Simultaneous outbreaks of two strains of toxigenic Clostridium difficile in a general hospital

Clostridium difficile infection in fever patients with gynecological malignancies

BACKGROUND

Although Clostridium difficile infection (CDI) often results in severe manifestations due to toxin-producing clostridium, the correlation between CDI and having a fever in gynecological malignancies is not completely understood.

AIMS

The incidence, and clinical features, and clinical management of CDI in patients with gynecological malignancies who have fevers were investigated, and the clinical managements of this complication are discussed.

METHODS AND RESULTS

We retrospectively reviewed 485 patients newly diagnosed with invasive gynecological cancers who underwent anticancer treatment between July 2012 and December 2016. The diagnosis of CDI was performed using enzyme immunoassays for C difficile glutamate dehydrogenase and toxin A/B enzyme immunoassay. The cumulative risk of CDI was 9.5% (six of 63) in overall fever patients and 6.3% (six of 95) in patients with fever episodes. Two CDI patients (33.3%) did not show diarrheal symptoms, with the fever of unknown origin criteria prompting their CDI testing and diagnosis. CDI patients were treated using vancomycin or metronidazole without suffering from fatal clinical course. Overall, eight patients with gynecological malignancies were diagnosed with CDI, including two patients with fever lower than 38.5°C. The cumulative risk of CDI was 0.48% (eight of 1652) for all admitted patients and 1.6% (eight of 485) in those with gynecological malignancies. Of all the patients with confirmed CDI, only one had a history of administration of antibiotics prior to onset of CDI symptoms.

CONCLUSION

CDI does not always present with typical manifestations in malignancy patients. Investigation of CDI, regardless of gastrointestinal symptoms or history of antibiotic use, is warranted in cases of fever of unknown origin in gynecological malignancy.

Parameters for the mathematical modelling of Clostridium difficile acquisition and transmission: a systematic review

INTRODUCTION

Mathematical modelling of Clostridium difficile infection dynamics could contribute to the optimisation of strategies for its prevention and control. The objective of this systematic review was to summarise the available literature specifically identifying the quantitative parameters required for a compartmental mathematical model of Clostridium difficile transmission.

METHODS

Six electronic healthcare databases were searched and all screening, data extraction and study quality assessments were undertaken in duplicate. Results were synthesised using a narrative approach.

RESULTS

Fifty-four studies met the inclusion criteria. Reproduction numbers for hospital based epidemics were described in two studies with a range from 0.55 to 7. Two studies provided consistent data on incubation periods. For 62% of cases, symptoms occurred in less than 4 weeks (3-28 days) after infection. Evidence on contact patterns was identified in four studies but with limited data reported for populating a mathematical model. Two studies, including one without clinically apparent donor-recipient pairs, provided information on serial intervals for household or ward contacts, showing transmission intervals of <1 week in ward based contacts compared to up to 2 months for household contacts. Eight studies reported recovery rates of between 75%-100% for patients who had been treated with either metronidazole or vancomycin. Forty-nine studies gave recurrence rates of between 3% and 49% but were limited by varying definitions of recurrence. No study was found which specifically reported force of infection or net reproduction numbers.

CONCLUSIONS

There is currently scant literature overtly citing estimates of the parameters required to inform the quantitative modelling of Clostridium difficile transmission. Further high quality studies to investigate transmission parameters are required, including through review of published epidemiological studies where these quantitative estimates may not have been explicitly estimated, but that nonetheless contain the relevant data to allow their calculation.

[To go in-depth in the knowledge of the device to control fecal elimination in the critical patient]

OBJECTIVE

To describe the general characteristics of the patient and device use. To know retention balloon pressure (RBP) and related factors. To identify rate of leakage incidence, relocation and perineal damage due to the device (PSD) and related risk factors.

MATERIAL AND METHODS

An analytical observational, cross-sectional study conducted in a polyvalent ICU from June-December 2010 was performed. The sample included Flexi-Seal(®) carriers. Variables evaluated were patient and device use characteristics, RBP, leakage and quantity, relocation and reason, PSD, sedoanalgesia infusion, neuromuscular block, patient position, Flexi-Seal type catheter, ventilatory mode (VM), intra-abdominal pressure (IAP), mean intrathoracic pressure (MITP), PEEP, Glasgow, color-aspect, fecal consistency and volume. Significance P<.05.

RESULTS

Twenty-one patients were included, 52% male, aged 54±17 with 30 insertion episodes, Flexi-Seal-Signal(®) 33%, 10±8 days permanency, main indication 33% «diarrhea and injured skin»," 30% device removal «intolerance and/or spontaneous expulsion». Median (Me) PGR =40; RI (61-19) cmH2O. Factors associated to higher PGR: SCI absence, prone-decubitus position, leakage, relocation, conventional Flexi-Seal(®), MV, lower PEEP and IMP, Color-aspect, higher MITP. Leakage, relocation and PSD incidence density 43, 30 and 2 cases/100 days of catheter, respectively. Leakage and relocation risk factors: higher PGR, Glasgow and fecal volume, lower MITP, MV, assisted-spontaneous mode OR 2.5 CI (1.6-3.8) and OR 1.7(1.1-2.7), absence SCI OR 3.3 (2.2-5.1) and OR 2.4(1.5-3.8), absence neuromuscular block OR 2.4 (1.4-3.9) and OR 1.8 (1.1-3.1), Flexi-Seal(®) conventional OR 2.7(1.7-4.1) and OR 2 (1.2-3.3), respectively. Leakage risk factors: color-aspect, supine position, lower IMP and PEEP.

CONCLUSIONS

Monitoring RBP may alert us about leakage presence and relocation need. Knowing associated risk factors to RBP, leakage and relocation would help to develop strategies to reduce their high incidence rate such as decreasing RBP by reducing inflated volume.

Antibiotic Collateral Damage: Resistance and Antibiotic-Associated Diarrhea

The purpose of this review is to describe dilemmas associated with antibiotic collateral damage and provide clinical pharmacists with information to improve antibiotic utilization. The clinical use of antibiotics has been associated with acquisition and spread of nosocomial pathogens and multidrug-resistant strains, such as extended-spectrum beta-lactamases, AmpC hyper-producers, carbapenemases, and resistant gram-positive organisms. The mobility of plasmid-mediated resistance, such as extended-spectrum beta-lactamases and the more recently isolated Klebsiella pneumoniae carbapenemases, have been well-demonstrated with worldwide distribution across several different species. The challenges surrounding antibiotic-associated diarrhea, particularly Clostridium difficile infection (CDI), continue to evolve with outbreaks of hypervirulent strains linked to the use of less commonly implicated antibiotics. Published literature was searched and reviewed using PubMed. Undesirable attributes related to antibiotic use can have broad consequences in addition to their effect on individual patients. This collateral damage can evolve over time, and prescribers must be aware of current concerns and be diligent in their judicious use of antibiotics.

A review of mortality due to Clostridium difficile infection

SUMMARY

In this review we examine published literature to ascertain mortality in relation to Clostridium difficile infection (CDI) and the factors associated with mortality. In the 27 studies that had sufficient data, there were 10975 cases of CDI with great heterogeneity in the methods for reporting mortality. We calculated the overall associated mortality to be at least 5.99% within 3 months of diagnosis. The most important finding is that higher mortality is associated with advanced age, being 13.5% in patients over 80 years. Studies performed after 2000 had a significantly higher mortality than those before this date. We propose minimum standards for reporting mortality in future studies.

Antibiotic use and other risk factors at hospital level for outbreaks with Clostridium difficile PCR ribotype 027

The first Dutch outbreak due to Clostridium difficile ribotype 027 was observed in mid-2005; by the end of that year, eight hospitals were affected. To study the relationship between hospital-wide antibiotic use and the incidence of 027-linked C. difficile-associated disease (CDAD) three study groups were made: group A, all eight hospitals with an 027-associated epidemic; group B, five of a total of six hospitals with occasional 027 cases, without an increase in CDAD; and group C, ten randomly selected hospitals with no reported 027 epidemics or isolated 027 cases. Quarterly data on CDAD incidences, hygiene measures and the use of fluoroquinolones, second- and third-generation cephalosporins, extended-spectrum penicillins, penicillins with beta-lactamase inhibitors, carbapenems, lincomycins and macrolides were collected for 2004 and 2005, and divided into pre-epidemic and epidemic periods. Using a multilevel Poisson regression analysis, CDAD incidence was linked to antibiotic use in the previous quarter and to certain hygiene measures. In the pre-epidemic period, the total use of the studied antibiotics was comparable between affected and unaffected hospitals. Higher use of second-generation cephalosporins, macrolides and all of the studied antibiotics were independently associated with a small increase in CDAD incidence [relative risk (95% confidence interval): 1.14 per increase of 100 defined daily doses per 10,000 bed days (1.06-1.23), 1.10 (1.01-1.19) and 1.02 (1.01-1.03), respectively]. However the effect was too small to predict which hospitals might be more prone to 027-associated outbreaks.

Laboratory diagnosis of Clostridium difficile-associated disease in the Republic of Ireland: a survey of Irish microbiology laboratories

The Health Protection Surveillance Centre (HPSC) established a group to produce national guidelines for Clostridium difficile in Ireland in 2006. A laboratory questionnaire was distributed to determine current C. difficile diagnostic practices. Twenty-nine out of 44 laboratories providing C. difficile diagnostic services to 34 hospitals responded. Twenty-five out of 29 (86%) laboratories processed specimens for C. difficile and four (13.8%) forwarded specimens to another laboratory. Sixteen laboratories (64%) processed specimens for other healthcare facilities. None routinely examined stool for C. difficile, seven (28%) examined specimens only when requested to do so and 18 (72%) used specific selection criteria, including testing all liquid stools (39%), all nosocomial diarrhoea (44%), specific clinical criteria (28%) and history of antibiotic therapy (22%). All tested stool directly for C. difficile toxin with a variety of enzyme immunoassays, with 24 (96%) detecting both toxin A and B and one detecting toxin A only. Three (12%) laboratories used cytotoxicity assays; none used polymerase chain reaction and six (24%) laboratories performed C. difficile culture but only under specific circumstances. Seven (28%) laboratories had isolates typed during outbreaks, but none had the facilities to do so on-site. The HPSC group will produce national recommendations for laboratory diagnosis, surveillance and management of C. difficile infection. Since there are marked differences in diagnostic practices throughout the country and no national reference laboratory, the implementation of these recommendations will have cost implications that will need to be addressed.

Detection of Clostridium difficile in stool samples from patients in the early period after liver transplantation

OBJECTIVE

We examined the frequency of detection of Clostridium difficile (CD) toxins compared with the recovery of C. difficile in stool specimen cultures among orthotopic liver transplant (OLT) patients with nosocomial diarrhea in the early period.

MATERIALS AND METHODS

The study included stool samples obtained during the first 30 days after OLT in adults who were suspected of CD-associated diseases. The identification of cultured CD strains was performed by standard microbiological methods. The presence of CD toxins was assayed using a commercial immunoassay.

RESULTS

All patients were followed prospectively for CD infections from the date of OLT for the first 4 weeks after surgery. Among 54 samples, 16.7% were culture-positive for CD. CD toxins were tested on 54 samples, yielding 63% toxin-positive samples and 30% toxin- and culture-negative results. In the first week after OLT, samples from 19 patients were subjected to CD investigation. Among 19 samples positive for toxin, 52.6% of all samples were culture-negative. We analyzed 35 samples from the second to the fourth week after OLT in 31 recipients. Among 35 samples, 68.6% and 25.7% were positive for CD toxin and for culture, while 20% of samples were negative for toxin and culture.

CONCLUSION

In our study, 63% of samples were toxin-positive with 16.7% yielding growth of CD and 30% being negative for toxins and cultures.

Recent Advances in Real-time Mass Spectrometry Detection of Bacteria

The analysis of bio-aerosols poses a technology challenge, particularly when sampling and analysis are done in situ. Mass spectrometry laboratory technology has been modified to achieve quick bacteria typing of aerosols in the field. Initially, aerosol material was collected and subjected off-line to minimum sample treatment and mass spectrometry analysis. More recently, sampling and analysis were combined in a single process for the real-time analysis of bio-aerosols in the field. This chapter discusses the development of technology for the mass spectrometry of bio-aerosols, with a focus on bacteria aerosols. Merits and drawbacks of the various technologies and their typing signatures are discussed. The chapter concludes with a brief view of future developments in bio-aerosol mass spectrometry.

Surveillance of hospital-acquired infection in the Republic of Ireland: past, present and future

There is increasing interest in the surveillance of hospital-acquired infection (HAI) in the Republic of Ireland due to a greater awareness of the consequences of antibiotic resistance, and consumer pressure in the form of public expectations of the quality of health care. To date there have been no nationwide prospective surveillance projects but surveillance has taken place in the form of participation in international and national studies, and the description of local outbreaks. Infection control teams and others have participated in projects such as a European study of HAI in intensive care units conducted in 1992, the second national prevalence study conducted in the UK in 1993 and two surveys of methicillin-resistant Staphylococcus aureus (MRSA) carried out in 1995 and 1999, the latter involving colleagues in Northern Ireland. There have been a number of local surveys of antibiotic-resistant bacteria including the molecular characterization of MRSA in Dublin hospitals, vancomycin-resistant enterococci, and Gram-negative bacteria such as Enterobacter spp. and Serratia spp. affecting compromised patients such as bone marrow transplant recipients. In the future, it is hoped to standardize case definitions, automate data entry, increase collaboration with surveillance initiatives in Northern Ireland and link in with European networks such as EARSS and HELICS. Apart from the need to improve the quality of health care in Irish hospitals, approximate costings suggest that there are potential savings of 7.5 pounds sterling -15 pounds sterling m to be made following a reduction of HAI rates of 15%.

Mathematical modeling of Clostridium difficile infection

Clostridium difficile diarrhea is a major cause of morbidity and mortality in hospitals. However, the number of cases in an outbreak is usually relatively small. This precludes many traditional statistical methods of modeling epidemics. Stochastic models are designed to deal with small numbers and are promising methods of understanding C. difficile epidemiology. This is illustrated by a reversible jump Markov chain Monte Carlo model based on the herd immunity hypothesis of C. difficile outbreaks.

Epidemiology of nosocomial clostridium difficile diarrhoea

Clostridium difficile is a frequent and clinically important cause of diarrhoea that has been strongly but not exclusively associated with the hospital setting. The vast majority of cases of C. difficile diarrhoea are associated with antecedent treatment with antibiotics, of which cephalosporins and clindamycin appear to pose the highest risk. Within hospitals and chronic-care facilities, cross-infection of C. difficile has been related to transient carriage on hands of healthcare workers and contamination of diverse environmental surfaces, including electronic rectal thermometers. Prospective epidemiologic studies have demonstrated that acquisition of C. difficile is common in hospitalized patients. Although colonized patients contribute to nosocomial transmission of C. difficile, symptom-free carriage of C. difficile appears to reduce risk of subsequent development of C. difficile diarrhoea. Antimicrobial treatment with oral metronidazole or vancomycin to attempt to eradicate symptomless carriage is not recommended. Measures to control nosocomial C. difficile diarrhoea have focused on improved handwashing, use of barrier precautions with single rooms for symptomatic patients, reduction of environmental contamination, and antibiotic restriction. Restricting clindamycin has been particularly successful in terminating outbreaks of C. difficile diarrhoea associated with its use. The epidemiologic features of C. difficile and strategies for control are similar to those for micro-organisms that have acquired antimicrobial resistance. C. difficile may be indirectly or directly contributing to spread of resistant organisms, for instance, by causing diarrhoea and thereby enhancing environmental contamination with other gastrointestinal flora such as vancomycin-resistant enterococci. Thus, a consideration of C. difficile in the larger context of the world-wide spread of antibiotic resistance offers useful insights that may help form the basis for the development of more effective control measures.