Israel Medical Association Journal

Background: Nasal colonization with methicillin-resistant Staphylococcus aureus in the community is being increasingly reported, but there is a general lack of data on MRSA[1] colonization in children in chronic care institutions and on colonization rates in Israeli children.

Objectives: To define the rate of MRSA nasal colonization in a generally healthy pediatric population in Jerusalem, to compare it with that of children in chronic care institutions, to define risk factors for colonization, and to compare community and hospital-acquired MRSA strains.

Methods: Anterior nares culture for the presence of methicillin-sensitive and methicillin-resistant S. aureus was taken from 831 healthy children attending primary pediatric clinics or emergency department and 118 children hospitalized in three chronic care institutions in Jerusalem.

Results: Of the 831 healthy children, 195 (23.5%) were colonized with S. aureus, as compared to 43 of 118 (36.4%) chronically institutionalized children (P < 0.005). Five of the 195 S. aureus isolates from healthy children (2.6%) were MRSA, as compared to 9 of 43 (21%) from chronically institutionalized children (P < 0.001). Older age and a family member who is a healthcare worker were associated with S. aureus colonization in the population of healthy children, and older age was associated with MRSA colonization in the chronically institutionalized children. The antibiotic susceptibility pattern was similar for both groups, and pulsed field gel electrophoresis of the isolates showed a wide and random distribution in both groups.

Conclusions: MRSA colonization in the studied pediatric community in Jerusalem was very low, whereas that of patients hospitalized in chronic care institutions was significantly higher. In the small number of isolates detected, no significant differences were found in antibiotic susceptibility or PFGE[2] pattern between hospital-acquired and community-acquired strains.

Background: It has been argued that arginine replacement in locus16 (Arg16) of ß₂ adrenergic receptor with glycin (Gly16) increases asthma severity, while glutamin replacement in locus 27 (Gln27) with glutamic acid (Glu27) decreases it. In addition, ethnic dependency of these polymorphisms has been described, but few studies investigated its relation to asthma severity in a non-anglosaxic population.

Objectives: To investigate non-anglosaxic ethnic influences on ß₂AR[1] polymorphisms and its correlations to asthma severity.

Methods: Sixty-six Israeli Jewish and Arab asthmatics who had near-fatal asthma and/or severe nocturnal asthma and/or steroid-dependency were investigated for genetic polymorphisms of ß₂AR and compared to matched controls. The Jewish patients included both Ashkenazi (of East European origin) and non-Ashkenazi (originating from the Middle East or North Africa). The results were compared with those of ethnically matched 113 non-asthmatic Israelis, and of non-asthmatic Anglo-Saxons described in the literature.

Results: We found no significant genetic differences between the asthmatics and their controls or between the various ethnic groups of our population. However, the prevalence of Glu27 was significantly lower in non-asthmatic Israelis compared to non-asthmatic Anglo-Saxons.

Conclusions: The genetic distribution of ß₂AR polymorphisms in severe Israeli asthmatics is not different from that of non-asthmatic Israelis and therefore its clinical impact on asthma is probably minimal.

Background: Streptococcal pharyngotonsillitis remains a common illness in children and can lead to serious complications if left untreated.

Objective: To evaluate the diagnostic and management approach of a sample of primary care physicians in the largest sick fund in Israel to streptococcal pharyngotonsillitis in children.

Methods: A questionnaire was mailed to all physicians who treat children and are employed by the General Health Services (Kupat Holim Klalit) in the Jerusalem District. The questionnaire included data on demographics, practice type and size, and availability of throat culture and rapid strep test; as well as a description of three hypothetical cases followed by questions relating to their diagnosis and treatment.

Results: Of the 188 eligible physicians, 118 (62.5%) responded, including 65 of 89 pediatricians (73%) and 53 of 99 family and general practitioners (53.5%). Fifty-six physicians (47.4%) had more than 18 years experience, and 82 (70%) completed specialization in Israel.  Mean practice size was 950 patients. Fifty-three physicians (43%) worked in Kupat Holim community clinics, 25 (21%) worked independently in private clinics, and 40 (34%) did both. A total of 91 (77%) had access to laboratory facilities for daily throat culture. The time it took for the results to arrive was 48 to 72 hours.  For the three clinical scenarios, 90% of the physicians accurately evaluated case A, a 1-year-old with viral pharyngotonsillitis, and 100 (85%) correctly diagnosed case C, a 7-year-old with streptococcal infection.  As expected, opinions were divided on case B, a 3-year-old child with uncertain diagnosis.  Accordingly, 75 (65.3%) physicians did not recommend treatment for case A, compared to 109 (92.5%) for case C.  For case B, 22 (19%) said they would always treat, 43 (36%) would sometimes treat, and 35 (30%) would await the result of the throat culture.  For 104 (88%) physicians the antibiotic of choice for case C was penicillin, while only 9 (7.5%) chose amoxicillin. However, the recommended dosage regimens varied from 250 to 500 mg per dose, and from two to four doses daily.  For case C, 110 physicians (93%) chose a 10 day duration of treatment.

Conclusions: The primary care physicians in the sample (pediatricians, general practitioners and family physicians) accurately diagnosed viral and streptococcal pharyngotonsillitis. However, there was a lack of uniformity regarding its management in general, and the dosage regimen for penicillin in particular.