted from nursing homes (68 [7%]), and hospital-acquired infections (424 [41%]). Thus, 234 (39%) of the 604 bloodstream infections traditionally defined as community acquired were reclassified into 3 newly defined groups, each of which has distinct epidemiologic, clinical, and bacteriologic characteristics, as well as distinct antimicrobial susceptibility profiles. There is a conceptual and practical need for such a new classification.

Hospital-acquired infective endocarditis: should the definition be broadened?

Hospital-acquired infective endocarditis (IE) is a growing health-care problem. Hospital-acquired IE, according to the commonly used definition, is IE manifesting > or =72 h after admission to the hospital or within several weeks after a hospital-based invasive procedure. To assess the validity of this definition, we evaluated 87 episodes of IE, with special attention to recent hospitalizations. The incidence rate of IE in the 6-month period after discharge from the hospital was 27 cases per 100,000 person-years, compared with 1.1 cases per 100,000 person-years in a population with no recent hospitalizations. Furthermore, episodes of IE manifesting during this 6-month period were notable for a high proportion of typically hospital-acquired pathogens (26% vs. 0%; P=.001) and a low proportion of viridans streptococci (0% vs. 36%; P<.001), compared with community-acquired episodes that did not involve recent hospitalization. We conclude that characteristics of hospital-acquired IE extend to episodes arising within 6 months after discharge from the hospital and suggest that the definition of hospital-acquired IE be broadened to include these episodes.

Healthcare associated infective endocarditis: a distinct entity.

The terms hospital- and community-acquired infections do not cover any longer the full spectrum of acquisition of infection. Consequently, the term healthcare associated infection (HCA) has been recently introduced. In order to examine the applicability of 'HCA infection' to patients with infective endocarditis (IE), 125 episodes of culture-positive IE were categorized into 3 groups of acquisition. 14 (11%) of 125 episodes were defined as hospital acquired (HA) IE (onset of more than 72 h after admission), 52 (42%) as HCA (IE on admission in patients with significant previous healthcare contact), and 59 (47%) as community acquired (CA) (IE on admission in people without recent healthcare contact). 41 (77%) of the 53 causative agents in the HCA IE group were typical nosocomial pathogens, whereas these types of pathogens constituted only 22% (14/64) of the microorganisms in the group of CA IE (p<0.0001). Mortality in the HA and HCA groups combined was significantly higher than that in the CA group (19/62, 31%, vs 6/59, 10%, p=0.01). HCA IE should be recognized as a distinct category that constitutes a large proportion of all cases of IE. HCA IE is significantly different from CA IE and, therefore, may require a different therapeutic approach.

Enterococcal bacteraemia: epidemiological, microbiological, clinical and prognostic characteristics, and the impact of high level gentamicin resistance.

Enterococci are increasingly common nosocomial pathogens that can cause serious infections and often acquire antibiotic resistance. This study focused on the epidemiological, microbiological and clinical characteristics of enterococcal bacteraemia with special attention to the impact of high level gentamicin resistance (HLGR) on prognosis. 117 cases of enterococcal bacteraemia constituted 8% of all bacteraemic episodes during the y 2002. The most common source of infection was the urinary tract, more than half of the episodes were polymicrobial and the vast majority of cases was healthcare-associated. 50 of 117 isolates (43%) were resistant to gentamicin. Infection-related mortality (22 of 117, 19%) was associated with 2 independent variables in multivariate analysis: severity-of-illness score (OR=39.6, p<0.00001) and HLGR (OR=6.4, p=0.006). It was concluded that HLGR adversely affects the outcome of bacteraemic enterococcal infection.

Multidrug-resistant Acinetobacter baumannii.

To understand the epidemiology of multidrug-resistant (MDR) Acinetobacter baumannii and define individual risk factors for multidrug resistance, we used epidemiologic methods, performed organism typing by pulsed-field gel electrophoresis (PFGE), and conducted a matched case-control retrospective study. We investigated 118 patients, on 27 wards in Israel, in whom MDR A. baumannii was isolated from clinical cultures. Each case-patient had a control without MDR A. baumannii and was matched for hospital length of stay, ward, and calendar time. The epidemiologic investigation found small clusters of up to 6 patients each with no common identified source. Ten different PFGE clones were found, of which 2 dominated. The PFGE pattern differed within temporospatial clusters, and antimicrobial drug susceptibility patterns varied within and between clones. Multivariate analysis identified the following significant risk factors: male sex, cardiovascular disease, having undergone mechanical ventilation, and having been treated with antimicrobial drugs (particularly metronidazole). Penicillins were protective. The complex epidemiology may explain why the emergence of MDR A. baumannii is difficult to control.

Coronary stent bacterial infection with multiple organ septic emboli.

We describe an 80-year-old patient who developed Staphylococcus aureus septicemia several days after the implantation of a double stent in the proximal and mid-left anterior descending artery. The infection was complicated by multiple abscesses in the lungs and liver, as well as by bilateral bacterial endophthalmitis requiring right vitrectomy. Long-term antibiotic treatment was successful. Rarity notwithstanding, heightened awareness of this potential complication of a common cardiac procedure is important since diagnosis and immediate therapy are mandatory.

The role of vancomycin in the persistence or recurrence of Staphylococcus aureus bacteraemia.

Persistence and recurrence of Staphylococcus aureus bacteraemia (SAB) have been linked primarily with difficult-to-eradicate foci of infection such as endocarditis, osteomyelitis or abscess formation. Although vancomycin therapy has been suggested as a predictor of relapse of SAB, it has never been shown to be associated with persistent SAB. The purpose of this study was to examine the possible association of vancomycin therapy and persistence of SAB. Two groups of patients were retrospectively studied. One group consisted of 124 patients who completed > or =10 d of appropriate anti-staphylococcal therapy (from among a total of 284 patients with SAB during 2 y, 1997-8). In this group, persistence of SAB (methicillin resistant and susceptible combined) for >3 d while on therapy, occurred in 11 (22%) of 55 vancomycin recipients and in none of 52 cloxacillin recipients (p = 0.002). When calculated for methicillin susceptible SAB alone, the numbers were 3 of 13 vs 0 of 52, respectively (p = 0.007). The second study group included all patients with persistence and/or relapse of SAB while on appropriate anti-staphylococcal therapy during 4 y (1997-2000). In this group, the persistence occurred while on vancomycin therapy, in 32 (94%) of 34 patients with >3 d of persistence of SAB. In the majority of these patients a secondary focus of infection serving as the site of persistence was identified in addition to the primary focus (or portal of entry). It was concluded that vancomycin is inferior to cloxacillin therapy in terminating SAB and therefore may predispose to prolonged bacteraemia and secondary seeding of infection during therapy.

Streptococcus bovis revisited: a clinical review of 81 bacteremic episodes paying special attention to emerging antibiotic resistance.

Following 2 Cases of Streprococcus bovis endocarditis with a high level of resistance to clindamycin during 2002, the authors reviewed their clinical experience with S. bovis bacteremia during 2 periods, starting in 1980. 81 episodes of S. bovis bacteremia represented approximately 1% of all episodes of bacteremia. In 32 (40%) cases the bacteremia represented endocarditis, in 15 (19%) the bacteremia originated from sick bowel, 11 (14%) were suspected to arise from urinary tract infection, 10 (12%) originated from biliary or peritoneal infection, and 13 from other or unknown sources. 25 (31%) of the bacteremias were polymicrobial. All of the isolates were highly susceptible to penicillin and clindamycin, with the following exceptions: 2 isolates had a minimal inhibitory concentration (MIC) of 0.5 mg/l to penicillin (in 1997) and 5 isolates had an MIC of > 2 mg/l to clindamycin (in 1997, 1998, 2000 and 2002). The 2 most recent of these 5 had high-level resistance to clindamycin of > 256 mg/l. It seems that clindamycin resistance in S. bovis is an emerging phenomenon, in contrast to penicillin resistance, high levels of which have not yet been described in S. bovis.

Listeria monocytogenes infection in Israel and review of cases worldwide.

Listeria monocytogenes, an uncommon foodborne pathogen, is increasingly recognized as a cause of life-threatening disease. A marked increase in reported cases of listeriosis during 1998 motivated a retrospective nationwide survey of the infection in Israel. From 1995 to 1999, 161 cases were identified; 70 (43%) were perinatal infections, with a fetal mortality rate of 45%. Most (74%) of the 91 nonperinatal infections involved immunocompromised patients with malignancies, chronic liver disease, chronic renal failure, or diabetes mellitus. The common clinical syndromes in these patients were primary bacteremia (47%) and meningitis (28%). The crude case-fatality rate in this group was 38%, with a higher death rate in immunocompromised patients.