Decontamination of the digestive tract and oropharynx in ICU patients.

BACKGROUND: Selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) are infection-prevention measures used in the treatment of some patients in intensive care, but reported effects on patient outcome are conflicting. METHODS: We evaluated the effectiveness of SDD and SOD in a crossover study using cluster randomization in 13 intensive care units (ICUs), all in The Netherlands. Patients with an expected duration of intubation of more than 48 hours or an expected ICU stay of more than 72 hours were eligible. In each ICU, three regimens (SDD, SOD, and standard care) were applied in random order over the course of 6 months. Mortality at day 28 was the primary end point. SDD consisted of 4 days of intravenous cefotaxime and topical application of tobramycin, colistin, and amphotericin B in the oropharynx and stomach. SOD consisted of oropharyngeal application only of the same antibiotics. Monthly point-prevalence studies were performed to analyze antibiotic resistance. RESULTS: A total of 5939 patients were enrolled in the study, with 1990 assigned to standard care, 1904 to SOD, and 2045 to SDD; crude mortality in the groups at day 28 was 27.5%, 26.6%, and 26.9%, respectively. In a random-effects logistic-regression model with age, sex, Acute Physiology and Chronic Health Evaluation (APACHE II) score, intubation status, and medical specialty used as covariates, odds ratios for death at day 28 in the SOD and SDD groups, as compared with the standard-care group, were 0.86 (95% confidence interval [CI], 0.74 to 0.99) and 0.83 (95% CI, 0.72 to 0.97), respectively. CONCLUSIONS: In an ICU population in which the mortality rate associated with standard care was 27.5% at day 28, the rate was reduced by an estimated 3.5 percentage points with SDD and by 2.9 percentage points with SOD. (Controlled Clinical Trials number, ISRCTN35176830.)

[A midwife involved in patients with puerperal fever in three different hospitals]. / Een verloskundige betrokken bij patiënten met kraamvrouwenkoorts in drie verschillende ziekenhuizen.

In three hospitals three women aged 34, 33 and 25 years respectively, developed fever following delivery; in two of them a beta-haemolytic streptococcus of Lancefield group A (GAS) was cultured. Between the time of transmission of the infective agent of the first and the third patients there was a period of ten days. Because the intervals between the emergence of cases were relatively long, the suspicion of a common vector, i.e. the midwife, was raised only after some time. The midwife who had been present at all three deliveries turned out to be negative for GAS carriership on three occasions. However, cultures taken from her son and partner were positive for GAS carriership. A number of typing systems were unable to distinguish the GAS-isolates from the first two patients and from the son. After the midwife and her family members had been treated, no new cases occurred. This case illustrates the importance of keeping midwives as well as the department of public health informed of a rise in the number of cases of puerperal fever, whether the cases involve more than one hospital or not, in order to prevent a potential epidemic. Only then can a common source be looked for and the epidemic contained.

[Rapid diagnosis of psittacosis using a recently developed real-time PCR technique]. / Snelle diagnostiek van psittacose met behulp van een recent ontwikkelde realtime-PCR.

A 37-year-old man was admitted with cough and fever. Three days after admission he was tested using a newly developed real-time PCR technique that detects the DNA of Chlamydophila psittaci. The result was positive; serological investigation was not positive until 14 days later. Psittacosis is a potentially life-threatening infectious disease. Laboratory diagnosis relies mainly on the assessment of paired sera, but this approach has obvious disadvantages in the acute setting. Routine use of the real-time PCR technique led to the rapid diagnosis of psittacosis in 6 other patients. All 7 patients recovered after antibiotic treatment. This PCR technique is a valuable adjuvant to serological testing for the rapid diagnosis of psittacosis.

[Fitz-Hugh-Curtis syndrome: 2 patients with perihepatitis and sepsis]. / Het syndroom van Fitz-Hugh-Curtis: 2 patiëntes met perihepatitis en ook sepsis.

Two women aged 53 and 22 years presented with abdominal pain and signs of sepsis with metabolic acidosis. The first patient had ecchymoses all over her body, the second patient had an enlarged left kidney with wedge-shaped hypo-intense areas on the CT scan. The clinical condition of both women deteriorated. On laparoscopy perihepatitis with fibrin wires ('violin strings') was seen, pathognomonic for Fitz-Hugh-Curtis syndrome. Upon appropriate antibiotic treatment, both patients fully recovered. Although it is common belief that Fitz-Hugh-Curtis syndrome is caused by local spread from the fallopian tubes into the peritoneal cavity, these presentations suggest a haematogenous spread of Neisseria gonorrhoeae as well as Chlamydia trachomatis in the first case, and C. trachomatis in the second case.

Management of an outbreak of Enterobacter cloacae in a neonatal unit using simple preventive measures.

Enterobacter cloacae is becoming an increasingly important nosocomial pathogen. Outbreaks of E. cloacae in intensive care units and burns units have been described frequently. In December 1999, a neonate with line sepsis was transferred from a university hospital to the neonatal unit of the Diakonessen Hospital. Blood culture yielded E. cloacae. An outbreak of E. cloacae was occurring in the university hospital at that time. In February 2000, a second neonate in our hospital developed line sepsis caused by E. cloacae. Direct measures taken included cohorting of infected children, disinfection of incubators, thermometers and wards, and screening patients. Of nine neonates, seven were colonized with E. cloacae. Despite these measures, the outbreak continued. Forty-one patients were screened; 15 were colonized. Environmental searches yielded E. cloacae in a sink and on two thermometers. Sixteen isolates were typed by arbitrarily primed PCR using four primers. All the patient isolates and the two isolates from thermometers were identical. The strain isolated from the sink was unrelated. Amplified fragment length polymorphism typing showed that the outbreak clone was identical to that in the university hospital. After the introduction of disposable thermometer covers, E. cloacae colonization slowly decreased.

Impact of hospital-wide surveillance on hospital-acquired infections in an acute-care hospital in the Netherlands.

The goal of surveillance is to identify hospital-acquired infections (HAI) and risk factors, to apply targeted interventions and to evaluate their effect in an ongoing system. Continuing active surveillance in a 270-bed acute-care hospital is being performed on clinical patients, excluding day-care. The period 1984-1997 is described here. Specific surveillance-based interventions included the introduction of antimicrobial prophylaxis in gynaecology patients with postoperative urinary tract catheters and inpatients scheduled for appendicectomy and hysterectomy. General measures included education, implementation of protocols, feedback of surgeon-specific infection rates. In total, 3545 HAI were found in 13 years of surveillance. The incidence was 4.7/100 admissions and 4. 5/1000 patient days. Age-specific incidences ranged from 1.3 in the age-category 1-14 years, to 10.2 in patients aged 75 years and above. If age-specific incidences had remained at their 1984 level, over 3000 additional infections would have occurred, affecting all age groups except those up to 14 years. The distribution of types of infections differed between services. Following the targeted interventions, the rate of infections in gynaecology decreased from 19.4 per 1000 patient days in 1984 to 2.4 per 1000 patient days in 1996. The rates of wound infection following appendicectomy and hysterectomy decreased by 69% and 82%, respectively, in the period following the institution of antimicrobial prophylaxis. Over 4000 micro-organisms were isolated from the HAI; multi-resistant strains were isolated sporadically. We conclude that hospital-wide surveillance of hospital-acquired infections provides appropriate targets for interventions tailored to the specific needs of the hospital. The impact of such interventions can readily be documented from the surveillance data.

Bacterial filters in anesthesia: results of 9 years of surveillance.

In 9 years of surveillance of postoperative lower respiratory infections, the infection rate in patients following regional anesthesia was 0.2% and 0.1% in patients following general anesthesia. No bacterial filters in the breathing circuit were used. Infected patients had risk factors such as type of surgery, American Society of Anesthesiologists class > or =2, old age, chronic obstructive pulmonary disease, or smoking habits. Infections were not clustered. This suggests that, in our setting, patient factors are most important in the development of postoperative lower respiratory infections and that the role of bacterial filters as a preventive measure is negligible.

[Clostridium difficile outbreak in surgical wards]. / Een Clostridium difficile-uitbraak op chirurgische afdelingen.

OBJECTIVE: To evaluate the clinical consequences of a hospital outbreak of Clostridium difficile infections in the Netherlands. DESIGN: Descriptive. SETTING: Diakonessen Hospital Utrecht, the Netherlands. METHODS: In the period from 1 August 1995 to 1 September 1996 C. difficile infections were recorded (gastrointestinal symptoms after use of antibiotics and findings at C. difficile toxin assay in faeces, or sigmoidoscopy). The monthly incidence of infections increased to 5 patients in December 1995; at that time strict hygienic measures were implemented and perioperative antimicrobial prophylaxis was adjusted. Data on the clinical course were collected retrospectively from the records of the patients involved. RESULTS: In 20 patients, admitted for various reasons to the surgical wards, hospital stay was complicated by a C. difficile infection. The mean age was 70 years. Eleven patients presented with diarrhoea, eight patients had nausea and vomiting as well. Diagnosis was confirmed by C. difficile toxin determination in most patients (n = 15). Despite antibiotic treatment in 19 patients, recurrences were seen in five patients (25%) and five patients died (25%). The monthly incidence declined to 0-1 per month. CONCLUSION: C. difficile infections in surgical patients carry a significant morbidity and mortality. Preventive hygienic measures are important to control spread of the infection.

Intermethod variation in detection of human papillomavirus DNA in cervical smears.

In order to investigate the reliability of detection of human papillomavirus (HPV) DNA in cervical smears, we have compared the performance of two HPV PCR systems, the CPI/IIG and MY09/11 primer-mediated PCRs and the Hybrid Capture System HPV DNA detection test (hybrid capture assay), in detecting HPV DNA in cervical smears. We also included in our study the MY09/11B PCR plus SHARP (solution hybridization assay for PCR products) Signal System. This SHARP Signal System was recently developed to detect MY09/11B-generated biotinylated PCR products. The detection rate of the hybrid capture assay was lower than those of the CPI/IIG and MY09/11 PCRs and the MY09/11B PCR plus SHARP Signal System. The detection rates of the CPI/IIG PCR and the MY09/11B PCR plus SHARP Signal System were similar and higher than that of the conventional MY09/11 PCR system. The agreement beyond chance of the PCR methods was nearly perfect (kappa value between 0.82 and 0.84). The agreement beyond chance of the hybrid capture assay and the PCR methods was fair to good (kappa value between 0.64 and 0.70). The systems detected HPV DNA in different but overlapping sets of smears. Our results indicate that each of the detection methods alone underestimates the prevalence of HPV.

Routine application of the polymerase chain reaction for detection of Mycobacterium tuberculosis in clinical samples.

AIM: To investigate the use of the polymerase chain reaction (PCR) in the routine laboratory for the detection of Mycobacterium tuberculosis in clinical samples. METHODS: Samples were divided and processed separately for the detection of M tuberculosis by microscopy, culture and PCR. After DNA extraction, PCR was performed with primers specific for the insertion element IS6110 and the product was analysed by agarose gel electrophoresis, Southern blotting or dot blotting and hybridisation with a digoxigenin labelled internal probe. Each sample was tested for inhibitors of Taq polymerase with the aid of an internal control. Multiple negative and positive controls were used to monitor each step of the procedure. RESULTS: The data from two laboratories, using the same operating procedures, were combined. Of 1957 specimens, 79 (4%) were culture and PCR positive, while 1839 (93.9%) were negative in both tests. Thirty specimens (1.5%) were PCR positive only and nine (0.5%) were culture positive but PCR negative. CONCLUSION: Using culture and clinical history as the gold standard, sensitivity and specificity for PCR were 92.1% and 99.8%, respectively. With elaborate precautions, PCR is a suitable and reliable method for the detection of M tuberculosis in clinical samples in a routine microbiology laboratory.

Coxsackievirus B1-based antibody-capture enzyme-linked immunosorbent assay for detection of immunoglobulin G (IgG), IgM, and IgA with broad specificity for enteroviruses.

An antibody-capture enzyme-linked immunosorbent assay (ELISA) with coxsackievirus B1 as the antigen was evaluated for detection of immunoglobulin G (IgG), IgM, and IgA antibodies and showed broad specificity for enteroviruses. In total, 116 serum or cerebrospinal fluid samples from 62 patients were tested by ELISA and the complement fixation test (CFT). Additionally, 15 serum samples that contained poliovirus-specific IgM antibody were tested. Serum samples from 200 healthy blood donors were used for standardization of the assays. The sensitivity of the ELISA varied with time of serum sampling, with a relatively low sensitivity when serum was collected within 3 days after the onset of symptoms (23%; 5 of 22) but good sensitivity when serum was collected later (83%; 20 of 24). The sensitivity was better than that of the CFT. The ELISAs were broadly reactive as concluded from typing of virus isolates that were simultaneously obtained. The assay did, furthermore, detect antibody against poliovirus type 3. Sera that contained rheumatoid factor, antinuclear antibody, or cardiolipin antibody (by the Venereal Disease Research Laboratory test) did not react in this ELISA. Nonspecific reactivity did occur, however, in cases of infectious mononucleosis and in Mycoplasma pneumoniae infection. The enterovirus-specific ELISA is found to be simple to perform, more sensitive than the CFT, and far less laborious than the neutralization test.

[A fatal influenza infection in a 10-year-old boy]. / Een fatale influenza-infectie bij een 10-jarige jongen.

A previously healthy 10-year-old boy died a few days after onset of septicaemia with non-specific clinical symptoms. Influenza B virus was isolated post mortem from pulmonary tissue. The histopathological findings did not indicate a virus disease. Specimens were taken for virus culture from other people in contact with the patient and affected with influenza-like illnesses. One other strain of influenza B virus was isolated. The strains could not be distinguished either serologically or genetically from other influenza B isolates of the season 1992/'93.

[A man with spontaneous regression of non-Hodgkin lymphoma, hypergammaglobulinemia and infection caused by 2 herpesviruses; causality or coincidence?]. / Een man met spontane regressie van non-Hodgkin-lymfoom, hypergammaglobulinemie en infectie met twee herpes-virussen; causaliteit of coïncidentie?

A febrile illness with atypical peripheral blood lymphocytosis (polyclonal CD8+ suppressor/cytotoxic phenotype), complement activation and IgA/G class hypergammaglobulinaemia was found in a 76-year old male with clinical stage III follicular non-Hodgkin lymphoma (NHL). There was serological evidence of active cytomegalovirus (CMV) as well as reactivated chronic Epstein-Barr virus (EBV) infection. Spontaneous regression of NHL appeared, the signs of viral infection improved but hypergammaglobulinaemia persisted. In patients with malignant lymphoma, clinical signs and abnormalities of peripheral blood lymphocytes and serum immunoglobulins should not automatically be considered a consequence of the lymphoma.

[Extra-intestinal infections caused by Vibrio spp. in The Netherlands]. / Extra-intestinale infecties door Vibrio spp. in Nederland.

Six patients with serious cellulitis or ear infection due to Vibrio vulnificus, V. parahaemolyticus or V. alginolyticus are described. Four patients were infected during the summer in the Netherlands and two outside the Netherlands. Contact with seawater was the most probable source in four patients. In two patients the infection, caused by V. vulnificus, was transmitted by eel. This is a new way of transmission.

Immunogenicity of measles vaccine from a hospital based and outreach programme in rural Kenya.

Data on efficacy of rural immunization programmes are scarce. We investigated the seroconversion rate following measles vaccination in an outreach programme in Kakamega District, Kenya. Of 170 children, 120 (71%) showed seroconversion after vaccination. Haemagglutination inhibition test was performed on paired blood samples before and 30 days or more (mean 46, range 30-70 days) after vaccination. These results are comparable to results found by other studies in developing countries. Geometrical mean titres before vaccination of children in the age group above 14 months were significantly lower than in the younger age groups (P less than 0.001). This investigation indicates that seroconversion rate studies are feasible in remote rural areas.

Effect of Bacteroides fragilis grown in the presence of clindamycin, metronidazole and fusidic acid on opsonization and killing of Escherichia coli.

Bactericidal action of human polymorphonuclear leucocytes on Escherichia coli in the presence of Bacteroides fragilis grown in subinhibitory concentrations of clindamycin, metronidazole and fusidic acid was studied. Bacteroides fragilis grown in the absence of drugs significantly inhibited the killing of Escherichia coli. Bacteroides fragilis grown in the presence of the drugs had a reduced inhibitory effect on the killing of Escherichia coli but this reduction was only significant for Bacteroides fragilis grown in 1/2 MIC of clindamycin. The phagocytosis of Bacteroides fragilis grown with and without clindamycin, as measured by killing, was the same. Complement consumption of Bacteroides fragilis grown with and without clindamycin did not differ. Clindamycin-treated Bacteroides fragilis fixed C3 to a significantly lower degree than did untreated bacteria. The chemiluminescence of Escherichia coli opsonized with serum preincubated with clindamycin-treated Bacteroides fragilis was significantly higher than with serum preincubated with untreated bacteria. These results suggested that in killing experiments of mixed Escherichia coli and Bacteroides fragilis, the mechanism underlying the reduced inhibitory capacity of clindamycin-exposed Bacteroides fragilis is related to greater availability of C3 in serum for opsonization of Escherichia coli.