Increased risk of stress urinary incontinence surgery after hysterectomy for benign indication-a population-based cohort study.

BACKGROUND: Hysterectomy is a common procedure used to treat different gynecologic conditions. The association between hysterectomy for benign indication and stress urinary incontinence has previously been established. Stress urinary incontinence can be treated surgically, and options have improved after introduction of the midurethral sling procedure in 1998. OBJECTIVE: This study aimed to estimate the risk of stress urinary incontinence surgery after hysterectomy for benign indication. STUDY DESIGN: The study was carried out as a matched register-based cohort study including Danish women born from 1947 to 2000. Women who underwent hysterectomy for benign indication were matched to nonhysterectomized women in a 1:5 ratio on the basis of age and calendar year of hysterectomy. The risk of stress urinary incontinence surgery after hysterectomy was estimated. We adjusted for income, educational level, and parity. The risk of stress urinary incontinence surgery was further estimated in a subcohort excluding all vaginal hysterectomies. The joint effect of hysterectomy and parity was estimated in the main cohort, and the joint effect of hysterectomy and vaginal birth or cesarean delivery on stress urinary incontinence surgery was explored in a subgroup of women who only had 1 mode of delivery. All analyses were made using the Cox proportional hazards model. RESULTS: We included 83,370 women who underwent hysterectomy and 413,969 reference women. The overall risk of stress urinary incontinence surgery was more than doubled for women who underwent hysterectomy (adjusted hazard ratio, 2.6; 95% confidence interval, 2.4-2.8). The adjusted hazard ratio decreased slightly to 2.4 (95% confidence interval, 2.3-2.6) when excluding all vaginal hysterectomies. We found a trend of increasing risk of stress urinary incontinence surgery with increased parity among both women who underwent hysterectomy and the reference group. In the subgroup of women who only had 1 mode of delivery, we found the risk of stress urinary incontinence surgery to be particularly increased for women with a history of ≥1 vaginal births. The hazard ratio was 15.1 (95% confidence interval, 10.3-22.1) for women with a history of 1 vaginal birth who underwent hysterectomy, whereas the hazard ratio for women in the reference group with 1 vaginal birth was 5.1 (95% confidence interval, 3.8-8.1). Overall, women who underwent hysterectomy had a 3 times higher risk of stress urinary incontinence surgery than the reference group, irrespective of the number of vaginal births. CONCLUSION: This study indicates, in accordance with previous studies, that hysterectomy increases the risk of subsequent stress urinary incontinence surgery. Women should be informed and gynecologists include this knowledge in decision-making. Further precautions should be taken when treating parous women, particularly those with a history of ≥1 vaginal births.

Cervical cancer after the Manchester procedure: a nationwide cohort study.

INTRODUCTION AND HYPOTHESIS: The Manchester procedure is a successful operation to treat uterine prolapse. However, the influence on cervical cancer remains unknown. We hypothesized a lower risk of cervical cancer after the Manchester procedure. METHODS: We included all Danish women undergoing the Manchester procedure during 1977-2018 (N = 23,935). Women undergoing anterior colporrhaphy (N = 51,008) were included as references due to comparable health-seeking behaviors. The study cohort is as previously described. We assessed the risk of cervical cancer mortality after the Manchester procedure versus anterior colporrhaphy using cumulated incidence plots and Cox hazard regressions. We applied Fisher's exact test to compare the distribution of histological subtypes after the operations. RESULTS: Generally, few women were diagnosed with cervical cancer (0.1% after Manchester procedure and 0.2% after anterior colporrhaphy). After the Manchester procedure, the risk of cervical cancer was reduced (HR 0.60 [95% CI 0.39-0.94]). Furthermore, we found a slightly reduced risk of overall death (HR 0.96 [95% 0.94-0.99]), but no association regarding death due to cervical cancer (HR 0.66 [95% 0.34-1.25]). The distribution of histological subtypes was not changed. CONCLUSIONS: Women undergoing the Manchester procedure are at lower risk of being diagnosed with cervical cancer, while the risk of cancer specific mortality is unchanged compared to women undergoing anterior colporrhaphy. Based on this study, we cannot recommend that women exit ordinary screening programs for human papillomavirus/cervical dysplasia after a Manchester procedure.

Bacteremia With Anaerobic Bacteria and Association With Colorectal Cancer: A Population-based Cohort Study.

BACKGROUND: There is a well-described association between bacteremia with bovis group streptococci or Clostridium septicum and an increased probability of a colorectal cancer (CRC) diagnosis. We wanted to investigate the existence of a similar association between CRC and bacteremia with other bacteria belonging to the gut microbiota.. METHODS: A population based cohort study in a population about 2 million people including 45 774 bacteremia episodes and 231 387 blood culture negative cases was performed in the Region of Southern Denmark and Region Zealand from 2007-2016. Episodes of bacteremia were combined with the Danish central register for CRC. We performed Cox's regression analysis with hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS: The study results confirmed previous findings of an increased risk of a CRC diagnosis after bacteremia with the bovis group streptococci (risk within a year: 4.3%; HR [95% CI]: 8.46 [3.51-20.4]) or C. septicum (20.8%; 76.2 [42.0-138]). Furthermore, Bacteroides ovatus (6.7%; 20.3 [5.04-81.8]), Bacteroides uniformis (5.4%; 16.2 [4.02-65.7]), Clostridium tertium (3.6 %; 13.9 [1.96-99.4]), Fusobacterium spp. (excluding F. necrophorum) (3.0 %; 8.51 [2.73-26.5]), and Gram-positive anaerobic cocci (3.6 %; 10.9 [4.50-26.3]) were also associated with an increased risk of a CRC diagnosis compared to patients with negative blood cultures (0.4%). CONCLUSIONS: Bacteremia with specific gut microbiota anaerobic bacteria is associated with a high risk of a diagnosis of CRC, indicating the need for colorectal workup. Importantly, this strategy also holds the possible additional benefit of detecting adenomas or other premalignant conditions, which were not included in the present study.

Pelvic organ prolapse following hysterectomy on benign indication: a nationwide, nulliparous cohort study.

BACKGROUND: Hysterectomy is commonly performed and may increase the risk of pelvic organ prolapse. Previous studies in parous women have shown an increased risk of pelvic organ prolapse surgery after hysterectomy. Parity is a strong risk factor for pelvic organ prolapse and may confuse the true relation between hysterectomy and pelvic organ prolapse. OBJECTIVE: This study aimed to investigate whether hysterectomy performed for benign conditions other than pelvic organ prolapse leads to an increased risk of pelvic organ prolapse surgery in a cohort of nulliparous women. STUDY DESIGN: We conducted a historical matched cohort study based on a nationwide population of nulliparous women born in 1947 to 2000 and living in Denmark during 1977 to 2018 (N=549,197). The data were obtained from the Danish Civil Registration System, the Danish National Patient Registry, the Fertility Register, and Statistics Denmark. Women who had a hysterectomy performed in 1977 to 2018 were included in the study (n=9535). For each of these women we randomly retrieved five nonhysterectomized women matched on age and calendar year to constitute the reference group (n=47,370). Cox proportional hazard regression analyses were performed to compare the risk of pelvic organ prolapse surgery in the 2 groups of women. RESULTS: The study included 56,905 women whom we observed for up to 42 years, entailing 809,435 person-years in risk. Overall, 9535 women who underwent a hysterectomy were matched individually with 47,370 reference women. Subsequently, a total of 29 women (30.4%) who underwent a hysterectomy and 85 reference women (17.9%) had a pelvic organ prolapse surgery performed, corresponding to incidence rates of 20.5 and 12.7 per 100,000 risk years, respectively. In addition, the risk of pelvic organ prolapse surgery increased by 60% in women who underwent a hysterectomy compared with women in the reference group (crude hazard ratio, 1.6; 95% confidence interval, 1.0-2.5; P=.04; adjusted hazard ratio, 1.6; 95% confidence interval, 1.0-2.5; P=.04). After the exclusion of women who underwent vaginal hysterectomy and their matches, the results were significantly the same (crude hazard ratio, 1.5; 95% confidence interval, 1.0-2.4; P=.05). Furthermore, we found higher rates of pelvic organ prolapse surgery in women who had a subtotal hysterectomy, total hysterectomy, or vaginal and laparoscopic-assisted vaginal hysterectomies than in women in the reference group. CONCLUSION: Hysterectomy increased the risk of pelvic organ prolapse surgery for nulliparous women by 60%. Previous studies of multiparous women have similarly shown an increased risk of prolapse after hysterectomy. As the most common risk factor for pelvic organ prolapse-vaginal birth-was not included and women were >72 years of age in this study, the numbers of pelvic organ prolapse surgeries were low. Despite the low absolute risk of pelvic organ prolapse surgery in nulliparous women, they were important in investigating the association between hysterectomy and pelvic organ prolapse, excluding vaginal birth, which is the most common risk factor for pelvic organ prolapse. As this cohort study of nulliparous women found an increased risk of pelvic organ prolapse surgery after hysterectomy, it is implied that the uterus per se protects against pelvic organ prolapse. As such, gynecologists should be aware of the risks associated with hysterectomy, and alternative uterus-sparing treatments should be considered when possible. Furthermore, women should be informed about the risks before being offered a hysterectomy.

Endometrial cancer after the Manchester procedure: a nationwide cohort study.

INTRODUCTION AND HYPOTHESIS: We aimed to investigate whether the Manchester procedure affects the risk and prognosis of endometrial cancer. METHODS: All Danish residents have a personal number permitting linkage of nationwide registers on the individual level enabling epidemiological studies with lifelong follow-up. We performed a nationwide historical cohort study including Danish women born before 2000 undergoing the Manchester procedure (N = 23,935) during 1977-2018. We included women undergoing anterior colporrhaphy as a reference group (N = 51,008) because of comparable inclination to consult a doctor and clinical similarities. Main outcomes were the number of women diagnosed with endometrial cancer, the stage of endometrial cancer at time of diagnosis, and cancer-specific and overall mortality. We followed the cohort until endometrial cancer/death/emigration/hysterectomy/31 December 2018. We performed chi-square test for trend to compare the diagnostic stage and Cox regressions to analyze the risk of endometrial cancer and mortality. The models were adjusted for age, calendar year, income level, and parity. RESULTS: During follow-up (median 13 years), 271 (1.13%) women were diagnosed with endometrial cancer after the Manchester procedure and 520 (1.05%) after anterior colporrhaphy. The adjusted hazard ratio (HR) for endometrial cancer was 1.00 [95% confidence interval (CI) 0.86-1.16]. No difference in stage of cancer was found (p = 0.18) nor when stratifying for calendar year. The HR for cancer-specific mortality and overall mortality after the Manchester procedure was 0.87 (95% CI 0.65-1.16) and 0.93 (95% CI 0.77-1.12), respectively. CONCLUSIONS: The Manchester procedure does not affect the risk or prognosis of endometrial cancer.

Impact of appropriate empirical antibiotic treatment on recurrence and mortality in patients with bacteraemia: a population-based cohort study.

BACKGROUND: Data on the impact of empirical antibiotic treatment (EAT) on patient outcome in a population-based setting are sparse. We assessed the association between EAT and the risk of recurrence within one year, short-term- (2-30 days) and long-term (31-365 days) mortality in a Danish cohort of bacteraemia patients. METHODS: A cohort study including all patients hospitalized with incident bacteraemia during 2007-2008 in the Copenhagen City and County areas and the North Denmark Region. EAT was defined as the antibiotic treatment given at the 1st notification of a positive blood culture. The definition of recurrence took account of pathogen species, site of infection, and time frame and was not restricted to homologous pathogens. The vital status was determined through the civil registration system. Association estimates between EAT and the outcomes were estimated by Cox and logistic regression models. RESULTS: In 6483 eligible patients, 712 (11%) had a recurrent episode. A total of 3778 (58%) patients received appropriate EAT, 1290 (20%) received inappropriate EAT, while EAT status was unrecorded for 1415 (22%) patients. The 2-30 day mortality was 15.1%, 17.4% and 19.2% in patients receiving appropriate EAT, inappropriate EAT, and unknown EAT, respectively. Among patients alive on day 30, the 31-365 day mortality was 22.3% in patients given appropriate EAT compared to 30.7% in those given inappropriate EAT. Inappropriate EAT was independently associated with recurrence (HR 1.25; 95% CI = 1.03-1.52) and long-term mortality (OR 1.35; 95% CI = 1.10-1.60), but not with short-term mortality (OR 0.85; 95% CI = 0.70-1.02) after bacteraemia. CONCLUSIONS: Our data indicate that appropriate EAT is associated with reduced incidence of recurrence and lower long-term mortality following bacteraemia.

Colorectal cancer and association with anaerobic bacteraemia: a Danish nationwide population-based cohort study.

OBJECTIVES: We aimed to identify specific anaerobic bacteria causing bacteraemia and a subsequent diagnosis of colorectal cancer. METHODS: A nationwide population-based cohort study, which included all episodes of defined specific anaerobic bacteraemia from 2010 (5,534,738 inhabitants) through 2020 (5,822,763 inhabitants) and all cases of colorectal cancer diagnosed from 2010 through 2021 in Denmark. We calculated the incidence and risk of colorectal cancer after bacteraemia with specific anaerobic bacteria using Escherichia coli bacteraemia as reference. RESULTS: Nationwide data on colorectal cancer and specific anaerobic bacteraemia (100% complete, representing 11,124 episodes). The frequencies of colorectal cancer within one year following anaerobic bacteraemia were higher for species, which almost exclusively reside in the colon, such as Phocaeicola vulgatus/dorei (5.5%), Clostridium septicum (24.2%), and Ruminococcus gnavus (4.6%) compared to 0.6% in 50,650 E. coli bacteraemia episodes. Bacteroides spp. had a subhazard ratio for colorectal cancer of 3.9 (95% confidence interval [CI], 3.0 to 5.1) and for Clostridium spp. it was 8.9 (95% CI, 6.7 to 11.8, with C. septicum 50.0 [95% CI, 36.0 to 69.5]) compared to E. coli (reference). CONCLUSION: This nationwide study identified specific colorectal cancer-associated anaerobic bacteria, which almost exclusively reside in the colon. Bacteraemia with these bacteria could be an indicator of colorectal cancer.

Stress Urinary Incontinence After Operations for Uterine Prolapse: A Nationwide Cohort Study.

IMPORTANCE: Concomitant surgery for stress urinary incontinence (SUI) during pelvic organ prolapse (POP) operations are debated. OBJECTIVES: We aimed to assess the risk of an SUI operation after a uterine prolapse operation and compare the risk after the Manchester procedure versus vaginal hysterectomy. STUDY DESIGN: We performed a nationwide historical cohort study including women with no history of hysterectomy undergoing the Manchester procedure (n = 6065) or vaginal hysterectomy (n = 9,767) for POP during 1998 to 2018. We excluded women with previous surgery for SUI and POP, concomitant surgery for SUI (n = 34, 0.2%), and diagnosed with gynecological cancer before or within 90 days from surgery. Women were followed up until SUI operation/death/emigration/diagnosis of gynecological cancer/December 31, 2018, whichever came first. Women undergoing the Manchester procedure were censored if they had undergone hysterectomy.We assessed the rate of SUI surgery with cumulative incidence plots. We performed Cox Regression to analyze the risk of SUI surgery, adjusting for age, calendar year, income level, concomitant surgery in anterior and posterior compartments, and diagnosis of SUI before POP operation. RESULTS: We found that 12.4% women with and 1.6% without SUI diagnosed before the POP surgery who underwent SUI surgery within 10 years.During follow-up (median, 8.5 years), 129 (2.1%) underwent SUI surgery after the Manchester procedure and 175 (1.8%) after vaginal hysterectomy (adjusted hazard ratio, 1.06 [0.84-1.35]). CONCLUSIONS: Of women diagnosed with SUI before POP operation 1 in 8 subsequently underwent SUI surgery. Few women not diagnosed with SUI subsequently underwent SUI surgery. There was no difference in risk of SUI after the Manchester procedure and vaginal hysterectomy.

Classification of positive blood cultures: computer algorithms versus physicians' assessment--development of tools for surveillance of bloodstream infection prognosis using population-based laboratory databases.

BACKGROUND: Information from blood cultures is utilized for infection control, public health surveillance, and clinical outcome research. This information can be enriched by physicians' assessments of positive blood cultures, which are, however, often available from selected patient groups or pathogens only. The aim of this work was to determine whether patients with positive blood cultures can be classified effectively for outcome research in epidemiological studies by the use of administrative data and computer algorithms, taking physicians' assessments as reference. METHODS: Physicians' assessments of positive blood cultures were routinely recorded at two Danish hospitals from 2006 through 2008. The physicians' assessments classified positive blood cultures as: a) contamination or bloodstream infection; b) bloodstream infection as mono- or polymicrobial; c) bloodstream infection as community- or hospital-onset; d) community-onset bloodstream infection as healthcare-associated or not. We applied the computer algorithms to data from laboratory databases and the Danish National Patient Registry to classify the same groups and compared these with the physicians' assessments as reference episodes. For each classification, we tabulated episodes derived by the physicians' assessment and the computer algorithm and compared 30-day mortality between concordant and discrepant groups with adjustment for age, gender, and comorbidity. RESULTS: Physicians derived 9,482 reference episodes from 21,705 positive blood cultures. The agreement between computer algorithms and physicians' assessments was high for contamination vs. bloodstream infection (8,966/9,482 reference episodes [96.6%], Kappa = 0.83) and mono- vs. polymicrobial bloodstream infection (6,932/7,288 reference episodes [95.2%], Kappa = 0.76), but lower for community- vs. hospital-onset bloodstream infection (6,056/7,288 reference episodes [83.1%], Kappa = 0.57) and healthcare-association (3,032/4,740 reference episodes [64.0%], Kappa = 0.15). The 30-day mortality in the discrepant groups differed from the concordant groups as regards community- vs. hospital-onset, whereas there were no material differences within the other comparison groups. CONCLUSIONS: Using data from health administrative registries, we found high agreement between the computer algorithms and the physicians' assessments as regards contamination vs. bloodstream infection and monomicrobial vs. polymicrobial bloodstream infection, whereas there was only moderate agreement between the computer algorithms and the physicians' assessments concerning the place of onset. These results provide new information on the utility of computer algorithms derived from health administrative registries.

C-reactive protein level as a predictor of mortality in liver disease patients with bacteremia.

BACKGROUND AND OBJECTIVE: C-reactive protein (CRP) is synthesized in the liver in response to inflammation, and CRP is a widely used marker of sepsis. In bacteremia the initial CRP level is an independent predictor of mortality. Since the CRP response in patients with chronic liver disease is lower than in patients without liver disease the objective was to assess whether CRP levels in chronic liver disease and bacteremia was associated with case fatality. PATIENTS: The study enrolled 105 patients with chronic liver disease and bacteremia as well as 202 patients with bacteremia and no recorded liver disease from the same region and time period. METHODS: Retrospective review of medical records with registration of demography, co-morbidity, bacteriological, biochemical and clinical findings, and Child-Turcotte-Pugh scores. The primary outcome was 30-day mortality. RESULTS: Mortality was significantly higher in patients with chronic liver disease (mortality rate ratio 2.2; 95% confidence interval 1.2-3.9) and it was correlated to Child-Turcotte-Pugh scores. CRP levels were not different between the three Child-Turcotte-Pugh classes (p = 0.33), and no linear correlation with 30-day mortality was observed. CONCLUSION: Mortality associated with bacteremia is increased in patients with chronic liver disease and it is correlated with Child-Turcotte-Pugh score. The prognostic information of initial CRP levels in patients with chronic liver disease is weak. The clinical management of patients with chronic liver disease and suspected infection should initiate antimicrobial therapy based on clinical, radiological and microbiological findings, whereas the measurement of CRP in bacteremia is less helpful as compared with patients without liver disease.

Non-typhoidal Salmonella and Campylobacter infections among HIV-positive patients in Denmark.

Non-typhoidal Salmonella (NTS) and Campylobacter are common causes of diarrhoea in human immunodeficiency virus (HIV)-positive patients. To investigate if incidence has changed since the introduction of highly active antiretroviral therapy (HAART), we combined data from The Danish Surveillance Registry for Enteric Pathogens and The Danish National Hospital Registry. We found that the incidences of NTS- and Campylobacter-related illness among HIV-positive patients in Denmark have declined since the introduction of HAART, although the incidences remained higher compared to the background population. Moreover our study suggests that there is an increased incidence of Campylobacter-related illness among homosexual men in the HIV-positive population.

Epidemiology, diagnostic delay and outcome of tuberculosis in North Jutland, Denmark.

INTRODUCTION: The objective of this study was to evaluate the clinical outcome of tuberculosis (TB) with regards to epidemiology, symptoms, delay, diagnostics, use of HIV-test, treatment, treatment outcome and mortality in the North Jutland Region from 2000 through 2008. MATERIAL AND METHODS: The present study is a retrospective study of all new TB cases in the 2000-2008 period. RESULTS: The period saw a total of 251 TB patients (an average of 28 per year). Almost 60% of the patients were not Danish-born, being mostly from Somalia and Greenland. The mean age was 43 years. 31% were alcohol abusers. 2% had AIDS. Cough was the most frequent symptom followed by weight loss, fever and fatigue. In 78.5% of the cases, it was possible to retrieve a positive culture, 53% had a positive sputum smear. However, in 8% of all patients, it was not possible to isolate Mycobacterium tuberculosis and these cases were diagnosed in accordance with the clinical signs. Almost all patients received the standard treatment comprising four antibiotics. 83% were treated successfully, while 5% ended their treatment prematurely. At the end of the study, 14% were dead. In all, 55% of all patients were HIV-tested. Two tested positive before their TB diagnosis and three after. CONCLUSION: The incidence of TB did not seem to decrease over the course of the study period as seen in the rest of Europe. The relatively high rate of alcohol abusers as compared with earlier Danish literature seems to be due to previous underreporting. A treatment success of 83% is high. This first study of HIV testing in Danish TB patients revealed that it was an acceptable result compared with other studies in this field, but the result was not satisfactory because we may miss patients with HIV/TB co-infection when only half of the patients are tested.

Increased short- and long-term risk of inflammatory bowel disease after salmonella or campylobacter gastroenteritis.

BACKGROUND & AIMS: Various commensal enteric and potentially pathogenic bacteria may be involved in the pathogenesis of inflammatory bowel diseases (IBD). We compared the risk of IBD between a cohort of patients with documented Salmonella or Campylobacter gastroenteritis and an age- and gender-matched control group from the same population in Denmark. METHODS: We identified 13,324 patients with Salmonella/Campylobacter gastroenteritis from laboratory registries in North Jutland and Aarhus counties, Denmark, from 1991 through 2003, and 26,648 unexposed controls from the same counties. Of these, 176 exposed patients with IBD before the infection, their 352 unexposed controls, and 80 unexposed individuals with IBD before the Salmonella/Campylobacter infection were excluded. The final study cohort of 13,148 exposed and 26,216 unexposed individuals were followed for up to 15 years (mean, 7.5 years). RESULTS: A first-time diagnosis of IBD was reported in 107 exposed (1.2%) and 73 unexposed individuals (0.5%). By age, gender, and comorbidity adjusted Cox proportional hazards regression analysis, the hazard ratio (95% confidence interval) for IBD was 2.9 (2.2-3.9) for the whole period and 1.9 (1.4-2.6) if the first year after the Salmonella/Campylobacter infection was excluded. The increased risk in exposed subjects was observed throughout the 15-year observation period. The increased risk was similar for Salmonella (n = 6463) and Campylobacter (n = 6685) and for a first-time diagnosis of Crohn's disease (n = 47) and ulcerative colitis (n = 133). CONCLUSIONS: In our population-based cohort study with complete follow-up, an increased risk of IBD was demonstrated in individuals notified in laboratory registries with an episode of Salmonella/Campylobacter gastroenteritis.

Increased risk of zoonotic Salmonella and Campylobacter gastroenteritis in patients with haematological malignancies: a population-based study.

We hypothesised that haematological malignancies increase the risk of acquiring zoonotic Salmonella or Campylobacter gastroenteritis. The population-based study comprised all first-time Salmonella/Campylobacter gastroenteritis cases in two Danish counties (1991-2003), with age- and gender-matched controls from the background population. We linked the study cohort to registries to obtain data on malignancies, chemotherapy (yes/no), and main comorbidities diagnosed before Salmonella/Campylobacter gastroenteritis. Based on this design, we determined incidence rate ratios (IRR) in conditional logistic regression analyses, and we used weighted mean regression curves to evaluate fluctuations in risk 0-5 years after the malignancy diagnosis. Sixty-eight of 13,324 cases (0.5%) and 29 of 26,648 controls (0.1%) had haematological malignancy before their Salmonella/Campylobacter gastroenteritis. Comorbidity-adjusted IRR for Salmonella/Campylobacter gastroenteritis in patients with haematological malignancy as compared to patients without malignancy were 4.46 [95% confidence intervals (CI), 2.88-6.90] for all individuals, 8.33 (95% CI, 4.31-16.1) for Salmonella, and 2.17 (95% CI, 1.15-4.08) for Campylobacter. Stratification on chemotherapy treatment did not change these estimates. In time-related analyses, IRR were 7-8 in the first 2 years after the haematological malignancy diagnosis and 4-5 in the following 3 years. Patients with haematological malignancy had increased long-term risk of enquiring Salmonella or Campylobacter gastroenteritis.

Are host characteristics or exposure factors mainly involved in the acquisition of zoonotic Salmonella and Campylobacter coinfection in humans?

We hypothesized that patients coinfected with zoonotic Salmonella and Campylobacter were frailer than monoinfected Salmonella or Campylobacter patients. The study cohort included all first-time Salmonella/Campylobacter infections in Aarhus and North Jutland counties, Denmark, from 1991 through 2003. Data on comorbidity, hospitalization in relation to the Salmonella/Campylobacter infection, and 1-year mortality were obtained from electronic registries. Among 13,449 individuals, 114 (0.85%) had Salmonella/Campylobacter coinfection, 6567 (48.8%) had Salmonella monoinfection, and 6768 (50.3%) had Campylobacter monoinfection. There were no major differences in age, gender, comorbidity, hospitalization rates, 1-year mortality, or seasonal variation between coinfected patients on the one hand and each of the monoinfected patient groups on the other. The main difference was encountered between the Salmonella serotype distribution as 49.1% of coinfected patients versus 20.3% of monoinfected Salmonella patients had Salmonella serotypes other than Salmonella Enteritidis and Salmonella Typhimurium (odds ratio [95% confidence interval]: 4.07 [2.73-6.06]). In conclusion, Salmonella/Campylobacter coinfected patients were not frailer than monoinfected patients. The difference in Salmonella serotype distribution was compatible with a higher proportion of coinfections acquired during foreign travel.

Magnitude of bacteraemia is associated with increased mortality in non-typhoid salmonellosis: a one-year follow-up study.

We examined whether the number of positive bottles in a routinely used three-bottle blood culture (BC) set predicted one-year mortality in adult patients with non-typhoid Salmonella (NTS). Data from 1994 through 2003 in North Jutland County, Denmark, were retrieved from health databases and medical records. We used the number of positive BC bottles as an index of magnitude of NTS bacteraemia: Index 0 (reference) patients had a negative BC coincident with an NTS-positive faecal culture and index 1, 2, or 3 patients had increasing levels of NTS bacteraemia. For all patients and for patients with gastroenteritis we computed Kaplan-Meier curves to summarize survival over time and Cox regression analysis to estimate mortality in crude analyses and in analyses adjusted for comorbidity and age. There were 115, 43, 21, and 41 patients with index 0, 1, 2, and 3, respectively. One-year cumulative mortality was 4.4%, 14.0%, 28.6%, and 41.5% for indices 0 to 3. Adjusted one-year mortality rate ratios (with 95% confidence intervals) were 1.7 (0.5-5.8), 5.2 (1.5-17.4), and 5.3 (1.9-14.9) for index 1, 2, and 3 patients, respectively. These estimates remained robust for patients with gastroenteritis. We conclude that higher magnitude of bacteraemia predicted one-year mortality in NTS patients.

A questionnaire-based, retrospective field study of persistence of Salmonella Enteritidis and Salmonella Typhimurium in Danish broiler houses.

A questionnaire-based, retrospective field study was conducted in 78 Danish broiler houses (analytical units) on 42 farms. In spring 1997, all these broiler houses had been infected with Salmonella Enteritidis, phage type 8, and/or Salmonella Typhimurium, definitive-type 66, by day-old chicks delivered from the same hatchery. Because these two salmonella types had not been detected in the Danish broiler sector before and the broiler houses were infected in a period of low salmonella prevalence, the study could focus on farm-related factors, without being distorted by other salmonella infections. The same person visited all 78 broiler houses, and farm-related factors were listed both from personal observations and by interrogating the person in charge of attending to the broilers. Additional factors (noted at the visits) were recorded in a later telephone interview. Altogether, 187 variables were analyzed.Broiler houses were divided into single-infection houses (which had one or both of the salmonella types in only one crop), and multiple-infection houses (where infection occurred in multiple crops). This was done both generally and separately for each of the salmonella types. Factors associated with house status-but that were beyond the control of the farmer-were the salmonella type and the percentage of salmonella positive samples in the first crop. Factors which could be controlled by the farmer and which were associated with reduced prevalence of multiple-infection houses included antiseptic soap and water for washing hands in the anteroom, hygiene barriers when removing dead broilers, gravel alongside the broiler house, systematic checks of indoor rodent-bait depots, and combined surface and pulse-fogging disinfection.

Does C-reactive protein independently predict mortality in adult community-acquired bacteremia patients with known sepsis severity?

We evaluated whether sepsis severity and C-reactive protein (CRP) level on admission prognostically corroborated or annulled each other in adult patients with incident community-acquired bacteremia (Funen, Denmark, 2000-2008). We used logistic regression and area under the receiver operating characteristic curve (AUC) to evaluate 30-day mortality in four models: (i) age, gender, comorbidity, bacteria, and ward. (ii) Model 1 and sepsis severity. (iii) Model 1 and CRP. (iv) Model 1, sepsis severity, and CRP. Altogether, 416 of 1999 patients died within 30 days. CRP independently predicted 30-day mortality [Model 4, odds ratio (95% CIs) for 100 mg/L: 1.16 (1.06-1.27)], but it did not contribute to the AUC (Model 2 vs Model 4: p = 0.31). In the 963 non-severe sepsis patients, CRP independently predicted 30-day mortality [Model 4: 1.42 (1.20-1.69)] and it increased the AUC (Model 2 vs Model 4: p = 0.06), thus CRP contributed as much as sepsis severity to prognosis.

Epidemiology of Haemophilus influenzae bacteremia: a multi-national population-based assessment.

OBJECTIVES: Haemophilus influenzae is an important cause of invasive infection but contemporary data in non-selected populations is limited. METHODS: Population-based surveillance for Haemophilus influenzae bacteremia was conducted in seven regions in Australia, Canada, and Denmark during 2000-2008. RESULTS: The overall annual incidence rate was 1.31 per 100,000 population and type specific rates were 0.08 for H. influenzae serotype b (Hib), 0.22 for H. influenzae serotypes a, c-f (Hiac-f), and 0.98 per 100,000 for non-typeable H. influenzae (NTHi). Very young and old patients were at highest risk. The serotypes causing disease varied according to age with nearly all cases in the elderly due to NTHi. The presence of comorbid medical illness was common with 14%, 16%, and 29% patients having Charlson comorbidity scores of 1, 2, and ≥ 3, respectively. The 30-day all-cause case-fatality rate was 18%. Factors independently associated with death at 30-days in logistic regression analysis included male gender, hospital-onset disease, older age, and lower respiratory tract, central nervous system, or unknown focus of infection. CONCLUSIONS: Haemophilus influenzae is an important cause of morbidity and mortality particularly with NTHi in the elderly. These data serve as a baseline to assess the future effectiveness of new preventative interventions.