Risk of cardiac conduction disorders, and pacemaker implantations among individuals tested for serum Borrelia burgdorferi antibodies, a nationwide, matched, population-based cohort study

OBJECTIVES

To investigate the short- and long-term risks of atrioventricular block and other cardiac conduction disorders associated with being tested for Borrelia burgdorferi (Bb) antibodies or Bb seropositivity as measures of confounding by indication and Bb infection, respectively.

METHODS

We performed a nationwide population-based matched cohort study (Denmark, 1993-2021). We included 52 200 Bb-seropositive individuals (stratified as only Bb-IgM-seropositive [n = 26 103], only Bb-IgG-seropositive [n = 18 698], and Bb-IgM-and-IgG-seropositive [n = 7399]) and two age- and sex-matched comparison cohorts: 104 400 Bb-seronegative individuals and 261 000 population controls. We investigated the risk associated with being tested for serum Bb antibodies and being Bb seropositive. Outcomes were atrioventricular block and other conduction disorders. We calculated short-term odds ratios (aOR) (within 1 month), and long-term hazard ratios (aHR) (after 1 month) adjusted for age, sex, diabetes, chronic heart failure, and kidney disease with 95% CI.

RESULTS

Compared with population controls, individuals tested for Bb antibodies had increased short- and long-term risks of atrioventricular block (aOR 47.9, 95% CI: 30.0-76.7, aHR 1.3, 95% CI:1.2-1.3), and other conduction disorders (aOR 18.2, 95% CI: 10.1-32.8, aHR 1.2, 95% CI: 1.1-1.4). Compared with Bb-seronegative individuals, only Bb-IgM-and-IgG-seropositive individuals had increased short-term risk of atrioventricular block (aOR: 2.1, 95% CI: 1.5-3.1).

DISCUSSION

The results suggest that Bb antibody testing is included in the diagnostic work-up of conduction disorders. Finally, that Bb seropositivity is not associated with other conduction disorders than atrioventricular block or with increased long-term risk of conduction disorders.

Risk of heart failure among individuals tested for Borrelia burgdorferi sensu lato antibodies, and serum Borrelia burgdorferi sensu lato seropositive individuals; a nationwide population-based, registry-based matched cohort study

BACKGROUND

Lyme borreliosis is a tick-borne disease caused by the bacterium Borrelia burgdorferi (Bb) sensu lato complex. Previous studies have suggested an association between Lyme borreliosis and heart failure, which have been suggested to be a possible manifestation of Lyme carditis. We aimed to investigate the risk of heart failure among individuals tested for serum Bb antibodies, and serum Bb seropositive individuals.

METHODS

We performed a matched nationwide cohort study (Denmark, 1993-2020) and included 52,200 Bb seropositive individuals, and two age- and sex-matched comparison cohorts: 1) 104,400 Bb seronegative comparison cohort members, and 2) 261,000 population controls. We investigated the risk associated with 1) being tested for serum Bb antibodies, and 2) being Bb seropositive. Outcomes were: 1) a composite of heart failure, cardiomyopathy, and/or myocarditis diagnosis, and 2) redemption of cardiovascular medicine used for treatment of heart failure. We calculated short-term odds ratios (aOR) (within 1 month) and long-term hazard rates (aHR) (after 1 month) adjusted for age, sex, diabetes, pre-existing heart failure, and kidney disease.

RESULTS

Compared with the population controls, individuals tested for Bb antibodies, regardless of the test result, had increased short-term risk of heart failure, cardiomyopathy, and myocarditis (aOR 8.3, 95 %CI: 6.7-10.2), and both increased short- and long-term risk of redemption of cardiovascular medicine (aOR 4.3, 95 %CI: 3.8-4.8, aHR 1.13, 95 % CI: 1.11-1.15). The Bb seropositive individuals had no increased short- or long-term risk of any outcome compared with Bb seronegative comparison cohort members.

CONCLUSIONS

In conclusion, Bb antibody tests seemed to be performed in the diagnostic work-up of heart failure, but Bb seropositivity was not associated with heart failure.

Characteristics and long-term prognosis of Danish residents with a positive intrathecal antibody index test for herpes simplex virus or varicella-zoster virus compared with individuals with a positive cerebrospinal fluid PCR: a nationwide cohort study

OBJECTIVES

We compared characteristics and outcomes of individuals who in the cerebrospinal fluid (CSF) were positive for herpes simplex virus (HSV) or varicella-zoster virus (VZV)-intrathecal antibody index test ([AI]-positive) vs. individuals who were PCR-positive for HSV type 1 (HSV1), type 2 (HSV2), and for VZV.

METHODS

Nationwide cohort study of all Danish residents with positive CSF-AI or -PCR for HSV or VZV (1995-2021). We calculated short- and long-term risks as age-, sex-, and comorbidity-adjusted odds ratios (aOR), adjusted hazard ratios (aHR), and absolute risk differences with 95% CIs.

RESULTS

Compared with individuals with positive PCR for HSV1 (n = 321), HSV2 (n = 497), and VZV (n = 1054), individuals with a positive AI for HSV (n = 177) and VZV (n = 219) had CSF pleocytosis less frequently (leucocyte count >10/μL: HSV-AI: 39%, VZV-AI: 52%, HSV1-PCR: 81%, HSV2-PCR: 92%, VZV-PCR: 83%), and were less frequently diagnosed with central nervous system infection ([aOR {95%CI}]: HSV-AI vs. HSV1-PCR: [0.1 {0.1, 0.2}], HSV-AI vs. HSV2-PCR: [0.1 {0.0, 0.1}], VZV-AI vs. VZV-PCR: [0.2 {0.2, 0.3}]). Individuals with a positive HSV-AI or VZV-AI had increased risk of demyelinating disease ([aOR {95%CI}; aHR {95%CI}]: HSV-AI vs. HSV1-PCR: [4.6 {0.9, 24.5}; aHR not applicable], HSV-AI vs. HSV2-PCR: [10.4 {2.3, 45.9}; 12.4 {2.3, 66.0}], VZV-AI vs. VZV-PCR: [aOR not applicable; 10.3 {1.8, 58.8}]). Disability pension was less frequent among HSV-AI than HSV1-PCR cohort members (5-year risk difference: -23.6%, 95%CI: -35.2, -11.8), and more frequent among VZV-AI than VZV-PCR cohort members (5-year risk difference: 16.8%, 95%CI: 5.0, 28.7).

DISCUSSION

AI-positive individuals differ from PCR-positive individuals in several aspects. AI appears unspecific for current central nervous system infections.

No Association Between Previous General Infection and Prosthetic Joint Infection After Total Hip Arthroplasty-A National Register-Based Cohort Study on 58,449 Patients Who Have Osteoarthritis

BACKGROUND

Prosthetic joint infection (PJI) following total hip arthroplasty (THA) is a complication associated with increased risk of death. There is limited knowledge about the association between infection before THA, and risk of revision due to PJI. We investigated the association between any previous hospital-diagnosed or community-treated infection 0 to 6 months before primary THA and the risk of revision.

METHODS

We obtained data on 58,449 patients who were operated with primary unilateral THA between 2010 and 2018 from the Danish Hip Arthroplasty Register. Information on previous infection diagnoses, redeemed antibiotic prescriptions up to 1 year before primary THA, intraoperative biopsies, and cohabitations was retrieved from Danish health registers. All patients had a 1-year follow-up. Primary outcome was revision due to PJI. Secondary outcome was any revision. We calculated the adjusted relative risk with 95% confidence intervals (CI), treating death as competing risk.

RESULTS

Among 1,507 revisions identified, 536 were due to PJI with a cumulative incidence of 1.0% ([CI] 0.9 to 1.2) and 0.9% ([CI] 0.8 to 1.0) for patients who did and did not have previous infection. For any revision, the cumulative incidence was 3.1% ([CI] 2.9 to 3.4) and 2.4% ([CI] 2.3 to 2.6) for patients who did and did not have previous infection. The adjusted relative risk for PJI revision was 1.1 ([CI] 0.9 to 1.4) and for any revision 1.3 ([CI] 1.1 to 1.4) for patients who did have previous infection compared to those who did not.

CONCLUSION

Previous hospital-diagnosed or community-treated infection 0 to 6 months before primary THA does not increase the risk of PJI revision. It may be associated with increased risk of any revision.

Risk of haematologic cancers among individuals tested for Borrelia burgdorferi antibodies, and Borrelia burgdorferi seropositive individuals: a nationwide population-based matched cohort study

OBJECTIVES

In a nationwide, matched cohort study, we aimed to investigate risks of haematologic cancers among individuals tested for Borrelia burgdorferi (Bb) antibodies, and among serum Bb seropositive individuals.

METHODS

We identified all Bb seropositive individuals in Denmark (1993-2020) (n = 52 200) and constructed two age- and sex-matched comparison cohorts: (a) Bb seronegative controls (n = 104 400) and (b) background population controls (n = 261 000). We calculated short-term OR (aOR) (<1 month of study inclusion), and long-term hazard ratios (aHR) (>1 month after study inclusion) adjusted for age and sex. We stratified seropositive individuals on only Bb-IgM seropositive (n = 26 103), only Bb-IgG seropositive (n = 18 698), and Bb-IgM-and-IgG seropositive (n = 7399).

RESULTS

Compared with the background population, individuals tested for Bb antibodies had increased short-term (aOR: 12.6, 95% CI: 10.1-15.6) and long-term (aHR: 1.3, 95% CI: 1.2-1.4) risk of haematologic cancers. The Bb seropositive individuals had no increased risk of haematologic cancers compared with those who tested negative for Bb, except that Bb-IgM-and-IgG seropositive individuals had increased long-term risk of chronic lymphatic leukaemia (aHR: 2.0, 95% CI: 1.2-3.4).

DISCUSSION

Our results suggest that Bb antibody testing is included in the work-up of unspecific symptoms preceding diagnosis of haematologic cancers. Bb-IgM-and-IgG seropositivity was associated with a two-fold increased long-term risk of chronic lymphatic leukaemia, which warrants further investigation.

Comparatively low rates of COVID-19 in women admitted in labor and their newborns prior to routine vaccination of pregnant women: insights from Denmark

Background: In a country with a high-test frequency, societal lockdown, and pregnancy leave granted from 28 gestational weeks, we investigated SARS-CoV-2 infection in women admitted in labor and their newborn in the pre-vaccine period.Material and methods: A total of 1042 women admitted for delivery in two Danish hospitals agreed to a plasma sample and nasopharyngeal, vaginal, and rectal swabs and to sampling of umbilical cord blood and a nasopharyngeal swab from their newborn at delivery. Plasma samples from women were examined for SARS-CoV-2 antibodies. If antibodies were detected, or the woman had a positive nasopharyngeal swab upon admission or had a household contact with symptoms consistent with COVID-19, SARS-CoV-2 PCR was performed on plasma and swab samples from mother and child.Results: Seventeen women (1.6%) were seropositive. Half the newborn (n = 9 (53%)) of seropositive mothers were also seropositive. None of the seropositive women or newborns had clinical signs of COVID-19 and all had SARS-CoV-2 PCR negative plasma and swab samples.Conclusion: Adherence to specific national guidelines pertaining to testing, self-imposed isolation, and cautious behaviors among pregnant women likely contributed to the exceptionally low prevalence of both prior and current COVID-19 infections detected at the time of childbirth preceding the routine vaccination of pregnant women in Denmark.

The association between socioeconomic factors and the success of decolonization treatment among individuals diagnosed with methicillin-resistant Staphylococcus aureus: A cohort study from 2007 to 2020

OBJECTIVES

To examine associations between socioeconomic factors and (1) adherence to methicillin-resistant Staphylococcus aureus (MRSA) posttreatment follow-up swab sampling after 1 and 6 months and (2) successful decolonization treatment.

DESIGN

Cohort study with 2 years of follow-up. Data on patients diagnosed with MRSA were extracted from a regional MRSA database and national registries. We used a cluster-based logistic regression model to estimate the adjusted odds ratios (aOR) and 95% confidence interval (CI) for associations between socioeconomic factors and decolonization treatment.

SETTING

Danish primary health care.

RESULTS

The rate of adherence to posttreatment follow-up swab sampling among 2,536 cases 1 month after decolonization treatment was 66% (95% CI, 64%-68%), and it decreased to 30% (95% CI, 28%-32%) after 6 months. Living in intermediate municipalities (76-159 inhabitants/km2) or having retired were associated with completed posttreatment follow-up swabs 1 month after decolonization treatment: aOR, 1.40 (95% CI, 1.2-1.74) and aOR, 2.67 (95% CI, 1.16-6.13), respectively. The rate of successful decolonization treatment 2 years after initiating treatment was 36% (95% CI, 34%-38%). Factors associated with successful decolonization treatment included individuals with higher education (aOR, 1.62; 95% CI, 1.22-2.15), early retirees (aOR, 1.63; 95% CI, 1.12-2.38), those living in intermediate municipalities (ie, 160-900+ inhabitants/km2; aOR, 1.35; 95% CI, 1.08-1.68), and those living in predominantly urban municipalities (ie, 160-900+ inhabitants/km2; aOR, 2.04; 95% CI, 1.5-2.76).

CONCLUSIONS

Disparities in the effect of decolonization treatment and adherence to MRSA follow-up sampling among MRSA-positive individuals appear to be largely explained by the level of education, area of residence, and employment status.

PATHPOD - A loop-mediated isothermal amplification (LAMP)-based point-of-care system for rapid clinical detection of SARS-CoV-2 in hospitals in Denmark

Sensitive and rapid detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been a vital goal in the ongoing COVID-19 pandemic. We present in this comprehensive work, for the first time, detailed fabrication and clinical validation of a point of care (PoC) device for rapid, onsite detection of SARS-CoV-2 using a real-time reverse-transcription loop-mediated isothermal amplification (RT-LAMP) reaction on a polymer cartridge. The PoC system, namely PATHPOD, consisting of a standalone device (weight less than 1.2 kg) and a cartridge, can perform the detection of 10 different samples and two controls in less than 50 min, which is much more rapid than the golden standard real-time reverse-transcription Polymerase Chain Reaction (RT-PCR), typically taking 16-48 h. The novel total internal reflection (TIR) scheme and the reactions inside the cartridge in the PoC device allow monitoring of the diagnostic results in real-time and onsite. The analytical sensitivity and specificity of the PoC test are comparable with the current RT-PCR, with a limit of detection (LOD) down to 30-50 viral genome copies. The robustness of the PATHPOD PoC system has been confirmed by analyzing 398 clinical samples initially examined in two hospitals in Denmark. The clinical sensitivity and specificity of these tests are discussed.

Detection of infections by computerized capture of peaks in longitudinally measured C-reactive protein levels

We developed four algorithms for the automatic capture of C-reactive protein (CRP) peaks in 296 adult patients with acute myeloid leukemia who had bloodstream infection (BSI) episodes, negative blood cultures (BCs) or possible infections where no BCs were performed. The algorithms detected CRP peaks for 418-446 of the 586 documented BSI episodes (71.3-76.1%) and 2714-3118 of the 4382 negative BCs (61.9-71.2%). The four algorithms captured 382-789 CRP peaks in which there were neither BSI episodes nor negative BCs. We conclude that automatic capture of CRP peaks is a tool for the monitoring of BSI episodes and possibly other infections in patients with acute myeloid leukemia.

Detection of Borrelia burgdorferi sensu lato DNA in cerebrospinal fluid samples following pre-enrichment culture

Molecular methods for diagnosing Lyme neuroborreliosis (LNB) have shown suboptimal diagnostic sensitivities. The objective of this study was to improve the clinical sensitivity of PCR detection of Borrelia burgdorferi sensu lato spirochetes by inoculating cerebrospinal fluid (CSF) from patients suspected of LNB directly into culture medium at the time of lumbar puncture, with this pursuing enrichment of Borrelia spirochetes before PCR analysis. Adult patients with symptoms suggestive of LNB were prospectively enrolled at two hospitals in the Region of Southern Denmark. The CSF-culture samples were incubated for at least eight weeks. During this period, culture sample aliquots were analysed for the presence of Borrelia DNA by separate PCR protocols in two independent clinical laboratories. The included patients were diagnosed with definite (n=12) or possible (n=2) LNB, and non-LNB (n=171) based on clinical and paraclinical findings. Patients in the LNB and the non-LNB group had a median duration from symptom onset to lumbar puncture of 40 days (IQR [23-90] days) and 120 days (IQR [32-365] days), respectively. Pre-enrichment growth of Borrelia spirochetes was accomplished from three patients (21 %) in the LNB group. The positive culture samples were confirmed by both the digital droplet PCR and the real-time PCR methods employed. All CSF samples were PCR negative in the non-LNB group. The results of this study do not support the use of Borrelia-specific PCR as a general routine diagnostic tool in adults. Still, they suggest it may prove of additional value in selected patients with a limited time from symptom onset to sample collection.

Impact of C-reactive protein and albumin levels on short, medium, and long term mortality in patients with diffuse large B-cell lymphoma

Objectives and study design: In this population-based study of 602 patients, we amended C-reactive protein (CRP) and plasma albumin (PA) levels around the diagnosis of diffuse large B-cell lymphoma (DLBCL) to the International Prognostic Index (IPI) and assessed 0-90, 91-365, and +365-day survival.Results: The CRP did not contribute to the IPI's prognostic or discriminatory ability, regardless of time period, particularly not in models with PA. In contrast, the PA was an important contributor, especially in the 0-90 day period, but also up to one year after the diagnosis. For day 0-90, the model with the IPI only had an Area Under the Receiver Operating Characteristics (AUROC) of 0.742, whereas the IPI with PA as a continuous variable rendered an AUROC of 0.841. Especially the lower PA quartile (18-32 g/L) contributed to the worse prognosis.Conclusions: The amendment of PA to the IPI may significantly improve the short-term prognostic and discriminative ability.Key messagesThe amendment of the plasma albumin (PA) level to the International Prognostic Index significantly improved the prediction of mortality up to one year after the diagnosis of diffuse large B-cell lymphoma.It was especially the lower quartile of the PA level (18-32 g/L) that contributed to the worse prognosis.

Establishment of a digital PCR method for detection of Borrelia burgdorferi sensu lato complex DNA in cerebrospinal fluid

Direct detection of Borrelia burgdorferi sensu lato bacteria in patient samples for diagnosis of Lyme neuroborreliosis (LNB) is hampered by low diagnostic sensitivity, due to few bacteria in cerebrospinal fluids (CSF) samples. Evaluation of novel molecular methods, including digital PCR (dPCR), as future tools in diagnostics of LNB is desirable. This study aimed to establish a dPCR assay and validate pre-PCR procedures for detection of Borrelia in CSF. Synthetic DNA fragments and cultured Borrelia reference strains were used during optimisation experiments. In addition, 59 CSF specimens from patients examined for LNB were included for clinical validation. The results showed that the pre-PCR parameters with the highest impact on Borrelia-specific dPCR method performance were incubation of the PCR-plate at 4 °C for stabilization of droplets, centrifugation for target concentration, quick-spin for dPCR rain reduction, and PCR inhibition by matrix components. Borrelia DNA in CSF was detected in one out of nine patients with LNB. Diagnostic sensitivity was determined to be 11.1% and specificity 100%. In conclusion, this study reports an optimized Borrelia-specific dPCR method for direct detection of Borrelia in CSF samples. The present study does not support the use of Borrelia-specific dPCR as a routine method for diagnosing LNB.

The diagnostic value of serum Borrelia burgdorferi antibodies and seroconversion after Lyme neuroborreliosis, a nationwide observational study

OBJECTIVES

Clinical guidelines disagree on the diagnostic usefulness of Borrelia burgdorferi (Bb) serum antibodies (serum-Bb) in investigation of Lyme neuroborreliosis (LNB). We investigated the association between serum-Bb and Bb intrathecal antibody index (Bb-AI) and rates of seroconversion and seroreversion after LNB.

METHODS

Danish residents who had a Bb-AI and corresponding serum-Bb measured between 1994-2020 were identified at all Danish departments of clinical microbiology. We used descriptive statistics to examine the proportions of positive Bb-AI combined with positive or negative serum-Bb antibody tests. Next, the rate of seroconversion and seroreversion among those with positive Bb-AI and either an initial negative or positive serum-Bb was estimated.

RESULTS

We included 34 609 individuals with a Bb-AI and corresponding serum-Bb. The proportion of individuals with positive Bb-AI who had negative serum-Bb was 16.8% (95% confidence interval (CI), 15.1-18.6). The proportion of individuals with positive serum-Bb IgM, serum-Bb IgG or serum-Bb IgM and IgG antibodies who had positive Bb-AI was 10.6% (95% CI, 9.5-11.8), 24.7% (95% CI, 23.0-26.4) and 45.0% (95% CI, 42.4-48.0), respectively. The proportion of children (<18 years) with positive serum-Bb IgM and IgG antibodies who had a positive Bb-AI was 59.7% (95% CI, 53.4-65.8). The proportion of individuals with positive Bb-AI with initial negative or positive serum-Bb antibodies who seroconverted or seroreverted within 2 years was 17.3% (95% CI, 6.9-27.8) and 23.2% (95% CI, 19.1-27.7), respectively.

CONCLUSIONS

Serum-Bb antibodies could not predict results of Bb-AI. A fifth of both seronegative and seropositive individuals with positive Bb-AI seroconverted or seroreverted within 2 years.

Reduction of intrapartum antibiotic prophylaxis by combining risk factor assessment with a rapid bedside intrapartum polymerase chain reaction testing for group B streptococci

OBJECTIVE

To investigate the impact of administering Intrapartum Antibiotic Prophylaxis (IAP) to laboring women with one or more risk factors for Early Onset Group B Streptococcal neonatal infection (EOGBS) based on the result of a rapid bedside test for Group B Streptococci (GBS).

STUDY DESIGN

Quality assessment study.

METHODS

Three-hundred-sixty-six laboring women admitted to our maternity ward, with one or more risk factors for EOGBS, were prospectively included. Rectovaginal swab-samples were examined bedside by the GenomEra® GBS Polymerase Chain Reaction (PCR) assay upon admission. Time from administration of IAP to delivery was registered. According to national guidelines, one-hundred-two women mandatorily received IAP independent of the PCR test result fulfilling one of the following three risk factors: prior infant with EOGBS, preterm labor before 35 gestational week, temperature ≥ 38 °C during labor. Women with GBS bacteriuria during current pregnancy, rupture of membranes ≥ 18 h IAP, and preterm labor between 35 and 37 gestational week, received IAP solely if the PCR test was positive. Predictive values were calculated for each risk factor.

RESULTS

Previous GBS bacteriuria was strongly associated (PPV = 71%) with a positive GBS PCR test, whilst the corresponding positive percent of ROM > 18 h and of GA 35-37 was only PPV = 16% and 22%, respectively. Seventy-four women, 74/251 (31%), received IAP because they were GBS PCR positive. IAP was thus reduced by about two-thirds compared to the risk-based strategy of offering IAP to all women with one or more risk factors for EOGBS. Two women, 2/254 (0.8%), received inferior care, as they did not receive IAP within the recommended 4 h prior to delivery due to the extra time spend on the test procedure.

CONCLUSION

Bedside intrapartum PCR testing of women with risk factors for EOGBS effectively diminishes use of IAP during labor compared to the present risk factor-based strategy alone. In this project, the extra time spend on the PCR test procedure did not lead to noticeable delay in IAP.

The serotype distribution of Streptococcus agalactiae (GBS) carriage isolates among pregnant women having risk factors for early-onset GBS disease: a comparative study with GBS causing invasive infections during the same period in Denmark

Background

We describe the serotype distribution of Streptococcus agalactiae (GBS) carriage isolates from women in labor and among GBS isolates causing invasive infections during the same period to see if the distribution of carriage serotypes reflects the GBS serotypes causing invasive diseases including early-onset disease (EOGBS).

Methods

Data on invasive isolates from 2019 including serotype, erythromycin and clindamycin susceptibility was retrieved from the Danish national reference laboratory, Statens Serum Institut. Carriage isolates were collected from women with risk factors for EOGBS enrolled at delivery at the maternity ward at a Danish University Hospital, first half of 2019.

Results

Among carriage isolates, the dominant serotype was IX (21 %) followed by serotype III (19 %). The resistance to erythromycin and clindamycin was 21 and 26 %, respectively. Among invasive GBS isolates, no case of EOGBS with serotype IX was detected but the distribution of serotypes were otherwise similar to the GBS carrier strains. The corresponding resistance to erythromycin and clindamycin was 23  and 15 %, respectively. Penicillin resistance was not detected among carriage nor invasive isolates.

Conclusions

The distribution of serotypes among carriage and invasive GBS reflects the assumption that EOGBS occur following transmission of GBS from mother to newborn, with the exception of serotype IX.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06820-2.

A comparison of predictors for mortality and bacteraemia in patients suspected of infection

Background

Stratification by clinical scores of patients suspected of infection can be used to support decisions on treatment and diagnostic workup. Seven clinical scores, SepsisFinder (SF), National Early Warning Score (NEWS), Sequential Orgen Failure Assessment (SOFA), Mortality in Emergency Department Sepsis (MEDS), quick SOFA (qSOFA), Shapiro Decision Rule (SDR) and Systemic Inflammatory Response Syndrome (SIRS), were evaluated for their ability to predict 30-day mortality and bacteraemia and for their ability to identify a low risk group, where blood culture may not be cost-effective and a high risk group where direct-from-blood PCR (dfbPCR) may be cost effective.

Methods

Retrospective data from two Danish and an Israeli hospital with a total of 1816 patients were used to calculate the seven scores.

Results

SF had higher Area Under the Receiver Operating curve than the clinical scores for prediction of mortality and bacteraemia, significantly so for MEDS, qSOFA and SIRS. For mortality predictions SF also had significantly higher area under the curve than SDR. In a low risk group identified by SF, consisting of 33% of the patients only 1.7% had bacteraemia and mortality was 4.2%, giving a cost of € 1976 for one positive result by blood culture. This was higher than the cost of € 502 of one positive dfbPCR from a high risk group consisting of 10% of the patients, where 25.3% had bacteraemia and mortality was 24.2%.

Conclusion

This may motivate a health economic study of whether resources spent on low risk blood cultures might be better spent on high risk dfbPCR.

Electronic reporting of diagnostic laboratory test results from all healthcare sectors is a cornerstone of national preparedness and control of COVID-19 in Denmark

The COVID‐19 pandemic has led to an unprecedented demand for real‐time surveillance data in order to inform critical decision makers regarding the management of the pandemic. The aim of this review was to describe how the Danish national microbiology database, MiBa, served as a cornerstone for providing data to the real‐time surveillance system by linkage to other nationwide health registries. The surveillance system was established on an existing IT health infrastructure and a close network between clinical microbiologists, information technology experts, and public health officials. In 2020, testing capacity for SARS‐CoV‐2 was ramped up from none to over 10,000 weekly PCR tests per 100,000 population. The crude incidence data mirrored this increase in testing. Real‐time access to denominator data and patient registries enabled adjustments for fluctuations testing activity, providing robust data on crude SARS‐CoV‐2 incidence during the changing diagnostic and management strategies. The use of the same data for different purposes, for example, final laboratory reports, information to the public, contact tracing, public health, and science, has been a critical asset for the pandemic response. It has also raised issues concerning data protection and critical capacity of the underlying technical systems and key resources. However, even with these limitations, the setup has enabled decision makers to adopt timely interventions. The experiences from COVID‐19 may motivate a transformation from traditional indicator‐based public health surveillance to an all‐encompassing information system based on access to a comprehensive set of data sources, including diagnostic and reference microbiology.

Prioritize effluent quality, operational costs or global warming? - Using predictive control of wastewater aeration for flexible management of objectives in WRRFs

This study presents a general model predictive control (MPC) algorithm for optimizing wastewater aeration in Water Resource Recovery Facilities (WRRF) under different management objectives. The flexibility of the MPC is demonstrated by controlling a WRRF under four management objectives, aiming at minimizing: (A) effluent concentrations, (B) electricity consumption, (C) total operations costs (sum electricity costs and discharge effluent tax) or (D) global warming potential (direct and indirect nitrous oxide emissions, and indirect from electricity production) . The MPC is tested with data from the alternating WRRF in Nørre Snede (Denmark) and from the Danish electricity grid. Results showed how the four control objectives resulted in important differences in aeration patterns and in the concentration dynamics over a day. Controls B and C showed similarities when looking at total costs, while similarities in global warming potential for controls A and D suggest that improving effluent quality also reduced greenhouse gasses emissions. The MPC flexibility in handling different objectives is shown by using a combined objective function, optimizing both cost and greenhouse emissions. This shows the trade-off between the two objectives, enabling the calculation of marginal costs and thus allowing WRRF operators to carefully evaluate prioritization of management objectives. The long-term MPC performance is evaluated over 51 days covering seasonal and inter-weekly variations. On a daily basis, control A was 9-30% cheaper on average compared to controls A, D and to the current rule-based control. Similarly, control D resulted on average in 35-43% lower greenhouse gasses daily emission compared to the other controls. Difference between control performance increased for days with greater inter-diurnal variations in electricity price or greenhouse emissions from electricity production, i.e. when MPC has greater possibilities for exploiting input variations. The flexibility of the proposed MPC can easily accommodate for additional control objectives, allowing WRRF operators to quickly adapt the plant operation to new management objectives and to face new performance requirements.

Polymerase chain reaction for Group B Streptococci (GBS) at labor highly correlates with vaginal GBS load

OBJECTIVE

To explore factors associated with a high vaginal GBS load during labor considering (1) the recto-vaginal GBS load at 35-37 weeks' gestation determined by culture and (2) the vaginal GBS colonization determined by a polymerase chain reaction (PCR) assay during labor.

METHODS

From an unselected cohort of 902 pregnant women, we obtained (1) recto-vaginal swabs for culture of GBS at 35-37 weeks' gestation (GBS_rectovag-36), (2) vaginal swabs for GBS PCR detection at labor (PCR_vag-labor), and (3) vaginal swabs for culture of GBS at labor (GBS_vag-labor). The GBS load was classified semi quantitatively according to a culture protocol without prior broth enrichment of the swab samples: none (0), few (+), some (++), or many (+++) GBS colonies.

RESULTS

Among 902 unselected pregnant women, 859 (95%) had a vaginal swab culture taken at labor, which was classified semi quantitatively. High load GBS_vag-labor (+++) were found in 31 participants. GBS_rectovag-36 showed a sensitivity of 90% (28/31) and a PPV of 23% (28/121), whereas PCR_vag-labor had a sensitivity of 98% (30/31, non-significant difference) and a PPV of 42% (30/71, p < .01). PCR at labor had a lower sensitivity (78%) for detection of vaginal colonization with GBS at labor (any load) compared to recto/vaginal colonization with GBS at 36 weeks (92%). Vaginal colonization with GBS at 36 weeks seemed to have a lower sensitivity for detecting GBS in vagina at labor for high load (48%) and for any load (39%).

CONCLUSION

PCR at labor has higher detection rate (non-significant) and PPV in identification of laboring women with a high load of vaginal GBS compared with recto-vaginal culture at 36 weeks' gestation.

Prediction of risk of acquiring urinary tract infection during hospital stay based on machine-learning: A retrospective cohort study

Background

Healthcare associated infections (HAI) are a major burden for the healthcare system and associated with prolonged hospital stay, increased morbidity, mortality and costs. Healthcare associated urinary tract infections (HA-UTI) accounts for about 20–30% of all HAI’s, and with the emergence of multi-resistant urinary tract pathogens, the total burden of HA-UTI will most likely increase.

Objective

The aim of the current study was to develop two predictive models, using data from the index admission as well as historic data on a patient, to predict the development of UTI at the time of entry to the hospital and after 48 hours of admission (HA-UTI). The ultimate goal is to predict the individual patient risk of acquiring HA-UTI before it occurs so that health care professionals may take proper actions to prevent it.

Methods

Retrospective cohort analysis of approx. 300 000 adult admissions in a Danish region was performed. We developed models for UTI prediction with five machine-learning algorithms using demographic information, laboratory results, data on antibiotic treatment, past medical history (ICD10 codes), and clinical data by transformation of unstructured narrative text in Electronic Medical Records to structured data by Natural Language Processing.

Results

The five machine-learning algorithms have been evaluated by the performance measures average squared error, cumulative lift, and area under the curve (ROC-index). The algorithms had an area under the curve (ROC-index) ranging from 0.82 to 0.84 for the entry model (T = 0 hours after admission) and from 0.71 to 0.77 for the HA-UTI model (T = 48 hours after admission).

Conclusion

The study is proof of concept that it is possible to create machine-learning models that can serve as early warning systems to predict patients at risk of acquiring urinary tract infections during admission. The entry model and the HA-UTI models perform with a high ROC-index indicating a sufficient sensitivity and specificity, which may make both models instrumental in individualized prevention of UTI in hospitalized patients. The favored machine-learning methodology is Decision Trees to ensure the most transparent results and to increase clinical understanding and implementation of the models.

Risk-based screening and intrapartum group B streptococcus polymerase chain reactionresults reduce use of antibiotics during labour

INTRODUCTION

This study investigated the feasibility of a risk-based screening approach combined with testing of Group B streptococcus (GBS) by polymerase chain reaction (PCR), the effect on use of intrapartum antibiotic prophylaxis (IAP) and the impact on the incidence of early-onset GBS infection (EOGBS).

METHODS

During one year, 551 women giving birth at Lillebaelt Hospital, Denmark, having one or more risk factors for EOGBS (previous birth of infant with EOGBS, GBS bacteriuria during current pregnancy, gestational age less than 37 weeks, rupture of membranes greater than 18 hours, and temperature ≥ 38 °C) were tested by a GBS PCR assay intrapartum. IAP was administered when the woman tested positive.

RESULTS

Among 2,889 women in labour, 19.1% (n = 551) had one or more risk factors for EOGBS, and 5.1% (n = 146) had both risk factors for EOGBS and a positive intrapartum GBS PCR test. In total, 185 women with risk factors for EOGBS received IAP. If the former risk-based approach had been applied, 551 women giving birth would have received IAP. Implementing IAP based on the GBS PCR results produced a two-thirds reduction of IAP. No children were diagnosed with EOGBS.

CONCLUSIONS

The GBS PCR assay was easy to perform and provided test results within 50 minutes. Implementation of risk-based screening combined with intrapartum GBS PCR testing reduces the use of IAP by two thirds compared with risk-based screening alone, thus minimising antibiotic resistance. The study material was too small to evaluate the effect on the incidence of EOGBS. Since EOGBS is a rare disease, more studies are required.

FUNDING

The study was supported by Forskningsraadet Lillebaelt Hospital, Udviklingsraadet Lillebaelt Hospital, Johs. M. Klein og Hustrus Mindelegat, the Region of Southern Denmark, Farusa Emballage A/S.

TRIAL REGISTRATION

not relevant.

International travel as source of a hospital outbreak with an unusual meticillin-resistant Staphylococcus aureus clonal complex 398, Denmark, 2016

In May 2016, an unusual outbreak with the Panton-Valentine leukocidin-positive human variant of meticillin-resistant Staphylococcus aureus (MRSA) clonal complex 398 occurred among mothers and infants in the maternity unit of a Danish hospital. MRSA sharing genotypic and phenotypic characteristics was confirmed in 36 cases, including 26 patients, nine household members and a healthcare worker (HCW) who had contact with all the patients. The national MRSA database contained 37 seemingly unlinked MRSA cases whose isolates shared the same genotypic and phenotypic characteristics as the outbreak strain. Whole genome sequencing showed that three of these isolates clustered together with the 36 outbreak isolates, suggesting spread outside the hospital. The HCW and 21 of 37 cases from the national MRSA database had links to south-eastern Asia, where the outbreak strain is endemic. These findings suggest that the HCW acquired the outbreak strain while travelling in south-eastern Asia and then introduced it into the hospital; from there, it spread within the patients’ households and into the community. Screening of travellers returning from countries with high levels of MRSA could be an important intervention to prevent spread of these bacteria into hospitals via patients or HCWs.

A comparison of GenomEra® GBS PCR and GeneXpert ® GBS PCR assays with culture of GBS performed with and without broth pre-enrichment

This study was designed to compare the performance of GeneXpert® and GenomEra® group B streptococcus (GBS) PCR assays, held up against standard culture of GBS performed with and without broth pre-enrichment. In Denmark, the strategy for preventing early onset GBS infection (EOGBS) is risk factor based. Three hundred and sixty six women fulfilling one or more of the criteria for presence of risk factors for EOGBS were prospectively included. Rectovaginal swab samples were taken intrapartum and tested bed-site by the GenomEra® and the GeneXpert® GBS PCR assays and cultured at the microbiology laboratory using Granada agar plates with and without prior growth of sampling material in selective enrichment broth. Among 366 participants tested intrapartum, 99 were GBS-positive by culture, 95 by GenomEra, and 95 by GeneXpert. Compared with culture, the GenomEra and the GeneXpert performed with a sensitivity of 91.8% and 91.7% and a specificity of 98.1% and 97.3%, respectively. A combined reference standard was established by defining true positives as either culture-positive samples or culture-negative samples where both the GeneXpert and the GenomEra GBS PCR assays were positive. Using this, the sensitivity increased to 92.2% and the specificity to 99.6% for GenomEra and to 92.0% and 96.8% for GeneXpert. The use of selective broth enrichment found only three additional GBS culture-positive samples. The performance of the two PCR methods examined was very similar and close to the findings by culture, and both PCR assays are thus applicable as rapid intrapartum bed-site tests.

A Chlamydia trachomatis 23S rRNA G1523A variant escaping detection in the Aptima Combo 2 assay (Hologic) was widespread across Denmark in July-September 2019

Chlamydia trachomatis infection is the most common bacterial sexually transmitted infection globally, and nucleic acid amplification tests (NAATs) are recommended for highly sensitive and specific diagnosis. In early 2019, the Finnish new variant of Chlamydia trachomatis (FI-nvCT) was identified. The FI-nvCT has a C1515T mutation in the 23S rRNA gene, making it escaping detection in the Aptima Combo 2 (AC2; Hologic) NAAT, and the FI-nvCT has been subsequently reported in Sweden and Norway. In the present study, we investigated the presence of the FI-nvCT and other AC2 diagnostic-escape CT mutants in July-September 2019 in Denmark. The FI-nvCT was present but rare in Denmark. However, another AC2 diagnostic-escape CT mutant (with a 23S rRNA G1523A mutation) was found to be widespread across Denmark, accounting for 95% (76/80) of AC2 diagnostic-escape nvCT samples from five Danish CT-diagnostic laboratories. This nvCT-G1523A has previously only been detected in one single sample in the United Kingdom and Norway, respectively. It is vital to monitor the continued stability of the NAAT targets in local, national and international settings and monitor as well as appropriately analyse incidence, unexplained shifts in diagnostics rates and/or annual collections of samples diagnosed as negative/equivocal using NAATs with different target(s). Furthermore, diagnostic CT NAATs with dual target sequences are crucial, and fortunately, an updated Hologic AC2 assay including one additional target sequence is in advanced development.

Clinical experiences with a new system for automated hand hygiene monitoring: A prospective observational study

BACKGROUND

Hand hygiene compliance (HHC) among health care workers remains suboptimal, and good monitoring systems are lacking. We aimed to evaluate HHC using an automated monitoring system.

METHODS

A prospective, observational study was conducted at 2 Danish university hospitals employing a new monitoring system (Sani nudge). Sensors were located on alcohol-based sanitizers, health care worker name tags, and patient beds measuring hand hygiene opportunities and sanitations.

RESULTS

In total, 42 nurses were included with an average HHC of 52% and 36% in hospitals A and B, respectively. HHC was lowest in patient rooms (hospital A: 45%; hospital B: 29%) and highest in staff toilets (hospital A: 72%; hospital B: 91%). Nurses sanitized after patient contact more often than before, and sanitizers located closest to room exits and in hallways were used most frequently. There was no association found between HHC level and the number of beds in patient rooms. The HHC level of each nurse was consistent over time, and showed a positive correlation between the number of sanitations and HHC levels (hospital A: r = 0.69; hospital B: r = 0.58).

CONCLUSIONS

The Sani nudge system can be used to monitor HHC at individual and group levels, which increases the understanding of compliance behavior.

Longitudinal trajectory patterns of plasma albumin and C-reactive protein levels around diagnosis, relapse, bacteraemia, and death of acute myeloid leukaemia patients

Background

No study has evaluated C-reactive protein (CRP) and plasma albumin (PA) levels longitudinally in patients with acute myeloid leukaemia (AML).

Methods

We studied defined events in 818 adult patients with AML in relation to 60,209 CRP and PA measures. We investigated correlations between CRP and PA levels and daily CRP and PA levels in relation to AML diagnosis, AML relapse, or bacteraemia (all ±30 days), and death (─30–0 days).

Results

On the AML diagnosis date (D0), CRP levels increased with higher WHO performance score (PS), e.g. patients with PS 3/4 had 68.1 mg/L higher CRP compared to patients with PS 0, adjusted for relevant covariates. On D0, the PA level declined with increasing PS, e.g. PS 3/4 had 7.54 g/L lower adjusted PA compared to PS 0. CRP and PA levels were inversely correlated for the PA interval 25–55 g/L (R = − 0.51, p < 10–5), but not for ≤24 g/L (R = 0.01, p = 0.57). CRP increases and PA decreases were seen prior to bacteraemia and death, whereas no changes occurred up to AML diagnosis or relapse. CRP increases and PA decreases were also found frequently in individuals, unrelated to a pre-specified event.

Conclusions

PA decrease is an important biomarker for imminent bacteraemia in adult patients with AML.

Urine dipstick for predicting intrapartum recto-vaginal colonisation by group B streptococci

INTRODUCTION

In pregnant women, bacteriuria with group B streptococci (GBS) may be associated with a high degree of recto-vaginal GBS colonisation and therefore an increased risk of early-onset GBS disease. The aim of this study was to assess the performance of routine use of dipstick urine analysis during pregnancy for prediction of recto-vaginal GBS colonisation at the time of labour.

METHODS

Among 902 unselected Danish pregnant women, we obtained results from 1) dipstick urine analysis, 2) urine culture carried out during pregnancy, if indicated, and 3) recto-vaginal culture at labour. The inclusion criteria were age > 18 years and gestational age ≥ 37 weeks.

RESULTS

Intrapartum recto-vaginal GBS colonisation was predicted by a positive urine dipstick with 5% sensitivity only.

CONCLUSION

Dipstick urine analysis had a low sensitivity for predicting intrapartum recto-vaginal colonisation with GBS.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

Associations between blood cultures after surgery for colorectal cancer and long-term oncological outcomes

BACKGROUND

Systemic inflammation following curative surgery for colorectal cancer may be associated with increased risk of recurrence. [Correction added on 29 November 2019, after first online publication: text amended for accuracy.] This study investigated whether a clinically suspected infection, for which blood cultures were sent within 30 days after surgery for colorectal cancer, was associated with long-term oncological outcomes.

METHODS

This register-based national cohort study included all Danish residents undergoing surgery with curative intent for colorectal cancer between January 2003 and December 2013. Patients who developed recurrence or died within 180 days after surgery were not included. Associations between blood cultures taken within 30 days after primary surgery and overall survival, disease-free survival and recurrence-free survival were analysed using Cox regression models adjusted for relevant clinical confounders, including demographic data, cancer stage, co-morbidity, blood transfusion, postoperative complications and adjuvant chemotherapy.

RESULTS

The study included 21 349 patients, of whom 3390 (15·9 per cent) had blood cultures taken within 30 days after surgery. Median follow-up was 5·6 years. Patients who had blood cultures taken had an increased risk of all-cause mortality (hazard ratio (HR) 1·27, 95 per cent c.i. 1·20 to 1·35; P < 0·001), poorer disease-free survival (HR 1·22, 1·16 to 1·29; P < 0·001) and higher risk of recurrence (HR 1·15, 1·07 to 1·23; P < 0·001) than patients who did not have blood cultures taken.

CONCLUSION

A clinically suspected infection requiring blood cultures within 30 days of surgery for colorectal cancer was associated with poorer oncological outcomes.

Association between risk factors and testicular microlithiasis

Background

Testicular microlithiasis and its clinical significance are not fully understood. Testicular microlithiasis and risk factors have been associated with testicular cancer. The role of testicular microlithiasis is investigated.

Purpose

To investigate the association between testicular microlithiasis and socioeconomic and other pre-diagnostic factors.

Material and Methods

All men who had a scrotal ultrasound examination at the Department of Radiology, Vejle Hospital, during 2001–2013 were included. They were categorized as patients with and without testicular microlithiasis and compared with pre-diagnostic data from a nationwide registry. A total of 2404 men (283 [11.8%] with testicular microlithiasis and 2121 [88.2%] without testicular microlithiasis) were included. The association between testicular microlithiasis and pre-diagnostic conditions was investigated with logistic regression.

Results

Overall, we found no statistically significant differences in demographics, socioeconomic characteristics, or testicular diseases in men with and without testicular microlithiasis. Men with testicular microlithiasis had more often been treated for infertility (odds ratio [OR] 2.09, 95% confidence interval [CI] 0.84–5.24) and testicular torsion (OR 1.58, 95% CI 0.34–7.36) compared to men without testicular microlithiasis. We found no association between sexually transmitted diseases and testicular microlithiasis.

Conclusion

Treatment for infertility and torsion was non-significantly associated with testicular microlithiasis and no other association was found. These data do not suggest early exposure is related to testicular microlithiasis.

Community-acquired meningitis caused by beta-haemolytic streptococci in adults: a nationwide population-based cohort study

The objective of this study was to examine the clinical presentation of community-acquired beta-haemolytic streptococcal (BHS) meningitis in adults. This is a nationwide population-based cohort study of adults (≥ 16 years) with BHS meningitis verified by culture or polymerase chain reaction of the cerebrospinal fluid (CSF) from 1993 to 2005. We retrospectively evaluated clinical and laboratory features and assessed outcome by Glasgow Outcome Scale (GOS). We identified 54 adults (58% female) with a median age of 65 years (IQR 55-73). Mean incidence rate was 0.7 cases per 1,000,000 person-years. Alcohol abuse was noted among 11 (20%) patients. Group A streptococci (GAS) were found in 17 (32%) patients, group B (GBS) in 18 (34%), group C (GCS) in four (8%) and group G (GGS) in 14 (26%). Patients with GAS meningitis often had concomitant otitis media (47%) and mastoiditis (30%). Among patients with GBS, GCS or GGS meningitis, the most frequent concomitant focal infections were bone and soft tissue infections (19%) and endocarditis (16%). In-hospital mortality was 31% (95% CI 19-45), and 63% (95% CI 49-76) had an unfavourable outcome at discharge (GOS < 5). BHS meningitis in adults is primarily observed among the elderly and has a poor prognosis. GAS meningitis is primarily associated with concomitant ear-nose-throat infection.

Danish Childhood Cancer Registry

Aim of database

The overall aim is to monitor the quality of childhood cancer care in Denmark; to register late effects of treatment; to analyze complications of permanent central venous catheters (CVCs); to study blood stream infections in children with cancer; and to study acute toxicity of high-dose methotrexate infusions in children with leukemia.

Study population

All children below 15 years of age at diagnosis living in Denmark diagnosed after January 1, 1985 according to the International Classification of Diseases 10, including diagnoses DC00–DD48.

Main variables

Cancer type, extent of disease, treatment, participation in international studies, recurrence of malignant disease, survival, yearly follow-up status, causes of death, and development of secondary malignancies. Type of CVC, causes for removal of the CVC, type of blood stream infection, pathogens isolated, antimicrobial sensitivity, and outcome of antimicrobial chemotherapy.

Descriptive data

Since 1985, 4,944 children below 15 years of age have been registered in the database. There has been no significant change in the incidence of childhood cancer in Denmark since 1985. The 5-year survival has increased significantly since 1985 and is now 86%. The median number of days from diagnosis to initiation of therapy is 7 days and in 80% of the children less than 14 days. Clinical data of 95% of the patients are reported to open international studies.

Conclusion

The survival of Danish children with cancer since 2003 compares favorably with other international population-based studies. The annual reports support the collaboration within pediatric oncology in Denmark.

[Two cases of neonatal meningitis after new gentamicin dosing guidelines]

Neonates with suspected or proven sepsis are treated with ampicillin and until recently with 5 mg gentamicin/kg every 24 h. New guidelines recommend the same gentamicin dose, but with longer intervals depending on gestational age. Two neonates receiving gentamicin every 48 h improved initially, but both deteriorated again before the second dose. In both infants ampicillin-resistant but gentamicin-sensitive Escherichia coli was found. In one of the infants a resistant/less sensitive E. coli strain was also found in the cerebrospinal fluid. The rationale for the new dosing guidelines is discussed.

Incidence rates of hospital-acquired urinary tract and bloodstream infections generated by automated compilation of electronically available healthcare data

BACKGROUND

Monitoring of hospital-acquired infection (HAI) by automated compilation of registry data may address the disadvantages of laborious, costly and potentially subjective and often random sampling of data by manual surveillance.

AIM

To evaluate a system for automated monitoring of hospital-acquired urinary tract (HA-UTI) and bloodstream infections (HA-BSI) and to report incidence rates over a five-year period in a Danish hospital trust.

METHODS

Based primarily on electronically available data relating to microbiology results and antibiotic prescriptions, the automated monitoring of HA-UTIs and HA-BSIs was validated against data from six previous point-prevalence surveys (PPS) from 2010 to 2013 and data from a manual assessment (HA-UTI only) of one department of internal medicine from January 2010. Incidence rates (infections per 1000 bed-days) from 2010 to 2014 were calculated.

FINDINGS

Compared with the PPSs, the automated monitoring showed a sensitivity of 88% in detecting UTI in general, 78% in detecting HA-UTI, and 100% in detecting BSI in general. The monthly incidence rates varied between 4.14 and 6.61 per 1000 bed-days for HA-UTI and between 0.09 and 1.25 per 1000 bed-days for HA-BSI.

CONCLUSION

Replacing PPSs with automated monitoring of HAIs may provide better and more objective data and constitute a promising foundation for individual patient risk analyses and epidemiological studies. Automated monitoring may be universally applicable in hospitals with electronic databases comprising microbiological findings, admission data, and antibiotic prescriptions.

Season is an unreliable predictor of Lyme neuroborreliosis

INTRODUCTION

Lyme neuroborreliosis (LNB) is a tick-borne infection of the nervous system caused by the spirochete Borrelia burgdorferi sensu lato. The primary symptoms are usually painful radiculitis, facial palsy and lymphocytic meningitis. The aim of this study was to provide data on the seasonal variation, anamnesis, symptoms, laboratory data and course of the disease in adults (≥ 16 years).

METHODS

The medical records of 69 patients with confirmed LNB who attended the Department of Neurology, Lillebaelt Hospital, Vejle, Denmark, were analysed. The diagnosis was confirmed by the presence of leucocytosis in the cerebrospinal fluid and intrathecal production of immunoglobulin M and/or G anti-B. burgdorferi antibodies.

RESULTS

Onset of neurological symptoms in LNB occurred year round in the Region of Southern Denmark. Only half of the patients had a history of a tick bite or erythema migrans (EM). Half of the patients who observed a tick bite subsequently reported EM. The duration from the onset of neurological symptoms to referral to hospital was remarkably long for patients with radiculoneuritis, whereas the onset of facial palsy led to a swift referral. Patients who were ≥ 50 years old had a significantly lower age-related risk of facial palsy without radicular symptoms.

CONCLUSION

In this study, winter as a low-risk season was not a reliable factor in ruling out LNB. This finding may be relevant when investigating the cause of facial palsy and radicular symptoms.

The "true" incidence of surgically treated deep prosthetic joint infection after 32,896 primary total hip arthroplasties: a prospective cohort study

BACKGROUND AND PURPOSE

It has been suggested that the risk of prosthetic joint infection (PJI) in patients with total hip arthroplasty (THA) may be underestimated if based only on arthroplasty registry data. We therefore wanted to estimate the "true" incidence of PJI in THA using several data sources.

PATIENTS AND METHODS

We searched the Danish Hip Arthroplasty Register (DHR) for primary THAs performed between 2005 and 2011. Using the DHR and the Danish National Register of Patients (NRP), we identified first revisions for any reason and those that were due to PJI. PJIs were also identified using an algorithm incorporating data from microbiological, prescription, and clinical biochemistry databases and clinical findings from the medical records. We calculated cumulative incidence with 95% confidence interval.

RESULTS

32,896 primary THAs were identified. Of these, 1,546 had first-time revisions reported to the DHR and/or the NRP. For the DHR only, the 1- and 5-year cumulative incidences of PJI were 0.51% (0.44-0.59) and 0.64% (0.51-0.79). For the NRP only, the 1- and 5-year cumulative incidences of PJI were 0.48% (0.41-0.56) and 0.57% (0.45-0.71). The corresponding 1- and 5-year cumulative incidences estimated with the algorithm were 0.86% (0.77-0.97) and 1.03% (0.87-1.22). The incidences of PJI based on the DHR and the NRP were consistently 40% lower than those estimated using the algorithm covering several data sources.

INTERPRETATION

Using several available data sources, the "true" incidence of PJI following primary THA was estimated to be approximately 40% higher than previously reported by national registries alone.

Effect of Correctly Using Alcohol-Based Hand Rub in a Clinical Setting

We evaluated hand antisepsis in clinical practice at Aarhus University Hospital in Skejby, Denmark. The rate of compliance with the correct use of alcohol-based hand rub exceeded 55% of all routine clinical procedures observed. With the correct use of alcohol-based hand rub by hospital staff, bacterial counts were reduced by 90% before and 82% after a clinical procedure; with incorrect use, the bacterial counts were reduced by 60% before and 54% after a clinical procedure.

Cohort Study of Adherence to Correct Hand Antisepsis Before and After Performance of Clinical Procedures

Objective.

To investigate the rate of adherence by hospital staff members to the correct use of alcohol-based hand rub before and after performance of clinical procedures.

Design.

A cohort study conducted during the period from 2006 through 2007 and 2 cross-sectional studies conducted in 2006 and 2007.

Setting.

Århus University Hospital, Skejby, in Århus, Denmark.

Participants.

Various hospital staff members.

Methods.

Following an ongoing campaign promoting the correct use of alcohol-based hand rub, we observed rates of adherence by hospital staff to the correct use of alcohol-based hand rub. Observations were made before and after each contact with patients or patient surroundings during 5 weekdays during the period from 2006 through 2007 in 10 different hospital units. A logistic regression model was used to estimate the rate of adherence to the correct use of alcohol-based hand rub before and after performance of a clinical procedure.

Results.

A total of 496 participants were observed during 22,906 opportunities for hand hygiene (ie, 11,177 before and 11,729 after clinical procedures) that required the use of alcohol-based hand rub. The overall rates of adherence to the correct use of alcohol-based hand rub were 62.3% (6,968 ofthe 11,177 opportunities) before performance and 68.6% (8,041 ofthe 11,729 opportunities) after performance of clinical procedures. Compared with male participants, female participants were significantly better at adhering to the correct use of alcohol-based hand rub before performance (odds ratio [OR] 1.51 [95% confidence interval {CI}, 1.09–2.10]) and after performance (OR, 1.73 [95% CI, 1.27–2.36]) of clinical procedures. In general, the rate of adherence was significantly higher after the performance of clinical procedures, compared with before (OR, 1.43 [95% CI, 1.35–1.52]). For our cohort of 214 participants who were observed during 14,319 opportunities, the rates of adherence to the correct use of alcohol-based hand rub were 63.2% (4,469 of the 7,071 opportunities) before performance and 69.3% (5,021 of the 7,248 opportunities) after performance of clinical procedures, and these rates increased significantly from 2006 to 2007, except for physicians.

Conclusion.

We found a high and increasing rate of adherence to the correct use of alcohol-based hand rub before and after performance of clinical procedures following a campaign that promoted the correct use of alcohol-based hand rub. More hospital staff performed hand hygiene with alcohol-based hand rub after performance of clinical procedures, compared with before performance. Future campaigns to improve the rate of adherence to the correct use of alcohol-based hand rub ought be aware that certain groups of hospital staff (eg, male staff members) are known to exhibit a low level of adherence to the correct use of alcohol-based hand rub.

Importance of blood cultures from peripheral veins in pediatric patients with cancer and a central venous line

BACKGROUND

When an infection is suspected in a child with cancer and a central venous line (CVL), cultures are often only obtained from the CVL and not from a peripheral vein (PV). This study was undertaken to evaluate the importance of concomitant blood cultures from the CVL and a PV.

PROCEDURE

Clinical data and the results of all cultures taken concomitantly from the CVL and a PV were registered prospectively in children admitted with fever from April 2008 to December 2012 at the Department of Pediatrics at Aarhus University Hospital Skejby.

RESULTS

During the study period 654 paired cultures obtained from the CVL and from a PV within two hour of each other were included. A true bloodstream infection (BSI) was registered in 112 episodes. In 20 (17%) out of 112, true BSI growth of a microorganism was detected only in the culture from a PV including seven cases of Escherichia coli and three cases of Staphylococcus aureus. In 52 episodes the same microorganism was cultured from both the CVL and a PV. Twenty-four of these episodes were classified as catheter-related bloodstream infections (CRBSI) using differential time to positivity. In total, 64 (57%) of all true BSI were defined as CRBSI.

CONCLUSIONS

Blood cultures should be obtained from a PV in addition to cultures from CVL at the onset of fever in pediatric patients with cancer in order to maximize the findings of true BSIs. The frequency of CRBSI may be over-estimated if blood cultures are drawn from CVL only.

Central venous catheters and catheter locks in children with cancer: a prospective randomized trial of taurolidine versus heparin

BACKGROUND

To determine if the catheter lock taurolidine can reduce the number of catheter-related bloodstream infections (CRBSI) in pediatric cancer patients with tunneled central venous catheters (CVC).

PROCEDURE

During a study period of 34 months, 129 newly placed tunneled CVCs in 112 patients were randomly assigned to standard lock with heparin solution or experimental lock with a taurolidine solution (ClinicalTrials.gov Identifier NCT00735813).

RESULTS

Sixty-five CVCs were included in the standard group and 64 CVCs in the experimental group. The groups were comparable regarding patients' characteristics. A total number of 72 bloodstream infections of which 33 were CRBSIs were observed during 39,127 CVC-days. A lower rate of CRBSI (0.4 per 1,000 CVC-days) was observed in the experimental arm compared with the standard arm (1.4 per 1,000 CVC-days, incidence rate ratio (IRR) = 0.26; 95% confidence interval (CI) 0.09-0.61; P = 0.001). A lower rate of total bloodstream infections (1.2 per 1,000 CVC-days) was also observed in the experimental arm compared with the standard arm (2.5 per 1,000 CVC-days, IRR = 0.49; 95% CI 0.29-0.82; P = 0.004). Median interval from catheter insertion until first CRBSI was significantly lower in the standard group (156 days, range 12-602) compared with the experimental group (300 days, range 12-1,176; P = 0.02). Premature removal of the CVC due to infection and overall CVC survival were similar in the two study groups.

CONCLUSION

Locking of long-term tunneled CVC with taurolidine significantly reduces catheter-related bloodstream infections in children with cancer.

[Fighting drug-resistant hospital bacteria--less antibiotics and more infection control]

Antibiotic resistant bacteria are a global problem. Drug resistance may spread rapidly due to mobile resistance genes shared by many species. The selection of resistant bacteria is promoted by ever increasing human and veterinarian use of antibiotics. A new paradigm in fighting drug-resistant hospital bacteria is needed to stop the vicious circle of drug-resistance and bring back antibiotic susceptible bacteria. Less antibiotics and more infection control by an improved compliance with hand hygiene is the choice left to minimize the spread of hospital infections with drug resistant bacteria.

[Infections related to central venous catheters in children affected from malignant diseases]

Central venous catheters (CVC) are an essential part of the treatment of children with haematological and oncological diseases. Unfortunately, CVC also represent a major risk factor of bloodstream infections. Catheter-related bloodstream infections (CRBSI) in children are often diagnosed based on blood cultures from the CVC only. Most CRBSI can be treated without catheter removal. On suspicion of CRBSI empirical antibiotic treatment with piperacillin-tazobactam, meropenem or ampicillin in combination with gentamicin is recommended. The systemic treatment can be combined with catheter-lock therapy.

Obesity, diabetes, and the risk of infections diagnosed in hospital and post-discharge infections after cesarean section: a prospective cohort study

OBJECTIVE

To assess the impact of obesity and diabetes on the risk of post-cesarean infections.

DESIGN

Prospective cohort study.

SETTING

Obstetric departments at three hospitals in Denmark.

POPULATION

2,492 consecutive women having cesarean section (CS) from February 2007 to August 2008.

METHODS

We collected complete data from medical records and databases on CS, body mass index, diabetes (type 1, type 2, and gestational), and post-cesarean infections. Post-discharge infections diagnosed by general practitioners were ascertained through positive microbiological cultures and antibiotic prescriptions.

MAIN OUTCOME MEASURES

Cumulative incidences of infections within 30 days after CS.

RESULTS

Of 2,492 women having CS, 373 (15.2%) were obese and 123 (4.9%) had diabetes. Overall, 458 women (18.4%) had a post-cesarean infection within 30 days and 174 (7.0%) were diagnosed in-hospital. The risk of post-cesarean infections was higher among obese than non-obese women: adjusted (for diabetes and emergency/elective CS) odds ratio (OR)=1.43; 95% confidence interval (CI): 1.09-1.88, particularly for in-hospital infections (OR=1.86; 95%CI: 1.28-2.72). After controlling for obesity and mode of CS, type 2 or gestational diabetes were weak predictors of infection risk (OR=1.18; 95%CI: 0.72-1.93), whereas the adjusted OR in women with type 1 diabetes was 1.65 (95%CI: 0.64-4.25). Among diabetic women, obesity increased the risk of post-cesarean infections more than twofold; the adjusted ORs were 2.06 (95%CI: 1.13-3.75) for infections overall and 2.74 (95%CI: 1.25-6.01) for in-hospital infections.

CONCLUSION

Obesity increases the risk of post-cesarean infections and diabetes further strengthens this association.

Culture confirmation of gonococcal infection by recall of subjects found to be positive by nucleic acid amplification tests in general practice

OBJECTIVES

To evaluate a routine notification of general practitioners to recall nucleic acid amplification test (NAAT)-positive subjects for culture of Neisseria gonorrhoeae to confirm gonococcal infection in the community.

METHODS

A retrospective observational study of the routine testing for N gonorrhoeae by analysis of test results compiled from the laboratory information system in two departments of clinical microbiology.

RESULTS

Altogether, 158 male and female subjects with NAAT-positive results for N gonorrhoeae were included in the study. Samples for culture of N gonorrhoeae were collected from 102/158 (64.6%) subjects recalled after a NAAT assay was found positive. Growth of N gonorrhoeae was seen in the samples from 54/102 (52.9%) of the re-examined NAAT-positive subjects. Among subjects with samples collected within the first week after the positive NAAT test, 34/44 (77.3%) were confirmed positive by culture.

CONCLUSION

This study shows that it is possible for the general practitioner to recall a substantial number of NAAT-positive subjects to collect swabs for culture of N gonorrhoeae to confirm gonococcal infection in the community. Most recall samples are culture positive if collected within a week of the NAAT-positive test, and may provide a sufficient monitoring of the drug susceptibility of N gonorrhoeae strains in the community.