Ten years with colistin: a retrospective case series

OBJECTIVE

At the Shaare Zedek Medical Center, we have been using colistimethate sodium (CMS) for empiric as well as pathogen-directed treatment. We present our 10-year experience.

METHODS

We conducted a retrospective case-series analysis of patients admitted from 1 January 2004 through 1 May 2014 who received at least one dose of CMS. Patient characteristics analysed for all admission for which patients received CMS, included: age, number of re-admissions, admission ward, renal function, disposition and microbiology results. Overall trend in defined daily dose (DDD) for CMS and resistant isolates was analysed.

RESULTS

A total of 5603 admissions met inclusion criteria. Patients' mean (±SD) age was 80 ± 14 years, 1162 (48%) of the admissions were from a healthcare facility and 4367 (78%) of the admissions were to general Internal Medicine wards. The median number of hospital admissions per patient was 5, median admission and discharge creatinine (mg/dl) were 1.05 and 1.01, respectively; 2.3% of admissions required first-time dialysis. The discharge rate from the hospital was 58.4%. Excluding intrinsically CMS-resistant gram-negative organisms, bloodstream and urine isolates were 98% and 100% susceptible, respectively. CMS use (DDDs) increased during the study (p for trend = 0.04) without significant increase in incidence of multidrug-resistant organisms.

CONCLUSIONS

Colistimethate sodium use at our institution has increased during this 10-year period. Nevertheless, there is no increasing trend in CMS-resistant organisms, 58% of the patients were discharged alive, and we did not observe significant nephrotoxicity in patients prescribed CMS. CMS should be reserved for microbiologically confirmed extensively drug-resistant gram-negative infections.

Clinical and demographic characteristics of elderly patients hospitalised in an internal medicine department in Israel

The number of elderly patients hospitalised in acute medical wards is increasing rapidly. It is important to understand the demographic and clinical characteristics of these patients so as to plan appropriate resource allocation and geriatric training programmes. The aim of the study is to describe the demographic and clinical characteristics of elderly patients admitted to an internal medicine department. During a 3-months prospective study, 779 patients over the age of 65 with acute illness admitted to internal medicine wards. The mean age of the patients was 80 +/- 8 years; 277 (36%) were defined as dependent. The latter had significantly more moderate or severe dementia, higher APACH II scores, lower serum albumin levels, needed more mechanical ventilation, a higher mortality rate and more prolonged admissions (for all variables p < 0.001). Infectious disease was the main indication for admission in the dependent patients while in the independent patients it was cardiac disease (54 vs. 29% and 17 vs. 45%, respectively, p < 0.001). In-hospital mortality was 11%. Functional capacity during hospitalisation declined significantly in all patients but more in those over the age of 85. Of those patients discharged from hospital, mental deterioration during the hospitalisation was observed in only 3%. Our study supports the concept of the introduction of specialised geriatric facilities within the general hospital framework, including the geriatric training and education of all residents in internal medicine.

[Malaria in travelers returning to Israel from endemic areas: diagnosis of two patients in a family practice]

2 cases of malaria in family practice are described in a 26- and a 50-year-old woman. Both probably could have been prevented had common chemoprophylactic drugs been taken. The risk of malaria is greater than the risk of possible side-effects of the drugs commonly used by travelers for prevention. Family physicians must be aware of the possibility of malaria in young people with fever, especially those who have travelled to equatorial areas and special attention should be given to encourage chemoprophylaxis.

Pneumococcal bacteremia in hospitalized Israeli adults: epidemiology and resistance to penicillin. Israeli Adult Pneumococcal Bacteremia Group

In April 1993 a national survey of pneumococcal bacteremia in hospitalized Israeli adults was started, and this survey covered 23 of the 24 Israeli medical centers. During the first 2 years, 603 episodes of pneumococcal bacteremia were recorded. The overall annual incidence of pneumococcal bacteremia in Israeli adults was 14.5 episodes per 100,000 inhabitants, and the overall mortality rate was 27.8%. Pneumonia was the source of bacteremia in 70.8% of cases, primary bacteremia was the source in 17.5%, meningitis was the source in 7.5%, and otitis media/sinusitis was the source in 4.2%. Of the 258 pneumococcal isolates for which an MIC was determined, 88.8% were susceptible to penicillin, 9.3% were partially resistant, and only 1.9% were highly resistant. Twenty-four serogroups were identified from 398 strains tested. The highest percentage of penicillin-resistant strains belonged to serogroups 23, 19, 9, 4, and 6. Although only 13 of these 24 serogroups correspond to the serotypes included in the 23-valent pneumococcal vaccine, they accounted for 94% of all isolates.

Protective efficacy of combined live intranasal and inactivated influenza A virus vaccines in the elderly

OBJECTIVE

To evaluate the efficacy of adding intranasal live attenuated cold-adapted influenza A vaccine to inactivated influenza vaccine to prevent influenza A in elderly residents of long-term-care institutions.

DESIGN

Randomized, double-blind, placebo-controlled study conducted over 3 years.

SETTING

Three large nursing homes.

PARTICIPANTS

A total of 523 residents of nursing homes (mean age, 84.2 years).

INTERVENTIONS

All participants received trivalent inactivated influenza vaccine parenterally and were randomly assigned to receive either live attenuated influenza A (H3N2) virus vaccine or placebo intranasally.

MEASUREMENTS

Laboratory-documented influenza A was defined as a respiratory illness plus isolation of influenza A virus from nasal secretions, significant serologic response, or both. Participants were considered to have been exposed to influenza A if they resided in an institution in which cases of influenza A were documented. Outbreak-associated illnesses were defined as those occurring between the first and last isolation of influenza virus from within the institution, +/- 3 days.

RESULTS

Participants who received intranasal vaccine and were subsequently exposed to influenza A had significantly lower rates of laboratory-documented influenza A (9 of 162 vaccine recipients compared with 24 of 169 placebo recipients; vaccine protective efficacy, 60.6%; 95% CI, 18% to 82%), outbreak-associated respiratory illnesses (13 of 162 vaccine recipients compared with 34 of 169 placebo recipients; vaccine protective efficacy, 56.8%; CI 23% to 76%), and outbreak-associated influenza-like illnesses (6 of 162 vaccine recipients compared with 18 of 169 placebo recipients; vaccine protective efficacy, 65.0%; CI 17% to 86%).

CONCLUSIONS

Intranasal immunization with live attenuated influenza A virus vaccine provided additional protection against influenza A when added to parenteral trivalent inactivated influenza vaccine among elderly nursing home residents.

Quality of life and survival following intensive medical care

The relation between quality of life before admission and the outcome of admissions to the intensive care unit (ICU) was studied prospectively among 126 patients in a community hospital with a predominantly geriatric patient population. Fifty-four per cent of our patients were older than 65 years and 66 per cent suffered from chronic ill health. Their mean APACHE score was 18 +/- 8 (mean +/- SD). Quality of life was assessed by the Karnofsky index of physical performance; the linear analogue self assessment (LASA) score; sleep index; level of employment; sexual activity; housing status. Thirty-seven per cent of the patients died in ICU and another 10 per cent in hospital. The one year survival of the entire group was 37 per cent. Survival rates were significantly higher in patients with a Karnofsky index of 6 or more, LASA score of 55 or more, in employment, and with sleep index of 2 or more (p less than 0.05). The 12-month survival among patients with four favourable indicators was 59 per cent, with two or three favourable indicators 36 per cent (p less than 0.05), and in patients with no favourable indicators of quality of life or only one 17 per cent (p less than 0.001). Quality of life in patients who survived longer than six months after ICU care was high (Karnofsky index 7.9 +/- 2.0; LASA score 71 +/- 20 (mean +/- SD) and unimpaired when compared with their ratings before admission to the unit. These findings indicate that quality of life before admission is an important predictor of survival and that a high proportion of critically-ill subjects whose quality of life was relatively good before the episode requiring admission will be long-term survivors whose quality of life is comparable to that preceding critical care.

Diagnostic value of ferritin in malignant pleural and peritoneal effusions

The diagnostic usefulness of ferritin measurements in pleural and peritoneal effusions has been evaluated in 57 patients. Mean (+/- standard error [SE]) ferritin levels were 291 +/- 50 ng/ml in 24 patients with noninflammatory transudates (Group I), 942 +/- 253 in 15 patients with nonmalignant exudates (Group II), and 1805 +/- 257 in 18 patients with malignant exudates (Group III). The mean (+/- SE) ratio of effusion/serum ferritin in Groups I, II, and III was 0.7 +/- 0.1, 2.7 +/- 0.7, and 5.7 +/- 1.2, respectively. The specificity and predictive value of a ferritin ratio in excess of 1.5 in distinguishing transudates from all exudates and in distinguishing transudates from malignant exudates were both very high (94%) to 96%). In the lower range of values considerable overlap existed between ferritin ratios obtained in patients with benign versus malignant inflammatory exudates. However, very high ferritin levels (greater than 3000 ng/ml) and ferritin ratios (greater than 20:1) were only encountered in malignant exudates. These results indicate that the measurement of ferritin levels and ferritin ratios may be a useful aid in the diagnosis of malignant pleural and peritoneal effusions.

Evolution of malignant lymphoma in agnogenic myeloid metaplasia

Two young arab patients are described in whom malignant lymphoma developed within less than 1 year of the diagnosis of agnogenic myeloid metaplasia. Both patients showed a satisfactory response to combined chemotherapy. One of them died of hepatitis B at 10 months and the other is alive and in clinical remission 25 months after initial diagnosis. These observations demonstrate the close relation between myeloproliferative and lymphoproliferative syndromes and illustrate the diversity of malignant lymphoproliferative disorders into which agnogenic myeloid metaplasia may evolve in the course of disease. Our experience also demonstrates the ease with which some patients with an 'end stage' myeloproliferative disorder may respond to standard chemotherapy designed for the treatment of malignant lymphoma.