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Hsu C, Moore-Gillon C, Vithayathil M, Karim S. Pseudomembranous colitis and Parabacteroides distasonis bacteraemia: a rare clinical presentation. Clin J Gastroenterol 2024; 17:457-460. [PMID: 38483783 DOI: 10.1007/s12328-024-01939-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 02/13/2024] [Indexed: 05/26/2024]
Abstract
We present the case of a male with end-stage diabetic nephropathy on haemodialysis who initially presented with acute-on-chronic digital ulceration. While awaiting vascular intervention, he became septic with abdominal pain and diarrhoea. Flexible sigmoidoscopy confirmed pseudomembranous colitis secondary to Clostridium difficile. Blood cultures grew Parabacteroides distasonis, a Gram-negative gut anaerobe. Enterobacter cloacae, another Gram-negative anaerobic gut bacilli, was grown in colonic cultures and swabs of the digital ulcers. We hypothesise that the pseudomembranous colitis increased gut translocation and thus led to the systemic spread of both gut anaerobes. This is the first reported case of Parabacteroides distasonis bacteraemia in the context of Clostridium difficile infection. Our patient recovered with antibiotics and went on to have vascular intervention for his digital ulceration.
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Affiliation(s)
| | | | - Mathew Vithayathil
- Imperial College Healthcare NHS Trust, London, UK.
- Imperial College London, London, UK.
| | - Shwan Karim
- Imperial College Healthcare NHS Trust, London, UK
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Rohra S, Poojary A, Patil P, John S, Michael R, Johnson S, Pardeshi P. Surveillance and epidemiology of Clostridioides difficile infection using the national health surveillance network criteria: A 7-year study from Mumbai, India. Indian J Med Microbiol 2023; 46:100425. [PMID: 37945118 DOI: 10.1016/j.ijmmb.2023.100425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 05/24/2023] [Accepted: 07/03/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION Clostridioides difficile (CD) is a significant cause of morbidity and mortality. While considerable data is available in the developed world regarding Clostridioides difficile infection (CDI), Indian data is sparse especially using the standardized surveillance systems. AIM AND OBJECTIVES OF THE STUDY To identify the incidence, risk factors, and mortality rate associated with CDI in a tertiary care hospital based on the Laboratory-Identified (LabID) event criteria of the Centers for Disease Control and Prevention (CDC) National Health Surveillance Network (NHSN). MATERIALS AND METHODS During a 7- year prospective observational study, CDI was diagnosed using CD polymerase chain reaction (PCR). CDI Laboratory-Identified (LabID) events were classified using the CDC NHSN surveillance definition, and CDI incidence was calculated per 10,000 Patient Days (PDs). Clinical details were collected as part of healthcare-associated infection (HCAI) surveillance. Healthcare Facility-Onset (HO) and Community-Onset Healthcare Facility-Associated (CO-HCFA) incident CDI events were analyzed further. RESULTS Among 898 tested stool samples, 77 CDI LabID events were observed, with 68 being Incident events. Of 68 events, 76.5% (52/68), 19.1% (13/68), and 4.4% (3/68) were HO, Community-Onset (CO), and CO-HCFA CDI events respectively. The overall incidence of CDI events was 1.66 per 10,000 PDs. Risk factors observed were antibiotics exposure (100%), comorbidities (87.3%), antacids exposure (87.3%), age over 60 years (80%), and hospitalization within the past 6 months (67.3%). The crude mortality rate was 25.5% (14/55). CONCLUSION These findings highlight the predominance of HO-CDI and the need for further investigation into CO-CDI in the Indian context to identify at-risk populations. Utilizing standardized surveillance methods such as NHSN definitions can facilitate accurate disease burden estimation, trend monitoring, and meaningful comparisons with global data.
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Affiliation(s)
- Seema Rohra
- Department of Pathology and Microbiology, Breach Candy Hospital Trust, Second Floor, Annex wing, 60 A, Bhulabhai Desai Marg, Breach Candy, Cumballa Hill, Mumbai, Maharashtra, 400026, India.
| | - Aruna Poojary
- Department of Pathology and Microbiology, Breach Candy Hospital Trust, Second Floor, Annex wing, 60 A, Bhulabhai Desai Marg, Breach Candy, Cumballa Hill, Mumbai, Maharashtra, 400026, India.
| | - Priyanka Patil
- Department of Pathology and Microbiology, Breach Candy Hospital Trust, Second Floor, Annex wing, 60 A, Bhulabhai Desai Marg, Breach Candy, Cumballa Hill, Mumbai, Maharashtra, 400026, India.
| | - Sheeba John
- Department of Pathology and Microbiology, Breach Candy Hospital Trust, Second Floor, Annex wing, 60 A, Bhulabhai Desai Marg, Breach Candy, Cumballa Hill, Mumbai, Maharashtra, 400026, India.
| | - Runu Michael
- Department of Pathology and Microbiology, Breach Candy Hospital Trust, Second Floor, Annex wing, 60 A, Bhulabhai Desai Marg, Breach Candy, Cumballa Hill, Mumbai, Maharashtra, 400026, India.
| | - Sneha Johnson
- Department of Pathology and Microbiology, Breach Candy Hospital Trust, Second Floor, Annex wing, 60 A, Bhulabhai Desai Marg, Breach Candy, Cumballa Hill, Mumbai, Maharashtra, 400026, India.
| | - Pritam Pardeshi
- Department of Pathology and Microbiology, Breach Candy Hospital Trust, Second Floor, Annex wing, 60 A, Bhulabhai Desai Marg, Breach Candy, Cumballa Hill, Mumbai, Maharashtra, 400026, India.
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Deshpande A, Klompas M, Guo N, Imrey PB, Pallotta AM, Higgins T, Haessler S, Zilberberg MD, Lindenauer PK, Rothberg MB. Intravenous to Oral Antibiotic Switch Therapy Among Patients Hospitalized With Community-Acquired Pneumonia. Clin Infect Dis 2023; 77:174-185. [PMID: 37011018 PMCID: PMC10527888 DOI: 10.1093/cid/ciad196] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 03/09/2023] [Accepted: 03/30/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is a leading cause of hospital admissions and antimicrobial use. Clinical practice guidelines recommend switching from intravenous (IV) to oral antibiotics once patients are clinically stable. METHODS We conducted a retrospective cohort study of adults admitted with CAP and initially treated with IV antibiotics at 642 US hospitals from 2010 through 2015. Switching was defined as discontinuation of IV and initiation of oral antibiotics without interrupting therapy. Patients switched by hospital day 3 were considered early switchers. We compared length of stay (LOS), in-hospital 14-day mortality, late deterioration (intensive care unit [ICU] transfer), and hospital costs between early switchers and others, controlling for hospital characteristics, patient demographics, comorbidities, initial treatments, and predicted mortality. RESULTS Of 378 041 CAP patients, 21 784 (6%) were switched early, most frequently to fluoroquinolones. Patients switched early had fewer days on IV antibiotics, shorter duration of inpatient antibiotic treatment, shorter LOS, and lower hospitalization costs, but no significant excesses in 14-day in-hospital mortality or late ICU admission. Patients at a higher mortality risk were less likely to be switched. However, even in hospitals with relatively high switch rates, <15% of very low-risk patients were switched early. CONCLUSIONS Although early switching was not associated with worse outcomes and was associated with shorter LOS and fewer days on antibiotics, it occurred infrequently. Even in hospitals with high switch rates, <15% of very low-risk patients were switched early. Our findings suggest that many more patients could be switched early without compromising outcomes.
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Affiliation(s)
- Abhishek Deshpande
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Infectious Disease, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ning Guo
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Peter B Imrey
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | | | - Thomas Higgins
- Department of Medicine, Division of Pulmonary Critical Care Medicine, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA
| | - Sarah Haessler
- Department of Medicine, Division of Infectious Diseases, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA
| | | | - Peter K Lindenauer
- Institute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA
| | - Michael B Rothberg
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio, USA
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Guo Y, Ashley ED. Is the standardized antibiotic administration ratio (SAAR) ready for prime time? ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e127. [PMID: 37502235 PMCID: PMC10369436 DOI: 10.1017/ash.2023.186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/08/2023] [Accepted: 05/08/2023] [Indexed: 07/29/2023]
Abstract
The standardized antibiotic administration ratio (SAAR) enables comparison of antibiotic use (AU) within and between hospitals and identifies target locations and antimicrobials for stewardship interventions. Thousands of institutions have already been submitting AU to the National Healthcare Safety Network. We highlight the benefits and meaningful utilization of SAAR in conjunction with antimicrobial stewardship interventions to improve antimicrobial prescribing in the clinical setting.
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Affiliation(s)
- Yi Guo
- Department of Pharmacy, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Elizabeth Dodds Ashley
- Division of Infectious Diseases & International Health, Duke University School of Medicine, Durham, NC, USA
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Hooper GA, Klippel CJ, McLean SR, Stenehjem EA, Webb BJ, Murnin ER, Hough CL, Bledsoe JR, Brown SM, Peltan ID. Concordance Between Initial Presumptive and Final Adjudicated Diagnoses of Infection Among Patients Meeting Sepsis-3 Criteria in the Emergency Department. Clin Infect Dis 2023; 76:2047-2055. [PMID: 36806551 PMCID: PMC10273369 DOI: 10.1093/cid/ciad101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/21/2023] [Accepted: 02/16/2023] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND Guidelines emphasize rapid antibiotic treatment for sepsis, but infection presence is often uncertain at initial presentation. We investigated the incidence and drivers of false-positive presumptive infection diagnosis among emergency department (ED) patients meeting Sepsis-3 criteria. METHODS For a retrospective cohort of patients hospitalized after meeting Sepsis-3 criteria (acute organ failure and suspected infection including blood cultures drawn and intravenous antimicrobials administered) in 1 of 4 EDs from 2013 to 2017, trained reviewers first identified the ED-diagnosed source of infection and adjudicated the presence and source of infection on final assessment. Reviewers subsequently adjudicated final infection probability for a randomly selected 10% subset of subjects. Risk factors for false-positive infection diagnosis and its association with 30-day mortality were evaluated using multivariable regression. RESULTS Of 8267 patients meeting Sepsis-3 criteria in the ED, 699 (8.5%) did not have an infection on final adjudication and 1488 (18.0%) patients with confirmed infections had a different source of infection diagnosed in the ED versus final adjudication (ie, initial/final source diagnosis discordance). Among the subset of patients whose final infection probability was adjudicated (n = 812), 79 (9.7%) had only "possible" infection and 77 (9.5%) were not infected. Factors associated with false-positive infection diagnosis included hypothermia, altered mental status, comorbidity burden, and an "unknown infection source" diagnosis in the ED (odds ratio: 6.39; 95% confidence interval: 5.14-7.94). False-positive infection diagnosis was not associated with 30-day mortality. CONCLUSIONS In this large multihospital study, <20% of ED patients meeting Sepsis-3 criteria had no infection or only possible infection on retrospective adjudication.
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Affiliation(s)
- Gabriel A Hooper
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Carolyn J Klippel
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
| | - Sierra R McLean
- University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Physical Medicine and Rehabilitation, University of North Carolina Health, Chapel Hill, North Carolina, USA
| | - Edward A Stenehjem
- Division of Infectious Diseases and Epidemiology, Department of Medicine, Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Brandon J Webb
- Department of Medicine, University of Wisconsin School of Medicine, Madison, Wisconsin, USA
| | - Emily R Murnin
- University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Medicine, University of Wisconsin School of Medicine, Madison, Wisconsin, USA
| | - Catherine L Hough
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Joseph R Bledsoe
- Department of Emergency Medicine, Intermountain Medical Center, Murray, Utah, USA
- Department of Emergency Medicine, Stanford University, Palo Alto, California, USA
| | - Samuel M Brown
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ithan D Peltan
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Mokrani D, Chommeloux J, Pineton de Chambrun M, Hékimian G, Luyt CE. Antibiotic stewardship in the ICU: time to shift into overdrive. Ann Intensive Care 2023; 13:39. [PMID: 37148398 PMCID: PMC10163585 DOI: 10.1186/s13613-023-01134-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 04/20/2023] [Indexed: 05/08/2023] Open
Abstract
Antibiotic resistance is a major health problem and will be probably one of the leading causes of deaths in the coming years. One of the most effective ways to fight against resistance is to decrease antibiotic consumption. Intensive care units (ICUs) are places where antibiotics are widely prescribed, and where multidrug-resistant pathogens are frequently encountered. However, ICU physicians may have opportunities to decrease antibiotics consumption and to apply antimicrobial stewardship programs. The main measures that may be implemented include refraining from immediate prescription of antibiotics when infection is suspected (except in patients with shock, where immediate administration of antibiotics is essential); limiting empiric broad-spectrum antibiotics (including anti-MRSA antibiotics) in patients without risk factors for multidrug-resistant pathogens; switching to monotherapy instead of combination therapy and narrowing spectrum when culture and susceptibility tests results are available; limiting the use of carbapenems to extended-spectrum beta-lactamase-producing Enterobacteriaceae, and new beta-lactams to difficult-to-treat pathogen (when these news beta-lactams are the only available option); and shortening the duration of antimicrobial treatment, the use of procalcitonin being one tool to attain this goal. Antimicrobial stewardship programs should combine these measures rather than applying a single one. ICUs and ICU physicians should be at the frontline for developing antimicrobial stewardship programs.
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Affiliation(s)
- David Mokrani
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Juliette Chommeloux
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Marc Pineton de Chambrun
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Guillaume Hékimian
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Charles-Edouard Luyt
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France.
- Sorbonne Université, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
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Siewierska M, Gajda M, Opalska A, Brudło M, Krzyściak P, Gryglewska B, Różańska A, Wójkowska-Mach J. Hospital antibiotic consumption-an interrupted time series analysis of the early and late phases of the COVID-19 pandemic in Poland, a retrospective study. Pharmacol Rep 2023; 75:715-725. [PMID: 37017868 PMCID: PMC10073786 DOI: 10.1007/s43440-023-00479-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/16/2023] [Accepted: 03/17/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND COVID-19 has been challenging for the entire healthcare system, due to the lack of sufficient treatment protocols, especially during initial phases and as regards antibiotic use. The aim of this study was to identify the trends of antimicrobial consumption in one of the largest tertiary hospitals in Poland during COVID-19. METHODS This is a retrospective study conducted at the University Hospital in Krakow, Poland, between Feb/Mar 2020 and Feb 2021. It included 250 patients. All included patients were hospitalized due to COVID-19 with confirmed SARS-CoV-2 infection without bacterial co-infections during the first phase of COVID-19 in Europe and following 3-month intervals: five equal groups of patients in each. COVID severity and antibiotic consumption were assessed according to WHO recommendations. RESULTS In total 178 (71.2%) patients received antibiotics with a incidence rate of laboratory-confirmed healthcare-associated infection (LC-HAI) was 20%. The severity of COVID-19 was mild in 40.8%, moderate in 36.8%, and severe in 22.4% cases. The ABX administration was significantly higher for intensive care unit (ICU) patients (97.7% vs. 65.7%). Length of hospital stay was extended for patients with ABX (22.3 vs. 14.4 days). In total, 3 946.87 DDDs of ABXs were used, including 1512.63 DDDs in ICU, accounting for 780.94 and 2522.73 per 1000 hospital days, respectively. The median values of antibiotic DDD were greater among patients with severe COVID-19 than others (20.92). Patients admitted at the beginning of the pandemic (Feb/Mar, May 2020) had significantly greater values of median DDDs, respectively, 25.3 and 16.0 compared to those admitted in later (Aug, Nov 2020; Feb 2021), respectively, 11.0, 11.0 and 11.2, but the proportion of patients receiving ABX therapy was lower in Feb/Mar and May 2020 (62.0 and 48.0%), whereas the highest during the late period of the pandemic, i.e., in Aug, Nov. 2020 and Feb. 2021 (78% and both 84.0%). CONCLUSIONS Data suggest great misuse of antibiotics without relevant data about HAIs. Almost all ICU patients received some antibiotics, which was correlated with prolonged hospitalization.
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Affiliation(s)
| | - Mateusz Gajda
- Department of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Aleksandra Opalska
- Directorate-General for Health and Food Safety, European Commission, Brussels, Belgium
- Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Michał Brudło
- Department of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Paweł Krzyściak
- Department of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Barbara Gryglewska
- Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, Kraków, Poland
- Department of Internal Medicine and Geriatrics, University Hospital, Kraków, Poland
| | - Anna Różańska
- Department of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Jadwiga Wójkowska-Mach
- Department of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland.
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Sustained reductions in unnecessary antimicrobial administration and hospital Clostridioides difficile rates via stewardship in a nonacademic setting. Infect Control Hosp Epidemiol 2023; 44:491-493. [PMID: 34915961 DOI: 10.1017/ice.2021.490] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
A large community hospital sought to reduce its burden of hospital-acquired Clostridioides difficile infection (CDI). We implemented an antimicrobial stewardship program (ASP), resulting in marked reductions in unnecessary antimicrobial use, CDI rates, antimicrobial acquisition costs, with preservation of gram-negative susceptibilities. ASP programs are effective in a community setting.
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Shiode J, Fujii M, Nasu J, Itoh M, Ishiyama S, Fujiwara A, Yoshioka M. Correlation between hospital-onset and community-onset Clostridioides difficile infection incidence: Ward-level analysis following hospital relocation. Am J Infect Control 2022; 50:1240-1245. [PMID: 35167897 DOI: 10.1016/j.ajic.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/05/2022] [Accepted: 02/07/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The development of hospital-onset Clostridioides difficile infection (HO-CDI) is affected by patient and environmental risk factors. We investigated changes in the incidence of HO-CDI after relocation to a newly built hospital with 50% private rooms and evaluated the associated factors. METHODS A retrospective study was conducted to assess trends in CDI incidences before and after the relocation using segmented regression analysis model. The association between CDI incidence and environmental factors at the ward-level was assessed using a linear regression analyses model. RESULTS The HO-CDI incidence decreased from 6.14 to 1.17 per 10,000 patient-days in the old and new hospital, respectively. Similarly, the community-onset CDI (CO-CDI) incidence decreased from 1.71 to 0.46 per 1000 admissions. HO-CDI incidence was positively correlated with CO-CDI incidence and inversely correlated with the private room ratio (adjusted R2 = 0.83). Almost half of the CO-CDI patients had been hospitalized within 28 days preceding the onset. DISCUSSION Environmental improvements after relocation may have reduced the reservoir of C. difficile, resulting in a decrease in the number of asymptomatic carriers and CO-CDI patients. CONCLUSION Relocation to a new hospital significantly reduced HO-CDI incidence, concomitantly decreasing the incidence of CO-CDI, potentially due to environmental improvements.
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Affiliation(s)
- Junji Shiode
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Japan.
| | - Masakuni Fujii
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Japan
| | - Junichiro Nasu
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Japan
| | - Mamoru Itoh
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Japan
| | - Shuhei Ishiyama
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Japan
| | - Akiko Fujiwara
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Japan
| | - Masao Yoshioka
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Japan
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Effect of Reduced Fluoroquinolone Use on Cephalosporin Use, Susceptibilities and Clostridioides difficile Infections. Antibiotics (Basel) 2022; 11:antibiotics11101312. [PMID: 36289969 PMCID: PMC9598913 DOI: 10.3390/antibiotics11101312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/20/2022] [Accepted: 09/23/2022] [Indexed: 11/21/2022] Open
Abstract
Background: Overuse of fluoroquinolones has led to concerning rates of resistance, particularly among Gram-negative organisms. They are also highly implicated as a risk factor for Clostridioides difficile infection, and reports of other serious adverse events led to recommendations to restrict their use. Our health system began targeting the reduction in unnecessary fluoroquinolone prescribing in 2018, aiming to promote their safe and effective use. Broad-spectrum cephalosporins are often used as an alternative to fluoroquinolones. We sought to evaluate whether decreased fluoroquinolone use was associated with increased third- and fourth-generation cephalosporin use and whether these changes in utilization impacted other outcomes, including C. difficile infection (CDI) rates and susceptibilities among Gram-negative organisms. Methods: This retrospective descriptive analysis included adult patients who received a fluoroquinolone or broad-spectrum cephalosporin in a three-year time period across a large healthcare system. The primary objective was to evaluate the change in days of therapy (DOT) of fluoroquinolones and third- and fourth-generation cephalosporins. Secondary objectives included rates of resistance among common Gram-negative organisms, CDI, and analyses stratified by antibiotic indication. Results: Cephalosporin use increased by an average of 1.70 DOT/1000 PD per month (p < 0.001). Additionally, fluoroquinolone use decreased by an average of 1.18 DOT/1000 PD per month (p < 0.001). C. difficile infections decreased by 0.37 infections/10,000 patient-days per month (p < 0.001). Resistance to fluoroquinolones remained stable from 2018 to 2020, and a declining trend was observed in 2021. Conclusion: This study demonstrated that reduced fluoroquinolone use in a large healthcare system was associated with increased usage of broad-spectrum cephalosporins, decreased CDI and improvements in resistance patterns.
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Perić A, Rančić N, Dragojević-Simić V, Milenković B, Ljubenović N, Rakonjac B, Begović-Kuprešanin V, Šuljagić V. Association between Antibiotic Use and Hospital-Onset Clostridioides difficile Infection in University Tertiary Hospital in Serbia, 2011–2021: An Ecological Analysis. Antibiotics (Basel) 2022; 11:antibiotics11091178. [PMID: 36139957 PMCID: PMC9495030 DOI: 10.3390/antibiotics11091178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 08/24/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022] Open
Abstract
This ecological study is the largest to date examining the association between rates of antibiotic use (AU) and hospital-onset (HO) Clostridioides difficile infection (CDI) in a tertiary university hospital in Serbia. There was no clear trend in the incidence of HO-CDI over time. Total utilization of antibacterials for systemic use increased from 38.57 DDD/100 bed-days (BD) in 2011 to 56.39 DDD/100 BD in 2021. The most commonly used antibiotics were third-generation cephalosporins, especially ceftriaxone, with maximum consumption in 2021 (19.14 DDD/100 BD). The share of the Access group in the total utilization of antibiotics ranged from 29.95% to 42.96% during the observed period. The utilization of the Reserve group of antibiotics indicated a statistically significant increasing trend (p = 0.034). A statistically significant difference in the consumption of medium-risk antibiotics from 2011 to 2021 was shown for penicillins and a combination of sulfamethoxazole and trimethoprim. The consumption of cefotaxime showed a statistically significant negative association with the rate of HO-CDI (r = −0.647; p = 0.031). Ampicillin and the combination of amoxicilline with clavulanic acid have shown a negative statistically significant correlation with the ID of HO-CDI (r = −0.773 and r = −0.821, respectively). Moreover, there was a statistically significant negative correlation between consumption of “medium-risk antibiotics” and the rate of HO-CDI (r = −0.677). The next challenging step for the hospital multidisciplinary team for antimicrobials is to modify the antibiotic list according to the Access, Watch, and Reserve classification, in such a way that at least 60% of the AU should be from the Access group, according to the World Health Organization recommendation.
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Affiliation(s)
- Aneta Perić
- Department for Pharmacy, Military Medical Academy, 11000 Belgrade, Serbia
- Medical Faculty, Military Medical Academy, University of Defence, 11000 Belgrade, Serbia
| | - Nemanja Rančić
- Medical Faculty, Military Medical Academy, University of Defence, 11000 Belgrade, Serbia
- Centre for Clinical Pharmacology, Military Medical Academy, 11000 Belgrade, Serbia
- Correspondence:
| | - Viktorija Dragojević-Simić
- Medical Faculty, Military Medical Academy, University of Defence, 11000 Belgrade, Serbia
- Centre for Clinical Pharmacology, Military Medical Academy, 11000 Belgrade, Serbia
| | - Bojana Milenković
- Department for Pharmacy, Military Medical Academy, 11000 Belgrade, Serbia
| | - Nenad Ljubenović
- Institute of Epidemiology, Military Medical Academy, 11000 Belgrade, Serbia
| | - Bojan Rakonjac
- Institute of Medical Microbiology, Military Medical Academy, 11000 Belgrade, Serbia
| | - Vesna Begović-Kuprešanin
- Medical Faculty, Military Medical Academy, University of Defence, 11000 Belgrade, Serbia
- Clinic for Infectious and Tropic Diseases, Military Medical Academy, 11000 Belgrade, Serbia
| | - Vesna Šuljagić
- Medical Faculty, Military Medical Academy, University of Defence, 11000 Belgrade, Serbia
- Department of Healthcare-Related Infection Control, Military Medical Academy, 11000 Belgrade, Serbia
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12
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Schnizlein MK, Young VB. Capturing the environment of the Clostridioides difficile infection cycle. Nat Rev Gastroenterol Hepatol 2022; 19:508-520. [PMID: 35468953 DOI: 10.1038/s41575-022-00610-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2022] [Indexed: 12/11/2022]
Abstract
Clostridioides difficile (formerly Clostridium difficile) infection is a substantial health and economic burden worldwide. Great strides have been made over the past several years in characterizing the physiology of C. difficile infection, particularly regarding how gut microorganisms and their host work together to provide colonization resistance. As mammalian hosts and their indigenous gut microbiota have co-evolved, they have formed a complex yet stable relationship that prevents invading microorganisms from establishing themselves. In this Review, we discuss the latest advances in our understanding of C. difficile physiology that have contributed to its success as a pathogen, including its versatile survival factors and ability to adapt to unique niches. Using discoveries regarding microorganism-host and microorganism-microorganism interactions that constitute colonization resistance, we place C. difficile within the fiercely competitive gut environment. A comprehensive understanding of these relationships is required to continue the development of precision medicine-based treatments for C. difficile infection.
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Affiliation(s)
- Matthew K Schnizlein
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, MI, USA
| | - Vincent B Young
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, MI, USA.
- Department of Internal Medicine/Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI, USA.
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13
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Schneider JE, Dick K, Cooper JT, Chami N. Pancreatic stone protein point-of-care testing can reduce healthcare expenditure in sepsis. HEALTH ECONOMICS REVIEW 2022; 12:39. [PMID: 35867213 PMCID: PMC9306195 DOI: 10.1186/s13561-022-00381-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/31/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Sepsis is a life-threatening organ dysfunction in response to infection. Early recognition and rapid treatment are critical to patient outcomes and cost savings, but sepsis is difficult to diagnose because of its non-specific symptoms. Biomarkers such as pancreatic stone protein (PSP) offer rapid results with greater sensitivity and specificity than standard laboratory tests. METHODS This study developed a decision tree model to compare a rapid PSP test to standard of care in the emergency department (ED) and intensive care unit (ICU) to diagnose patients with suspected sepsis. Key model parameters included length of hospital and ICU stay, readmission due to infection, cost of sepsis testing, length of antibiotic treatment, antibiotic resistance, and clostridium difficile infections. Model inputs were determined by review of sepsis literature. RESULTS The rapid PSP test was found to reduce costs by $1688 per patient in the ED and $3315 per patient in the ICU compared to standard of care. Cost reductions were primarily driven by the specificity of PSP in the ED and the sensitivity of PSP in the ICU. CONCLUSIONS The results of the model indicate that PSP testing is cost saving compared to standard of care in diagnosis of sepsis. The abundance of sepsis cases in the ED and ICU make these findings important in the clinical field and further support the potential of sensitive and specific markers of sepsis to not only improve patient outcomes but also reduce healthcare expenditures.
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Affiliation(s)
- John E Schneider
- Avalon Health Economics, 119 Washington Street, Morristown, NJ, 07960, USA
| | - Katherine Dick
- Avalon Health Economics, 119 Washington Street, Morristown, NJ, 07960, USA
| | - Jacie T Cooper
- Avalon Health Economics, 119 Washington Street, Morristown, NJ, 07960, USA.
| | - Nadine Chami
- Avalon Health Economics, 119 Washington Street, Morristown, NJ, 07960, USA
- Ontario Medical Association, Toronto, Ontario, Canada
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14
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Papanikolopoulou A, Maltezou HC, Gargalianos-Kakolyris P, Pangalis A, Pantazis N, Pantos C, Tountas Y, Tsakris A, Kantzanou M. Association between consumption of antibiotics, infection control interventions and Clostridioides difficile infections: Analysis of six-year time-series data in a tertiary-care hospital in Greece. Infect Dis Health 2022; 27:119-128. [PMID: 35153189 DOI: 10.1016/j.idh.2022.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/21/2021] [Accepted: 01/16/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND To investigate the association between Clostridioides difficile infection (CDI), antibiotic use, and infection control interventions, during an antibiotic stewardship program (ASP) implemented in a tertiary-care hospital in Greece from 2013 to 2018. METHODS Analysis was applied for the following monthly indices: 1. consumption of antibiotics; 2. use of hand hygiene disinfectant solutions; 3. percentage of isolations of patients either with multidrug-resistant (MDR) bacteria, or CDI, or admitted from another hospital; and 4. percentage of patients with CDI divided into two groups: community-acquired CDI (CACDI) and hospital-associated CDI (HACDI) (onset ≤72 h and >72 h after admission, respectively). RESULTS During the study, a significant reduction in CACDI rate from 0.3%/admissions [95% CI 0.1-0.6] to 0.1%/admissions [95% CI 0.0-0.3] (p-value = 0.035) was observed in adults ICU, while CDI rates were stable in the rest of the hospital. Antibiotic consumption showed a significant reduction in total hospital, from 91.7 DDDs [95% CI 89.7-93.7] to 80.1 DDDs [95% CI 79.1-81.1] (p-value<0.001), except adults ICU. Non-advanced antibiotics correlated with decreased CDI rates in Adults Clinic Departments and ICU. Isolation of patients one and two months earlier correlated with decreased CACDI rates per 20% [95% CI 0.64-1.00, p-value = 0.046] and HACDI per 23% [95% CI 0.60-1.00, p-value = 0.050] in Adults Clinic Departments. Consumption of disinfectant solutions current month correlated with decreased rate for CACDI per 33% [95% CI 0.49-0.91, p-value = 0.011] and HACDI per 38% [95% CI 0.40-0.98, p-value = 0.040] in total Hospital Clinics. CONCLUSION Rational antibiotic prescribing during ASP along with multipronged intervention strategy focusing on hand hygiene and patient isolation measures prevent and control CDI outbreaks in the hospital setting.
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Affiliation(s)
| | - Helena C Maltezou
- Directorate of Research, Studies and Documentation, National Public Health Organization, Athens, 15123 Greece.
| | | | - Anastasia Pangalis
- Biopathology Department, Athens Medical Center, Marousi, Athens, 15125 Greece
| | - Nikos Pantazis
- Department of Hygiene, Epidemiology and Medical Statistics, Faculty of Medicine, School of Health Sciences, National and Kapodistrian University of Athens, Athens, 15772 Greece
| | - Constantinos Pantos
- Department of Pharmacology, School of Medicine, National and Kapodistrian University of Athens, Athens, 15772 Greece
| | - Yannis Tountas
- Department of Hygiene, Epidemiology and Medical Statistics, Faculty of Medicine, School of Health Sciences, National and Kapodistrian University of Athens, Athens, 15772 Greece
| | - Athanasios Tsakris
- Department of Microbiology, School of Medicine, National and Kapodistrian University of Athens, Athens, 15772 Greece
| | - Maria Kantzanou
- Department of Hygiene, Epidemiology and Medical Statistics, Faculty of Medicine, School of Health Sciences, National and Kapodistrian University of Athens, Athens, 15772 Greece
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15
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A Rare Case of Pseudomembranous Colitis Presenting with Pleural Effusion and Ascites with Literature Review. Case Rep Gastrointest Med 2022; 2021:6019068. [PMID: 35003814 PMCID: PMC8741396 DOI: 10.1155/2021/6019068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 12/20/2021] [Indexed: 11/25/2022] Open
Abstract
Clostridium difficile infection usually results from long-term and irregular antibiotic intake. The high-risk individuals for this infection include the patients undergoing chemotherapy due to malignancy, immunocompromised patients, and hospitalized patients receiving broad-spectrum antibiotics. The most common clinical manifestation of Clostridium difficile infection is diarrhea. However, pleural effusion and ascites have rarely been observed. As mentioned, these manifestations can be developed in a patient being treated with broad-spectrum antibiotics. Therefore, the present study reports a rare case of Clostridium difficile infection manifesting with these rare manifestations who was a 78-year-old female patient with a history of COVID-19, orthopedic surgery, and antibiotic treatment with cefixime and gentamicin.
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16
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Okeah BO, Morrison V, Huws JC. Antimicrobial stewardship and infection prevention interventions targeting healthcare-associated Clostridioides difficile and carbapenem-resistant Klebsiella pneumoniae infections: a scoping review. BMJ Open 2021; 11:e051983. [PMID: 34348956 PMCID: PMC8340296 DOI: 10.1136/bmjopen-2021-051983] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 07/23/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES This study assessed antimicrobial stewardship (AMS) and infection prevention (IP) interventions targeting healthcare-associated Clostridioides difficile and carbapenem-resistant Klebsiella pneumoniae (CRKP) infections, their key outcomes and the application of behaviour change principles in these interventions. DESIGN This scoping review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines while focusing on acute healthcare settings in both low-to-middle income and high-income countries. DATA SOURCES The databases searched were MEDLINE, PubMed, Web of Science and CINAHL between 22 April 2020 and 30 September 2020. ELIGIBILITY The review included peer-reviewed articles published in English language between 2010 and 2019. Studies that focussed on IP and/or AMS interventions primarily targeting C. difficile or CRKP were included. Studies that assessed effectiveness of diagnostic devices or treatment options were excluded from this review. DATA EXTRACTION AND SYNTHESIS An abstraction sheet calibrated for this study was used to extract data on the main study characteristics including the population, intervention and outcomes of interest (antimicrobial use, compliance with IP interventions and risk for C. difficile and CRKP). A narrative synthesis of the results is provided. RESULTS The review included 34 studies. Analysis indicates that interventions targeting C. difficile and CRKP include Education, Surveillance/Screening, Consultations, Audits, Policies and Protocols, Environmental measures, Bundles, Isolation as well as Notifications or alerts (represented using the ESCAPE-BIN acronym). The identified outcomes include antimicrobial use, resistance rates, risk reduction, adherence to contact precautions, hospital stay and time savings. AMS and IP interventions tend to be more adhoc with limited application of behaviour change principles. CONCLUSION This scoping review identified the AMS and IP interventions targeting C. difficile and CRKP in healthcare settings and described their key outcomes. The application of behaviour change principles in AMS and IP interventions appears to be limited.
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Affiliation(s)
| | | | - Jaci C Huws
- School of Medical & Health Sciences, Bangor University, Bangor, UK
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17
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Chrysou K, Zarkotou O, Kalofolia S, Papagiannakopoulou P, Mamali V, Chrysos G, Themeli-Digalaki K, Sypsas N, Tsakris A, Pournaras S. Impact of a 4-year antimicrobial stewardship program implemented in a Greek tertiary hospital. Eur J Clin Microbiol Infect Dis 2021; 41:127-132. [PMID: 34264401 DOI: 10.1007/s10096-021-04290-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 06/09/2021] [Indexed: 01/22/2023]
Abstract
This study aimed to investigate the effects of a 4-year antibiotic stewardship program (ASP) in a tertiary hospital. We monitored data for 2015 (pre-intervention) and 2016-2019 (post-intervention) about antibiotic consumption (DDD/100 bed days), Clostridioides difficile infections (CDIs), resistance rates, length of stay (LOS), and annual antibiotic costs. Significant reductions were observed for total antibiotics/colistin/carbapenems/quinolones/tigecycline consumption and resistance rates of Pseudomonas aeruginosa, Klebsiella pneumoniae, and vancomycin-resistant enterococci. Considerable reductions occurred for LOS (4.18 [2015]/3.0 [2019] days), CDIs (1.47 [2015]/0.86 [2019] per 1000 patients), antibiotic cost/patient (39.45€ [2015]/23.69€ [2019]). The ASP was successful in reducing antibiotic consumption, antibiotic costs, length of hospital stay, and CDIs.
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Affiliation(s)
- Konstantina Chrysou
- Department of Microbiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Olympia Zarkotou
- Department of Clinical Microbiology, Tzaneio General Hospital of Piraeus, Athens, Greece
| | - Sofia Kalofolia
- Hospital Pharmacy, Tzaneio General Hospital of Piraeus, Athens, Greece
| | | | - Vasiliki Mamali
- Department of Clinical Microbiology, Tzaneio General Hospital of Piraeus, Athens, Greece
| | - Georgios Chrysos
- 2nd Department of Medicine and Infectious Disease Unit, Tzaneio General Hospital of Piraeus, Athens, Greece
| | | | - Nikolaos Sypsas
- General Hospital of Athens "Laiko", National and Kapodistrian University of Athens, Athens, Greece
| | - Athanasios Tsakris
- Department of Microbiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Spyros Pournaras
- Department of Microbiology, National and Kapodistrian University of Athens, Athens, Greece. .,Laboratory of Clinical Microbiology, ATTIKON University Hospital, National and Kapodistrian University of Athens, 1 Rimini Street, 12462, Chaidari, Athens, Greece.
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18
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Castro-Lopes A, Correia S, Leal C, Resende I, Soares P, Azevedo A, Paiva JA. Increase of Antimicrobial Consumption in a Tertiary Care Hospital during the First Phase of the COVID-19 Pandemic. Antibiotics (Basel) 2021; 10:antibiotics10070778. [PMID: 34202340 PMCID: PMC8300755 DOI: 10.3390/antibiotics10070778] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/18/2021] [Accepted: 06/23/2021] [Indexed: 01/15/2023] Open
Abstract
Background: The COVID-19 pandemic poses novel challenges in antimicrobial consumption metrics and stewardship strategies. COVID-19 patients became the major cause of hospital admission during the first wave of the pandemic, often leading to an antimicrobial prescription upon admission or treatment for superinfections. The aim of this study was to understand how antimicrobial consumption was impacted at the beginning of the pandemic in a tertiary care hospital, a reference center for COVID-19. Materials and Methods: A retrospective before-and-after study was done. Descriptive statistics of discharges, patient-days, and antimicrobial use indicators (defined daily doses (DDD)/100 discharges, DDD/100 patient-days) for various groups were calculated for the first three months of the pandemic (March, April, and May 2020) as a quarterly value, and for each year in 2011–2019, and their annual percentage changes were used to estimate 95% confidence intervals. The indicators were compared to patient type (medical/surgical), type of admission (urgent/elective), and age groups using Spearman’s correlation coefficient. Results: Statistically significant increases occurred in 2020 for total antibacterials, macrolides, cephalosporins, amoxicillin/clavulanic acid, carbapenems, meropenem, and third-generation cephalosporins, while a reduction was seen in cefazolin/cefoxitin. A correlation was found between antibacterial consumption and patient or admission type. In 2020, unlike in pre-pandemic years, there was a different impact in DDD/100 discharges and DDD/100 patient-days due to increased lengths-of-stay and longer antimicrobial therapy. Conclusions: The COVID-19 pandemic led to an increase in antimicrobial consumption with a different impact in DDD/100 discharges and DDD/100 patient-days. This highlights the need to use both indicators simultaneously to better understand the causes of antimicrobial consumption variation and improve the design of effective antimicrobial stewardship interventions.
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Affiliation(s)
- Alexandre Castro-Lopes
- Faculty of Medicine of the University of Porto, 4200-319 Porto, Portugal
- Correspondence: ; Tel.: +351-915875818
| | - Sofia Correia
- EPIUnit, Public Health Institute of University of Porto, 4050-091 Porto, Portugal; (S.C.); (C.L.); (A.A.)
- Laboratory for Integrative and Translational Research in Population Health (ITR), 4200-319 Porto, Portugal
- Department of Public Health and Forensic Sciences and Medical Education, Faculty of Medicine of the University of Porto, 4200-319 Porto, Portugal
| | - Cátia Leal
- EPIUnit, Public Health Institute of University of Porto, 4050-091 Porto, Portugal; (S.C.); (C.L.); (A.A.)
- Laboratory for Integrative and Translational Research in Population Health (ITR), 4200-319 Porto, Portugal
| | - Inês Resende
- Pharmaceutical Service, Centro Hospitalar Universitário São João, 4200-319 Porto, Portugal; (I.R.); (P.S.)
| | - Pedro Soares
- Pharmaceutical Service, Centro Hospitalar Universitário São João, 4200-319 Porto, Portugal; (I.R.); (P.S.)
| | - Ana Azevedo
- EPIUnit, Public Health Institute of University of Porto, 4050-091 Porto, Portugal; (S.C.); (C.L.); (A.A.)
- Laboratory for Integrative and Translational Research in Population Health (ITR), 4200-319 Porto, Portugal
- Department of Public Health and Forensic Sciences and Medical Education, Faculty of Medicine of the University of Porto, 4200-319 Porto, Portugal
- Hospital Epidemiology Center, Centro Hospitalar Universitário São João, 4200-319 Porto, Portugal
| | - José-Artur Paiva
- Intensive Care Medicine Service, Centro Hospitalar Universitário São João, 4200-319 Porto, Portugal;
- Department of Medicine, Faculty of Medicine of the University of Porto, 4200-319 Porto, Portugal
- Infection and Sepsis Group, Centro Hospitalar Universitário São João, 4200-319 Porto, Portugal
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19
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Clostridioides difficile Infection. Dis Colon Rectum 2021; 64:650-668. [PMID: 33769319 DOI: 10.1097/dcr.0000000000002047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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20
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Song Y, Shao HY, Cheng X, Guo Y. First case of periprosthetic joint infection due to Clostridioides difficile in China. BMC Infect Dis 2021; 21:462. [PMID: 34020604 PMCID: PMC8139080 DOI: 10.1186/s12879-021-06171-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 05/12/2021] [Indexed: 11/10/2022] Open
Abstract
Background Clostridioides difficile usually causes intestinal infections. However, a 75-year-old lady had a periprosthetic joint infection due to this microorganism. We report a C. difficile infection of a prosthetic hip joint. Such an infection is rarely reported around the world. Case presentation The elder female patient presented with a 2-year history of right hip pain with movement restriction. Her right leg was shorter than another. The skin around the right hip joint was red and swollen without sinus. Her lab test result showed elevator ESR and CRP. Her X-ray film showed a massive bone defect. The patient had a total hip arthroplasty 16years ago and had a revision 5 years ago. During this hospitalization, her cultures of the synovial fluid and tissue repeatedly grew C. difficile. She improved following two-stage revision surgery and antibiotic treatment. The patient has no recurrence of infection after a one-year follow-up. Conclusion A rapid and accurate sample collection is significant for culture results, making an outstanding contribution to the successful treatment.
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Affiliation(s)
- Yang Song
- Department of Orthopaedic, Jishuitan Hospital and Fourth Medical College of Peking University, Beijing, China
| | - Hong Yi Shao
- Department of Orthopaedic, Jishuitan Hospital and Fourth Medical College of Peking University, Beijing, China
| | - Xiang Cheng
- Department of Microbiology and Molecule Laboratory, Jishuitan Hospital and Fourth Medical College of Peking University, 31 East Street, Xinjiekou, Xicheng District, Beijing, 100035, CN, China
| | - Yu Guo
- Department of Microbiology and Molecule Laboratory, Jishuitan Hospital and Fourth Medical College of Peking University, 31 East Street, Xinjiekou, Xicheng District, Beijing, 100035, CN, China.
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21
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Kim B, Kim J, Pai H. Association between Antibiotic Consumption and Incidence of Clostridioides difficile Infection in a Hospital. J Korean Med Sci 2020; 35:e407. [PMID: 33289370 PMCID: PMC7721558 DOI: 10.3346/jkms.2020.35.e407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 11/10/2020] [Indexed: 11/20/2022] Open
Abstract
Previous exposure to antimicrobials is a major risk factor for Clostridioides difficile infection (CDI). Antibiotic prescription and C. difficile toxin assay records of patients admitted to a tertiary hospital in Korea from 2009 to 2013 were collected to investigate the association between antibiotic consumption and CDI incidence. A Spearman's correlation analysis between CDI incidence (positive result of toxin assay/10,000 admissions) and antibiotic consumption (defined daily dose/1,000 patient-days) was performed on a monthly basis. Using the matched month approach, we found a significant correlation between CDI rate and moxifloxacin consumption (Spearman's r = 0.351, P < 0.001). Furthermore, using the one-month delay approach, we found that the consumption of clindamycin (Spearman's r = 0.272, P = 0.037) and moxifloxacin (Spearman's r = 0.297, P = 0.022) was significantly correlated with CDI incidence. Extended-spectrum cephalosporins did not have any effect on CDI incidence.
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Affiliation(s)
- Bongyoung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Jieun Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Hyunjoo Pai
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea.
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22
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Durant TJS, Kubilay NZ, Reynolds J, Tarabar AF, Dembry LM, Peaper DR. Antimicrobial Stewardship Optimization in the Emergency Department: The Effect of Multiplex Respiratory Pathogen Testing and Targeted Educational Intervention. J Appl Lab Med 2020; 5:1172-1183. [DOI: 10.1093/jalm/jfaa130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/13/2020] [Indexed: 11/13/2022]
Abstract
Abstract
Background
Antibacterial agents are often prescribed for patients with suspected respiratory tract infections even though these are most often caused by viruses. In this study, we sought to evaluate the effect of Respiratory Pathogen Panel (RPP) PCR result availability and antimicrobial stewardship education on antibiotic prescription rates in the adult emergency department (ED).
Methods
We compared rates of antibacterial and oseltamivir prescriptions between 2 nonconsecutive influenza seasons among ED visits, wherein the latter season followed the implementation of a comprehensive educational stewardship campaign. In addition, we sought to elucidate the effect of RPP-PCR on antibiotic prescriptions, with focus on result availability prior to the conclusion of emergency department encounters.
Results
Antibiotic prescription rates globally decreased by 17.9% in the FS-17/18 cohort compared to FS-14/15 (P < 0.001), while oseltamivir prescription rates stayed the same overall (P = 0.42). Multivariate regression across both cohorts revealed that patients were less likely to receive antibiotics if RPP-PCR results were available before the end of the ED visit or if the RPP-PCR result was positive for influenza. Patients in the educational intervention cohort were also less likely to receive an antibiotic prescription.
Conclusion
This study provides evidence that RPP-PCR results are most helpful if available prior to the end of the provider-patient interaction. Further, these data suggest that detection of influenza remains an influential result in the context of antimicrobial treatment decision making. In addition, these data contribute to the body of literature which supports comprehensive ASP interventions including leadership and patient engagement.
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Affiliation(s)
| | | | | | - Asim F Tarabar
- Department of Emergency Medicine, Yale University, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Louise M Dembry
- Department of Internal Medicine, Yale University, New Haven, CT
- Yale School of Public Health, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - David R Peaper
- Department of Laboratory Medicine, Yale University, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
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Matsuo T, Hayashi K, Uehara Y, Mori N. The STAPH Score: A Predictor of Staphylococcus aureus as the Causative Microorganism of Native Vertebral Osteomyelitis. Open Forum Infect Dis 2020; 8:ofaa504. [PMID: 33447627 PMCID: PMC7790121 DOI: 10.1093/ofid/ofaa504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 10/14/2020] [Indexed: 11/12/2022] Open
Abstract
Background Staphylococcus aureus (SA) is the most common causative microorganism in native vertebral osteomyelitis (NVO). Few studies have compared the clinical features of NVO due to SA (SA-NVO) and NVO due to other organisms (NSA-NVO). This study was conducted to validate a predictive score for SA-NVO to facilitate NVO treatment without broad-spectrum antimicrobial agents. Methods This retrospective study compared the clinical features of patients with SA-NVO and NSA-NVO who were diagnosed from 2004 to 2019. Univariate associations were assessed using χ 2, Fisher's exact, or Mann-Whitney U test. Multivariable analysis was conducted using logistic regression. The optimal age cutoff point was determined by classification and regression tree analysis. Results Among 155 NVO patients, 98 (63.2%) had a microbiologically confirmed diagnosis: 40 (25.8%) with SA-NVO and 58 (37.4%) with NSA-NVO. Six predictors, either independently associated with SA-NVO or clinically relevant, were used to develop the STAPH prediction score: atopic dermatitis (Skin) (3 points); recent Trauma (2 points); Age < 67 years (1 point); Abscess (1 point); central venous Port catheter (2 points); and History of puncture (2 points). In a receiver operating characteristic analysis, the area under the curve was 0.84 (95% confidence interval, 0.76-0.91). The best cutoff point was 3. A score ≥3 had a sensitivity, specificity, positive predictive value, and negative predictive value of 58%, 84%, 84%, and 73%, respectively. Conclusions The STAPH score has relatively high specificity for use by clinicians to predict SA as the causative microorganism in patients with NVO until results of a confirmatory culture are available.
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Affiliation(s)
- Takahiro Matsuo
- Department of Infectious Diseases, St. Luke's International Hospital, Tokyo, Japan
| | - Kuniyoshi Hayashi
- Graduate School of Public Health, St. Luke's International University, Tokyo, Japan
| | - Yuki Uehara
- Department of Infectious Diseases, St. Luke's International Hospital, Tokyo, Japan.,Department of Clinical Laboratory, St. Luke's International Hospital, Tokyo, Japan.,Department of Microbiology, Juntendo University Faculty of Medicine, Tokyo, Japan.,Department of General Medicine, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Nobuyoshi Mori
- Department of Infectious Diseases, St. Luke's International Hospital, Tokyo, Japan
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Šuljagić V, Milenković B, Perić A, Jovanović D, Begović-Kuprešanin V, Starčević S, Tomić A, Vezmar Kovačević S, Dragojević-Simić V. Healthcare associated Clostridioides difficile infection in adult surgical and medical patients hospitalized in tertiary hospital in Belgrade, Serbia: a seven years prospective cohort study. Libyan J Med 2020; 15:1708639. [PMID: 31905110 PMCID: PMC6968563 DOI: 10.1080/19932820.2019.1708639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Introduction: Clostridioides difficile (C. difficile) infection (CDI) is one of the most common healthcare-associated (HA) infections in contemporary medicine. The risk factors (RFs) for HA CDI in medical and surgical patients are poorly investigated in countries with a limited resource healthcare system. Therefore, the aim of the study was to investigate differences in patients' characteristics, factors related to healthcare and outcomes associated with HA CDI in surgical and medical patients in tertiary healthcare centre in Serbia.Materials and Methods: A prospective cohort study was conducted including adult patients diagnosed with initial episode of HA CDI, first recurrence of disease, readmission to hospital, while deaths within 30 days of CDI diagnosis and in-hospital mortality were also recorded. Patients hospitalized for any non-surgical illness, who developed initial HA CDI were assigned to medical group, whereas those who developed initial HA CDI after surgical procedures were in surgical group. The data on patients' characteristics and factors related to healthcare were collected, too.Results: During 7-year period, from 553 patients undergoing in-hospital treatment and diagnosed with CDI, 268 (48.5%) and 285 (51.5%) were surgical and medical patients, respectively. Age ≥ 65 years, use of proton pump inhibitors, chemotherapy and fluoroquinolones were positively associated with being in medical group, whereas admission to intensive care unit and use of second- and third-generation cephalosporins were positively associated with being in surgical group.Conclusions: Based on obtained results, including significant differences in 30-day mortality and in-hospital mortality, it can be concluded that medical patient were more endangered with HA CDI than surgical ones.
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Affiliation(s)
- Vesna Šuljagić
- Military Medical Academy, Belgrade, Serbia.,Medical Faculty, University of Defence, Belgrade, Serbia
| | | | - Aneta Perić
- Military Medical Academy, Belgrade, Serbia.,Medical Faculty, University of Defence, Belgrade, Serbia
| | | | - Vesna Begović-Kuprešanin
- Military Medical Academy, Belgrade, Serbia.,Medical Faculty, University of Defence, Belgrade, Serbia
| | - Srđan Starčević
- Military Medical Academy, Belgrade, Serbia.,Medical Faculty, University of Defence, Belgrade, Serbia
| | - Aleksandar Tomić
- Military Medical Academy, Belgrade, Serbia.,Medical Faculty, University of Defence, Belgrade, Serbia
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25
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Kipnis M, Schwab F, Kramer TS, Stegemann MS, Isner C, Pilarski G, Märtin N, Bui MT, Boldt AC, Behnke M, Denkel LA, Wiese-Posselt M, Zweigner J, Gastmeier P, Rohde AM. Incidence of healthcare-associated Clostridioides difficile infections and association with ward-level antibiotic consumption in a German university hospital: an ecological study. J Antimicrob Chemother 2020; 74:2400-2404. [PMID: 31098633 DOI: 10.1093/jac/dkz195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/03/2019] [Accepted: 04/06/2019] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Clostridioides difficile infection (CDI) is one of the most important healthcare-associated infections. We aimed to describe the incidence density of healthcare-associated CDI (HA-CDI) in Germany's largest hospital and to identify associations with ward-level antimicrobial consumption. METHODS We used surveillance data on CDI and antimicrobial consumption from 2014 to 2017 and analysed a potential association by means of multivariable regression analysis. RESULTS We included 77 wards with 404998 admitted patients and 1850862 patient-days. Six hundred and seventy-one HA-CDI cases were identified, resulting in a pooled mean incidence density of 0.36/1000 patient-days (IQR = 0.34-0.39). HA-CDI incidence density on ICU and haematological-oncological wards was about three times higher than on surgical wards [incidence rate ratio (IRR) = 3.00 (95% CI = 1.96-4.60) and IRR = 2.78 (95% CI = 1.88-4.11), respectively]. Ward-level consumption of third-generation cephalosporins was the sole antimicrobial risk factor for HA-CDI. With each DDD/100 patient-days administered, a ward's HA-CDI incidence density increased by 2% [IRR = 1.02 (95% CI = 1.01-1.04)]. Other risk factors were contemporaneous community-associated CDI cases [IRR = 1.32 (95% CI = 1.07-1.63)] and CDI cases in the previous month [IRR = 1.27 (95% CI = 1.07-1.51)]. Furthermore, we found a significant decrease in HA-CDI in 2017 compared with 2014 [IRR = 0.68 (95% CI = 0.54-0.86)]. CONCLUSIONS We confirmed that ward-level antimicrobial use influences HA-CDI and specifically identified third-generation cephalosporin consumption as a risk factor.
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Affiliation(s)
- Marina Kipnis
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Frank Schwab
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Tobias S Kramer
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Miriam S Stegemann
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Infectious Diseases and Respiratory Medicine, Berlin, Germany
| | - Caroline Isner
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Infectious Diseases and Respiratory Medicine, Berlin, Germany
| | - Georg Pilarski
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Nayana Märtin
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Minh Trang Bui
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Anne-C Boldt
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Michael Behnke
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Luisa A Denkel
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Miriam Wiese-Posselt
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Janine Zweigner
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Petra Gastmeier
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany.,German Centre for Infection Research (DZIF), Braunschweig, Germany
| | - Anna M Rohde
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany.,German Centre for Infection Research (DZIF), Braunschweig, Germany
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26
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Choy A, Freedberg DE. Impact of microbiome-based interventions on gastrointestinal pathogen colonization in the intensive care unit. Therap Adv Gastroenterol 2020; 13:1756284820939447. [PMID: 32733601 PMCID: PMC7370550 DOI: 10.1177/1756284820939447] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 06/15/2020] [Indexed: 02/04/2023] Open
Abstract
In the intensive care unit (ICU), colonization of the gastrointestinal tract by potentially pathogenic bacteria is common and often precedes clinical infection. Though effective in the short term, traditional antibiotic-based decolonization methods may contribute to rising resistance in the long term. Novel therapies instead focus on restoring gut microbiome equilibrium to achieve pathogen colonization resistance. This review summarizes the existing data regarding microbiome-based approaches to gastrointestinal pathogen colonization in ICU patients with a focus on prebiotics, probiotics, and synbiotics.
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Affiliation(s)
| | - Daniel E. Freedberg
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, USA
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27
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Antibiotic modification versus withhold in febrile patients without evidence of bacterial infection, unresponsive to initial empiric regimen: a multicentre retrospective study conducted in Israel. Eur J Clin Microbiol Infect Dis 2020; 39:2027-2035. [PMID: 32572653 DOI: 10.1007/s10096-020-03957-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/16/2020] [Indexed: 10/23/2022]
Abstract
Prescribing antibiotics for febrile patients without proof of bacterial infection contributes to antimicrobial resistance. Lack of clinical response in these patients often leads to antibiotic escalation, although data supporting this strategy are scarce. This study compared outcomes of modifying, withholding, or continuing the same antibiotic regimen for such patients. Febrile or hypothermic stable patients with suspected infection, unresponsive to empiric antibiotic treatment, admitted to one of 15 internal medicine departments in three hospitals during a 5-year study period, were included. Patients with a definitive clinical or microbiological bacterial infection, malignancy, immunodeficiency, altered mental status, or need for mechanical ventilation were excluded. Participants were divided into groups based on treatment strategy determined 72 h after antibiotic initiation: antibiotic modified, withheld or continued. Outcomes measured included in-hospital and 30-day post-discharge-mortality rates, length of hospital stay (LOS) and days of antimicrobial therapy (DOT). A total of 486 patients met the inclusion criteria: 124 in the Antibiotic modified group, 67 in the Antibiotic withheld group and 295 in the Initial antibiotic continued group. Patient characteristics were similar among groups with no differences in mortality rates in-hospital (23% vs. 25% vs. 20%, p = 0.58) and within 30 days after discharge (5% vs. 3% vs. 4%, p = 0.83). Changing antibiotics led to longer LOS (9.0 ± 6.8 vs. 6.2 ± 5.6 days, p = 0.003) and more DOT (8.6 ± 6.0 vs. 3.2 ± 1.0 days, p < 0.001) compared to withholding treatment. Withholding as compared to modifying antibiotics, in febrile patients with no clear evidence of bacterial infection, is a safe strategy associated with decreased LOS and DOT.
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28
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Effect of a prospective audit with intervention and feedback on Clostridioides difficile infection management. Int J Clin Pharm 2020; 42:923-930. [PMID: 32410207 DOI: 10.1007/s11096-020-01050-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 04/28/2020] [Indexed: 10/24/2022]
Abstract
Background Clostridioides difficile infections are associated with morbidity and mortality in several countries. Their increasing incidence and frequent recurrence make them an urgent public health threat. The lack of adherence to international treatment guidelines for Clostridioides difficile infections is a proven mortality risk factor. Objective To evaluate long-term prescribers' adherence to recommendations on the management of Clostridioides difficile infections and its impact on clinical outcomes after an educational and Clostridioides difficile-prospective audit with intervention and feedback period. Setting All patients admitted to a 1500-bed university hospital with positive Clostridioides difficile tests identified were included. Methods Data were collected retrospectively over a baseline period (May-November 2014) and prospectively over a Clostridioides difficile-prospective audit with intervention and feedback period (November 2015-May 2016) and an observation period (November 2017-September 2018). All Clostridioides difficile cases were reviewed by a Clostridioides difficile-prospective audit with intervention and feedback team composed of pharmacists, an infectious diseases specialist and a microbiologist to obtain a complete overview of patient records in each area of expertise. Main outcome measures Percentage of conformity to the protocol, percentage of recovery at 10 days and percentage of relapse, as well as Clostridioides difficile incidence and percentage of Fidaxomicin use. Results A total of 183 patients were included over the three periods. A significant improvement in conformity to the local protocol was observed between the intervention period (23.9%) and the observation period (67.3%) (P < 10-3). Fidaxomicin prescriptions increased significantly (P = 0.006). Clinical outcomes improved significantly with an increase in the percentage of recovery at 10 days (P = 0.001) and a decrease in the percentage of relapse (P = 0.016). The Clostridioides difficile incidence rate improved significantly to 1.3 per 10,000 patient-days during the observation period. Conclusion This study shows the lasting effect of an educational and Clostridioides difficile-prospective audit with intervention and feedback period on prescribers' adherence to recommendations and a significant impact on clinical outcomes.
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29
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Bonnassot P, Barben J, Tetu J, Bador J, Bonniaud P, Manckoundia P, Putot A. Clostridioides difficile infection after pneumonia in older patients: Which antibiotic is at lower risk? J Hosp Infect 2020; 105:S0195-6701(20)30240-1. [PMID: 32437825 DOI: 10.1016/j.jhin.2020.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 05/05/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Clostridioides difficile infection (CDI) is a frequent and severe complication of antibiotic treatment in older patients hospitalized for acute pneumonia (AP). AIMS We aimed to assess the burden and risk factors of CDI and to determine which of the usual antibiotics regimens is at lower risk for post-AP CDI incidence. METHODS Among patients aged >75y hospitalized for AP in all departments of a university hospital between 2007 and 2017, all the 92 patients developing a CDI were compared with 213 patients without CDI. Factors associated with 1) in-hospital and one-year mortality, 2) CDI incidence were assessed using logistic regression models. FINDINGS In patients with and without CDI after AP, mortality rates were respectively at 34% vs 20% in hospital and 63% vs 42% at one-year. After adjustment for confounders, CDI was associated with a two-fold risk of in-hospital and one-year mortality after pneumonia (Respective Odds Ratio (95% Confidence Interval), OR (95%CI): 1.95 (1.06-3.58) and 2.02 (1.43-7.31)). High number of antibiotics (Per antibiotic, OR (95%CI): 1.89 (1.18-3.06)), rather than antibiotics duration (Per day, OR 95%CI): 1.04 (0.96-1.11)) was associated with a higher risk of CDI. Compared with other antibiotics, use of penicillin + beta-lactamase inhibitors was associated with a lower risk of CDI (OR (95%CI): 0.43 (0.19 -0.99)) CONCLUSION: In older inpatients, CDI highly increase the burden of AP at both short and long term. If confirmed, these results suggest the preferential use of penicillin + beta-lactamase inhibitors for a lower incidence of CDI in older inpatients with AP.
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Affiliation(s)
- Pauline Bonnassot
- Department of Geriatrics and Internal Medicine, Hospital of Champmaillot, University Hospital, Dijon, France
| | - Jeremy Barben
- Department of Geriatrics and Internal Medicine, Hospital of Champmaillot, University Hospital, Dijon, France
| | - Jennifer Tetu
- Department of Microbiology, University Hospital, Dijon, France
| | - Julien Bador
- Department of Microbiology, University Hospital, Dijon, France
| | | | - Patrick Manckoundia
- Department of Geriatrics and Internal Medicine, Hospital of Champmaillot, University Hospital, Dijon, France
| | - Alain Putot
- Department of Geriatrics and Internal Medicine, Hospital of Champmaillot, University Hospital, Dijon, France.
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30
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Abstract
Clostridioides difficile remains a leading cause of healthcare-associated infection. Efforts at C. difficile prevention have been hampered by an increasingly complex understanding of transmission patterns and a high degree of heterogeneity among existing studies. Effective prevention of C. difficile infection requires multimodal interventions, including contact precautions, hand hygiene with soap and water, effective environmental cleaning, use of sporicidal cleaning agents, and antimicrobial stewardship. Roles for probiotics, avoidance of proton pump inhibitors, and isolation of asymptomatic carriers remain poorly defined.
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Affiliation(s)
- Nicholas A Turner
- Duke University Medical Center, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | - Deverick J Anderson
- Duke University Medical Center, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
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31
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Combining Procalcitonin and Rapid Multiplex Respiratory Virus Testing for Antibiotic Stewardship in Older Adult Patients With Severe Acute Respiratory Infection. J Am Med Dir Assoc 2019; 21:62-67. [PMID: 31791902 PMCID: PMC7106143 DOI: 10.1016/j.jamda.2019.09.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 09/14/2019] [Accepted: 09/27/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Virus infection is underevaluated in older adults with severe acute respiratory infections (SARIs). We aimed to evaluate the clinical impact of combining point-of-care molecular viral test and serum procalcitonin (PCT) level for antibiotic stewardship in the emergency department (ED). DESIGN A prospective twin-center cohort study was conducted between January 2017 and March 2018. SETTING AND PARTICIPANTS Older adult patients who presented to the ED with SARIs received a rapid molecular test for 17 respiratory viruses and a PCT test. MEASURES To evaluate the clinical impact, we compared the outcomes of SARI patients between the experimental cohort and a propensity score-matched historical cohort. The primary outcome was the proportion of antibiotics discontinuation or de-escalation in the ED. The secondary outcomes included duration of intravenous antibiotics, length of hospital stay, and mortality. RESULTS A total of 676 patients were included, of which 169 patients were in the experimental group and 507 patients were in the control group. More than one-fourth (27.9%) of the patients in the experimental group tested positive for virus. Compared with controls, the experimental group had a significantly higher proportion of antibiotics discontinuation or de-escalation in the ED (26.0% vs 16.1%, P = .007), neuraminidase inhibitor uses (8.9% vs 0.6%, P < .001), and shorter duration of intravenous antibiotics (10.0 vs 14.5 days, P < .001). CONCLUSIONS AND IMPLICATIONS Combining rapid viral surveillance and PCT test is a useful strategy for early detection of potential viral epidemics and antibiotic stewardship. Clustered viral respiratory infections in a nursing home is common. Patients transferred from nursing homes to ED may benefit from this approach.
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32
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Langford BJ, Daneman N, Leung V, Wu JHC, Brown K, Schwartz KL, Garber G. The second-hand effects of antibiotics: communicating the public health risks of drug resistance. JAC Antimicrob Resist 2019; 1:dlz059. [PMID: 34222933 DOI: 10.1093/jacamr/dlz059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Antimicrobial resistance (AMR) poses a threat to modern medicine, but there are challenges in communicating its urgency and scope and potential solutions to this growing problem. It is recognized that AMR has a 'language problem' and the way in which healthcare professionals communicate about AMR may not always resonate with patients. Many patients are unaware that antibiotics can have detrimental effects to those beyond the recipient, due to transmission of drug-resistant organisms. The overestimation of benefits and underestimation of risks helps to fuel demand for antibiotic use in situations where they may be of little or no benefit. To better communicate risks, clinicians may borrow the term 'second-hand' from efforts to reduce smoking cessation. We present several examples where antibiotics themselves have second-hand effects beyond the individual recipient in hospitals, long-term care homes and the community. Incorporation of the concept of the second-hand effects of antibiotics into patient counselling, mass messaging and future research may help facilitate a more balanced discussion about the benefits and risks of antibiotic use in order to use these agents more appropriately.
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Affiliation(s)
| | - N Daneman
- Public Health Ontario, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,The Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - V Leung
- Public Health Ontario, Toronto, Ontario, Canada
| | - J H C Wu
- Public Health Ontario, Toronto, Ontario, Canada
| | - K Brown
- Public Health Ontario, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - K L Schwartz
- Public Health Ontario, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Unity Health Toronto, Toronto, Ontario, Canada
| | - G Garber
- Public Health Ontario, Toronto, Ontario, Canada.,Ottawa Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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McDonald EG, Dendukuri N, Frenette C, Lee TC. Time-Series Analysis of Health Care-Associated Infections in a New Hospital With All Private Rooms. JAMA Intern Med 2019; 179:1501-1506. [PMID: 31424489 PMCID: PMC6705142 DOI: 10.1001/jamainternmed.2019.2798] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
IMPORTANCE Health care-associated infections are often caused by multidrug-resistant organisms and substantially factor into hospital costs and avoidable iatrogenic harm. Although it is recommended that new facilities be built with single-room, low-acuity beds, this process is costly and evidence of reductions in health care-associated infections is weak. OBJECTIVE To examine whether single-patient rooms are associated with decreased rates of common multidrug-resistant organism transmissions and health care-associated infections. DESIGN, SETTING, AND PARTICIPANTS A time-series analysis comparing institution-level rates of new multidrug-resistant organism colonization and health care-associated infections before (January 1, 2013-March 31, 2015) and after (April 1, 2015-March 31, 2018) the move to the hospital with 100% single-patient rooms. In the largest hospital move in Canadian history, inpatients in an older, tertiary care, 417-bed hospital in Montréal, Canada, that consisted of mainly mixed 3- and 4-person ward-type rooms were moved to a new 350-bed facility with all private rooms. EXPOSURES A synchronized move of all patients on April 26, 2015, to a new hospital with 100% single-patient rooms equipped with individual toilets and showers and easy access to sinks for hand washing. MAIN OUTCOMES AND MEASURES Rates of nosocomial vancomycin-resistant Enterococcus (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) colonization, VRE and MRSA infection, and Clostridioides difficile (formerly known as Clostridium difficile) infection (CDI) per 10 000 patient-days. RESULTS Compared with the 27 months before, during the 36 months after the hospital move, an immediate and sustained reduction in nosocomial VRE colonization (from 766 to 209 colonizations; incidence rate ratio [IRR], 0.25; 95% CI, 0.19-0.34) and MRSA colonization (from 129 to 112 colonizations; IRR, 0.57; 95% CI, 0.33-0.96) was noted, as well as VRE infection (from 55 to 14 infections; IRR, 0.30, 95% CI, 0.12-0.75). Rates of CDI (from 236 to 223 infections; IRR, 0.95; 95% CI, 0.51-1.76) and MRSA infection (from 27 to 37 infections; IRR, 0.89, 95% CI, 0.34-2.29) did not decrease. CONCLUSION AND RELEVANCE The move to a new hospital with exclusively single-patient rooms appeared to be associated with a sustained decrease in the rates of new MRSA and VRE colonization and VRE infection; however, the move was not associated with a reduction in CDI or MRSA infection. These findings may have important implications for the role of hospital construction in facilitating infection control.
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Affiliation(s)
- Emily G McDonald
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada.,Division of Infectious Diseases, Department of Medicine, McGill University, Montréal, Québec, Canada.,McGill Interdisciplinary Initiative in Infection and Immunity, Montréal, Québec, Canada
| | - Nandini Dendukuri
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada
| | - Charles Frenette
- Division of Infectious Diseases, Department of Medicine, McGill University, Montréal, Québec, Canada.,McGill Interdisciplinary Initiative in Infection and Immunity, Montréal, Québec, Canada
| | - Todd C Lee
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada.,Division of Infectious Diseases, Department of Medicine, McGill University, Montréal, Québec, Canada.,McGill Interdisciplinary Initiative in Infection and Immunity, Montréal, Québec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada
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34
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Dragan V, Wei Y, Elligsen M, Kiss A, Walker SAN, Leis JA. Prophylactic Antimicrobial Therapy for Acute Aspiration Pneumonitis. Clin Infect Dis 2019; 67:513-518. [PMID: 29438467 DOI: 10.1093/cid/ciy120] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 02/07/2018] [Indexed: 11/12/2022] Open
Abstract
Background Prophylactic antimicrobial therapy is frequently prescribed for acute aspiration pneumonitis, with the intent of preventing the development of aspiration pneumonia. However, few clinical studies have examined the benefits and harms of this practice. Methods A retrospective cohort study design was used to compare outcomes of patients with aspiration pneumonitis who received prophylactic antimicrobial therapy with those managed with supportive care only during the initial 2 days following macroaspiration. The primary outcome was in-hospital mortality within 30 days. Secondary outcomes included transfer to critical care and antimicrobial therapy received between days 3 and 14 following macroaspiration including escalation of therapy and antibiotic-free days. Results Among 1483 patients reviewed, 200 met the case definition for acute aspiration pneumonitis, including 76 (38%) who received prophylactic antimicrobial therapy and 124 (62%) who received supportive management only. After adjusting for patient-level predictors, antimicrobial prophylaxis was not associated with any improvement in mortality (odds ratio, 0.9; 95% confidence interval [CI], 0.4-1.7; P = .7). Patients receiving prophylactic antimicrobial therapy were no less likely to require transfer to critical care (5% vs 6%; P = .7) and subsequently received more frequent escalation of antibiotic therapy (8% vs 1%; P = .002) and fewer antibiotic-free days (7.5 vs 10.9; P < .0001). Conclusions Prophylactic antimicrobial therapy for patients with acute aspiration pneumonitis does not offer clinical benefit and may generate antibiotic selective pressures that results in the need for escalation of antibiotic therapy among those who develop aspiration pneumonia.
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Affiliation(s)
- Vlad Dragan
- Department of Medicine, University of Toronto, Ontario, Canada
| | - Yanliang Wei
- Department of Medicine, University of Toronto, Ontario, Canada
| | - Marion Elligsen
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Alex Kiss
- Sunnybrook Research Institute and Institute of Health Policy, Management and Evaluation, Ontario, Canada
| | - Sandra A N Walker
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Ontario, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Ontario, Canada
| | - Jerome A Leis
- Department of Medicine, University of Toronto, Ontario, Canada.,Sunnybrook Research Institute and Institute of Health Policy, Management and Evaluation, Ontario, Canada.,Division of Infectious Diseases and General Internal Medicine, Sunnybrook Health Sciences Centre, Ontario, Canada.,Centre for Quality Improvement and Patient Safety, University of Toronto, Ontario, Canada
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McDonald LC, Gerding DN, Johnson S, Bakken JS, Carroll KC, Coffin SE, Dubberke ER, Garey KW, Gould CV, Kelly C, Loo V, Shaklee Sammons J, Sandora TJ, Wilcox MH. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2019; 66:e1-e48. [PMID: 29462280 DOI: 10.1093/cid/cix1085] [Citation(s) in RCA: 1221] [Impact Index Per Article: 244.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.
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Affiliation(s)
| | | | - Stuart Johnson
- Edward Hines Jr Veterans Administration Hospital, Hines.,Loyola University Medical Center, Maywood, Illinois
| | | | - Karen C Carroll
- Johns Hopkins University School of Medicine, Baltimore, Maryl
| | | | - Erik R Dubberke
- Washington University School of Medicine, St Louis, Missouri
| | | | - Carolyn V Gould
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ciaran Kelly
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Vivian Loo
- McGill University Health Centre, McGill University, Montréal, Québec, Canada
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Rohde JM, Jones K, Padron N, Olmsted RN, Chopra V, Dubberke ER. A Tiered Approach for Preventing Clostridioides difficile Infection. Ann Intern Med 2019; 171:S45-S51. [PMID: 31569223 DOI: 10.7326/m18-3444] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jeffrey M Rohde
- University of Michigan Medical School, Ann Arbor, Michigan (J.M.R., K.J.)
| | - Karen Jones
- University of Michigan Medical School, Ann Arbor, Michigan (J.M.R., K.J.)
| | - Norma Padron
- Health Research & Educational Trust, American Hospital Association, Chicago, Illinois (N.P.)
| | - Russell N Olmsted
- Integrated Clinical Services, Trinity Health, Livonia, Michigan (R.N.O.)
| | - Vineet Chopra
- University of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (V.C.)
| | - Erik R Dubberke
- Washington University School of Medicine, St. Louis, Missouri (E.R.D.)
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Risk factors for Clostridioides difficile infection in hospitalized patients and associated mortality in Japan: a multi-centre prospective cohort study. J Hosp Infect 2019; 104:350-357. [PMID: 31542458 DOI: 10.1016/j.jhin.2019.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/13/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Although population characteristics and antimicrobial prescribing practices suggest that the hospitalized population in Japan is at high risk of Clostridioides difficile infection (CDI), the epidemiology of CDI in Japan is poorly understood. AIM This prospective cohort study aimed to investigate the epidemiology of CDI at 12 hospitals in Japan. METHODS Patients with clinically significant diarrhoea (CSD) were enrolled. Stool specimens were tested for C. difficile by toxin A and/or B enzyme immunoassay (EIA) in the hospital laboratories, and a toxigenic culture and nucleic acid amplification tests were performed at a central laboratory. The risk factors of CDI and the impact of CDI on mortality were investigated. FINDINGS In total, 566 patients with CSD were included in the analyses. A total of 152 patients received the diagnosis of CDI by Toxin A/B EIA, toxigenic culture, or nucleic acid amplification test. Factors associated with CDI included low albumin (adjusted odds ratio (aOR): 1.56; 95% confidence interval (CI): 1.03-2.34) and length of hospital stay before stool collection >18 days (aOR: 1.73; 95% CI: 1.09-2.75). CDI was associated with an increased mortality on univariate analysis (OR: 1.6, 95% CI: 1.0-2.6) but was not associated with an increased risk of mortality on multivariable analysis. CONCLUSION Risk factors for CDI in Japan were similar to those identified in the USA and Europe. However, CDI was not associated with an increased risk of mortality in this population of patients with CSD.
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Hospital-level high-risk antibiotic use in relation to hospital-associated Clostridioides difficile infections: Retrospective analysis of 2016-2017 data from US hospitals. Infect Control Hosp Epidemiol 2019; 40:1229-1235. [PMID: 31522695 DOI: 10.1017/ice.2019.236] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Antibiotics are widely used by all specialties in the hospital setting. We evaluated previously defined high-risk antibiotic use in relation to Clostridioides difficile infections (CDIs). METHODS We analyzed 2016-2017 data from 171 hospitals. High-risk antibiotics included second-, third-, and fourth-generation cephalosporins, fluoroquinolones, carbapenems, and lincosamides. A CDI case was a positive stool C. difficile toxin or molecular assay result from a patient without a positive result in the previous 8 weeks. Hospital-associated (HA) CDI cases included specimens collected >3 calendar days after admission or ≤3 calendar days from a patient with a prior same-hospital discharge within 28 days. We used the multivariable Poisson regression model to estimate the relative risk (RR) of high-risk antibiotic use on HA CDI, controlling for confounders. RESULTS The median days of therapy for high-risk antibiotic use was 241.2 (interquartile range [IQR], 192.6-295.2) per 1,000 days present; the overall HA CDI rate was 33 (IQR, 24-43) per 10,000 admissions. The overall correlation of high-risk antibiotic use and HA CDI was 0.22 (P = .003), and higher correlation was observed in teaching hospitals (0.38; P = .002). For every 100-day (per 1,000 days present) increase in high-risk antibiotic therapy, there was a 12% increase in HA CDI (RR, 1.12; 95% CI, 1.04-1.21; P = .002) after adjusting for confounders. CONCLUSIONS High-risk antibiotic use is an independent predictor of HA CDI. This assessment of poststewardship implementation in the United States highlights the importance of tracking trends of antimicrobial use over time as it relates to CDI.
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Hygienemaßnahmen bei Clostridioides difficile-Infektion (CDI). Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2019; 62:906-923. [DOI: 10.1007/s00103-019-02959-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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40
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Estimating the Attributable Disease Burden and Effects of Interhospital Patient Sharing on Clostridium difficile Infections. Infect Control Hosp Epidemiol 2019; 40:656-661. [DOI: 10.1017/ice.2019.73] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AbstractObjective:To estimate the burden of Clostridium difficile infections (CDIs) due to interfacility patient sharing at regional and hospital levels.Design:Retrospective observational study.Methods:We used data from the Healthcare Cost and Utilization Project California State Inpatient Database (2005–2011) to identify 26,878,498 admissions and 532,925 patient transfers. We constructed a weighted, directed network among the hospitals by defining an edge between 2 hospitals to be the monthly average number of patients discharged from one hospital and admitted to another on the same day. We then used a network autocorrelation model to study the effect of the patient sharing network on the monthly average number of CDI cases per hospital, and we estimated the proportion of CDI cases attributable to the network.Results:We found that 13% (95% confidence interval [CI], 7.6%–18%) of CDI cases were due to diffusion through the patient-sharing network. The network autocorrelation parameter was estimated at 5.0 (95% CI, 3.0–6.9). An increase in the number of patients transferred into and/or an increased CDI rate at the hospitals from which those patients originated led to an increase in the number of CDIs in the receiving hospital.Conclusions:A minority but substantial burden of CDI infections are attributable to hospital transfers. A hospital’s infection control may thus be nontrivially influenced by its neighboring hospitals. This work adds to the growing body of evidence that intervention strategies designed to minimize HAIs should be done at the regional rather than local level.
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Miller AW, Orr T, Dearing D, Monga M. Loss of function dysbiosis associated with antibiotics and high fat, high sugar diet. ISME JOURNAL 2019; 13:1379-1390. [PMID: 30700790 DOI: 10.1038/s41396-019-0357-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 01/17/2019] [Accepted: 01/18/2019] [Indexed: 02/08/2023]
Abstract
The incidence of urinary stone disease (USD) has increased four-fold in 50 years. Oxalate, which is degraded exclusively by gut bacteria, is an important constituent in 80% of urinary stones. We quantified the effects of antibiotics and a high fat/high sugar (HFHS) diet on the microbial metabolism of oxalate in the gut. High and low oxalate-degrading mouse models were developed by administering fecal transplants from either the wild mammalian rodent Neotoma albigula or Swiss-Webster mice to Swiss-Webster mice, which produces a microbiota with or without the bacteria necessary for persistent oxalate metabolism, respectively. Antibiotics led to an acute loss of both transplant bacteria and associated oxalate metabolism. Transplant bacteria exhibited some recovery over time but oxalate metabolism did not. In contrast, a HFHS diet led to an acute loss of function coupled with a gradual loss of transplant bacteria, indicative of a shift in overall microbial metabolism. Thus, the effects of oral antibiotics on the microbiome form and function were greater than the effects of diet. Results indicate that both antibiotics and diet strongly influence microbial oxalate metabolism.
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Affiliation(s)
- Aaron W Miller
- Department of Urology, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, USA. .,Department of Inflammation & Immunity, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, USA.
| | - Teri Orr
- Department of Biology, University of Utah, 257 South 1400 East, Salt Lake City, UT, USA
| | - Denise Dearing
- Department of Biology, University of Utah, 257 South 1400 East, Salt Lake City, UT, USA
| | - Manoj Monga
- Department of Urology, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, USA
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Balsells E, Shi T, Leese C, Lyell I, Burrows J, Wiuff C, Campbell H, Kyaw MH, Nair H. Global burden of Clostridium difficile infections: a systematic review and meta-analysis. J Glob Health 2019; 9:010407. [PMID: 30603078 PMCID: PMC6304170 DOI: 10.7189/jogh.09.010407] [Citation(s) in RCA: 149] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background Clostridium difficile is a leading cause of morbidity and mortality in several countries. However, there are limited evidence characterizing its role as a global public health problem. We conducted a systematic review to provide a comprehensive overview of C. difficile infections (CDI) rates. Methods Seven databases were searched (January 2016) to identify studies and surveillance reports published between 2005 and 2015 reporting CDI incidence rates. CDI incidence rates for health care facility-associated (HCF), hospital onset-health care facility-associated, medical or general intensive care unit (ICU), internal medicine (IM), long-term care facility (LTCF), and community-associated (CA) were extracted and standardized. Meta-analysis was conducted using a random effects model. Results 229 publications, with data from 41 countries, were included. The overall rate of HCF-CDI was 2.24 (95% confidence interval CI = 1.66-3.03) per 1000 admissions/y and 3.54 (95%CI = 3.19-3.92) per 10 000 patient-days/y. Estimated rates for CDI with onset in ICU or IM wards were 11.08 (95%CI = 7.19-17.08) and 10.80 (95%CI = 3.15-37.06) per 1000 admission/y, respectively. Rates for CA-CDI were lower: 0.55 (95%CI = 0.13-2.37) per 1000 admissions/y. CDI rates were generally higher in North America and among the elderly but similar rates were identified in other regions and age groups. Conclusions Our review highlights the widespread burden of disease of C. difficile, evidence gaps, and the need for sustainable surveillance of CDI in the health care setting and the community.
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Affiliation(s)
- Evelyn Balsells
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Joint first authorship
| | - Ting Shi
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Joint first authorship
| | - Callum Leese
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Iona Lyell
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - John Burrows
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | | | - Harry Campbell
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Moe H Kyaw
- Sanofi Pasteur, Swiftwater, Pennsylvania, USA.,Joint last authorship
| | - Harish Nair
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Joint last authorship
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Appearance of Clostridium difficile infections in health care institutions in Slovakia and in the district of martin. ACTA MEDICA MARTINIANA 2018. [DOI: 10.2478/acm-2018-0007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Abstract
Introduction: Decrease of nonspecific imunity in patients and the treatment with broad spectrum antibiotics form appropriate conditions for the appearance of medically severe Clostridium difficile infection (CDI) - enterocolitis that can have the characteristics of community or hospital acquired infection (HAI). The aim of our work is to identify the trend of their incidence in Slovakia and to define the risk groups according to age and department of hospitalisation.
Material and Methods: Retrospective analysis and comparison of the appearance of CDI was performed within the groups of patients hospitalised in health care institutions in the SR and those in the district of Martin during the period of years 2010 to 2017. The data of reported cases were taken from the Epidemiological information system of the Slovak Republic (EPIS SR), the source of demografic data was the National Center of Health Information.
Resuts: Analysis shows an important increase of incidence of CDI during years 2010 to 2017. Diseases had predominantly health care associated – nosocomial – character targeting mostly older patients (65+ - 24/10 000 in the Slovak Republic and 62/10,000 in the county of Martin) and less infants (7/10,000 and 11/10,000 repectively).
Conclusion: The results of our analyses are consistent with literature data about CDI enterocolitis and show their serious health and social impact in our society.
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Fuchs BB, Tharmalingam N, Mylonakis E. Vulnerability of long-term care facility residents to Clostridium difficile infection due to microbiome disruptions. Future Microbiol 2018; 13:1537-1547. [PMID: 30311778 DOI: 10.2217/fmb-2018-0157] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Aging presents a significant risk factor for Clostridium difficile infection (CDI). A disproportionate number of CDIs affect individuals in long-term care facilities compared with the general population, likely due to the vulnerable nature of the residents and shared environment. Review of the literature cites a number of underlying medical conditions such as the use of antibiotics, proton pump inhibitors, chemotherapy, renal disease and feeding tubes as risk factors. These conditions alter the intestinal environment through direct bacterial killing, changes to pH that influence bacterial stabilities or growth, or influence nutrient availability that direct population profiles. In this review, we examine some of the contributing risk factors for elderly associated CDI and the toll they take on the microbiome.
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Affiliation(s)
- Beth Burgwyn Fuchs
- Rhode Island Hospital, Alpert Medical School & Brown University, Providence, Rhode Island 02903
| | - Nagendran Tharmalingam
- Rhode Island Hospital, Alpert Medical School & Brown University, Providence, Rhode Island 02903
| | - Eleftherios Mylonakis
- Rhode Island Hospital, Alpert Medical School & Brown University, Providence, Rhode Island 02903
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Stewart DB. Anti-Sense Antibiotic Agents as Treatment for Bacterial Infections. Surg Infect (Larchmt) 2018; 19:831-835. [PMID: 30256744 DOI: 10.1089/sur.2018.200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: Conventional antibiotic agents are overused, leading to decreased efficacy because of a rising incidence in antimicrobial resistance. Further, conventional antibiotic agents result in widespread effects to human microbiota, which can lead directly to adverse events such as Clostridium difficile infection. Methods: This review provides a narrative summary of anti-sense therapies, an approach to managing bacterial infections by pursuing specific molecular targets that disrupt the flow of information from deoxyribonucleic acid to ribonucleic acid to protein, leading to the loss of bacterial functions. Included in this article is the rationale for this approach, the current data supporting its further investigation, and the challenges and future directions in this area of research. Results: There is a compelling proof-of-concept against both gram-positive and gram-negative organisms to commend the use of modified anti-sense oligonucleotides as antimicrobial therapy. There are data demonstrating that anti-sense therapies are capable of killing bacteria, silencing antimicrobial resistance mechanisms to restore sensitivity to conventional antibiotic agents, and to target virulence pathways such as biofilm production. Further, these drugs have a significantly greater degree of organismal specificity, limiting antibiotic-associated diarrhea and lowering the risk of antibiotic-related infections such as C. difficile infection. Conclusions: Anti-sense therapies show promise as a new class of antibiotic agents, providing molecular precision that leads to specific targeting of bacterial species and bacterial functions, including virulence mechanisms beyond the reach of current antibiotic agents. Further, changing the sequence of an anti-sense oligonucleotide provides a method of dealing with antimicrobial resistance that is more time- and cost-flexible than the available options with current conventional antibiotic agents.
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Affiliation(s)
- David B Stewart
- Department of Surgery, Section of Colorectal Surgery, University of Arizona , Tucson, Arizona
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Increased environmental sample area and recovery ofClostridium difficilespores from hospital surfaces by quantitative PCR and enrichment culture. Infect Control Hosp Epidemiol 2018; 39:917-923. [DOI: 10.1017/ice.2018.103] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AbstractObjectiveClostridium difficilespores play an important role in transmission and can survive in the environment for several months. Optimal methods for measuring environmentalC. difficileare unknown. We sought to determine whether increased sample surface area improved detection ofC. difficilefrom environmental samples.SettingSamples were collected from 12 patient rooms in a tertiary-care hospital in Toronto, Canada.MethodsSamples represented small surface-area and large surface-area floor and bedrail pairs from single-bed rooms of patients with low (without prior antibiotics), medium (with prior antibiotics), and high (C. difficileinfected) shedding risk. Presence ofC. difficilein samples was measured using quantitative polymerase chain reaction (qPCR) with targets on the 16S rRNA and toxin B genes and using enrichment culture.ResultsOf the 48 samples, 64·6% were positive by 16S qPCR (geometric mean, 13·8 spores); 39·6% were positive by toxin B qPCR (geometric mean, 1·9 spores); and 43·8% were positive by enrichment culture. By 16S qPCR, each 10-fold increase in sample surface area yielded 6·6 times (95% CI, 3·2–13) more spores. Floor surfaces yielded 27 times (95% CI, 4·9–181) more spores than bedrails, and rooms ofC. difficile–positive patients yielded 11 times (95% CI, 0·55–164) more spores than those of patients without prior antibiotics. Toxin B qPCR and enrichment culture returned analogous findings.ConclusionsClostridium difficilespores were identified in most floor and bedrail samples, and increased surface area improved detection. Future research aiming to understand the role of environmentalC. difficilein transmission should prefer samples with large surface areas.
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47
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Zhou MJ, Li J, Salmasian H, Zachariah P, Yang YX, Freedberg DE. The local hospital milieu and healthcare-associated vancomycin-resistant enterococcus acquisition. J Hosp Infect 2018; 101:69-75. [PMID: 30026006 DOI: 10.1016/j.jhin.2018.07.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 07/11/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Vancomycin-resistant enterococcus (VRE) causes 4% of all healthcare-associated infections in the USA. The process by which the local hospital milieu contributes to VRE acquisition is not fully understood. AIM To determine the importance of specific factors within the local hospital environment for healthcare-associated VRE acquisition. METHODS This retrospective cohort study included patients admitted to six intensive care units at an academic medical centre from January 2012 to December 2016 with negative rectal VRE cultures on admission. VRE acquisition was defined as a positive surveillance swab performed at any time after the initial negative swab during the index hospitalization. The exposures of interest were VRE colonization pressure, VRE importation pressure, and use of vancomycin. Multivariable Cox proportional hazards modelling was performed, with patients followed until VRE acquisition, death, or for up to 30 days. FINDINGS Of 8485 patients who were initially VRE negative, 161 patients acquired VRE. On univariate analysis, patients with VRE acquisition were more likely to have received vancomycin, to have had a neighbouring patient who received vancomycin, to have high VRE importation pressure, or to have high VRE colonization pressure. On multivariable analysis, only high VRE colonization pressure was an independent predictor of VRE acquisition (adjusted hazard ratio: 1.79; 95% confidence interval: 1.19-2.70). CONCLUSION VRE colonization pressure was the most important risk factor for healthcare-associated VRE acquisition, regardless of VRE importation pressure. Interventions seeking to reduce VRE acquisition should focus on minimizing transmission between patients with known VRE and the local hospital environment.
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Affiliation(s)
- M J Zhou
- Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - J Li
- Biomedical Informatics, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - H Salmasian
- Data Science and Evaluation, Brigham and Women's Hospital, Boston, MA, USA
| | - P Zachariah
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Y-X Yang
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - D E Freedberg
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, USA.
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Loo VG, Davis I, Embil J, Evans GA, Hota S, Lee C, Lee TC, Longtin Y, Louie T, Moayyedi P, Poutanen S, Simor AE, Steiner T, Thampi N, Valiquette L. Association of Medical Microbiology and Infectious Disease Canada treatment practice guidelines for Clostridium difficile infection. ACTA ACUST UNITED AC 2018. [DOI: 10.3138/jammi.2018.02.13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Vivian G Loo
- McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Ian Davis
- Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - John Embil
- Health Sciences Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gerald A Evans
- Kingston Health Sciences Centre, Queen’s University, Kingston, Ontario, Canada
| | - Susy Hota
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Christine Lee
- St. Joseph’s Healthcare, McMaster University, Hamilton, Ontario, Canada
| | - Todd C Lee
- McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Yves Longtin
- Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | - Thomas Louie
- Peter Lougheed Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Paul Moayyedi
- Health Sciences Centre, McMaster University, Hamilton, Ontario, Canada
| | - Susan Poutanen
- Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Andrew E Simor
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Theodore Steiner
- Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nisha Thampi
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Louis Valiquette
- Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Québec, Canada
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Ho J, Dai RZW, Kwong TNY, Wang X, Zhang L, Ip M, Chan R, Hawkey PMK, Lam KLY, Wong MCS, Tse G, Chan MTV, Chan FKL, Yu J, Ng SC, Lee N, Wu JCY, Sung JJY, Wu WKK, Wong SH. Disease Burden of Clostridium difficile Infections in Adults, Hong Kong, China, 2006-2014. Emerg Infect Dis 2018; 23:1671-1679. [PMID: 28930010 PMCID: PMC5621553 DOI: 10.3201/eid2310.170797] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Cross-sectional studies suggest an increasing trend in incidence and relatively low recurrence rates of Clostridium difficile infections in Asia than in Europe and North America. The temporal trend of C. difficile infection in Asia is not completely understood. We conducted a territory-wide population-based observational study to investigate the burden and clinical outcomes in Hong Kong, China, over a 9-year period. A total of 15,753 cases were identified, including 14,402 (91.4%) healthcare-associated cases and 817 (5.1%) community-associated cases. After adjustment for diagnostic test, we found that incidence increased from 15.41 cases/100,000 persons in 2006 to 36.31 cases/100,000 persons in 2014, an annual increase of 26%. This increase was associated with elderly patients, for whom incidence increased 3-fold over the period. Recurrence at 60 days increased from 5.7% in 2006 to 9.1% in 2014 (p<0.001). Our data suggest the need for further surveillance, especially in Asia, which contains ≈60% of the world’s population.
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Microbial Preparations (Probiotics) for the Prevention of Clostridium difficile Infection in Adults and Children: An Individual Patient Data Meta-analysis of 6,851 Participants. Infect Control Hosp Epidemiol 2018; 39:771-781. [PMID: 29695312 DOI: 10.1017/ice.2018.84] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVETo determine whether probiotic prophylaxes reduce the odds of Clostridium difficile infection (CDI) in adults and children.DESIGNIndividual participant data (IPD) meta-analysis of randomized controlled trials (RCTs), adjusting for risk factors.METHODSWe searched 6 databases and 11 grey literature sources from inception to April 2016. We identified 32 RCTs (n=8,713); among them, 18 RCTs provided IPD (n=6,851 participants) comparing probiotic prophylaxis to placebo or no treatment (standard care). One reviewer prepared the IPD, and 2 reviewers extracted data, rated study quality, and graded evidence quality.RESULTSProbiotics reduced CDI odds in the unadjusted model (n=6,645; odds ratio [OR] 0.37; 95% confidence interval [CI], 0.25-0.55) and the adjusted model (n=5,074; OR, 0.35; 95% CI, 0.23-0.55). Using 2 or more antibiotics increased the odds of CDI (OR, 2.20; 95% CI, 1.11-4.37), whereas age, sex, hospitalization status, and high-risk antibiotic exposure did not. Adjusted subgroup analyses suggested that, compared to no probiotics, multispecies probiotics were more beneficial than single-species probiotics, as was using probiotics in clinical settings where the CDI risk is ≥5%. Of 18 studies, 14 reported adverse events. In 11 of these 14 studies, the adverse events were retained in the adjusted model. Odds for serious adverse events were similar for both groups in the unadjusted analyses (n=4,990; OR, 1.06; 95% CI, 0.89-1.26) and adjusted analyses (n=4,718; OR, 1.06; 95% CI, 0.89-1.28). Missing outcome data for CDI ranged from 0% to 25.8%. Our analyses were robust to a sensitivity analysis for missingness.CONCLUSIONSModerate quality (ie, certainty) evidence suggests that probiotic prophylaxis may be a useful and safe CDI prevention strategy, particularly among participants taking 2 or more antibiotics and in hospital settings where the risk of CDI is ≥5%.TRIAL REGISTRATIONPROSPERO 2015 identifier: CRD42015015701Infect Control Hosp Epidemiol 2018;771-781.
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