Abstract: OBJECTIVES: To assess the effect of prolonging antibiotic prophylaxis in cardiac surgery. METHODS: Prospective before-after cohort study. In 2004, cefazolin was given pre- and intraoperatively at 1g doses while in 2007 it was continued after surgery for 24h. All consecutive adult patients undergoing coronary artery bypass graft, valve, and/or aortic operations during the study periods were included. The primary outcomes were deep sternal wound infection (DSWI) and mortality. Univariate and multivariate analyses were conducted to assess risk factors for DSWI. RESULTS: 954 patients between 1/2004 and 12/2004 were compared to 424 patients between 1/2007 and 6/2007. In 2007, there were significantly more patients >60yrs., emergency and combined operations and the mean logistic EuroSCORE was higher compared to 2004 (8.53% vs. 6.92%, p=0.006). The rate of DSWI decreased non-significantly from 3.8% (36/954) in 2004 to 2.6% (11/424) in 2007, p=0.27. The adjusted odds ratio of the study period for DSWI was 0.89 (95% confidence interval 0.70-1.13). There was no difference in 30-day (5.2% vs. 5.4%) or 6-month mortality (9.2% in both periods), despite increasing patients' risk. CONCLUSIONS: Increasing the duration of antibiotic prophylaxis did not result in a significant decrease in DSWI. The value of prolonging antibiotic prophylaxis after cardiac operations should be further evaluated.

Abstract: In a retrospective case-control study, adults with anaerobic bacteraemia (ANB) were matched to patients with aerobic bacteraemia based on source of infection (1:3), date and age. We identified diabetes mellitus as a significant risk factor for ANB when the source of the bacteraemia was unknown, OR 2.29 (95% CI 1.22-4.29).

Abstract: BACKGROUND: Studies have shown that soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) is upregulated by microbial products in the bronchoalveolar lavage fluid, and cerebrospinal fluid of patients with pneumonia and bacterial meningitis, respectively. Our goal was to evaluate whether sTREM-1 in pleural fluid can distinguish pleural empyema from postthoracotomy-related pleural effusion and effusions of other etiologies. METHODS: Patients who presented with pleural effusion were identified through laboratory records. In addition to routine biochemical markers, differential white blood cells, cytology, Gram stain, and pleural fluid culture, pleural fluid sTREM-1 was measured by enzyme-linked immunosorbent assay using a commercial kit (R&D Systems, Minneapolis, MN). RESULTS: Eighty-nine patients were included in the study: 17 with empyema, 7 simple parapneumonic effusion, 18 transudate, 12 postthoracotomy pleural effusion, 22 malignancy, 1 connective tissue disease, and 12 with undetermined effusion. Mean levels of sTREM-1 were significantly higher in empyema than in postthoracotomy pleural effusion (687 +/- 479 pg/mL vs 34 +/- 81 pg/mL, p < 0.0001, respectively) and in effusions of other etiologies (15 +/- 54 pg/mL, p < 0.0001). A cutoff value of 114 pg/mL for pleural sTREM-1 achieved a sensitivity of 94% and a specificity of 93% in differentiating empyema from pleural effusions of other etiologies. The area under the receiver operating characteristic curve for pleural effusion sTREM-1 as a predictor for empyema was 0.966. CONCLUSIONS: Our findings suggest that sTREM-1 in the pleural fluid can potentially assist clinicians in the differentiation of bacterial from nonbacterial pleural effusion, particularly in postthoracotomy pleural effusion.

Abstract: To identify the clinical and radiological features distinguishing Mycobacterium simiae respiratory infection from pulmonary tuberculosis, the demographics, underlying conditions, and clinical and radiological findings of 121 consecutive patients with pulmonary tuberculosis and 102 with M. simiae respiratory infection were compared retrospectively. In the M. simiae group, the patients were older (mean age 69 +/- 16 years vs. 47 +/- 21 years, p = 0.0001), with a female predominance (62% vs. 45%, p = 0.008). Only 4% were of Ethiopian origin compared to 25% of the tuberculosis group (p = 0.0001). M. simiae infection was associated with significantly higher rates of smoking history, underlying chronic obstructive pulmonary disease, zero human immunodeficiency virus (HIV) infection compared to 10% in the tuberculosis group (p = 0.001), blunted symptoms, and noncavitary infiltrates in the lower/middle lobes on chest X-ray. HIV-negative patients with M. simiae respiratory infection are distinguishable from patients with pulmonary tuberculosis by several demographic, clinical, and radiological features. These findings have important diagnostic and therapeutic implications.

Abstract: OBJECTIVES: Increased antibiotic consumption is associated with increased bacterial resistance worldwide. We aimed to analyse antibiotic consumption and potential contributory factors in internal medicine departments in Israel. METHODS: Data (2003-04) from 26 departments in 6 hospitals were retrieved. Defined daily doses (DDD)/100 bed-days were calculated for total antibiotic use and by antibiotic class. Patterns identified were correlated with 15 patients' and departmental variables by univariate and multivariate analyses. RESULTS: Total antibiotic consumption differed by a factor of 2.3 (115 DDD/100 bed-days to 49.1 DDD/100 bed-days) between the highest and lowest consuming departments. Antibiotic classes differed by a factor of 22.8 for macrolides, a factor of 20 for piperacillin/tazobactam, a factor of 17 for carbapenems, a factor of 13.3 for quinolones, a factor of 9 for vancomycin, a factor of 6.8 for amoxicillin/clavulanate, a factor of 6.6 for aminoglycosides, a factor of 5.3 for penicillins and a factor of 2.8 for cephalosporins. Even among departments within hospitals, there was a difference of up to 1.5-fold for total use and antibiotic class differences ranged between 2.5- and 7.2-fold for third- and fourth-generation cephalosporins, despite similar Charlson scores and other patient variables. In the multivariate analysis, hospital affiliation and rate of 1 day hospitalization were the only significant variables predicting total antibiotic use, contributing 43% and 7.3%, respectively, to the variance. By antibiotic class, controlling for hospital affiliation, patients with neutropenia, lower respiratory tract infections and assisted ventilation were the most common significant contributors, ranging from 3.5% for quinolones to 7.7% for piperacillin/tazobactam. CONCLUSIONS: Patterns of antibiotic use vary widely among internal medicine departments in Israel, which cannot be explained by objective parameters related either to patients or wards. Ongoing monitoring and guideline formulation are needed to regulate antibiotic prescription.

Abstract: Pericarditis as a presenting sign of infective endocarditis is rare. Here we describe 2 cases and an additional 19 cases of pericarditis as a presenting sign of infective endocarditis reported during the last 40 y. 71% of patients were young males (mean age 43.2 y). The most commonly reported underlying conditions were diabetes mellitus type 2 (5 patients, 24%), and substance or alcohol abuse (4 patients, 19%). The native aortic valve was the most frequently involved valve. The most common symptoms were fever, cough or dyspnoea, and chest pain. Overt tamponade was diagnosed in 47% of the patients. However, pulsus paradoxus and pericardial friction rub were rare. A heart murmur was heard in 12 patients (57%). Staphylococcus aureus was the most commonly isolated pathogen concomitantly from blood and pericardial fluid. 16 patients (76%) were operated. Six underwent a pericardial procedure, 5 underwent valve replacement, 4 both, and 1 patient was operated for pseudoaneurysm. Mortality rates were 60% and 31% of patients treated with antibiotics alone versus antibiotics and surgical intervention, respectively. In patients presenting with pericarditis with or without cardiac tamponade, the possibility of infective endocarditis should be considered. Optimal therapy should consist of antibiotics and surgical intervention.

Abstract: A new CHROMagar KPC medium was compared to MacConkey agar with carbapenem discs and PCR for the bla(KPC) gene for rapid detection of carbapenem-resistant Klebsiella pneumoniae. The sensitivity and specificity relative to PCR were 100% and 98.4%, respectively, for CHROMagar KPC and 92.7% and 95.9%, respectively, for MacConkey agar.

Abstract: This retrospective study sought to systematically identify clinical and radiological features of Mycobacterium kansasii and Mycobacterium simiae infections. The sample included consecutive patients with a culture-positive diagnosis of M. simiae infection (n=102) or M. kansasii infection (n=62) derived from the databases of the Laboratory of Microbiology of a tertiary medical centre and two outpatient tuberculosis centres. Data on patient background and clinical features were collected, and chest radiographs were analysed. Sixty percent of the M. kansasii group were native born compared to 18% of the M. simiae group (p=0.0001). M. simiae infection was associated with a higher rate of co-morbid disease, including diabetes mellitus, heart disease, and malignancy. A similar rate of lung disease was found in both groups. Clinical symptoms were significantly more common in patients with M. kansasii infection. On radiological study, M. kansasii infection was associated with more cavitations, and M. simiae infection with more pulmonary infiltrates. Patients with M. simiae infection had a higher likelihood of middle and lower lobe disease whereas patients with M. kansasii infection had more upper lobe disease (p=0.001). Pleural effusions and lymphadenopathy were found only in the presence of M. simiae infection. We concluded that there are major differences in the epidemiologic features of M. kansasii and M. simiae infection which have important diagnostic and therapeutic implications.

Abstract: OBJECTIVES: To assess the safety of a cytomegalovirus prophylaxis regimen using selective low-dose valganciclovir. METHODS: Retrospective before-after comparison, including consecutive kidney transplant recipients between 2002 and 2004. Excluded were deaths or graft loss within one month after transplantation. During the first period, universal prophylaxis with oral ganciclovir was used. During the second period, selective prophylaxis with low-dose valganciclovir (450 mg/day) was given to patients at high-risk for CMV disease (D+/R- recipients and patients treated with anti-lymphocyte antibodies) and oral acyclovir to all other patients. We compared the incidence of CMV disease between the two periods. RESULTS: Two hundred and sixty-four patients underwent kidney transplantation of which 221 were included. The incidence of CMV disease was higher with selective low-dose valganciclovir compared to universal ganciclovir without statistical significance, by intention to treat (4.7% vs. 8.5%, respectively, OR 1.88, 95% CI 0.63-5.60) and among patients adhering to the prophylaxis protocol (3.1% vs. 6.8% respectively, OR 2.85, 95% CI 0.65-12.38). Only late-onset CMV was observed for compliant patients. On multivariate analysis, only recipients' serostatus remained significantly associated with CMV disease (OR 0.22, 95% CI 0.07-0.70). CONCLUSIONS: Selective low-dose valganciclovir may provide similar protection against CMV when compared to universal oral ganciclovir. Prolongation of prophylaxis beyond 100 days should be explored.

Abstract: PATIENTS: We report on a 6-month-old patient with a right bundle, superior axis tachycardia at 197 beats per minute. The tachycardia was unresponsive to adenosine, propranolol, flecainide, or amiodarone, or synchronized cardioversion. Overdrive atrial pacing terminated the tachycardia and since initiating verapamil, no recurrences of his tachycardia have occurred. CONCLUSIONS: If an infant presents with a right bundle, superior axis ventricular tachycardia unresponsive to multiple antiarrhythmic medications and synchronized cardioversion, but responsive to overdrive atrial pacing, one must consider verapamil-sensitive ventricular tachycardia and initiate appropriate therapy.