Community versus health care-associated Clostridioides difficile infection: A comparison between clinical characteristics and outcomes in hospitalized patients.

BACKGROUND: Clostridioides difficile infection (CDI) can be divided according to its acquisition site, health care (HC) or community (CA) associated CDI. Studies showed severe disease, higher recurrence, and mortality among HC-CDI patients, while others reported the opposite. We aimed to compare the outcomes according to the CDI acquisition site. METHODS: The study analyzed medical records and laboratory computerized system data to identify patients (≥18 years old) who were hospitalized with the first CDI from January 2013 to March 2021. Patients were divided into HC-CDI and CA-CDI groups. The primary outcome was 30-day mortality. Other outcomes: CDI severity, colectomy, intensive care unit (ICU) admission, length of hospitalization, 30 and 90-day recurrence, and 90 days all-cause mortality. RESULTS: Of 867 patients, 375 were defined as CA-CDI and 492 as HC-CDI. CA-CDI patients had more underlying malignancy (26% vs 21% P = .04) and inflammatory bowel disease (7% vs 1%, P < .001). The 30 days mortality was similar (10% CA-CDI and 12% HC-CDI, P = .5), and the acquisition site was not found to be a risk factor. There was no difference in severity nor in complications, but the recurrence rate was higher among those with CA-CDI (4% vs 2%, P = .055). CONCLUSIONS: There were no differences between the CA-CDI and HC-CDI groups regarding rates, in-hospital complications, short-term mortality, and 90-day recurrence rates. However, the CA-CDI patients had a higher recurrence rate at 30 days.

Outcomes of neutropenic hemato-oncological patients with viridans group streptococci (VGS) bloodstream infection based on penicillin susceptibility.

Viridans group streptococci (VGS) bloodstream infection (BSI) in neutropenic patients can be a severe complication. A higher prevalence of vancomycin use has been reported due to reduced susceptibility to penicillin. We aimed to assess the impact on mortality of both penicillin minimal inhibitory concentration (MIC) and the use of vancomycin. We conducted a retrospective multicenter study including consecutive neutropenic patients with VGS BSI between 2007 and 2019. Univariable and multivariable analyses were conducted to evaluate risk factors for mortality, including penicillin susceptibility as an independent variable. Non-susceptibility to penicillin was defined as MIC ≥ 0.25. We included 125 neutropenic patients with VGS BSI. Mean age was 53 years and ~ 50% were women. Overall, 30-day mortality rate was 25/125 (20%), and 41 patients (33%) had a VGS isolate non-susceptible to penicillin. In univariable analysis, no significant association was demonstrated between penicillin non-susceptibility and mortality (9/25, 26% vs. 32/100, 32%, p = 0.81). Among patients with a non-susceptible strain, the use of vancomycin was not significantly associated with mortality (empirical, p = 0.103, or definitive therapy, p = 0.491). Factors significantly associated with increased mortality in multivariable analysis included functional status (ECOG > 1, adjusted odds ratio [aOR] 12.53, 95% CI 3.64-43.14; p < 0.0001); allogeneic transplantation (aOR 6.33, 95% CI 1.96-20.46; p = 0.002); and co-pathogen in blood cultures (aOR 3.99, 95% CI 1.34-11.89; p = 0.013). Among neutropenic hemato-oncological patients with VGS BSI, penicillin non-susceptibility and the use of vancomycin were not associated with mortality. Thus, vancomycin should not be used routinely as empirical therapy in neutropenic patients with suspected VGS BSI.

Outcomes of octogenarians and nonagenarians with Pseudomonas aeruginosa bacteremia: a multicenter retrospective study.

BACKGROUND: P. aeruginosa bacteremia is a common and severe infection carrying high mortality in older adults. We aimed to evaluate outcomes of P. aeruginosa bacteremia among old adults (≥ 80 years). METHODS: We included the 464/2394 (19%) older adults from a retrospective multinational (9 countries, 25 centers) cohort study of individuals hospitalized with P. aeruginosa bacteremia. Bivariate and multivariable logistic regression models were used to evaluate risk factors for 30-day mortality among older adults. RESULTS: Among 464 adults aged ≥ 80 years, the mean age was 84.61 (SD 3.98) years, and 274 (59%) were men. Compared to younger patients, ≥ 80 years adults had lower Charlson score; were less likely to have nosocomial acquisition; and more likely to have urinary source. Thirty-day mortality was 30%, versus 27% among patients 65-79 years (n = 894) and 25% among patients < 65 years (n = 1036). Multivariate analysis for predictors of mortality among patients ≥ 80 years, demonstrated higher SOFA score (odds ratio [OR] 1.36, 95% confidence interval [CI] 1.23-1.51, p < 0.001), corticosteroid therapy (OR 3.15, 95% CI: 1.24-8.01, p = 0.016) and hospital acquired P. aeruginosa bacteremia (OR 2.30, 95% CI: 1.33-3.98, p = 0.003) as predictors. Appropriate empirical therapy within 24 h, type of definitive anti-pseudomonal drug, and type of regimen (monotherapy or combination) were not associated with 30-day mortality. CONCLUSIONS: In older adults with P. aeruginosa bacteremia, background conditions, place of acquisition, and disease severity are associated with mortality, rather than the antimicrobial regimen. In this regard, preventive efforts and early diagnosis before organ failure develops might be beneficial for improving outcomes.

Systemic antifungal therapy for oesophageal candidiasis - systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION: Oesophageal candidiasis is a common infection among individuals with immunosuppression, associated with significant morbidity. Available guidelines recommend fluconazole as the preferred treatment; however, data regarding its effectiveness in an era of increased fluconazole resistance has not been systematically compiled. METHODS: A systematic review and meta-analysis of randomized controlled trials (RCTs) addressing systemic antifungal therapy for oesophageal candidiasis was undertaken. The primary outcome was clinical response. Subgroup analysis was planned based on immune status and Candida spp. RESULTS: Twelve RCTs were included, of which six compared fluconazole with other azoles, four compared fluconazole with echinocandins, and two compared amphotericin deoxycholate with echinocandins. Most RCTs mainly included human-immunodeficiency-virus-positive individuals. No significant differences were found between fluconazole and comparators for the outcomes of clinical response or combined clinical and endoscopic response [relative risk (RR) 1.02, 95% confidence interval (CI) 0.97-1.07 and RR 1.06, 95% CI 0.98-1.15, respectively]. No differences were found between fluconazole and other azoles for other outcomes; however, compared with echinocandins, fluconazole had significantly higher mycological response rates and lower early relapse rates (RR 1.09, 95% CI 1.02-1.17 and RR 0.42, 95% CI 0.26-0.68, respectively). No significant differences were demonstrated between fluconazole and comparators for overall or severe adverse events. Information required for the planned subgroup analyses was not available. CONCLUSIONS: No differences in efficacy or safety were found between fluconazole and other azoles for the treatment of candida oesophagitis. The use of echinocandins resulted in lower mycological cure rates and higher relapse rates. Additional RCTs should evaluate these interventions among broader patient populations and a wider spectrum of Candida spp.

Representation of women in editorial boards of infectious disease and microbiology journals-cross-sectional study.

OBJECTIVES: We aimed to assess whether there is an association between the proportion of female editors-in-chief and members of editorial boards in infectious disease (ID) and microbiology journals. METHODS: Our cross-sectional observational study included ID or microbiology journals according to the 2019 Clarivate Journal Citation Reports. Journals' Q ranking, open-access status, and number and gender of editors-in-chief and editorial board members were collected from the journals' official websites. We conducted a binary gender assignment for each editor using names, pictures, and other online descriptors. Journals with over 100 editorial board members and those with over 25% of board members for whom we could not determine gender were excluded. Editorial teams with >50% women were considered women dominant. Univariate and multivariable analyses for female editor dominance were performed. RESULTS: Overall, 167 journals were included, with total 6057 editorial members, 1655 (27.3%) of whom were women. Of 214 editors-in-chief, 48 (22%) were women, and only 25% (40 of 162) of journals had female editor-in-chief dominance. Factors associated with female dominance in the editor-in-chief role in univariate analysis were higher quartile rank, higher impact factor, and open access. Open-access journals remined significant in multivariable analysis (odds ratio (OR) 2.521; 95% CI, 1.140-5.576, p = 0.022). Larger editorial boards were less likely to have female dominance. Female editor-in-chief dominance was significantly associated with women-dominant editorial boards. DISCUSSION: ID and microbiology journals have significantly few women as editors-in-chief and editorial board members. Understanding the reasons for this inequality is required as an important step to confront and resolve it.

[THE COMPLIANCE AND ADHERENCE TO DIRECT ORAL ANTICOAGULANTS IN PATIENTS WITH A TRIAL FIBRILLATION AFTER HOSPITALIZATION].

INTRODUCTION: Guidelines recommend direct oral anticoagulants (DOACs) for the treatment of non-valvular atrial fibrillation. The heads of the medicine wards in Beilinson Hospital were nominated for regulatory approval of these agents for Clalit Health Services (CHS) patients. OBJECTIVES: To estimate the short and long term compliance and adherence to DOACs, and their association with the approval during hospitalization. METHODS: A retrospective study was conducted on patients hospitalized at the medical wards of Beilinson Hospital during 2017 and the first 6 months of 2018. Inclusion criteria: age>18 years, members of CHS, have non-valvular atrial fibrillation and DOACs were started during their hospitalization. Data was evaluated for: the rate of approvals during hospitalization, the time needed for it after discharge, the 30 days and 12 months compliance and adherence to DOACs agents and their association with approval during hospitalization. RESULTS: During the study period DOACs were started in 373 patients; 263 (71%) of them were included in the study: 59 patients (23%) received the approval during hospitalization, while 204 (77%) received it after discharge within a median of 3 days (range 1-10). There were no significant differences between the two groups concerning demographic, clinical parameters or length of stay. The DOACs 30-days compliance was 60% and 12-months adherence was 57%. There was a slight association between 30 days compliance and in-hospital approval (63% vs. 57%, p=0.3), while the 12 months adherence revealed the opposite (54% vs. 61%, p=0.5). CONCLUSIONS: The short and long term compliance and adherence to DOACs is poor, regardless of the timing of the regulatory approval. DISCUSSION: These findings represent the real world situation, other studies revealed different results according to the study populations and methods.

The Importance of Abnormal Platelet Count in Patients with Clostridioides difficile Infection.

BACKGROUND: Clostridium difficile infection (CDI) causes morbidity and mortality. Platelets have been increasingly recognized as an important component of innate and adaptive immunity. We aimed to assess the incidence of thrombocytopenia and thrombocytosis in CDI and the effect of an abnormal platelet count on clinical outcomes. METHODS: This single-center, retrospective cohort study consisted of all adult patients hospitalized in Rabin Medical Center between 1 January 2013 and 31 December 2018 with laboratory confirmed CDI. The primary outcome was 30-day all-cause mortality. Risk factors for 30-day all-cause mortality were identified by univariable and multivariable analyses, using logistic regression. RESULTS: A total of 527 patients with CDI were included. Among them 179 (34%) had an abnormal platelet count: 118 (22%) had thrombocytopenia and 61 (11.5%) had thrombocytosis. Patients with thrombocytosis were similar to control patients other than having a significantly higher white blood cell count at admission. Patients with thrombocytopenia were younger than control patients and were more likely to suffer from malignancies, immunosuppression, and hematological conditions. In a multivariable analysis, both thrombocytosis (OR 1.89, 95% CI 1.01-3.52) and thrombocytopenia (OR 1.70, 95% CI 1.01-2.89) were associated with 30-days mortality, as well as age, hypoalbuminemia, acute kidney injury, and dependency on activities of daily living. A sensitivity analysis restricted for patients without hematological malignancy or receiving chemotherapy revealed increased mortality with thrombocytosis but not with thrombocytopenia. CONCLUSIONS: In this retrospective study of hospitalized patients with CDI, we observed an association between thrombocytosis on admission and all-cause mortality, which might represent a marker for disease severity. Patients with CDI and thrombocytopenia also exhibited increased mortality, which might reflect their background conditions and not the severity of the CDI. Future studies should assess thrombocytosis as a severity marker with or without the inclusion of the WBC count.

Multidisciplinary team led by internists improves diabetic foot ulceration outcomes a before-after retrospective study.

STUDY OBJECTIVE: Diabetic foot ulceration (DFU) is associated with high mortality and morbidity. A multidisciplinary approach has been suggested, but as these patients usually present with various comorbidities, leadership of a multidisciplinary team by internists was initiated. Our aim was to evaluate the impact of the leadership of the multidisciplinary team by internists on the outcomes of patients with DFU. METHODS: Outcomes of patients with salvable DFU admitted pre and post introduction of the multidisciplinary team were compared, i.e., a major amputation (above or below the knee), blood stream infection, major medical complications, 30 day mortality, vascular interventions, diabetes control, medication regiments and laboratory results. RESULTS: The cohort included 315 patients, 207 - multidisciplinary pre-period and 108 - multidisciplinary period. During the multidisciplinary period, the rates of major amputations, blood stream infections were found significantly lower than the pre-multidisciplinary period (10% vs. 14%; p = 0.01 and 2% vs. 13%, p = 0.04, respectively). The 30 day mortality rates tended to be lower (5% vs. 11%, p = 0.08). Vascular interventions increased significantly (18% vs. 1%, p<0.01). The diabetes control significantly improved (median glucose levels 163 vs. 185 mg/dl, p = 0.03). Treatment consisting of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, statins) were updated and laboratory results at discharge (albumin, CRP) showed improved disease control. CONCLUSION: The treatment of hospitalized DFU patients by a multidisciplinary team led by internists using a holistic therapeutic approach demonstrated improved clinical outcomes.

The impact of obesity on seasonal influenza: a single-center, retrospective study conducted in Israel.

Obesity is associated with an increased susceptibility to infections. Several studies have reported adverse clinical outcomes of influenza among obese individuals. Our aim was to examine the association between obesity and the clinical outcomes of hospitalized adult patients ill with seasonal influenza. Consecutive hospitalized adult patients between 10/2017 and 4/2018 with laboratory confirmed influenza A and B were divided into an obese group (body mass index (BMI) ≥ 30 kg/m2) and controls. The primary outcome was a composite endpoint of 30-day all-cause mortality, vasopressor use, mechanical ventilation, ICU admission, and severe influenza complication (myocarditis and encephalitis). Secondary outcomes encompassed all the components of the primary outcome, 90-day all-cause mortality, occurrence of pneumonia, length of hospital stay, and 90-day readmission rates. The study comprised 512 hospitalized adults diagnosed with laboratory-confirmed influenza A (195/512) and B (317/512). Within this group, 17% (86/512) were classified obese; the remaining 83% (426/512) were controls. Results of the composite outcome (7/85, 8% vs. 45/422, 11%; p=0.5) and the crude 30-day all-cause mortality rate (5/86, 6% vs. 34/426, 8%, p=0.5) were similar between the two groups. The multivariate analysis demonstrated that obesity was not a significant risk factor for influenza adverse events (OR=1.3, CI 95% 0.3-3.3; p=0.5), whereas advanced age, chronic kidney disease, and hypoalbuminemia were significant risk factors (OR=1.03, OR=2.7, and OR=5.4, respectively). Obesity was not associated with influenza-related morbidity and mortality among the hospitalized adults during the 2017-2018 influenza season. Further studies researching different influenza seasons are essential.

Clostridioides difficile infection in immunocompromised hospitalized patients is associated with a high recurrence rate.

OBJECTIVE: Clostridioides difficile infection (CDI) may pose a serious threat to immunocompromised patients (IMC). Herein, we evaluated the clinical outcomes of IMC patients with CDI. METHODS: All consecutive hospitalized patients between January 1, 2013 and December 31, 2018 with laboratory confirmed CDI were included in the study. Subjects were divided into two groups: IMC patients and controls. Primary outcome was the recurrence rate of CDI (rCDI) at 30 and 90 days after the first CDI episode. Secondary outcomes included 30 and 90 day all-cause mortality, length of hospital stay (LOS) and readmission rates. A multivariate analysis adjusted other risk factors for recurrence. An analysis of IMC patient subgroups (based on type of IMC conditions) was also performed. Results are reported as odds ratios (OR) with a 95% confidence interval (95% CI). RESULTS: A total of 573 patients were included, amongst them 149 IMC patients (36 solid organ transplants, 38 undergoing chemotherapy, 62 haematological conditions, 13 receiving high dose prednisone) and 424 controls. IMC patients were younger, independent and exhibited less significant comorbidities. On multivariable analysis, the rate of rCDI was significantly higher in IMC patients (OR 2.7, 95% CI 1.6-5). rCDI was also associated with vancomycin therapy, haemodialysis and previous hospitalizations. Mortality, LOS, CDI complications and rehospitalization rates were similar in both. CONCLUSIONS: IMC patients with CDI have an increased risk of 90 days rCDI. Vancomycin treatment for CDI endangers recurrence in IMC patients. Further research should explore other therapies for IMC patients with CDI with alternative agents such as Fidaxomicin and Bezlotoxumab.