An outbreak case of Clostridium difficile-associated diarrhea among elderly inpatients of an intensive care unit of a tertiary hospital in Rio de Janeiro, Brazil

The aim of this study was to investigate Clostridium difficile-associated diarrhea (CDAD) in an intensive care unit (ICU) of a tertiary hospital in Rio de Janeiro, Brazil, and to characterize epidemiologically C. difficile strains obtained from an outbreak of CDAD. Within almost a 4-year surveillance period, CDAD incidence was determined for the first time in Brazil, and a 3-fold increase was observed in the average rate of CDAD, featuring an outbreak. About 80% of the patients were over 65 years. The main antibiotic that could be probably associated to CDAD was piperacillin/tazobactam. Four toxigenic strains were isolated, 3 from stools and 1 from environmental samples. They were all resistant to clindamycin and fluoroquinolones. Fingerprinting analysis revealed their distribution between 2 different polymerase chain reaction ribotypes, with one of them being exclusively found in Brazil. It was possible to detect cross-infection and environmental contamination in the ICU. Our results highlight the importance of a continuous CDAD surveillance in the hospitals, especially when a risk group is exposed.     

Surgical-site infection with toxin A-nonproducing and toxin B-producing <Emphasis Type="Italic">Clostridium difficile</Emphasis>

To date, few cases of extraintestinal infection with Clostridium difficile have been reported. We describe a case of surgical-site infection with C. difficile following a colonic operation. Administration of metronidazole was considered to be effective for treatment of the infection. The isolate was a toxin A-nonproducing and toxin B-producing strain.     

Clostridium difficile infection as a cause of severe sepsis

Although colitis is often seen in critically ill patients who have received multiple broad-spectrum antibiotics, there are no reports describing severe sepsis as a result ofClostridium difficile infection. We describe three cases of severe sepsis with local intestinalClostridium difficile infection as the only identifiable etiology. The mechanism of severe sepsis may be a derangement of the gastrointestinal barrier function. This could result in absorption of microbes or endotoxin or activation of inflammatory cascades in the submucosa of the intestine or liver.     

Prevalence of toxin A-nonproducing/toxin-B-producing <Emphasis Type="Italic">Clostridium difficile</Emphasis> in the Tsukuba-Tsuchiura district,Japan

In Japan, many clinical laboratories may not have recognized toxin A-nonproducing/toxin B-producing (A−/B+) Clostridium difficile, because rapid diagnostic kits detecting toxin B of C. difficile have not been available in the laboratories. Therefore, we examined the prevalence of A−/B+ strains in the Tsukuba-Tsuchiura district, Japan. Fecal specimens submitted for C. difficile toxin tests in four tertiary hospitals in the district were collected for 6 months. Several C. difficile A−/B+ strains, isolated in two nosocomial outbreaks that had occurred in geographically distant areas in Japan, were also simultaneously analyzed as controls. C. difficile was isolated from 159 of 332 specimens collected. Ten (6.3%) of the 159 C. difficile strains were A−/B+ strains. Nine A−/B+ strains, isolated in one hospital, had an identical genomic pattern by polymerase chain reaction (PCR) ribotyping and macrorestriction analysis with pulsed-field gel electrophoresis (PFGE). The A−/B+ strain isolated in another hospital and some of those in the geographically distant hospitals were indistinguishable from the nine strains by PCR ribotyping but were distinguishable with PFGE analysis. We concluded that A−/B+ strains are not epidemic in this district and that PFGE analysis may be preferable to PCR ribotyping for the genotyping of C. difficile A−/B+ strains. The reason why most of the A−/B+ strains were detected in the one hospital was unclear.     

High mortality of invasive pneumococcal disease compared with meningococcal disease in critically ill children

Objective To ascertain outcome, patterns of disease, incidence of concurrent infection, superinfection and penicillin resistance in children requiring intensive care for Streptococcus pneumoniae infection and compare it to a similar disease pattern, namely Neisseria meningitidisb infection.Design and setting Prospective cohort study in a regional paediatric intensive care unit (PICU).Patients and participants Children with invasive pneumococcal and meningococcal disease requiring intensive care.Measurements and results The study included 22 children with invasive pneumococcal disease (IPD), median age 14 months (interquartile range 3–52), median Paediatric Index of Mortality (PIM) 0.051 (0.028–0.066), median length of PICU stay 8.5 days (4–13). Four patients died, three (13.5%) attributable to IPD. Incidence of concurrent infection 27%. There were no superinfections. All S. pneumoniae were sensitive to cefotaxime; one isolate (3.7%) was resistant to penicillin. There were 186 children with meningococcal disease (MD), with a higher PIM (median 0.068, 0.033–0.108), older age (29 months, 10.7–77.9) and shorter length of PICU stay (median 3 days, 2–6). Eight (4.3%) children died from MD. Incidence of concurrent and superinfection was 18% and 6%, respectively in children with MD. All N. meningitidis cases were sensitive to cefotaxime and penicillin. The standardized mortality ratio was considerably higher with IPD (2.0) than with MD (0.52).Conclusions In invasive pneumococcal disease preventative measures including early recognition, immediate antibiotic therapy and vaccination need to be taken in the community, similar to the control of meningococcal disease. Invasive pneumococcal disease should command the same respect as meningococcal disease.     

Oral mucositis in patients treated with chemotherapy for solid tumors: a retrospective analysis of 150 cases

 The incidence and the severity of chemotherapy-associated oral mucositis were determined in a retrospective analysis of 150 patients with various solid tumors. In addition, possible risk factors for the development of mucositis were identified. Patients were treated with chemotherapeutic regimens appropriate to tumor type and disease stage on an in- or outpatient basis. Mucositis was scored using the World Health Organization (WHO) criteria. Eighty-seven episodes of mucositis occurred in 47 (31%) patients. Twenty-six patients each experienced only one episode, whereas 21 patients had up to eight episodes of mucositis. The 1,281 chemotherapy cycles that have been analyzed included 87 cycles in which mucositis was observed. In 16 patients (11%) only slight oral mucosal changes were recorded (maximum WHO score 1), while 25 patients (17%) experienced mild to moderate mucositis (maximum WHO score 2), and in 6 patients (4%) mucositis was moderate to severe (maximum WHO score 3). No grade 4 mucositis developed. In 24 of the 47 patients with mucositis (51%) clinical features of acute pseudomembranous candidiasis were present. Leukopenia, leukopenic fever, and use of corticosteroids and central venous catheters were associated with the chemotherapy cycles with mucositis. Multivariate analysis identified the administration of paclitaxel, doxorubicin, or etoposide as independent risk factor (adjusted rate ratios 8.06, 7.35, and 6.70, respectively), whereas low body mass was associated with a slightly increased risk (adjusted rate ratio 0.92) for the development of mucositis. In conclusion, almost one-third of patients receiving chemotherapy for solid tumors experienced one or more episodes of mild to more severe oral mucositis, indicating that this is a frequent complication in such patients. Published online: 7 March 2000     

Rapid analysis of Clostridium difficile strains recovered from hospitalized patients by using the slpA sequence typing system

Clostridium difficile is a nosocomial pathogen that is transmissible between patients via hospital staff and via contaminated environmental surfaces. Recently, a typing system based on the slpA sequence for C. difficile was developed. To elucidate the validity and efficacy of the system in the setting of a local hospital, we carried out typing of C. difficile from patients in our hospital using the system. Twenty-eight stool samples obtained from 17 patients with C. difficile-associated diarrhea were investigated. Twenty-two of the 28 samples were positive for C. difficile by stool culture, and they were able to be classified by slpA sequence typing. The smz-1 and smz-2 strains were revealed to be the predominant types in our hospital, accounting for 73% of all strains. The yok-1, yok-2, t25-1, hr-1, and hj2-2 strains were identified in 1 patient each. The smz-1 strain was identified in all wards except for ward D, while smz-2 was identified in 3 of 4 patients in ward D and was restricted to this ward. Nosocomial infection of smz-1 and smz-2 in our hospital was demonstrated. Distinguishing smz-1 from smz-2 by slpA sequence typing clarified the transmission of C. difficile among patients. In conclusion, slpA sequence typing was useful in the setting of a local hospital and may be a powerful tool for the epidemiological study of C. difficile infection.     

Antimicrobial phenotypes and molecular basis in clinical strains of Clostridium difficile

Clostridium difficile remains the leading cause of nosocomial-acquired diarrhea. This study investigated antimicrobial susceptibility patterns of C. difficile over a 3-year period. Three hundred seventeen C. difficile isolates recovered between 2002 and 2004 were analyzed for their susceptibility to erythromycin (ERY), clindamycin (CLI), moxifloxacin (MXF), doxycycline (DOX), vancomycin (VAN), and metronidazole (MTR) by Etest. The molecular basis for resistance was investigated using polymerase chain reaction (PCR) and DNA sequencing. PCR ribotyping was used to differentiate strains. All strains were susceptible to VAN and MTR. Resistance rates to ERY/CLI, MXF, and DOX increased during the study period. Eighty-four (26.5%) strains exhibited resistance against ERY/CLI, MXF, and DOX. Prevalence of resistance genes was as follows: ermB, 83; ermQ, 0; ermFS, 1; tetM, 84; tetP, 0; tetO, 2; and gyrA mutation, 76. These results indicate an increasing trend in the prevalence of combined resistance against macrolide-lincosamide-streptogramin B antibiotics, fluoroquinolones, and tetracycline in C. difficile. The lack of understanding of antibiotic resistance mechanisms in C. difficile and the increased resistant strains warrants further investigations.     

Comparison of eight commercial enzyme immunoassays for the detection of Clostridium difficile from stool samples and effect of strain type

We compared the performance of 8 Clostridium difficile enzyme immunoassays to cell cytotoxicity neutralization assay and toxigenic culture. The effect of strain type on assay performance was also examined. There were a total of 71 (14.4%) samples in which C. difficile was recovered; 58 (81.7%) of 71 were toxigenic. Compared to a composite reference standard of either C. difficile cytotoxin assay positive or toxigenic C. difficile culture positive, the sensitivities of these assays varied from 31.7% to 55.2%, while the specificities were excellent, ranging from 98.1% to 100%. Among the 57 C. difficile isolates, 30 (51.7%) were of the NAP1 genotype. Stool samples positive for the C. difficile NAP1 strain had a higher positivity rate for the toxin assays.     

Detection of toxigenic Clostridium difficile in pediatric stool samples: an evaluation of Quik Check Complete Antigen assay, BD GeneOhm Cdiff PCR, and ProGastro Cd PCR assays

The performance of C. Diff Quik Chek Complete (QCC), BD GeneOhm Cdiff PCR (BD), and ProGastro Cd PCR (PG) assays was evaluated in detecting Clostridium difficile infection (CDI) in children using 200 frozen stool specimens. The results of the tests were compared to the toxigenic culture (TC) as ‘gold standard.’ The sensitivity, specificity, positive predictive value, and negative predictive value were as follows. QCC antigen (GDH + Toxin-A/B) = 70.8%, 97.4%, 89.5%, and 91.4%; BD PCR = 89.6%, 96.7%, 89.6%, and 96.7%; PG PCR = 100%, 93.4%, 82.8%, and 100%. Polymerase chain reaction (PCR) assays detected an additional 11 positives missed by TC, 7 of which were confirmed positive by an alternate tcdB gene PCR assay. However, retrospective clinical chart review indicated CDI in only 3 of the 11 patients in whom C. difficile was detected by PCR only. A 2-step algorithm utilizing QCC antigen test as a screening test followed by confirmation of GDH-positive and toxin-negative samples with either BD or PG PCR assay will provide rapid and accurate results for majority of the samples and reduce laboratory testing cost.     

Elastase and granzymes during meningococcal disease in children: correlation to disease severity

Objective To investigate the levels of human neutrophil elastase and lymphocyte-derived granzymes A and B in relation to disease severity in children with meningococcal disease.Design Clinical observational cohort study.Setting Paediatric intensive care unit.Patients All patients with meningococcal disease during the study period were included.Measurements and results Blood sampling was done on the day of admission and on days 3 and 7. Assays for elastase and granzymes were done with ELISA. Sixty-one patients were included: 19 having distinct meningitis; 17 meningitis and shock; and 25 fulminant septicaemia. On admission levels of elastase were increased in all patients, being highest in those with fulminant septicaemia and lowest in those with distinct meningitis. Granzyme A (although marginally) and granzyme B levels were only increased in patients with shock. In 20 of the 28 patients admitted for 3 days elastase decreased from admission (rapid-decrease group). In the remaining 8 patients, elastase started to decrease after 2 days (slow-decrease group). Patients of the slow-decrease group had a higher temperature up to day 4, needed more respiratory support (mean airway pressure in cm H₂O on days 3 and 4: p=0.02 and p<0.01, respectively), and more circulatory support (>2 inotropic agents on day 3; p=0.04) compared with the rapid-decrease group.Conclusions Human neutrophil elastase and granzyme B are related with disease severity during the initial phase of meningococcal disease and prolonged neutrophil activation is associated with the extent of organ dysfunction during the period thereafter.     

Performance of TechLab C. DIFF QUIK CHEK and TechLab C. DIFFICILE TOX A/B II for the detection of Clostridium difficile in stool samples

Two membrane-bound enzyme immunoassays by TechLab, Blacksburg, VA, were evaluated and compared with the Triage Micro C. difficile Panel (Biosite Diagnostics, San Diego, CA), with culture, and with cytotoxic assay. The TechLab panels were C. DIFF QUIK CHEK (QC-GDH) and C. DIFFICILE TOX A/B II (QC-toxinA/B), which detect glutamate dehydrogenase (GDH) and Clostridium difficile toxins A and B, respectively. The Triage Panel detects GDH (TR-GDH) and toxin A (TR-toxinA). METHODS: Stool samples were inoculated onto CCFA plates (Q-Labs, Quebec, Canada) after alcohol shock, and suspected colonies were identified by the MicroScreen C. difficile latex slide agglutination test (Microgen Bioproducts, Surrey, UK). TR-GDH, TR-toxinA, QC-GDH, and QC-toxinA/B tests were performed according to the manufacturers' instructions on all the samples. Samples positive for GDH or culture but negative for TR-toxinA and QC-toxinA/B were further tested by cytotoxin assay (CTA). CTA was also performed on samples that caused blackening of the Triage Micro C. difficile Panel. RESULTS: A total of 313 of 401 stool samples were negative for GDH and toxins (78%). Eighty-eight samples were positive either for GDH or culture or both. Thirteen of these could not be evaluated for C. difficile-associated diarrhea (CDAD) because CTA test was not performed. Toxin/s was detected at least by one method in 46 (11.8%) of 388 samples that were positive for culture or GDH and were considered diagnostic of CDAD. The QC-GDH was more sensitive than culture and TR-GDH for the detection of C. difficile. However, in 18GDH-positive samples positive for either of the Triage or TechLab immunoassays, the culture remained negative. Ten (2%) results of the Triage immunoassays could not be evaluated because of discoloration of the panels. QC-GDH (93.5%) was more sensitive for detecting the presence of toxin-producing C. difficile than TR-GDH (79.5%). TR-toxinA was more specific for detecting the presence of toxin-producing C. difficile than QC-toxinA/B (100% and 96.9%, respectively). CONCLUSIONS: The GDH tests had a faster turnaround time than the traditional culture methods. QC-GDH was most sensitive for the detection C. difficile-positive stools and was easy to use.     

恶性实体肿瘤迭和急性白血病临床特点分析

目的探讨急性白血病与恶性实体肿瘤迭合时实体肿瘤和急性白血病的类型、血象及骨髓象改变、病程及预后。方法收集本院近5年来收治的恶性实体肿瘤迭和急性白血病8例,参照2008年WHO分类诊断标准重新复核其骨髓形态学改变,结合文献分析恶性实体肿瘤迭和急性白血病的临床特点。结果 8名恶性实体肿瘤迭和急性白血病患者中7例发病间隔时间6个月(中位值2年),其中2例手术后行化疗,3例手术后行放化疗,1例化疗后行局部放疗,1例行酒精注射治疗;1例发病间隔时间1月。急性白血病的骨髓形态学改变:6例有病态造血,包括6例均有粒系病态造血,4例又有红系病态造血,2例又有巨核系病态造血,2例伴有噬血现象。死亡5例,生存时间2～10(中位值5)个月,存活3例,仍在治疗中。结论恶性实体肿瘤迭和急性白血病的发生与放化疗及宿主内在因素有关,肿瘤相关性白血病细胞形态多见明显的病态造血,病程进展较快,常规化疗效果及预后很差,应根据行为状态和核型选择治疗方案。     

Clinical implication of prolonged fever in children with cat scratch disease

Cat scratch disease, caused by Bartonella henselae, typically presents with a localized lymphadenopathy with a brief period of fever and general symptoms. However, there are atypical cases with a wide spectrum of clinical manifestations including prolonged fever (37.5°C, for more than 7 days), or with systemic complication, or without lymphadenopathy. We analyzed relationships among those manifestations in children with cat scratch disease. A total of 127 patients were serologically diagnosed as having Bartonella infection between 1997 and 2003. Relationships among clinical manifestations were analyzed by use of multiple regression and multiple logistic regression analyses. Of the 127 seropositive cases, 75 (59.1%) had typical cat scratch disease and 52 (40.9%) had an atypical one. As atypical manifestations, 46 (36.2%) had prolonged fever, 23 (18.1%) had no lymphadenopathy, and 21 (16.5%) had complications: hepatic/splenic abscesses or low-echoic lesions, hepatic granuloma, and central nervous system involvements. Prolonged fever was observed in 20 (87%) of the 23 cases without lymphadenopathy and 16 (76.2%) of the 21 cases with complications. By multiple regression analysis, the duration of fever was significantly associated with both the absence of lymphadenopathy and the presence of complications. The child suffering from cat scratch disease without lymphadenopathy or with complication tends to have prolonged fever. Conversely, when a child has a prolonged fever of unknown origin, possibility of cat scratch disease should be considered, and a search for underlying systemic complications is recommended for prompt diagnosis and appropriate treatment.     

Evaluation of automated repetitive-sequence-based PCR (DiversiLab) compared to PCR ribotyping for rapid molecular typing of community- and nosocomial-acquired Clostridium difficile

Automated repetitive PCR (rep-PCR; DiversiLab) was compared to PCR ribotyping of the 16S-23S RNA intergenic spacer of Clostridium difficile (CD) as the "gold standard" method for CD typing. PCR products were separated on DiversiLab LabChips (bioMérieux, St. Laurent, Quebec, Canada) utilizing a 2100 Bioanalyzer (Agilent Technologies, Santa Clara, CA) operating the DiversiLab v1.4 assay. Bioanalyzer data were exported to a secure DiversiLab website and analyzed with DiversiLab v3.4 software. Replicability of each method was verified by confirming that the 5 CD reference strains (RS) formed distinct clusters (CD4, CD6, VL0047, VL0013 [ribotype 027], VL0018 [ribotype 001]) by both typing methods. Ninety randomly selected clinical isolates (CS) were analyzed by both methods: 49 from community-acquired and 41 from hospital-acquired cases. A similarity index (SI) of ≥90% was used to define clusters when comparing the known RS cluster to the PCR ribotyping and rep-PCR patterns of CS. Fourteen different PCR-ribotype clusters were identified, but most CS formed 4 major clusters (i.e., CD4 [15/90; 17%], CD6 [17%], 027 [12%], and 001 [9%]). A total of 7 rep-PCR types were identified, but most CS formed 2 major rep-PCR clusters (i.e., CD4 [29/90; 32%] and CD6 [23%]); several PCR ribotypes occurred within a single rep-PCR cluster. Rep-PCR did not distinguish 027 or 001 isolates; i) 027 RS strain did not cluster, ii) eleven 027 CS strains clustered as CD4, iii) no 027 CS strains clustered with the 027 RS, and iv) only 2 001 CS clustered with the RS. Agreement between the PCR-ribotype and rep-PCR clusters only occurred for 35/90 (39%) of the CS using a rep-PCR SI of ≥90%. Rep-PCR time to results was similar, but the annual costs of routinely using this method are 32% higher than PCR ribotyping. Routine use of rep-PCR for CD typing is limited by its lack of definitive separation of the hypertoxigenic 027 or 001 outbreak CD strains.     

Prospective surveillance for atypical pathogens in children with community-acquired pneumonia in Japan

A total of 141 children with community-acquired pneumonia (CAP) were studied prospectively to determine the causative microorganisms. Microbial investigations included examination of postnasal swabs, cultures, polymerase chain reaction (PCR), and serology. The atypical pathogens occurring most frequently were Mycoplasma pneumoniae (58 patients [41.1%]), Chlamydia pneumoniae (4 patients [2.8%]), and concurrent occurrence of both pathogens (1 patient [0.7%]). Patients aged under 4 years showed a relatively lower rate of atypical bacterial etiology compared with those aged 4 years or older. Major bacterial pathogens were detected in 89 patients (atypical pathogens were detected in 28 patients simultaneously), including Streptococcus pneumoniae in 34 patients, Haemophilus influenzae in 60, Moraxella catarrhalis in 48, and multiple pathogens in 42. In patients suspected of having atypical pneumonia, macrolides are recommended.     

Clinical and bacteriological evaluation of the efficacy of piperacillin in children with pneumonia

We aimed to prospectively evaluate the clinical and bacteriological effects of piperacillin in children with pneumonia. Twenty-eight patients (6 months to 5 years of age) with pneumonia were treated with piperacillin. In the same period, 95 strains of Haemophilus influenzae and 41 strains of Streptococcus pneumoniae were isolated in our department and the minimum inhibitory concentration (MIC) of piperacillin was determined. The clinical efficacy of piperacillin was excellent in 4 cases, good in 23, and fair in 1; the response rate was 96.4% (27/28). Among the isolates from our department, there were 4 strains (9.8%) of penicillin-susceptible S. pneumoniae (PSSP), 32 strains (78.0%) of penicillin-intermediate-resistant S. pneumoniae (PISP), and 5 strains (12.2%) of penicillin-resistant S. pneumoniae (PRSP). Against S. pneumoniae, the MIC₅₀ and MIC₉₀ for piperacillin were 0.5 μg/ml and 2 μg/ml, respectively. Panipenem showed the best results, followed by piperacillin, ampicillin, and flomoxef. Among the isolates from our department, there were 51 strains (53.7%) of β-lactamase-negative ampicillin-susceptible H. influenzae, 42 strains (44.2%) of β-lactamase-negative ampicillin-resistant H. influenzae, 1 strain (1.1%) of β-lactamase-positive ampicillin-resistant H. influenzae, and 1 strain (1.1%) of β-lactamase-positive amoxicillin-clavulanic acid-resistant H. influenzae. The MIC₅₀ and MIC₉₀ for piperacillin against H. influenzae were 0.0625 μg/ml and 0.125 μg/ml, respectively. Tazobactam/piperacillin and piperacillin showed the best results, followed by panipenem, ampicillin, and flomoxef. Piperacillin proved to be very useful for the treatment of pneumonia in children.     

Changes in quality of life during palliative chemotherapy for solid cancer

Background We conducted this prospective study to assess the changes in quality of life (QOL), anxiety and depression in patients receiving palliative chemotherapy for solid cancers.Patients and methods Patients were eligible if they had histologically confirmed metastatic or recurrent cancer and a life expectancy of more than 6 months, and were able to complete the self-administered questionnaires. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30) and Hospital Anxiety and Depression Scale (HADS) were used to measure the effects of chemotherapy on the patients QOL, anxiety and depression at baseline and three times after every three cycles of chemotherapy.Results From July 2001 to October 2003, 146 patients were recruited, and of these 98 completed the questionnaires and 48 were withdrawn from the trial (27 lost to follow-up, 11 withdrew consent, 5 for toxicity, 5 for progression of the cancer). Their median age was 58 years (range 28–78 years) and the male to female ratio was 1.6. Of the 146 patients, 52 had gastric cancer, 39 non-small-cell cancer, 29 colorectal cancer, 11 breast cancer, and 15 had other cancers. Initial QOL scores were closely related to performance status. Compared with baseline, clinically meaningful relief (score decreased by more than 10) of symptoms such as pain and sleep disturbance was observed. There was significant improvement (score increased by more than 10) in the functional scales after the first cycle of chemotherapy, but these effects did not persist throughout the whole course of therapy. The incidences of probable anxiety and depression disorder before chemotherapy were 20% and 29%, respectively. The anxiety scores decreased throughout the period of intervention. Pretreatment anxiety and depression were negatively correlated with baseline QOL scores.Conclusions Palliative chemotherapy treatment in patients with solid cancer improved cancer-related symptoms, lessened anxiety and did not disturb the QOL of cancer patients.