High incidence of candidaemia in a nationwide cohort: Underlying diseases, risk factors and mortality

BACKGROUND

Denmark has a high incidence rate of candidaemia. A Nordic study suggested a higher Danish prevalence of haematological malignancies as an underlying reason. This nationwide study ascertained clinical characteristics of Danish candidaemia patients and investigated potential factors contributing to the high incidence and mortality.

METHODS

Microbiological and clinical data for candidaemia patients in 2010-2011 were retrieved. 30-day mortality was estimated by hazard ratios (HR) with 95% confidence intervals (CI, Cox regression).

RESULTS

Data were available for 912/973 candidaemia episodes (93.7%). Intensive care unit (ICU) held the largest share of patients (43.2%). Prevalent host factors were multi-morbidity (≥2 underlying diseases, 74.2%) and gastrointestinal disease (52.5%). Haematological disease was infrequent (7.8%). Risk factors included antibiotic exposure (90.5%), CVC (71.9%) and Candida colonisation (66.7%). 30-day mortality was 43.4%, and 53.6% in ICU. Mortality was lower for patients with recent abdominal surgery (HR 0.70, 95% CI: 0.54-0.92).

CONCLUSION

A substantial prevalence of multi-morbidity and a high 30-day mortality was found. We hypothesise, that an increasing population of severely ill patients with prolonged supportive treatment and microbiological testing may in part explain the high candidaemia incidence in Denmark. Nationwide studies are warranted to clarify this issue.

Outbreak of Clostridium difficile 027 in North Zealand, Denmark, 2008-2009

We report an outbreak of Clostridium difficile PCR ribotype 027 in Denmark. The outbreak includes to date 73 cases from the area north of Copenhagen, but there may be related cases elsewhere in Zealand. Most infections are healthcare-associated and in patients who previously received antibiotic treatment. The strain is resistant to moxifloxacin, erythromycin, and clindamycin, and carries genes for toxin A, toxin B, and for the binary toxin. The antimicrobial pattern differs from that of the strain involved in a small cluster in Denmark in 2006-2007. Because of this outbreak, hygienic measures in the involved hospitals have been reinforced. Nationwide, microbiological laboratories were alerted to the outbreak and encouraged to send isolates for toxin profiling and PCR ribotyping.

Outbreak of Clostridium difficile 027 in North Zealand, Denmark, 2008-2009

We report an outbreak of Clostridium difficile PCR ribotype 027 in Denmark. The outbreak includes to date 73 cases from the area north of Copenhagen, but there may be related cases elsewhere in Zealand. Most infections are healthcare-associated and in patients who previously received antibiotic treatment. The strain is resistant to moxifloxacin, erythromycin, and clindamycin, and carries genes for toxin A, toxin B, and for the binary toxin. The antimicrobial pattern differs from that of the strain involved in a small cluster in Denmark in 2006-2007. Because of this outbreak, hygienic measures in the involved hospitals have been reinforced. Nationwide, microbiological laboratories were alerted to the outbreak and encouraged to send isolates for toxin profiling and PCR ribotyping.

Attaching and effacing Escherichia coli isolates from Danish children: clinical significance and microbiological characteristics

This study describes the prevalence, clinical manifestations and microbiological characteristics of attaching and effacing Escherichia coli isolates, i.e., enteropathogenic E. coli (EPEC) belonging to the classical EPEC serotypes, non-EPEC attaching and effacing E. coli (A/EEC) and verocytotoxin-producing E. coli (VTEC), isolated in a case-control study of Danish children aged <5 years. Among 424 children with diarrhoea and 866 healthy controls, EPEC and VTEC were more prevalent in cases (2.4% and 2.6%, respectively) than in controls (0.7% and 0.7%, respectively). There was a high frequency of A/EEC isolates (n = 121), but these were equally prevalent in cases (11.3%) and controls (12.5%), and comprised a heterogeneous distribution of O:H serotypes. The intimin (eae) subtypes in A/EEC isolates showed an even distribution; the eae-gamma subtype predominated in classical EPEC cases. The virulence genes encoding the bundle-forming pilus (bfpA) and enteroaggregative heat-stable enterotoxin (astA) were rare among all isolates, and seemed to be of limited pathogenic importance in this population. Virulence characterisation of A/EEC isolates did not reveal any significant differences between cases and controls. Colonisation of children with A/EEC was associated with contact with sheep or goats (OR 2.2). The role of A/EEC, not being VTEC or belonging to the classical EPEC serotypes, requires further clarification, but serotyping is useful in discriminating between EPEC and A/EEC strains.

[Patient satisfaction and duration of breast feeding]

INTRODUCTION

Only two out of three Danish women follow the recommendations for duration of breast-feeding given by The Danish National Board of Health, which recommend it as the sole source of nutrition for at least the first four months of life. The present study was carried out to investigate the influence of patient satisfaction on the duration of breast-feeding.

MATERIAL AND METHODS

Based on an earlier investigation into the satisfaction of primiparas with the public health service during pregnancy, delivery, and the puerperium, 145 women were interviewed by telephone about the period in which their child was fed solely by mother's milk. Mothers of twins and those who had had an elective caesarean or whose child had been transferred to the neonatal care unit were excluded. Data from the patient satisfaction study and data on the delivery retrieved from a local obstetric database were related to the duration of breast-feeding.

RESULTS

The mean duration of breast-feeding only was four months with no association to the women's satisfaction with the public health service in general. There was, however, an association between the period of breast-feeding only and satisfaction with issues dealing specifically with breast-feeding. In women who had had an oxytocin infusion breast-feeding was more often well-established. No other event during labour related to the initiation or duration of breast-feeding. There was an insignificant trend towards more use of a pacifier or formula supplementation in the first days in women, who did not initiate breast-feeding. It is unknown whether this is a cause or a consequence.

DISCUSSION

The initiation of breast-feeding is influenced by the woman's satisfaction with the public service in matters relating to breastfeeding. In other ways, it is a process that is difficult to disturb.

[Hemorrhagic diarrhea with competing etiologies]

A case history of a 41-year-old woman with bloody diarrhoea is described. A right-sided hemicolectomy was performed and histological findings showed pseudomembranous colitis. The woman was infected with verotoxin-producing E. coli O103:H2. She had taken an overdose of ergotamine and was using a contraceptive containing oestrogen. Each of these have previously been described as being the cause of bloody diarrhoea, but we suggest the combination as the aetiology in the present case.

Neonatal pneumonia: comparison of 4 vs 7 days of antibiotic therapy in term and near-term infants

OBJECTIVE

To compare a 4-day course of antibiotic therapy to a 7-day course in selected term and near-term neonates with pneumonia.

METHODS

The diagnosis of pneumonia was made in neonates admitted to the normal Newborn Nursery (NBN) who later had signs of respiratory distress and whose chest radiographs were consistent with pneumonia. Infants were excluded if any of the following was present: moderate or thick meconium-stained amniotic fluid, prior antibiotic therapy > 24 hours, or need for supplemental oxygen > 8 hours. Infants who were asymptomatic after 48 hours of antibiotic therapy were prospectively randomized to a 4-day group (n = 35) or a 7-day group (n = 38). Infants in the 4-day group were observed in the hospital for 24 hours following cessation of antibiotics and were seen in follow up within several days of discharge.

RESULTS

The groups were comparable with regard to demographic factors, duration of rupture of membranes, and incidence of maternal chorioamnionitis. Median postnatal age at the time of identification of respiratory distress symptomatology was 19 hours (range 0.5 to 55 hours) in the 4-day group and 12 hours (range 1 to 72 hours) in the 7-day group. No study infants had a positive blood culture. Mean reduction in length of hospitalization was 2.1 days, with estimated savings of greater than US$700 per shortened hospitalization. Two infants in the 4-day group developed tachypnea during the 24-hour observation period. However, no infants were rehospitalized for sepsis or pneumonia following discharge. With 95% confidence, the true rate of success for the 4-day group was at least 92%.

CONCLUSION

Four days of antibiotic therapy plus a 24-hour period of observation for selected cases of neonatal pneumonia appears to be comparable to 7 days of therapy. It is important to note that newborns in our institution receive a single dose of penicillin soon after birth as part of our group B streptococcal sepsis prophylaxis program, and all infants in this study received prophylaxis prior to the onset of respiratory symptoms. Furthermore, only infants who were asymptomatic after 48 hours of antibiotic therapy were included in this study, and a 24-hour observation period at the end of the 4-day course was required. These qualifications should be taken into account before use of this approach is considered, and additional studies are necessary to further establish its safety and benefits.

Two cases of human urinary tract infection complicated by hemolytic uremic syndrome caused by verotoxin-producing Escherichia coli

In 1993, 2 cases of urinary tract infection (UTI) caused by verotoxin-producing Escherichia coli were diagnosed at Rigshospitalet in Copenhagen, Denmark. Neither of the patients had any previous history of diarrhea. We suggest that E. coli strains isolated from UTI be examined for the production of verotoxin when hemolytic uremic syndrome is clinically suspected.

Escherichia coli bacteraemia in patients with and without haematological malignancies: a study of strain characters and recurrent episodes

We compared serotypes, virulence factors and susceptibility to antibiotics of Escherichia coli strains isolated from 282 patients with bacteraemia. Thirty-five of these were neutropenic patients with haematological malignancy and 247 were patients with a normal or raised total white blood cell count and no haematological malignancy. Strains isolated from recurrent bacteraemia were also bio- and ribotyped. Overall, no significant difference was found between O serogroups, K antigens, serum sensitivity, production of haemolysin, expression of P-fimbriae and patterns of antibiotic susceptibility in the two groups of strains. The haematological patients more often than the non-haematological patients had an unknown focus of infection, recurrent bacteraemia, shorter intervals between recurrences and recurrences caused by identical strains. Despite a well-defined focus, six of eight non-haematological patients had recurrences with a strain different from the strain isolated in a previous episode. A possible connection between shorter intervals and recurrence with identical strains is discussed. We suggest that strains from recurrent E. coli bacteraemia are sent to a reference laboratory for serotyping and possibly ribotyping.

Seinsheimer's classification of subtrochanteric fractures. Poor reproducibility of 4 observers' evaluation of 50 cases

We examined the reliability of the Seinsheimer classification of subtrochanteric fractures of the femur. 50 consecutive anteroposterior and lateral radiographs were assessed independently by 4 observers twice with a 6-week interval. The interobserver variation was large; only 13 of the 50 fractures were classified identically by all 4 observers. The intraobserver variation showed identical classification in 26-37 of 50 radiographs. When assessing only whether the fracture was subtype 3A or not, the 4 observers agreed in 31 of 50 radiographs. We conclude that the Seinsheimer classification has no value in clinical practice.

Ennoblement of Stainless Steel by the Manganese-Depositing Bacterium Leptothrix discophora

The noble shift in open-circuit potential exhibited by microbially colonized stainless steel (ennoblement) was investigated by examining the relationship among surface colonization, manganese deposition, and open-circuit potential for stainless steel coupons exposed to batch cultures of the manganese-depositing bacterium Leptothrix discophora. Open-circuit potential shifted from -100 to +330 mV(infSCE) as a biofilm containing 75 nmol of MnO(infx) cm(sup-2) formed on the coupon surface but changed little further with continued MnO(infx) deposition up to 270 nmol cm(sup-2). Increased open-circuit potential corresponded to decreasing Mn(II) concentration in solution and to increased MnO(infx) accumulation and attached cell density on the coupon surfaces. MnO(infx) deposition was attributable to biological activity, and Mn(II) was observed to enhance cell attachment. The experimental results support a mechanism of ennoblement in which open-circuit potential is fixed near +350 mV(infSCE) by the cathodic activity of biomineralized MnO(infx).

A comparative study of nosocomial and community-acquired strains of Escherichia coli causing bacteraemia in a Danish University Hospital

In a previous study we found a considerably higher mortality rate in patients with nosocomial (NO) compared with community-acquired (CA) Escherichia coli bacteraemia. To establish whether this was due to host differences or to differences in the infecting bacteria, we compared 205 NO with 172 CA bacteraemic isolates of E. coli with respect to serotype, virulence factors and antimicrobial susceptibility. Overall the six most frequent O antigens were O18ac, O6, O1, O2, O15 and O75, respectively. The six most frequent capsular antigens were K1, K5, K52, K2, K7 and K34, respectively. No major differences were found regarding O-antigens, capsular antigens, production of haemolysin, P-fimbriation, serum sensitivity or antimicrobial susceptibility. Surprisingly we found 17 strains of serotype O15:K52:[H1] of both NO (eight) and CA (nine) origin with similar phenotypic characteristics to a strain causing a CA outbreak in London 1986-1987. Possibly the Danish and the English strains belong to the same clone. Our findings argue against the existence of a distinct NO flora. NO E. coli bacteraemia strains seem to originate primarily from the patients' own flora.

[Subcutaneous fat necrosis with hypercalcemia]

A case of subcutaneous fat necrosis (SFN) is presented. The infant developed late onset hypercalcaemia of severe degree. Calcitonin failed to normalize the hypercalcaemia. Glucocorticoids and withdrawal of dietary calcium and vitamin D are the treatment of choice. Like hypercalcaemia in association with other granulomatous diseases, SFN is possibly secondary to locally produced 1,25-dihydroxy-cholecalciferol. Our results were not able to confirm this theory. Infants with SFN should have calcium levels monitored closely for months.

Bacteraemia due to Escherichia coli in a Danish university hospital, 1986-1990

433 episodes of E. coli bactereaemia over a 5-year period in a Danish university hospital were studied with special emphasis on possible differences between nosocomial (NO) and community-acquired (CA) cases. Data from 186 males and 247 females with ages ranging from 9 days to 94 years were recorded. The average incidence of E. coli bacteraemia was 24.4 episodes/10,000 admissions/year. Older females accounted for the largest number of cases, which reflected the composition of the background population. The highest risk of infection was in males 80-89 years of age. The highest frequency of NO infections was in the departments of Intensive Care (90%) Orthopaedic Surgery (87%) and Haematology (80%). The most common focus was the urinary tract, with 72% of the episodes with a known focus, while the biliary tract was the focus in 14%. NO bacteraemia was independently related to immunosuppressive therapy, presence of predisposing factors, polymicrobial bacteraemia and presence of a non-urinary tract focus. A urinary tract focus was associated with CA bacteraemia, monomicrobial infection, female sex and a normal or elevated total white blood cell count. Patients with NO bacteraemia had predisposing factors more often than had CA patients, especially haematological malignancies and immunosuppressive therapy. Lack of a known bacterial focus was more common in NO than CA episodes, particularly among patients with haematologic malignancies. The overall mortality was 21%. Increased mortality was independently related to leukopenia (45%), immunosuppressive therapy and NO bacteraemia.

Branhamella catarrhalis in children and adults. A study of prevalence, time of colonisation, and association with upper and lower respiratory tract infections

The colonisation rate of Branhamella catarrhalis in patients from 0 to 45 years of age was examined. Of 561 women admitted to hospital in labour, 6 (1%) carried B. catarrhalis in their throats but none carried the organism in their vaginas. None of 534 newborn babies became colonised at birth or during their 5 days' stay in hospital. Neither were 102 neonates < 1 month of age in hospital colonised. The maximum colonisation rate during childhood was observed in children 1-48 months of age with 143 of 266 (54%) children colonised. Among children 4-15 years of age, four of 57 (7%) children with healthy respiratory tracts were colonised. Significantly more children with upper or lower respiratory tract infections (RTI) were colonised (68%) than were children without such infections (36%), (P < 0.001). After recovery from RTI, the isolation rate in the RTI group fell to that of the non-RTI group. A seasonal variation in prevalence was not observed. Of all the strains of B. catarrhalis isolated, 84% produced beta-lactamase.

Cluster of multiresistant Escherichia coli O78:H10 in Greater Copenhagen

A multiresistant, lactose-negative Escherichia coli O78:H10 was isolated from 19 patients in Greater Copenhagen over a period of 8 months. At least 14 cases were community-acquired. 18 isolates originated from urine cultures and 1 from a faecal sample. 13 patients were predisposed to urinary tract infection (UTI) and 11 patients showed clinical signs of UTI. This is the first report of E. coli O78:H10 causing human disease. The cluster was probably food-borne, but the source was not identified. This cluster of identical disease associated E. coli was only uncovered because of its multiresistance and lactose-negative phenotype.

Poor reproducibility of Evans' classification of the trochanteric fracture. Assessment of 4 observers in 52 cases

The radiographs of trochanteric fractures in 52 consecutive patients were assessed by 4 observers, using the Evans' classification. The interobserver variation was large; only 23 of 52 radiographs were classified identically by all 4 observers. When only assessing stability, the 4 observers agreed in 34 of 52 radiographs. To assess the intraobserver variation, the same observers classified the same radiographs 6 weeks later. The first and second classifications were identical in 35-44 of 52 radiographs.

Cerebrospinal fluid beta-2-microglobulin in adult patients with acute leukemia or lymphoma: a useful marker in early diagnosis and monitoring of CNS-involvement

Beta-2-microglobulin (B2m) was measured in the cerebrospinal fluid (CSF) and serum from 18 adults with acute lymphoblastic leukemia, acute myeloblastic leukemia or lymphoma in order to detect early central nervous system (CNS) involvement or relapse. Six had CNS-involvement documented by neurologic symptoms and tumor cells in the CSF. Their CSF-B2m-concentrations were significantly higher before intrathecal chemotherapy than in those without this complication (P less than 0.01). During therapy CSF-B2m levels fell rapidly to normal values on repeated measurements. The study demonstrates that serial determination of CSF-B2m alone may be a useful and sensitive marker of CNS-dissemination in acute leukemia and malignant lymphoma. Using the criteria of CSF-B2m greater than 160 nmol/l as a positive diagnostic test the sensitivity of the test was 100%, the specificity was 76%. The same values for the CSF/serum-ratio greater than 1 were 75% and 64%, respectively.

Loss of erythrocyte complement receptors (CR1; CD35) in patients with acute episodes of septicaemia or bacterial meningitis

14 patients with septicaemia or bacterial meningitis were examined for serum levels of erythrocyte complement receptors CR1 (C3b/C4b; CD35) by an enzyme-linked immunosorbent assay and levels of circulating immune complexes (IC) by a polyethylene glycol precipitation complement consumption method, and concentrations of complement C3d split products in plasma by intermediate gel rocket immunoelectrophoresis. The CR1 receptor levels were significantly lower on day 7-8 after admission than on day 1-2 (p = 0.01), and than the levels 3-4 months later (p = 0.002). Both the levels of IC in serum and the C3d concentrations were significantly higher on day 7-8 than 3-4 months later (p = 0.02 and p = 0.004). The mechanism behind a temporary decreased expression of CR1 in patients with acute episodes of septicaemia or purulent meningitis is not fully known, and further investigations are needed to clarify whether this reduction in erythrocyte CR1 causes an impaired disposal of IC in patients with infections.

[Prognosis of patients with rectal cancer treated in a department of general surgery]

The results of treatment of 355 patients with adenocarcinoma of the rectum treated during the period 1973-1982 in a department for general surgery were compared with the results obtained in other more specialized departments. The 5 year survival rate, corrected for deaths from other causes than cancer of the rectum, was calculated retrospectively to be 35% which was comparable with certain departments. Some highly specialized departments had, however, better results. The postoperative mortality was high (14%). Highly differentiated tumours resulted in better prognoses than poorly differentiated tumours (p less than 0.001). The median age was relatively high (67 years) and relatively many of the patients were men (62%). Patients in whom haemorrhage was the first symptom had better prognoses than patients with other symptoms (p = 0.018). The prognoses were similar regardless of the durations of symptoms.

Fractional excretion of beta-2-microglobulin in the urine of patients with normal or reduced renal function and hepatic coma

The purpose of this prospective study was to evaluate beta-2-microglobulin (beta 2m) as a differential diagnostic indicator between hepatic nephropathy (HN) and acute tubulointerstitial nephropathy (ATIN) in patients with reduced renal function and hepatic coma, and to determine whether beta 2m excretion could be used as a marker of renal impairment before increased serum creatinine (S-Cr) concentration or decreased creatinine clearance (Cr-Cl). Finally, the use of beta 2m as a prognostic indicator was investigated. Eighteen patients in hepatic coma grade III-IV were entered in the study and were divided into two groups in accordance with their renal function (serum creatinine above/below 180 mumol/l). The fractional excretion of beta 2m (FE-beta 2m) was used to monitor beta 2m elimination. The study failed to show any distinction in FE-beta 2m between HN and ATIN patients, presumably owing to the small number of patients. FE-beta 2m could not predict the development of renal failure earlier than the increase in S-Cr or decrease in Cr-Cl. However, a few patients who survived paracetamol intoxication had increased FE-beta 2M in the beginning of the coma and normal S-Cr and Cr-Cl. Patients who died as a result of paracetamol intoxication had both abnormal FE-beta 2m and abnormal S-Cr and Cr-Cl, suggesting that if therapy had been initiated earlier, when only FE-beta 2m was affected, these patients might have survived. All patients who survived, except three paracetamol- and one aminoglycoside-intoxicated patient, had normal FE-beta 2m in the beginning of the coma.(ABSTRACT TRUNCATED AT 250 WORDS)

Yield of diagnostic tests for opportunistic infections in AIDS: a survey of 33 patients

To examine the therapeutic consequences of diagnostic tests for AIDS-related infections, case records from 33 deceased AIDS patients were reviewed; 23 were autopsied. Determination of serum antibody titres was not important. In particular, there was no relation between titres and isolation of cytomegalovirus (CMV); isolation attempts or possibly antigen determination would be better. Samples for CMV isolation were obtained from 31 patients; only 7 were negative. Blood, faeces, and particularly sputum cultures gave a low yield; the number of such examinations could be reduced considerably. However, 4/7 disseminated infections with atypical mycobacteria were only revealed at autopsy, despite numerous cultures in vivo. Liver biopsies were not helpful. Diagnostic procedures for Pneumocystis carinii pneumonia by lung biopsy caused pneumothorax in 3/15 patients; bronchoalveolar lavage or treatment/prophylaxis without diagnosis could be considered. In 8 autopsies, microscopy was suggestive of cerebral toxoplasmosis, but only 1 patient had presented important clinical symptoms. We suggest a schedule with regular microbiologic and parasitic examinations and few antibody tests, but with more antigen tests.

Plasma pentachlorophenol concentrations in calves exposed to treated wood in the environment

Six calves were fed grain and hay from a pentachlorophenol (PCP)-treated feeder twice daily. Samples of blood were collected twice a week. Plasma PCP concentrations increased rapidly to a maximum of 1,086 microgram/L within 10 days. After the 3rd week, calves were denied access to the treated feeder; PCP values returned rapidly to near base line (before calves were fed from the treated feeder). After base-line plasma PCP values were reached, 4 of the 6 calves were housed in a total confinement building and exposed (by inhalation) to lumber that was commercially treated with PCP. The building itself was free of structural PCP-treated lumber. The ratio of building volume to treated wood surface was approximately 49 to 1. During the 3 weeks the calves were confined, PCP values did not increase and were markedly lower than those associated with oral exposure to treated wood. Oral dosing of calves with PCP in capsules--0.05 and 0.5 mg/kg--resulted in maximal plasma PCP values of 1,449 and 9,555 micrograms/L, respectively. Oral exposures (feeding from contaminated feeder; capsule) appeared to be more important than inhalation in causing increased plasma PCP concentrations in cattle. Exposure from these sources may be estimated by comparison with experimental values from dose-response studies. Feeding from treated feeders resulted in lower plasma PCP values than did dosing with 0.05 mg/kg daily.

Electron microscopy of cultured human corneas. Osmotic hydration and the use of a dextran fraction (dextran T 500) in organ culture

Human corneas were studied by means of electron microscopy after culture at 31 degrees C for two to 20 days in a medium containing 8% dextran T 500. Dextran T 500, a strong osmotic agent, was included in the culture medium to prevent excessive swelling of the cornea. In order to exclude the possibility that the observed effects were the result of osmotic changes during fixation, in each experiment, fixatives with different osmolalities were used (430, 574, 727, and 812 mOsm). After 8, 16, and 20 days of culture, vacuoles appeared that were filled with dextran; the cytoplasm was completely filled with these vacuoles. The vacuolization was not limited to the endothelium, but was also observed in stromal keratocytes and to a limited extent in the epithelium. It was concluded that the monolayer of endothelium was still intact after 20 days of culture in medium containing 8% dextran T 500, and, secondly, that the dextran might have been taken up by endocytosis. Whether or not the uptake of dextran has a long-term toxic effect on the corneal cells remains to be elucidated.