Clostridium difficile in the ICU: study of the incidence, recurrence, clinical characteristics and complications in a university hospital

OBJECTIVE

Although several studies have established the association between antibiotics and Clostridium difficile infection (CDI), there is a lack of epidemiological studies on the incidence of CDI in European Intensive Care Units outside the context of infection outbreaks. The present study describes the incidence, patient characteristics, complications, and recurrence rates of CDI in a Spanish ICU.

DESIGN

A retrospective study was carried out.

SETTING

A clinical-surgical ICU with 34 beds, a tertiary referral hospital with 1400 beds.

PATIENTS

All patients over 18 years of age admitted to the ICU from January 2010 to December 2011 with diarrhea for more than 48 h.

INTERVENTIONS

None.

STUDY VARIABLES

Underlying diseases, risk factors, fever, leukocyte count, complications, recurrence of infection.

RESULTS

A total of 1936 adult patients were admitted. Seven patients acquired CDI (0.36%), representing an infection rate of 3.1 per 10,000 bed-days and a cumulative incidence rate of 3.6 in two years. The mean age was 61 years. Six patients showed some degree of immunosuppression. The mean APACHE II score at ICU admission was 17 (IQR 13-24). Severe sepsis was reported in 5 cases of CDI, three of which presented shock and multiorgan dysfunction. Four patients presented recurrence of CDI during hospitalization. ICU admission was prolonged for a mean of 24 days (SD 17.8) after diagnosis.

CONCLUSIONS

Less than 1% of the patients admitted to a clinical-surgical ICU in a large teaching institution in Spain developed CDI. However, a high risk of recurrence/complications was associated with prolonged ICU stay.

Cloning, expression and decoding of the cold adaptation of a new widely represented thermolabile subtilisin-like protease

AIMS

Cloning, expression and characterization of a new cold-adapted protease with potential biotechnological application, isolated from Antarctic bacteria.

METHOD AND RESULTS

A subtilisin-like gene was isolated from several Antarctic bacterial genus using CODPEHOP-designed primers and a genome walking method. This gene encodes a precursor protein, which undergoes an autocatalytic cleavage resulting in a 34.6 kDa active cold-adapted protease with a maximum activity at 25-35°C and optimum pH of 8.0-9.0. It showed a higher catalytic efficiency at lower temperatures compared to its mesophilic counterpart. Heat-induced inactivation resulted in a very low melting point. Local packing analysis using the homology model indicated Ala284 as an important cold-adaptation determinant, which was corroborated by the site-directed mutagenesis.

CONCLUSIONS

A new thermolabile subtilisin-like protease has been successfully cloned and analysed, and an important hot spot in the evolution of the cold adaptation and substrate specificity of this enzyme was identified and tested.

SIGNIFICANCE AND IMPACT OF THE STUDY

This work reports a new cold-adapted protease with a vast representation amongst Antarctic genus, suggesting therefore its evolutionary success in this cold environment. Likewise, important sites for genetic potentiation have been identified, which are extrapolated to other enzymes of the same kind.

ASEAN benchmarking in terms of science, technology, and innovation from 1999 to 2009

This article provides an empirical assessment of the performance of the member states of the Association of Southeast Asian Nations in terms of science, technology, and innovation. This study is relevant because it employs a larger data set, examines more countries, and covers more years than previous studies. The results indicate that these countries had differing patterns of performance, and the pattern of growth among them was asymmetrical. Additional findings suggest that these countries performed idiosyncratically with respect to the six quantitative dimensions we examined. Our research includes a form of comparative policy evaluation that might assist the monitoring of the implementation of “Vision 2020”. The results simplify how we determine the relative strengths and weaknesses of national innovation systems and are relevant to policy discussions. In relation to transferability, the findings demonstrate similarities to the European Union with regard to performance and governance.

Intravascular ultrasound and drug-eluting stents. Where are we now?

Drug-eluting stents (DES) have revolutionized interventional cardiology. The profound ability of DES to suppress neointimal hyperplasia results in a reduced need for revascularization and improved clinical outcomes. DES, however, are not immune to in-stent restenosis. This problem particularly affects DES implanted for "off-label" indications and in challenging clinical and anatomic scenarios. In addition, as compared to bare-metal stents, DES do not reduce the incidence of stent thrombosis. Therefore, optimization of DES deployment is becoming increasingly important and, in this regard, intravascular ultrasound (IVUS) provides unique insights. IVUS assessment of neointimal growth has been of major value to understand the mechanisms of action of DES and also to compare different DES. Notably, IVUS enables optimization of DES implantation. DES underexpansion, edge-restenosis, residual dissections, plaque prolapse, stent fracture, incomplete stent apposition and DES-related aneurysms, are readily assessed by IVUS. The use of IVUS to study and manage DES failures (namely in-stent restenosis and DES thrombosis) is of major value. In conclusion, IVUS provides unique insights during DES implantation, allows DES optimization and should always be used during the management of DES failures: in-stent restenosis and DES thrombosis.

Central venous access devices for paediatric patients with haemophilia: a single-institution experience

Use of a central venous access device (CVAD) can facilitate early introduction of home-based infusion of factor concentrate for long-term prophylaxis or immune tolerance therapy in children with bleeding disorders. The aim was to review outcomes associated with use of CVAD. Retrospective review of paediatric patients with bleeding disorders was observed at the Mayo Clinic Comprehensive Hemophilia Center. Thirty-seven CVAD were placed in 18 patients (haemophilia A [n = 15], type 3 von Willebrand disease [n = 2] and haemophilia B [n = 1]). Follow-up was for 45 952 CVAD days, and median time that CVAD remained in place was 1361 days per device. Factor VIII (FVIII) inhibitors were present in 4 of the 15 patients. Ten CVAD-related infections occurred (median, 672 days; range, 72-1941 days), of which six were in one patient with FVIII inhibitors. Overall infection rate was 0.22 (95% confidence interval [CI], 0.10-0.40) per 1000 CVAD days, with 0.11 infections in patients without FVIII inhibitors compared with a pooled incidence of 0.66 (95% CI, 0.44-0.97) reported in the literature. Indications for removal of 27 CVAD were blockage, change to peripheral venous access, catheter displacement, infection, leak in the port septum, short catheter and skin erosion. No clinically apparent thrombosis or sequelae of thrombosis were observed. Infection is the most common complication associated with CVAD use and is increased in patients who have inhibitors. The low rate of clinically apparent thrombosis reflects our practice of not screening for thrombosis. The low infection rate reflects our practice of using and reinforcing the aseptic technique.