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Biomedical subjects

L Leibovici

Publications and source records attributed to L Leibovici.

At least 37 records · Page 2Linked to original sources
PubMed2003

Antibiotic prophylaxis of bacterial infections in cirrhotic inpatients: a meta-analysis of randomized controlled trials.

BACKGROUND: Antibiotic prophylaxis has been reported to decrease bacterial infections and fatality rates in inpatients with cirrhosis. We performed a systematic review to evaluate the efficacy of antibiotic prophylaxis in inpatients with cirrhosis, regardless of the underlying risk factors that led to hospital admission. METHODS: A comprehensive literature search strategy was performed including the Cochrane Library, Embase, Medline, a manual search of bibliographic references, and contacting the authors of each included trial. We included any randomized clinical trial comparing different types of antibiotic prophylaxis with placebo or no intervention in inpatients with cirrhosis. Two reviewers independently applied the selection criteria to all identified references, appraised the methodological quality of each trial and extracted the relevant data. Relative risks and 95% confidence intervals were estimated using the fixed effect model. A test of heterogeneity and a funnel plot were performed and an intention-to-treat approach was used for the outcome measures. RESULTS: Nineteen randomized trials were identified, 13 of which were included in the review. A significant beneficial effect on mortality (RR: 0.70; 95% CI: 0.56, 0.89) and prevention of bacterial infections (RR: 0.39; 95% CI: 0.32, 0.48) was observed, regardless of the underlying risk factors. Few adverse events were reported and there was no heterogeneity between studies. We identified a funnel plot asymmetry for the included trials. CONCLUSIONS: Antibiotic prophylaxis for inpatients with cirrhosis is efficacious in reducing the number of deaths and bacterial infections regardless of the underlying risk factors.

Antibiotic Prophylaxis↗
PubMed2002

Antibiotic prophylaxis for cirrhotic patients with gastrointestinal bleeding.

BACKGROUND: Bacterial infections are a frequent complication in patients with cirrhosis and gastrointestinal bleeding. Antibiotic prophylaxis seems to decrease the incidence of bacterial infections. Oral antibiotics, active against enteric bacteria, have been most often used as antibiotic prophylaxis in cirrhotic patients with gastrointestinal bleeding. OBJECTIVES: This review aims to evaluate the effects of antibiotic prophylaxis in the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding. SEARCH STRATEGY: Electronic searches on The Cochrane Hepato-Biliary Group Controlled Trials Register (May 2001), The Cochrane Library (Issue 2, 2001), EMBASE (1980-2001), and MEDLINE (1966-2001); handsearching the references of all identified studies; contacting the first author of each included trial. SELECTION CRITERIA: Randomised clinical trials comparing different types of antibiotic prophylaxis with placebo, no intervention, or another antibiotic to prevent bacterial infections in cirrhotic patients with gastrointestinal bleeding. DATA COLLECTION AND ANALYSIS: Two reviewers independently appraised the quality of each trial and extracted the data from the included trials. Relative risks (RR) or average differences, with their 95% confidence intervals (CI) were estimated. The reviewers assumed an intention to treat basis for the outcome measures. MAIN RESULTS: Eight trials evaluated the effects of antibiotic prophylaxis compared with placebo or no antibiotic prophylaxis in 864 patients. A significant beneficial effect on decreasing mortality (RR 0.73, 95% CI 0.55 to 0.95) and the incidence of bacterial infections (RR 0.40, 95% CI 0.32 to 0.51) was observed. No serious adverse events were reported. The trials showed no significant heterogeneity. Three additional trials evaluated the effects of antibiotics compared with a different regimen of antibiotics in 503 patients. Data could not be combined as each trial used different interventions. None of the examined antibiotic regimens was superior to the control regimen regarding mortality or the incidence of bacterial infections. REVIEWER'S CONCLUSIONS: Antibiotic prophylaxis for cirrhotic inpatients with gastrointestinal bleeding is efficacious in reducing the number of deaths and bacterial infections, are well tolerated, and should be advocated.

Antibiotic Prophylaxis↗
PubMed2002

Beta-lactam versus beta-lactam-aminoglycoside combination therapy in cancer patients with neutropaenia.

BACKGROUND: Chemotherapy treated cancer patients are prone to neutropaenia and life-threatening infections. Early, empirical antibiotic treatment is therefore administered routinely to febrile neutropaenic patients. Currently, either beta-lactam-aminoglycoside combination treatment or beta-lactam monotherapy are recommended. OBJECTIVES: We compared beta-lactam monotherapy versus beta-lactam-aminoglycoside combination therapy for cancer patients with fever and neutroepaenia. SEARCH STRATEGY: Cochrane Library (Issue 4,2001), the Cochrane Cancer Network Register of trials (July 2000), EMBASE (January 1980-2000), MEDLINE (1966-8/2001), and ICAAC conference proceedings (1995 onwards). We scanned references of all included studies, pertinent reviews, and contacted the first author of each included trial and the pharmaceutical companies. SELECTION CRITERIA: Randomised controlled trials comparing any beta-lactam antibiotic monotherapy to any combination of a beta-lactam and an aminoglycoside antibiotic, for the initial, empirical treatment of febrile neutropaenic cancer patients. DATA COLLECTION AND ANALYSIS: Data concerning mortality, treatment failure (including treatment modifications), superinfections, adverse effects and study quality measures were extracted independently by two reviewers. Relative risks with their 95% confidence intervals (CI) were estimated. Outcomes were extracted by intention-to-treat analysis whenever possible. MAIN RESULTS: Forty-six trials and 7642 patients were included. All cause mortality was the primary outcome assessed. For all mortality comparisons, no significant difference between monotherapy and combination therapy was seen, relative risk 0.85 (95% CI 0.72-1.02) for all studies combined. Treatment failure was the outcome reported in all included trials. No significant difference between study groups was shown for studies comparing the same beta-lactam, relative risk 1.12 (95% CI 0.96-1.29). A significant advantage to monotherapy was observed for studies comparing different beta-lactams, relative risk 0.86 (95% CI 0.80-0.93). Bacterial and fungal superinfections developed with similar frequencies in the monotherapy and combination treatment groups. Adverse events were significantly more common in the combination treatment group, relative risk 0.83, (95% CI 0.72-0.97). These included events associated with significant morbidity, primarily renal toxicity. Results were consistent for subgroup and sensitivity analyses. REVIEWER'S CONCLUSIONS: We have shown an advantage to broad-spectrum beta-lactam monotherapy over beta-lactam-aminoglycoside combination therapy for febrile neutropaenia. This advantage comprises of 1) a similar, if not better, survival, 2) a significantly lower treatment failure rate, 3) comparable probability for secondary infections and, 4) most importantly, a lower rate of adverse events associated with significant morbidity. Monotherapy can be regarded, therefore, as the standard of care for febrile neutropaenic patients.

Aminoglycosides↗
PubMed2001

Long-term outcome of infective endocarditis: the impact of early surgical intervention.

To determine the impact of early surgical intervention on long-term survival in patients with infective endocarditis (IE), charts of all patients who had IE from January 1987 through December 1996 were reviewed. A total of 252 patients with definite or possible IE were included. Forty-four patients (17.5%) had early surgery on median hospital day 2 (range, 0-30 days), and 208 patients (82.5%) received medical treatment alone. On multivariate analysis, several variables, including early surgical intervention, improved long-term survival rates (hazard ratio, 1.5; P=.03), mainly in patients with Staphylococcus aureus etiology (P=.04). When patients with prosthetic devices were excluded, the median duration of survival for patients who had early surgery was >150 months, compared with 61.5 months for patients in the medical group (P=.1). Early surgical intervention compared with medical therapy alone is associated with increased short- and long-term survival rates in patients with IE, primarily when IE is caused by S. aureus.

Adolescent↗
PubMed2001

Antibiotics for spontaneous bacterial peritonitis in cirrhotics.

BACKGROUND: Spontaneous bacterial peritonitis is mainly a complication of cirrhotic ascites that occurs in the absence of any intra-abdominal, surgically treatable source of infection. Antibiotics have been recommended as the mainstay treatment for spontaneous bacterial peritonitis. However, this recommendation is not based on convincing evidence. It has been proposed that treatment should cover Gram-negative enteric bacteria and Gram-positive cocci, that are responsible for up to 90% of cases. OBJECTIVES: To evaluate the effectiveness and safety of different types and ways of antibiotic therapy for spontaneous bacterial peritonitis in cirrhotic patients. SEARCH STRATEGY: Electronic searches on the Cochrane Library (Issue 3, 2000), the Cochrane Hepato-Biliary Group Trials Register (March 2000), EMBASE (1980-2000), MEDLINE (1966-2000); scanning the references of all identified studies; contacting the first author of each included trial. SELECTION CRITERIA: Randomised trials comparing different types of antibiotics for spontaneous bacterial peritonitis in cirrhotic patients. DATA COLLECTION AND ANALYSIS: Data were independently extracted by two reviewers. Relative risks or weighted mean differences, with their 95% confidence intervals were estimated using 'intention-to-treat' analyses. MAIN RESULTS: Nine trials dealing with 684 patients diagnosed with spontaneous bacterial peritonitis were included. No placebo-controlled trial was found. Each of the included trials compared different antibiotics, and no meta-analysis could be performed. We were unable to establish the optimal dose or duration of antibiotic therapy and found no convincing evidence that cefotaxime is more effective than ampicillin-tobramycin or that oral quinolones should be recommended for patients with less severe manifestations of the disease. REVIEWER'S CONCLUSIONS: This review provides no clear evidence for the treatment of cirrhotic patients with spontaneous bacterial peritonitis. Until large, well-conducted, trials provide adequate evidence, treatment must be based on clinical experience.

Anti-Bacterial Agents↗
PubMed2001

Excess mortality in women with hospital-acquired bloodstream infection.

PURPOSE: We examined the outcomes of bloodstream infection in men and in women and whether any sex-related differences were explained by underlying disorders, severity of disease, or clinical management. SUBJECTS AND METHODS: Using a prospectively collected database, we compared in-hospital mortality in men and women. We used multivariable logistic regression analysis to test whether sex-related differences could be due to potential confounders. RESULTS: Of 4250 patients with bloodstream infections, 1750 (41%) had hospital-acquired infections. The overall case fatality was 31% (625 of 2032) in women and 29% (631 of 2218, P = 0.1) in men. However, 43% (325/758) of the women with hospital-acquired infections died, compared with 33% (327/992) of the men (P = 0.0001). In a multivariate analysis, female sex was associated with greater mortality in patients with hospital-acquired infections (odds ratio = 1.7; 95% confidence interval: 1.1 to 2.6). The excess mortality in women was mainly seen in patients with major underlying disorders (fatality rate of 45% [234 of 525] in women vs. 32% in men [234 of 743, P = 0.0001). CONCLUSIONS: Mortality in women with hospital-acquired bloodstream infections is substantially greater than in men. The excess mortality was concentrated in women with severe underlying disorders, suggesting that sepsis might have accentuated differences in the outcome of underlying disorders in women.

Adult↗
PubMed2001

Departmental consumption of antibiotic drugs and subsequent resistance: a quantitative link.

OBJECTIVE: To look for a quantitative model linking departmental consumption of antibiotic drugs to the subsequent isolation of resistant hospital-acquired coliform pathogens. MATERIALS AND METHODS: Included in the study were all patients with hospital-acquired bloodstream infections caused by a coliform pathogen, detected in six departments of internal medicine of one university hospital during the period 1991-1996, who had not been hospitalized in the month before the infection (n = 394). Departmental consumption of antibiotics in the year before the infection [expressed as defined daily dosages (DDD)/100 patient days], antibiotic treatment given to the individual patient before the infection, the day of hospital stay on which the infection occurred, and the department and the calendar year were all included in a logistic model to predict the isolation of a resistant pathogen. We looked at five drugs: gentamicin, amikacin, cefuroxime, ceftazidime and ciprofloxacin. RESULTS: Five logistic models were fitted for the resistance to each of the antibiotic drugs. The multivariable-adjusted odds ratios for a pathogen resistant to the specific antibiotic were 1.03 [95% confidence interval (CI) 0.70-1.50] for gentamicin, 1.80 (95% CI 1.00-3.24) for amikacin, 1.12 (95% CI 1.02-1.23) for cefuroxime, 1.45 (95% CI 1.19-1.76) for ceftazidime and 1.06 (95% CI 0.57-1.97) for ciprofloxacin, per 1 DDD/100 patient days. CONCLUSIONS: The departmental consumption of cephalosporin drugs and amikacin in six autonomous departments of medicine in the same hospital was associated with a measurable and statistically significant increase in the probability of infection caused by a resistant pathogen.

Amikacin↗
PubMed2001

Antibiotic use in patients with erysipelas: a retrospective study.

BACKGROUND: Erysipelas is a skin infection generally caused by group A streptococci. Although penicillin is the drug of choice, some physicians tend to treat erysipelas with antibiotics other than penicillin. OBJECTIVES: To define the pattern of antibiotic use, factors affecting antibiotic selection, and outcome of patients treated with penicillin versus those treated with other antimicrobial agents. METHODS: A retrospective review of charts of adult patients with discharge diagnosis of erysipelas was conducted for the years 1993-1996. RESULTS: The study group comprised 365 patients (median age 67 years). In 76% of the cases infection involved the leg/s. Predisposing condition/s were present in 82% of cases. Microorganisms were isolated from blood cultures in only 6 of 176 cases (3%), and Streptococcus spp. was recovered in four of these six patients. Cultures from skin specimens were positive in 3 of 23 cases. Penicillin alone was given to 164 patients (45%). Other antibiotics were more commonly used in the second half of the study period (P < 0.0001) in patients with underlying conditions (P = 0.06) and in those hospitalized in the dermatology ward (P < 0.0001). Hospitalization was significantly shorter in the penicillin group (P = 0.004). There were no in-hospital deaths. CONCLUSIONS: We found no advantage in using antibiotics other than penicillin for treating erysipelas. The low yield of skin and blood cultures and their marginal impact on management, as well as the excellent outcome suggest that this infection can probably be treated empirically on an outpatient basis.

Adult↗
PubMed2000

Seven-year study of bacteraemic pneumonia in a single institution.

In order to enhance current knowledge of nosocomial and community-acquired bacteraemic pneumonia in a single tertiary hospital in Israel, a 7-year study was conducted. Using a computerised database, all patients who had bacteraemic pneumonia from March 1988 to August 1995 were studied. During the study period, pneumonia was the source of bacteraemia in 319 of 4,548 (7%) episodes, occurring in 295 patients; 211 (66%) episodes were community-acquired and 108 (34%) were nosocomial. The microoroganisms isolated most frequently from patients with community-acquired bacteraemic pneumonia were Streptococcus pneumoniae (46%), Staphylococcus aureus (10%) and Haemophilus influenzae (8%); while Pseudomonas spp. (17%), Klebsiella spp. (11%) and Staphylococcus aureus (10%) were isolated most often from the patients with nosocomial bacteraemic pneumonia. The median age of patients was 68 years (range, 0.003-100). The overall mortality was 34%. No significant difference was found between the mortality rates of patients with community-acquired (31%) and nosocomial (40%) bacteraemic pneumonia (P=0.1). Multivariate analysis showed that hypothermia, respiratory failure, impaired consciousness, tracheal intubation, Staphylococcus aureus aetiology, septic shock, inappropriate empiric antibiotic treatment and age significantly increased mortality.

Aged↗
PubMed2000

Bacteraemia caused by hospital-type micro-organisms during hospital stay.

A sharp transition between community-type and hospital-type pathogens at the second or third day of hospital stay is often assumed. This study aimed to test whether such a threshold phenomenon exists for bloodstream infections and to examine the relationship between the proportion of infections caused by hospital-type pathogens and length of stay in the hospital. Blood stream infections were studied in a referral and a university hospital in west Denmark, and a university hospital in central Israel during three study periods (1994-1996, 1992-1995, 1989-1995 in the three hospitals respectively). No threshold effect at 2-3 days stay in the hospital could be demonstrated. However the percentage of Pseudomonas aeruginosa bloodstream infections increased constantly in the three hospitals from 1%, 1% and 7% during the first 2 days to 7%, 4%, and 14% during the third week of hospital stay (P<0.01 for all three comparisons-chi(2)for linear trends). For Candida sp. the increase was from 0%, 2%, 1% during the first 2 days to 3%, 4%, and 9% during the third week, P<0.05. Methicillin-resistant Staphylococcus aureus in Israel increased from 26% of the total number of S. aureus during the first 2 days to 69% during the third week, P<0.0001. For penicillin-resistant S. aureus in Denmark, the percentages were 84% and 100%, P<0.05.The percentage of infections caused by hospital-type pathogens increased almost linearly during the first 3 weeks of hospital stay, with no threshold effect. This trend should be taken into account when prescribing empirical therapy for nosocomial infections.

Bacteremia↗
PubMed2000

Prediction of mortality in patients with bacteremia: the importance of pre-existing renal insufficiency.

Pre-existing renal insufficiency serves as a common risk factor in the development of acute renal failure. Acute renal failure is a common finding in patients with bacteremia and is associated with poor prognosis. A total of 2722 consecutive patients 18 years old or older, fulfilling strike criteria of bacteremia or fungemia were prospectively evaluated to establish the prognostic importance of pre-existing renal insufficiency in bacteremic patients. They were classified according to serum creatinine levels upon admission into three groups. 915 patients had normal creatinine levels (< or = 1.0 mg/dL), 1528 had mild to moderate renal failure (creatinine 1.1-3 mg/dL) and 279 patients had severe renal failure upon admission (creatinine > 3.0 mg/dL). Mild to severe renal failure upon admission was associated with old age, male gender, diabetes mellitus, ischemic heat disease, hypertension and congestive heart failure. The serum albumin in patients with severe renal failure was significantly low, with a mean of 2-9 mg/dL. Urinary tract infections were more prevalent in patients with mild to severe renal failure, while intravenous line infections, bacterial endocarditis and soft and skin tissue infections were more common in patients with normal renal function. In the 279 patients with severe renal failure the mortality rate was significantly higher (50%) compared to patents with mild to moderate renal failure and patients with normal renal function (21% and 26% respectively, p = 0.0001). Multiple regression analysis revealed that pre-existing serum creatinine > 3 mg/dL was significantly associated with death attributable to bacteremia (OR = 1.7, 95% CI 1.0-2.7). In conclusion, adult bacteremic patients with pre-existing serum creatinine above 3 mg/dL upon admission are at increased risk of mortality due to bacteremia than patients with normal or mild to moderate renal failure.

Aged↗
PubMed1999

Using probabilistic and decision-theoretic methods in treatment and prognosis modeling.

Causal probabilistic networks, also called Bayesian networks, allow both qualitative knowledge about the structure of a problem and quantitative knowledge, derived from case databases, expert opinion and literature to be exploited in the construction of decision support systems for diagnosis, treatment and prognosis. This mixing of qualitative and quantitative knowledge will be illustrated, using the selection of antibiotics for a subset of patients with severe infections. The subset consists of patients where bacteria or fungi have been found in the blood. A simple pathophysiological model of infection is used to calculate a prognosis, dependent on the choice of antibiotics. A decision-theoretic approach is used to balance the therapeutic benefit of antibiotic treatment against the cost of antibiotics in the form of direct monetary cost, side effects and ecological cost. A retrospective trial on patients with bacteria or fungi in the blood stemming from the urinary tract indicates that with this approach, it may be possible to suggest balanced choices of antibiotics that not only achieve greater therapeutic benefit, but also reduce the cost of therapy.

Anti-Bacterial Agents↗
PubMed1999

Seroprevalence of Helicobacter pylori and length of stay in a nursing home.

BACKGROUND: Helicobacter pylori infection appears to be contracted mainly in childhood, and it is associated with disadvantaged socioeconomic conditions, overcrowding, and living in institutions. In this study we determined the seroprevalence of H. pylori among elderly patients (age > or = 70 years) admitted to a major medical center in Israel, and studied the relationship between seroprevalence of H. pylori and the duration of stay in a nursing home prior to the admission. PATIENTS AND METHODS: Whole blood from 182 consecutive patients hospitalized at the Rabin Medical Center was tested for the presence of anti-H. pylori IgG using Helisal Rapid Blood Test kit (Cortecs Diagnostics). Multivariate logistic regression analysis was used to study the relation between H. pylori seropositivity and possible predictive factors such as age, gender and duration of stay in a nursing home. RESULTS: Of the 182 patients included in the study, 80 (44%) were living in nursing homes (NH) and 102 (56%) were living in their own homes (H) prior to admission. Subjects that stayed in nursing homes for more than 15 months were significantly more likely to be seropositive than subjects with a shorter duration of stay (84% and 63% respectively, p = 0.03). Using a multivariate logistic regression analysis on both the NH group and the whole group, seropositivity was found to be significantly associated with duration of stay in a nursing home (p = 0.03 and p = 0.01 respectively). Seropositivity was not associated with age in either group. CONCLUSIONS: Living in a nursing home is associated with increased risk for H. pylori infection in the elderly. There is a strong correlation between the duration of stay in a nursing home and the prevalence of H. pylori infection.

Age Factors↗
PubMed1999

Nontyphoid Salmonella bacteremia: age-related differences in clinical presentation, bacteriology, and outcome.

In a retrospective study, 80 episodes of nontyphoid salmonella (NTS) bacteremia in children were compared with 55 episodes in adults over a 10-year period. The study disclosed major differences in the predisposition, clinical presentation, and outcome as well as the microbiology of NTS bacteremia in relation to age. Adults were more likely than children to have predisposing diseases (95% vs. 15%, respectively; P < .0001) and to receive prior medications (95% vs. 23%, respectively; P < .0001), particularly immunosuppressive agents (58% vs. 5%, respectively; P < .0001). In most adults (67%), NTS infection presented as a primary bacteremia and was associated with a high incidence of extraintestinal organ involvement (34%) and a high mortality rate (33%). In children, NTS bacteremia was usually secondary to gastroenteritis (75%) and caused no fatalities. Although group D Salmonella (78%) and the serovar Salmonella enteritidis were the predominant isolates from adults, the emergence of infections due to group C Salmonella (46%) and the serovar Salmonella virchow in children was noted.

Adolescent↗