Biofilm Formation of Clostridioides difficile, Toxin Production and Alternatives to Conventional Antibiotics in the Treatment of CDI

Clostridioides difficile is considered a nosocomial pathogen that flares up in patients exposed to antibiotic treatment. However, four out of ten patients diagnosed with C. difficile infection (CDI) acquired the infection from non-hospitalized individuals, many of whom have not been treated with antibiotics. Treatment of recurrent CDI (rCDI) with antibiotics, especially vancomycin (VAN) and metronidazole (MNZ), increases the risk of experiencing a relapse by as much as 70%. Fidaxomicin, on the other hand, proved more effective than VAN and MNZ by preventing the initial transcription of RNA toxin genes. Alternative forms of treatment include quorum quenching (QQ) that blocks toxin synthesis, binding of small anion molecules such as tolevamer to toxins, monoclonal antibodies, such as bezlotoxumab and actoxumab, bacteriophage therapy, probiotics, and fecal microbial transplants (FMTs). This review summarizes factors that affect the colonization of C. difficile and the pathogenicity of toxins TcdA and TcdB. The different approaches experimented with in the destruction of C. difficile and treatment of CDI are evaluated.

Postoperative Endophthalmitis After Cataract Surgery: An Update

Postoperative endophthalmitis is a serious complication that can happen after cataract surgery. It occurs mainly due to invasion of the globe by microbial flora, bacteria, or fungi from the adnexa and environment during the time of surgery. All patients undergoing cataract surgery should be evaluated for any potential risk factors that can enhance the development of postoperative endophthalmitis; managing the intraoperative risk and prophylaxis protocols should be considered in order to reduce the risk of endophthalmitis. Early follow-up after cataract surgery is highly recommended to detect any sign of endophthalmitis so as to treat it immediately and ensure patient compliance on post-surgery medication and precautions to reduce the serious complications caused by late diagnosis and treatment of post-cataract endophthalmitis.

Approaches to multidrug-resistant organism prevention and control in long-term care facilities for older people: a systematic review and meta-analysis

BACKGROUND

Despite clear evidence of benefits in acute-care hospitals, controversy over the effectiveness of IPC measures for MDROs is perceptible and evidence-based practice has not been established.

OBJECTIVE

To investigate the effects of IPC interventions on MDRO colonization and infections in LTCFs.

DATA SOURCES

Ovid MEDLINE, EMBASE, and CINAHL from inception to September 2020.

ELIGIBILITY CRITERIA

Original and peer-reviewed articles examining the post-intervention effects on MDRO colonization and infections in LTCFs.

INTERVENTIONS

(i) Horizontal interventions: administrative engagement, barrier precautions, education, environmental cleaning, hand hygiene, performance improvement, and source control; and (ii) vertical intervention: active surveillance plus decolonization.

STUDY APPRAISAL AND SYNTHESIS

We employed a random-effects meta-analysis to estimate the pooled risk ratios (pRRs) for methicillin-resistant Staphylococcus aureus (MRSA) colonization by intervention duration; and conducted subgroup analyses on different intervention components. Study quality was assessed using Cochrane risk of bias tools.

RESULTS

Of 3877 studies identified, 19 were eligible for inclusion (eight randomized controlled trials (RCTs)). Studies reported outcomes associated with MRSA (15 studies), vancomycin-resistant Enterococci (VRE) (four studies), Clostridium difficile (two studies), and Gram-negative bacteria (GNB) (two studies). Eleven studies were included in the meta-analysis. The pRRs were close to unity regardless of intervention duration (long: RR 0.81 [95% CI 0.60-1.10]; medium: RR 0.81 [95% CI 0.25-2.68]; short: RR 0.95 [95% CI 0.53-1.69]). Vertical interventions in studies with a small sample size showed significant reductions in MRSA colonization while horizontal interventions did not. All studies involving active administrative engagement reported reductions. The risk of bias was high in all but two studies.

CONCLUSIONS

Our meta-analysis did not show any beneficial effects from IPC interventions on MRSA reductions in LTCFs. Our findings highlight that the effectiveness of interventions in these facilities is likely conditional on resource availability-particularly decolonization and barrier precautions, due to their potential adverse events and uncertain effectiveness. Hence, administrative engagement is crucial for all effective IPC programmes. LTCFs should consider a pragmatic approach to reinforce standard precautions as routine practice and implement barrier precautions and decolonization to outbreak responses only.

Diagnostic Approach of Hypersensitivity Reactions to Cefazolin in a Large Prospective Cohort

BACKGROUND

Cefazolin is a common trigger of perioperative anaphylaxis. The diagnostic approach is controversial because the optimal concentration for skin testing is uncertain, drug provocation tests (DPTs) are contraindicated in severe reactions, and in vitro tests are not thoroughly validated.

OBJECTIVE

We aimed to characterize a large number of patients reporting cefazolin allergic reactions and to analyze the diagnostic role of in vivo and in vitro tests.

METHODS

We prospectively evaluated patients with suspicion for allergic reactions to cefazolin by clinical history, skin tests (STs), and, if negative, DPT. In a subgroup of patients, basophil activation test (BAT) and radioallergosorbent test were done before allergologic workup was performed and the final diagnosis was achieved.

RESULTS

We evaluated 184 patients, 76 of whom were confirmed as allergic (41.3%), 90 were nonallergic (48.9%), and 18 were nonconfirmed (9.8%). All patients reporting anaphylactic shock and most reporting anaphylaxis were confirmed to be allergic (P < .001). Forty allergic patients (52.6%) were confirmed by STs, 22 by DPT (28.9%), and 14 by clinical history (18.4%). All subjects manifesting exanthemas and pruritus were nonallergic. The BAT sensitivity was 66.7% when CD63 and CD203c were combined as activation markers. Six of 8 patients with negative STs and positive DPT had a positive BAT.

CONCLUSIONS

Patients allergic to cefazolin often reported severe immediate-type reactions. Skin tests enabled a diagnosis in half of patients when using cefazolin at 20 mg/mL. Unfortunately, DPT could not be performed in all patients owing to reaction severity, which makes BAT a promising diagnostic tool. Further research is needed to clarify the underlying mechanisms, especially in severe reactions.

Prevalence of vancomycin-resistant enterococci in Asia-A systematic review and meta-analysis

WHAT IS KNOWN AND OBJECTIVE

The rise of vancomycin-resistant enterococci (VRE) has been a major health problem in most countries of the world including Asia, since its discovery. There is a paucity of data on VRE in many countries of Asia as well as limited pooled estimates. Therefore, we performed a systematic review and meta-analysis to estimate a pooled prevalence of VRE in Asia.

METHODS

A literature search in electronic databases like PubMed, Embase and Google Scholar and manual searching of references and grey literature, comprising the information on the prevalence of VRE with at least two species of enterococci, conducted in different countries of Asia from January 1, 2000, to September 20, 2020, was done. The random-effect model and 95% CIs was used to calculate the pooled prevalence. Subgroup, sensitivity and meta-regression analyses were performed to address heterogeneity while Egger's test for publication bias.

RESULTS AND DISCUSSIONS

We identified 39 studies, comprising a total of 11,875 enterococcal isolates. The result of the analysis showed that the pooled prevalence of VRE in Asia was 8.10% (95% CI; 7-9; I²  = 93.79%; p < 0.001). Resistance to vancomycin was greater among strains of E. faecium compared to the strains of E. faecalis (22.40% vs. 3.70%). Amongst various regions of Asia, the highest prevalence of VRE was found in the Western Asian region and the lowest in the South-east Asian region. Moreover, the rate of VRE was higher than most European countries and lower than USA.

WHAT IS NEW AND CONCLUSIONS

With an upsurge of VRE in Asia in recent years, efficient infection control programmes, robust surveillance systems and adherence to antibiotic stewardship are paramount to halt the further rise of VRE.

Antibiotic stewardship from a decision-making, behavioral economics, and incentive design perspective

Antibiotic-resistant infections cause over 20 thousand deaths and $20 billion annually in the United States. Antibiotic prescribing decision making can be described as a "tragedy of the commons" behavioral economics problem, for which individual best interests affecting human decision-making lead to suboptimal societal antibiotic overuse. In 2015, the U.S. federal government announced a $1.2 billion National Action Plan to combat resistance and reduce antibiotic use by 20% in inpatient settings and 50% in outpatient settings by 2020. We develop and apply a behavioral economics model based on game theory and "tragedy of the commons" concepts to help illustrate why rational individuals may not practice ideal stewardship and how to potentially structure three specific alternate approaches to accomplish these objectives (collective cooperative management, usage taxes, resistance penalties), based on Ostrom's economic governance principles. Importantly, while each approach can effectively incentivize ideal stewardship, the latter two do so with 10-30% lower utility to all providers. Encouraging local or state-level self-managed cooperative stewardship programs thus is preferred to national taxes and penalties, in contrast with current trends and with similar implications in other countries.

Strategies to Prevent Healthcare-Associated Infections: A Narrative Overview

Healthcare-associated infections (HCAIs) are a major source of morbidity and mortality and are the second most prevalent cause of death. Furthermore, it has been reported that for every one-hundred patients admitted to hospital, seven patients in high-income economies and ten in emerging and low-income economies acquire at least one type of HCAI. Currently, almost all pathogenic microorganisms have developed antimicrobial resistance, and few new antimicrobials are being developed and brought to market. The literature search for this narrative review was performed by searching bibliographic databases (including Google Scholar and PubMed) using the search terms: "Strategies," "Prevention," and "Healthcare-Associated Infections," followed by snowballing references cited by critical articles. We found that although hand hygiene is a centuries-old concept, it is still the primary strategy used around the world to prevent HCAIs. It forms one of a bundle of approaches used to clean and maintain a safe hospital environment and to stop the transmission of contagious and infectious microorganisms, including multidrug-resistant microbes. Finally, antibiotic stewardship also has a crucial role in reducing the impact of HCAIs through conserving currently available antimicrobials.

Commonly used intracameral antibiotics for endophthalmitis prophylaxis: A literature review

Endophthalmitis is a serious complication of cataract surgery that occurs in thousands of patients each year. To decrease the incidence of postoperative endophthalmitis, many surgeons inject intracameral antibiotics (cefuroxime, moxifloxacin, and vancomycin) routinely at the end of surgery. A large number of recently published retrospective studies and large database analyses have reported decreased endophthalmitis rates with routine antibiotic use, and the only prospective, multicenter, randomized trial performed by the European Society of Cataract and Refractive Surgery demonstrated that intracameral cefuroxime decreases the incidence of postoperative endophthalmitis. Routine cefuroxime use has become common in many European countries, whereas moxifloxacin is the most commonly used drug in India, and vancomycin use predominates in Australia. The decision regarding whether or not to use intracameral prophylaxis and the drug that is selected varies considerably throughout the world because of antibiotic availability and cost, and the spectrum of causative organisms. Adverse events due to intracameral antibiotics are infrequent, but complications such as hemorrhagic occlusive retinal vasculitis have been reported. Because additional prospective, comparative trials have not been performed, a consensus regarding best practices to prevent postoperative endophthalmitis has not been reached. Additionally, many surgeons do not routinely use intracameral antibiotics because they believe them unnecessary with modern aseptic techniques, small incision surgery, and shorter operating times. We discuss the most commonly used intracameral antibiotics, present the risks and potential benefits of this approach, and highlight challenges with drug compounding and safety.

Comparison of Vancomycin versus Cefazolin as Initial Therapy for Peritonitis in Peritoneal Dialysis Patients

The incidence of peritonitis ranges from 1 episode every 24 patient treatment months to 1 episode every 60 patient treatment months [Keane WF, et al. ISPD Guidelines/Recommendations. Adult peritoneal dialysis-related peritonitis treatment recommendations: 2000 update. Perit Dial Int 2000; 20:396–411.]. Gram-positive organisms account for over 80% of continuous ambulatory peritoneal dialysis (PD)-associated peritonitis. Recent fear of vancomycin-resistant enterococci (VRE) has prompted suggestions of limiting vancomycin use.

Fifty-one episodes of peritonitis in 30 patients studied over 2 years were evaluated. Cloudiness of the PD fluid and/or abdominal pain were considered suggestive of peritonitis and were confirmed by cell count and culture. Baseline cell count, Gram stain, and cultures were obtained, with periodic follow-up. Patients were randomized to receive either vancomycin 1 g/L intraperitoneally (IP) as loading dose, repeated on day 5 or day 8, depending on residual renal function, for 2 weeks, or cefazolin 1 g in the first PD bag and continued with 125 mg/L every exchange for 2 or 3 weeks, depending on culture results. All patients also received gentamicin 40 mg IP every day until the culture results were available. A similar randomized trial comparing vancomycin and cefazolin in the past used a lower concentration of cefazolin 50 mg/L [Flanigan MJ, Lim VS. Initial treatment of dialysis associated peritonitis: a controlled trial of vancomycin versus cefazolin. Perit Dial Int 1991; 11:31–7.].

Peritoneal dialysate fluid cultures revealed 31 (60.7%) gram-positive organisms, 7 (13.7%) gram-negative organisms, and 2 (3.9%) cultured yeast; 11 (21.5%) cultures yielded no growth.

The incidence of peritonitis at our center was 1 episode every 42 patient treatment months. No case of VRE was noted. There was no statistical difference in clinical response or relapse rate for the two protocols. It was the authors’ and nurses’ observation that patient compliance and satisfaction was better with vancomycin, and the cost per treatment was 23% less than cefazolin. Based on these data we believe vancomycin should still be considered for first-line treatment of PD-associated peritonitis.

Despite the Safety of Preoperative Cefazolin for Patients With Non-anaphylactic Penicillin Allergy, 20% of Practitioners Avoid Its Use

Cefazolin is commonly used for surgical site infection prophylaxis due to its low cost and effective coverage. However, it is controversial to use cefazolin in patients with a penicillin allergy despite the cross-reactivity between cefazolin and penicillin being only 1%. Ample literature shows that it is safe to use cefazolin in patients with non-anaphylactic penicillin allergies. However, there is often hesitation by anesthesiologists or orthopedists when prescribing this medication in this population. The current authors sent a 16-question survey to all the residency programs in the United States in anesthesiology and orthopedics asking physicians affiliated with these programs to answer a series of questions about their demographics, prescribing patterns, and knowledge of the cross-reactivity between penicillin and cefazolin. A total of 146 responses in each group, with 82.9% (n=121) of orthopedists and 78.8% (n=115) of anesthesiologists preferring cefazolin for patients with non-anaphylactic penicillin allergies. However, only 57.5% of anesthesiologists and 41.1% of orthopedists knew the correct cross-reactivity between cephalosporins and penicillin. If a provider knew the correct cross-reactivity between cefazolin and penicillin, he or she had an increased odds of prescribing cefazolin to patients with nonanaphylactic penicillin allergies (orthopedics odds ratio [OR], 4.77, P<.01; anesthesiologists OR, 3.59, P<.01). Therefore, this study supports that further education of orthopedic and anesthesia providers about the cross-reactivity between cefazolin and penicillin would lead to more evidence-based, cost-effective care. [Orthopedics. 2019; 42(5):e437-e442.].

Clinical review of Clostridium difficile infection: an update on treatment and prevention

INTRODUCTION

Clostridium difficile infection (CDI) has become a significant healthcare-associated infection and is strongly associated with antibiotic use. Practice guidelines have recently been revised incorporating updated recommendations for diagnosis, treatment, and prevention.

AREAS COVERED

This review discusses updated aspects of CDI management. New and emerging pharmacologic options for treatment and prevention are reviewed.

EXPERT OPINION

Metronidazole is associated with lower rates of treatment success compared to vancomycin and should no longer be used as primary therapy for the first episode of CDI or recurrent disease. Vancomycin or fidaxomicin are now recommended for first-line therapy for most cases of CDI. Fecal microbiota transplant is effective and safe for the treatment of recurrent CDI. Evidence supports the use of fidaxomicin and bezlotoxumab for prevention of recurrent CDI; however, the costs associated with these therapies may limit their use. Validated risk prediction tools are needed to identify patients most likely to benefit from these treatments. Future advancements in microbiota targeting treatments will emerge as promising alternatives to standard CDI treatments. Antibiotic stewardship and infection control measures will remain essential components for CDI management.

Hand hygiene in hospitals: anatomy of a revolution

Healthcare-associated infections (HAIs) affect hundreds of millions of individuals worldwide. Performing hand hygiene is widely accepted as a key strategy of infection prevention and control (IPC) to prevent HAIs, as healthcare workers' contaminated hands are the vehicle most often implicated in the cross-transmission of pathogens in health care. Over the last 20 years, a paradigm shift has occurred in hand hygiene: the change from handwashing with soap and water to using alcohol-based hand rubs. In order to put this revolution into context and understand how such a change was able to be implemented across so many different cultures and geographic regions, it is useful to understand how the idea of hygiene in general, and hand hygiene specifically, developed. This paper aims to examine how ideas about hygiene and hand hygiene evolved from ancient to modern times, from a ubiquitous but local set of ideas to a global phenomenon. It reviews historical landmarks from the first known documented recipe for soap by the Babylon civilization to the discovery of chlorine, and significant contributions by pioneers such as Antoine Germain Labarraque, Alexander Gordon, Oliver Wendell Holmes, Ignaz Philip Semmelweis, Louis Pasteur and Joseph Lister. It recalls that handwashing with soap and water appeared in guidelines to prevent HAIs in the 1980s; describes why alcohol-based hand rub replaced this as the central tool for action within a multi-modal improvement strategy; and looks at how the World Health Organization and other committed stakeholders, governments and dedicated IPC staff are championing hand hygiene globally.

Comparative analysis of the safety and efficacy of intracameral cefuroxime, moxifloxacin and vancomycin at the end of cataract surgery: a meta-analysis

BACKGROUND

Current practice methods are unclear as to the most safe and effective prophylactic pharmacotherapy and method of delivery to reduce postoperative endophthalmitis occurrence.

METHODS

A systematic review and meta-analysis using Meta-analysis of Observational Studies in Epidemiology guidelines was performed to compare the efficacy of intracameral cefuroxime, moxifloxacin and vancomycin in preventing postphacoemulsification cataract surgery endophthalmitis. A safety analysis of intracameral antibiotics was concurrently performed.

DATA SOURCES

BIOSIS Previews, CINAHL, ClinicalTrials.gov, Cochrane Library, Dissertations & Theses, EMBASE, PubMed, ScienceDirect and Scopus were searched from inception to January 2017. Data were pooled using a random effects model. All articles were individually reviewed and data were extracted by two independent reviewers. Funnel plot, risk of bias and quality of evidence analyses were performed.

RESULTS

Seventeen studies with over 900 000 eyes were included, which favoured the use of intracameral antibiotics at the end of cataract surgery (OR 0.20; 95% CI 0.13 to 0.32; P<0.00001). The average weighted postoperative endophthalmitis incidence rates with intracameral cefuroxime, moxifloxacin and vancomycin were 0.0332%, 0.0153% and 0.0106%, respectively. Secondary analyses showed no difference in efficacy between intracameral plus topical antibiotics versus intracameral alone (P>0.3). Most studies had low to moderate risk of bias. The safety analysis showed minimal toxicity for moxifloxacin. Dosing errors led to the majority of toxicities with cefuroxime. Although rare, vancomycin was associated with toxic retinal events.

CONCLUSION

Intracameral cefuroxime and moxifloxacin reduced endophthalmitis rates compared with controls with minimal or no toxicity events at standard doses. Additionally, intracameral antibiotics alone may be as effective as intracameral plus topical antibiotics.

Antibiotic Prophylaxis and Prevention of Surgical Site Infection in Shoulder and Elbow Surgery

Infection after orthopedic procedures is a devastating and serious complication associated with significant clinical and financial challenges to the health care system and unfortunate patient. The time and resource-intensive nature of treating infection after orthopedic procedures has turned attention toward enhancing prevention and establishing quality improvement measures. Prevention strategies throughout the perioperative period include host optimization, risk mitigation, reducing bacterial burden and proper wound management. Understanding the most common offending organisms of the shoulder, Propionibacterium acnes and coagulase negative Staphylococcus species, and their hypothesized mechanism of infection is crucial to selecting appropriate preventative measures.

Do local antibiotics reduce periprosthetic joint infections? A retrospective review of 744 cases

Periprosthetic joint infections (PJI) are uncommon but not rare and have significant morbidity and financial implications. Local antibiotics have been used successfully in other areas of orthopedics to reduce postoperative infections, but this method has not been proven in total joint arthroplasty (TJA). Beginning January 1, 2014, our primary investigators began using surgical site lavage with providone-iodine solution and administering 2 g of vancomcyin powder in the surgical wound prior to capsule closure for all primary and revision total hip and knee arthroplasties. We performed a retrospective chart review of patients two years prior to this date and two years after to compare occurrence of PJI. The groups were broken down into patients who received local antibiotics versus those who did not. The groups were further broken down by type of surgery performed; primary or revision total hip or knee arthroplasty. Administration of local antibiotics was preventative for PJI only in the primary total knee arthroplasty group (aOR = 0.28, 0.09-0.89). Administration of local antibiotics trended towards a preventative effect for PJI in the other groups but was not statistically significant. Patients receiving local antibiotics had similar blood urea nitrogen and creatinine levels postoperatively compared to the no antibiotics group indicating minimal systemic effects of local vancomycin powder. While the use of local antibiotics may prevent PJI, more data is required especially in the revision arthroplasty groups.

The Rise and Fall of Metronidazole for Clostridium difficile Infection

Clostridium difficile is posing urgent health threats. Older studies have shown that metronidazole and vancomycin are equally effective in the treatment of Clostridium difficile infection (CDI). Given its inexpensive cost and low propensity to select antimicrobial resistant organisms, metronidazole became rapidly the drug of choice despite its pharmacokinetic limitations in the treatment of CDI. However, newer studies demonstrated that metronidazole is inferior to vancomycin, prompting clinicians to change their long-standing position on using metronidazole for mild to moderate infections and on reserving vancomycin for severe infections. Moving forward, metronidazole will fall out of favor in the treatment of CDI.

Infection Prevention and Control in Pediatric Ambulatory Settings

Since the American Academy of Pediatrics published its statement titled "Infection Prevention and Control in Pediatric Ambulatory Settings" in 2007, there have been significant changes that prompted this updated statement. Infection prevention and control is an integral part of pediatric practice in ambulatory medical settings as well as in hospitals. Infection prevention and control practices should begin at the time the ambulatory visit is scheduled. All health care personnel should be educated regarding the routes of transmission and techniques used to prevent the transmission of infectious agents. Policies for infection prevention and control should be written, readily available, updated every 2 years, and enforced. Many of the recommendations for infection control and prevention from the Centers for Disease Control and Prevention for hospitalized patients are also applicable in the ambulatory setting. These recommendations include requirements for pediatricians to take precautions to identify and protect employees likely to be exposed to blood or other potentially infectious materials while on the job. In addition to emphasizing the key principles of infection prevention and control in this policy, we update those that are relevant to the ambulatory care patient. These guidelines emphasize the role of hand hygiene and the implementation of diagnosis- and syndrome-specific isolation precautions, with the exemption of the use of gloves for routine diaper changes and wiping a well child's nose or tears for most patient encounters. Additional topics include respiratory hygiene and cough etiquette strategies for patients with a respiratory tract infection, including those relevant for special populations like patients with cystic fibrosis or those in short-term residential facilities; separation of infected, contagious children from uninfected children when feasible; safe handling and disposal of needles and other sharp medical devices; appropriate use of personal protective equipment, such as gloves, gowns, masks, and eye protection; and appropriate use of sterilization, disinfection, and antisepsis. Lastly, in this policy, we emphasize the importance of public health interventions, including vaccination for patients and health care personnel, and outline the responsibilities of the health care provider related to prompt public health notification for specific reportable diseases and communication with colleagues who may be providing subsequent care of an infected patient to optimize the use of isolation precautions and limit the spread of contagions.

Active identification of patients who are methicillin-resistant Staphylococcus aureus colonized is not associated with longer duration of vancomycin therapy

BACKGROUND

Excessive prescribing of vancomycin among patients admitted to inpatient wards is a challenge for antimicrobial stewardship programs, especially in the setting of expanded screening programs for methicillin-resistant Staphylococcus aureus (MRSA). Studies examining factors associated with longer duration of vancomycin use are limited.

METHODS

We conducted a retrospective cohort study to assess the impact of universal MRSA admission screening on duration of vancomycin use at the VA Boston Healthcare System during the period from January 2013-November 2015.

RESULTS

A total of 2,910 patients were administered intravenous vancomycin during the study period. A clinical culture positive for MRSA was strongly associated with vancomycin administration lasting >72 hours (odds ratio [OR], 2.72; 95% confidence interval [CI], 1.86-3.97; P < .001). After controlling for clinical culture results, admission MRSA colonization was not associated with vancomycin use past 72 hours (OR, 0.94; 95% CI, 0.8-1.1). A negative MRSA nasal swab on admission had a high negative predictive value for all MRSA infections evaluated (99.6% for pneumonia, 99.6% for bloodstream infection, and 98.1% for skin and soft tissue infection).

CONCLUSIONS

Admission surveillance for MRSA nasal colonization is not a major driver of prolonged vancomycin use. A negative admission MRSA nasal screen may be a useful tool for antimicrobial stewardship programs to limit vancomycin use, particularly in noncritically ill patients.

Teixobactin as a scaffold for unlimited new antimicrobial peptides: SAR study

It looks that a new era of antimicrobial peptides (AMPs) started with the discovery of teixobactin, which is a "head to side-chain" cyclodepsipeptide. It was isolated from a soil gram-negative b-proteobacteria by means of a revolutionary technique. Since there, several groups have developed synthetic strategies for efficient synthesis of this peptide and its analogues as well. Herein, all chemistries reported as well as the biological activity of the analogues are analyzed. Finally, some inputs regarding new trends for the next generation of analogues are discussed.

Hand Hygiene: An Update

The medical field has long recognized the importance of hand hygiene in preventing health care-associated infections, yet studies indicate that this important task is performed only 40% of the time. Health care workers cite several barriers to optimal performance of hand hygiene, but the time required to perform this task is foremost among them. Introduction of alcohol-based hand rubs, bundled interventions, and incorporation of technologies designed to monitor and promote hand hygiene all represent promising advances in this field.

Antimicrobial agents for preventing peritonitis in peritoneal dialysis patients

BACKGROUND

Peritoneal dialysis (PD) is an important therapy for patients with end-stage kidney disease and is used in more than 200,000 such patients globally. However, its value is often limited by the development of infections such as peritonitis and exit-site and tunnel infections. Multiple strategies have been developed to reduce the risk of peritonitis including antibiotics, topical disinfectants to the exit site and antifungal agents. However, the effectiveness of these strategies has been variable and are based on a small number of randomised controlled trials (RCTs). The optimal preventive strategies to reduce the occurrence of peritonitis remain unclear.This is an update of a Cochrane review first published in 2004.

OBJECTIVES

To evaluate the benefits and harms of antimicrobial strategies used to prevent peritonitis in PD patients.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant's Specialised Register to 4 October 2016 through contact with the Information Specialist using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE, and EMBASE; handsearching conference proceedings; and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

RCTs or quasi-RCTs in patients receiving chronic PD, which evaluated any antimicrobial agents used systemically or locally to prevent peritonitis or exit-site/tunnel infection were included.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed risk of bias and extracted data. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratio (RR) with 95% confidence intervals (CI).

MAIN RESULTS

Thirty-nine studies, randomising 4435 patients, were included. Twenty additional studies have been included in this update. The risk of bias domains were often unclear or high; risk of bias was judged to be low in 19 (49%) studies for random sequence generation, 12 (31%) studies for allocation concealment, 22 (56%) studies for incomplete outcome reporting, and in 12 (31%) studies for selective outcome reporting. Blinding of participants and personnel was considered to be at low risk of bias in 8 (21%) and 10 studies (26%) for blinding of outcome assessors. It should be noted that blinding of participants and personnel was not possible in many of the studies because of the nature of the intervention or control treatment.The use of oral or topical antibiotic compared with placebo/no treatment, had uncertain effects on the risk of exit-site/tunnel infection (3 studies, 191 patients, low quality evidence: RR 0.45, 95% CI 0.19 to 1.04) and the risk of peritonitis (5 studies, 395 patients, low quality evidence: RR 0.82, 95% CI 0.57 to 1.19).The use of nasal antibiotic compared with placebo/no treatment had uncertain effects on the risk of exit-site/tunnel infection (3 studies, 338 patients, low quality evidence: RR 1.34, 95% CI 0.62 to 2.87) and the risk of peritonitis (3 studies, 338 patients, low quality evidence: RR 0.94, 95% CI 0.67 to 1.31).Pre/perioperative intravenous vancomycin compared with no treatment may reduce the risk of early peritonitis (1 study, 177 patients, low quality evidence: RR 0.08, 95% CI 0.01 to 0.61) but has an uncertain effect on the risk of exit-site/tunnel infection (1 study, 177 patients, low quality evidence: RR 0.36, 95% CI 0.10 to 1.32).The use of topical disinfectant compared with standard care or other active treatment (antibiotic or other disinfectant) had uncertain effects on the risk of exit-site/tunnel infection (8 studies, 973 patients, low quality evidence, RR 1.00, 95% CI 0.75 to 1.33) and the risk of peritonitis (6 studies, 853 patients, low quality evidence: RR 0.83, 95% CI 0.65 to 1.06).Antifungal prophylaxis with oral nystatin/fluconazole compared with placebo/no treatment may reduce the risk of fungal peritonitis occurring after a patient has had an antibiotic course (2 studies, 817 patients, low quality evidence: RR 0.28, 95% CI 0.12 to 0.63).No intervention reduced the risk of catheter removal or replacement. Most of the available studies were small and of suboptimal quality. Only six studies enrolled 200 or more patients.

AUTHORS' CONCLUSIONS

In this update, we identified limited data from RCTs and quasi-RCTs which evaluated strategies to prevent peritonitis and exit-site/tunnel infections. This review demonstrates that pre/peri-operative intravenous vancomycin may reduce the risk of early peritonitis and that antifungal prophylaxis with oral nystatin or fluconazole reduces the risk of fungal peritonitis following an antibiotic course. However, no other antimicrobial interventions have proven efficacy. In particular, the use of nasal antibiotic to eradicate Staphylococcus aureus, had an uncertain effect on the risk of peritonitis and raises questions about the usefulness of this approach. Given the large number of patients on PD and the importance of peritonitis, the lack of adequately powered and high quality RCTs to inform decision making about strategies to prevent peritonitis is striking.

Management of Inpatients Colonized or Infected With Antimicrobial-Resistant Bacteria in Hospitals in the United States

Background:

Although guidelines for multidrug-resistant organisms generally include recommendations for contact precautions and surveillance cultures, it is not known how frequently U.S. hospitals implement these measures on a routine basis and whether infectious diseases consultants endorse their use.

Methods:

The Emerging Infections Network surveyed its members, infectious diseases consultants, to assess their use of and support for contact precautions and surveillance cultures for routine management of multidrug-resistant organisms in their principal inpatient workplace. Specifically, members were asked about use of these strategies for methicillin-resistantStaphylococcus aureus, vancomycin-resistant enterococci, and multidrug-resistant, gram-negative bacilli on general wards, ICUs, and transplant units.

Results:

Overall, 400 (86%) of 463 respondents supported the routine use of contact precautions to control one or more multidrug-resistant organisms in at least one unit, and 89% worked in hospitals that use them. In contrast, 50% of respondents favored routine use of surveillance cultures to manage at least one multidrug-resistant organism in any unit, and 30% of respondents worked in hospitals that use them routinely in any unit. Members favored routine use of surveillance cultures significantly more in ICUs and transplant units than in general wards for each multidrug-resistant organism (P<.001).

Conclusions:

Most of the infectious diseases consultants endorsed the use of contact precautions for routine management of patients colonized or infected with multidrug-resistant organisms and work in hospitals that have implemented them. In contrast, infectious diseases consultants are divided about the role of routine surveillance cultures in multidrug-resistant organism management, and few work in hospitals that use them.

Descriptive Epidemiology and Case-Control Study of Patients Colonized With Vancomycin-Resistant Enterococcus and Methicillin-ResistantStaphylococcus aureus

Background.

Patients colonized or infected with vancomycin-resistant enterococcus and methicillin-resistantStaphylococcus aureusmay be at risk of acquiring vancomycin-resistantS. aureusif the vanA gene is transferred from vancomycin-resistant enterococcus to methicillin-resistantS. aureus..

Objective.

Our goal was to identify risk factors for cocolonization or coinfection (CC/CI) with vancomycin-resistant enterococcus and methicillin-resistantS. aureus.

Design.

We conducted a descriptive, epidemiologic study of all patients with CC/CI identified from January 1998 to May 2003 and a nested case-control study of a cohort of patients hospitalized in the burn and wound unit.

Setting.

We conducted our study in a 813-bed tertiary care university teaching hospital.

Population.

The study population consisted of patients found to have CC/CI during the study period.

Methods.

Descriptive epidemiologic data were collected from hospital records of all patients identified as having CC/CI. A subset of patients hospitalized in the burn and wound unit were included in a case-control study.

Results.

CC/CI was detected in 71% of the patients during a single hospital stay. The burn and wound unit, which does active surveillance for both organisms, and the general medicine unit, which does not do active surveillance for either organism, cared for more than one-half of these patients. Among patients being cared for in the burn and wound unit, having exposure to 2 or more invasive devices (central venous catheters, indwelling urinary catheters, and enteral feeding tubes) and renal insufficiency were independent risk factors for CC/CI.

Conclusions.

Patients with CC/CI are the population at greatest risk for vancomycin-resistantS. aureuscolonization or infection. The number of invasive devices to which patients are exposed and, thus, possibly the patients' underlying severity of illness, as well as renal insufficiency, appear to be risk factors for CC/CI.

Colonization with Multi-Drug Resistant Organisms in Nursing Homes: Scope, Importance, and Management

Bacterial infections are among the most common causes of morbidity and mortality in Nursing Homes (NH) and other long term care facilities. Multi-drug resistant organisms (MDROs) represent an ever-increasing share of causative agents of infection, and their prevalence in NHs is now just as high as in acute-care facilities, or even higher. Indeed, NHs are now considered a major reservoir of MDROs for the community at large. Asymptomatic colonization is usually a prerequisite to development of symptomatic infection. While progress has been made in defining epidemiology of MDROs in NHs, few studies have evaluated the role of changing healthcare delivery in introducing and further transmitting MDROs in this setting. Furthermore, the factors influencing the spread of colonization and the key prognostic indicators leading to symptomatic infections in the burgeoning short stay population need to be explored further. The difficulty of this task lies in the heterogeneity of NHs in terms of focus of care, organization and resources, and on the diversity among the many MDRO species encountered, which harbor different resistance genes and with a different prevalence depending on the geographic location, local antimicrobial pressure and residents risk factors such as use of indwelling devices, functional disability, wounds and other comorbidities. We present literature findings on the scope and importance of colonization as a pathway to infection with MDROs in NHs, underline important open questions that need further research, and discuss the strength of the evidence for current and proposed screening, prevention, and management interventions.

Comparison of Vancomycin and Cefuroxime for Infection Prophylaxis in Coronary Artery Bypass Surgery

OBJECTIVE: To investigate clinically significant differences between vancomycin and cefuroxime for perioperative infection prophylaxis in coronary artery bypass surgery.

DESIGN: A total of 884 patients were randomized prospectively to receive either cefuroxime (444) or van-comycin (440) and were assessed for infectious complications during hospitalization and 1 month postoperatively.

SETTING: A university hospital.

RESULTS: The overall immediate surgical-site infection rate was 3.2% in the cefuroxime group and 3.5% in the vancomycin group (difference, −0.3; 95% confidence interval, −2.6-2.1).

CONCLUSIONS: The data suggest that vancomycin has no clinically significant advantages over cephalosporin in terms of antimicrobial prophylaxis. We suggest that cefuroxime (or first-generation cephalosporins, which were not studied here) is a good choice for infection prophylaxis in connection with coronary artery bypass surgery in institutions without methicillin-resistantStaphylococcus aureusproblems. In addition to the increasing vancomycin-resistant enterococci problem, the easier administration and usually lower price of cefuroxime make it preferable to vancomycin.

Vancomycin Control Measures at a Tertiary-Care Hospital: Impact of Interventions on Volume and Patterns of use

OBJECTIVE: Evaluate vancomycin prescribing patterns in a tertiary-care hospital before and after interventions to decrease vancomycin utilization.

DESIGN: Before/after analysis of interventions to limit vancomycin use.

SETTING: 420-bed academic tertiary-care center.

INTERVENTIONS: Educational efforts began August 10, 1994, and involved lectures to medical house staff followed by mailings to all physicians and posting of guidelines for vancomycin use on hospital information systems. Active interventions began November 15, 1994, and included automatic stop orders for vancomycin at 72 hours, alerts attached to the medical record, and, for 2 weeks only, computer alerts to physicians following each vancomycin order. Parenteral vancomycin use was estimated from the hospital pharmacy database of all medication orders. Records of a random sample of 344 patients receiving van-comycin between May 1, 1994, and April 30, 1995, were reviewed for an indication meeting published guidelines.

RESULTS: Vancomycin prescribing decreased by 22% following interventions, from 8.5 to 6.8 courses per 100 discharges (P<.05). The estimated proportion of van-comycin ordered for an indication meeting published guidelines was 36.6% overall, with no significant change following interventions. However, during the 2 weeks that computer alerts were in place, 60% of vancomycin use was for an approved indication.

CONCLUSIONS: Parenteral vancomycin prescribing decreased significantly following interventions, but the majority of orders still were not for an indication meeting published guidelines. Further improvement in the appropriateness of vancomycin prescribing potentially could be accomplished by more aggressive interventions, such as computer alerts, or by targeting specific aspects of prescribing patterns.

Efficacy of Infection Control Strategies to Reduce Transmission of Vancomycin-Resistant Enterococci in a Tertiary Care Hospital in Korea: A 4-Year Follow-Up Study

To determine the effectiveness of infection control strategies to reduce transmission of vancomycin-resistant enterococci (VRE), a cohort study was performed in a university hospital. Contact precautions alone were not effective in reducing transmission of VRE. Strict isolation of affected patients in private rooms, in addition to use of contact precautions, showed a significantly improved reduction in the transmission of VRE.

Acquisition of Nosocomial Pathogens on Hands After Contact With Environmental Surfaces Near Hospitalized Patients

We examined the frequency of acquisition of bacterial pathogens on investigators' hands after contacting environmental surfaces near hospitalized patients. Hand imprint cultures were positive for one or more pathogens after contacting surfaces near 34 (53%) of 64 study patients, withStaphylococcus aureusand vancomycin-resistantEnterococcusbeing the most common isolates.

Emergence of Vancomycin-Resistant Enterococci in San Francisco Bay Area Hospitals During 1994 to 1998

Objective:

To determine the magnitude of van-comycin-resistant enterococci (VRE) in three counties in the San Francisco Bay area.

Design:

Active laboratory-based surveillance for VRE from January 1995 through December 1996 and a laboratory-based and hospital-based questionnaire survey for 1993 to 1994 and 1997 to 1998.

Setting:

All 33 general acute care hospitals in three counties in the San Francisco Bay area.

Participants:

Laboratories and infection control professionals serving these hospitals, and staff of the California Emerging Infections Program.

Results:

The number of hospitals reporting 1 or more patient clinical VRE isolates was 1 (3%) in 1993, 7 (21%) in 1994, 31 (94%) in 1995, and 33 (100%) in 1996 to 1998. The number of patient isolates increased from 1 in 1993 to 24 in 1994, 176 in 1995,429 in 1996, 730 in 1997, and 864 in 1998. Most VRE isolates in 1995 and 1996 were from urine and were not associated with serious clinical disease. However, the number of isolates from blood increased from 9 (6% of total) in 1995 to 44 (12% of the total) in 1996, 90 (14%) in 1997, and 100 (13%) in 1998.

Conclusions:

Our data document the rapid emergence and increase of VRE in all hospitals in three counties in the San Francisco Bay area during 1994 to 1998. Infection control measures for VRE together with antibiotic utilization programs should be implemented to limit further spread.

Nosocomial Infection Caused by Antibiotic-Resistant Organisms in the Intensive-Care Unit

Resistance to antimicrobial agents is an evolving process, driven by the selective pressure of heavy antibiotic use in individuals living in close proximity to others. The intensive care unit (ICU), crowded with debilitated patients who are receiving broad-spectrum antibiotics and being cared for by busy physicians, nurses, and technicians, serves as an ideal environment for the emergence of antibiotic resistance. Problem pathogens presently include multiply resistant gram-negative bacilli, methicillin-resistantStaphylococcus aureus, and the recently emerged vancomycin-resistant enterococci. The prevention of antimicrobial resistance in ICUs should focus on recognition via routine unit-based sur veillance, improved compliance with handwashing and barrier precautions, and antibiotic-use policies tailored to individual units within hospitals.

Adherence to and Outcomes Associated with a Clostridium difficile Guideline at a Large Teaching Institution

Purpose

The incidence and virulence of Clostridium difficile infection (CDI) has recently increased. National CDI treatment guidelines stratify patients based on clinical symptoms and recommend treatment based on severity of illness. In 2009, Advocate Lutheran General Hospital (Park Ridge, Illinois) adopted guidelines with treatment algorithms identical to the national guidelines. The purpose of this study was to determine whether patients were being treated in accordance with the CDI guidelines and whether adherence impacted patient outcomes.

Methods

This was a retrospective, descriptive study. Subjects were identified by CDI-associated ICD-9 codes from July 1, 2009 to June 30, 2011 and stratified by disease severity. Guideline adherence was assessed based on initial treatment selection, and subjects were then further categorized as undertreated (UT), overtreated (OT), or appropriately treated (AT). Secondary endpoints included need for therapy escalation, clinical cure, recurrence rates, 90-day all-cause mortality, proton pump inhibitor (PPI), and antimicrobial use.

Results

Two hundred fifty subjects totaling 324 encounters were analyzed. Overall guideline adherence was 42.9%. Adherence rates by CDI severity were mild-moderate, 53.9%; severe, 39.0%; and severe-complicated, 17.9% ( P < .001). Of all the subjects, 42.9% were AT, 30.9% were OT, and 26.2% were UT. Clinical outcomes between UT versus AT subjects were as follows: therapy escalation required, 34.1% versus 27.5% ( P = .289); clinical cure, 41.2% versus 55.7% ( P = .033); mortality, 24.7% versus 10.1% ( P = .003); and recurrence, 44.7% versus 24.8% ( P < .02). Clinical outcomes between AT versus OT subjects were as follows: therapy escalation required 27.5% versus 14.4% ( P < .02); clinical cure, 55.7% versus 66.7% ( P = .089); mortality, 10.1% versus 7.8% ( P = .553); recurrence, 24.8% versus 27.8% ( P = .871).

Conclusions

The majority of subjects were not treated according to CDI guidelines, particularly those with severe and severe-complicated disease. UT subjects had worse clinical outcomes and OT subjects failed to show significant improvements in clinical outcomes compared to AT subjects. Emphasis should be placed on CDI guideline adherence as this may be associated with improved outcomes.

[Bacterial colonization due to increased nurse workload in an intensive care unit]

INTRODUCTION

the rates of multiresistant bacteria colonization or infection (MRB+) development in intensive care units are very high. The aim of this study was to determine the possible association between the risk of development of nosocomial infections and increased daily nurse workload due to understaffing in intensive care unit.

METHODS

we included 168 patients. Intensity of workload and applied procedures to patients were scored with the Project de Recherché en Nursing and the Omega scores, respectively. The criteria used for infections were those defined by the Centers for Disease Control.

RESULTS

of the 168 patients, 91 (54.2%) were female and 77 (45.8%) were male patients. The mean age of female and male was 64.9±6.2 years and 63.1±11.9 years, respectively. The mean duration of hospitalization in intensive care unit was 18.4±6.1 days. Multiresistant bacteria were isolated from cultures of 39 (23.2%) patients. The development of MRB+ infection was correlated with length of stay, Omega 1, Omega 2, Omega 3, Total Omega, daily PRN, and Total PRN (p<0.05). There was no correlation between development of MRB+ infection with gender, age and Apache-II scores (p>0.05).

CONCLUSION

the risk of nosocomial infection development in an intensive care unit is directly correlated with increased nurse workload, applied intervention, and length of stay. Understaffing in the intensive care unit is an important health problem that especially affects care-needing patients. Nosocomial infection development has laid a heavy burden on the economy of many countries. To control nosocomial infection development in the intensive care unit, nurse workload, staffing level, and working conditions must be arranged.

Vancomycin-resistant Enterococcus faecium: report of two cases

Vancomycin-resistant Enterococci (VRE), especially Enterococcus faecium has emerged as an important nososcomial pathogen and represents a serious threat to patients with impaired host defense. Early detection of patients colonised or infected with VRE is an essential component of any hospital program designed to prevent nosocomial transmission of this organism. The authors report two cases of VRE isolated from blood and surgical site pus of two neonates admitted in the same neonatal unit, highlighting that early detection, prompt and appropriate infection control measures were keys to successful containment of this dreaded pathogen.

Bacterial colonization due to increased nurse workload in an intensive care unit

INTRODUCTION

The rates of multiresistant bacteria colonization or infection (MRB+) development in intensive care units are very high. The aim of this study was to determine the possible association between the risk of development of nosocomial infections and increased daily nurse workload due to understaffing in intensive care unit.

METHODS

We included 168 patients. Intensity of workload and applied procedures to patients were scored with the Project de Recherché en Nursing and the Omega scores, respectively. The criteria used for infections were those defined by the Centers for Disease Control.

RESULTS

Of the 168 patients, 91 (54.2%) were female and 77 (45.8%) were male patients. The mean age of female and male was 64.9 ± 6.2 years and 63.1 ± 11.9 years, respectively. The mean duration of hospitalization in intensive care unit was 18.4 ± 6.1 days. Multiresistant bacteria were isolated from cultures of 39 (23.2%) patients. The development of MRB+ infection was correlated with length of stay, Omega 1, Omega 2, Omega 3, Total Omega, daily PRN, and Total PRN (p < 0.05). There was no correlation between development of MRB+ infection with gender, age and APACHE-II scores (p > 0.05).

CONCLUSION

The risk of nosocomial infection development in an intensive care unit is directly correlated with increased nurse workload, applied intervention, and length of stay. Understaffing in the intensive care unit is an important health problem that especially affects care-needing patients. Nosocomial infection development has laid a heavy burden on the economy of many countries. To control nosocomial infection development in the intensive care unit, nurse workload, staffing level, and working conditions must be arranged.

Tolerability of cefazolin after immune-mediated hypersensitivity reactions to nafcillin in the outpatient setting

The objective of the present study was to assess the safety and tolerability of cefazolin therapy among patients with methicillin-sensitive Gram-positive bacterial infections who develop non-IgE-mediated hypersensitivity reactions (HSRs) to nafcillin. In this retrospective cohort analysis of the Outpatient Parenteral Antimicrobial Therapy program at the Massachusetts General Hospital from 2007 through 2013, we identified patients switched from nafcillin to cefazolin after an immune-mediated HSR. We reviewed patient demographics, details about the original HSR, and outcomes after the switch to cefazolin therapy. HSRs were classified by reaction type and likely mechanism. There were 467 patients treated with nafcillin, of which 60 (12.8%) were switched to cefazolin during their prescribed course. Of the 60 patients who transitioned to cefazolin, 17 (28.3%) were switched because of non-IgE-mediated HSRs. HSRs included maculopapular rash (n = 10), immune-mediated nephritis (n = 3), isolated eosinophilia (n = 2), immune-mediated hepatitis (n = 1), and a serum sickness-like reaction (n = 1). All but one patient (94.1%) who switched to cefazolin tolerated the drug with resolution of the HSR and completed their therapy with cefazolin. No patient experienced worsening of their rash or progressive organ dysfunction. With appropriate monitoring, therapy with cefazolin after non-IgE-mediated HSRs to nafcillin appears to be safe.

Identification of vancomycin-resistant enterococci clones and inter-hospital spread during an outbreak in Taiwan

BACKGROUND

In 2003, nosocomial infections caused by vancomycin-resistant enterococci (VRE) occurred rarely in Taiwan. Between 2003 and 2010, however, the average prevalence of vancomycin resistance among enterococci spp. increased from 2% to 16% in community hospitals and from 3% to 21% in medical centers of Taiwan. We used molecular methods to investigate the epidemiology of VRE in a tertiary teaching hospital in Taiwan.

METHODS

Between February 2009 and February 2011, rectal samples and infection site specimens were collected from all inpatients in the nephrology ward after patient consent was obtained. VRE strain types were determined by pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST).

RESULTS

A total of 59 vanA gene-containing VRE isolates (1 per patient) were obtained; 24 originated from rectal sample surveillance of patients who exhibited no symptoms (22 Enterococcus faecium and 2 Enterococcus faecalis), and 35 had developed infections over 3 days after admission (32 E. faecium, 2 E. faecalis, and 1 Enterococcus durans). The 59 VRE isolates demonstrated vancomycin minimum inhibitory concentrations (MICs) of ≥256 μg/m. The MIC range for linezolid, tigecycline, and daptomycin was 0.25-1.5 μg/mL, 0.032-0.25 and 1-4 μg/mL, respectively. For 56 isolates, the MIC for teicoplanin was >8 μg/mL. The predominant types in the nephrology ward were MLST types 414, 78, and18 as well as PFGE types A, C, and D.

CONCLUSION

VREs are endemic in nephrology wards. MLST 414 is the most predominant strain. The increase VRE prevalence is due to cross-transmission of VRE clones ST 414,78,18 by undetected VRE carriers. Because similar VRE STs had been reported in a different hospital of Taiwan, this finding may indicate inter-hospital VRE spread in Taiwan. Active surveillance and effective infection control policies are important controlling the spread of VRE in high risk hospital zones. All endemic VRE strains are resistant to teicoplanin but are sensitive to daptomycin, linezolid, and tigecycline.

Clostridium difficile-associated diarrhea in dialysis patients

BACKGROUND

Dialysis patients have impaired host defense mechanisms and frequently require antibiotics for various infective complications. In this study, we investigated whether dialysis patients have greater risk for Clostridium difficile-associated diarrhea (CDAD).

METHODS

During the 4-year study period (2004-2008), 85 patients with CDAD were identified based on a retrospective review of C difficile toxin assay or histology records. Nosocomial diarrheal patients without CDAD were considered as controls (n=403). We assessed the association between renal function and the prevalence and clinical outcomes of CDAD.

RESULTS

There was a significant difference in the prevalence rate of chronic kidney disease (CKD) between CDAD and non-CDAD patients (P<0.001). Sixteen patients (18.8%) of the CDAD group were treated with dialysis, whereas 21 patients (5.2%) of the non-CDAD group were treated with dialysis. There was a significant association between renal function and CDAD in patients on dialysis [odds ratio (OR)=4.44, 95% confidence interval (CI) 2.19-8.99, P<0.001], but not in patients with CKD stage 3-5 (OR=1.10, 95% CI 0.63-1.92, P=0.73). In multivariate analysis, CKD stage 5D was an independent risk factor for the development of CDAD (OR=13.36, 95% CI 2.94-60.67, P=0.001).

CONCLUSION

Our data indicate that dialysis patients might be at a greater risk of developing CDAD, which suggests that particular attention should be provided to CDAD when antibiotic treatment is administered to dialysis patients.

Genetic characterization of a vancomycin-resistant Staphylococcus aureus isolate from the respiratory tract of a patient in a university hospital in northeastern Iran

Emergence of vancomycin-intermediate Staphylococcus aureus (VISA) and vancomycin-resistant S. aureus (VRSA) strains has led to global concerns about treatments for staphylococcal infections. These strains are currently rare even though there is an upward trend in their reported incidence. Therefore, appropriate screening and epidemiological evaluation of VRSA strains can affect future global health care policies. Isolates of Staphylococcus aureus were obtained from various clinical samples and were then evaluated with agar screening, disk diffusion, and MIC methods to determine resistance to vancomycin and methicillin. After confirmation of the isolated VRSA strain, genetic analysis was performed by evaluating mecA and vanA gene presence, SCCmec, agr, and spa types, and toxin profiles. Multilocus sequence typing (MLST) and plasmid analysis were also performed. The VRSA strain was resistant to oxacillin (MIC of 128 μg/ml) and vancomycin (MIC of 512 μg/ml). Disk diffusion antimicrobial susceptibility tests showed resistance to oxacillin, vancomycin, levofloxacin, ciprofloxacin, trimethoprim-sulfamethoxazole, clindamycin, rifampin, and tetracycline. The isolate was susceptible to minocycline and gentamicin. PCRs were positive for the mecA and vanA genes. Other genetic characteristics include SCCmec type III, agr I, spa type t037, and sequence type (ST) 1283. The plasmid profile shows five plasmids with a size of ~1.7 kb to >10 kb. The isolated VRSA strain was obtained from a critically ill hospitalized patient. Genetic analysis of this strain suggested that the strain was a methicillin-resistant S. aureus (MRSA) clone endemic in Asia that underwent some genetic changes, such as mutation in the gmk gene and acquisition of the vanA gene.

Rates and appropriateness of antimicrobial prescribing at an academic children's hospital, 2007-2010

OBJECTIVE AND DESIGN

Antimicrobial use in hospitalized children has not been well described. To identify targets for antimicrobial stewardship interventions, we retrospectively examined pediatric utilization rates for 48 antimicrobials from 2007 to 2010 as well as appropriateness of vancomycin and cefepime use in 2010.

PATIENTS AND SETTING

All children hospitalized between 2007 and 2010 at the Mayo Clinic Children's Hospital, a 120-bed facility within a larger adult hospital in Rochester, Minnesota.

METHODS

We calculated antimicrobial utilization rates in days of therapy per 1,000 patient-days. Details of vancomycin and cefepime use in 2010 were abstracted by chart review. Two pediatric infectious disease physicians independently assessed appropriateness of antibiotic use.

RESULTS

From 2007 to 2010, 9,880 of 17,242 (57%) hospitalized children received 1 or more antimicrobials. Antimicrobials (days of therapy per 1,000 patient-days) used most frequently in 2010 were cefazolin (97.8), vancomycin (97.1), fluconazole (76.4), piperacillin-tazobactam (70.7), and cefepime (67.6). Utilization rates increased significantly from 2007 to 2010 for 10 antimicrobials, including vancomycin, fluconazole, piperacillin-tazobactam, cefepime, trimethoprim-sulfamethoxazole, caspofungin, and cefotaxime. In 2010, inappropriate use of vancomycin and cefepime was greater in the pediatric intensive care unit than ward (vancomycin: 17.8% vs 6.4%, P = .001; cefepime: 9.2% vs 3.9%, P = .142) and on surgical versus medical services (vancomycin: 20.5% vs 8.0%, P = .001; cefepime: 19.4% vs 3.4%, P ≤ .001). The most common reason for inappropriate antibiotic use was failure to discontinue or de-escalate therapy.

CONCLUSIONS

In our children's hospital, use of 10 antimicrobials increased during the study period. Inappropriate use of vancomycin and cefepime was greatest on the critical care and surgical services, largely as a result of failure to de-escalate therapy, suggesting targets for future antimicrobial stewardship interventions.