Low prevalence of VRE gastrointestinal colonization of hospitalized patients in Manitoba tertiary care and community hospitals

OBJECTIVE:

To determine the prevalence of vancomycin-resistant enterococci (VRE) bowel colonization in hospitalized patients in Manitoba who had stool specimens collected for Clostridium difficile toxin and/or culture testing.

DESIGN:

Two tertiary care and five community hospitals in Winnipeg and three rural Manitoba community hospitals participated in this study. From January 1 to December 31, 1997 stool specimens, one per patient, submitted to hospital microbiology laboratories for C difficile toxin and/or culture testing were screened for VRE on colistin-nalidixic acid-vancomycin (6 μg/mL) (CNAV) agar plates. The study was divided into six, eight-week intervals. Stool specimens received in the first two weeks of each eight week interval were screened for VRE.

MAIN RESULTS:

A total of 1408 stool specimens were submitted over the 48-week study period. Sixty-seven (4.8%) patients with VRE colonization of their lower gastrointestinal tract were identified. Three of the 67 (4.5%) VRE isolates were Enterococcus faecium, with the remaining 64 (95.5%) were Enterococcus gallinarum. The three vancomycin-resistant E faecium -VREF- (from two different Winnipeg hospitals) demonstrated the vanA genotype, and were resistant to vancomycin, teicoplanin and ampicillin. All three VREF isolates also demonstrated high level resistance to both gentamicin and streptomycin but were susceptible to quinuprisitin/dalfopristin and {"type":"entrez-nucleotide","attrs":{"text":"LY333328","term_id":"1257359838"}}LY333328.

CONCLUSION:

VRE colonization in hospitalized patients in Manitoba is infrequent and most commonly due to E gallinarum. The prevalence of VREF colonization in the patients studied was 0.2% (three of 1408).Key Words: Manitoba, Prevalence, Vancomycin-resistant enterococciVancomycin-resistant Enterococcus faecium (VREF) accounts for up to 65% of E faecium isolates in hospitalized patients across the United States and is endemic in many North American tertiary care institutions (1,2). The management of these infections presents a significant clinical challenge because species of the genus Enterococcus, and in particular E faecium, are frequently resistant to several antimicrobial agents (3). High level penicillin resistance, high level aminoglycoside resistance and most recently vancomycin resistance are emerging as significant concerns in the treatment of enterococcal infections. This has prompted the development and evaluation of new antimicrobial agents such as quinupristin/dalfopristin and {"type":"entrez-nucleotide","attrs":{"text":"LY333328","term_id":"1257359838"}}LY333328, a glycopeptide, which may offer activity against enterococci resistant to conventional therapy (2).VREF is not endemic in Manitoba hospitals, and infection with VREF is extremely rare (4). However, the prevalence of VREF lower gastrointestinal tract (GIT) carriage, which frequently precedes infection (5,6), is presently unknown for patients hospitalized in Manitoba. To determine whether the lack of VREF endemnicity correlated with an absence of lower GIT colonization, we assessed lower GIT carriage of VREF for patients hospitalized in 10 Manitoba hospitals from January 1 to December 31, 1997. Our study was consistent with Centers for Disease Control and Prevention guidelines (Atlanta, Georgia) that suggest surveillance programs for vancomycin-resistant enterococci (VRE) be undertaken on an intermittent basis in areas where VRE is not known to be endemic (6). Isolates of VREF identified were phenotypically and genotypically characterized, and tested for their susceptibilities against a panel of antimicrobial agents.     

Diverticulitis of the midrectum

Diverticulitis of the rectum is a rare condition. This report covers patient history, diagnosis, and treatment involved in such a case. The patient presented with a history of rectal pain and muscle spasm of six months' duration. After several available examinations had been completed,i.e., digital examination, sigmoidoscopy, and barium-enema examination, the diagnosis of a rectal diverticulum was made. Initially, conservative treatment, including high-fiber diet and sitz baths, proved effective. Approximately nine months later, the patient developed severe rectal pain, unrelieved by previously effective measures. After the above-described examinations had been repeated, the rectal wall was found to be ulcerated and inflamed, and a diagnosis of diverticulitis of the rectum was made. Antibiotic therapy and evacuation of the 3- to 4-cm mass under anesthesia resulted in subsidence of symptoms and resolution of the mass. Segmental resection will be considered if the diverticulum becomes infected again.     

Sodium salicylate

To study the mechanism of salicylate-induced choleresis in rhesus monkeys, we utilized animals with indwelling common bile duct catheters under phencyclidine anesthesia. Bile flow, [¹⁴C]erythritol clearance (an estimate of canalicular flow), and bile acid secretion were measured during baseline and for 1 1/2 hr during salicylate infusion. Bile flow increased from 91.2±7.3 ml/24 hr (sem) to 180.1±8.0 ml/24 hr (P<0.001) with salicylate infusion and [¹⁴C]erythritol clearance from 114.5±8.9 ml/24 hr (P<0.001), but bile acid secretion was unchanged, suggesting increased bile acid-independent canalicular bile flow. Salicylate concentration in bile averaged, 1.48±0.08 mmol/ liter, and salicylate concentration in extra bile produced by salicylate was unlikely to result in choleresis of the magnitude observed. [³H]inulin bile-plasma ratios, measured in these same studies, were unchanged after salicylate administration, suggesting that permeability of the biliary tree was not altered. Bile lipid secretion, like bile acid secretion, was unchanged after salicylate administration, so no change occurred in the lithogenic index of the bile. These results demonstrate that salicylate is a potent choleretic in rhesus monkeys because of enhancement of bile acid-independent bile flow. Salicylate produced no change in the lithogenic index of the bile.Supported in part, by the Gastrointestinal Research Foundation, Chicago, Illinois.     

Management of skin,mucosa and joint involvement of Behçet’s syndrome: A systematic review for update of the EULAR recommendations for the management of Behçet’s syndrome

Objectives

The aim of this systematic review was to inform the update of European League Against Rheumatism (EULAR) Recommendations for the management of Behçet’s syndrome (BS), on the evidence for the treatment of skin, mucosa and joint involvement of BS.

Survival in patients undergoing transjugular intrahepatic portosystemic shunt: ePTFE-covered stentgrafts versus bare stents

In patients with liver cirrhosis, implantation of a transjugular intrahepatic shunt (TIPS) leads to reduction of portal pressure, but not of mortality compared with other therapies. The high stenosis rates of conventional bare stents causes high reintervention rates and costs and may be correlated with poor survival. ePTFE-covered stentgrafts provide much improved patency rates, but their impact on survival is unclear. All suitable patients receiving either bare TIPS (419/466) or undergoing implantation of ePTFE endoprostheses (89/100) in several centers in Austria up to 2002 were included in this retrospective analysis. Both patient groups were compared regarding survival with Kaplan-Meier and Cox regression analysis. Unmatched and 1:1-matched survival analyses were performed. Patients undergoing ePTFE stentgraft implantation had significantly higher survival rates in all analyses. The 3-month, 1-year, and 2-year survival rates were 93%, 88%, and 76% for the ePTFE-group and 83%, 73%, and 62% for conventional TIPS patients, respectively. The matched survival analyses validated these findings. The model of the stent, patient age, and Child-Pugh Class (CPC) were independent predictors of survival. In conclusion, patients undergoing ePTFE-endoprosthesis implantation had higher survival rates within 2 years after TIPS-implantation. This may be the result of improved patency rates after correct placement (up to the inferior caval vein [ICV]) of the ePTFE stentgraft. These data should be validated in a prospective series.     

Current knowledge and significance of coronary artery ectasia: A chronologic review of the literature,recommendations for treatment,possible etiologies,and future considerations

Coronary artery ectasia is the abnormal enlargement of the coronary artery. The prognosis, treatment, and etiology of this disease remain an enigma. There is some evidence to suggest that the incidence of ectasia is increasing, and therefore understanding of this entity needs to improve. This article reviews the current literature on coronary artery ectasia and summarizes the findings. A treatment plan that targets each of the suggested clinical complications is provided. Using multiple indirect observations and current understanding of endothelium-derived relaxation factor, a possible etiology that implicates overstimulation of endogenous nitric oxide is provided. Current literature suggests that ectatic coronary arteries, even without the presence of coronary stenosis, are subject to thrombus formation, vasospasm, and spontaneous dissection. Newer subgroups of ectasia are arising with the use of multiple interventional devices to dilate coronary artery stenosis. By design, these destroy the media of the coronary artery, and it is not clear whether these “iatrogenic” ectatic arteries are subject to the same complications as “idiopathic” coronary artery ectasia. Further investigation is necessary to help define the benefit of the proposed treatment regimen, to clarify the prognosis of these newer groups of “iatrogenic” ectasia, and to confirm or disprove the hypothesis targeting nitric oxide as an etiologic factor.     

Subclinical impairment of brain function in chronic hepatitis C infection

BACKGROUND/AIMS: Central nervous system abnormalities such as fatigue and depression occur more frequently in chronic hepatitis C virus (HCV) infection than in many other causes of chronic liver disease. The finding that fatigue is unrelated to activity of hepatitis or mode of infection could indicate an independent effect of HCV on brain function. This study tested the hypothesis of a subclinical cognitive dysfunction in HCV-infected patients. METHODS: One-hundred untreated HCV-RNA positive biopsy-proven patients were investigated by P300 event-related potentials, a sensitive electrophysiologic test of cognitive processing. Health-related quality of life and fatigue were assessed using the SF-36 questionnaire and the Fatigue Impact Scale, respectively. RESULTS: Cognitive brain function was subclinically impaired in the cohort of HCV-infected patients as indicated by significantly prolonged P300 latencies (P=0.01 for comparison to matched healthy subjects) and reduced P300 amplitudes (P<0.001, respectively). Seventeen of the 100 HCV-infected patients had P300 latencies outside the age-adjusted normal range. Abnormal P300 characteristics were not related to the degree of histologic or biochemical activity of hepatitis, severity of fatigue or mental health impairment. CONCLUSIONS: This study demonstrates that patients with HCV infection showed a slight but significant neurocognitive impairment, possibly indicating a further extrahepatic manifestation of chronic hepatitis C.     

Risk of sudden versus nonsudden cardiac death in patients with coronary artery disease

Background Patients at high risk of sudden cardiac death, yet at low risk of nonsudden death, might be ideal candidates for antiarrhythmic drugs or devices. Most previous studies of prognostic markers for sudden cardiac death have ignored the competitive risk of nonsudden cardiac death. The goal of the present study was to evaluate the ability of clinical factors to distinguish the risks of sudden and nonsudden cardiac death. Methods We identified all deaths during a 3.3-year follow-up of 30,680 patients discharged alive after admission to the cardiac care unit of a Seattle hospital. Detailed chart reviews were conducted on 1093 subsequent out-of-hospital sudden deaths, 973 nonsudden cardiac deaths, and 442 randomly selected control patients. Results Patients who died in follow-up (suddenly or nonsuddenly) were significantly different for many clinical factors from control patients. In contrast, patients with sudden cardiac death were insignificantly different for most clinical characteristics from patients with nonsudden cardiac death. The mode of death was 20% to 30% less likely to be sudden in women, patients who had angioplasty or bypass surgery, and patients prescribed β-blockers. The mode of death was 20% to 30% more likely to be sudden in patients with heart failure, frequent ventricular ectopy, or a discharge diagnosis of acute myocardial infarction. A multivariable model had only modest predictive capacity for mode of death (c-index of 0.62). Conclusion Standard clinical evaluation is much better at predicting overall risk of death than at predicting the mode of death as sudden or nonsudden. (Am Heart J 2002;144:390-6.)