The impact of Clostridium difficile on a surgical service: a prospective study of 374 patients.

OBJECTIVE: To evaluate the epidemiology of Clostridium difficile colitis (CDC) in a subset of patients admitted specifically to a surgical service. SUMMARY BACKGROUND DATA: CDC is an increasingly prevalent nosocomial infection that can prolong hospitalization and adversely affect patient outcome. Although this disease has been investigated extensively in patients admitted to medical services, the incidence and risk factors for the development of this disease in patients admitted to a surgical service have not been studied. METHODS: Over a 5-month period, 374 patients admitted to the general, vascular, thoracic, and urologic surgery services were monitored for the development of symptomatic CDC (defined as >3 bowel movements per 24 hours and a positive cytotoxin assay or culture). RESULTS: Twenty-one patients developed CDC (incidence, 5.6%). Factors that independently predisposed to infection included admission from a skilled care facility, use of the antibiotic cefoxitin, and an operative procedure for bowel obstruction. Other factors associated with CDC included colectomy, treatment with any antibiotic, nasogastric tube suction, advanced age, and prior antibiotic treatment. Abdominal pain and fever were also more common in patients with CDC. Morbidity included prolonged hospitalization in all patients and urgent colectomy in one. CONCLUSIONS: CDC frequently affects surgical patients, producing morbidity ranging from mild diarrhea to life-threatening illness. A variety of factors, many of which are associated with intestinal stasis, predispose to the development of CDC.

Diagnostic yield of bronchoalveolar lavage and bronchoscopic lung biopsy for detection of Pneumocystis carinii.

OBJECTIVE: To assess the need to perform a bronchoscopic lung biopsy (BLB) in addition to bronchoalveolar lavage (BAL) to obtain a definitive diagnosis of Pneumocystis carinii pneumonia. DESIGN: We retrospectively reviewed the results of concurrently collected paired BAL and BLB specimens to determine the diagnostic yield of both methods for the detection of P. carinii organisms. MATERIAL AND METHODS: During a 3-year period, the BAL fluid specimens stained with a commercially available direct immunofluorescence monoclonal antibody (DFA) reagent and the BLB specimens stained with Grocott methenamine-silver nitrate (GMS) were assessed for the presence of P. carinii. BAL fluid was routinely collected from multiple sites and combined into a single specimen for testing. RESULTS: During the 3-year period of study, 119 patients were identified who had paired BAL fluid and BLB specimens tested for the presence of P. carinii. Of the 119 patients, 16 had either BAL fluid that could not be interpreted or BLB tissue that was inadequate. Of the other 103 patients, 21 had P. carinii pneumonia. The sensitivity of the DFA method on BAL fluid and of the GMS method on BLB was 95% and 43%, respectively. CONCLUSION: For detection of P. carinii, the diagnostic yield is significantly higher for DFA-stained BAL specimens than for GMS-stained BLB specimens.

Chlamydial cervical infection in jailed women.

OBJECTIVES: The prevalence of Chlamydia trachomatis cervical infection in incarcerated adult women has not been reported. To develop a policy for testing and treatment, we determined the prevalence of and risk factors for chlamydial infection in women in a New York City jail. METHODS: Interviews and cervical cultures for C trachomatis were obtained from 101 consenting female inmates. RESULTS: Positive cultures for C trachomatis were found in 27% of the participants. Mucopurulent cervical discharge and education of 8 years or less were two independent risk factors for infection, but only 63% of the infected women had one or both of these factors. If pelvic tenderness were considered as a third factor, an additional 7% of the infected women would have been identified. CONCLUSIONS: The prevalence of chlamydial infection in this population was as high as that in populations for which presumptive treatment is recommended. Although the optimal policy for detection and treatment of chlamydial infection may vary depending on practical considerations, we suggest that women entering correctional facilities should be screened or offered presumptive therapy for C trachomatis infection.

Antibiotic-loaded biodegradable bone cement for prophylaxis and treatment of experimental osteomyelitis in rats.

A biodegradable, particulate composite bone cement containing gentamicin and vancomycin was used for both treatment and prophylaxis of Staphylococcus aureus osteomyelitis in rats. Osteomyelitis was established by inoculating S. aureus into holes that were drilled in the proximal tibiae and were filled with polymethylmethacrylate (PMMA) cylinders. The cylinders were left in place for 3 weeks. The infections were serially evaluated by clinical and radiographic examination and by quantitative culture for colony forming units (CFUs) at the time the rats were killed. For treatment, cements containing antibiotic were implanted in animals that had established osteomyelitis and were left in place for an additional 3 weeks. Sites treated with biodegradable cement containing antibiotics exhibited significantly fewer CFUs in comparison with controls (p < 0.01). Sites treated prophylactically with the biodegradable cement developed no infections as evaluated by clinical or radiographic criteria or by quantitative culture. At this relatively early time, no significant difference in therapeutic effectiveness was found when either the biodegradable cement or PMMA was used as a carrier for antibiotics.

Multicenter evaluation of a new enzyme immunoassay for detection of Clostridium difficile enterotoxin A.

The Premier Clostridium difficile toxin A enzyme immunoassay (PTA EIA) (Meridian Diagnostics, Inc., Cincinnati, Ohio) for rapid diagnosis of antibiotic-associated colitis (AAC) was evaluated in a multicenter study. Stool samples from 421 patients suspected of having AAC were tested for toxin A by the PTA EIA and for toxin B by three tissue culture assays (TCA) employing WI-38 cells (New England Deaconess Hospital) in conventional tubes or foreskin fibroblasts (Children's Hospital) or Vero cells (Beth Israel Hospital) in microwells. The tubes and plates were examined at 24 and 48 h for cytotoxicity. Clinical criteria, repeat testing at another site, and culture of frozen stool samples for C. difficile were used to evaluate discrepant results. Of 504 samples, 66 were positive and 409 were negative by both tests. Eight samples had indeterminate PTA EIA results and were excluded from this analysis. Of 21 discrepancies, 9 were PTA EIA positive and TCA negative and 12 were PTA EIA negative TCA positive. Following resolution of the discrepancies, 11 of 12 PTA EIA-negative-TCA-positive and 5 of 9 PTA EIA-positive-TCA-negative samples were considered true positive for AAC. The sensitivity and specificity were, respectively, 86.6 and 99.0% for the PTA EIA and 93.9 and 99.8% for TCA. The predictive values of positive and negative tests were, respectively, 94.7 and 97.4% for the PTA EIA and 98.7 and 98.8% for TCA. We conclude that the PTA EIA is a rapid, simple EIA technique whose accuracy in detecting enterotoxin A approaches that of reference TCA methods for detection of cytotoxin B.

Chlamydia trachomatis cervical infection in women seeking routine gynecologic care: criteria for selective testing.

PURPOSE: Chlamydia trachomatis infection is one of the most common sexually transmitted diseases. Developing methods to identify patients who are at higher risk would enable clinicians to perform selective testing for C. trachomatis infection, which may reduce morbidity, sequelae, and overall costs. Risk factors for C. trachomatis infection of the cervix in women seen for routine gynecologic care were therefore analyzed. PATIENTS AND METHODS: Extensive clinical data and cervical cultures were obtained from 1,141 women between the ages of 18 and 50. Multivariate techniques were used to develop and prospectively test a model to predict infection. RESULTS: In the model development series of 530 patients seen in a hospital-based practice, 24 (4.5%) had a positive culture result. In the validation series of 611 patients seen in private practice, 17 (2.8%) had positive culture results. The majority of infected patients (61%) were asymptomatic. For sexually active women 18 to 35 years of age, the optimal predictive model was based on three factors: level of education (high school or less), a sex partner with other partners during the prior three months, and endocervical bleeding induced by the initial swab. In the validation series, the prevalence of infection for women with one or more of these factors was 5.8% (95% confidence interval, 4.0 to 8.6) compared with 0.9% in patients without these factors (p = 0.005). CONCLUSION: Clinical information can be used in a low-prevalence population to predict a patient's risk for C. trachomatis infection and to select patients for testing.

Gonorrhea in women seen for routine gynecologic care: criteria for testing.

PURPOSE: This study was initiated to determine risk factors for Neisseria gonorrhoeae infection of the cervix in women seen for routine care in a hospital-based obstetrics and gynecology practice. PATIENTS AND METHODS: Extensive clinical data and cervical culture specimens for N. gonorrhoeae were obtained prospectively from 1,441 women between the ages of 18 and 50. Fifty clinical factors were evaluated by multivariate analysis. RESULTS: Of the 1,441 patients tested, 25 (1.7 percent) had a positive culture result. The majority of infected women were asymptomatic. The following five factors were found to be associated independently with gonococcal infection: (1) sex with a partner who may have had gonorrhea or a urethral discharge within the prior three months, (2) endocervical bleeding induced by the initial swab, (3) age at first intercourse less than or equal to 16, (4) method of payment (Medicaid), and (5) low abdominal or pelvic pain. Race, a univariate risk factor, was not associated with gonorrhea when these other factors were considered. The risk of infection for women with none, one, two, or three or more of these multivariate risk factors was 0.2, 0.8, 2.9, and 9.8 percent, respectively. CONCLUSION: Clinical data are helpful in identifying women at risk for gonorrhea. If resources are insufficient to evaluate all sexually active women, we suggest routine testing based on the presence of the multivariate risk factors identified.

Use of a direct fluorescent antibody test for detecting Chlamydia trachomatis cervical infection in women seeking routine gynecologic care.

We determined the sensitivity, specificity, and predictive value of a direct fluorescence test for Chlamydia trachomatis infection compared with culture of the endocervix in women seeking routine gynecologic care. Of 527 patients seen in a hospital-based practice, 23 (4.4%) had a positive culture for C. trachomatis. The overall sensitivity of the direct test was 70%, and the specificity was 98%. When five or more endocervical cells were present on the direct test slide, the sensitivity increased to 92%, and the specificity decreased to 96% (P less than .05). When the presence of any columnar epithelial cells, five or more elementary bodies, or both was used as the criteria for accepting specimens, the sensitivity and specificity of the direct test were 80% and 96%, respectively. However, 44% of the specimens would be rejected if these criteria were used. The overall probability that an individual with a positive direct test would have a positive culture was 62%.

Percoll-purified Treponema pallidum, an improved fluorescent treponemal antibody-absorbed antigen.

Percoll-purified Treponema pallidum was evaluated as a fluorescent treponemal antibody-absorbed antigen. Borderline and false-positive reactions were essentially eliminated, resulting in sensitivity and specificity of 100 and 95.5%, respectively. The lack of background debris improved the ease and speed of reading the test.

Humoral immunity in experimental syphilis: the demonstration of IgG as a treponemicidal factor in immune rabbit serum.

The neutralizing activity present in immune rabbit serum (IRS) against virulent Treponema pallidum was shown to be mediated by IgG and complement. IgG was isolated and purified from both IRS and nonimmune rabbit serum (NRS) by the use of an affinity system in which staphylococcal protein A was conjugated to Sepharose 4B. The purity of the isolated IgG fractions was demonstrated by both immunoelectrophoresis and SDS-polyacrylamide gel electrophoresis. Fractions of IgG were tested for specific neutralizing activity as measured by an in vitro-in vivo neutralization test. Lesions failed to develop at 80% of the sites inoculated with treponemal suspensions containing IgG from IRS in the presence of unheated NRS as a source of complement; delayed atypical lesions were observed at the remaining sites. In contrast, typical lesions developed at all sites inoculated with suspensions containing IgG from IRS in the presence of heated NRS. They were significantly delayed, however, as compared with lesion development at control sites inoculated with suspensions containing IgG from NRS. These results provide the first direct evidence for an IgG complement-mediated treponemicidal mechanism operative in immune serum from rabbits with latent syphilis.

Purification of Treponema pallidum, Nichols strain, by Percoll density gradient centrifugation.

The purification of motile and virulent Treponema pallidum, Nichols strain, from rabbit testicular tissue is reported. Suspensions of T. pallidum were overlayed onto 20-ml cushions of 43% Percoll and in-situ density gradients were formed by centrifugation at 34,800 g for 30 min. Gradient fractionation indicated that T. pallidum banded at a density of 1.051 g/cc3 and that soluble proteineous testicular components remained in the upper portion of the gradient. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) confirmed the removal of host testicular and serum components. Purified suspensions of T. pallidum were greater than 95% actively motile and fully virulent, and greater than 50% motility could be maintained in vitro for up to five days. As determined by electron microscopy, Percoll-purified T. pallidum was structurally unaltered and contained much less tissue debris than did crude extracts or T. pallidum prepared by differential centrifugation. The Percoll purification method has been applied successfully to physiology, recombinant DNA, and antigenic structure studies, and to the preparation of antigen for the fluorescent treponemal antibody-absorbed (FTA-Abs) test for syphilis.

Humoral immune response in experimental syphilis to polypeptides of Treponema pallidum.

The ontogeny of the IgG response in rabbits with experimental syphilis to individual polypeptides of Treponema pallidum, Nichols strain, was examined. The polypeptides of motile, virulent T. pallidum, purified from host tissue by Percoll density gradient centrifugation, were separated on SDS-polyacrylamide gels and were electrophoretically transferred to a solid-phase matrix of nitrocellulose for antigen analysis. Serum from rabbits early in infection at day 3 post-infection showed a weak but detectable IgG response to two polypeptides of 60,000 and 46,000 m.w. This was followed on days 11, 17, and 19 by an apparent quantitative increase in antibody to other treponemal protein antigens. By day 19, 21 of the 22 detectable polypeptides could be identified. A similar set of antigens was detected by serum from patients with human secondary and early latent syphilis. A close correlation was found between the presence of IgG antibody to T. pallidum polypeptides at day 9 and 1, 4.5, 13.5, and 17 mo post-infection and the immune status of the rabbit to symptomatic reinfection. Serum from rabbits that were partially immune to challenge at day 9 detected three polypeptides of 60,000, 46,000, and 36,000 daltons. By 1 mo post-infection, at a time when a more complete immunity had developed, the number of detectable antigens increased to 21 polypeptides ranging in m.w. from 94,000 to 14,400 daltons. IgG antibody to 22 treponemal antigens persisted in animals that were solidly immune to symptomatic reinfection at 3, 4.5, 13.5, and 17 mo post-infection. Serum neutralizing activity was not demonstrable at day 9 or 1 mo post-infection, however, but was present at 3, 4.5, 13.5, and 17 mo. The results suggest that after intratesticular challenge a vigorous IgG response to T. pallidum polypeptides can be detected. The potential role of humoral immune mechanisms in the development and maintenance of immunity is discussed.

Molecular characterization of common treponemal antigens.

A molecular characterization of cross-reactive antigens of Treponema pallidum Nichols and Treponema phagedenis biotype Reiter that are reactive with normal and syphilitic human sera is described. At least 8 common polypeptides, 14 T. pallidum-specific antigens, and 2 T. phagedenis biotype Reiter-specific antigens were identified.

Humoral immune response in human syphilis to polypeptides of Treponema pallidum.

A molecular characterization of the polypeptide antigens of Treponema pallidum reactive with sera from patients with different stages of syphilis is described. Polypeptides of motile, virulent T. pallidum, purified from rabbit testes, were separated on SDS polyacrylamide gels and electrophoretically transferred to nitrocellulose for antigenic analysis ("Western blotting"). Serum IgG from uninfected individuals reacts weakly with three polypeptides of 45,000, 33,000, and 30,000 m.w. In this study patients with primary syphilis have IgM antibody, and all patients with syphilis have IgG antibody to at least four polypeptides of 45,000, 33,000, 30,000, and 15,500 m.w. Antibody to polypeptides of 42,000 and 16,500 m.w. appear to be markers for nonprimary syphilis. These six polypeptides have been termed the major antigenic proteins (MAP) of T. pallidum. Those patients studied with secondary and early latent syphilis acquire antibody to a set of 16 additional polypeptide antigens. Those patients studied with late latent or late syphilis have antibody to a much smaller set of five or four antigens, respectively, in addition to MAP. The results suggest that a correlation exists between acquisition of antibody and the development of "chancre immunity." Additionally, the loss of antibody that characterizes late latent and late syphilis may be associated with the potential development of destructive late syphilis.

Expression of Treponema pallidum antigens in Escherichia coli.

Treponema pallidum DNA was cloned in a bacteriophage. Clones were screened for expression of Treponema pallidum antigens by an in situ radioimmunoassay on nitrocellulose, with the use of subsequent reactions with syphilitic serum and radioiodinated Staphylococcus aureus protein A. One clone, which gave a strong signal, codes for at least seven antigens that react specifically with human antibodies to Treponema pallidum.