Mervyn Shapiro - Academia.edu (original) (raw)
Papers by Mervyn Shapiro
Pharmacoepidemiology and Drug Safety, 2005
To evaluate the variance in rates of physician adherence to guidelines for the empiric treatment ... more To evaluate the variance in rates of physician adherence to guidelines for the empiric treatment of uncomplicated urinary tract infection (UTI) in women recommending either trimethoprim-sulfamethoxazole (TMP-SMX) or nitrofurantoin, in all relevant physician subspecialities practising in a managed care community setting in Israel. Data were derived from the computerised medical records of Maccabi Healthcare Services, a health maintenance organisation (HMO) in Israel providing care to more than 1.6 million members nation-wide. The study population included women aged 18-75 years without risk factors for complicated UTI who were treated empirically with antibiotics for a diagnosis of acute cystitis or UTI. The data set consisted of 64,236 initial physician-patient encounters from July 2000 to June 2002. Physician adherence to guidelines was calculated by comparing the proportion of cases treated with each individual drug. A binary regression model was used to evaluate factors associated with suboptimal adherence to the guidelines. Nitrofurantoin was the most frequently prescribed drug (18.51%), followed by TMP-SMX (17.04%) for a crude rate of adherence of 35.6%. Adherence was observed to be highest in cases treated by urologists (OR=2.8, 95%CI: 2.4, 3.3), followed by gynaecologists (OR=1.9, 95%CI: 1.7, 2.31), with family practice as the referent speciality. The medical school attended was also found to be significant. Physician speciality was found to be significantly associated with rate of adherence to guidelines, with higher rates being observed amongst specialities such as urologists who presumably have greater familiarity with the subject matter.
The Israel Medical Association journal : IMAJ, 2013
Spinal epidural abscess (SEA) is a rare disease with a potentially devastating outcome, and a rep... more Spinal epidural abscess (SEA) is a rare disease with a potentially devastating outcome, and a reported incidence traditionally estimated at 0.2-2 cases/10,000 hospital admissions. Since the implementation in October 2007 of a program to increase medical personnel's awareness of SEA, we have documented a sharp increase in the incidence of SEA at our medical center To investigate the cause of the increased incidence of SEA. All cases diagnosed with SEA during the period 1998-2010 were retrospectively reviewed. Cases diagnosed before 2007 were compared with those diagnosed thereafter. From January 1998 to October 2007 SEA was diagnosed in 22 patients (group A), giving an annual incidence of 0.14-0.6 cases per 10,000 admissions. During the period November 2007 to April 2010, 26 additional patients were diagnosed (group B), yielding an incidence of 0.81-1.7 cases per 10,000 admissions (P < 0.01). The two groups did not differ significantly in epidemiological, clinical or laborator...
The Israel Medical Association journal : IMAJ, 2004
The complexity of medical problems is a well-recognized phenomenon. In the presence of economic a... more The complexity of medical problems is a well-recognized phenomenon. In the presence of economic and cultural restrictions, medical decision-making can be particularly challenging. This paper outlines a system of analysis and decision-making for solving such problems, and briefly describes a case study in which the method was used to analyze the case of antibiotic overprescribing in a large health maintenance organization. The purpose of the study was to determine if a technique for problem-solving in the field of engineering could be applied to the complex problems facing primary care. The method is designated Systematic Inventive Thinking and consists of a three-step procedure: problem reformulation, general search-strategy selection, and an application of idea-provoking techniques. The problem examined is the over-prescribing of antibiotics by general practitioners working in Maccabi Healthcare Services, an HMO serving one and a half million patients in Israel. The group of health...
The Pediatric infectious disease journal, 1995
An increase in the incidence and severity of bacteremia caused by group A streptococci was noted ... more An increase in the incidence and severity of bacteremia caused by group A streptococci was noted in 1993 and 1994 in the Hadassah University Medical Center, Jerusalem. During the 6-year period 1987 to 1992, 12 children with group A streptococcal bacteremia were hospitalized, whereas in 1993 and 1994 there were 17 patients, 5 of them with 1 each of the following severe clinical manifestations: meningitis and septic shock; streptococcal toxic shock syndrome; septic shock; pleural empyema; and fatal outcome. Our 29 patients with group A streptococcal bacteremia were younger than those reported in the literature: 10 (35%) were < 3 months of age; 17 (59%) were < 1 year old. Most children were previously healthy and only 3 had an underlying immunodeficiency predisposing to infection (1 case each): leukemia; Di George syndrome; and congenital nephrotic syndrome. Two children were recovering from varicella. The skin was the most common site of primary infection (16 of 29). The average...
Archives of orthopaedic and traumatic surgery. Archiv für orthopädische und Unfall-Chirurgie, 1983
High dose intravenous methicillin therapy is a common form of treatment for post traumatic acute ... more High dose intravenous methicillin therapy is a common form of treatment for post traumatic acute osteomyelitis and septic arthritis, with positive staphylococcus aureus cultures. A high and spiking fever, persisting in the face of adequate antibiotic therapy, presents a difficult diagnostic dilemma in such patients. In seven patients, methicillin induced drug fever was found to be the cause of such as persisting pyrexia, inspite of an adequate antibiotic regime. This diagnosis must be established by a cautious clinical evaluation and by a careful elimination of all other causes for fever. Upon discontinuation of methicillin, the body temperature reverted to normal within 24 h.
New England Journal of Medicine, 1982
We studied risk factors for postoperative infections at the operative site after hysterectomies. ... more We studied risk factors for postoperative infections at the operative site after hysterectomies. Data were collected prospectively on all women undergoing vaginal hysterectomies (323 patients) or abdominal hysterectomies (1125 patients) at the Boston Hospital for Women between February 1976 and April 1978. Logistic-regression analysis indicated that factors significantly associated (P less than 0.05) with a higher risk of infection at the operative site were increased duration of operation, lack of antibiotic prophylaxis, younger age, being a clinic patient, and an abdominal approach. After these variables were accounted for, the variables of obesity, preoperative functional and anatomical diagnoses, postoperative anatomical and pathological diagnoses, estimated blood loss, menopausal status, and operation by a specific surgeon did not add predictive power. An increasing duration of operation was associated with a decreasing effect of antibiotic prophylaxis, the preventive fraction of which diminished from 80 per cent at one hour to an unmeasurable effect at 3.3 hours.
Trichosporon asahii (Trichosporon beigelii) infections are rare but have been associated with a w... more Trichosporon asahii (Trichosporon beigelii) infections are rare but have been associated with a wide spectrum of clinical manifestations, ranging from superficial involvement in immunocompetent individuals to severe systemic disease in immunocompromised patients. We report on the recent recovery of T. asahii isolates with reduced susceptibility in vitro to amphotericin B (AMB), flucytosine, and azoles from six nongranulocytopenic patients who exhibited
The Pediatric Infectious Disease Journal, 1989
Giardia lamblia infection was identified in 33 of 89 (37%) 3-month-old to 3-yr-old children who w... more Giardia lamblia infection was identified in 33 of 89 (37%) 3-month-old to 3-yr-old children who were followed with monthly stool examinations for up to 12 months in a day care center. The infection was mainly asymptomatic and usually associated with prolonged carriage of the parasite. There were no significant differences for height and weight achievements and mean hemoglobin values between Giardia-positive and Giardia-negative children. However, Giardia-positive children tended to achieve higher weight and height for age than Giardia-negative children; weight for age was above the 50th percentile in 69% of Giardia-positive vs. 40% of Giardia-negative children (alpha = 0.01). Giardia-positive children tended to have fewer symptoms related to the gastrointestinal and respiratory tracts as recorded by a weekly questionnaire. Lactase deficiency was detected by breath hydrogen testing in 8 of 26 Giardia-positive vs. only 1 of 21 Giardia-negative children (P less than 0.02). Healthy day care children with asymptomatic Giardia infection show no disadvantage and perhaps even an advantage in nutritional status and freedom from other illnesses.
Transplantation, 1995
Bacterial pneumonia as an important complication of bone marrow transplantation (BMT) has not bee... more Bacterial pneumonia as an important complication of bone marrow transplantation (BMT) has not been subjected to comprehensive analysis. Two hundred fifty-five consecutive allogeneic and autologous BMT recipients, ranging in age from 1 month to 53 years, were prospectively followed for 3 days to 3 years (median, 108 days) for development of bacterial pneumonia. Etiology, place acquired, chest radiography, and outcome were recorded and the association between bacterial pneumonia and demographic and clinical variables was analyzed. Thirty-seven (15%) patients experienced 52 episodes of bacterial pneumonia: onset of 13 episodes occurred within 30 days after transplantation, 10 episodes occurred on days +31 to +100, and 29 episodes occurred thereafter. Bacterial pneumonia was the terminal event or contributed to fatal outcome in 8 patients (22% of bacterial pneumonia cases, 3% total study population). Mortality due to hospital-acquired pneumonia (6/21) was significantly higher than (P = 0.03). Bacterial pathogens were identified in 27 (52%) episodes. During the first 100 days after BMT, hospital-acquired Gram-negative bacteria predominated, caused mainly by Pseudomonas aeruginosa, Klebsiella pneumoniae, Acinetobacter lwoffi, and Enterobacter cloacae. After day +100, community-acquired, Gram-positive bacteria predominated, particularly Streptococcus pneumoniae. Haemophilus influenzae occurred periodically. Considering all episodes, significant association was found between bacterial pneumonia and veno-occlusive disease (VOD) (P &amp;amp;amp;lt; 0.01) and chronic graft-versus-host disease (GVHD) (P &amp;amp;amp;lt; 0.02). For culture-positive episodes, the association between bacterial pneumonia and VOD was significant (P &amp;amp;amp;lt; 0.001) and borderline for acute GVHD (P = 0.07). It is concluded that VOD and GVHD are positively associated with post-BMT bacterial pneumonia. Its incidence, etiology, risk factors, and outcome are important considerations in its prevention and treatment.
Journal of Maternal-Fetal and Neonatal Medicine, 2008
Little is known regarding the prevalence of early postpartum bacteriuria. We sought to evaluate t... more Little is known regarding the prevalence of early postpartum bacteriuria. We sought to evaluate the incidence of bacteriuria following labor and to identify risk factors predisposing to this condition. Three hundred and fifty parturients were recruited, 301 were included in the analysis. Women receiving antibiotic drugs during delivery were excluded. Urine cultures were obtained from the study group before delivery and prior to discharge. Data regarding management of labor was collected prospectively. Positive urine cultures were present on admission in 5.4% of women, whereas 12.9% had a positive urine culture at discharge (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.003). Bacteriuria was acquired during labor in 12.7% of patients who had negative cultures on admission. Escalating number of digital vaginal examinations (p = 0.04), recurrent bladder catheterization (p = 0.05), duration of epidural anesthesia (p = 0.002), and vacuum delivery (p = 0.02) correlated significantly with an increased risk for acquiring bacteriuria. Labor is a bacteriuric event. Iatrogenic interventions can predispose parturients with sterile urine cultures to postpartum bacteriuria.
Medical Mycology, 2002
We report the recent isolation of Cryptococcus laurentii from the blood of a patient given the di... more We report the recent isolation of Cryptococcus laurentii from the blood of a patient given the diagnosis of ganglioneuroblastoma. The organism was identified using physiological and molecular characteristics, including morphology, carbohydrate and nitrate assimilation, urease activity, inability to form melanin on appropriate media, positive staining with diazonium blue B and sequence analysis of the D1/D2 domain of 26S ribosomal DNA. The isolate was resistant to fluconazole and 5-fluorocytosine using both the Etest and a broth microdilution assay. Repeated recovery of the organism from different blood cultures, and the patient's good response to treatment with amphotericin B support its etiological role. C. laurentii has rarely been implicated as a cause of clinically significant infections. The identity of reported isolates has not always been adequately documented, and some appear to have been isolated from lesions caused by Cryptococcus neoformans, emphasizing the true rarity of disease due to this fungus.
Journal of the American Medical Directors Association, 2001
Urinary tract infection is the most common cause of nosocomial infections in patients hospitalize... more Urinary tract infection is the most common cause of nosocomial infections in patients hospitalized in chronic care facilities. The changing spectrum of microorganisms involved in urinary tract infections and the emerging resistance require continuous monitoring to provide crucial information to guide empirical therapy and encourage prudent use of antibiotics. The aim of this survey was to assess the antimicrobial resistance profile of urine isolates from patients hospitalized in a geriatric hospital and from elderly patients hospitalized in an acute care hospital in order to guide empirical therapy of urinary tract infections. The survey was performed in two hospitals in Jerusalem: a university-affiliated geriatric hospital- Herzog -and an acute secondary- and tertiary-care university hospital- Hadassah. We performed a retrospective analysis of antimicrobial resistance of all positive urine cultures obtained from patients in the geriatric division of Herzog Hospital and from patients aged 65 years and older hospitalized in the Internal Medicine departments in Hadassah Hospital during a 1-year period. The most common bacteria isolated from urine specimens in Herzog Hospital were, in order of frequency, Escherichia coli, Proteus mirabilis, and Pseudomonas aeruginosa. We demonstrated a high rate of antimicrobial resistance of those bacteria in both hospitals. The pattern we observed necessitates recommending ceftazidime as the most appropriate empirical therapy for urinary tract infection in Herzog Hospital. In Hadassah Hospital we recommend cefuroxime for those patients in good general condition and ceftazidime for those who present with clinical sepsis. Antimicrobial resistance patterns should be assessed periodically and recommendations modified accordingly. Infection control guidelines should be implemented in order to try to decrease the rate of antimicrobial resistance. Further research is requested to assess the efficacy of such interventions in long-term care facilities.
Journal of Infectious Diseases, 1979
The patterns of use of antimicrobial drugs in a random sample of general hosptials in Pennsylvani... more The patterns of use of antimicrobial drugs in a random sample of general hosptials in Pennsylvania were studied. The sample was tested for validity, and all deaths and discharges were analyzed for 10 random days drawn across the year spanning July 1973 to June 1974. Methods were developed for abstracting the hospital records and for determining the reproducibility of the findings of the physician and nonphysician chart reviewers. More than 99% of the requested charts were available. In the 5,288 charts reviewed, most of the required data were readily available. The study population was 84% white and 58% female; most patients were in hospitals that had more than 300 beds and that were located in towns with populations of greater than 10,000. In 41% of the 2,070 antimicrobial courses administered to almost 30% of the patients, an explicit clinical statement of why the drug was being given could be found in the chart. The information for review was found in clinical charts, but in half of the charts, the information required was not on face sheets and discharge summaries.
Journal of Hospital Infection, 2000
Most published studies of the activity of biocides against methicillin-resistant Staphylococcus a... more Most published studies of the activity of biocides against methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) have been based on suspension tests. This study was undertaken to provide information on the effect of chlorhexidine and povidone iodine on bacteria dried on to surfaces, a situation in which biocide activity is known to be reduced. The inactivation of MRSA (10 strains), methicillin-sensitive Staphylococcus aureus (MSSA, 10 strains), VRE (nine strains) and vancomycin-sensitive Enterococcus faecalis (VSE, 10 strains) by 0.5% aqueous chlorhexidine gluconate or 10% povidone iodine was evaluated by applying the European surface test method. Povidone iodine was equally active against resistant and sensitive strains of both species with microbicidal effects (ME), i.e. the log(10)concentration of micro-organisms compared with controls treated with distilled water, after 1.5 min of 3.14 and 3.49 for VRE and VSE respectively, and 3.47 and 3.78 for MRSA and MSSA. Chlorhexidine was equally active against VRE and VSE (ME 3.37 vs. 3. 56 after 7 min, respectively), but was significantly less active against MRSA as opposed to MSSA (ME 3.07 vs. 3.83 after 10 min, P= 0. 017).
Journal of Hospital Infection, 1997
The local patterns of fungal isolates were studied by a retrospective analysis of fungal species ... more The local patterns of fungal isolates were studied by a retrospective analysis of fungal species isolated from clinical specimens in a university hospital in Jerusalem. Between 1984 and 1993, 5630 fungi [4071 patient unique isolates (PUI)] were isolated and identified. During the study decade, the annual incidence of all isolates increased 2.7-fold, and PUI increased 1.6-fold. Candida albicans accounted for 61% of PUI; urine was the source of 53%. The intensive care units (ICUs) and the Bone Marrow Transplantation (BMT) Department had the highest incidence of fungal isolation. The following trends were observed: (1) a decrease in the relative frequency of C. albicans and increase in Candida tropicalis; (2) increased number of isolates from urine, surgical wounds and intra-abdominal sites; (3) increased number of isolates from ICUs and BMT. Fungi are emerging as important hospital-acquired pathogens in tertiary care and teaching hospitals, and are associated with high rates of morbidity and mortality. It is important to be familiar with the local patterns of fungal isolation in order to improve treatment.
Journal of Clinical Microbiology, 2001
In a retrospective 10-year analysis of 3,536 patient-unique isolates, Acinetobacter baumannii imi... more In a retrospective 10-year analysis of 3,536 patient-unique isolates, Acinetobacter baumannii imipenem susceptibility declined from 98.1 (1990) to 64.1% (2000), and ciprofloxacin susceptibility decreased from 50.5 to 13.1%. Imipenem median zone diameters decreased from 27.7 (1997) to 18.8 mm (2000). No outbreaks were detected. Two clusters were identified for 41 strains genotyped by pulsed-field gel electrophoresis, but imipenem resistance was not clonal.
Journal of Clinical Microbiology, 2004
Fusarium infections are an important problem worldwide, commonly affecting immunocompromised indi... more Fusarium infections are an important problem worldwide, commonly affecting immunocompromised individuals. We conducted a retrospective study in two Israeli tertiary medical centers of factors predisposing to infection by Fusarium spp. and their influence on the epidemiology and clinical outcome of this infection. Fusarium spp. were isolated from 89 patients with a median age of 57 years. Sixty-eight patients were considered immunocompetent. Seven patients had disseminated disease, 34 had locally invasive disease, and 48 had superficial infection. Most infections were limited and occurred mainly in lower limbs. Factors associated with in-hospital mortality were chronic renal failure, hematological malignancy, immunosuppression, disseminated infection, and positive blood culture. Multivariate analysis showed that chronic renal failure, hematological malignancy, burns, and disseminated infection were independently associated with mortality. A surge in the frequency of infections was noticed during the summer for patients from rural areas, involving mainly the eyes and lungs. At one of the hospitals (in a mountainous area), there was an increase in the isolation rate over time.
Journal of Clinical Microbiology, 2001
Trichosporon asahii (Trichosporon beigelii) infections are rare but have been associated with a w... more Trichosporon asahii (Trichosporon beigelii) infections are rare but have been associated with a wide spectrum of clinical manifestations, ranging from superficial involvement in immunocompetent individuals to severe systemic disease in immunocompromised patients. We report on the recent recovery of T. asahii isolates with reduced susceptibility in vitro to amphotericin B (AMB), flucytosine, and azoles from six nongranulocytopenic patients who exhibited risk factors and who developed either superficial infections (four individuals) or invasive infections (two individuals) while in intensive care units. The latter two patients responded clinically and microbiologically to AMB treatment. All six isolates were closely related according to random amplified polymorphic DNA studies and showed 71% similarity by amplified fragment length polymorphism analysis, suggesting a common nosocomial origin. We also review the literature pertaining to T. asahii infections and discuss the salient characteristics of this fungus and recent taxonomic proposals for the genus.
Journal of Clinical Microbiology, 2001
An outbreak of pseudobacteremia due to Streptococcus pyogenes (group A streptococci [GAS]) and me... more An outbreak of pseudobacteremia due to Streptococcus pyogenes (group A streptococci [GAS]) and methicillin-susceptible Staphylococcus aureus (MSSA) was traced to the venting procedure for aerobic bottles prior to their loading into the incubator of the BacT/Alert analyzer (Organon Teknika). Bacteria shed by a laboratory worker suffering from impetigo and cellulitis contaminated the aerobic bottles of 10 patients. All blood culture isolates, in addition to the isolates from the laboratory worker, were of the same GAS M and T types. All MSSA isolates from blood cultures and the index case's hands had the same lytic phage profile. Procedural breakdowns were identified in the laboratory. Bottles were vented outside the biological safety cabinet, gloves were not worn, and unprotected needles were used for the venting procedure. The source of the aspirated bacteria that contaminated the bottles was identified and the index case was treated promptly.
Journal of Clinical Microbiology, 2003
Dermatophytes are common pathogens of skin but rarely cause invasive disease. We present a case o... more Dermatophytes are common pathogens of skin but rarely cause invasive disease. We present a case of deep infection by Trichophyton rubrum in an immunocompromised patient. T. rubrum was identified by morphological characteristics and confirmed by PCR. Invasiveness was apparent by histopathology and immunohistochemistry. The patient was treated successfully with itraconazole.
Pharmacoepidemiology and Drug Safety, 2005
To evaluate the variance in rates of physician adherence to guidelines for the empiric treatment ... more To evaluate the variance in rates of physician adherence to guidelines for the empiric treatment of uncomplicated urinary tract infection (UTI) in women recommending either trimethoprim-sulfamethoxazole (TMP-SMX) or nitrofurantoin, in all relevant physician subspecialities practising in a managed care community setting in Israel. Data were derived from the computerised medical records of Maccabi Healthcare Services, a health maintenance organisation (HMO) in Israel providing care to more than 1.6 million members nation-wide. The study population included women aged 18-75 years without risk factors for complicated UTI who were treated empirically with antibiotics for a diagnosis of acute cystitis or UTI. The data set consisted of 64,236 initial physician-patient encounters from July 2000 to June 2002. Physician adherence to guidelines was calculated by comparing the proportion of cases treated with each individual drug. A binary regression model was used to evaluate factors associated with suboptimal adherence to the guidelines. Nitrofurantoin was the most frequently prescribed drug (18.51%), followed by TMP-SMX (17.04%) for a crude rate of adherence of 35.6%. Adherence was observed to be highest in cases treated by urologists (OR=2.8, 95%CI: 2.4, 3.3), followed by gynaecologists (OR=1.9, 95%CI: 1.7, 2.31), with family practice as the referent speciality. The medical school attended was also found to be significant. Physician speciality was found to be significantly associated with rate of adherence to guidelines, with higher rates being observed amongst specialities such as urologists who presumably have greater familiarity with the subject matter.
The Israel Medical Association journal : IMAJ, 2013
Spinal epidural abscess (SEA) is a rare disease with a potentially devastating outcome, and a rep... more Spinal epidural abscess (SEA) is a rare disease with a potentially devastating outcome, and a reported incidence traditionally estimated at 0.2-2 cases/10,000 hospital admissions. Since the implementation in October 2007 of a program to increase medical personnel's awareness of SEA, we have documented a sharp increase in the incidence of SEA at our medical center To investigate the cause of the increased incidence of SEA. All cases diagnosed with SEA during the period 1998-2010 were retrospectively reviewed. Cases diagnosed before 2007 were compared with those diagnosed thereafter. From January 1998 to October 2007 SEA was diagnosed in 22 patients (group A), giving an annual incidence of 0.14-0.6 cases per 10,000 admissions. During the period November 2007 to April 2010, 26 additional patients were diagnosed (group B), yielding an incidence of 0.81-1.7 cases per 10,000 admissions (P < 0.01). The two groups did not differ significantly in epidemiological, clinical or laborator...
The Israel Medical Association journal : IMAJ, 2004
The complexity of medical problems is a well-recognized phenomenon. In the presence of economic a... more The complexity of medical problems is a well-recognized phenomenon. In the presence of economic and cultural restrictions, medical decision-making can be particularly challenging. This paper outlines a system of analysis and decision-making for solving such problems, and briefly describes a case study in which the method was used to analyze the case of antibiotic overprescribing in a large health maintenance organization. The purpose of the study was to determine if a technique for problem-solving in the field of engineering could be applied to the complex problems facing primary care. The method is designated Systematic Inventive Thinking and consists of a three-step procedure: problem reformulation, general search-strategy selection, and an application of idea-provoking techniques. The problem examined is the over-prescribing of antibiotics by general practitioners working in Maccabi Healthcare Services, an HMO serving one and a half million patients in Israel. The group of health...
The Pediatric infectious disease journal, 1995
An increase in the incidence and severity of bacteremia caused by group A streptococci was noted ... more An increase in the incidence and severity of bacteremia caused by group A streptococci was noted in 1993 and 1994 in the Hadassah University Medical Center, Jerusalem. During the 6-year period 1987 to 1992, 12 children with group A streptococcal bacteremia were hospitalized, whereas in 1993 and 1994 there were 17 patients, 5 of them with 1 each of the following severe clinical manifestations: meningitis and septic shock; streptococcal toxic shock syndrome; septic shock; pleural empyema; and fatal outcome. Our 29 patients with group A streptococcal bacteremia were younger than those reported in the literature: 10 (35%) were < 3 months of age; 17 (59%) were < 1 year old. Most children were previously healthy and only 3 had an underlying immunodeficiency predisposing to infection (1 case each): leukemia; Di George syndrome; and congenital nephrotic syndrome. Two children were recovering from varicella. The skin was the most common site of primary infection (16 of 29). The average...
Archives of orthopaedic and traumatic surgery. Archiv für orthopädische und Unfall-Chirurgie, 1983
High dose intravenous methicillin therapy is a common form of treatment for post traumatic acute ... more High dose intravenous methicillin therapy is a common form of treatment for post traumatic acute osteomyelitis and septic arthritis, with positive staphylococcus aureus cultures. A high and spiking fever, persisting in the face of adequate antibiotic therapy, presents a difficult diagnostic dilemma in such patients. In seven patients, methicillin induced drug fever was found to be the cause of such as persisting pyrexia, inspite of an adequate antibiotic regime. This diagnosis must be established by a cautious clinical evaluation and by a careful elimination of all other causes for fever. Upon discontinuation of methicillin, the body temperature reverted to normal within 24 h.
New England Journal of Medicine, 1982
We studied risk factors for postoperative infections at the operative site after hysterectomies. ... more We studied risk factors for postoperative infections at the operative site after hysterectomies. Data were collected prospectively on all women undergoing vaginal hysterectomies (323 patients) or abdominal hysterectomies (1125 patients) at the Boston Hospital for Women between February 1976 and April 1978. Logistic-regression analysis indicated that factors significantly associated (P less than 0.05) with a higher risk of infection at the operative site were increased duration of operation, lack of antibiotic prophylaxis, younger age, being a clinic patient, and an abdominal approach. After these variables were accounted for, the variables of obesity, preoperative functional and anatomical diagnoses, postoperative anatomical and pathological diagnoses, estimated blood loss, menopausal status, and operation by a specific surgeon did not add predictive power. An increasing duration of operation was associated with a decreasing effect of antibiotic prophylaxis, the preventive fraction of which diminished from 80 per cent at one hour to an unmeasurable effect at 3.3 hours.
Trichosporon asahii (Trichosporon beigelii) infections are rare but have been associated with a w... more Trichosporon asahii (Trichosporon beigelii) infections are rare but have been associated with a wide spectrum of clinical manifestations, ranging from superficial involvement in immunocompetent individuals to severe systemic disease in immunocompromised patients. We report on the recent recovery of T. asahii isolates with reduced susceptibility in vitro to amphotericin B (AMB), flucytosine, and azoles from six nongranulocytopenic patients who exhibited
The Pediatric Infectious Disease Journal, 1989
Giardia lamblia infection was identified in 33 of 89 (37%) 3-month-old to 3-yr-old children who w... more Giardia lamblia infection was identified in 33 of 89 (37%) 3-month-old to 3-yr-old children who were followed with monthly stool examinations for up to 12 months in a day care center. The infection was mainly asymptomatic and usually associated with prolonged carriage of the parasite. There were no significant differences for height and weight achievements and mean hemoglobin values between Giardia-positive and Giardia-negative children. However, Giardia-positive children tended to achieve higher weight and height for age than Giardia-negative children; weight for age was above the 50th percentile in 69% of Giardia-positive vs. 40% of Giardia-negative children (alpha = 0.01). Giardia-positive children tended to have fewer symptoms related to the gastrointestinal and respiratory tracts as recorded by a weekly questionnaire. Lactase deficiency was detected by breath hydrogen testing in 8 of 26 Giardia-positive vs. only 1 of 21 Giardia-negative children (P less than 0.02). Healthy day care children with asymptomatic Giardia infection show no disadvantage and perhaps even an advantage in nutritional status and freedom from other illnesses.
Transplantation, 1995
Bacterial pneumonia as an important complication of bone marrow transplantation (BMT) has not bee... more Bacterial pneumonia as an important complication of bone marrow transplantation (BMT) has not been subjected to comprehensive analysis. Two hundred fifty-five consecutive allogeneic and autologous BMT recipients, ranging in age from 1 month to 53 years, were prospectively followed for 3 days to 3 years (median, 108 days) for development of bacterial pneumonia. Etiology, place acquired, chest radiography, and outcome were recorded and the association between bacterial pneumonia and demographic and clinical variables was analyzed. Thirty-seven (15%) patients experienced 52 episodes of bacterial pneumonia: onset of 13 episodes occurred within 30 days after transplantation, 10 episodes occurred on days +31 to +100, and 29 episodes occurred thereafter. Bacterial pneumonia was the terminal event or contributed to fatal outcome in 8 patients (22% of bacterial pneumonia cases, 3% total study population). Mortality due to hospital-acquired pneumonia (6/21) was significantly higher than (P = 0.03). Bacterial pathogens were identified in 27 (52%) episodes. During the first 100 days after BMT, hospital-acquired Gram-negative bacteria predominated, caused mainly by Pseudomonas aeruginosa, Klebsiella pneumoniae, Acinetobacter lwoffi, and Enterobacter cloacae. After day +100, community-acquired, Gram-positive bacteria predominated, particularly Streptococcus pneumoniae. Haemophilus influenzae occurred periodically. Considering all episodes, significant association was found between bacterial pneumonia and veno-occlusive disease (VOD) (P &amp;amp;amp;lt; 0.01) and chronic graft-versus-host disease (GVHD) (P &amp;amp;amp;lt; 0.02). For culture-positive episodes, the association between bacterial pneumonia and VOD was significant (P &amp;amp;amp;lt; 0.001) and borderline for acute GVHD (P = 0.07). It is concluded that VOD and GVHD are positively associated with post-BMT bacterial pneumonia. Its incidence, etiology, risk factors, and outcome are important considerations in its prevention and treatment.
Journal of Maternal-Fetal and Neonatal Medicine, 2008
Little is known regarding the prevalence of early postpartum bacteriuria. We sought to evaluate t... more Little is known regarding the prevalence of early postpartum bacteriuria. We sought to evaluate the incidence of bacteriuria following labor and to identify risk factors predisposing to this condition. Three hundred and fifty parturients were recruited, 301 were included in the analysis. Women receiving antibiotic drugs during delivery were excluded. Urine cultures were obtained from the study group before delivery and prior to discharge. Data regarding management of labor was collected prospectively. Positive urine cultures were present on admission in 5.4% of women, whereas 12.9% had a positive urine culture at discharge (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.003). Bacteriuria was acquired during labor in 12.7% of patients who had negative cultures on admission. Escalating number of digital vaginal examinations (p = 0.04), recurrent bladder catheterization (p = 0.05), duration of epidural anesthesia (p = 0.002), and vacuum delivery (p = 0.02) correlated significantly with an increased risk for acquiring bacteriuria. Labor is a bacteriuric event. Iatrogenic interventions can predispose parturients with sterile urine cultures to postpartum bacteriuria.
Medical Mycology, 2002
We report the recent isolation of Cryptococcus laurentii from the blood of a patient given the di... more We report the recent isolation of Cryptococcus laurentii from the blood of a patient given the diagnosis of ganglioneuroblastoma. The organism was identified using physiological and molecular characteristics, including morphology, carbohydrate and nitrate assimilation, urease activity, inability to form melanin on appropriate media, positive staining with diazonium blue B and sequence analysis of the D1/D2 domain of 26S ribosomal DNA. The isolate was resistant to fluconazole and 5-fluorocytosine using both the Etest and a broth microdilution assay. Repeated recovery of the organism from different blood cultures, and the patient's good response to treatment with amphotericin B support its etiological role. C. laurentii has rarely been implicated as a cause of clinically significant infections. The identity of reported isolates has not always been adequately documented, and some appear to have been isolated from lesions caused by Cryptococcus neoformans, emphasizing the true rarity of disease due to this fungus.
Journal of the American Medical Directors Association, 2001
Urinary tract infection is the most common cause of nosocomial infections in patients hospitalize... more Urinary tract infection is the most common cause of nosocomial infections in patients hospitalized in chronic care facilities. The changing spectrum of microorganisms involved in urinary tract infections and the emerging resistance require continuous monitoring to provide crucial information to guide empirical therapy and encourage prudent use of antibiotics. The aim of this survey was to assess the antimicrobial resistance profile of urine isolates from patients hospitalized in a geriatric hospital and from elderly patients hospitalized in an acute care hospital in order to guide empirical therapy of urinary tract infections. The survey was performed in two hospitals in Jerusalem: a university-affiliated geriatric hospital- Herzog -and an acute secondary- and tertiary-care university hospital- Hadassah. We performed a retrospective analysis of antimicrobial resistance of all positive urine cultures obtained from patients in the geriatric division of Herzog Hospital and from patients aged 65 years and older hospitalized in the Internal Medicine departments in Hadassah Hospital during a 1-year period. The most common bacteria isolated from urine specimens in Herzog Hospital were, in order of frequency, Escherichia coli, Proteus mirabilis, and Pseudomonas aeruginosa. We demonstrated a high rate of antimicrobial resistance of those bacteria in both hospitals. The pattern we observed necessitates recommending ceftazidime as the most appropriate empirical therapy for urinary tract infection in Herzog Hospital. In Hadassah Hospital we recommend cefuroxime for those patients in good general condition and ceftazidime for those who present with clinical sepsis. Antimicrobial resistance patterns should be assessed periodically and recommendations modified accordingly. Infection control guidelines should be implemented in order to try to decrease the rate of antimicrobial resistance. Further research is requested to assess the efficacy of such interventions in long-term care facilities.
Journal of Infectious Diseases, 1979
The patterns of use of antimicrobial drugs in a random sample of general hosptials in Pennsylvani... more The patterns of use of antimicrobial drugs in a random sample of general hosptials in Pennsylvania were studied. The sample was tested for validity, and all deaths and discharges were analyzed for 10 random days drawn across the year spanning July 1973 to June 1974. Methods were developed for abstracting the hospital records and for determining the reproducibility of the findings of the physician and nonphysician chart reviewers. More than 99% of the requested charts were available. In the 5,288 charts reviewed, most of the required data were readily available. The study population was 84% white and 58% female; most patients were in hospitals that had more than 300 beds and that were located in towns with populations of greater than 10,000. In 41% of the 2,070 antimicrobial courses administered to almost 30% of the patients, an explicit clinical statement of why the drug was being given could be found in the chart. The information for review was found in clinical charts, but in half of the charts, the information required was not on face sheets and discharge summaries.
Journal of Hospital Infection, 2000
Most published studies of the activity of biocides against methicillin-resistant Staphylococcus a... more Most published studies of the activity of biocides against methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) have been based on suspension tests. This study was undertaken to provide information on the effect of chlorhexidine and povidone iodine on bacteria dried on to surfaces, a situation in which biocide activity is known to be reduced. The inactivation of MRSA (10 strains), methicillin-sensitive Staphylococcus aureus (MSSA, 10 strains), VRE (nine strains) and vancomycin-sensitive Enterococcus faecalis (VSE, 10 strains) by 0.5% aqueous chlorhexidine gluconate or 10% povidone iodine was evaluated by applying the European surface test method. Povidone iodine was equally active against resistant and sensitive strains of both species with microbicidal effects (ME), i.e. the log(10)concentration of micro-organisms compared with controls treated with distilled water, after 1.5 min of 3.14 and 3.49 for VRE and VSE respectively, and 3.47 and 3.78 for MRSA and MSSA. Chlorhexidine was equally active against VRE and VSE (ME 3.37 vs. 3. 56 after 7 min, respectively), but was significantly less active against MRSA as opposed to MSSA (ME 3.07 vs. 3.83 after 10 min, P= 0. 017).
Journal of Hospital Infection, 1997
The local patterns of fungal isolates were studied by a retrospective analysis of fungal species ... more The local patterns of fungal isolates were studied by a retrospective analysis of fungal species isolated from clinical specimens in a university hospital in Jerusalem. Between 1984 and 1993, 5630 fungi [4071 patient unique isolates (PUI)] were isolated and identified. During the study decade, the annual incidence of all isolates increased 2.7-fold, and PUI increased 1.6-fold. Candida albicans accounted for 61% of PUI; urine was the source of 53%. The intensive care units (ICUs) and the Bone Marrow Transplantation (BMT) Department had the highest incidence of fungal isolation. The following trends were observed: (1) a decrease in the relative frequency of C. albicans and increase in Candida tropicalis; (2) increased number of isolates from urine, surgical wounds and intra-abdominal sites; (3) increased number of isolates from ICUs and BMT. Fungi are emerging as important hospital-acquired pathogens in tertiary care and teaching hospitals, and are associated with high rates of morbidity and mortality. It is important to be familiar with the local patterns of fungal isolation in order to improve treatment.
Journal of Clinical Microbiology, 2001
In a retrospective 10-year analysis of 3,536 patient-unique isolates, Acinetobacter baumannii imi... more In a retrospective 10-year analysis of 3,536 patient-unique isolates, Acinetobacter baumannii imipenem susceptibility declined from 98.1 (1990) to 64.1% (2000), and ciprofloxacin susceptibility decreased from 50.5 to 13.1%. Imipenem median zone diameters decreased from 27.7 (1997) to 18.8 mm (2000). No outbreaks were detected. Two clusters were identified for 41 strains genotyped by pulsed-field gel electrophoresis, but imipenem resistance was not clonal.
Journal of Clinical Microbiology, 2004
Fusarium infections are an important problem worldwide, commonly affecting immunocompromised indi... more Fusarium infections are an important problem worldwide, commonly affecting immunocompromised individuals. We conducted a retrospective study in two Israeli tertiary medical centers of factors predisposing to infection by Fusarium spp. and their influence on the epidemiology and clinical outcome of this infection. Fusarium spp. were isolated from 89 patients with a median age of 57 years. Sixty-eight patients were considered immunocompetent. Seven patients had disseminated disease, 34 had locally invasive disease, and 48 had superficial infection. Most infections were limited and occurred mainly in lower limbs. Factors associated with in-hospital mortality were chronic renal failure, hematological malignancy, immunosuppression, disseminated infection, and positive blood culture. Multivariate analysis showed that chronic renal failure, hematological malignancy, burns, and disseminated infection were independently associated with mortality. A surge in the frequency of infections was noticed during the summer for patients from rural areas, involving mainly the eyes and lungs. At one of the hospitals (in a mountainous area), there was an increase in the isolation rate over time.
Journal of Clinical Microbiology, 2001
Trichosporon asahii (Trichosporon beigelii) infections are rare but have been associated with a w... more Trichosporon asahii (Trichosporon beigelii) infections are rare but have been associated with a wide spectrum of clinical manifestations, ranging from superficial involvement in immunocompetent individuals to severe systemic disease in immunocompromised patients. We report on the recent recovery of T. asahii isolates with reduced susceptibility in vitro to amphotericin B (AMB), flucytosine, and azoles from six nongranulocytopenic patients who exhibited risk factors and who developed either superficial infections (four individuals) or invasive infections (two individuals) while in intensive care units. The latter two patients responded clinically and microbiologically to AMB treatment. All six isolates were closely related according to random amplified polymorphic DNA studies and showed 71% similarity by amplified fragment length polymorphism analysis, suggesting a common nosocomial origin. We also review the literature pertaining to T. asahii infections and discuss the salient characteristics of this fungus and recent taxonomic proposals for the genus.
Journal of Clinical Microbiology, 2001
An outbreak of pseudobacteremia due to Streptococcus pyogenes (group A streptococci [GAS]) and me... more An outbreak of pseudobacteremia due to Streptococcus pyogenes (group A streptococci [GAS]) and methicillin-susceptible Staphylococcus aureus (MSSA) was traced to the venting procedure for aerobic bottles prior to their loading into the incubator of the BacT/Alert analyzer (Organon Teknika). Bacteria shed by a laboratory worker suffering from impetigo and cellulitis contaminated the aerobic bottles of 10 patients. All blood culture isolates, in addition to the isolates from the laboratory worker, were of the same GAS M and T types. All MSSA isolates from blood cultures and the index case's hands had the same lytic phage profile. Procedural breakdowns were identified in the laboratory. Bottles were vented outside the biological safety cabinet, gloves were not worn, and unprotected needles were used for the venting procedure. The source of the aspirated bacteria that contaminated the bottles was identified and the index case was treated promptly.
Journal of Clinical Microbiology, 2003
Dermatophytes are common pathogens of skin but rarely cause invasive disease. We present a case o... more Dermatophytes are common pathogens of skin but rarely cause invasive disease. We present a case of deep infection by Trichophyton rubrum in an immunocompromised patient. T. rubrum was identified by morphological characteristics and confirmed by PCR. Invasiveness was apparent by histopathology and immunohistochemistry. The patient was treated successfully with itraconazole.