Predictors of mortality and length of stay in patients with hospital-acquired Clostridioides difficile infection: a population-based study in Alberta, Canada.

In a population-based, five-year retrospective cohort study of 5304 adult patients with hospital-acquired Clostridioides difficile infection across Alberta (N=101 hospitals), 30-day all-cause and attributable mortality were 12.2% and 4.5%, respectively. Patients >75 years of age had the highest odds of attributable mortality (odds ratio (OR) 9.34, 95% confidence interval (CI) 2.92-29.83) and largest difference in mean length of stay (11.7 days, 95% CI 8.2-15.2). A novel finding was that elevated white blood cell count at admission was associated with reduced attributable mortality (OR 0.67, 95% CI 0.50-0.90) which deserves further study. Advancing age was incrementally and significantly associated with all outcomes.

Role of diabetic microvascular disease in the development of foot wounds.

The influence of microvascular changes in diabetic foot tissue breakdown is not fully known. Research on the role of vascular mediators in diabetes and their effect on the microvasculature may help to create a more unified theory.

Comparison of higher-dose intradermal hepatitis B vaccination to standard intramuscular vaccination of healthcare workers.

OBJECTIVE: To compare the immunogenicity of hepatitis B vaccine administered via intradermal (ID) versus intramuscular (IM) route. METHODS: Subjects chose either to specify the route of immunization or to undergo random allocation to vaccination by the ID (0.15 mL) or the IM (1.0 mL) route. Yeast-derived recombinant hepatitis B vaccine was given at 0, 30, and 180 days. Hepatitis B surface antibody (HBsAb) and hepatitis B core antibody (HBcAb) were measured by microparticle enzyme immunoassay. RESULTS: 763 subjects were enrolled. Baseline screening identified 65 subjects (8%) who were positive for HBsAb or HBcAb. Vaccination was completed by 590 (85%) of 698 enrollees (370 ID, 220 IM). Seroconversion rates (geometric mean titers [GMT]>0 IU/mL HBsAb) for those vaccinated ID were 99% and 96% for screening at 9 months and 1 year post-vaccination, respectively; subjects vaccinated intramuscularly had similar rates of 95% and 96%. Seropositivity rates (GMT > or = 10 IU/mL HBsAb) showed a similar pattern, with 95%, 92%, and 73% at 9 months and 1 and 2 years, respectively, for those vaccinated ID, and 94%, 93%, and 81% for those having IM vaccination. GMT for HBsAb was significantly higher for individuals vaccinated IM than for those vaccinated ID (P<.0001). The GMT ratio for the IM and ID routes decreased over time, being 9.3 at 9 months, 7.8 at 1 year, and 5.9 at 2 years. An unanticipated side effect of intradermal vaccination was skin discoloration at injection sites, which persisted for at least 2 years postvaccination. Two thirds (112/166) of respondents reported that they would have selected the ID route despite the discoloration. CONCLUSIONS: Higher-dose ID vaccination (3 vs 1 microg per injection) uses one sixth of the dose required for standard IM vaccination. It is a cost-effective way to vaccinate populations against hepatitis B virus, but the long-term efficacy of the ID route must still be investigated.

Proton pump inhibitors increase significantly the risk of Clostridium difficile infection in a low-endemicity, non-outbreak hospital setting.

BACKGROUND: Proton pump inhibitors (PPI) have been linked to higher risk of Clostridium difficile infection (CDI). The relevance of this association in hospitals with low disease activity, where an outbreak strain is nondominant, has been assessed in relatively few studies. AIM: To assess the association of PPI and CDI in a setting of low disease activity. METHODS: A retrospective cohort study was conducted at two hospitals. Patients admitted for > or = 7 days receiving antibiotics were included. Demographics, exposure to PPI, antibiotics and other drugs in relation to diagnosis of CDI were assessed by univariate and multivariate analyses. RESULTS: Of 14 719 patients, 149 (1%) first episode CDI were documented; PPI co-exposure increased CDI [1.44 cases/100 patients vs. 0.74 cases/100 non-exposed (OR: 1.96, 95% CI: 1.42-2.72)]. By logistic regression, PPI days (adjusted OR: 1.01 per day, 95% CI: 1.00-1.02), histamine-2 blockers, antidepressants, antibiotic days, exposure to medications, age, admission service and length of admission were significant predictors. CONCLUSIONS: A statistically significant increase in CDI was observed in antibiotic recipients who received PPI, but the absolute risk increase is modest. In settings of with low rates of CDI, the benefit of PPI therapy outweighs the risk of developing CDI. These data support programmes to decrease inappropriate use of PPI in hospitalized patients.

Rey II: redesigning the Rey screening test of malingering.

This study has redesigned the Rey 15-item Visual Memory Test (1964) by introducing more complex figures and by increasing internal logic and pattern redundancy. Standardized administrative procedures and rules for a simple qualitative scoring system were established. Performance on the original Rey continued to be significantly contaminated by ability components and illness while performance on the Rey II qualitative scoring system was not significantly related to intelligence, age, mental status or memory. The Rey II demonstrated improved face validity. Linear Discriminant Function Analysis indicated that the qualitative scoring system had a higher classification accuracy than the quantitative system on both instruments; the Rey II qualitative scoring system accurately detected 31% more college malingerers than the Rey quantitative and 21% more clinical malingerers than the Rey II quantitative. A malingering cut-off of two qualitative errors gave the Rey II a 79% higher sensitivity in the college malingerers and 29% higher specificity in the clinical population than the standard quantitative Rey cut-off of nine items.

Molecular epidemiology of Xanthomonas maltophilia colonization and infection in the hospital environment.

Between April 1992 and December 1993, 80 Xanthomonas maltophilia isolates were collected from 63 patients in three acute-care hospitals in Calgary, Alberta, Canada. On the basis of Centers for Disease Control and Prevention definitions, 48 patients had nosocomial and 15 had community-acquired X. maltophilia. Thirty-eight of the patients were colonized and 25 were infected. Sixty-four percent of patients who acquired X. maltophilia in the intensive care unit (ICU) became infected, whereas 32% of patients in a non-ICU setting became infected. ICU patients tended to be hospitalized for a shorter period of time than non-ICU patients before the onset of X. maltophilia infection. Regardless of being colonized or infected, all patients had debilitating conditions, with respiratory disease being the most common underlying illness (35%). Forty-two patients (88%) with hospital-acquired X. maltophilia received prior antibiotic therapy which included gentamicin, tobramycin, ceftazidime, piperacillin, and imipenem. Agar dilution MICs showed that patient isolates were resistant to these antimicrobial agents that patients had received. Pulsed-field gel electrophoresis of SpeI-digested genomic DNA revealed that six epidemiologically linked patient isolates from the ICU of one acute-care hospital had identical DNA profiles. In contrast, isolates from patients from the other two hospitals had unique genotype profiles (n = 57) regardless of the presence or absence of an epidemiologic association. In these patients there was genetic evidence against the acquisition of a resident hospital clone. These results indicate that pulsed-field gel electrophoresis can resolve genotypically distinct strains of X. maltophilia and, consequently, is a useful tool for evaluating nosocomial infections caused by X. maltophilia.