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Louie TJ, Miller MA, Mullane KM, Weiss K, Lentnek A, Golan Y, Gorbach S, Sears P, Shue YK. Fidaxomicin versus vancomycin for Clostridium difficile infection. N Engl J Med 2011; 364:422-31. [PMID: 21288078 DOI: 10.1056/nejmoa0910812] [Citation(s) in RCA: 1110] [Impact Index Per Article: 85.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Clostridium difficile infection is a serious diarrheal illness associated with substantial morbidity and mortality. Patients generally have a response to oral vancomycin or metronidazole; however, the rate of recurrence is high. This phase 3 clinical trial compared the efficacy and safety of fidaxomicin with those of vancomycin in treating C. difficile infection. METHODS Adults with acute symptoms of C. difficile infection and a positive result on a stool toxin test were eligible for study entry. We randomly assigned patients to receive fidaxomicin (200 mg twice daily) or vancomycin (125 mg four times daily) orally for 10 days. The primary end point was clinical cure (resolution of symptoms and no need for further therapy for C. difficile infection as of the second day after the end of the course of therapy). The secondary end points were recurrence of C. difficile infection (diarrhea and a positive result on a stool toxin test within 4 weeks after treatment) and global cure (i.e., cure with no recurrence). RESULTS A total of 629 patients were enrolled, of whom 548 (87.1%) could be evaluated for the per-protocol analysis. The rates of clinical cure with fidaxomicin were noninferior to those with vancomycin in both the modified intention-to-treat analysis (88.2% with fidaxomicin and 85.8% with vancomycin) and the per-protocol analysis (92.1% and 89.8%, respectively). Significantly fewer patients in the fidaxomicin group than in the vancomycin group had a recurrence of the infection, in both the modified intention-to-treat analysis (15.4% vs. 25.3%, P=0.005) and the per-protocol analysis (13.3% vs. 24.0%, P=0.004). The lower rate of recurrence was seen in patients with non–North American Pulsed Field type 1 strains. The adverse-event profile was similar for the two therapies. CONCLUSIONS The rates of clinical cure after treatment with fidaxomicin were noninferior to those after treatment with vancomycin. Fidaxomicin was associated with a significantly lower rate of recurrence of C. difficile infection associated with non–North American Pulsed Field type 1 strains. (Funded by Optimer Pharmaceuticals; ClinicalTrials.gov number, NCT00314951.)
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Dalton BR, Lye-Maccannell T, Henderson EA, Maccannell DR, Louie TJ. Proton pump inhibitors increase significantly the risk of Clostridium difficile infection in a low-endemicity, non-outbreak hospital setting. Aliment Pharmacol Ther 2009; 29:626-34. [PMID: 19183143 DOI: 10.1111/j.1365-2036.2008.03924.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Proton pump inhibitors (PPI) have been linked to higher risk of Clostridium difficile infection (CDI). The relevance of this association in hospitals with low disease activity, where an outbreak strain is nondominant, has been assessed in relatively few studies. AIM To assess the association of PPI and CDI in a setting of low disease activity. METHODS A retrospective cohort study was conducted at two hospitals. Patients admitted for > or = 7 days receiving antibiotics were included. Demographics, exposure to PPI, antibiotics and other drugs in relation to diagnosis of CDI were assessed by univariate and multivariate analyses. RESULTS Of 14 719 patients, 149 (1%) first episode CDI were documented; PPI co-exposure increased CDI [1.44 cases/100 patients vs. 0.74 cases/100 non-exposed (OR: 1.96, 95% CI: 1.42-2.72)]. By logistic regression, PPI days (adjusted OR: 1.01 per day, 95% CI: 1.00-1.02), histamine-2 blockers, antidepressants, antibiotic days, exposure to medications, age, admission service and length of admission were significant predictors. CONCLUSIONS A statistically significant increase in CDI was observed in antibiotic recipients who received PPI, but the absolute risk increase is modest. In settings of with low rates of CDI, the benefit of PPI therapy outweighs the risk of developing CDI. These data support programmes to decrease inappropriate use of PPI in hospitalized patients.
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Storck AJ, Laupland KB, Read RR, Mah MW, Gill JM, Nevett D, Louie TJ. Development of a Health-Related Quality of Life Questionnaire (HRQL) for patients with Extremity Soft Tissue Infections (ESTI). BMC Infect Dis 2006; 6:148. [PMID: 17034641 PMCID: PMC1618841 DOI: 10.1186/1471-2334-6-148] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2006] [Accepted: 10/11/2006] [Indexed: 12/26/2022] Open
Abstract
Background Past clinical trials of antimicrobial treatment in soft tissue infections have focused on non-standardized clinical and physiological outcome variables, and have not considered the subjective experience of patients. The objective of this study was to develop a health-related quality of life questionnaire (HRQL) for patients with extremity soft tissue infections (ESTI) for future use in clinical trials. Methods The design of this study followed published guidelines and included item generation, item reduction, and questionnaire preparation. Study subjects were consenting English-speaking adults with acute ESTI requiring prescription of at least two days of outpatient intravenous antibiotic therapy. Results A list of 49 items that adversely impact the quality of life of patients with ESTI was generated by literature review, informal health professional feedback, and semi-structured interviews with twenty patients. A listing of these items was then administered to 95 patients to determine their relative importance on quality of life. A questionnaire was prepared that included the twenty most important items with a 5-point Likert scale response. Questionnaire domains included physical symptoms, problems performing their activities of daily living, impairment of their emotional functioning, and difficulties in their social interactions as related to their ESTI. The final questionnaire was pre-tested on a further ten patients and was named the ESTI-Score. Conclusion The ESTI-Score is a novel instrument designed to quantify the impact of ESTI on quality of life. Future study is required to determine its validity and responsiveness before use as an outcome measure in clinical trials.
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MacCannell DR, Louie TJ, Gregson DB, Laverdiere M, Labbe AC, Laing F, Henwick S. Molecular analysis of Clostridium difficile PCR ribotype 027 isolates from Eastern and Western Canada. J Clin Microbiol 2006; 44:2147-52. [PMID: 16757612 PMCID: PMC1489423 DOI: 10.1128/jcm.02563-05] [Citation(s) in RCA: 140] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The prevalence and characteristics of PCR ribotype 027 strains of Clostridium difficile have come into question following recent outbreaks in Eastern Canada and elsewhere. In order to determine the distribution of this strain in other regions in Canada, we screened a bank of 1,419 isolates recovered from three different Canadian health regions between 2000 and 2004. Among isolates from a Montreal area hospital, PCR ribotype 027 strains represented 115/153 strains (75.2%) from 2003 to 2004, but ribotype 027 strains were absent in 2000 and 2001. In Calgary, by contrast, ribotype 027 rates have remained relatively stable over 4 years of surveillance, representing 51/685 (7.4%) hospital isolates and 62/373 (16.6%) strains from the community (P < 0.001). PCR ribotype 027 accounted for 8/135 (5.9%) hospital isolates in the Fraser Health Region in 2004. repetitive extragenic palindromic PCR was used to subtype a random selection of 027 isolates from each region. All 10 of the isolates from Quebec were of a single subtype, which was also dominant among isolates from Alberta (8/10 isolates) and British Columbia (6/8 isolates). Comparative sequencing of the tcdC repressor gene confirmed the documented 18-bp deletion and identified a second, single-base-pair deletion at position 117. Both deletions were conserved across all three provinces and were identified in a United Kingdom reference strain. The presence of a frameshift in the early portion of the tcdC gene implies serious functional disruption and may contribute to the hypervirulence of the 027 phenotype. PCR ribotype 027 strains appear to be widely distributed, to predate the Montreal outbreak, and to have measurable community presence in Western Canada.
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Louie TJ, Peppe J, Watt CK, Johnson D, Mohammed R, Dow G, Weiss K, Simon S, John JF, Garber G, Chasan-Taber S, Davidson DM. Tolevamer, a novel nonantibiotic polymer, compared with vancomycin in the treatment of mild to moderately severe Clostridium difficile-associated diarrhea. Clin Infect Dis 2006; 43:411-20. [PMID: 16838228 DOI: 10.1086/506349] [Citation(s) in RCA: 145] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2005] [Accepted: 04/01/2006] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Current antibiotic therapies for Clostridium difficile-associated diarrhea have limitations, including progression to severe disease, recurrent C. difficile-associated diarrhea, and selection for nosocomial pathogens. Tolevamer, a soluble, high-molecular weight, anionic polymer that binds C. difficile toxins A and B is a unique nonantibiotic treatment option. METHODS In this 3-arm, multicenter, randomized, double-blind, active-controlled, parallel-design phase II study, patients with mild to moderately severe C. difficile-associated diarrhea were randomized to receive 3 g of tolevamer per day (n = 97), 6 g of tolevamer per day (n = 95), or 500 mg of vancomycin per day (n = 97). The primary efficacy parameter was time to resolution of diarrhea, defined as the first day of 2 consecutive days when the patient had hard or formed stools (any number) or < or = 2 stools of loose or watery consistency. RESULTS In the per-protocol study population, resolution of diarrhea was achieved in 48 (67%) of 72 patients receiving 3 g of tolevamer per day (median time to resolution of diarrhea, 4.0 days; 95% confidence interval, 2.0-6.0 days), in 58 (83%) of 70 patients receiving 6 g of tolevamer per day (median time to resolution of diarrhea, 2.5 days; 95% confidence interval, 2.0-3.0 days), and in 73 (91%) of 80 patients receiving vancomycin (median time to resolution of diarrhea, 2.0 days; 95% confidence interval, 1.0-3.0 days). Tolevamer administered at a dosage of 6 g per day was found to be noninferior to vancomycin administered at a dosage of 500 mg per day with regard to time to resolution of diarrhea (P = .02) and was associated with a trend toward a lower recurrence rate. Tolevamer was well tolerated but was associated with an increased risk of hypokalemia. CONCLUSIONS Tolevamer, a novel polystyrene binder of C. difficile toxins A and B, effectively treats mild to moderate C. difficile diarrhea and merits further clinical development.
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Louie TJ. Treatment of First Recurrences of Clostridium difficile-Associated Disease: Waiting for New Treatment Options. Clin Infect Dis 2006; 42:765-7. [PMID: 16477550 DOI: 10.1086/501137] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2006] [Accepted: 01/04/2006] [Indexed: 11/03/2022] Open
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Louie TJ. How should we respond to the highly toxogenic NAP1/ribotype 027 strain of Clostridium difficile? CMAJ 2005; 173:1049-50. [PMID: 16247100 PMCID: PMC1266328 DOI: 10.1503/cmaj.051212] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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Laupland KB, Parkins MD, Church DL, Gregson DB, Louie TJ, Conly JM, Elsayed S, Pitout JDD. Population-based epidemiological study of infections caused by carbapenem-resistant Pseudomonas aeruginosa in the Calgary Health Region: importance of metallo-beta-lactamase (MBL)-producing strains. J Infect Dis 2005; 192:1606-12. [PMID: 16206075 DOI: 10.1086/444469] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2005] [Accepted: 05/13/2005] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND A study was conducted in the Calgary Health Region between May 2002 and April 2004 to define the population-based epidemiological characteristics of infections caused by imipenem-resistant Pseudomonas aeruginosa and to explore the clinical outcomes due to metallo- beta -lactamase (MBL)-producing and non-MBL-producing strains. METHODS Detailed clinical information was obtained by chart review, and phenotypic and molecular characterizations were performed using the MBL E-test, polymerase chain reaction with sequencing, and pulsed-field gel electrophoresis. RESULTS A total of 228 patients with infections caused by imipenem-resistant P. aeruginosa were identified (annual incidence, 10.5 cases/100,000 population), with the highest incidence rate in those >or=75 years old. MBL-producing strains (98/228) were associated with higher rates of multidrug resistance and bacteremia. Ninety MBL-producing strains also produced VIM-2, 4 produced IMP-7, and 4 were unclassified. A cluster of VIM-2-producing strains was responsible for a nosocomial outbreak during 2003. The case-fatality rate was significantly higher for infections caused by MBL-producing strains than for those caused by non-MBL-producing strains (25% vs. 13%; relative risk, 1.98 [95% confidence interval, 1.00-3.90]; P=.05). CONCLUSION MBL-producing P. aeruginosa strains were associated with a higher case-fatality rate and invasive disease. Our study highlights the potential importance of molecular laboratory techniques in infection control and patient care.
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Mah MW, Hagen NA, Pauling-Shepard K, Hawthorne JS, Mysak M, Lye T, Louie TJ. Understanding influenza vaccination attitudes at a Canadian cancer center. Am J Infect Control 2005. [PMID: 15877021 DOI: 10.1016/j.ajic.2004.12.006.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
BACKGROUND Although influenza vaccination benefits both health care workers and their patients, participation by staff in vaccination programs is disappointingly low. Understanding health care worker perceptions and needs is essential for improving rates of vaccination. METHODS A self-administered questionnaire was distributed to all staff at a Canadian cancer center. Information was sought on previous frequency of participation in influenza vaccination, as well as motivations, perceptions, and preferences. RESULTS Three hundred sixty-three (70%) of 515 cancer center staff members responded. Twenty-two percent of staff were vaccinated 4 or 5 times in the past 5 years and were primarily motivated by the desire to protect their own health (81%). Forty-nine percent participated 1 to 3 times in the past 5 years, and this group had diverse knowledge and vaccine-access needs. Twenty-nine percent received no vaccination in the previous 5 years because they believed the vaccine lacked efficacy (45%) or was harmful to health (19%). Moving from high to low levels of participation with influenza vaccination, the following trends were observed: increasing belief that vaccines cause illnesses or weaken the immune system, increasing belief that adverse effects of vaccination are underreported, and decreasing belief that vaccination programs are beneficial. CONCLUSIONS Cancer center staff perceptions about influenza vaccination differ according to the past frequency of vaccine uptake. Strategies for promoting vaccination should be guided by these differences.
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Mah MW, Hagen NA, Pauling-Shepard K, Hawthorne JS, Mysak M, Lye T, Louie TJ. Understanding influenza vaccination attitudes at a Canadian cancer center. Am J Infect Control 2005; 33:243-50. [PMID: 15877021 DOI: 10.1016/j.ajic.2004.12.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Although influenza vaccination benefits both health care workers and their patients, participation by staff in vaccination programs is disappointingly low. Understanding health care worker perceptions and needs is essential for improving rates of vaccination. METHODS A self-administered questionnaire was distributed to all staff at a Canadian cancer center. Information was sought on previous frequency of participation in influenza vaccination, as well as motivations, perceptions, and preferences. RESULTS Three hundred sixty-three (70%) of 515 cancer center staff members responded. Twenty-two percent of staff were vaccinated 4 or 5 times in the past 5 years and were primarily motivated by the desire to protect their own health (81%). Forty-nine percent participated 1 to 3 times in the past 5 years, and this group had diverse knowledge and vaccine-access needs. Twenty-nine percent received no vaccination in the previous 5 years because they believed the vaccine lacked efficacy (45%) or was harmful to health (19%). Moving from high to low levels of participation with influenza vaccination, the following trends were observed: increasing belief that vaccines cause illnesses or weaken the immune system, increasing belief that adverse effects of vaccination are underreported, and decreasing belief that vaccination programs are beneficial. CONCLUSIONS Cancer center staff perceptions about influenza vaccination differ according to the past frequency of vaccine uptake. Strategies for promoting vaccination should be guided by these differences.
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Louie TJ, Meddings J. Clostridium difficile infection in hospitals: risk factors and responses. CMAJ 2004; 171:45-6. [PMID: 15238495 PMCID: PMC437683 DOI: 10.1503/cmaj.1040966] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Laupland KB, Davies HD, Church DL, Louie TJ, Dool JS, Zygun DA, Doig CJ. Bloodstream infection-associated sepsis and septic shock in critically ill adults: a population-based study. Infection 2004; 32:59-64. [PMID: 15057568 DOI: 10.1007/s15010-004-3064-6] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2003] [Accepted: 11/19/2003] [Indexed: 11/25/2022]
Abstract
BACKGROUND Few studies have investigated the epidemiology of sepsis and septic shock in a large population and none have been from Canada. The objective of this study was to define the epidemiology of bloodstream infection (BSI)-associated sepsis and septic shock among all critically ill patients in a large, fully integrated health region in Canada. PATIENTS AND METHODS All critically ill adults admitted to multidisciplinary intensive care units (ICU) in the Calgary Health Region during May 1, 1999 to April 30, 2000 were included. Clinical, microbiologic and outcome information was obtained from regional databases. RESULTS We surveyed 1981 patients having at least one ICU admission. Systemic inflammatory response syndrome (SIRS) was diagnosed in 92%, BSI-associated sepsis (BSI with SIRS) in 6% and BSI-associated septic shock (BSI with SIRS and hypotension) in 3%; respective hospital mortality rates were 36%, 40% and 49%. The most common BSI etiologies were Staphylococcus aureus, Escherichia coli and Streptococcus species; only one isolate (1%) was highly antibiotic resistant. Independent risk factors for death among patients with SIRS included age (>or= 65), hypothermia (< 35 degrees C), and higher APACHE II and TISS scores. A surgical diagnosis was associated with decreased mortality risk. Neither a positive blood culture nor hypotension at presentation independently predicted death. CONCLUSION Knowledge of the epidemiology of these syndromes is important for assessing the burden of disease and providing background information for investigating new therapies.
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Laupland KB, Zygun DA, Davies HD, Church DL, Louie TJ, Doig CJ. Population-based assessment of intensive care unit-acquired bloodstream infections in adults: Incidence, risk factors, and associated mortality rate. Crit Care Med 2002; 30:2462-7. [PMID: 12441755 DOI: 10.1097/00003246-200211000-00010] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Nosocomial bloodstream infections have been extensively investigated, but relatively few studies have specifically evaluated the epidemiology of intensive care unit-acquired bloodstream infections. The study objective was to define the incidence, risk factors, microbiology, and clinical outcomes of intensive care unit-acquired bloodstream infections. DESIGN Population-based prospective cohort. SETTING Multidisciplinary intensive care units. PATIENTS All Calgary Health Region (population 930,000) adult patients admitted to multidisciplinary intensive care units (>/=48 hrs) from May 1, 1999, to April 30, 2000. INTERVENTIONS Blood sample analysis. MEASUREMENTS AND RESULTS There were 1,158 admission episodes in 1,017 patients; 37% involved females, and mean +/- sd age and Acute Physiology and Chronic Health Evaluation II scores were 59.6 +/- 18.7 yrs and 23.4 +/- 7.7, respectively. Fifty-one patients developed intensive care unit-acquired bloodstream infections (first positive blood culture >/=48 hrs after intensive care unit admission) for an incidence of 4.4% and an incidence density of 5.2 per 1000 intensive care unit days. Younger age (adjusted odds ratio, 0.98; 95% confidence interval, 0.96-1.00, p =.01), longer intensive care unit length of stay (adjusted odds ratio, 4.74; 95% CI, 3.26-6.90, p <.001), and lower hematocrit (adjusted odds ratio, 0.95; 95% confidence interval, 0.90-1.00, p =.04) were significant independent predictors of intensive care unit-acquired bloodstream infections, and these infections were associated with an increased intensive care unit length of stay of 2.86 days (95% confidence interval, 2.29-3.57, p <.001). Staphylococcus aureus (27%), coagulase-negative staphylococci (14%), and Enterococcus faecium (12%) were most commonly isolated. Four (8%) bloodstream infections involved antibiotic-resistant organisms, and ten (20%) were polymicrobial. In multivariate analysis, intensive care unit-acquired bloodstream infection was associated with an increased intensive care unit mortality rate (adjusted odds ratio, 2.03; 95% confidence interval, 1.03-4.00, p = 0.04) but not overall hospital mortality rate. CONCLUSIONS One patient in 20 admitted to Calgary Health Region intensive care units acquires bloodstream infection and suffers longer intensive care unit stay and increased mortality rates. In our region, multiple antibiotic-resistant organisms are uncommon causes of bloodstream infections, suggesting that it may be safe to use narrower spectrum empirical treatment regimens than current guidelines recommend.
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Laupland KB, Zygun DA, Davies HD, Church DL, Louie TJ, Doig CJ. Incidence and risk factors for acquiring nosocomial urinary tract infection in the critically ill. J Crit Care 2002; 17:50-7. [PMID: 12040549 DOI: 10.1053/jcrc.2002.33029] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE A urinary tract infection (UTI) is the most common hospital-acquired infection. However, the epidemiology of intensive care unit (ICU)-acquired UTIs is not well defined. The objective of this study was to describe the incidence, risk factors, and clinical outcomes of ICU-acquired UTIs. MATERIALS AND METHODS All patients admitted to adult multidisciplinary ICUs in the Calgary Health Region (CHR, population approximately 1 million) during May 1, 1999 to April 30, 2000 were studied using a cohort design. RESULTS A total of 1,158 admissions to a CHR ICU were 48 hours in duration or more. A total of 111 episodes of ICU-acquired UTI (defined as >10(5) CFU/mL of 1 or 2 organisms >48 hours after ICU admission) occurred in 105 (9%) patients and 5 (0.4%) had ICU-acquired bacteremic/fungemic UTIs for incidences of 11.3 and 0.5 UTIs per 1,000 ICU days, respectively. Significant independent risk factors for developing an ICU-acquired UTI as determined by a logistic regression model were female gender (adjusted odds ratio [OR(adj)], 2.31; 95% confidence interval [CI], 1.48-3.59) and natural logarithmic transformation of ICU length of stay (OR(adj), 3.96; 95% CI, 3.02-5.17). No differences in admitting vital signs, routine blood tests, APACHE II and TISS scores, or overall hospital mortality rate were observed among patients who developed an ICU-acquired UTI as compared with those who did not. The most common UTI etiologies were Enterococcus spp. (24%), Candida albicans (21%), and Escherichia coli (15%). Only 4 (3%) of the organisms were highly antibiotic resistant. CONCLUSIONS Nosocomial UTIs develop commonly in the critically ill and women and those with an extended ICU stay are at increased risk. Although ICU-acquired UTIs are markers of morbidity, they do not significantly increase mortality.
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Gibb AP, Tribuddharat C, Moore RA, Louie TJ, Krulicki W, Livermore DM, Palepou MFI, Woodford N. Nosocomial outbreak of carbapenem-resistant Pseudomonas aeruginosa with a new bla(IMP) allele, bla(IMP-7). Antimicrob Agents Chemother 2002; 46:255-8. [PMID: 11751148 PMCID: PMC126979 DOI: 10.1128/aac.46.1.255-258.2002] [Citation(s) in RCA: 108] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Pseudomonas aeruginosa isolates from an outbreak in Canada were highly resistant to carbapenems and ceftazidime but not piperacillin. They produced a novel integron-associated metallo-beta-lactamase, designated IMP-7, with 91% identity to IMP-1. bla(IMP-7) was not detected with standard bla(IMP)-specific primers, owing to mismatches in the forward primer.
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Winston DJ, Lazarus HM, Beveridge RA, Hathorn JW, Gucalp R, Ramphal R, Chow AW, Ho WG, Horn R, Feld R, Louie TJ, Territo MC, Blumer JL, Tack KJ. Randomized, double-blind, multicenter trial comparing clinafloxacin with imipenem as empirical monotherapy for febrile granulocytopenic patients. Clin Infect Dis 2001; 32:381-90. [PMID: 11170945 DOI: 10.1086/318500] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
In a double-blind, multicenter trial, 541 febrile granulocytopenic patients were randomized to receive either intravenous (iv) clinafloxacin (200 mg every 12 h) or i.v. imipenem (500 mg every 6 h) as empirical monotherapy. More baseline pathogens were susceptible to clinafloxacin (259 [99%] of 262 organisms) than to imipenem (253 [95%] of 265; P=.03). Initial favorable clinical response rates for clinafloxacin (88 [32%] of 272 patients) and imipenem (89 [33%] of 269) were similar. After addition of other antimicrobial agents, overall response rates were 259 (95%) of 272 for clinafloxacin and 251 (93%) of 269 for imipenem. During the study, only 13 clinafloxacin (5%) and 18 imipenem (7%) recipients died. Both drugs were generally well tolerated. Drug-related skin rash occurred more often with clinafloxacin (11% vs. 6%; P=.07), whereas nausea (2% vs. 5%; P=.16), Clostridium-difficile-associated diarrhea (3% vs. 8%; P=.02), and seizures (0% vs. 2%; P=.06) occurred more often with imipenem. These results suggest that clinafloxacin and imipenem have similar efficacy as empirical monotherapy in febrile granulocytopenic patients.
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Henderson EA, Louie TJ, Ramotar K, Ledgerwood D, Hope KM, Kennedy A. Comparison of higher-dose intradermal hepatitis B vaccination to standard intramuscular vaccination of healthcare workers. Infect Control Hosp Epidemiol 2000; 21:264-9. [PMID: 10782589 DOI: 10.1086/501756] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare the immunogenicity of hepatitis B vaccine administered via intradermal (ID) versus intramuscular (IM) route. METHODS Subjects chose either to specify the route of immunization or to undergo random allocation to vaccination by the ID (0.15 mL) or the IM (1.0 mL) route. Yeast-derived recombinant hepatitis B vaccine was given at 0, 30, and 180 days. Hepatitis B surface antibody (HBsAb) and hepatitis B core antibody (HBcAb) were measured by microparticle enzyme immunoassay. RESULTS 763 subjects were enrolled. Baseline screening identified 65 subjects (8%) who were positive for HBsAb or HBcAb. Vaccination was completed by 590 (85%) of 698 enrollees (370 ID, 220 IM). Seroconversion rates (geometric mean titers [GMT]>0 IU/mL HBsAb) for those vaccinated ID were 99% and 96% for screening at 9 months and 1 year post-vaccination, respectively; subjects vaccinated intramuscularly had similar rates of 95% and 96%. Seropositivity rates (GMT > or = 10 IU/mL HBsAb) showed a similar pattern, with 95%, 92%, and 73% at 9 months and 1 and 2 years, respectively, for those vaccinated ID, and 94%, 93%, and 81% for those having IM vaccination. GMT for HBsAb was significantly higher for individuals vaccinated IM than for those vaccinated ID (P<.0001). The GMT ratio for the IM and ID routes decreased over time, being 9.3 at 9 months, 7.8 at 1 year, and 5.9 at 2 years. An unanticipated side effect of intradermal vaccination was skin discoloration at injection sites, which persisted for at least 2 years postvaccination. Two thirds (112/166) of respondents reported that they would have selected the ID route despite the discoloration. CONCLUSIONS Higher-dose ID vaccination (3 vs 1 microg per injection) uses one sixth of the dose required for standard IM vaccination. It is a cost-effective way to vaccinate populations against hepatitis B virus, but the long-term efficacy of the ID route must still be investigated.
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Morck DW, Olson ME, Louie TJ, Koppe A, Quinn B. Comparison of ceftiofur sodium and oxytetracycline for treatment of acute interdigital phlegmon (foot rot) in feedlot cattle. J Am Vet Med Assoc 1998; 212:254-7. [PMID: 9448831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To determine whether ceftiofur sodium would be useful for treatment of acute interdigital phlegmon (foot rot) in cattle. DESIGN Randomized controlled trial. ANIMALS 308 cross-bred yearling steers with clinical signs of acute interdigital phlegmon (i.e., lameness with interdigital swelling, interdigital lesions, or both). PROCEDURE Steers were randomly assigned to 1 of 3 treatment groups: ceftiofur at a dosage of 0.1 mg/kg (0.045 mg/lb) of body weight, IM, every 24 hours; ceftiofur at a dosage of 1.0 mg/kg (0.45 mg/lb), IM, every 24 hours, and oxytetracycline at a dosage of 6.6 mg/kg (3 mg/lb), IM, every 24 hours. All animals were treated for 3 days; treatment was considered successful if animals were no longer lame on day 4. Biopsy specimens were collected prior to treatment from 5 animals in each group and submitted for anaerobic bacterial culture and histologic examination. RESULTS Success rates for the high-dosage ceftiofur (94/129; 73%) and oxytetracycline (87/128; 68%) groups were significantly higher than that for the low-dosage ceftiofur group (5/50; 10%), but there were no significant differences between the high-dosage ceftiofur and oxytetracycline groups. Anaerobic bacteria most frequently isolated from biopsy specimens were Porphyromonas levii and Provetella intermedia. CLINICAL IMPLICATIONS Use of ceftiofur at a dosage of 1.0 mg/kg for treatment of cattle with acute interdigital phlegmon was as effective as use of oxytetracycline at a dosage of 6.6 mg/kg. However, ceftiofur has a negligible withdrawal time and, therefore, may be a better choice for treatment of near-market weight animals.
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Bow EJ, Mandell LA, Louie TJ, Feld R, Palmer M, Zee B, Pater J. Quinolone-based antibacterial chemoprophylaxis in neutropenic patients: effect of augmented gram-positive activity on infectious morbidity. National Cancer Institute of Canada Clinical Trials Group. Ann Intern Med 1996; 125:183-90. [PMID: 8686975 DOI: 10.7326/0003-4819-125-3-199608010-00004] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE To determine whether augmented quinolone-based antibacterial prophylaxis in neutropenic patients with cancer reduces infections caused by gram-positive cocci and preserves the protective effect against aerobic gram-negative bacilli. DESIGN Open, randomized, controlled, multicenter clinical trial. SETTING Centers participating in the National Cancer Institute of Canada Clinical Trials Group. PATIENTS 111 eligible and evaluable patients hospitalized for severe neutropenia (neutrophil count < 0.5 x 10(9)/L lasting at least 14 days) who were receiving cytotoxic therapy for acute leukemia or bone marrow autografting. INTERVENTION One of three oral antibacterial prophylactic regimens (norfloxacin, 400 mg every 12 hours; ofloxacin, 400 mg every 12 hours; or ofloxacin, 400 mg, plus rifampin, 300 mg every 12 hours) beginning with cytotoxic therapy. MEASUREMENTS Incidence and cause of suspected or proven infection. RESULTS Microbiologically documented overall infection rates for norfloxacin, ofloxacin, and ofloxacin plus rifampin were 47%, 24%, and 9%, respectively (P < 0.001). Corresponding rates were 24%, 13%, and 3%, respectively for staphylococcal bacteremia (P = 0.03) and, 21%, 3%, and 3%, respectively for streptococcal bacteremia (P < 0.01). The pattern of bacteremia suggested that rifampin played a role in suppressing staphylococcal infection. Both ofloxacin alone and ofloxacin plus rifampin had a clinically significant antistreptococcal effect. Aerobic gram-negative rods were cleared from rectal surveillance cultures in all patients after a median of 5.5 days and caused infection in only one patient (0.9%). The reductions in the number of microbiologically documented infections among ofloxacin recipients and ofloxacin plus rifampin recipients were offset by concomitant increases in the number of unexplained fevers (24% of norfloxacin recipients, 53% of ofloxacin recipients, and 49% of ofloxacin plus rifampin recipients; P = 0.02). No statistically significant difference was found among the treatment arms with respect to the overall incidence of febrile neutropenic episodes as defined for this trial (79% for the norfloxacin group, 82% for the ofloxacin group, and 77% for the ofloxacin plus rifampin group). CONCLUSIONS Quinolone-based antibacterial chemoprophylaxis protected patients from aerobic gram-negative bacillary infections. Augmentation of the gram-positive activity reduced the incidence of gram-positive infections but did not influence the overall incidence of febrile neutropenic episodes.
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Hope KM, Henderson E, Ledgerwood D, Hume K, Louie TJ. Should infection control practitioners do follow-up of staff exposures to patient blood and body fluids? Am J Infect Control 1996; 24:57-66. [PMID: 8731027 DOI: 10.1016/s0196-6553(96)90000-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to determine the efficiency of a joint infection control/occupational health program for the follow-up of accidental blood or bloody body fluid exposures in health care workers. METHODS A comprehensive staff follow-up program for all blood exposures with known patient sources was initiated in 1989, consisting of patient follow-up by the Infection Control Department (risk assessment for hepatitis B virus [HBV] and [HIV] infection and obtaining of consent for HIV testing) and staff follow-up by the Occupational Health Department. In 1992 a mailed survey was conducted to examine exposure follow-up policies and responsibilities in large teaching hospitals across Canada. RESULTS A total of 924 blood exposures with known patient sources were reported between January 1989 and December 1993. HIV and HBV screening was obtained for 67.9% and 87.6% of patients assessed as at low risk and 82.3% and 92.2% of those assessed as at high risk for infection, respectively. Two previously unknown HIV-seropositive patients were identified, one of whom had been classified as at low risk (one of 530 [0.19%] patients at low risk who underwent screening). Primary reasons for screening being missed were patient discharge (46.3%) or communication problems (18.0%). The requirement for informed written consent before HIV screening accounted for the difference in completed HIV and HBV screens. Results of the hospital survey indicated that 40.8% of Canadian hospitals follow up all patients who are involved in blood exposures; however, most hospitals still rely on the physician to obtain consent (87.6%). CONCLUSIONS Use of ICPs to screen patients involved in staff blood exposures during regular hours may be the most efficient method of follow-up, particularly if supplemented by a backup team of health professionals on nights and weekends. Although screening all patients for HBV/HIV may detect patients with undisclosed high-risk behaviors, institutions must decide whether the practice is cost-effective in areas of low prevalence.
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Ramotar K, Henderson E, Szumski R, Louie TJ. Impact of free verotoxin testing on epidemiology of diarrhea caused by verotoxin-producing Escherichia coli. J Clin Microbiol 1995; 33:1114-20. [PMID: 7615714 PMCID: PMC228115 DOI: 10.1128/jcm.33.5.1114-1120.1995] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
During a 10-week period in the summer of 1990, an epidemiologic investigation of the prevalence of verotoxin (VT)-producing Escherichia coli infection was conducted in Calgary, Alberta, Canada. Consecutive stool specimens (n = 3,577) were cultured for E. coli O157:H7, and fecal filtrates were tested for free VTs (FVTs). E. coli O157:H7 was recovered from 22 specimens (0.6%), but VT was detected in 74 specimens (2.1%). Sixty-nine stool specimens positive for FVTs or E. coli O157:H7 were probed for VT genes by colony blot hybridization; 22 of 38 VT gene probe-positive isolates were non-O157:H7 E. coli organisms. Fourteen of 22 strains could not be induced to produce VT in vitro, despite the presence of FVTs in the stool sample, positivity on colony blot hybridization, positive PCR probes with the primers described by Pollard et al. (D. R. Pollard, W. M. Johnson, H. Lior, S. D. Tyler, and K. R. Rozee, J. Clin. Microbiol. 28:540-545, 1990) or Gannon et al. (V. P. Gannon, R. K. King, J. Y. Kim, and E. J. Golsteyn-Thomas, Appl. Environ. Microbiol. 58:3809-3815, 1992) (but not those described by Karch and Meyer [H. Karch and T. Meyer, J. Clin. Microbiol. 27:2751-2757, 1989]), and positive Southern blot analysis of isolates in 10 of 14 strains. The patient survey questionnaire showed that E. coli O157:H7 infection was associated with bloody diarrhea of short duration, whereas infection with other serotypes or persistence of FVT only was associated with longer-duration nonbloody diarrheal illness. We conclude that (i) detection of FVT in stools enhances the diagnosis of VT infection threefold over cultures for E. coli O157:H7, (ii) cultures for E.coli O157:H7 detect the majority of organisms of that serotype, (iii) the spectrum of disease produced by organisms of non-O157:H7 serotypes may include less severe but more protracted illness, and (iv) differences in the in vivo and in vitro expression of toxin and results of genetic probe studies highlight the need to examine control mechanisms of toxin production.
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Laing FP, Ramotar K, Read RR, Alfieri N, Kureishi A, Henderson EA, Louie TJ. Molecular epidemiology of Xanthomonas maltophilia colonization and infection in the hospital environment. J Clin Microbiol 1995; 33:513-8. [PMID: 7751349 PMCID: PMC227982 DOI: 10.1128/jcm.33.3.513-518.1995] [Citation(s) in RCA: 75] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Between April 1992 and December 1993, 80 Xanthomonas maltophilia isolates were collected from 63 patients in three acute-care hospitals in Calgary, Alberta, Canada. On the basis of Centers for Disease Control and Prevention definitions, 48 patients had nosocomial and 15 had community-acquired X. maltophilia. Thirty-eight of the patients were colonized and 25 were infected. Sixty-four percent of patients who acquired X. maltophilia in the intensive care unit (ICU) became infected, whereas 32% of patients in a non-ICU setting became infected. ICU patients tended to be hospitalized for a shorter period of time than non-ICU patients before the onset of X. maltophilia infection. Regardless of being colonized or infected, all patients had debilitating conditions, with respiratory disease being the most common underlying illness (35%). Forty-two patients (88%) with hospital-acquired X. maltophilia received prior antibiotic therapy which included gentamicin, tobramycin, ceftazidime, piperacillin, and imipenem. Agar dilution MICs showed that patient isolates were resistant to these antimicrobial agents that patients had received. Pulsed-field gel electrophoresis of SpeI-digested genomic DNA revealed that six epidemiologically linked patient isolates from the ICU of one acute-care hospital had identical DNA profiles. In contrast, isolates from patients from the other two hospitals had unique genotype profiles (n = 57) regardless of the presence or absence of an epidemiologic association. In these patients there was genetic evidence against the acquisition of a resident hospital clone. These results indicate that pulsed-field gel electrophoresis can resolve genotypically distinct strains of X. maltophilia and, consequently, is a useful tool for evaluating nosocomial infections caused by X. maltophilia.
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Ramotar K, Waldhart B, Church D, Szumski R, Louie TJ. Direct detection of verotoxin-producing Escherichia coli in stool samples by PCR. J Clin Microbiol 1995; 33:519-24. [PMID: 7751350 PMCID: PMC227983 DOI: 10.1128/jcm.33.3.519-524.1995] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
A method for the rapid detection of verotoxin-producing Escherichia coli in stool samples by PCR was evaluated. Verotoxin-1 and verotoxin-2 genes in DNA extracted directly from stool samples were amplified with oligonucleotide primers. Stools spiked with control organisms, E. coli C600 (H19B) (verotoxin-1) or E. coli C600 (933W) (verotoxin-2), demonstrated that verotoxin-1-containing organisms could be detected at 10(2) CFU per 0.1 g of stool and verotoxin-2-containing organisms could be detected at 10(7) CFU per 0.1 g of stool. Testing of stool samples from patients with diarrhea showed a high concordance between PCR positivity and the presence of verotoxin-producing E. coli, determined by isolation of serotype O157:H7 on sorbitol-MacConkey medium (34 of 35 stool samples) or by colony blots with gene probes (19 of 21 stool samples). Conversely, only 1 of 20 (5.0%) stool samples that were O157:H7 culture negative and colony blot negative and that contained free verotoxin only was positive by PCR. As well, only 4 of 145 (2.8%) stool samples that were negative for serotype O157:H7 or free verotoxin were PCR positive. PCR of DNA extracted directly from stool samples provides a rapid method for the detection of stool samples containing verotoxin-producing E. coli compared with colony blot testing.
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Nicolle LE, Louie TJ, Dubois J, Martel A, Harding GK, Sinave CP. Treatment of complicated urinary tract infections with lomefloxacin compared with that with trimethoprim-sulfamethoxazole. Antimicrob Agents Chemother 1994; 38:1368-73. [PMID: 8092839 PMCID: PMC188212 DOI: 10.1128/aac.38.6.1368] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
The efficacy of lomefloxacin given at 400 mg once daily for 14 days compared with that of trimethoprim-sulfamethoxazole at 160 and 800 mg, respectively, given twice daily for 14 days in the treatment of symptomatic complicated urinary tract infections was studied in a prospective, randomized, single-blind multicenter study. A total of 133 subjects presenting with signs and symptoms of urinary tract infection and an underlying abnormality consistent with complicated urinary tract infection were enrolled in the study. Bacteriologic cure was significantly better in 68 subjects randomized to lomefloxacin than in 65 subjects randomized to trimethoprim-sulfamethoxazole at short-term follow-up (88 versus 52%; 95% confidence intervals [CIs] 77 and 94% and 39 and 65%, respectively) this difference was no longer significant at long-term follow-up (64 versus 47%; CIs, 52 and 75% and 32 and 57%, respectively). Clinical outcomes were similar for both therapeutic regimens at short- and long-term follow-ups. The organisms that infected the subjects pretherapy were more frequently resistant to trimethoprim-sulfamethoxazole, and drug therapy was discontinued more frequently in subjects treated with trimethoprim-sulfamethoxazole because of adverse antimicrobial effects. In secondary analyses, outcomes did not differ with age or underlying genitourinary abnormality.(ABSTRACT TRUNCATED AT 250 WORDS)
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Morhart M, Rennie R, Ziola B, Bow E, Louie TJ. Evaluation of enzyme immunoassay for Candida cytoplasmic antigens in neutropenic cancer patients. J Clin Microbiol 1994; 32:766-76. [PMID: 8195392 PMCID: PMC263122 DOI: 10.1128/jcm.32.3.766-776.1994] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
A Candida albicans cytoplasmic antigen enzyme immunoassay (CACP antigen EIA) was developed with antibodies raised against antigens prepared from yeast cells grown under standardized growth conditions. The C. albicans components reactive in the EIA were shown to be predominantly proteins with associated carbohydrates. Denaturing gel electrophoresis revealed the presence of five major CACP proteins with molecular weights between 36,000 and 44,000. The clinical usefulness of the CACP EIA was evaluated by retrospective blinded measurement of 89 serum samples from 31 granulocytopenic patient episodes. Twice-weekly surveillance cultures, sequential serum samples (approximately once per week or with change of the clinical course), and standard diagnostic criteria of fungal infection were used to categorize patients. The sensitivity and specificity of the CACP assay on the basis of serum samples were 82 and 100%, respectively (67 and 100% on the basis of patient episodes). The positive and negative predictive values were 100 and 97% for serum (100 and 93% for patient episodes). By comparison, the CANDTEC assay had low sensitivity (33%) and poor positive predictive values (50%). The CACP EIA may be a useful test suitable for further evaluations as a method for the diagnosis of invasive Candida infection in neutropenic cancer patients.
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