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עמוד בית
Tue, 23.04.24

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January 2023
Yehonatan Azulai BA, Shepard Schwartz MD, Eyal Heiman MD, Elihay Berliner MD, Giora Weiser MD

Background: Clinical dysentery causes hundreds of thousands of deaths annually worldwide. However, current recommendations reserve antibiotics for those either clinically sick or with highly suspected cases of shigellosis. This treatment stems from rising antibiotic resistance. Children diagnosed with clinical dysentery in the pediatric emergency department (PED) are regarded more cautiously.

Objectives: To explore the use of antibiotics in children diagnosed with clinical dysentery in the PED.

Methods: A retrospective case study of children with clinical dysentery at a single PED during the years 2015 and 2018. Demographics as well as clinical findings were compared to culture results and antibiotic treatment.

Results: The study included 281 children who were diagnosed with clinical dysentery during the study period; 234 (83%) were treated with antibiotics. However, cultures were positive in only 162 cases (58%). Only 32% were Shigella spp. Younger age, fever, and leukocytosis were related to antibiotic treatment.

Conclusions: The diagnosis of clinical dysentery is misgiven commonly in the PED leading to widespread use of antibiotics when not indicated. This treatment may impact antibiotic resistance patterns. Further studies and interventions are necessary to create clear guidelines in the PED setting.

May 2018
Viktoria Leikin-Zach MD, Eilon Shany MD, Maayan Yitshak-Sade PhD, Ron Eshel B Med Sc, Tali Shafat MD, Avraham Borer MD and Rimma Melamed MD

Background: Extended-spectrum beta-lactamase (ESBL) production is the most common antimicrobial resistance mechanism in the neonatal intensive care unit (NICU), with colonization and blood stream infections being a major threat to this population. Since 2013, all NICU admissions at our facility were screened twice weekly for ESBL colonization.

Objectives: To determine independent risk factors for colonization of infants with ESBL-producing bacteria in the NICU.

Methods: A retrospective case study of ESBL-colonized infants vs. controls (matched by date of birth and gestational age) was conducted in the NICU of Soroka University Medical Center, Israel, between 2013 and 2014. Epidemiological, laboratory, and clinical data were extracted from medical files. Univariable and multivariable analyses were used to assess associations between ESBL colonization and possible clinical risk factors.

Results: Of 639 admissions during the study period, 87 were found to be ESBL-colonized (case infants) and were matched to 87 controls. Five case infants became infected (5.7%) with ESBL strains. Klebsiella pneumoniae was the most common isolated bacteria. The mean time from admission to colonization was 15 days. Univariable analysis showed an association of male gender and highest Apgar score at 1 and 5 minutes with ESBL colonization (P < 0.05). Multivariable analysis yielded only a possible association of higher Apgar score at 1 and 5 minutes (hazard ratio [HR] 1.515, 95% confidence interval [95%CI] 0.993-2.314; HR 1.603, 95%CI 0.958–2.682, respectively) with ESBL colonization.

Conclusions: Future studies should focus on maternal colonization and possible strategies for preventing vertical transmission of ESBL strains to high-risk neonates.

March 2018
Michal Solomon MD, Aviv Barzilai MD, Hila Elphasy MD, Henri Trau MD and Sharon Baum MD

Background: Erysipelas, an acute infection of the dermal and subcutaneous tissue, is normally treated with antibiotics. Previous data indicated that treatment with prednisone in combination with antibiotics results in significant acceleration of the healing phase.

Objectives: To investigate the effectiveness of corticosteroids combined with antibiotics for the treatment of erysipelas.

Methods: A retrospective study was conducted on hospitalized patients diagnosed with erysipelas between 2004 and 2011 at the Department of Dermatology at Sheba Medical Center, Israel. Data included epidemiology, medical background, and course of the disease as documented at admission and during hospitalization. 

Results: Data were collected on 173 patients (66% males) who were divided into two groups: a control group treated with antibiotics only (97 patients) and a study group treated with antibiotics and prednisone (76 patients). The study group presented with a more severe form of erysipelas (bullous) and those patients were hospitalized for a longer period (8.5 vs. 7 days). Nevertheless, the study group exhibited a 71% clinical improvement shortly after being treated with prednisone, without significant side effects. Short-term follow-up revealed more edema in the study group; however, long-term follow-up revealed a higher incidence of erythema and recurrence of erysipelas in the control group. The return to full function was faster in the study group than in the control group. 

Conclusions: Combining prednisone with antibiotics for the treatment of erysipelas should be considered, especially in severe cases. In addition, a prospective double-blind study should be conducted to verify these conclusions.

December 2010
M. Ojeniran, R. Shouval, I.N. Miskin,A.E. Moses and A. Shmueli

Background: Appropriate antibiotic use is of both clinical and economic significance to any health system and should be given adequate attention. Prior to this study, no in-depth information was available on antibiotic use patterns in the emergency department of Hadassah Medical Center.

Objectives: To describe the use and misuse of antibiotics and their associated costs in the emergency department of Hadassah Medical Center.

Methods: We analyzed the charts of 657 discharged patients and 45 admitted patients who received antibiotics in Hadassah Medical Center’s emergency department during a 6 week period (29 April – 11 June 2007). A prescription was considered appropriate or inappropriate if the choice of antibiotic, dose and duration by the prescribing physician after diagnosis was considered suitable or wrong by the infectious diseases consultant evaluating the prescriptions according to Kunin’s criteria.

Results: The overall prescribing rate of antibiotics was 14.5% (702/4830) of which 42% were broad- spectrum antibiotics. The evaluated antibiotic prescriptions numbered 1105 (96 prescriptions containing 2 antibiotics, 2 prescriptions containing 3 antibiotics), and 54% of them were considered appropriate. The total inappropriate cost was 3583 NIS[1] (1109 USD PPP[2]) out of the total antibiotic costs of 27,300 NIS (8452 USD PPP). The annual total antibiotic cost was 237,510 NIS (73,532 USD PPP) and the annual total inappropriate cost was 31,172 NIS (9648 USD PPP). The mean costs of inappropriate prescriptions were highest for respiratory (112 NIS, 35 USD PPP) and urinary tract infection (93 NIS, 29 USD PPP). There were more cases when the optimal cost was lower than the actual cost (N=171) than when optimal cost was higher than the actual cost (N=9). In the first case, the total inappropriate costs were 3805 NIS (1,178 USD PPP), and in the second case, -222 NIS (68.7 USD PPP).

Conclusions: The use of antibiotics in emergency departments should be monitored, especially in severely ill patients who require broad-spectrum antibiotics and for antibiotics otherwise restricted in the hospital wards. Our findings indicate that 12% of the total antibiotic costs could have been avoided if all prescriptions were optimal.






[1] NIS = New Israeli Shekel



[2] USD PPP = US dollar purchasing power parity


November 2009
N. Fisch, S. Ashkenazi and M. Davidovits

Background: Although febrile urinary tract infections are very common in young children, the need for antimicrobial prophylaxis and evaluation following a first event is controversial.

Objectives: To assess the approach of leading pediatric specialists throughout Israel.

Methods: A questionnaire regarding the approach to antibiotic prophylaxis and diagnostic evaluation following a first event of febrile UTI[1], according to age and underlying renal abnormality, was sent to all 58 directors of departments of pediatrics, units of pediatric infectious diseases and pediatric nephrology in Israel.

Results: Fifty-six directors (96%) responded. Most prescribed prophylactic antibiotics after UTI. Heads of infectious disease departments prescribed less prophylaxis following UTI at the age of 18 months than heads of pediatrics or heads of pediatric nephrology units (34% vs. 72–75%, P = 0.018), but more often in cases of severe vesico-ureteral reflux without UTI. Cephalosporins were used prophylactically more often by directors of pediatrics compared to heads of pediatric nephrology units (71% vs. 38%, P = 0.048); the latter used non-beta-lactam prophylaxis (61% vs. 23%, P = 0.013) more often. Most pediatricians used renal sonography for evaluation; renal scan was used more commonly by pediatric nephrologists.

Conclusions: The administration of prophylactic antibiotics after UTI is still common practice among pediatric opinion leaders, although the specific approach differs by subspecialty. According to up-to-date evidence-based data, educational efforts are needed to formulate and implement judicious guidelines.

 




[1] UTI = urinary tract infection


March 2009
A. Maayan-Metzger, A. Barzilai, N. Keller and J. Kuint

Background: Early-onset neonatal sepsis is a major cause of morbidity and mortality among newborn infants.

Objectives: To determine the incidence, type of pathogens and resistance to antibiotics among newborns with early-onset neonatal sepsis, and to identify the risk factors predisposing infants to resistant pathogens in order to reevaluate antibiotic regimens appropriate for resistant bacteria in these high risk neonates.

Methods: We retrospectively studied maternal and neonatal variables of 73 term and near-term infants and 30 preterm infants, born over a period of 10.5 years and exhibiting early-onset neonatal sepsis (positive blood cultures in the first 72 hours of life).

Results: Predominant pathogens in term and near-term infants were gram-positive compared with gram-negative organisms (mostly Escherichia coli) in preterm infants. Mothers of infants with antibiotic-resistant organisms were more likely to have prolonged rupture of membranes and prolonged hospitalization before delivery and to be treated with antibiotics. No trends towards more resistant strains of pathogens were recorded over the 10.5 years of the study period.

Conclusions: Early-onset neonatal sepsis in term infants differs in bacterial species from that in preterm infants, with predominantly gram-positive organisms in term and near-term infants and gram-negative organisms in preterms. Rates of bacterial resistance to the combination of ampicillin and gentamicin, though higher among infants born to mothers with prolonged hospitalization who had been treated with antibiotics, still remained very low in our department. Thus, it seems that our classic antibiotic regimen is still appropriate for both term and preterm newborns.
 

June 2007
A. Gafter-Gvili, M. Paul, A. Fraser, L. Leibovici.
January 2007
B. Chazan, R. Ben Zur Turjeman, Y. Frost, B. Besharat, H. Tabenkin, A. Stainberg, W. Sakran, R. Raz

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 interventions programs – continuous versus seasonal medical education – oriented to primary care physicians with emphasis on 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.
 

August 2006
Z. Kaufman, G. Aharonowitz, R. Dichtiar and M.S. Green
Background: Early clinical signs of influenza caused by a pandemic strain will presumably not differ significantly from those caused by other respiratory viruses. Similarly, early signs of diseases that may result from bioterrorism are frequently non-specific and resemble those of influenza-like illness. Since the time window for effective intervention is narrow, treatment may need to be initiated prior to a definitive diagnosis. Consequently, planning of medications, manpower and facilities should also account for those who would be treated for an unrelated acute illness.

Objectives: To estimate usual patterns of acute illness in the community as a baseline for integration into pandemic influenza and bioterrorism preparedness plans.

Methods: Between 2000 and 2003 we conducted 13 telephone surveys to estimate the usual incidence and prevalence of symptoms of acute illness in the community.

Results: On average, 910 households were included in each of the surveys, representing about 3000 people. The compliance rates for full interviews ranged from 72.3% to 86.0%. In winter, on average, about 2% of the Israeli population (individuals) suffered each day from fever of ≥ 38ºC, and about 0.8% during the other months. The prevalence of cough was higher, 9.2% in winter and 3% during summer. Daily incidence of fever ranged from about 0.4% per day in winter to about 0.2% in the fall. The prevalence and incidence of both fever and cough were highest for infants followed by children aged 1–5 years.

Conclusions: These background morbidity estimates can be used for planning the overall treatment requirements, in addition to actual cases, resulting from pandemic influenza or a bioterrorist incident.

May 2006
O. Hochwald, E. Bamberger and I. Srugo

The Israel Ministry of Health’s epidemiology department reported a record number of 1564 new pertussis cases in 2004. This brings the incidence rate to 23 per 100,000 population, indicating a marked increase in the prevalence of pertussis, from 1–3/100,000 in 1998, 9 in 2001, to 14 in 2003. The rate of atypical pertussis presentations in vaccinated patients, the decline in pertussis immunity post-vaccination, and the decreased awareness of potential infections in the adult population make the diagnosis of pertussis difficult and contribute to the rising incidence. In this article we review the current literature in order to increase awareness of the occurrence of pertussis in children as well as adults, discuss the laboratory diagnostic methods being used, and report the currently recommended means of treating the disease.

November 2005
R. Raz, H. Edelstein, L. Grigoryan and F.M. Haaijer-Ruskamp
 Background: The current study is part of the larger study on 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: Our results show that 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.

May 2005
J. Bishara, G. Livne, S. Ashkenazi, I. Levy, S. Pitlik, O. Ofir, B. Lev and Z. Samra

Background: The prevalence of extended-spectrum β-lactamase-producing organisms and their antimicrobial resistance patterns may vary between geographic areas.

Objectives: To evaluate the prevalence and susceptibility of ESBL[1]-producing organisms among Klebsiella pneumoniae and Escherichia coli isolated from adult and pediatric patients in two Israeli hospitals.

Methods: ESBL production was tested according to recommendations of the Clinical and Laboratory Standards Institute, using ceftazidime (30 μg) and a combination of ceftazidime/clavulanate (30/10 μg) disks with a ≥5 mm difference indicating positivity. Antibiotic susceptibilities were determined by the disk diffusion method according to CLSI[2] standards. Minimum inhibitory concentrations were determined by the E-test.

Results: The prevalence of ESBL-producing organisms was significantly higher among K. pneumoniae than E. coli isolates – 32% (241/765) vs. 10% (57/547) respectively (P < 0.001), and more frequently isolated from adults than children (odds ratio 2.27 for K. pneumoniae and 12.94 for E. coli). Resistance rates for amoxicillin/clavulanate, piperacillin-tazobactam, amikacin, and ciprofloxacin among the ESBL-producing K. pneumoniae and E. coli isolates were 95%, 82%, 49% and 77% for K. pneumoniae, and 77%, 35%, 25% and 100% for E. coli. Two (0.8%) ESBL-producing and 4 (0.7%) ESBL-negative K. pneumoniae isolates showed intermediate susceptibility (MIC[3] 6 μg/ml) to meropenem. All isolates were sensitive to ertapenem and colistin.  

Conclusion: ESBL production among K. pneumoniae and E. coli is more prevalent in the adult population than the pediatric population and is associated with multidrug resistance.







[1] ESBL = extended spectrum β-lactamase

[2] CLSI = Clinical and Laboratory Standards Institute (formerly the NCCLS)

[3] MIC = minimum inhibitory concentration





 

March 2005
Z. Samra, O. Ofer and H. Shmuely
 Background: Methicillin-resistant Staphylococcus aureus is a major nosocomial pathogen worldwide. Vancomycin is the traditional drug of choice, but decreasing susceptibility to vancomycin and other glycopeptides has been reported since 1996.

Objectives: To test the in vitro activity of linezolid (oxazolidinone) and other antimicrobial agents against MRSA[1] isolates recovered from hospitalized patients.

Methods: We tested 150 MRSA isolates recovered from hospitalized patients. The minimal inhibitory concentration of vancomycin, teicoplanin, pristinamycin (quinupristin-dalforistin), and linezolid was determined by the Etest method. Susceptibility to other antibiotics was tested by the disk diffusion method.

Results: All isolates were sensitive to vancomycin, teicoplanin, pristinamycin, and linezolid. The MIC90 was 2.0 mg/ml for vancomycin and teicoplanin (range 0.5–2.0 mg/ml and 0.125–2.0 mg/ml, respectively), and 0.5 mg/ml for pristinamycin and linezolid (range 0.125–0.75 mg/ml and 0.125–0.5 mg/m, respectively). Of the other antibiotics, fusidic acid showed the best in vitro activity, with 96.7% susceptibility, associated with trimethoprim/sulfamethoxazole (85.8%) and minocycline (84%). Penicillin was associated with the lowest susceptibility (1.3%), associated with ofloxacin (3%) and erythromycin (14%). An increase in the minimal inhibitory concentration value of vancomycin was associated with a significant decrease in resistance to TMP-SMZ[2] (P < 0.01) and an apparent increase in resistance to other antibiotics.

Conclusion: The excellent in vitro activity of linezolid and its reported in vivo effectiveness renders it an important therapeutic alternative to vancomycin in the treatment of MRSA infection.

__________________

[1] MRSA = methicillin-resistant Staphylococcus aureus

[2] TMP-SMX = trimethoprim/sulfamethoxazole

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