Lack of adherence to SHEA-IDSA treatment guidelines for Clostridium difficile infection is associated with increased mortality.

OBJECTIVES: The objective of this study was to determine our institution's compliance with 2010 Society for Healthcare Epidemiology of America and IDSA Clostridium difficile infection (CDI) treatment guidelines and their respective outcomes. METHODS: We collected clinical parameters, laboratory values, antibiotic therapy and clinical outcomes from the electronic medical records for all patients hospitalized at our institution with a diagnosis of CDI from December 2012 to November 2013. We specifically evaluated whether SHEA-IDSA treatment guidelines were followed and evaluated the associations between guideline adherence and severe outcomes including mortality. RESULTS: We identified 230 patients with CDI meeting inclusion criteria during the study period. Of these, 124 (54%) were appropriately treated, 46 (20%) were under-treated and 60 (26%) were over-treated. All-cause 90 day mortality was 17.4% overall; 43.5% in the under-treated group versus 12.9% in those appropriately treated (P < 0.0001) and 10.9% in those appropriately treated plus over-treated (P < 0.0001). Similarly, 90 day mortality attributed to CDI was 21.7% in those under-treated versus 8.9% in those appropriately treated (P = 0.03) and 8.2% in those either appropriately treated or over-treated (P = 0.015). Severe-complicated CDI occurred in 46 patients. In this subgroup, there was a non-significant trend towards increased mortality in under-treated patients (56.7%) compared with appropriately treated patients (37.5%, P = 0.35). Under-treatment was also associated with a higher rate of CDI-related ICU transfer (17.4% versus 4.8% in those appropriately treated, P = 0.023). CONCLUSIONS: Adherence to CDI treatment guidelines is associated with improved outcomes especially in those with severe disease. Increased emphasis on provision of appropriate, guideline-based CDI treatment appears warranted.

Emerging pathogen in immunocompromised hosts: Exophiala dermatitidis mycosis in graft-versus-host disease.

Infection with the dematiaceous environmental fungus Exophiala, an emerging pathogen in immunocompromised individuals, poses a diagnostic and therapeutic challenge. Herein, we report the first Exophiala dermatitidis fungemia case, to our knowledge, in an allogeneic hematopoietic stem cell transplant patient with graft-versus-host disease, expanding the clinical setting where Exophiala species mycosis should be suspected.

Epidemiology, outcomes, and mortality predictors of invasive mold infections among transplant recipients: a 10-year, single-center experience.

BACKGROUND: The epidemiology of invasive mold infections (IMI) in transplant recipients differs based on geography, hosts, preventative strategies, and methods of diagnosis. METHODS: We conducted a retrospective observational study to evaluate the epidemiology of proven and probable IMI, using prior definitions, among all adult hematopoietic stem cell transplant (HSCT) and solid organ transplant (SOT) recipients in the era of "classic" culture-based diagnostics (2000-2009). Epidemiology was evaluated before and after an initiative was begun to increase bronchoscopy in HSCT recipients after 2005. RESULTS: In total, 106 patients with one IMI were identified. Invasive aspergillosis (IA) was the most common IMI (69; 65.1%), followed by mucormycosis (9; 8.5%). The overall rate of IMI (and IA) was 3.5% (2.5%) in allogeneic HSCT recipients. The overall incidence for IMI among lung, kidney, liver, and heart transplant recipients was 49, 2, 11, and 10 per 1000 person-years, respectively. The observed rate of IMI among human leukocyte antigen-matched unrelated and haploidentical HSCT recipients increased from 0.6% annually to 3.0% after bronchoscopy initiation (P < 0.05). The 12-week mortality among allogeneic HSCT, liver, kidney, heart, and lung recipients with IMI was 52.4%, 47.1%, 27.8%, 16.7%, and 9.5%, respectively. Among allogeneic HSCT (odds ratio [OR]: 0.07, P = 0.007) and SOT (OR: 0.22, P = 0.05) recipients with IA, normal platelet count was associated with improved survival. Male gender (OR: 14.4, P = 0.007) and elevated bilirubin (OR: 5.7, P = 0.04) were significant predictors of mortality for allogeneic HSCT and SOT recipients with IA, respectively. CONCLUSIONS: During the era of culture-based diagnostics, observed rates of IMI were low among all transplants except lung transplant recipients, with relatively higher mortality rates. Diagnostic aggressiveness and host variables impact the reported incidence and outcome of IMI and likely account for institutional variability in multicenter studies. Definitions to standardize diagnoses among SOT recipients are needed.

Epidemiology, risk factors, and outcomes of Clostridium difficile infection in kidney transplant recipients.

BACKGROUND: We sought to describe the epidemiology and risk factors for Clostridium difficile infection (CDI) among kidney transplant recipients (KTR) between 1 January 2008 and 31 December 2010. METHODS: A single-institution retrospective study was conducted among all adult KTR with CDI, defined as a positive test for C. difficile by a cell cytotoxic assay for C. difficile toxin A or B or polymerase chain reaction test for toxigenic C. difficile. RESULTS: Among 603 kidney transplants performed between 1 January 2008 and 31 December 2010, 37 (6.1%) patients developed CDI: 12 (of 128; 9.4%) high-risk (blood group incompatible and/or anti-human leukocyte antigen donor-specific antibodies) vs. 25 (of 475; 5.3%, P = 0.08) standard-risk patients. The overall rate of CDI increased from 3.7% in 2008 to 9.4% in 2010 (P = 0.05). The median time to CDI diagnosis was 9 days, with 27 (73.0%) patients developing CDI within the first 30 days after their transplant, and 14 (51.8%) developing CDI within 7 days. A case-control analysis of 37 CDI cases and 74 matched controls demonstrated the following predictors for CDI among KTR: vancomycin-resistant Enterococcus colonization before transplant (odds ratio [OR]: 3.6, P = 0.03), receipt of an organ from Centers for Disease Control high-risk donor (OR: 5.9, P = 0.006), and administration of high-risk antibiotics within 30 days post transplant (OR: 6.6, P = 0.001). CONCLUSIONS: CDI remains a common early complication in KTR, with rates steadily increasing during the study period. Host and transplant-related factors and exposure to antibiotics appeared to significantly impact the risk for CDI among KTR.

Rapidly progressive cutaneous Rhizopus microsporus infection presenting as Fournier's gangrene in a patient with acute myelogenous leukemia.

Members of the genus Rhizopus within the class Zygomycetes can cause devastating opportunistic infections. Cutaneous disease arising from direct inoculation of fungal spores has the potential to disseminate widely. Here, we describe a dramatic case of cutaneous Rhizopus infection involving the penis in a patient with acute myelogenous leukemia. Despite aggressive surgical debridement, systemic antifungal therapy, and donor lymphocyte infusion, the infection was ultimately fatal. This case illustrates the unique diagnostic and therapeutic challenges in the clinical management of cutaneous Rhizopus infection.

Mutagenicity of airborne particulate organic material from urban and industrial areas of São Paulo, Brazil.

The mutagenicity of airborne particulate matter at three different sites within the São Paulo urban area and the Cubatão industrial area, São Paulo State, Brazil, was evaluated using the Salmonella mutagenicity assay over a year's period (June 1990-May 1991). Total suspended particles (TSP) were collected using a Hi-vol sampler and extracted with methylene chloride by ultrasonication. Pooled seasonal extracts were tested using S. typhimurium TA98 and TA100 with and without metabolic activation (S9) and TA98NR and TA98/1,8-DNP6 without metabolic activation. Organic extracts of the samples with the highest monthly TSP concentration were also assayed for mutagenicity. All samples collected at São Paulo and Cubatão showed mutagenicity with strain TA98, and in general the addition of S9 did not modify the mutagenic response, suggesting the prevalence of direct-acting frameshift mutagens in the atmosphere of these sites. The mutagenicity detected in the urban areas of São Paulo (mainly downtown) was much higher than in the Cubatão industrial area and similar to the more urbanized cities in the world, where vehicle emissions are the major pollution source. Results obtained with the strains TA98NR and TA98/1,8-DNP6 suggested the presence of mononitro- and dinitroarenes contributed to the mutagenicity of these atmospheric samples. A seasonal variation was observed with higher levels of frameshift mutagens during Spring in São Paulo and Summer in Cubatão. During the Winter, more significant responses were found with strain TA100 in the presence of S9 at all sites. Monthly samples presented high levels of mutagenicity during the period of June to November. Results from this research provide support for Air Pollution Control Programs in the detection of the more potent organic mutagenic compounds in the atmosphere and may help in the establishment of priorities for control and regulatory actions.

Determination of trace elements in aerosol samples by instrumental neutron activation analysis.

Two nuclear techniques, Energy-Dispersive X-Ray Fluorescence Analysis (EDXRF) and Instrumental Neutron Activation Analysis (INAA), were used to analyze aerosol samples collected in the city of São Paulo, Brazil. Na, Cl, Mn, V, Al, Sm, Mo, W, La, As, Br, Sb, K, Ba, Se, Th, Cr, Rb, Ca, Fe, Ce, and Sc were determined by INAA, and Al, Si, P, S, Cl, K, Ca, Ti, V, Cr, Mn, Fe, Ni, Cu, Zn, Ga, As, Se, Br, Rb, Sr, Hg, and Pb were determined by EDXRF. A preliminary identification of the main source of the atmospheric aerosol was performed based on enrichment factor and correlation coefficient calculations.

São Paulo aerosol characterization study.

The São Paulo Metropolitan area (SPMA) is characterized as having one of the worst air pollution problems in Brazil, with frequent violations of air quality standards for particulate matter. This paper presents the results of a receptor model source apportionment study carried out to develop a quantitative database on which a control strategy could be developed. The study was conducted in four sites with distinct land uses. Fine, coarse (CP), and total suspended particles (TSP) samples were collected on Teflon and glass filters and analyzed by x-ray fluorescence (XRF), ion chromatography, and thermal evolution. The sources were characterized by similar methodology. Chemical mass balance (CMB) receptor modeling indicated that carbonaceous material plays an important role in the aerosol composition; that the three major source categories contributing to the fine particles are vehicles, secondary carbon, and sulfates; and that the main contributors to CP and TSP are road dust and vehicles. All sampling sites presented the same general pattern in terms of source contribution, although this contribution varied from site to site.