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Haran JP, Ward DV, Bhattarai SK, Loew E, Dutta P, Higgins A, McCormick BA, Bucci V. The high prevalence of Clostridioides difficile among nursing home elders associates with a dysbiotic microbiome. Gut Microbes 2022; 13:1-15. [PMID: 33764826 PMCID: PMC8007149 DOI: 10.1080/19490976.2021.1897209] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Clostridioides difficile disproportionally affects the elderly living in nursing homes (NHs). Our objective was to explore the prevalence of C. difficile in NH elders, over time and to determine whether the microbiome or other clinical factors are associated with C. difficile colonization.We collected serial stool samples from NH residents. C. difficile prevalence was determined by quantitative polymerase-chain reaction detection of Toxin genes tcdA and tcdB; microbiome composition was determined by shotgun metagenomic sequencing. We used mixed-effect random forest modeling machine to determine bacterial taxa whose abundance is associated with C. difficile prevalence while controlling for clinical covariates including demographics, medications, and past medical history.We enrolled 167 NH elders who contributed 506 stool samples. Of the 123 elders providing multiple samples, 30 (24.4%) elders yielded multiple samples in which C. difficile was detected and 78 (46.7%) had at least one C. difficile positive sample. Elders with C. difficile positive samples were characterized by increased abundances of pathogenic or inflammatory-associated bacterial taxa and by lower abundances of taxa with anti-inflammatory or symbiotic properties. Proton pump inhibitor (PPI) use is associated with lower prevalence of C. difficile (Odds Ratio 0.46; 95%CI, 0.22-0.99) and the abundance of bacterial species with known beneficial effects was higher in PPI users and markedly lower in elders with high C. difficile prevalence.C. difficile is prevalent among NH elders and a dysbiotic gut microbiome associates with C. difficile colonization status. Manipulating the gut microbiome may prove to be a key strategy in the reduction of C. difficile in the NH.
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Affiliation(s)
- John P. Haran
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, USA,Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA,Program in Microbiome Dynamics, University of Massachusetts Medical School, Worcester, MA, USA,CONTACT John P. Haran Department of Emergency Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA01655
| | - Doyle V. Ward
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA,Program in Microbiome Dynamics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Shakti K. Bhattarai
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA,Program in Microbiome Dynamics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Ethan Loew
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA,Program in Microbiome Dynamics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Protiva Dutta
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Amanda Higgins
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Beth A. McCormick
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA,Program in Microbiome Dynamics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Vanni Bucci
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA,Program in Microbiome Dynamics, University of Massachusetts Medical School, Worcester, MA, USA
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Doll M, Marra AR, Apisarnthanarak A, Al-Maani AS, Abbas S, Rosenthal VD. Prevention of Clostridioides difficile in hospitals: A position paper of the International Society for Infectious Diseases. Int J Infect Dis 2020; 102:188-195. [PMID: 33122100 DOI: 10.1016/j.ijid.2020.10.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 10/19/2020] [Accepted: 10/20/2020] [Indexed: 02/07/2023] Open
Abstract
Clostridioides difficile infection is an increasing presence worldwide. Prevention is multipronged, reflecting a complex and evolving epidemiology. Multiple guidelines exist regarding the prevention of C. difficile infection in healthcare settings; however, existing guidelines do not address C. difficile in low- and middle-income countries (LMIC). Nevertheless, the prevalence of C. difficile in LMIC likely parallels, if not exceeds, that of high-income countries, and LMIC may experience additional challenges in C. difficile diagnosis and control. A panel of experts was convened by the International Society for Infectious Diseases (ISID) to review the current state of C. difficile infections globally and make evidence-based recommendations for infection prevention that are broadly applicable.
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Affiliation(s)
- Michelle Doll
- Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Alexandre R Marra
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA; Division of Medical Practice, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Anucha Apisarnthanarak
- Division of Infectious Diseases, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Amal Saif Al-Maani
- Department of Infection Control and Prevention, Ministry of Health, Muscat, Oman
| | - Salma Abbas
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Victor D Rosenthal
- International Nosocomial Infection Control Consortium (INICC), Buenos Aires, Argentina
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Chasing the rate: An interrupted time series analysis of interventions targeting reported hospital onset Clostridioides difficile, 2013-2018. Infect Control Hosp Epidemiol 2020; 41:1142-1147. [PMID: 32493530 DOI: 10.1017/ice.2020.247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess the impact of major interventions targeting infection control and diagnostic stewardship in efforts to decrease Clostridioides difficile hospital onset rates over a 6-year period. DESIGN Interrupted time series. SETTING The study was conducted in an 865-bed academic medical center. METHODS Monthly hospital-onset C. difficile infection (HO-CDI) rates from January 2013 through January 2019 were analyzed around 5 major interventions: (1) a 2-step cleaning process in which an initial quaternary ammonium product was followed with 10% bleach for daily and terminal cleaning of rooms of patients who have tested positive for C. difficile (February 2014), (2) UV-C device for all terminal cleaning of rooms of C. difficile patients (August 2015), (3) "contact plus" isolation precautions (June 2016), (4) sporicidal peroxyacetic acid and hydrogen peroxide cleaning in all patient areas (June 2017), (5) electronic medical record (EMR) decision support tool to facilitate appropriate C. difficile test ordering (March 2018). RESULTS Environmental cleaning interventions and enhanced "contact plus" isolation did not impact HO-CDI rates. Diagnostic stewardship via EMR decision support decreased the HO-CDI rate by 6.7 per 10,000 patient days (P = .0079). When adjusting rates for test volume, the EMR decision support significance was reduced to a difference of 5.1 case reductions per 10,000 patient days (P = .0470). CONCLUSION Multiple aggressively implemented infection control interventions targeting CDI demonstrated a disappointing impact on endemic CDI rates over 6 years. This study adds to existing data that outside of an outbreak situation, traditional infection control guidance for CDI prevention has little impact on endemic rates.
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Miller AC, Segre AM, Pemmeraju SV, Sewell DK, Polgreen PM. Association of Household Exposure to Primary Clostridioides difficile Infection With Secondary Infection in Family Members. JAMA Netw Open 2020; 3:e208925. [PMID: 32589232 PMCID: PMC7320299 DOI: 10.1001/jamanetworkopen.2020.8925] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 03/14/2020] [Indexed: 12/14/2022] Open
Abstract
Importance Clostridioides difficile infection (CDI) is a common hospital-acquired infection. Whether family members are more likely to experience a CDI following CDI in another separate family member remains to be studied. Objective To determine the incidence of potential family transmission of CDI. Design, Setting, and Participants In this case-control study comparing the incidence of CDI among individuals with prior exposure to a family member with CDI to those without prior family exposure, individuals were binned into monthly enrollment strata based on exposure status (eg, family exposure) and confounding factors (eg, age, prior antibiotic use). Data were derived from population-based, longitudinal commercial insurance claims from the Truven Marketscan Commercial Claims and Encounters and Medicare Supplemental databases from 2001 to 2017. Households with at least 2 family members continuously enrolled for at least 1 month were eligible. CDI incidence was computed within each stratum. A regression model was used to compare incidence of CDI while controlling for possible confounding characteristics. Exposures Index CDI cases were identified using inpatient and outpatient diagnosis codes. Exposure risks 60 days prior to infection included CDI diagnosed in another family member, prior hospitalization, and antibiotic use. Main Outcomes and Measures The primary outcome was the incidence of CDI in a given monthly enrollment stratum. Separate analyses were considered for CDI diagnosed in outpatient or hospital settings. Results A total of 224 818 cases of CDI, representing 194 424 enrollees (55.9% female; mean [SD] age, 52.8 [22.2] years) occurred in families with at least 2 enrollees. Of these, 1074 CDI events (4.8%) occurred following CDI diagnosis in a separate family member. Prior family exposure was significantly associated with increased incidence of CDI, with an incidence rate ratio (IRR) of 12.47 (95% CI, 8.86-16.97); this prior family exposure represented the factor with the second highest IRR behind hospital exposure (IRR, 16.18 [95% CI, 15.31-17.10]). For community-onset CDI cases without prior hospitalization, the IRR for family exposure was 21.74 (95% CI, 15.12-30.01). Age (IRR, 9.90 [95% CI, 8.92-10.98] for ages ≥65 years compared with ages 0-17 years), antibiotic use (IRR, 3.73 [95% CI, 3.41-4.08] for low-risk and 14.26 [95% CI, 13.27-15.31] for high-risk antibiotics compared with no antibiotics), and female sex (IRR, 1.44 [95% CI, 1.36-1.53]) were also positively associated with incidence. Conclusions and Relevance This study found that individuals with family exposure may be at significantly greater risk for acquiring CDI, which highlights the importance of the shared environment in the transmission and acquisition of C difficile.
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Affiliation(s)
| | | | | | | | - Philip M. Polgreen
- Department of Epidemiology, University of Iowa, Iowa City
- Department of Internal Medicine, University of Iowa, Iowa City
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Bearman G, Doll M, Cooper K, Stevens MP. Hospital Infection Prevention: How Much Can We Prevent and How Hard Should We Try? Curr Infect Dis Rep 2019; 21:2. [PMID: 30710181 DOI: 10.1007/s11908-019-0660-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW To summarize the extent to which hospital-acquired infections (HAIs) are preventable and to assess expectations, challenges, and barriers to improve patient outcomes. RECENT FINDINGS HAIs cause significant morbidity and mortality. Getting to zero HAIs is a commonly stated goal yet leads to unrealistic expectations. The extent to which all HAIs can be prevented remains debatable and is subject to multiple considerations and barriers. Current infection prevention science is inexact and evolving. Evidence-based infection prevention practices are often incompletely implemented and at times controversial. Highly sensitive surveillance results in overdiagnosis, calling into question the real incidence of HAIs. Perceived reductions in HAIs by gaming the system lead to false conclusions about preventability and may cause harm. Successful HAI reduction programs require executive oversight yet keeping hospital leaders engaged in infection prevention is a challenge given competing priorities. Medicine is not a physical science with precisely defined laws; thus, infection prevention interventions are subject to variable outcomes. Perhaps up to 55-70% of HAIs are potentially preventable. This is subject to a law of diminishing returns as the preventable proportion of HAIs may reduce over time with improvements in patient safety. As the principle tenet of medicine is first do no harm, infection prevention programs should relentlessly pursue reliable, sustainable, and practical strategies for heightened patient safety.
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Affiliation(s)
- Gonzalo Bearman
- Virginia Commowealth University Hospital Infection Prevention Program, North Hospital, 2nd Floor, Room 2-073, 1300 East Marshall Street, Richmond, VA, 23298-0019, USA.
| | - Michelle Doll
- Virginia Commowealth University Hospital Infection Prevention Program, North Hospital, 2nd Floor, Room 2-073, 1300 East Marshall Street, Richmond, VA, 23298-0019, USA
| | - Kaila Cooper
- Virginia Commowealth University Hospital Infection Prevention Program, North Hospital, 2nd Floor, Room 2-073, 1300 East Marshall Street, Richmond, VA, 23298-0019, USA
| | - Michael P Stevens
- Virginia Commowealth University Hospital Infection Prevention Program, North Hospital, 2nd Floor, Room 2-073, 1300 East Marshall Street, Richmond, VA, 23298-0019, USA
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Yan D, Chen Y, Lv T, Huang Y, Yang J, Li Y, Huang J, Li L. Clostridium difficile colonization and infection in patients with hepatic cirrhosis. J Med Microbiol 2017; 66:1483-1488. [PMID: 28945189 DOI: 10.1099/jmm.0.000596] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Dong Yan
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China
| | - Yunbo Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China
| | - Tao Lv
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China
| | - Yandi Huang
- Department of Laboratory Medicine, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China
| | - Jiezuan Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China
| | - Yongtao Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China
| | - Jianrong Huang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China
| | - Lanjuan Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China
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Evaluation of Correlation between Pretest Probability for Clostridium difficile Infection and Clostridium difficile Enzyme Immunoassay Results. J Clin Microbiol 2016; 55:596-605. [PMID: 27927930 DOI: 10.1128/jcm.02126-16] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 12/03/2016] [Indexed: 12/18/2022] Open
Abstract
The objective of this study was to evaluate the clinical characteristics and outcomes of hospitalized patients tested for Clostridium difficile and determine the correlation between pretest probability for C. difficile infection (CDI) and assay results. Patients with testing ordered for C. difficile were enrolled and assigned a high, medium, or low pretest probability of CDI based on clinical evaluation, laboratory, and imaging results. Stool was tested for C. difficile by toxin enzyme immunoassay (EIA) and toxigenic culture (TC). Chi-square analyses and the log rank test were utilized. Among the 111 patients enrolled, stool samples from nine were TC positive and four were EIA positive. Sixty-one (55%) patients had clinically significant diarrhea, 19 (17%) patients did not, and clinically significant diarrhea could not be determined for 31 (28%) patients. Seventy-two (65%) patients were assessed as having a low pretest probability of having CDI, 34 (31%) as having a medium probability, and 5 (5%) as having a high probability. None of the patients with low pretest probabilities had a positive EIA, but four were TC positive. None of the seven patients with a positive TC but a negative index EIA developed CDI within 30 days after the index test or died within 90 days after the index toxin EIA date. Pretest probability for CDI should be considered prior to ordering C. difficile testing and must be taken into account when interpreting test results. CDI is a clinical diagnosis supported by laboratory data, and the detection of toxigenic C. difficile in stool does not necessarily confirm the diagnosis of CDI.
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Rajabally N, Kullin B, Ebrahim K, Brock T, Weintraub A, Whitelaw A, Bamford C, Watermeyer G, Thomson S, Abratt V, Reid S. A comparison of Clostridium difficile diagnostic methods for identification of local strains in a South African centre. J Med Microbiol 2016; 65:320-327. [PMID: 26860329 DOI: 10.1099/jmm.0.000231] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Accurate diagnosis of Clostridium difficile infection is essential for disease management. A clinical and molecular analysis of C. difficile isolated from symptomatic patients at Groote Schuur Hospital, South Africa, was conducted to establish the most suitable clinical test for the diagnosis and characterization of locally prevalent strains. C. difficile was detected in stool samples using enzyme-based immunoassays (EIA) and nucleic acid amplification methods, and their performance was compared with that of C. difficile isolation using direct selective culture combined with specific PCR to detect the C. difficile tpi gene, toxin A and B genes and binary toxin genes. Toxigenic isolates were characterized further by ribotyping. Selective culture isolated 32 C. difficile strains from 145 patients (22 %). Of these, the most prevalent (50 %) were of ribotype 017 (toxin A- B+) while 15.6 % were ribotype 001 (toxin A+B+). No ribotype 027 strains or binary toxin genes (cdtA and cdtB) were detected. The test sensitivities and specificities, respectively, of four commercial clinical diagnostic methods were as follows: ImmunoCard Toxins A & B (40 % and 99.1 %), VIDAS C. difficile Toxin A & B (50 % and 99.1 %), GenoType CDiff (86.7 % and 88.3 %) and Xpert C. difficile (90 % and 97.3 %). Ribotype 001 and 017 strains had a 100 % detection rate by Xpert C. difficile, 100 % and 93.3 % by GenoType CDiff, 75 % and 53.3 % by ImmunoCard and 75 % and 60 % by VIDAS, respectively. The overall poor performance of EIA suggests that a change to PCR-based testing would assist diagnosis and ensure reliable detection of locally prevalent C. difficile 017 strains.
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Affiliation(s)
- Naayil Rajabally
- Department of Medicine, Division of Gastroenterology, University of Cape Town, Cape Town, South Africa
| | - Brian Kullin
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Kaleemuddeen Ebrahim
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
| | - Tunehafo Brock
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Andrej Weintraub
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, 14186 Stockholm, Sweden
| | - Andrew Whitelaw
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa.,Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Colleen Bamford
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa.,Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Gillian Watermeyer
- Department of Medicine, Division of Gastroenterology, University of Cape Town, Cape Town, South Africa
| | - Sandie Thomson
- Department of Medicine, Division of Gastroenterology, University of Cape Town, Cape Town, South Africa
| | - Valerie Abratt
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Sharon Reid
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
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Thabit AK, Housman ST, Burnham CD, Nicolau DP. Association of healthcare exposure with acquisition of different Clostridium difficile strain types in patients with recurrent infection or colonization after clinical resolution of initial infection. J Hosp Infect 2015; 92:167-72. [PMID: 26792686 DOI: 10.1016/j.jhin.2015.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 11/08/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Following the resolution of an episode of Clostridium difficile infection (CDI), the factors associated with acquisition of different C. difficile strain types in patients with recurrent infection or persistent colonization have not been evaluated. AIM To explore factors with potential correlation with acquisition of different C. difficile strain types in patients clinically cured of CDI through long-term follow-up across the continuum of care. METHODS Polymerase chain reaction ribotyping was performed on C. difficile isolates recovered at baseline and follow-up (days 19-38) from stool samples of patients successfully treated for CDI, and those who had recurrence and/or colonization following symptom resolution. Chart review was conducted to determine factors associated with acquisition of a different C. difficile ribotype. FINDINGS Of 25 patients initially cured of CDI, five had a recurrence and eight were colonized at follow-up. Patients did not differ with regard to age, sex, and whether the initial infection was with the BI/NAP1/027 strain. Ribotyping revealed that two out of five patients had recurrence attributed to a different strain type. Three of the colonized patients demonstrated strain switching compared with five patients who carried the same baseline strain. All patients (both infected and colonized) with different C. difficile ribotypes were exposed to the healthcare system. Exposure to antibiotics and proton pump inhibitors were not related to strain switching. CONCLUSION Exposure to healthcare, but not to antibiotics or proton pump inhibitors, was consistently associated with recurrence or colonization with a different C. difficile ribotype.
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Affiliation(s)
- A K Thabit
- Center for Anti-infective Research and Development, Hartford Hospital, Hartford, CT, USA; Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - S T Housman
- Western New England University, Springfield, MA, USA
| | - C D Burnham
- Department of Pathology and Immunology, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - D P Nicolau
- Center for Anti-infective Research and Development, Hartford Hospital, Hartford, CT, USA; Division of Infectious Diseases, Hartford Hospital, Hartford, CT, USA.
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