Search

Introduction: Among the many medical challenges presented by the COVID-19 pandemic, management of the majority of COVID-19 patients in community outpatient settings rather than in hospital is crucial for the resource allocation of healthcare systems. This real-life study describes COVID-19 patients in three management settings: two outpatient settings and one inpatient. Methods: A retrospective database cohort study was conducted in a large Israeli Health Maintenance Organization. All laboratory-confirmed SARS-CoV-2 cases diagnosed 2/28/2020-6/20/2020, were included. Cases in the community setting were managed by physicians and other healthcare personnel through a nationwide remote monitoring center, using preliminary telehealth triage, 24/7 virtual care , all based on the individual patient’s clinical and social circumstances. Data were extracted from medical records. Outcome parameters included hospital admission, disease severity, need for respiratory support and mortality. Results: 5,525 cases tested positive. Seventy-seven cases who live in long- term facilities were excluded. 5448 cases, aged 36.36±20.31 (range 0-97 years) were enrolled. 88.7% were initially managed as outpatient either at home or in designated hotels, and 11.3% were hospitalized. 3.1% and 2.1% of the patients who were initially allocated for home or hotel stay, respectively, later required hospitalization. The main reason for hospitalization was dyspnea; twelve were diagnosed with severe disease. Fifty-six patients (1.3%) died, five (0.1%) of whom were initially allocated to the outpatient settings. Conclusions: Care for appropriately selected COVID-19 patients in the community provides a safe and effective option. This can contribute to reducing the hospitalization burden, with no evidence of increased morbidity or mortality.

Bacterial and viral lower respiratory tract infections (LRTIs) are often clinically indistinguishable, leading to antibiotic overuse. We compared the diagnostic accuracy of a new assay that combines 3 host-biomarkers (TRAIL, IP-10, CRP) with parameters in routine use to distinguish bacterial from viral LRTIs. Study cohort included 184 potentially eligible pediatric and adult patients. Reference standard diagnosis was based on adjudication by an expert panel following comprehensive clinical and laboratory investigation (including respiratory PCRs). Experts were blinded to assay results and assay performers were blinded to reference standard outcomes. Evaluated cohort included 88 bacterial and 36 viral patients (23 did not fulfill inclusion criteria; 37 had indeterminate reference standard outcome). Assay distinguished bacterial from viral LRTI patients with sensitivity of 0.93±0.06 and specificity of 0.91±0.09, outperforming routine parameters, including WBC, CRP and chest x-ray signs. These findings support the assay's potential to help clinicians avoid missing bacterial LRTIs or overusing antibiotics.

This study establishes rates of Guillain-Barré syndrome relapse among Pfizer-BioNTech BNT162b2 vaccine receivers.

Background Identifying bacterial coinfection in influenza patients can be difficult as the symptoms of simple influenza versus mixed infections are often similar, leading to antibiotic overuse. A new host-response assay (ImmunoXpert™) that integrates the levels of three proteins (TRAIL, IP-10, and CRP) was shown to exhibit high performance in distinguishing between bacterial and viral disease in two double-blind validation studies. Here we sought to evaluate its ability to differentiate between simple influenza and influenza with bacterial coinfection. Material/Methods The study population included 653 febrile pediatric and adult patients prospectively recruited in the ‘Curiosity’ study. Patient etiology (simple viral versus mixed infection) was determined by unanimous expert adjudication based on comprehensive clinical, laboratory and radiological assessment. Influenza strains (A or B) were detected using multiplex PCR applied to nasal swabs (Seeplex-RV15). We compared the expert panel diagnosis with the assay that gives three possible outcomes: viral, bacterial (including viral with bacterial coinfection) or equivocal. An equivocal outcome does not provide diagnostic information and is observed in ∼10% of cases. Results Out of 653 patients, 51 had positive influenza detection and unanimous expert diagnosis: 44 simple viral infections and 7 influenza with bacterial coinfections (Figure 1). Antibiotics were prescribed to all 7 cases of influenza with bacterial coinfection and to 20/44 cases adjudicated as simple viral infections, indicating an overuse rate of 45%. The assay correctly classified 40 of the 44 simple viral cases (out of the remaining 4, 2 were assigned viral with bacterial coinfection and 2 received equivocal outcomes) as well as 5 of the 7 viral with bacterial coinfection cases (the remaining 2 received equivocal outcomes) supporting the assay’s potential to reduce antibiotic overuse 5-fold (from 45% to 4/44=9%, P Conclusion The host-response assay can differentiate between simple influenza and influenza patients with bacterial coinfection, with potential to reduce antibiotic overuse. Utility studies are warranted to demonstrate that the assay can safely assist physicians in correct management of influenza patients

We present the case of a 45 year old woman with acute Q fever pneumonia who progressed to the chronic phase of the disease despite azithromycin therapy. A trial of doxycycline was halted because of severe allergy and she was put on clarithromycin and later moxifloxacin. Failure of both drugs required desensitization to doxycycline with escalating doses. After two-year treatment with doxycycline-hydroxychloroquine combination, complete recovery was declared. Our case highlights the option of doxycycline desensitization when an acute allergic reaction poses an obstacle to optimal treatment.

Asymptomatic infectious diseases (AI) are frequent, occasionally even more common than overt febrile presentations. Yet, the literature covering this topic is scarce. Acknowledging the role of AI is crucial both to public health practitioners, because AI silently perpetuate epidemics, such as influenza or malaria, and also crucial to newborns' health and their long-term sequelae. The recent developments in metagenomics and rapid diagnostics open new horizons for the study of AI. The purpose of this review is to highlight key elements in the epidemiology, mechanisms and implications of well-studied infectious agents: Plasmodium, T. gondii, C. burnetii, Cytomegalovirus, Rhinovirus and Zika virus.

The optimal approach to the evaluation of asymptomatic bacteruria in stroke patients is uncertain.To compare elderly patients after an acute stroke with and without asymptomatic bacteriuria for the development of symptomatic urinary tract infections (UTI).We prospectively monitored patients over 65 years of age admitted to our rehabilitation hospital after an acute stroke, with and without asymptomatic bacteriuria, for the development of symptomatic UTIs. The prevalence of bacteriuria was determined by urine cultures obtained 2 and 4 weeks after admission. Patients with and without persistent bacteriuria were compared to identify variables associated with bacteriuria.Fifty-five patients were included in the study. The prevalence of asymptomatic bacteriuria at baseline was 20%. Of all 55 stroke patients, 13 (23.6%) developed a symptomatic UTI during the 30 day follow-up. Patients with stroke and asymptomatic bacteriuria at baseline had an increased risk of developing a symptomatic UTI (54.5% with asymptomatic bacteriuria vs. 15.9% without, P = 0.011). To exclude the effects of several confounders, we performed multivariate Cox regression analysis, which showed that bacteruria remained a significant covariate for symptomatic UTI (hazard ratio 2.86, 95% confidence interval 0.71-10.46, P = 0.051). When subjects who experienced symptomatic urinary infection were included, the prevalence of bacteriuria in the study cohort declined to about 45.5% by 30 days.Elderly patients with stroke and asymptomatic bacteriuria have an increased risk of developing a symptomatic UTI compared to those without asymptomatic bacteriuria during a 30 day post-stroke follow-up.

Background A major challenge in the effective management of children with RSV infection is the clinical difficulty of distinguishing a simple viral from viral–bacterial coinfections. As a result, despite the low rates of viral–bacterial coinfection, RSV patients are often prescribed antibiotics with recent reports demonstrating more than 60% antibiotic overuse rates (Van Houten et al. 2018). Here, we examined whether a host-immune signature combining the viral-induced proteins TRAIL and IP-10 with the bacterial-induced protein CRP (ImmunoXpert; Oved et al. 2015) can distinguish simple viral from viral–bacterial coinfection in RSV patients. Methods We studied 402 febrile children enrolled as part of “Curiosity,” a prospective study designed to develop and validate the host-immune signature. Infection etiology—viral or viral-bacterial coinfection—was determined by a panel of experts following a review of patients’ clinical, laboratory, radiological, microbiological, and follow-up data. RSV strains were detected using a respiratory multiplex PCR applied to nasal swabs (Seeplex-RV15). Results Out of the 402 children with suspected acute infection 29 had a positive RSV detection (Figure 1); of them, 27 had a unanimous expert panel etiology determination: 24 viral and 3 viral–bacterial coinfections. Out of the 24 patients unanimously assigned viral by the expert panel, 13 were given antibiotics, indicating a 54% antibiotic overuse rate. The host-immune signature correctly identified all 3 viral-bacterial coinfection cases, as well as 22 out of the 24 (92%) simple viral patients. This finding supports that the signature has the potential to reduce antibiotic overuse by 6.5-fold (from an overuse of 13/24 = 54% to 2/24 = 8%, P < 0.001). Conclusion Our results demonstrate high antibiotic overuse rates for RSV patients, consistent with previous reports. The host-immune signature correctly distinguished simple viral from viral–bacterial coinfection and therefore may have the potential to aid physicians in the correct management of children with RSV infection. Implementation studies are required to evaluate its utility in safely decreasing unnecessary antibiotic use for RSV patients. Disclosures N. Mastboim, MeMed Diagnostics: Employee, Salary. K. Oved, MeMed Diagnostics: Board Member, Employee and Shareholder, Salary. T. Gottlieb, MeMed Diagnostics: Employee, Salary. A. Cohen, MeMed Diagnostics: Employee, Salary. R. Navon, MeMed Diagnostics: Employee, Salary. M. Paz, MeMed Diagnostics: Employee, Salary. E. Bamberger, MeMed Diagnostics: Employee, Salary. T. Friedman, MeMed Diagnostics: Employee, Salary. L. Etshtein, MeMed Diagnostics: Employee, Salary. O. Boico, MeMed Diagnostics: Employee, Salary. I. Potasman, MeMed Diagnostics: Holding stock options, Stock options. E. Eden, MeMed Diagnostics: Board Member, Employee and Shareholder, Salary. L. Shani, MeMed Diagnostics: Employee, Salary.

Background The seroprevalence of toxoplasmosis among Israeli Arabs is high. Yet, the regulation of the Israeli Ministry of Health suggests not screening pregnant women for toxoplasmosis. During 2017/8 we have seen a surge in cases of acute toxoplasmosis in pregnancy in Northern Israel. We aimed to explore this surge and compare the rates of acute toxoplasmosis in pregnancy in Northern Israel among Jews and Arabs. Methods The database of the lab of Meuhedet HMO (Northern Israel only) was retrospectively screened for all tests for Toxoplasma serology during 2013–2017. We focused on women of childbearing age and compared rates of seropositivity in Jews and Arabs. IgG and IgM were carried out using Abbott Architect, and IgG avidity by Vidas, BioMerieux. Birth rates were retrieved from the central computer of Meuhedet HMO. Results : In 2017, Northern Israel had 1,397,833 citizens of whom 53% were Arabs. Of this population, 13% were insured by Meuhedet HMO, and of these 60% were Arabs (Muslims or Christians). During the 5-year period 16,044 Toxoplasma serology tests have been requested (both sexes), of which 26% returned IgG positive. 88% of the positive ones were of Arab citizens (P < 0.0001). Excluding duplicates, we found 118 women of childbearing age with a positive IgM test (2.8%). Of the latter, 37 had a low/medium avidity test (31.4%). 112 of the women were Arabs, while only 6 were Jews (P < 0.0001). Two-thirds of the women had a positive βHCG test at the same time. During this 5-year period there were 23,074 live births in this HMO (11,512 Arab newborns). Thus, had all these women delivered an infected newborn, the rate of congenital toxoplasmosis in the Arab population (97.2/10,000) was 19-fold higher than among the Jewish (5.2/10,000; P < 0.00001). Interview of 35 acute cases during 2017/8 revealed that most of the women had consumed raw meat called “Kibbe Niyye”—a popular dish unique to Northern Israeli Arabs (Galilee) and served on festive occasions. Conclusion We found that Northern Israeli Arab women are at a high risk to contract toxoplasmosis during pregnancy due to consumption of traditional raw meat. This finding calls for awareness among women as well as doctors. We believe that the regulation not to screen pregnant women in the Arab sector should be reevaluated. Disclosures All authors: No reported disclosures.

Background: Ocular injury caused by insect bites or by contact with insects’ excreta is rare. The electrical ant-Wasmannia auropunctata has recently spread to many corners of the globe. Design: A descriptive case report. Results: A 66-year old woman experienced severe, acute ocular pain and conjunctival irritation within minutes following contact with electrical ant. Irrigation of the eye and systemic analgesics alleviated her symptoms after one hour. Conclusions: With the abundance of electrical ants we are bound to see more cases of ocular injury. These injuries, though painful are short-lived, so reassurance, irrigation and analgesics are adequate.

The last decades have seen a marked increase in the number of immunocompromised patients. These patients are at higher risk for severe outcomes from infections, many of which are vaccine-preventable diseases. However, such complex cases raise several important issues of concern: 1. The administration of live vaccines to an immunocompromised patient may lead to adverse events and exacerbate the underlying condition? 2. Vaccines should preferably be administered prior to the planned immunosuppressive therapies. 3. Vaccination with inactivated vaccines may not ensure complete immune responses and may lead to lower and shorter protection rates depending on the extent of immunosuppression. 4. Should household contacts of immunocompromised patients receive vaccines? Which vaccines can be safely administered to household members? 5. Do clinicians have sufficient or updated information concerning the safety, efficacy and contraindications to vaccination of such at-risk patients? 6. Which vaccines can be safely administered to immunocompromised travelers to tropical destinations? The answers to those questions are multifaceted, and data on safety, immunogenicity, and efficacy of vaccines for immunocompromised populations are limited. This article summarizes the current recommendations for immunizations in immunocompromised patients, indications and potential adverse effects.

Background The issue of travel to developing countries during pregnancy has not been sufficiently studied. The aim of this study is to investigate the rate, course, and outcome of pregnancies in women who traveled to developing countries while pregnant, or became pregnant during such travel. Methods Women visiting two major travel clinics in Israel for consultation within the years 2004 to 2009, who were pregnant or declared an intention of becoming pregnant during travel were contacted. This was followed by a telephone interview by an obstetrician with those women who were actually pregnant. Background characteristics, morbidity during travel, and pregnancy course and outcome were collected. Results Overall 52,430 travelers' records had been screened. Of these, we identified 49 women who were pregnant during their trip, but 3 declined participation. Of the remaining 46 women, 33 were pregnant at departure, and 13 conceived during travel. The incidence of pregnancy during travel was thus 0.93/1000 travelers. Thirty-three women traveled to East Asia, 8 to South and Central America, 5 to Africa. More than two thirds of women received pretravel vaccinations. Adherence to the World Health Organization recommendations regarding food and drink was high (87%) and travelers' diarrhea occurred in only 11% of women. Five of 22 women traveling to malarious areas had taken antimalarial prophylaxis. Six women required medical therapy during travel. Pregnancy outcome was not different from the normal population except for an unusually low rate of preterm delivery. Conclusions In this cohort, travel to developing countries was not associated with adverse pregnancy outcome. Larger studies are needed to support these findings.

Tungiasis is a skin disease caused by the ectoparasite sand flea Tunga penetrans. Although tungiasis is an important health problem in endemic areas, mainly South America and sub-Saharan Africa, it is reported uncommonly in travelers. We describe an outbreak of tungiasis in a group of travelers to Ethiopia. Following the diagnosis of tungiasis in a member of a group of 17 Israeli travelers to Ethiopia, other affected members were identified by photograph assisted self diagnosis. The characteristics, including relevant demographic and epidemiologic data were recorded using a telephone interview and computerized questionnaire, and analyzed subsequently. The attack rate of tungiasis in the travel group was 53% (9 patients). Most of the patients (89%) wore open sandals during prolonged periods of their journey, but the pattern of shoeware use was similar in unaffected group members. An insect bite was not felt by any patient. The median number of skin lesions was one, and most lesions were located on the foot (7 of 9 travelers), but the hands were also affected in 2 travelers. All skin lesions healed without a need for a major intervention and without major sequela within 5 weeks of their appearance. Tungiasis may be underdiagnosed in travelers. Medical personnel should include tungiasis in pre-travel recommendations, and post-travel assessment.

Recent exposure to azoles is an important risk factor for infection with fluconazole-resistant Candida spp., but little is known about the role of antibacterial drug exposure in the emergence of drug-resistant Candida . We did a prospective nationwide surveillance study of candidemia in Israel and analyzed the propensity score-adjusted association between antifungal and antibacterial drug exposure and bloodstream infection with C. glabrata and fluconazole-resistant Candida isolates. Four hundred forty-four episodes of candidemia (450 Candida isolates, 69 [15%] C. glabrata isolates, and 38 [8.5%] fluconazole-resistant isolates) from 18 medical centers in Israel were included. C. glabrata bloodstream infection was strongly associated with recent metronidazole exposure (odds ratio [OR], 3.2; P < 0.001). Infection with a fluconazole-resistant isolate was associated with exposure to carbapenems, trimethoprim-sulfamethoxazole, clindamycin, and colistin (odds ratio, 2.8; P = 0.01). The inclusion of antibacterial drug exposure in a multivariable model significantly enhanced the model's predictive accuracy for fluconazole-resistant Candida bloodstream infection. Our findings may be relevant to the selection of empirical antifungal treatment and broaden the scope of antibiotic-associated collateral damage.

Background Bacterial and viral infections are often clinically indistinguishable, particularly in upper respiratory tract infections (URTI), which leads to antibiotic misuse. A novel assay (ImmunoXpert™) that integrates measurements of three host-response proteins (TRAIL, IP-10, CRP) was recently developed to assist in differentiation between bacterial and viral etiologies. We evaluated the assay performance in URTI patients and compared it with standard laboratory measures. Methods We performed a sub-analysis of 464 patients with clinical suspicion of URTI enrolled in three previously conducted multi-center clinical studies that evaluated the assay performance in patients with acute infections: ‘Curiosity’ study (NCT01917461), ‘Opportunity’ study (NCT01931254), and ‘Pathfinder’ study (NCT01911143). Comparator method was predetermined criteria combined with expert panel adjudication, which was blinded to the test results. Diagnostic performance was evaluated by comparing test and comparator method outcomes. Results A unanimous panel adjudication was attained for 61 bacterial (13%) and 241 viral (52%) patients (162 patients (35%) had an indeterminate diagnosis). The assay distinguished between bacterial and viral infected patients with a sensitivity of 92% (95% CI: 82%- 98%) and specificity of 93% (88%-96%) with 11% equivocal test results. Overall the assay outperformed other routine laboratory tests (FIG 1), including: white blood cell count (WBC; cutoff 15,000 cells/µL, sensitivity 48% (35%-60%), P < 10-−6; specificity 85% (80%-90%), P < 0.05); CRP (cutoff 40 mg/L, sensitivity 82% (72%–92%), P = 0.16, specificity 79% (74%–84%), P < 10-4); Procalcitonin (PCT; cutoff 0.5 ng/mL, sensitivity 22% (11%–32%), P < 10–14, specificity 80% (74%–85%), P < 0.001); absolute neutrophil count (ANC; cutoff 10,000 cells/µL, sensitivity 58% (45%–71%), P < 10-−4, specificity 94% (91%–97%), P = 0.7). Conclusion The novel assay demonstrated superior performance compared with routine laboratory tests (WBC, ANC) and biomarkers (CRP, PCT), in distinguishing bacterial from viral etiologies in patients with URTI. It has the potential to help clinicians avoid missing bacterial infections or prescribing unwarranted antibiotics for viral URTIs. Disclosures K. Oved, MeMed Diagnostics: Board Member, Employee and Shareholder, Salary E. Eden, MeMed Diagnostics: Board Member, Employee and Shareholder, Salary T. Gottlieb, MeMed Diagnostics: Employee, Salary R. Navon, MeMed Diagnostics: Employee, Salary A. Cohen, MeMed Diagnostics: Employee, Salary O. Boico, MeMed Diagnostics: Employee, Salary M. Paz, MeMed Diagnostics: Employee, Salary L. Etshtein, MeMed Diagnostics: Employee, Salary G. Kronenfeld, MeMed Diagnostics: Employee, Salary T. Friedman, MeMed Diagnostics: Employee, Salary E. Bamberger, MeMed Diagnostics: Employee, Salary I. Chistyakov, MeMed Diagnostics: Consultant, Consulting fee I. Potasman, MeMed Diagnostics: Holding stock options, stock options

Background Identifying bacterial coinfection in influenza patients can be difficult as the symptoms of simple influenza vs. mixed infections are often similar, leading to antibiotic overuse. A new host-response assay (ImmunoXpert™) that integrates the levels of three proteins (TRAIL, IP-10, and CRP) was shown to exhibit high performance in distinguishing between bacterial and viral disease in two double-blind validation studies. Here we sought to evaluate its ability to differentiate between simple influenza and influenza with bacterial coinfection. Methods The study population included 653 febrile pediatric and adult patients prospectively recruited in the “Curiosity” study. Patient etiology (simple viral vs. mixed infection) was determined by unanimous expert adjudication based on comprehensive clinical, laboratory and radiological assessment. Influenza strains (A or B) were detected using multiplex PCR applied to nasal swabs (Seeplex-RV15). We compared the expert panel diagnosis with the assay that gives three possible outcomes: viral, bacterial (including viral with bacterial coinfection) or equivocal. An equivocal outcome does not provide diagnostic information and is observed in ~10% of cases. Results Out of 653 patients, 51 had positive influenza detection and unanimous expert diagnosis: 44 simple viral infections and seven influenza with bacterial coinfections (Figure 1). Antibiotics were prescribed to all seven cases of influenza with bacterial coinfection and to 20/44 cases adjudicated as simple viral infections, indicating an overuse rate of 45%. The assay correctly classified 40 of the 44 simple viral cases (out of the remaining four, two were assigned viral with bacterial coinfection, and two received equivocal outcomes) as well as five of the seven viral with bacterial coinfection cases (the remaining two received equivocal outcomes) supporting the assay’s potential to reduce antibiotic overuse 5-fold (from 45% to 4/44 = 9%, P < 0.001). Conclusion The host–response assay can differentiate between simple influenza and influenza patients with bacterial coinfection, with potential to reduce antibiotic overuse. Utility studies are warranted to demonstrate that the assay can safely assist physicians in correct management of influenza patients. Disclosures M. Paz, MeMed Diagnostics: Employee, Salary. K. Oved, MeMed Diagnostics: Board Member, Employee and Shareholder, Salary. T. Gottlieb, MeMed Diagnostics: Employee, Salary. A. Cohen, MeMed Diagnostics: Employee, Salary. R. Navon, MeMed Diagnostics: Employee, Salary. N. Mastboim, MeMed Diagnostics: Employee, Salary. E. Bamberger, MeMed Diagnostics: Employee, Salary. T. Friedman, MeMed Diagnostics: Employee, Salary. L. Etshtein, MeMed Diagnostics: Employee, Salary. O. Boico, MeMed Diagnostics: Employee, Salary. I. Potasman, MeMed Diagnostics: Holding stock options, Stock options. E. Eden, MeMed Diagnostics: Board Member, Employee and Shareholder, Salary. L. Shani, MeMed Diagnostics: Employee, Salary.

This article focuses on tourists’ perception of health risk among tourists who intend to travel to developing countries. It examines the relative importance tourists assign to this risk. It unveils the factors that shape health risk perceptions and explores the relative role of each factor in shaping tourists’ perception. With a sample of 232 and a self-administered questionnaire, the study interviewed visitors at a travelers medical clinic before their trip. Using ordered logistic regression, the results show that health risk perception ranks relatively high against other types of risk perception. The study unveiled the relative contribution of the various determinants to the overall travelers’ perception of health risk. Furthermore, three groups of perception-type hierarchy were discovered, representing levels of importance and tourists’ potential behavioral control: first, difficult-to-control environmental components; second, partially behaviorally controllable by the tourist; third, fully behaviorally controlled types of health risks perceptions.

Israel Defense Forces (IDF) guidelines for drinking water require the use of water only from sources that have been inspected and authorized by a medical expert. This study aimed to compare canteen water quality of two military units (infantry and armoured corps), to search for sources of possible microbial contamination and to look for any impact on gastrointestinal symptoms. Statistical analysis revealed that canteens of armoured corp soldiers were significantly more contaminated compared to those of infantry soldiers. Outdoor taps and water in trailers were found to harbour significantly higher numbers of microbial indicators compared to showers/lavatory sources; however, the numbers were much lower compared to canteens. Canteen water retention for more than one day revealed significantly increased numbers of examined microbial parameters, possibly due to secondary contamination or regrowth. Gastrointestinal symptoms were not significantly different between the two units despite the significant canteen water quality difference. An odds ratio evaluation was conducted on 45 exposure-illness combinations based on gastrointestinal symptoms, exposure and soldiers affiliation. Out of these 45 combinations only 14 resulted in odds ratio > 1, where 3 had high values (7.44, 7.46 and 11.2) suggesting a possible connection between diarrhoea and/or vomiting versus coliphages and faecal coliforms.

As automated blood cell analysers and sophisticated diagnostic technologies become widespread, requests for peripheral blood smear (PBS) examination—for the diagnosis of infectious diseases—diminish. Yet, PBS examination can provide rapid and invaluable information on infection—host susceptibility, aetiology, severity, and systemic impact. Besides direct visualisation of certain microorganisms (for example, Plasmodium, Ehrlichia), PBS examination may detect characteristic footprints left by various infections on the morphology of blood cells, thus yielding the cytologic clues of the disease (for example, Döhle bodies, haemophagocytosis). Additionally, PBS examination may disclose certain infection predisposing conditions (for example, May–Hegglin anomaly, hyposplenism), and several infection related haematological and systemic complications. Combined with a careful medical history and physical examination data, all this information may yield a speedy diagnosis, a rationalised diagnostic work-up, and timely initiation of treatment. The intention of the following review is to highlight the value of PBS, and recommend that PBS examination should be fostered in the diagnostic work-up of infectious diseases.

Environmental factors in airplanes may precipitate headaches. We conducted a questionnaire-based study among consecutive travellers to determine the rate, severity and duration of flight-associated headaches (FAHA). Of the 906 eligible travellers (mean age 33.3 ± 13.8 years), 22.3% reported headaches at least once per month. FAHA occurred in 52 travellers (5.7%), of whom 34 were women ( P = 0.0023 vs. none FAHA). The duration of pain was 4.0 ± 10.2 h after takeoff and continued for 5.7 ± 14.2 h after landing. Migraine was diagnosed in 19.2% of those with FAHA. The magnitude of headache was 6 ± 2 (on a scale of 1-10). Among those who suffer from FAHA, 45.4% reported that their pain was unilateral, in contrast to 72.7% among those with ‘non-flight’ headaches ( P = 0.019). Nine travellers had headaches when descending to −400 m below sea level, and nine upon climbing to high altitude. This preliminary observation indicates that FAHA is not uncommon and should be further investigated.

Two sisters showed a similar disorder with cachexia, sensory deafness, and upper gastrointestinal abnormalities. The family pedigree suggests autosomal recessive inheritance of the disorder. Demyelinization demonstrated by a peripheral nerve biopsy may explain the basis for the manifestations. Only one family with this unique syndrome has been reported in the literature. The term "The Groll-Hirschowitz Syndrome" has been suggested, named after the two physicians who first described this condition.

Fluoroquinolones are increasingly used for the treatment of community-acquired pneumonia. However, their use has been associated with a delay in the diagnosis and treatment of pulmonary tuberculosis. We describe the clinical and insightful bacteriological course of a 39-year-old patient with pulmonary tuberculosis who had presented as having community-acquired pneumonia and was treated empirically with levofloxacin. The case highlights a major problem associated with the indiscriminate use of fluoroquinolones.

Background. Knowledge of the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) colonization, and the frequency of transmission is vital for the implementation of MRSA infection control measures in hospitals. We assessed risk factors for and rates of colonization of MRSA upon admission to a geriatric rehabilitation hospital, and studied the contribution of the colonization on hospital mortality. Methods. This was a prospective study conducted over a 6-month period. All patients were screened at admission, using nasal and throat swabs. Whenever necessary, blood, sputum, urine, or wound cultures were obtained. Data collected on admission included age, sex, functional status, reasons for admission to the rehabilitation unit, previous hospitalizations, known carriage or infection with MRSA in previous hospitalizations, underlying diseases, prescribed antibiotics in previous hospitalization, serum albumin, creatinine clearance, and patient management data. Risk factors for MRSA carriage on admission were estimated by using multivariate analysis. Results. Of the 337 patients admitted during the study period, 24 (7.1%) had a MRSA isolate, and 87.4% of these were detectedthroughscreeningspecimensonly.Ofthe24positiveadmissionswithMRSA,23(95.8%)werenewlyidentifiedMRSA carriers. In the multivariate analysis, the following variables were highly associated with MRSA carriage: presence of tracheotomy (p ¼.0001), hospitalization for deconditioning (p ¼.007), renal failure (p ¼.039), and quinolone use prior to hospitalization (p ¼.037). The morbidity associated with MRSA was very low, and length of stay was not influenced by carriage. Conclusion. The prevalence of MRSA carriage on admission to geriatric rehabilitation hospitals is high. Screening on admission is probably useful, as it detects almost all MRSA carriers. However, given the low morbidity associated with MRSA observed in this study, eradication of the MRSA carrier state is questionable. Further studies are needed to determine the usefulness and cost/benefit ratio of screening.

Background Acute mountain sickness (AMS) affects almost half of those ascending to heights over 3,000 m. The knowledge and practices concerning AMS have not been adequately studied. Methods We conducted a prospective on-site study in the Himalayas. Between July and October 2004, we approached a convenience sample of trekkers during or after their ascent to high altitudes and provided them with detailed questionnaires regarding knowledge of and personal experience with AMS. Results One hundred ninety-two travelers (of whom 106 were Israelis and 86 Western Europeans) participated in the study. One hundred thirty travelers (68%) had received any written/oral information about AMS prior to their departure. The most common source of information among Israeli travelers was the travel clinic (65%), compared to only 9% among Europeans. Overall, 89% were found to have good “basic knowledge” about symptoms of AMS (defined as headache plus ≥2 of the following: fatigue, dizziness, nausea, insomnia). Travelers who had received information about AMS prior to their trip were significantly more knowledgeable about symptoms of AMS (p= 0.0001), and treatment options, such as oxygen, medications, and rest (p= 0.023, p= 0.024, p= 0.011, respectively). Only 2% of the Israelis versus 16% of the Europeans (p= 0.0004) knew that O2 was a treatment option. Forty-seven percent suffered from AMS, which in 50% began at 3,000 m. About 33 of 90 (37%) of those who suffered AMS symptoms had acetazolamide with them, but only 14 actually used it as treatment. Conclusions Knowledge of AMS among climbers to high altitudes should be fostered, with specific emphasis on practical advice.

Hands and instruments used by healthcare workers may serve as vectors for the nosocomial transmission of microorganisms. The use of cellular telephones by medical personnel and the associated nosocomial transmission of pathogens have not been thoroughly examined. Findings from our study show that cellular telephones are commonly used by hospital personnel, even during patient contact. One-fifth of the cellular telephones examined in this study were found to harbor pathogenic microorganisms, showing that these devices may serve as vectors for transmission to patients.

Emphysematous cystitis is a rare disease characterized by primary infection of the urinary bladder with gas-producing pathogens. There is a paucity of information on this entity in the English-language literature covering the last 45 years, and the clinical picture is poorly outlined. We carried out a comprehensive, retrospective review of the English-language literature from 1986 to 2006, searching for reports describing cases of emphysematous cystitis. The demographic, clinical, laboratory, imaging, and outcome characteristics of every eligible patient were excerpted. In the present report, we describe a typical case of emphysematous cystitis, followed by an analysis of the literature. Of the 53 eligible cases, most were elderly women with diabetes mellitus (62.2%). Classic symptoms of urinary tract infection were present in only 53.3% of cases. Abdominal tenderness and hematuria were noted in 65.6% and 82.3% of cases, respectively. Plain abdominal X-ray was highly sensitive (97.4%), while abdominal computerized tomography was the most sensitive and specific diagnostic tool. A complicated course attributable to emphysematous cystitis was described in 18.8% of cases. The exact mechanism contributing to the formation of gas in such cases is unknown. Various theories have been suggested, including fermentation of glucose in urine, with emphasis on disequilibrium between gas formation and clearance. Emphysematous cystitis has a highly variable presentation and course, with a considerable potential for complications. Further diagnostic imaging is highly recommended in diabetic patients with urinary tract infection who present with abdominal pain and hematuria. Knowledge of this rare entity may lead to early diagnosis and appropriate management.

Background: Drug abuse constitutes a worldwide problem. The purpose of this study was to investigate the characteristics of illicit drug use during long-term travel to the tropics, and to estimate the effects of antidrug brochures provided before travel on the use of drugs during travel. Methods: An interventional study was done on 1,000 travelers to the tropics aged 18 to 30 years. Pretravel brochures explaining the hazards of drug abuse were provided to 500 of them. A control group of 500 travelers did not receive the brochures. Questionnaires exploring drug abuse habits were sent to all travelers after their return. Results: Among 223 travelers (108 and 115 of the intervention and control groups, respectively) who returned their questionnaires, 82 (36.8%, 95% Cl 30.5-43.5%) had experienced illicit drug use during their trip, whereas only 52 of them had tried drugs before (p

Background: The prevalence and features of travel associated neuropsychiatric problems (NPP) and their relation to previous psychological consultations, antimalarials and recreational drug use have not been adequately studied. Methods: A two-phase postal and telephone survey has been conducted among 2,500 young travelers to tropical countries. We measured the rate and duration of NPP, characterized their features, and their association with previous psychological profiles, itinerary, type of travel, consumption of recreational drugs, and malaria prophylaxis. Results: First phase: Out of 1,340 respondents, 151 (11.3%) indicated that they had NPP during travel, in contrast with 2.3% who needed psychological consultation before travel (p

Background: Travelers— diarrhea is the most common infectious disease afflicting travelers to developing countries. Most studies investigating the benefits of recommendations regarding the consumption of food and water have focused on short-term travelers. We investigated the benefits of adherence to the precautions from the World Health Organization (WHO) among long-term travelers. Methods: We asked 140 incidental travelers in India traveling for at least 2 months to complete a questionnaire about their adherence to the WHO precautions and the occurrence of diarrhea. Adherence was graded on a scale of 1 to 6 (least to most). Results: The mean age of the 114 travelers whose questionnaires were eligible was 26.6 ± 5.7 years, and the median duration of their trip was 5 months. None of them adhered strictly to the entire set of rules. The mean individual adherence was 3.4 (range 1.2–5.8). The vast majority of the travelers (83%) suffered from diarrhea. Most travelers (60%) had diarrhea for up to 3% of their journey time. Diarrhea was accompanied by fever among 18% and necessitated hospitalization in 3%. Forty-five percent indicated that they had lost traveling days due to diarrhea, for an average of 0.7% of the traveling time. We found no correlation between the percentage of traveling time with diarrhea and the following variables: adherence to the WHO recommendations, receipt of advice regarding prevention, duration of the trip, age, sex, and nationality of the travelers. Conclusions: Dietary self-restraint of travelers as proposed by the WHO is both difficult to comply with and lacks a proven value for the long-term traveler to a developing country.

Guidelines issued by the WHO call for immunization against yellow fever (YF) at least 10 days before entering an endemic area. We assessed the extent at which travelers complied with these guidelines.A two-phase study at one travel center in Israel. Phase I-travelers planning to visit YF-endemic areas (n = 295) were evaluated in regard to the timing of administration of YF vaccine before travel. Phase II-the specific causes of arriving late were studied prospectively in another group of 132 travelers.Phase I-one-half of the travelers (n = 148) headed to South America (SA), and 147 to Africa. The mean age (+/-SD) of this cohort was 30.9 (+/-14.9) years (range 6-75 years). Overall, 64 (21.7%; 95% confidence interval, 17.4-26.8) received the vaccine less then 10 days before departure. However, only 10.8% of those heading to SA arrived late, as compared to 32.7% of those heading to Africa (p0.0001). Phase II-a last minute's decision was the commonest reason given for arriving late (43.2%).One-fifth of travelers fail to comply with the WHO guidelines concerning YF vaccination. Travelers and travel agents alike need to be reminded of the importance of timely vaccination against YF.

Implanted foreign bodies are associated with a higher risk of infection. Little has been published on infectious complications associated with ureteral double-J stents. The aim of this study was to define risk factors and characterize the febrile complications of the insertion of double-J stents.One hundred consecutive cases of retrograde stent insertion (55 men and 45 women) were evaluated retrospectively. Eighty-one patients had an obstructing stone, either in the ureter or at the ureteropelvic junction; 10 had an obstructing tumor; and 9 had hydronephrosis and pain without calculi. Risk assessment was calculated for two major categories: urgent (N = 47) and elective (N = 53) insertion. Potentially confounding factors such as age, sex, accompanying medical problems, and types of prophylaxis were assessed. All but six patients received prophylactic antibiotics prior to stent insertion.All thirteen patients who had fever at the initial evaluation underwent urgent stent insertion. Of the 87 afebrile patients (53 elective and 34 urgent insertions), 22 (25%) developed fever (or = 38 degrees C) after the procedure. Fever developed in 19 (56%) of the 34 urgent-insertion group who were not originally febrile as opposed to 3 (6%) of the elective-insertion group (P0.001). Six of these 22 patients (27%) had a positive urine culture after insertion. None had a positive blood culture, including the 13 patients who underwent the procedure while febrile.Urgent insertion of a double-J stent is associated with a high risk of fever but a favorable outcome.

Fear of injections may interfere with receipt of vaccines. The frequency, associations, and precipitators of fear-provoking factors of 400 travelers visiting a travel health clinic were evaluated. The median age of this group was 25, 7% were medical staff members, and 2.8% were regular injectors (insulin). Eighty-five (21.7%; 95% confidence interval, 17.3-25.6%) of the travelers indicated that they were afraid of injections, and in 8.2%, the fear was unreasonably intense. Multivariate analysis revealed that watching other people being vaccinated, fear of pain, needle size, and a history of fainting were highly and independently associated with injection phobia. The sensitivity, specificity, and discrimination accuracy of this model were 79.5%, 78.0%, and 78.3%, respectively. Injection phobia and a bad past vaccination experience were significantly associated with fainting. Perceived empathy, on the other hand, was a significant protective factor. Fear of injections was common in this cohort and was highly associated with past fainting after vaccination.

Reports of coccidioidomycosis are rare outside the Western hemisphere. We report the case of a 57 year-old Israeli who had returned from California with pneumonia. As his condition had deteriorated despite macrolides and beta-lactams, coccidioidomycosis was suspected. Both sputum culture and serology confirmed the diagnosis. Conventional doses of fluconazole were marginally beneficial, and a complete resolution was achieved only with very high doses. Travel to the South-Western United States may expose travelers to this uncommon disease.

We present 2 cases and examine the developments that occurred in diagnosis, treatment, and outcome of 19 additional patients with mycoplasmal peri- and myocarditis. The mean age of this group was 33 years. The final diagnoses were pericarditis (n = 15), myocarditis (n = 5), and myopericarditis (n = 1); pulmonary involvement was noted in 13 patients. Serology established the diagnosis in 12 cases, and isolation in 9 others. In contrast to previous reviews, an echocardiogram was carried out in all patients, thus enabling pericardiocentesis in 13 patients. Antibiotics were given to 19 patients, including 4 who received a newer macrolide. Three patients were left with long-term sequelae, and 1 patient died. The outcome of Mycoplasma carditis has improved over the years, although a minority of patients may suffer long-term sequelae.

Pick N, Potasman I, Strenger C, Keysary A, Schwartz I (Bnai Zion Medical Center, and Technion Faculty of Medicine, Haifa; Israel Institute for Biological Research, Ness-Ziona, Israel; New York Medical College, USA). Ehrlichiosis associated vasculitis. J Intern Med 2000; 247: 674–678. Objective. To test the hypothesis that some cases of primary vasculitis are caused by ehrlichiosis. Design. A retrospective case study and serological analysis of stored sera. Setting. University hospital. Subjects. Fifty-five patients discharged with any type of vasculitis over a 6-year period. Main outcome measures. Serology for human monocytic ehrlichiosis, and the human granulocytic ehrlichiosis agent, and polymerase chain reaction (PCR) analysis of biopsy specimens. Results. Three patients (5.5%) had titres of 1 : 128 or higher against E. chaffeensis; none was positive for the human granulocytic ehrlichiosis agent. Skin biopsies of these patients showed lesions compatible with polyarteritis nodosa, allergic purpura and unspecified vasculitis. PCR analysis of the biopsies was unrevealing. Conclusions. Infection with human monocytic ehrlichiosis may underlie some forms of vasculitis. If confirmed, these findings may help identify patients with vasculitis who would benefit from antibiotic treatment.

Iatrogenic meningitis following lumbar puncture is a rare event. We present a 52-y-old man who developed symptoms of meningitis within 12 h after spinal anaesthesia. Cerebrospinal fluid cultures grew Streptococcus salivarius partially resistant to penicillin and ceftriaxone. The patient was successfully treated with ceftriaxone and vancomycin and left the hospital with minor sequelae. A literature review of 60 cases revealed the median age of the patients to be 44 y. The median incubation period was 24 h. Most cases occurred after spinal anaesthesia (n = 27), myelography (n = 20) and diagnostic lumbar puncture (n = 5). Organisms were isolated in 52 cases, and streptococcal species were responsible for 33 (63%) of them. An upward trend in resistance of S. viridans isolates is cause for concern and may change empirical treatment strategies. Death was reported in 3 cases (5%) and was associated with Pseudomonas and staphylococcal isolates. The recognition of this entity and the importance of proper infection control measures are underlined.

We tested for dengue seroconversion among 104 Israeli young adults who traveled to tropical countries for at least 3 months. Seven (6. 7%) seroconverted during travel; four (3.8%) had immunoglobulin (Ig) M antibodies; one was symptomatic with borderline IgM and a rise in IgG; two others (1.9%) had a rise in IgG titers, without detectable IgM. All four IgM-positive patients had traveled to Southeast Asia.

We conducted a retrospective serosurvey of 1,000 persons in Israel who had fever of undetermined cause to look for Ehrlichia chaffeensis antibodies. Four of five cases with antibodies reactive to E. chaffeensis were diagnosed in the summer, when ticks are more active. All patients had influenzalike symptoms with high fever. None of the cases was fatal. Three serum samples were also seroreactive for antibodies to E. canis, and one was also reactive to the human granulocytic ehrlichiosis (HGE) agent. The titer to the HGE agent in this patient was higher than the serum titer to E. chaffeensis, and the Western blot analysis also indicated that the HGE agent was the primary cause of infection. We present the first serologic evidence that the agents of human monocytic ehrlichiosis (HME) and HGE are present in Israel. Therefore, human ehrlichiosis should be included in the differential diagnoses for persons in Israel who have been exposed to ticks and have influenzalike symptoms.