Recurrent Clostridioides difficile infection: Recognition, management, prevention.

Clostridioides difficile infection (CDI) is the most common cause of diarrhea in hospitalized patients and results in substantial morbidity, mortality, and costs. Its clinical management, primarily with antibiotics, is often complicated by recurrent episodes. These recurrent CDI episodes are thought to be caused by antibiotic disruption of colonic microbiota and usually occur within 4 weeks of completing antibiotic therapy. The risk of recurrent CDI increases after the first episode, creating a need for management strategies to diagnose, treat, and prevent these complications.

Incidence and mortality of sepsis, severe sepsis, and septic shock in intensive care unit patients with candidemia.

In this incidence study, of 16 074 patients admitted to the intensive care unit (ICU) from 1/1/2003 to 7/31/2011, 161 cases of candidemia were identified. The incidence of sepsis (27%), severe sepsis (31%), and septic shock (40%) was remarkably high in these cases of candidemia, as was the all-cause in-hospital mortality for sepsis (30%), severe sepsis (44%), and septic shock (65%).

Risk of Clostridium difficile infection in intensive care unit patients with sepsis exposed to metronidazole.

BACKGROUND: Antimicrobial agents used to treat Clostridium difficile infection (CDI), such as metronidazole and vancomycin, have been used during antibiotic treatment of other infections to try to prevent the development of CDI. We evaluated the hypothesis that intensive care unit (ICU) patients who receive metronidazole as part of an antibiotic treatment regimen for sepsis have a lower risk of subsequently developing CDI. METHODS: This was a nested case-control study in a cohort of ICU patients who received antibiotic therapy for sepsis. RESULTS: A total of 10 012 patients aged ≥ 18 years were admitted to the Cooper University Hospital medical/surgical ICU from 1/1/2003 to 12/31/2008. After applying inclusion criteria including having received antibiotic therapy for sepsis and subsequently having developed CDI, 67 cases were identified. The cases were matched for age, gender, date of ICU admission, and hospital length of stay to 67 controls that also received antibiotic therapy for sepsis but did not subsequently develop CDI. In the multivariate analysis, there was no association between metronidazole exposure and the risk of CDI (odds ratio (OR) = 0.57; p = 0.23). The only significant associations on multivariate analysis were antifungal therapy (OR = 0.30; p = 0.02) and aminoglycoside and/or colistin therapy (OR = 0.17; p = 0.02). CONCLUSIONS: No association was found between metronidazole use and subsequent CDI in ICU patients who received antibiotic therapy for sepsis.

Salmonella aortitis treated with endovascular aortic repair.

Salmonella aortitis is a known complication of Salmonella infection that usually requires surgical therapy. It is unknown whether endovascular aortic repair (EVAR) is an acceptable alternative to conventional aortic surgery for patients with Salmonella aortitis who are at high risk for perioperative complications. We therefore report 2 cases of Salmonella aortitis treated with EVAR and review the literature to further characterize previously published cases.

Treatment of endocarditis due to Proteus species: a literature review.

Endocarditis due to Proteus species is very rare. We report a case of endocarditis due to Proteus mirabilis that was successfully treated with ampicillin and gentamicin, and review the treatment regimens of previously published cases of Proteus endocarditis.

Antimicrobial resistance in the intensive care unit: mechanisms, epidemiology, and management of specific resistant pathogens.

Infections caused by drug-resistant and multidrug-resistant microbial pathogens pose tremendous challenges to health care systems, including challenges related to the diagnosis, treatment, and containment of these infections. These challenges are amplified in the intensive care unit (ICU), where pressures for selection and emergence of resistance and risks of transmission of resistant pathogens are highest, and where the threat of resistance drives selection of empiric antimicrobial regimens. This article reviews basic concepts of resistance to antibacterial agents including mechanisms and modes of transmission, and discusses management issues for the important drug-resistant pathogens found in the ICU.

Influence of asthma status on serotype-specific pneumococcal antibody levels.

BACKGROUND: Asthma has been reported to be associated with an increased risk of invasive pneumococcal disease (IPD). OBJECTIVE: We compared serotype-specific antibody responses with pneumococcal polysaccharide antigens of individuals with and without asthma. METHODS: A cross-sectional study was conducted for 16 subjects with asthma and 14 subjects without asthma from the community of Rochester, MN. Asthma was determined by predetermined criteria based on comprehensive medical record reviews. Serotype-specific antibody to 23 pneumococcal polysaccharide antigens was measured by enzyme-linked immunosorbent assay, and seropositivity was considered ≥ 1.3 µg/mL. Interferon-γ (IFN-γ) and interleukin-5 (IL-5) were measured from peripheral blood mononuclear cells cultured with house dust mites and staphylococcal enterotoxin B. RESULTS: Of the 30 subjects, 16 (53%) were male, 21 (70%) were white, and the median age was 26 years. The median numbers of positive serotype-specific antibodies for asthmatics and nonasthmatics were 8.5 and 15.5, respectively (P = 0.034). There was an inverse relationship between the ratio of log-transformed IL-5/IFN-γ and the number of positive serotype-specific antibodies (r = -0.36; P = 0.052). As potential covariates and confounders, a history of pneumococcal vaccination (P = 0.84), having a high-risk condition for IPD (P = 0.68), and taking asthma medications, including inhaled/systemic corticosteroids (P = 0.79), were not associated with the number of positive serotype-specific antibodies. CONCLUSION: Asthmatics had significantly lower serotype-specific pneumococcal antibody levels than nonasthmatics. House dust mite-induced T-helper 2 (Th2) cytokine immune profile may be related to the association. This may account for an increased risk of IPD in asthmatics and deserves further investigation.

Candidatus Bartonella mayotimonensis and endocarditis.

We describe a new Bartonella species for which we propose the name Candidatus Bartonella mayotimonensis. It was isolated from native aortic valve tissue of a person with infective endocarditis. The new species was identified by using PCR amplification and sequencing of 5 genes (16S rRNA gene, ftsZ, rpoB, gltA, and internal transcribed spacer region).

Incidence of invasive pneumococcal disease among children after introduction of a 7-valent pneumococcal conjugate vaccine: a population-based study in Olmsted County, Minnesota.

OBJECTIVE: To examine the effect of the 7-valent pneumococcal conjugate vaccine in a well-characterized population in Olmsted County, Minnesota, with a combination of urban and rural residents likely to have a relatively low risk of invasive pneumococcal disease (IPD). PATIENTS AND METHODS: This population-based study analyzed data from children younger than 5 years to determine the incidence of IPD from January 1, 1995, to December 31, 2007. RESULTS: From 1995 through 2007, 29 cases of IPD were identified in the study population, but 2 patients denied research authorization; thus, 27 cases were available for review. From 1995-1999 to 2001-2003, the incidence of IPD decreased from 33.5 (95% confidence interval [CI], 16.6-50.5) to 10.8 (95% CI, 0.0-23.0) cases per 100,000 person-years (68% decrease; P=.046). The incidence subsequently increased to 15.2 (95% CI, 3.0-27.4) cases per 100,000 person-years from 2004 through 2007; however this change was not significant (P=.62). All cases of IPD with available serotype data from 2002 through 2007 (n=5) were due to non-7-valent conjugate vaccine serotypes. CONCLUSION: Although the baseline incidence of IPD was much lower than that reported in other populations, the overall incidence of IPD decreased significantly in children younger than 5 years after introduction of a 7-valent conjugate vaccine.

Trends in invasive pneumococcal disease among older adults in Olmsted County, Minnesota.

OBJECTIVE: Following the introduction of a 7-valent pneumococcal conjugate vaccine (PCV-7) for children in early 2000 in the United States, a decrease in the incidence of invasive pneumococcal disease (IPD) was seen in adults, likely due to a herd effect. However, there have been recent increases in IPD in adults caused by Streptococcus pneumoniae serotypes not included in PCV-7, so called "replacement disease". We performed a population-based study to further investigate this emerging concern. METHODS: Population-based incidence study in Olmsted County, Minnesota, United States, in adults aged > or =50 years. RESULTS: From 1/1/1995 to 12/31/2007, 104 cases of IPD were identified in Olmsted County in adults aged > or =50 years. We found a 45% increase in the incidence rate of IPD from 2001-2003 (17.7 cases per 100,000 person-years) to 2004-2007 (32.1 cases per 100,000 person-years) (p=0.029). From 2002-2004 to 2005-2007, the incidence rate of IPD caused by S. pneumoniae serotypes not included in PCV-7 increased from 9.2 to 32.8 cases per 100,000 person-years (p<0.001). CONCLUSION: A recent increase in the incidence of IPD in adults aged > or =50 years was demonstrated in Olmsted County, Minnesota due to serotypes not found in PCV-7. These findings are unique and merit further investigation.

Skeletal muscle abscess caused by Blastomyces dermatitidis.

Muscle involvement is an extremely rare manifestation of blastomycosis. We, therefore, report a case of a large gluteal muscle abscess caused by Blastomyces dermatitidis in a young, immunocompetent male. In addition, we review the literature to further characterize the syndrome of skeletal muscle blastomycosis.

Decreases in case-fatality and mortality rates for invasive pneumococcal disease in Olmsted County, Minnesota, during 1995-2007: a population-based study.

BACKGROUND: Following the introduction of a 7-valent pneumococcal conjugate vaccine for children in 2000, there has been a decrease in the incidence of invasive pneumococcal disease among both children and adults in the United States. We evaluated the hypothesis that the case-fatality and mortality rates for invasive pneumococcal disease have also decreased since 2000. METHODS: We conducted a population-based outcome study in Olmsted County, Minnesota, during the period 1995-2007 that involved patients of all ages. RESULTS: From 1 January 1995 through 31 December 2007, a total of 180 eligible cases of invasive pneumococcal disease were identified in Olmsted County. During the 13-year study period, the overall case-fatality rate for invasive pneumococcal disease decreased from 19% (14 of 74 cases) in 1995-1999 to 5% (5 of 91 cases) in 2001-2007, an 83% decrease, after adjustment for age, sex, and Charlson comorbidity index score (P =.003). The largest decreases in case-fatality rate were seen among adults aged >/=65 years (an 86% decrease, from 31% [9 of 29 cases] to 8% [3 of 40 cases]; P=.02) and patients with invasive pneumonia (a 78% decrease, from 22% [12 of 55 cases] to 7% [5 of 72 cases]; P=.01). The overall mortality rate for invasive pneumococcal disease decreased from 2.9 deaths per 100,000 person-years in 1995-1999 to 0.7 deaths per 100,000 person-years in 2001-2007, a 78% decrease, after adjustment for age and sex in a Poisson regression model (P=.002). CONCLUSIONS: Significant decreases in the case-fatality and mortality rates for invasive pneumococcal disease were demonstrated in the population of Olmsted County. Additional studies are needed to confirm our findings in other populations.

Infective endocarditis due to community-associated methicillin-resistant Staphylococcus aureus in injection drug users may be associated with Panton-Valentine leukocidin-negative strains.

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) isolates that cause infective endocarditis in injection drug users (IDUs) are distinct from CA-MRSA strains that cause endocardial infection as a complication of skin and soft tissue infections. We present a case of CA-MRSA infective endocarditis, review pertinent cases previously published, and describe the molecular characteristics of strains from IDUs and patients with skin and soft tissue infections.

Vancomycin-resistant Enterococcus faecalis endocarditis: linezolid failure and strain characterization of virulence factors.

Infective endocarditis due to vancomycin-resistant (VR) Enterococcus faecalis has only rarely been reported. We report a case of VR E. faecalis endocarditis that failed to respond to linezolid therapy, outline the virulence traits of the isolate, and review previously published cases of VR E. faecalis endocarditis.

Pravastatin: a potential cause for acute pancreatitis.

Acute pancreatitis (AP) secondary to drugs is un-common, with an incidence ranging from 0.3% to 2.0% of AP cases. Drug-induced AP due to statins is rare, and only 12 cases have thus far been reported. In this case report, we report a case of a 50-year-old female on pravastatin therapy for 3 d prior to developing symptoms of AP. The common etiological factors for AP were all excluded. The patient was admitted to the intensive care unit secondary to respiratory distress, though she subsequently improved and was discharged 14 d after admission. Although the incidence of drug-induced AP is low, clinicians should have a high index of suspicion for it in patients with AP due to an unknown etiology. Clinicians should be aware of the association of statins with AP. If a patient taking a statin develops abdominal pain, clinicians should consider the diagnosis of AP and conduct the appropriate laboratory and diagnostic evaluation if indicated.

Viral opportunistic infections in HIV-infected adults.

Despite the development of highly active antiretroviral therapy (HAART), opportunistic infections continue to be seen in HIV-infected patients throughout the world. The primary reason for this is the lack of access to HAART for most people living with HIV/AIDS. For patients that have access to HAART, some may not have an effective response to therapy, due to reasons such as medication toxicity, poor adherence, or drug-resistant strains of HIV. Viral infections, in particular, are a major cause of opportunistic infections in HIV-infected adults, and can lead to significant morbidity and mortality. We have reviewed the epidemiology, clinical manifestations, diagnosis, and treatment of the most common viral opportunistic infections, including cytomegalovirus, JC virus, varicella-zoster virus, herpes simplex virus, and human papillomavirus.

Methemoglobinemia revisited: an important complication after transesophageal echocardiography.

Methemoglobinemia induced by the use of benzocaine-containing topical anesthetics is a rare, but potentially lethal complication after transesophageal echocardiography (TEE). We report a patient who developed methemoglobinemia after TEE. A review of the literature was performed and the majority of cases of benzocaine-induced methemoglobinemia reported thus far have occurred in patients undergoing TEE, endotracheal intubation, esophagogastroduodenoscopy, and bronchoscopy. All of these procedures have become more frequent than before, and there is a need to reemphasize the potential problem and to reconsider the need for further use of topical anesthetics.