A176 ASSOCIATIONS OF ANTIBIOTICS, HORMONAL THERAPIES, ORAL CONTRACEPTIVES, AND LONG-TERM NSAIDS WITH INFLAMMATORY BOWEL DISEASE: RESULTS FROM THE PROSPECTIVE URBAN RURAL EPIDEMIOLOGY (PURE) STUDY

Background

The pathogenesis of inflammatory bowel disease (IBD) which includes Crohn’s disease (CD) and ulcerative colitis (UC), is believed to involve activation of the intestinal immune system in response to the gut microbiome among genetically susceptible hosts. IBD has been historically regarded as a disease of developed nations, though in the past two decades there has been a reported shift in the epidemiological pattern of disease. High-income nations with known high prevalence of disease are seeing a stabilization of incident cases, while a rapid rise of incident IBD is being observed in developing nations. This suggests that environmental exposures may play a role in mediating the risk of developing IBD. The potential environmental determinants of IBD across various regions is vast, though medications have been increasingly recognized as one broad category of risk factors.

Purpose

Several medications have been considered to contribute to the etiology of IBD. This study assessed the association between medication use and risk of developing IBD using the Prospective Urban Rural Epidemiology (PURE) cohort.

Method

This was a prospective cohort study of 133,137 individuals between the ages of 20-80 from 24 countries. Country-specific validated questionnaires documented baseline and follow-up medication use. Participants were followed prospectively at least every 3 years. The main outcome was development of IBD, including CD and UC. Short-term (baseline but not follow-up use) and long-term use (baseline and subsequent follow-up use) was evaluated. Results are presented as adjusted odds ratios (aOR) with 95% confidence intervals (CI).

Result(s)

During the median follow-up of 11.0 years [interquartile range (IQR) 9.2-12.2], we recorded 571 incident cases of IBD (143 CD and 428 UC). Higher risk of incident IBD was associated with baseline antibiotic use [aOR: 2.81 (95% CI: 1.67-4.73), p=0.0001] and hormonal medication use [aOR: 4.43 (95% CI: 1.78-11.01), p=0.001]. Among females, previous or current oral contraceptive use was also associated with IBD development [aOR: 2.17 (95% CI: 1.70-2.77), p=5.02E-10]. NSAID users were also observed to have increased risk of IBD [aOR: 1.80 (95% CI: 1.23-2.64), p=0.002], which was driven by long-term users [aOR: 5.58 (95% CI: 2.26-13.80), p<0.001]. All significant results were consistent in direction for CD and UC with low heterogeneity.

Conclusion(s)

Antibiotics, hormonal medications, oral contraceptives, and long-term NSAID use were associated with increased odds of incident IBD after adjustment for covariates.

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Salim Yusuf is supported by the Heart & Stroke Foundation/Marion W. Burke Chair in Cardiovascular Disease. The PURE Study is an investigator-initiated study funded by the Population Health Research Institute, the Canadian Institutes of Health Research (CIHR), Heart and Stroke Foundation of Ontario, support from CIHR’s Strategy for Patient Oriented Research (SPOR) through the Ontario SPOR Support Unit, as well as the Ontario Ministry of Health and Long-Term Care and through unrestricted grants from several pharmaceutical companies, with major contributions from AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, and GlaxoSmithkline, and additional contributions from Novartis and King Pharma and from various national or local organisations in participating countries; these include: Argentina: Fundacion ECLA; Bangladesh: Independent University, Bangladesh and Mitra and Associates; Brazil: Unilever Health Institute, Brazil; Canada: Public Health Agency of Canada and Champlain Cardiovascular Disease Prevention Network; Chile: Universidad de la Frontera; China: National Center for Cardiovascular Diseases; Colombia: Colciencias, grant number 6566-04-18062; India: Indian Council of Medical Research; Malaysia: Ministry of Science, Technology and Innovation of Malaysia, grant numbers 100 -IRDC/BIOTEK 16/6/21 (13/2007) and 07-05-IFN-BPH 010, Ministry of Higher Education of Malaysia grant number 600 -RMI/LRGS/5/3 (2/2011), Universiti Teknologi MARA, Universiti Kebangsaan Malaysia (UKM-Hejim-Komuniti-15-2010); occupied Palestinian territory: the UN Relief and Works Agency for Palestine Refugees in the Near East, occupied Palestinian territory; International Development Research Centre, Canada; Philippines: Philippine Council for Health Research & Development; Poland: Polish Ministry of Science and Higher Education grant number 290/W-PURE/2008/0, Wroclaw Medical University; Saudi Arabia: the Deanship of Scientific Research at King Saud University, Riyadh, Saudi Arabia (research group number RG -1436-013); South Africa: the North-West University, SANPAD (SA and Netherlands Programme for Alternative Development), National Research Foundation, Medical Research Council of SA, The SA Sugar Association (SASA), Faculty of Community and Health Sciences (UWC); Sweden: grants from the Swedish state under the Agreement concerning research and education of doctors; the Swedish Heart and Lung Foundation; the Swedish Research Council; the Swedish Council for Health, Working Life and Welfare, King Gustaf V’s and Queen Victoria Freemasons Foundation, AFA Insurance, Swedish Council for Working Life and Social Research, Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning, grant from the Swedish State under the Läkar Utbildnings Avtalet agreement, and grant from the Västra Götaland Region; Turkey: Metabolic Syndrome Society, AstraZeneca, Turkey, Sanofi Aventis, Turkey; United Arab Emirates (UAE): Sheikh Hamdan Bin Rashid Al Maktoum Award For Medical Sciences and Dubai Health Authority, Dubai UAE.

Disclosure of Interest

C. Pray: None Declared, N. Narula Grant / Research support from: Neeraj Narula holds a McMaster University Department of Medicine Internal Career Award. Neeraj Narula has received honoraria from Janssen, Abbvie, Takeda, Pfizer, Merck, and Ferring, E. C. Wong: None Declared, J. K. Marshall Grant / Research support from: John K. Marshall has received honoraria from Janssen, AbbVie, Allergan, Bristol-Meyer-Squibb, Ferring, Janssen, Lilly, Lupin, Merck, Pfizer, Pharmascience, Roche, Shire, Takeda and Teva., S. Rangarajan: None Declared, S. Islam: None Declared, A. Bahonar: None Declared, K. F. Alhabib: None Declared, A. Kontsevaya: None Declared, F. Ariffin: None Declared, H. U. Co: None Declared, W. Al Sharief: None Declared, A. Szuba: None Declared, A. Wielgosz: None Declared, M. L. Diaz: None Declared, R. Yusuf: None Declared, L. Kruger: None Declared, B. Soman: None Declared, Y. Li: None Declared, C. Wang: None Declared, L. Yin: None Declared, M. Erkin: None Declared, F. Lanas: None Declared, K. Davletov: None Declared, A. Rosengren: None Declared, P. Lopez-Jaramillo: None Declared, R. Khatib: None Declared, A. Oguz: None Declared, R. Iqbal: None Declared, K. Yeates: None Declared, Á. Avezum: None Declared, W. Reinisch Consultant of: Speaker for Abbott Laboratories, Abbvie, Aesca, Aptalis, Astellas, Centocor, Celltrion, Danone Austria, Elan, Falk Pharma GmbH, Ferring, Immundiagnostik, Mitsubishi Tanabe Pharma Corporation, MSD, Otsuka, PDL, Pharmacosmos, PLS Education, Schering-Plough, Shire, Takeda, Therakos, Vifor, Yakult, Consultant for Abbott Laboratories, Abbvie, Aesca, Algernon, Amgen, AM Pharma, AMT, AOP Orphan, Arena Pharmaceuticals, Astellas, Astra Zeneca, Avaxia, Roland Berger GmBH, Bioclinica, Biogen IDEC, Boehringer-Ingelheim, Bristol-Myers Squibb, Cellerix, Chemocentryx, Celgene, Centocor, Celltrion, Covance, Danone Austria, DSM, Elan, Eli Lilly, Ernest & Young, Falk Pharma GmbH, Ferring, Galapagos, Genentech, Gilead, Grünenthal, ICON, Index Pharma, Inova, Janssen, Johnson & Johnson, Kyowa Hakko Kirin Pharma, Lipid Therapeutics, LivaNova, Mallinckrodt, Medahead, MedImmune, Millenium, Mitsubishi Tanabe Pharma Corporation, MSD, Nash Pharmaceuticals, Nestle, Nippon Kayaku, Novartis, Ocera, Omass, Otsuka, Parexel, PDL, Periconsulting, Pharmacosmos, Philip Morris Institute, Pfizer, Procter & Gamble, Prometheus, Protagonist, Provention, Robarts Clinical Trial, Sandoz, Schering-Plough, Second Genome, Seres Therapeutics, Setpointmedical, Sigmoid, Sublimity, Takeda, Therakos, Theravance, Tigenix, UCB, Vifor, Zealand, Zyngenia, and 4SC, Advisory board member for Abbott Laboratories, Abbvie, Aesca, Amgen, AM Pharma, Astellas, Astra Zeneca, Avaxia, Biogen IDEC, Boehringer-Ingelheim, Bristol-Myers Squibb, Cellerix, Chemocentryx, Celgene, Centocor, Celltrion, Danone Austria, DSM, Elan, Ferring, Galapagos, Genentech, Grünenthal, Inova, Janssen, Johnson & Johnson, Kyowa Hakko Kirin Pharma, Lipid Therapeutics, MedImmune, Millenium, Mitsubishi Tanabe Pharma Corporation, MSD, Nestle, Novartis, Ocera, Otsuka, PDL, Pharmacosmos, Pfizer, Procter & Gamble, Prometheus, Sandoz, Schering-Plough, Second Genome, Setpointmedical, Takeda, Therakos, Tigenix, UCB, Zealand, Zyngenia, and 4SC, P. Moayyedi: None Declared, S. Yusuf: None Declared

Patients and healthcare professionals views on injectables for cardiovascular disease

Introduction

Injectable medicines are increasingly used to manage risk factors for cardiovascular (CV) events, such as PCSK-9 inhibitors in dyslipidaemia and GLP-1 agonists in diabetes. However, there is a paucity of data around the administrative and clinical practicalities when using these injectables, and limited information on patient and healthcare professionals' perceptions.

Purpose

To identify the facilitators and barriers on the use of injectable therapies with CV benefits by undertaking interviews with patients, caregivers and healthcare professionals (HCPs).

Methods

Interviews were conducted via telephone and using MS Teams due to Covid-19 restrictions in the United Kingdom (London and Leeds) and Italy (Rome and Milan) in 2021. Coding was undertaken using NVivo and thematic analysis performed.

Results

A total of 56 patients were interviewed: 30 in the U.K. (mean age 66 yrs, 60% male) and 26 patients in Italy (mean age 63 yrs, 80% male) and 11 caregivers (mean age 59 yrs, 73% female). A total of 38 HCPs were interviewed, 19 in each country and composed of physicians (n=18), pharmacists (n=10), nurses (n=9) and pharmacy technician (n=1). Three distinct themes were identified: (i) Organisational and governance issues - relating to prescribing restrictions and availability of the drugs locally (PCSK9i are initiated and supplied from hospitals) and lack of communication between hospital and primary care setting; (ii) Clinical issues around HCPs' skills and experience - including: lack of experience with these injectables, lack of time to provide education to patients and caregivers, therapeutic inertia (HCPs not adopting a change in practice despite the evidence or due to bureaucratic restrictions) as well as lack of knowledge on long-term effects, and finally (iii) Patient-related issues - relating to behaviours and beliefs such as reluctance about using injectable therapies, and lack of education about these injectables in terms of indications/clinical benefits for use. Despite some differences in the prescribing of these injectables in the two countries, the analysis captured similar facilitators and barriers. Facilitators included prior use of injectables (e.g. insulin), and the ability to reach a clinical target of lower cholesterol by having just a “one shot”. HCPs stated that access to rapid pathology tests would aid uptake of injectables with CV benefit as well as having educational tools on these injectables in practice.

Conclusion

This qualitative study identified barriers to initiation, continuation, and adherence with injectable therapies with CV benefits but also highlighted areas where changes can be made especially around education and support for patients and HCPs.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): ACNAP education grant. Sponsored by Amgem and Novo Nordisk

Management of statin intolerance in a pharmacy led cardiology innovative medicines optimisation lipid clinic

Background

Statins are cornerstone in the management of atherosclerotic cardiovascular disease. If a patient has experienced clinically significant adverse drug reactions (ADRs), representing an unacceptable risk or may result in adherence issues, we would consider them intolerant. The prevalence is lower in randomised trials than cohort observational studies, 5% vs. 17%.

Purpose

To assess how many people we reviewed in clinic were able to be re-challenged and successfully continued on a statin, free from side effects.

Methods

Over 6 months we reviewed all patients referred to our innovative clinic for lipid optimisation labelled as “statin intolerant”. Initially, as per our protocol, we adopted a person-centred approach and explored this label (actual vs. potential concerns, any previous issues, symptoms experienced and timings, statins tried (if any), and patient's feelings on re-challenge). A statin re-challenge was offered if not contraindicated. If agreed, based on shared-decision making, we offered patients a once weekly statin (usually rosuvastatin 5mg) with a clear self-management plan to up/down-titrate frequency and dose, until they identify a tolerated regimen. We measured LDL-C at baseline and every 3 months thereafter until satisfactory.

Results

Of 207 patients referred 152 (73%) were labelled as “statin intolerant”. Average age was 62 (±11), 51% females. 78% for secondary prevention and 37% had familial hypercholesterolaemia. The average baseline LDL-C was 4.4mmol/L. 108 (71%) qualified for PCSK9 inhibitors therapy (PCSK9i) as per UK NICE guidance.

The top 3 reported ADRs were musculoskeletal side effects (48%), GI upsets (13%) and deranged LFTs (7%).

25 (58%) of those “intolerant” who did not qualify for PCSK9i attempted a re-challenge with statins vs. 44 (41%) among those who qualified.

Of the 69 patients, who accepted a re-challenge, 43 (62%) were successfully restarted on a statin. At an average of 14 months post re-challenge, LDL-C (available for &gt;80% of the sample) was reduced by an average of 31% in those not on PCSK9i, compared to a 62% reduction (sustained over an average of 40 months) in those on combination therapy with PCSK9i.

The top 3 rosuvastatin regimens established were 5mg OD (29%), 5mg weekly (24%) and 10mg OD (15%). Approximately 80% of patients were on rosuvastatin, and the rest accepted atorvastatin, pravastatin or simvastatin.

There was no attempt to re-challenge in 77 (51%) patients, mostly due to choice (45%) or statins re-challenged prior to referral (44%). We stopped statins in 6 cases due to intolerable ADRs.

Conclusion(s)

By using a person-centred approach, and a variety of strategies to tackle “statin intolerance” we have successfully re-established over 60% of patients with very high CVD risk on statins. While patients who qualified for PCSK9i therapy were less likely to consider re-challenge with statins (41% v 58%), combination lipid-lowering therapies produced better reduction in LDL-C.

Funding Acknowledgement

Type of funding sources: None.

Innovative 12 months ticagrelor virtual clinic – supporting appropriate extended dual anti-platelet therapy in post MI

Background

The ESC and NICE guidelines recommend extended dual antiplatelet therapy (DAPT) with Ticagrelor 60mg twice a day for 3 years after 12 months of a myocardial infarction (MI) among high risk patients with low risk of bleeding. As those patients in our health system are not routinely reviewed by a cardiologist, we introduced a 12 months Virtual Review clinic to support primary care in ensuring that appropriate patients are offered extended DAPT.

Methods

Working with primary care, a group for cardiologists and cardiology pharmacists established a clear guidance and pathway for identifying patients who are suitable for extended DAPT with Ticagrelor 60mg twice a day for 3 years inline with ESC guidelines. A virtual review clinic was established where primary care can refer potential candidates to be considered for extended DAPT. Patients needed to have had an MI approximately 12 months before the referral, have uptodate full blood counts and creatinine. Patients were reviewed virtually by a cardiology pharmacist against an agreed protocol. Patient risk factors and eligibility were identified and their risk of bleeding was assessed using the PRECISE-DAPT scoring. Complicated patients were discussed with a cardiologist and the final recommendation was sent to primary care electronically.

Results

201 patients were reviewed in the virtual clinic; Mean age 69, 58% were males. 60% had NSTEMI, 37% STEMI, and the rest had either Unstable Angina or Type II MI. 28% had diabetes, 22% had prior MI, 60% had multivessel disease, and 22% were anaemic. 93% of patients had at least one high risk factor according to PEGASUS trial. 33% (n=67) of all patients reviewed were high risk of bleeding according to PRECISE-DAPT. Of these 78% (n=52) were not suitable to extended DAPT despite 71% (n=37) having risk factors.

The virtual clinic recommended extended DAPT for 40% (n=81) of patients referred. In the case of 15 patients extended DAPT was recommended despite High risk of bleeding as deemed appropriate by the MDT with close monitoring.

At discharge post index point, 18% (n=37) had recommendations to extend DAPT or not by the interventionist. 11% (n=4) of those recommendations were reversed at the 12 months review.

40% (n=80) of patients reviewed in clinic were inappropriately on Ticagrelor 90mg twice a day (with aspirin) beyond 12 months post MI. That is a total of 556 months of excess ticagrelor. 19 patients were HIGH risk of bleeding

Discussion and conclusion

The multidisciplinary innovative 12 months virtual review clinic improved appropriate initiation of extended DAPT in high risk patients and reduced risk of bleeding by stopping inappropriate antiplatelet dosing (90mg vs. 60mg). The clinic supported the low levels of recommendations made by the interventionist at index point and assured safety when actioning these recommendations. The virtual review clinic improved levels of extended DAPT prescribing and improved patient safety.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): This is a service development project funded by the Leeds NHS Community Commissioning Group

Evaluation of the Methods and Management of Acute Coronary Events (EMMACE)-3: protocol for a longitudinal study

INTRODUCTION

Patients with cardiovascular disease are living longer and are more frequently accessing healthcare resources. The Evaluation of the Methods and Management of Acute Coronary Events (EMMACE)-3 national study is designed to improve understanding of the effect of quality of care on health-related outcomes for patients hospitalised with acute coronary syndrome (ACS).

METHODS AND ANALYSIS

EMMACE-3 is a longitudinal study of 5556 patients hospitalised with an ACS in England. The study collects repeated measures of health-related quality of life, information about medications and patient adherence profiles, a survey of hospital facilities, and morbidity and mortality data from linkages to multiple electronic health records. Together with EMMACE-3X and EMMACE-4, EMMACE-3 will assimilate detailed information for about 13 000 patients across more than 60 hospitals in England.

ETHICS AND DISSEMINATION

EMMACE-3 was given a favourable ethical opinion by Leeds (West) Research Ethics committee (REC reference: 10/H131374). On successful application, study data will be shared with academic collaborators. The findings from EMMACE-3 will be disseminated through peer-reviewed publications, at scientific conferences, the media, and through patient and public involvement.

STUDY REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT01808027. Information about the study is also available at EMMACE.org.

Is Early Treatment with a Cervical Pessary an Option in Patients with a History of Surgical Conisation and a Short Cervix?

Objective: Patients with a history of one or more conizations have an increased risk of spontaneous preterm birth (SPTB). The aim of this study was to investigate the outcome of pregnancies in patients with a history of conization and early treatment with a cervical pessary. Methods: In this pilot observational study we included 21 patients and evaluated the obstetric history, the interval between pessary placement and delivery, gestational age at delivery, the neonatal outcome and the number of days of maternal and neonatal admission. Results: Among the study group of 21 patients, 20 patients had a singleton and one had a dichorionic/diamniotic twin pregnancy. At insertion, the mean gestational age was 17 + 2 (10 + 5-24 + 0) weeks and the mean cervical length was 19 (4-36) mm. Six patients presented with funneling at insertion with a mean funneling width of 19.7 (10-38) mm and funneling length of 19.9 (10-37) mm. Five patients had already lost at least one child due to early spontaneous preterm birth and another five had at least one previous abortion, who have now delivered beyond 34 weeks. The mean gestational age at delivery was 38 (31 + 1-41 + 0) gestational weeks and the mean interval between insertion and delivery was 145 (87-182) days. Conclusion: Our findings suggest a beneficial effect of an early pessary placement for patients at high-risk for preterm birth due to conization.

Treatment of infection: a cross-sectional survey of antibiotic drug utilisation in the Ramallah district of Palestine

Objective

To characterise the use of antibiotics in outpatients treated for infection in the Ramallah district of Palestine.

Setting

A purposive sample of general and specialist outpatient clinics in the public and private sector in Ramallah.

Method

A prospective, cross-sectional survey over 3 months (February-May 2000) of patients diagnosed with infection, conducted through questionnaires to treating physicians (n = 25) and patients (n = 575).

Key findings

Infection associated with the respiratory tract was the most common type of infection diagnosed, accounting for over 80% of all infections, followed by urinary tract infection and otitis media (14% and 10%, respectively). Amoxicillin was the antibiotic prescribed most often, prescribed for 44% of all patients and for infection of all types and across all age groups. A wide variety of other antibiotics was prescribed, and in the private sector there was more use of newer, more expensive antibiotics. Antibiotic use was rated as appropriate in only 35% of patients, with inappropriate prescribing largely resulting from inappropriate indication (73%) and to a lesser extent choice of drug (17%) or cost (9%). Duration of therapy was seldom specified by the prescriber and depended on pack size dispensed. Seventy-six per cent of patients followed up at 1 week had recovered partially or completely, but lack of compliance was noted in 30%.

Conclusions

There was considerable evidence of inappropriate use of antibiotics, including prescribing for likely self-limiting or non-bacterial infection and failure to specify duration of therapy. A number of patients failed to complete the course. Strategies to promote optimal antibiotic use should be targeted initially to respiratory tract infection, and both physicians and patients require educational input. The community pharmacist can play a lead role on account of both drug expertise and ability to advise health professionals and patients.

Interinstitutional and intrainstitutional transmission of a strain of Acinetobacter baumannii detected by molecular analysis: comparison of pulsed-field gel electrophoresis and repetitive sequence-based polymerase chain reaction

Pulsed-field gel electrophoresis and repetitive sequence-based polymerase chain reaction provided comparable strain discrimination with minor discordance in typing Acinetobacter baumannii clinical isolates from patients at our hospital and affiliated institutions. Typing revealed a cluster strain with intrainstitutional and interinstitutional spread during the study period. A long-term acute care facility may have been the reservoir.

Impact of initial antibiotic choice and delayed appropriate treatment on the outcome of Staphylococcus aureus bacteremia

The study presented here investigated the impact of initial antibiotic choice (beta-lactams vs vancomycin) on the outcome of 342 patients with Staphylococcus aureus bacteremia (50.9% with methicillin-resistant isolates) encountered between 1 January 2002 and 30 June 2003. Initial antibiotics were inappropriate (beta-lactams) in 60 (34.5%) methicillin-resistant cases and suboptimal (vancomycin) in 62 (36.9%) methicillin-susceptible cases. Time to effective antibiotic therapy was longer in methicillin-resistant cases (25.5+/-28.6 vs 9.6+/-16.6 h; p<0.0005). All-cause in-hospital mortality was higher with inappropriate therapy (35.0 vs 20.9%; p=0.02). Initial vancomycin treatment was associated with a higher incidence of delayed clearance (>or=3 days) of methicillin-susceptible bacteremia (56.3 vs 37.0%; p=0.03). The results indicate inappropriate initial therapy is associated with higher in-hospital mortality and initial vancomycin may delay clearance.

Repeating blood cultures during hospital stay: practice pattern at a teaching hospital and a proposal for guidelines

Guidelines for blood culture (BC) address the appropriate frequency, number and volume, but no guidelines exist for repeating BCs. The pattern of repeated BCs was studied in all patients hospitalised in December 2001 to determine the extent of and reasons for repeating cultures. BC was repeated in 127 (31.6%) of 405 adults with an initial BC during the study period. All patients with available records (n = 96; 75.6%) were included. The average patient age was 62.2 +/- 15.9 years. In total, 295 BC sets (one to four BCs/set) were obtained, comprising 96 initial and 199 repeats (one to nine repeats/patient). Sixty-nine (34.7%) repeats were taken within 24 h, and 89 (44.7%) within 2-4 days. The most common reason (32.2%) was persistent fever. The result of repeated cultures was: no growth (83.4%), same pathogen (9.1%), new pathogen (2.5%) or contamination (5.0%). Thus, BC repeats accounted for one-third of all BCs handled in the laboratory, with little additional yield. Guidelines for repeating BCs may decrease unnecessary testing.

Limited genetic diversity of Candida albicans in fecal flora of healthy volunteers and inpatients: a proposed basis for strain homogeneity in clinical isolates

Molecular analysis of Candida albicans isolates from individual patients often yields a single strain at multiple sites. Whether this strain-limitation is due to virulence factors favoring the invasive strain or to lack of genetic diversity in the gastrointestinal reservoir is uncertain. We elected to study C. albicans genotypes in the fecal flora among healthy volunteers and inpatients. Self-obtained stool swabs or stool samples were cultured on inhibitory mold agar. From each subject with C. albicans, nine colonies were randomly selected, individually propagated, and typed utilizing random amplified polymorphic DNA. Colonies were considered identical (all bands matched), related variants (one to three unique bands), or distinct strains (more than three unique bands). Analysis showed a single clone in 33/43 (76.7%) volunteers and 6/18 (33.3%) inpatients (P = 0.018), two to four related variants in eight (18.6%) volunteers and 10 (55.6%) inpatients, and two distinct strains in two volunteers (4.6%) and two inpatients (11.1%). Strain variation was more common in females (33.5 versus 5.6%; P = 0.04) and tended to increase with age (r = 0.245, P = 0.06). These findings illustrate that most healthy subjects harbor a single strain of C. albicans in the fecal flora. This strain may undergo genetic evolution leading to minor clonal variations. The mechanisms for strain selection, maintenance and possible evolution remain to be delineated.

Meningococcemia following tonsillectomy

A 22-y-old male developed fever, arthralgias and skin rash 2 d after tonsillectomy. Blood culture grew Neisseria meningitidis. He responded well to antibiotics. Only 1 other case of meningococcal sepsis following adenotonsillectomy has previously been reported. These cases suggest a temporal association of meningococcemia with tonsillectomy.

Molecular analysis of coagulase-negative Staphylococcus isolates from blood cultures: prevalence of genotypic variation and polyclonal bacteremia

Fifty-seven coagulase-negative Staphylococcus isolates from 22 inpatients who had > or =2 blood cultures that were positive for Staphylococcus within 24 hours were analyzed to determine the frequency of polyclonal bacteremia. Patients were considered to have bacteremia (14 patients) or contamination of sample (8 patients) on the basis of clinical criteria. Nine colonies were randomly selected from each blood culture and genotyped by means of SmaI digestion/pulsed-field gel electrophoresis. Relatedness was determined by calculation of the Dice coefficient of banding-pattern similarity (S(AB)). Analysis of bacteremic isolates demonstrated the presence of a single species in 35 of 41 blood cultures, 1 related variant in 5 blood cultures (87%-92% S(AB)), and an unrelated strain in 1 blood culture (79% S(AB)). Analysis of contaminated samples demonstrated the presence of a single strain in 10 of 16 blood cultures and 1-3 variants (28%-97% S(AB)) in the remainder. Genotype diversity was significantly more common in the contaminated samples (P=.036). Almost all coagulase-negative Staphylococcus bacteremias were monoclonal.

Faecal fungal flora in healthy volunteers and inpatients

The faecal fungal flora was analysed in healthy volunteers and inpatients. Self-obtained stool swabs from volunteers (n = 228) and inpatient stool-samples (n = 34) were cultured on Inhibitory-Mould-Agar plates. All yeast isolates were identified. Fungi were detected in 51.8% of volunteers; the majority (88.1%) had single species. The prevalence increased steadily with age. Candida albicans was detected in 62.7%, non-albicans Candida species in 22.0%, yeasts--other than Candida in 20.3% and moulds in 8.5% of volunteers with fungi. No gender-related differences were noted in the prevalence or types of yeast. Candida glabrata and C. krusei were detected in adults only. Intra-household species-similarity (excluding C. albicans) was noted in seven of 31 (22.6%) households with fungi in two or more members. Inpatients had higher prevalence of yeast (88.2%) with a single species in the majority (73.3%). Yeasts other than Candida were less common in inpatients (3.3%; P = 0.013) whereas C. glabrata was significantly more prevalent (33.3 versus 2.5%; P < 0.001). This study delineates the faecal fungal flora in volunteers and inpatients. Most subjects harbour a single species that may be shared with other households. The prevalence is somewhat higher in adults and the types of yeast may vary with age. Finally, C. glabrata appears to be acquired nosocomially.

Candidemia before and during the fluconazole era: prevalence, type of species and approach to treatment in a tertiary care community hospital

The characteristics of candidemia before and after the introduction of fluconazole were compared at our institution. In the pre-fluconazole era (1986-89), the incidence of candidemia rose from 0.02% to 13% over the course of 4 y. Candida albicans accounted for 44/66 isolates (67%) and C. glabrata and C. parapsilosis were the predominant non-albicans species (9% each). In one-third of cases antifungal therapy was not given and the overall mortality rate was 55%. During the fluconazole era (1994-97), the incidence of candidemia remained constant between 1994 and 1996 at 0.09-0.11% and dropped to 0.06% in 1997. Bloodstream infection associated with neutropenia increased significantly but only accounted for 13% of cases; antifungal prophylaxis was not employed. The isolation of C. albicans decreased (n = 49; 50%) whereas isolation of both C. parapsilosis (n = 23; 24%) and C. tropicalis (n = 16; 16%) increased. The vast majority of patients received antifungal therapy and the overall mortality rate was 39%. These findings show that the incidence of candidemia rose steadily prior to the fluconazole era and then stabilized in spite of a shift towards non-albicans species. When candidemia was encountered in the fluconazole era, it was rare not to give antifungal treatment.

Recurrent vancomycin-resistant Enterococcus bacteremia: prevalence, predisposing factors, and strain relatedness

We studied the prevalence of recurrent vancomycin-resistant Enterococcus (VRE) bacteremia, predisposing factors, and strain relatedness during a 3 year period at our institution. Of 36 inpatients who had episodes of bacteremia, 3 (8.3%) had recurrent episodes. Predisposing factors were mucositis and neutropenia (1 patient) and chronic renal failure requiring hemodialysis (2). Recurrent episodes separated by < or = 3 months were caused by identical or related strains, and those at greater intervals by distinct strains. Recurrent VRE bacteremia is uncommon.

Tricuspid valve endocarditis due to a moderately susceptible Streptococcus constellatus: persistent bacteremia and fatal outcome despite penicillin plus gentamicin therapy

An intravenous drug-user developed tricuspid valve endocarditis caused by a moderately susceptible strain of Streptococcus constellatus. Bacteremia and fever persisted despite penicillin and gentamicin therapy. Eventually, he developed massive hemoptysis and expired. We believe that the propensity of this group of organisms for suppurative complications and the suboptimal antibiotic susceptibility may have contributed to the failure of medical therapy and the fatal outcome. Similar cases may benefit from a higher dose of penicillin or early surgical intervention.

Pyopneumothorax: a complication of Streptococcus pyogenes pharyngitis

A 20-y-old African-American female with Streptococcus pyogenes pharyngitis presented with tension pyopneumothorax. Her illness began with fever and sore throat that persisted for several days. She then developed a left neck swelling, followed by difficult swallowing and cough. Subsequently, she developed shortness of breath that became severe. On physical examination fever (39.2 degrees C), exudative pharyngitis, tenderness and swelling in the left anterior cervical area were noted. Chest X-ray revealed left side pneumothorax, air-fluid level and near-complete collapse of the left lung with displacement of the heart and trachea to the right. Computed tomography scan of the neck revealed swelling and enhancement of the sternocleidomastoid muscle with loculated fluid collection, inflammation in the left anterior medial neck displacing the trachea extending into the mediastinum and the left apex. Thoracentesis revealed purulent fluid; Gram stain showed Gram-positive cocci in chains; culture yielded pure growth of Streptococcus pyogenes. She was treated with high dose penicillin, several chest tubes and intra-pleural injections of streptokinase with gradual resolution. This complication has not been described previously in Streptococcus pyogenes pharyngitis.

Herpes simplex virus esophagitis in the immunocompetent host: an overview

OBJECTIVE

The aim of this study was to delineate the characteristics of herpes simplex virus esophagitis (HSVE) in the immunocompetent host.

METHODS

The study entailed a case report and a review of relevant literature through a MEDLINE search back to 1966. All cases with documented HSVE in patients without immunosuppression were selected and their characteristics defined.

RESULTS

A total of 38 cases were identified. The age range was 1-76 yr and the male/female ratio 3.2/1. Antecedent exposure to HSV disease was described in eight cases (21.1%). A prodrome of systemic manifestations preceded the onset of esophageal symptoms in nine subjects (23.6%). Manifestations included acute odynophagia (76.3%), heartburn (50%), and fever (44.7%). Concurrent oropharyngeal lesions were uncommon (n = 8, 21.1%). Endoscopically, extensive involvement was common, showing friable mucosa (84.2%), numerous ulcers (86.8%), and whitish-exudates (39.5%). The distal esophagus was most commonly affected (63.8%). Microscopic examination showed characteristic viral cytopathology in 26 (68.4%) cases. Virus was recovered from esophageal-brushes or biopsies in 23 of 24 (95.8%) patients and immunocytochemistry was positive in seven of eight (87.5%) cases. Immune status was consistent with primary HSV infection in eight (21.1%) cases. The disease was self-limiting, although esophageal perforation and upper GI bleeding were reported in one case each.

CONCLUSIONS

HSVE in the immunocompetent host is a rare but distinct entity, and is significantly more common in male subjects. It represents either primary infection or reactivation, and is characterized by acute onset, systemic manifestations, and extensive erosive-ulcerative involvement of the mid-distal esophagus. Histopathological examination alone may miss the diagnosis; adding tissue-viral culture optimizes the diagnostic sensitivity. It is usually self-limiting; whether antiviral therapy is beneficial remains unknown.

Herpes simplex virus esophagitis in the immunocompetent host: an overview

OBJECTIVE

The aim of this study was to delineate the characteristics of herpes simplex virus esophagitis (HSVE) in the immunocompetent host.

METHODS

The study entailed a case report and a review of relevant literature through a MEDLINE search back to 1966. All cases with documented HSVE in patients without immunosuppression were selected and their characteristics defined.

RESULTS

A total of 38 cases were identified. The age range was 1-76 yr and the male/female ratio 3.2/1. Antecedent exposure to HSV disease was described in eight cases (21.1%). A prodrome of systemic manifestations preceded the onset of esophageal symptoms in nine subjects (23.6%). Manifestations included acute odynophagia (76.3%), heartburn (50%), and fever (44.7%). Concurrent oropharyngeal lesions were uncommon (n = 8, 21.1%). Endoscopically, extensive involvement was common, showing friable mucosa (84.2%), numerous ulcers (86.8%), and whitish-exudates (39.5%). The distal esophagus was most commonly affected (63.8%). Microscopic examination showed characteristic viral cytopathology in 26 (68.4%) cases. Virus was recovered from esophageal-brushes or biopsies in 23 of 24 (95.8%) patients and immunocytochemistry was positive in seven of eight (87.5%) cases. Immune status was consistent with primary HSV infection in eight (21.1%) cases. The disease was self-limiting, although esophageal perforation and upper GI bleeding were reported in one case each.

CONCLUSIONS

HSVE in the immunocompetent host is a rare but distinct entity, and is significantly more common in male subjects. It represents either primary infection or reactivation, and is characterized by acute onset, systemic manifestations, and extensive erosive-ulcerative involvement of the mid-distal esophagus. Histopathological examination alone may miss the diagnosis; adding tissue-viral culture optimizes the diagnostic sensitivity. It is usually self-limiting; whether antiviral therapy is beneficial remains unknown.

Trends in antifungal susceptibility among Candida sp. Urinary isolates from 1994 and 1998

Antifungal susceptibilities were determined from 80 urinary isolates of Candida species collected in 1994 and 1998. Our findings demonstrate increasing geometric means of fluconazole MICs and fluconazole resistance in Candida albicans and Candida tropicalis (those for Candida glabrata were unchanged) within the 4-year span. Amphotericin B and voriconazole MICs remained constant.

Limits of detection of Mycobacterium tuberculosis in spiked cerebrospinal fluid using the polymerase chain reaction in tuberculous meningitis

The limit of detection of Mycobacterium tuberculosis in spiked cerebrospinal fluid (CSF) using polymerase chain reaction (PCR) was compared to that of a radiometric liquid culture. Serial dilutions of clinical isolates of Mycobacterium tuberculosis were prepared in CSF (n=3) or broth (n=11) with estimated concentrations of 0-550 cfu/ml. Each dilution was examined concurrently by PCR and radiometric culture. PCR and radiometric culture detected Mycobacterium tuberculosis DNA in all dilutions with an estimated 2 cfu/ml in the CSF. At lower concentrations (estimated <2 cfu/ml), PCR and radiometric culture were positive in three of five (60%) and five of five (100%) CSF samples, respectively. In comparison to PCR in broth dilutions, no evidence of inhibition or interference was noted. These results imply that PCR can provide a rapid and reliable diagnosis of tuberculous meningitis, although there is a potential for false-negative results to occur in samples containing very few organisms ( < 2 cfu/ml).

Clinicians' reaction to positive urine culture for Candida organisms

Clinicians' reaction to isolating Candida organisms in urine culture (> or = 10(4) CFU ml-1) was assessed in a retrospective review of 133 consecutive in-patients (> or = 15 years-of-age) over a 5 month period. The average age was 68.8 years and male/female ratio was 0.36 (35/98). Most (78.2%) patients had an indwelling catheter, and many (35.3%) were in the intensive care unit (ICU). In response to culture-result, clinicians initiated antifungal therapy in 80 instances (60.2%). Treatment was often based on a single culture without documenting the infection (n = 53/80, 66.3%) in the absence of risk for invasive disease. Removing the indwelling-catheter was never attempted and antibiotics were rarely discontinued or modified (1.3%). Fluconazole was most frequently utilized (n = 42, 52.5%), followed by amphotericin-B bladder-irrigation (n = 26, 32.5%), and combined fluconazole/amphotericin-B bladder-irrigation (n = 12, 15%). Therapy was more frequently initiated in ICU-cases (76.6 versus 55.6%; P = 0.023) and less often in non-catheterized individuals (40.7 versus 69%; P = 0.012) and patients with 10(4) CFU ml-1 (25.9 versus 72.7%; P < 0.0001). These findings show that clinicians nowadays do not follow current guidelines for the management of candiduria. Efforts to increase clinicians' awareness of these guidelines, which are intended to confirm the diagnosis and stratify treatment according to patient risk factors, appear to be necessary.

Sequential peripartum herpes simplex virus type 2 disease in parents and their newborn mimicking intrafamily spread of common viruses

Herpes simplex type 2 (HSV2) disease developed sequentially among two parents and their newborn. The father first became ill with upper-respiratory symptoms and fever. Then, 5 days later, shortly after delivery, the mother had fever, pharyngitis, and diarrhea. Subsequently, the infant developed undifferentiated febrile illness at the age of 3 days. HSV etiology was recognized by incidental isolation of HSV2 from the newborn naospharynx. The father never developed genital lesions and the mother's symptoms remained nonspecific for several days prior to the onset of genital manifestations. The sequential emergence and manifestations of these infections could have been misconstrued for an intrafamily spread of respiratory or enteric viruses. This cluster illustrates that HSV2 may cause sequential symptomatic disease in susceptible individuals mimicking other viruses.

Cytomegalovirus colitis in the immunocompetent host: an overview

This paper describes 2 immunocompetent patients with cytomegalovirus colitis and reviews all previously reported cases (n = 13). Affected patients were generally older (69.13+/-15.62 y-old) with probable reactivation (n = 8) or younger (43.86+/-19.73 y-old) with probable primary infection (n = 7). The onset of illness was found to be hospital-associated in 4 (50.0%) reactivation cases and 1 (14.3%) primary case. Presenting manifestations included diarrhoea (86.7%), fever (80.0%), gastrointestinal bleeding (66.7%) and abdominal pain (60.0%). Endoscopy showed erosive colitis with multiple (n = 11; 73.3%) or single ulcers (n = 2, 13.3%); biopsy was diagnostic in 12/13 (92.3%) patients. Complications included massive haemorrhage (13.3%), toxic megacolon (13.3%), perforation (13.3%) and protracted inflammatory bowel disease (20.0%; exclusively in primary-infection). The mortality rate was 26.7%. Antiviral-agents were given in 8 (53.3%) cases; assessment of treatment-efficacy was not possible. In conclusion, cytomegalovirus colitis in the immunocompetent-host is a rare but potentially severe erosive disease with significant morbidity. It may occur during primary infection or reactivation; the diagnosis requires careful histopathological examination and the benefit of antiviral-therapy is unknown.

Typing of Candida albicans and Candida parapsilosis: species-related limitations of electrophoretic karyotyping and restriction endonuclease analysis of genomic DNA

Species-related discrimination limits of electrophoretic karyotyping (EK) and restriction endonuclease analysis of genomic DNA (REAG), using pulse-field gel electrophoresis, in typing Candida albicans (CA) and Candida parapsilosis (CP) were compared. Eleven CA and 12 CP isolates from individual neonates and three CA and three CP control isolates were used. For CA, EK and REAG with sfiI displayed seven and six banding-patterns, respectively. One karyotype and two SfiI banding-patterns were observed among the control-isolates. Combining EK/REAG (SfiI) demonstrated nine composites and three distinct control-composites. For CP, EK displayed nine karyotypes, REAG (SfiI) demonstrated four banding-patterns, and REAG (BssHII) yielded six banding-patterns. EK and REAG/SfiI failed to distinguish any CP-controls whereas REAG/BssHII distinguished 2/3 CP-controls. Combining EK/REAG (SfiI) showed 10 composites indistinguishable from CP-controls whereas EK/REAG (BssHII) demonstrated 11 composites and three distinct control-composites. These results illustrate that singly, EK and REAG have significant limitation in typing Candida species though EK is more precise. Combining both methods yields better results but the appropriate restriction endonuclease may vary by strains or species. These findings underscore the importance of combining multiple typing methods, testing several control isolates, and correlating the results with careful epidemiological assessment.

Strain relatedness in persistent and recurrent candiduria

PURPOSE

We assessed the value of determining strain relatedness in differentiating persistent from recurrent candiduria.

MATERIALS AND METHODS

Prospective monitoring of patients with candiduria (10(4) or greater colony forming units per ml.) during a 5-month period. All patients with persistent or recurrent infection after documented clearance were selected. Pair isolates were typed using restriction endonuclease analysis of genomic deoxyribonucleic acid with SfiI. Isolates were considered related if all deoxyribonucleic acid bands matched.

RESULTS

We encountered 22 and 5 patients with persistent and recurrent infection, respectively. The isolates were recovered 1 to 140 days apart (21.56 +/- 28.97). Most patients were women (85.2%) with a mean age of 66.41 +/- 18.11 years. Risk factors included antibiotics (100%), indwelling catheter (88.9%) and diabetes mellitus (40.7%). Of 15 individuals who received antifungal therapy candiduria persisted in 10 and resolved but recurred within 4 to 26 days (13.00 +/- 9.08) after treatment in 5. Candida albicans accounted for 34 of 58 isolates (58.6%), and it was mixed with other species in 4 cultures. Paired strains were genetically identical in 26 of 27 patients. Strain persistence was documented in 21 of 22 cases with persistent infection and in all 5 patients with recurrent disease.

CONCLUSIONS

These findings show that strain persistence is exceedingly frequent in candiduria. These results imply that determining strain relatedness of Candida urinary isolates may not be reliable in differentiating persistent from recurrent infection.

Clustering of Candida infections in the neonatal intensive care unit: concurrent emergence of multiple strains simulating intermittent outbreaks

BACKGROUND

Clusters of Candida albicans and Candida parapsilosis infections were noted intermittently in our neonatal intensive care unit (NICU). We attempted to determine whether these clusters represented single strain outbreaks or coincidental emergence of unrelated strains.

METHODS

A retrospective examination of the frequency of candidemia during a 9-year period, two point prevalence studies of colonization and assessment of strain relatedness of individual infant isolates during and in between clusters during a 2-year period with karyotyping and restriction endonuclease analysis of genomic DNA (REAG).

RESULTS

C. albicans and C. parapsilosis infections emerged in a scattered pattern (1 to 2 cases every few months) with intermittent clustering of 3 cases/month. The colonization rate was 50% 5 weeks after an apparent cluster, equally distributed between C. albicans and C. parapsilosis, and 17.6% (exclusively with C. parapsilosis) 4 months after absence of invasive disease. Utilizing REAG or karyotyping singly we noted 12 and 16 DNA banding patterns, respectively, among 23 infant isolates. Few patterns were observed repeatedly over 2- to 20-month periods, implying recurrent emergence of the same strains. Combining karyotyping with REAG revealed a different epidemiologic pattern. It identified 20 distinct composites with identical composites in 3 infant pairs. All infants with identical composites were in the NICU concurrently. The frequency of strain relatedness was comparable among clustered cases (16.7%), scattered cases (7.7%) and simultaneously colonized infants (16.7%).

CONCLUSIONS

These findings illustrate that Candida infections clustered periodically in our NICU but that these clusters were often caused by unrelated strains with infrequent cross-infection during and between clusters. With suboptimal typing this pattern of emergence can be mistaken for same strain outbreaks.

Prolonged Captopril Therapy in Murine Viral Myocarditis

BACKGROUND: Acute myocarditis can progress to chronic heart muscle disease and cardiomyopathy. In the coxsackievirus B(3) (CB(3)) mouse model of myocarditis, early administration of captopril, an angiotensin-converting enzyme (ACE) inhibitor, ameliorated histopathological changes in inflammation, necrosis, and calcification and reduced heart weight. Late administration of captopril reduced heart weight but did not affect the histological findings. In this study, we investigated the effects of prolonged captopril treatment in the chronic phase of this model. METHODS AND RESULTS: Three-week-old male CD(1) mice were infected with CB(3) and then randomized to receive placebo or captopril starting on day 7 of infection. Captopril, 2 g/L, was given as the drinking water daily for up to 6 months. Autopsies were performed at 6 and 10 months. Heart-to-body weight ratios were obtained, and deaths were tallied. Myocardial fibrosis was graded according to a score system. In addition, picrosirius red stain (PSR) also was used for assessment of collagen deposition. Mean heart weights were similar in both groups. Mean body weight was significantly lower in captopril-treated mice (40.7 g) than in the untreated group (43.6 g) at 6 months (P =.0155), and mortality was higher (8.7 vs 0.87%; P =.009). At 6 months, the mean myocardial fibrosis score in treated mice (0.12) was significantly less than in untreated animals (0.35; P =.035). With PSR, the mean myocardial fibrosis score in the captopril group (1.20) was also significantly less than in the untreated group (1.58; P =.045). At 10 months, fibrosis scores were similar in both groups. CONCLUSIONS: Chronic captopril treatment in CB(3) myocarditis reduces myocardial fibrosis.

Respiratory isolation in a teaching hospital with low-to-moderate rate of tuberculosis: compliance with Centers for Disease Control and Prevention guidelines for identifying patients who may have active tuberculosis

BACKGROUND

Because of the limitation of isolation spaces suitable for tuberculosis, proper use of these spaces is prudent. We examined the current approach to respiratory isolation to determine the compliance with Centers for Disease Control and Prevention (CDC) guidelines for identifying active tuberculosis.

METHODS

A retrospective review was performed of all patients placed in respiratory isolation and those with pulmonary tuberculosis.

RESULTS

Seventy-seven instances of isolation and three admissions without isolation were encountered. Isolated patients met CDC guidelines for infectiousness in 59 of 77 instances (76.6%). The remaining patients were isolated with findings not characteristic of active tuberculosis (10 instances), normal chest radiograph (6 occasions), or without chest radiograph (2 instances). The time of implementing isolation was the first hospital day in 58 instances (75.3%) and 2 to 14 days in 19 instances (24.7%). Isolated human immunodeficiency virus-infected patients were more likely to meet CDC guidelines for infectiousness (21/22 [95.5%] vs 38/55 [69.1%] instances) and to be isolated on a timely basis (18/22 [81.8%] vs 40/55 [72.7%]). Tuberculosis was documented in 15 instances and isolation was delayed or never implemented in 5 and 3 instances, respectively.

CONCLUSIONS

Compliance with CDC guidelines for respiratory isolation in patients not infected with human immunodeficiency virus is suboptimal. Many isolated patients do not meet these guidelines, and isolation is delayed or not implemented in patients who may have tuberculosis.