Association of Acid Suppression and Antimicrobial Use with Clostridium difficile Infection in Children

Background

Clostridium difficileinfections (CDIs) can cause severe diarrhea and be potentially life-threatening, especially in children. Possible risk factors include age, being immunocompromised, prior antibiotic exposure, the use of antacids, and diseases that alter intestinal microbiota. Data in adults are vast while limited data is available in children. The objectives of this study are to identify pediatric risk factors and determine if an association between acid suppression and CDI’s in children exists.

Methods

A retrospective study was conducted between November 1, 2013 and October 31, 2016 at Arkansas Children’s Hospital. Children ages 1 – 18 years with a positive C. diff PCR test and ≥3 loose stools documented were included. Cases were excluded if previous positive PCR was within 60 days. Data collection included age, sex, encounter type (inpatient or outpatient), acid suppressing agents, previous antimicrobials within last 90 days and comorbidities including transplant, chronic pulmonary, hematology/oncology, and GI tract diseases. Statistical methods included descriptive analyses, χ²test, and Kruskal–Wallis test.

Results

A total of 139 cases of CDI among 123 patients were evaluated. Of these cases, the median (IQR) age is 8 years (3–13) with 77 (55.4%) being male and 86 (61.9%) of CDI cases identified inpatient of which 75 came from outpatient. Pediatric risk factors identified in C. diff cases included exposure to acid suppressing agents [61 (43.9%)] and antimicrobials [98 (70.5%)] with 90 (64.7%) having ≥1 comorbidities. Cases having ≥1 comorbidities were found to be associated with previous antacid exposure (P < 0.0005) while antimicrobial(s) use was associated with CDI hospitalization (P = 0.001). Similarly, exposure to either antacid suppression or antimicrobials or both with comorbidities were found to have a significant association (P < 0.0005) and associated with CDI hospitalization (P = 0.001).

Conclusion

Exposure to acid suppression in patients with comorbidities was associated with increased risk of CDI. Antimicrobial usage was associated with increased risk for hospitalization due to CDI. As pediatric outpatient antimicrobial stewardship evolves, improving CDI rates can center on improving antimicrobial and acid suppressive agents usage.

Disclosures

All authors: No reported disclosures.

The effect of plasmapheresis on blood pressure in voluntary plasma donors

BACKGROUND AND OBJECTIVES

Donor plasmapheresis involves the removal of a weight-adjusted volume of plasma and the return of cellular components to the donor. Although plasma volume generally returns to normal, some residual effect on vital signs may be possible. This analysis was performed to determine the possible effects of plasmapheresis on blood pressure.

MATERIALS AND METHODS

A 16-week study was conducted to evaluate the effects of plasma donations on cholesterol levels in healthy donors. From this study, the vital signs obtained prior to donation were analysed using statistical and dynamic analytical predictive models.

RESULTS

Preliminary analyses revealed a change in systolic and diastolic blood pressure from the corresponding baseline values (Pearson Coefficient -0.44 and -0.47, respectively). Statistical models predicted a marked decrease in systolic and diastolic blood pressure following multiple donations in donors with baseline pressure in the Stage 2 hypertension range with less pronounced decreases predicted in Stage 1 donors. Little or no change in blood pressure was predicted in donors with baseline normal blood pressure or prehypertension. Dynamic models including time between donations supported these results and predicted a recovery period of about 14 days without donation in donors with Stage 2 baseline levels.

CONCLUSIONS

Results suggest that systolic and diastolic blood pressure may be decreased following plasmapheresis used for plasma donations at intervals of <14 days in donors with high baseline blood pressure levels.

Parental perceptions about required influenza immunization of pediatric healthcare personnel

Annual influenza vaccination is recommended for all healthcare personnel (HCP). During 2010-2011, a cross-sectional design was used to survey 372 parents of hospitalized children regarding their influenza vaccination perceptions. Independent of their feelings regarding vaccine safety and efficacy, 76% of parents felt that annual influenza vaccination should be required for HCP.

Prospective multicentre study of the effect of voluntary plasmapheresis on plasma cholesterol levels in donors

Background and Objectives LDL apheresis is used to treat patients with familial hypercholesterolaemia, and low-volume plasmapheresis for plasma donation may similarly lower cholesterol levels in some donors. This study was designed to assess the effect of plasmapheresis on total, LDL and HDL cholesterol levels in a plasma donor population.

Materials and Methods This was a prospective, unblinded longitudinal cohort study in which a blood sample was obtained for analysis before each donation. Data from 663 donors were analysed using a multivariable repeated measures regression model with a general estimating equations approach with changes in cholesterol as the primary outcome measure.

Results The model predicted a significant decrease in total and LDL cholesterol for both genders and all baseline cholesterol levels (P < 0·01). The greatest total cholesterol decreases (women, −46·8 mg/dL; men, −32·2 mg/dL) were associated with high baseline levels and 2–4 days between donations. Small but statistically significant increases (P ≤ 0·01) in HDL cholesterol were predicted for donors with low baseline levels.

Conclusions These results suggest that, in donors with elevated baseline cholesterol levels, total and LDL cholesterol levels may decrease during routine voluntary plasmapheresis.

Fluosol DA-20 in the treatment of severe anemia: randomized, controlled study of 46 patients

We evaluated the safety and efficacy of Fluosol DA-20% (FDA) as a blood substitute in the treatment of severe anemia. Thirty-six patients received either FDA (n = 21) or crystalloid/hydroxyethyl starch (CHS) (n = 15) as part of a randomized, controlled trial. Ten patients received FDA as part of a humanitarian protocol. All were Jehovah's Witnesses who refused transfusion, had bled recently, and had average Hgb levels of 4.3 g/dl. After pulmonary artery catheter insertion, each patient was infused with CHS to attain a pulmonary artery wedge pressure (WP) of 10 to 18 mm Hg. FDA was given as a one-time dose of 30 ml/kg. Data were collected at baseline, 12, 24, and 48 h. None of the patients with negative reactions to a 0.5-ml test dose of FDA had adverse reactions to the subsequent infusion. The plasma or dissolved component of oxygen content was significantly higher in the FDA group at 12 h (FDA group 1.58 +/- 0.47 ml/dl, control group 1.01 +/- 0.31 ml/dl, p less than .02, t-test). Nineteen patients died: 12 (37.5%) FDA, seven (46.6%) control. The difference was not significant. We conclude the following: a) FDA can be given safely to severely anemic patients in doses of 30 ml/kg; b) FDA significantly increased the dissolved component of oxygen content after 12 h but the effect did not persist; c) severely anemic patients can survive without transfusion although mortality is high. In this study, inability of FDA to sustain increased oxygen content was due in part to the rapid elimination of FDA and also to the limited amount given.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of controlled-released morphine on quality of life for cancer pain

Oncology nursing is concerned with pain relief and overall Quality of Life (QOL). The purpose of this study was to determine the effects of controlled-release morphine on QOL for patients with cancer. Eighty-three subjects were randomly assigned in a clinical trial of short-acting versus controlled-release analgesia (MS Contin, Purdue Frederick Co., Norwalk, CT). Data was collected in a repeated measures design every 2 weeks for 6 weeks yielding a total of 240 visits. Five instruments were used to assess QOL, pain, and functional status. Study findings indicate improved pain management with controlled-release MS Contin and important nursing implications for the management of analgesia-induced gastrointestinal symptoms. Through appropriate pain management with pain therapies such as controlled-release analgesia, nurses can greatly enhance QOL for the patient with cancer.

Quality of life as an outcome variable in the management of cancer pain

Valid measurement tools are needed by oncology researchers to help in the evaluation of the effectiveness of pain relief methods used in the treatment of cancer patients. A study was conducted to assess the validity and reliability of a tool designed to evaluate quality of life as a measure of pain management outcome in the individual patient. Items in the tested quality of life survey represented the areas of psychologic well-being, physical well-being, general and specific symptom control, and degree of social support. Using the test instrument, two oncology nurses interviewed subjects in three groups, each consisting of 50 subjects: cancer patients with pain, cancer patients without pain, and subjects with no cancer. Statistical analysis of the interview results revealed that the instrument has test-retest reliability, internal consistency, and interrater reliability, as well as content and construct validity for the major factors, psychologic well-being, worry, and nutrition. Further revision of the instrument is needed to restructure its subscales. The quality of life tool will enable researchers to evaluate a treatment regarding not only its effect on pain intensity but also its impact on the total individual.

Quality of life as an outcome variable in the management of cancer pain

Valid measurement tools are needed by oncology researchers to help in the evaluation of the effectiveness of pain relief methods used in the treatment of cancer patients. A study was conducted to assess the validity and reliability of a tool designed to evaluate quality of life as a measure of pain management outcome in the individual patient. Items in the tested quality of life survey represented the areas of psychologic well-being, physical well-being, general and specific symptom control, and degree of social support. Using the test instrument, two oncology nurses interviewed subjects in three groups, each consisting of 50 subjects: cancer patients with pain, cancer patients without pain, and subjects with no cancer. Statistical analysis of the interview results revealed that the instrument has test-retest reliability, internal consistency, and interrater reliability, as well as content and construct validity for the major factors, psychologic well-being, worry, and nutrition. Further revision of the instrument is needed to restructure its subscales. The quality of life tool will enable researchers to evaluate a treatment regarding not only its effect on pain intensity but also its impact on the total individual.

Effects of intravenously infused Fluosol-DA 20% in rats

Rats were injected with a fractionated 50 ml/kg dose of Fluosol-DA 20% with and without exposure to 100% oxygen. Animals were killed at 24, 43, 92, and 183 days post-treatment and samples taken for hematological, hepatic enzyme, histological, and perfluorochemical analyses. There were no significant differences in hemograms or hepatic enzyme findings between treatment and control groups. Differences in organ weights and histology were a result of perfluorochemical (PFC) accumulation in the tissues of treated animals. All changes were reversible. There were no effects from breathing high oxygen levels in either treatment or control animals.

Effects of Clostridium botulinum toxins on infant and adult mice

Toxic supernatants of many Clostridium botulinum type B isolates from various sources, especially those of isolates obtained from cases of infant botulism, appeared to more toxic in infant mice than in adult mice. The significance of this finding in diagnostic situations is discussed.

Action of Escherichia coli enterotoxin: adenylate cyclase behavior of intestinal epithelial cells in culture

Heat-labile enterotoxin preparations obtained from two enteropathogenic strains of Escherichia coli of porcine and human origin were shown to stimulate adenylate cyclase activity of human embryonic intestinal epithelial cells in culture. Comparable results were also obtained when cholera toxin was used. The degree of enzyme stimulation was proportional to the concentration of enterotoxin. Similar preparations from two strains of non-enterotoxigenic E. coli had no effect on adenylate cyclase activity. Cells exposed to enterotoxin could be washed after 1 min of contact time without altering the subsequent course of maximum adenylate cyclase activity, which was maintained for at least 18 h at 37 C. During long periods (18 h) of tissue culture incubation, the determination of adenylate cyclase activity was 200- to 300-fold more sensitive than quantitating fluid accumulation in the adult rabbit ileal loop model. Decreasing the incubation time appreciably reduced the sensitivity of the epithelial cells to enterotoxin. E. coli enterotoxin is an effective activator of nonintestinal adenylate cyclase systems. Treatment of KB and HEp-2 cell lines with enterotoxin also resulted in significant enzyme stimulation. The intestinal epithelial cell tissue culture model provides a sensitive homogenous biological system for studying the response of intestinal adenylate cyclase to enterotoxin while eliminating the numerous cellular and tissue components present in the ligated ileal loop model.

Membranes of Bacillus stearothermophilus: factors affecting protoplast stability and thermostability of alkaline phosphatase and reduced nicotinamide adenine dinucleotide oxidase

Protoplasts of Bacillus stearothermophilus NCA 1503-4R are resistant to osmotic rupture and are not sensitive to mechanical manipulation. Protoplast stability is maintained by divalent cations. The thermostability of protoplasts is enhanced when the cells are grown at elevated temperatures. The membrane content of the cell and the protein-to-lipid ratio of the membrane increases as the growth temperature is increased. The membrane-bound nicotinamide adenine dinucleotide (reduced form) oxidase system from cultures grown at 70 C was more thermostable than the same enzyme system from cultures grown at 55 C. Alkaline phosphatase was resistant to thermal inactivation in the intact protoplast. The extent of this protection is dependent on protoplast stability.