Epidemiology and mortality of candidemia both related and unrelated to the central venous catheter: a retrospective cohort study.

Our objective was to compare mortality, epidemiology, and morbidity in hospitalized patients with candidemia which was both related and unrelated to the central venous catheter (CVC). This was a monocentric, retrospective cohort study of candidemia. The sample consisted of 103 patients with laboratory-confirmed nosocomial candidemia hospitalized between 2006 and 2013 in a tertiary care public hospital. We included 65 (63.1 %) patients (24 in the CVC-positive group, 41 in the CVC-negative group). Demographic data and risk factors were recorded using a structured case report form. In the group of candidemia associated to the CVC, survival at day 50 was 58.6 ± 11.9 %, compared to 26.5 ± 8.9 % for the CVC-negative group (p-value = 0.012); the hazard ratio of death was 0.38 (95 % confidence interval 0.17-0.85, p-value = 0.019). Compared with the CVC-positive patients, CVC-negative patients were often colonized with yeast (41.5 % vs. 16.7 %, p-value = 0.041), had a shorter previous in-hospital stay (20 days vs. 34 days, p-value = 0.023), and were more severely ill (severe sepsis 85.4 % vs. 58.3 %, p-value = 0.016). In this study, when the origin of candidemia was not the CVC, patients were more seriously ill, had a higher mortality rate, and the removal of the catheter seemed to lead to disappointing results. It would be useful to explore the impact of retention of the CVC on survival in the CVC-negative patients, where the CVCs are essential to treating these patients.

Comparative epidemiology of Staphylococcus epidermidis isolates from patients with catheter-related bacteremia and from healthy volunteers.

Staphylococcus epidermidis is a major cause of catheter-related bloodstream infections (CRBSIs). Recent studies suggested the existence of well-adapted, highly resistant, hospital-associated S. epidermidis clones. The molecular epidemiology of S. epidermidis in Belgian hospitals and the Belgian community has not been explored yet. We compared a set of 33 S. epidermidis isolates causing CRBSI in hospitalized patients with a set of 33 commensal S. epidermidis isolates. The factors analyzed included resistance to antibiotics and genetic diversity as determined by pulsed-field gel electrophoresis (PFGE), multilocus sequence typing (MLST), and SCCmec typing. Additionally, the presence of virulence-associated mobile genetic elements, the ica operon and the arginine catabolic mobile element (ACME), was assessed and compared against clinical data. CRBSI S. epidermidis isolates were significantly resistant to more antibiotics than commensal S. epidermidis isolates. The two populations studied were very diverse and genetically distinct as only 23% of the 37 PFGE types observed were harbored by both CRBSI and commensal isolates. ACME was found in 76% of S. epidermidis strains, regardless of their origin, while the ica operon was significantly more prevalent in CRBSI isolates than in commensal isolates (P < 0.05). Nine patients presented a clinically severe CRBSI, eight cases of which were due to an ica-positive multiresistant isolate belonging to sequence type 2 (ST2) or ST54. S. epidermidis isolates causing CRBSI were more resistant and more often ica positive than commensal S. epidermidis isolates, which were genetically heterogeneous and susceptible to the majority of antibiotics tested. Clinically severe CRBSIs were due to isolates belonging to two closely related MLST types, ST2 and ST54.

Impact of ribotype 027 on Clostridium difficile infection in a geriatric department.

The purposes of this study were to describe the epidemiology (2001-2009) of Clostridium difficile infections (CDI) in a geriatric department and to compare the clinical data of patients infected with a 027 or non-027 strain. We retrospectively identified all geriatric patients with CDI and analysed the clinical and microbiological data of 133 patients for whom a ribotype was available between March 2003 and December 2009. The incidence of CDI in our geriatric department increased from 0.2 per 100 admissions in 2001 to 8.1 in 2004 and decreased to 1.3 in 2008 before a new rise to 2.1 in 2009. The percentage of ribotype 027 decreased from 2007 but it remained the most prevalent ribotype during the years 2007-2009, with a greater dispersion of ribotypes. The mean age of the patients was 84 years and the median Charlson index was 6.0. Previous use of fluoroquinolones was a significant risk factor for developing a CDI with an 027 strain (p = 0.001). Cure was significantly lower in the 027 group (p = 0.003). The total attributable mortality was 24.1 %. A multiparametric model showed that attributable mortality was influenced by the ribotype 027 (p = 0.037), the severity of clinical symptoms (p = 0.001) and the type of treatment (p = 0.002). Oral vancomycin had a protective effect against mortality. Attention should be paid to elderly patients developing a CDI, especially after the administration of fluoroquinolones. Oral vancomycin could be recommended as the first-line agent not only to protect against recurrence or severe CDI, but to diminish the attributable mortality risk.

Risk factors for meticillin resistance and outcome of Staphylococcus aureus bloodstream infection in a Belgian university hospital.

The aim of this study was to identify institution-specific risk factors for meticillin resistance in Staphylococcus aureus bloodstream infection (BSI) and to evaluate the impact of meticillin resistance on mortality. A total of 154 episodes of S. aureus BSI were identified between 1 January 2002 and 31 December 2004: 66 meticillin-resistant S. aureus (MRSA) BSI and 88 meticillin-susceptible S. aureus (MSSA) BSI. Seventy-eight episodes (51%) were considered to be community-acquired and 76 (49%) as nosocomial. Risk factors associated with MRSA BSI included not living at home (P=0.001), prior antibiotic exposure (P=0.002), insulin-requiring diabetes (P=0.028) and nosocomial BSI (P=0.031), especially more than 12.5 days after admission. There was an association between BSI-related mortality and the following variables: septic shock (P<0.001), endocarditis (P=0.002) and MRSA BSI (P=0.021). In conclusion, S. aureus BSI is a serious condition, especially when septic shock or endocarditis occurs, and is aggravated by meticillin resistance. We advise glycopeptides as empirical therapy for patients not arriving from home, those exposed to antibiotics, and those with insulin-requiring diabetes and/or nosocomial BSI.

[Aerococcus urinae endocarditis: first case report in Belgium and review of the literature]. / Endocardite a Aerococcus urinae: premier cas en Belgique et revue de la littérature.

Aerococcus urinae is a rarely reported pathogen, possibly due to difficulties in the identification of the organism. Only sixteen cases of A. urinae endocarditis have yet been described. Generally, patients were males with predisposing conditions and the outcomes were bad. We describe the first Belgian case of endocarditis due to A. urinae. Which occurred to a 79-year-old female patient. The diagnostic of A. urinae endocarditis was based on the cardiac ultrasonography and the isolation of the bacteria in 6/7 pairs of blood culture. The patient has been successfully treated by a long course of intravenous antibiotics (38 days) and surgery (aortic valve replacement by bioprothesis). We review the 14 cases published in the English literature and discuss the best clinical management of this type of endocarditis.

Outcome of totally implantable venous access device-related bacteraemia without device removal.

The optimal management of bacteraemia related to the presence of totally implantable venous access devices (TIVADs) remains controversial, particularly in terms of whether to remove the infected catheter. The objective of this study was to determine the factors associated with success or failure of treatment of TIVAD-related bacteraemia in patients from whom the infected device was not removed. The outcome of 92 episodes of TIVAD-related bacteraemia and the factors predictive of an unfavourable outcome were evaluated retrospectively. In 32 (35%) episodes, the devices were removed immediately. In 60 episodes, patients were treated with antibiotics infused through the device; treatment was successful in 56% of these cases (66% for infections caused by coagulase-negative staphylococci). Only the presence of sepsis (OR 9.42, 95% CI 1.29-68.92, p 0.0271) and of local signs of infection (OR 9.61, 95% CI 1.98-46.49, p 0.0049) independently predicted the failure of catheter-retaining treatment. Finally, only one-third of the devices were retained. In conclusion, the large number of TIVADs that are removed because of infection justifies reconsidering the criteria for device removal. During catheter-retaining treatment, the presence of local signs of infection or reported sepsis were independent factors for reduced probability of retaining the device.

A potential role for the secretogranin II-derived peptide EM66 in the hypothalamic regulation of feeding behaviour.

EM66 is a conserved 66-amino acid peptide derived from secretogranin II (SgII), a member of the granin protein family. EM66 is widely distributed in secretory granules of endocrine and neuroendocrine cells, as well as in hypothalamic neurones. Although EM66 is abundant in the hypothalamus, its physiological function remains to be determined. The present study aimed to investigate a possible involvement of EM66 in the hypothalamic regulation of feeding behaviour. We show that i.c.v. administration of EM66 induces a drastic dose-dependent inhibition of food intake in mice deprived of food for 18 hours, which is associated with an increase of hypothalamic pro-opiomelanocortin (POMC) and melanocortin-3 receptor mRNA levels and c-Fos immunoreactivity in the POMC neurones of the arcuate nucleus. By contrast, i.c.v. injection of EM66 does not alter the hypothalamic expression of neuropeptide Y (NPY), or that of its Y1 and Y5 receptors. A 3-month high-fat diet (HFD) leads to an important decrease of POMC and SgII mRNA levels in the hypothalamus, whereas NPY gene expression is not affected. Finally, we show that a 48 hours of fasting in HFD mice decreases the expression of POMC and SgII mRNA, which is not observed in mice fed a standard chow. Taken together, the present findings support the view that EM66 is a novel anorexigenic neuropeptide regulating hypothalamic feeding behaviour, at least in part, by activating the POMC neurones of the arcuate nucleus.

Management of an outbreak of Clostridium difficile-associated disease among geriatric patients.

OBJECTIVE: To describe a nosocomial outbreak of Clostridium difficile-associated disease (CDAD). DESIGN: A traditional outbreak investigation. SETTING: Geriatric department of a tertiary care teaching hospital from March through April 2003. METHODS: The outbreak was detected by the C. difficile surveillance program of the infection control unit. CDAD was diagnosed by stool culture and fecal toxin A detection with a qualitative rapid immunoassay. Isolates of C. difficile were serotyped and genotyped using pulsed-field gel electrophoresis. RESULTS: The incidence of CDAD increased from 27 cases per 100,000 patient-days in the 6-month period before the outbreak to 99 cases per 100,000 patient-days during the outbreak. This outbreak involved 21 of 92 patients in 4 geriatric wards, which were located at 2 geographically distinct sites and staffed by the same medical team. The mean age of patients was 83 years (range, 71-100 years). Five (24%) of the 21 patients had community-acquired diarrhea, and secondary hospital transmission resulted in 3 clusters involving 16 patients. Serotyping and genotyping were performed on isolates in stool specimens from 19 different patients; 16 of these isolates were serotype A1, whereas 3 displayed profiles different from the outbreak strain. Management of this outbreak consisted in reinforcement of contact isolation precautions for patients with diarrhea, cohorting of infected patients in the same ward, and promotion of hand hygiene. Relapses occurred in 6 (29%) of 21 patients. CONCLUSION: Control of this rapidly developing outbreak of CDAD was obtained with early implementation of cohorting and ward closure and reinforcement of environmental disinfection, hand hygiene, and enteric isolation precautions.

[Management of scabies in long term care facilities]. / La gestion de la gale en maisons de repos.

Regularly, cases of scabies are diagnosed. Old institutionalized persons with depressed immunity are particularly sensitive to this type of infestation. Scabies is an ectoparasitose related to Sarcoptes scabiei. Clinical picture can be highly variable depending of the type of scabies (typical scabies, profuse one or norvegian scabies). Even if the etiologic agent is the same, each type has its own characteristics and is different as far as the contagiosity is concerned. Diagnostic of scabies can be difficult due to atypical lesions. Delayed diagnostic, particularly in collectivities of old persons may be the cause of outbreaks that can be difficult to manage, are costly and very unpleasant for the patients and caregivers. The different types of treatment (local or sytemic) are discussed as well as rules to be take into account for prevention.

Hospital preparedness and clinical description of the 2009 influenza A (H1N1) pandemic in a Belgian tertiary hospital.

We describe hospital preparedness, including costs, and clinical characteristics of the 2009 influenza A (H1N1) pandemic in adult patients in a Belgian tertiary care centre. A task force coordinated the overall management, including triage and hospitalisation. Between 1 June and 30 November 2009, 521 patients with influenza-like illness were admitted to the emergency ward. We reviewed data from 43 hospitalised patients with confirmed influenza A. Median age was 44 years (range: 21-79), with 84% patients having underlying disease. Eleven needed admission to intensive care unit (ICU) and one patient died. The financial impact of the epidemic was estimated at €75,691, and approximately half of these costs were related to the enhanced infection control practices. The Belgian 2009 influenza A (H1N1) pandemic, as described in a cohort of 43 hospitalised patients, was associated with a relatively high ICU admission rate of 26% and a fairly typical mortality rate of 3%. This retrospective study may help us refine the management of future epidemics.

Saccharomyces cerevisiae fungemia in an elderly patient with Clostridium difficile colitis.

Saccharomyces boulardii is widely used as a probiotic compound and is generally thought to be safe. We report one case of fungemia caused by Saccharomyces cerevisiae occurring in an elderly patient treated orally with S. boulardii in association with vancomycin for Clostridium difficile colitis. We do not recommend administering this viable yeast particularly in debilited patient with active colitis.

Multidrug-resistant tuberculosis spondylitis.

We report a case of multidrug-resistant spinal tuberculosis complicated by epiduritis and paraspinal abscess in a 68-year-old black woman. Multidrug-resistant tuberculous spondylitis is still rare in Belgium. Two others cases were reported from 1992 to 1997. The optimal therapy is not standardized and the mandatory duration of treatment is not known. Clinical presentation, radiological findings, and treatment are presented. The need for prompt diagnosis and optimal therapy is emphasized.

A prospective randomised evaluation of G-CSF or G-CSF plus oral antibiotics in chemotherapy-treated patients at high risk of developing febrile neutropenia.

BACKGROUND: Febrile neutropenia (FN) remains a major dose-limiting complication among patients treated with chemotherapy. Haematopoietic colony stimulating factors (G-CSF and GM-CSF) made possible a significant improvement in the management of FN, both in the therapeutic and in the prophylactic approach. The use of antibiotic prophylaxis also permits a definite reduction of severe infections during neutropenia. Nevertheless, the possible role of these two interventions for secondary prevention of FN is still unclear. PATIENTS AND METHODS: We conducted a prospective randomised trial by comparing the efficacy of granulocyte-colony stimulating factor (G-CSF) and the association of G-CSF with oral antibiotics in the secondary prevention of FN. We included in our study those patients who, after an episode of FN, continued to be treated with the same chemotherapy without reduction of dose intensity. They were randomised into two groups: the first received G-CSF (group G; filgrastim, 5 microg/kg day), and the second was treated with an association of G-CSF and amoxicillin/clavulanate plus ciprofloxacin (group G/ACC). RESULTS: Forty-eight patients were randomised (group G: n=23 and group G/ACC: n=25). There was no recurrence of FN among the patients receiving G-CSF and only one episode in the combined therapy group (p=1). With regard to the side effects, there was no significant difference in the two groups. CONCLUSION: The use of G-CSF for the secondary prevention of FN is extremely effective and allows the maintenance of chemotherapy dose intensity. Our study showed that the addition of antibiotics does not seem to be required.