Clostridium difficile enteritis: a review and pooled analysis of the cases.

INTRODUCTION: Clostridium difficile is the most common cause of healthcare-associated infection diarrhea and usually restricted to infection of the colon. However, small bowel involvement of C. difficile infection has been reported. We performed a literature review and pooled analysis of the reported cases of C. difficile enteritis METHOD: A Pubmed literature database search and pooled analysis of the reported cases of C. difficile enteritis. RESULTS: 56 cases of C. difficile enteritis have been reported from 1980 to 2010; 48 cases were published since 2001. Median age was 55 years. 27 patients (48.2%) were female. 29 patients (51.8%) had inflammatory bowel disease (IBD) - Crohn's disease or ulcerative colitis and 20 patients (35.7%) had predisposing medical condition(s) that might lead to an immunoincompetent state. 33 patients (58.9%) had colectomy with ileostomy and 13 patients (23.2%) had other small and/or large bowel surgery. Thirty four patients (60.7%) received ICU management and 18 patients (32.1%) died. We categorized the patients into two groups, 38 survivors (67.9%) 18 non-survivors (32.1%). Significantly older age was noted in non-survivors. Median age was 48 years and 66 years, respectively for survivors and non-survivors, P < 0.001. There were more patients with predisposing medical condition(s) among non-survivors, (13/18, 72.2%) than among survivors (7/38, 18.4%), P < 0.001. CONCLUSIONS: C. difficile enteritis is still rare, however it seems to be increasingly reported in recent years. Surgically altered intestinal anatomies, advanced age, predisposing medical condition(s) that might lead to immunoincompetence appear to be at risk for developing C. difficile enteritis. Recognition of C. difficile infection not only in the colon but also in the small bowel may lead to improved outcomes.

A novel combination regimen for the treatment of refractory bacteremia due to multidrug-resistant Pseudomonas aeruginosa in a liver transplant recipient.

Both bacteremia and biliary cast syndrome are serious post-transplant complications in liver transplant recipients. In the setting of increasing drug resistance in the current era, management of infections caused by multidrug-resistant (MDR) bacteria has proven challenging. We present a case of a liver transplant recipient who developed biliary cast syndrome and intractable MDR Pseudomonas bacteremia that failed to resolve with conventional antimicrobial therapy and which was finally controlled by a novel combination regimen of colistimethate, doripenem, and tobramycin. Future studies validating the clinical efficacy of this combination strategy are warranted.

Pneumonia in a long-term care facility. A prospective study of outcome.

BACKGROUND: Pneumonia is a major cause of morbidity and mortality among patients in long-term care facilities. OBJECTIVES: To conduct a prospective study of 108 consecutive patients who acquired pneumonia in a Veterans Affairs facility from January through December 1993, and to identify (1) the short- and long-term outcome of pneumonia, (2) the determinants of outcome, and (3) the frequency of recurrent episodes. METHODS: Patient characteristics, including scores from the Activities of Daily Living (ADL) Index of Katz et al and the Comorbidity Index of Charlson et al, were recorded End points were survival at 14 days and 12 and 24 months, recurrent episodes of pneumonia, and hospitalization for nonpneumonic illness. RESULTS: Fourteen-day mortality was 19%; outcome was significantly related to the ADL score. There was no relationship between short-term outcome and age or the Comorbidity Index score. Mortalities at 12 and 24 months were 59% and 75%, respectively. Long-term survival also correlated with the ADL score. For the least debilitated patients (ie, those with an ADL score < or = 10), mortalities were 33% and 48% at 12 and 24 months, respectively; for those with ADL scores of 11 to 15, the corresponding mortalities were 60% and 75%; and for those with ADL scores of 16 or greater, the mortalities were 65% and 77% (P = .02). Within 12 months, 43% of the survivors had additional episodes, and 37% required transfer to an acute care facility for other diagnoses. Functional status did not change among the most dependent patients. CONCLUSIONS: Functional status is the major determinant of survival following pneumonia. Pneumonia in a debilitated patient in a long-term care facility predicts recurrent pneumonia and death within 1 to 2 years.

Pneumonia in long-term care: a prospective case-control study of risk factors and impact on survival.

BACKGROUND: Pneumonia is a major cause of morbidity and mortality in long-term care facilities. Prior studies of pneumonia have failed to identify risk factors potentially amenable to intervention. Our objectives were to (1) identify modifiable risk factors for the occurrence of pneumonia and (2) determine the long-term impact of pneumonia on survival. METHODS: We performed a case-control study among residents of a Veterans Affairs long-term care facility. Case patients included all patients developing pneumonia from 2 days to 1 year after admission. Control subjects were matched for admission date, level of nursing care, and dependence in activities of daily living. Patients were followed up for 2 years or until death or discharge from the facility. RESULTS: We identified 104 case-control pairs. Risk factors significantly associated with pneumonia included witnessed aspiration (odds ratio, 13.9; 95% confidence interval, 1.7-111.0; P =.01), sedative medication (odds ratio, 2.6; 95% confidence interval, 1.2-5.4; P =.01), and comorbidity score (odds ratio, 1.2; 95% confidence interval, 1.0-1.4; P =.05). Mortality due to pneumonia was 23% at 14 days. Patients with pneumonia had a significantly higher mortality than did controls at 1 year (75% vs 40%; P<.001); survival curves converged at 2 years. In a Cox proportional hazards regression model, an episode of pneumonia was independently associated with mortality during follow-up (odds ratio, 2.6; 95% confidence interval, 1.7-3.9; P<.001). CONCLUSIONS: Among long-term care patients closely matched for age, level of dependency, and duration of institutionalization, an episode of pneumonia is associated with significant excess mortality that persists for up to 2 years. Two identified risk factors, large-volume aspiration and receipt of sedating medication, are potentially amenable to intervention.

Infections caused by Pseudomonas maltophilia. Expanding clinical spectrum.

Pseudomonas maltophilia (Xanthomonas maltophilia) is a frequently isolated commensal that is gaining increasing recognition as an opportunistic pathogen in debilitated hosts. We report three unusual infections due to P maltophilia that illustrate the ability of the organism to cause life-threatening illness. We describe a case of postoperative meningitis, a case of recurrent bacteremia complicated by ecthyma gangrenosum, and a case of native valve endocarditis in a drug addict. Because of frequent isolation from noninfected sites, the pathogenic potential of P maltophilia may be overlooked. The notable resistance of this organism is commonly used beta-lactam and aminoglycoside antibiotics may complicate therapy.

Pneumonia due to the Pittsburgh pneumonia agent: new clinical perspective with a review of the literature.

We review the current knowledge concerning this newly recognized pathogen, Pittsburgh pneumonia agent (PPA), and present a new, comprehensive perspective of PPA based on our extensive clinical experience: 1) PPA pneumonia is more common and affects a broader range of patients than previously appreciated. 2) In the general population, the disease is not distinguishable from acute pneumonia due to other causes. Because specialized diagnostic tests are required for detection, it is likely that many cases in other hospitals go unrecognized. 3) Diagnosis is important, as erythromycin appears to improve outcome, whereas beta-lactam antibiotics and aminoglycosides, frequently used as empiric therapy for nosocomial bacterial pneumonias, do not. 4) The presence of both PPA and L. pneumophila in the same environmental sites, and the discovery of seven cases of simultaneous infection by both organisms suggest that both organisms are likely to share a common reservoir within the hospital and a common mode of transmission. 5) PPA infection occurs in a more debilitated population than does Legionnaires' disease. This may represent differences in intensity of exposure to the two organisms or may reflect inherent differences in virulence.

New and emerging etiologies for community-acquired pneumonia with implications for therapy. A prospective multicenter study of 359 cases.

Three hundred fifty-nine consecutive patients with community-acquired pneumonia admitted to university, community, and VA hospitals underwent a standardized evaluation, including specialized tests for Legionella spp. and Chlamydia pneumoniae (TWAR). The most common underlying illnesses were immunosuppression (36.3%), chronic obstructive pulmonary disease (32.4%), and malignancy (28.4%). The most frequent etiologic agents were Streptococcus pneumoniae (15.3%) and Hemophilus influenzae (10.9%). Surprisingly, Legionella spp. and C. pneumoniae were the third and fourth most frequent etiologies at 6.7% and 6.1%, respectively. Aerobic gram-negative pneumonias were relatively uncommon causes of pneumonia despite the fact that empiric broad-spectrum combination antibiotic therapy is so often directed at this subgroup. In 32.9%, the etiology was undetermined. Antibiotic administration before admission was significantly associated with undetermined etiology (p = 0.0003). There were no distinctive clinical features found to be diagnostic for any etiologic agent, although high fever occurred more frequently in Legionnaires' disease. Clinical manifestations for C. pneumoniae were generally mild, although 38% of patients had mental status changes. Mortality was highest for Staphylococcus aureus (50%) and lowest for C. pneumoniae (4.5%) and Mycoplasma pneumoniae (0%). We document that specialized laboratory testing for C. pneumoniae and Legionella spp. should be more widely used rather than reserved for cases not responding to standard therapy. Furthermore, realization that C. pneumoniae and Legionella spp. are common etiologies for community-acquired pneumonia should affect empiric antibiotic prescription.

Myelopathy after herpes zoster.

A 73-year-old woman with a remote history of carcinoma of the ovary had herpes zoster involving several lumbosacral dermatomes. There subsequently developed a progressive myelopathy with normal myelographic findings and CSF pleocytosis. Vidarabine (15 mg/kg/day) was given for ten days. No further progression occurred. The syndrome of progressive myelopathy following herpes zoster is rare; direct viral invasion of the cord with subsequent necrosis appears to be the pathogenic mechanism. Antiviral therapy may have halted progression, but it did not lead to recovery of function.

Pneumonia in residents of long-term care facilities: epidemiology, etiology, management, and prevention.

Pneumonia is a leading cause of morbidity and mortality among patients in long-term care facilities; the median reported incidence is 1 per 1,000 patient-days. Risk factors include functional dependency, chronic pulmonary disease, and conditions causing aspiration. The frequency of etiologic agents varies widely among reports; for example; Streptococcus pneumoniae ranges from 0% to 39% of cases, and gram negative bacilli ranges from 0% to 51% of reported cases. Viral respiratory infections, particularly influenza and respiratory syncytial virus, typically occur in outbreaks. Mortality varies from 5% to 40%; functional status is the major determinant of survival. Many patients receive inadequate initial evaluations, and as many as 40% receive no physician visit during the episode. Although transfer to an acute care facility occurs in 9% to 51% of cases, most transferred patients could be managed in the nursing home with minimal additional support. Appropriate evaluation includes examination by a practitioner, recording of vital signs, chest radiograph, and examination of an adequate sputum sample, if available. Patients without contraindications to oral therapy or severe abnormalities of vital signs (pulse > 120 beats per minute, respirations >30 per minute, systolic blood pressure < 90) may initially receive oral therapy. Appropriate oral agents include amoxicillin/clavulanate, second generation cephalosporins, quinolones active against S pneumoniae, or trimethoprim/sulfamethoxazole. Appropriate parenteral agents include beta-lactam/beta-lactamase inhibitor combinations, second or third generation cephalosporins, or quinolones. Pneumococcal and influenza vaccines should be administered to all residents. Future studies should focus on identifying risk factors for pneumonia that are amenable to intervention and to identifying highly effective, preferably oral, antimicrobial regimens in randomized trials.

Conjunctivitis associated with methicillin-resistant Staphylococcus aureus in a long-term-care facility.

PURPOSE: To determine the clinical characteristics of conjunctivitis associated with methicillin-resistant Staphylococcus aureus (MRSA) in a long-term-care facility. PATIENTS AND METHODS: We followed 20 episodes of MRSA-associated conjunctivitis in 19 patients occurring over a three-year period in a 432-bed long-term-care facility. RESULTS: The clinical picture was that of a purulent conjunctivitis from which MRSA was isolated on culture. Seventeen patients had severe, pre-existing neurologic impairment. Nine were colonized by MRSA before the onset of conjunctivitis. Seven of eight patients treated with oral ciprofloxacin and all eight patients treated with topical vancomycin showed clinical resolution of conjunctivitis. Persistence of MRSA colonization at a variety of anatomic sites was noted after therapy following 14 episodes. CONCLUSION: MRSA-associated conjunctivitis in our long-term-care facility was notable for its occurrence in patients with severe neurologic disease. Both oral ciprofloxacin and topical vancomycin therapy were associated with clinical resolution. Since MRSA is endemic in many long-term-care facilities, it is likely that MRSA-associated conjunctivitis will be increasingly recognized.

Significance of isolation of Aspergillus from the respiratory tract in diagnosis of invasive pulmonary aspergillosis. Results from a three-year prospective study.

The isolation of Aspergillus species from respiratory secretions has been regarded as being of limited usefulness in the antemortem diagnosis of invasive pulmonary aspergillosis. One hundred and eight consecutive patients were evaluated in whom Aspergillus species were isolated from respiratory secretions. Invasive aspergillosis was not demonstrated in non-immunosuppressed patients or in patients with solid tumors in the absence of neutropenia. Lung tissue was examined in 17 patients with leukemia and/or neutropenia; all had invasive aspergillosis. Tissue examination was not performed in 20 neutropenic patients; of 17 not receiving antifungal therapy, 16 died. Multivariate statistical analysis showed that neutropenia and absence of cigarette smoking were significant predictors of invasive aspergillosis in patients with respiratory tract cultures yielding Aspergillus. All cases of invasive aspergillosis were associated with A. fumigatus or A. flavus. The isolation of A. fumigatus or A. flavus from the respiratory tract of a patient with leukemia and/or neutropenia is highly predictive of invasive infection. Empiric amphotericin B therapy, without the necessity for tissue diagnosis, should be considered in this patient subgroup.

Simultaneous infection with Legionella pneumophila and Pittsburgh pneumonia agent. Clinical features and epidemiologic implications.

Nosocomial pneumonia caused simultaneously by two organisms, Legionella pneumophila and the Pittsburgh pneumonia agent, was documented in seven patients in one institution. In all seven cases, both organisms were demonstrated by isolation from culture or visualization by direct immunofluorescence. Four patients died as a result of pneumonia, including two who received erythromycin therapy. The hospital water distribution system appeared to be the reservoir for both L. pneumophila and Pittsburgh pneumonia agent. These seven cases constituted 26.9 percent and 17.9 percent of the cases of Pittsburgh pneumonia agent and Legionnaires' disease, respectively, at one institution. Given this relatively high incidence of dual infection, it is likely that the mode of transmission for both organisms is identical. Dual infection may account for some cases of antibody response to more than one Legionella species. Historical parallels of the discovery of L. pneumophila and Pittsburgh pneumonia agent are reviewed.

Antibiotic therapy for Pseudomonas aeruginosa bacteremia: outcome correlations in a prospective study of 200 patients.

PURPOSE AND PATIENTS AND METHODS: We performed a prospective clinical study of 200 consecutive patients with Pseudomonas aeruginosa bacteremias to analyze in vitro susceptibility and synergistic testing of antibiotics the patients received and clinical parameters to assess their relationship to survival. RESULTS: No significant correlation between in vitro susceptibility testing (minimal inhibitory concentrations/minimal bactericidal concentrations) and outcome could be demonstrated. Similarly, improved outcome could not be demonstrated for patients receiving antibiotic combinations that were synergistic in vitro (either time-kill or checker-board) versus those combinations that were not. There was also no correlation between results obtained by time-kill curve and checkerboard synergistic testing, i.e., combinations found to be synergistic by one method were not necessarily synergistic by the other method. Clinical parameters associated with improved survival were a urinary portal of entry and absence of neutropenia. Conversely, survival was significantly decreased when the portal was the respiratory tract. The mortality rate between patients receiving combination therapy (27%) and monotherapy (47%) was significant (p less than 0.02); this significant relationship held true for most subgroups including malignancy, nosocomial infection, and infection site. CONCLUSION: Increasing effort should be placed on ensuring timely administration of combination therapy to patients with P. aeruginosa bacteremia since the use of combination therapy was even more important in determining outcome than was underlying disease.

Prevalence of hepatitis C infection in health care workers affiliated with a liver transplant center.

The risk of hepatitis C to liver transplantation health care workers has not been identified. We compared the occupational risk of hepatitis C in health care workers associated with liver transplantation with risk of health care workers affiliated with the same institutions but not involved in transplantations. Health care workers were recruited from 2 transplant centers. Participation was voluntary; results were confidential. An occupational and health history questionnaire was completed and blood was donated for testing. Health care workers were categorized into 3 groups according to risk for hepatitis C infection: very high, high, and low risk. A total of 241 health care workers were recruited from 2 transplant centers. Fifty-nine percent (142/241) were female; mean age was 38.7 years. Health care workers included: 48.5% (117/241) nurses, 24.9% (60/241) physicians, and 17% (42/241) laboratory personnel. The mean number of years in their occupation was 13.5 years (range < 1 year to 38 years). Twenty-four percent (57/241) were categorized in a very high risk occupation for hepatitis C, 66% (158/241) in a high risk occupation, and 10.8% (26/241) in a low risk occupation. A total of 2.1% (5/241) of health care workers were reactive to hepatitis C by enzyme immunosorbent assay; three of these were positive by polymerase chain reaction testing. Of the 3, none had a history of hepatitis or transfusion. However, 5.3% (3/57) of health care workers involved with liver transplantation were infected, as compared with 0% (0/184) who were not (P = 0.013). We conclude that health care workers associated with liver transplantation may be at a higher risk for hepatitis C when compared with health care workers not associated with transplantation.

Fever, pulmonary infiltrates, and pleural effusion following acyclovir therapy for herpes zoster ophthalmicus.

A 71-year-old man presented with herpes zoster ophthalmicus and ocular involvement. Following the institution of intravenous therapy with acyclovir, the patient developed fever, hemoptysis, and a pleural friction rub. A ventilation-perfusion lung scan showed no defects; roentgenograms showed bilateral infiltrates and a left-sided pleural effusion. The fever abated promptly following discontinuation of acyclovir, and radiographic abnormalities resolved over ten days. No other anti-infective therapy was given. To our knowledge, the syndrome of fever, pulmonary infiltrates, and pleural effusion following use of acyclovir has not been previously reported.

Isolation of Legionella pneumophila serogroup 5 from empyema following esophageal perforation. Source of the organism and mode of transmission.

A patient undergoing esophageal dilatation for carcinoma of the esophagus suffered esophageal perforation and development of an empyema. Culture of pleural fluid yielded multiple organisms, including Legionella pneumophila serogroup 5. Epidemiologic investigation showed that the source of L pneumophila was a tap used by the nursing personnel to fill patients' water pitchers. Whole-cell restriction endonuclease analysis of DNA from the clinical and environmental isolates of L pneumophila serogroup 5 yielded identical patterns. Our findings suggest that L pneumophila was acquired by the patient at least 12 h prior to the procedure causing the esophageal perforation and empyema, suggesting that the organism can persist in an infectious form in the upper aerodigestive tract.

Pseudomonas aeruginosa infections associated with use of povidone-iodine in patients receiving continuous ambulatory peritoneal dialysis.

Fifteen episodes of infection due to Pseudomonas aeruginosa, including peritonitis and catheter site infections, occurred in nine patients receiving continuous ambulatory peritoneal dialysis over a 27-month period. Eight episodes were associated with catheter loss. Occurrence of P aeruginosa infection was significantly associated with use of povidone-iodine solution to cleanse the catheter site. There was no association with use of povidone-iodine solution to disinfect tubing connections, use of other skin care products or exposure to other environmental sources of P aeruginosa. Cultures of available povidone-iodine products were negative. Local irritation and alteration in skin flora caused by antiseptic solution or low-level contamination of povidone-iodine solution are potential mechanisms of infection.

Legionnaires' disease in a newly constructed long-term care facility.

OBJECTIVES: To determine whether a newly-constructed long-term care facility would become colonized with Legionella and whether Legionnaires' disease would occur in residents of this new facility. DESIGN: Prospective environmental surveillance of the hospital's water distribution system for the presence of Legionella pneumophila during construction. Utilization of diagnostic tests for Legionnaires' disease in cases of nosocomial pneumonia. SETTING: The Pittsburgh VA Health Care System, Aspinwall Division, a two-building 400-bed complex. PARTICIPANTS: Six patients who acquired Legionnaires' disease while in the facility. INTERVENTION: Installation of copper-silver ionization systems. MEASUREMENTS: Isolation of L. pneumophila from potable water and the occurrence of Legionnaires' disease. RESULTS: L. pneumophila serogroup 1 was recovered from the water distribution system within 1 month of operation; 74% (61/82) of distal sites were positive during construction. In the first 2 years of occupancy, six cases of legionellosis were diagnosed. Both clinical isolates of L. pneumophila were identical to environmental isolates by pulsed field gel electrophoresis (PFGE). Copper-silver ionization systems were installed to control Legionella in the water system. CONCLUSIONS: We conclude that long-term care residents are at risk for acquiring nosocomial Legionnaires' disease in the presence of a colonized water system, even in a newly constructed building.

Infection with methicillin-resistant Staphylococcus aureus among hospital employees.

OBJECTIVE: To describe the spectrum of clinical infection caused by methicillin-resistant Staphylococcus aureus (MRSA) in healthcare workers. DESIGN: Case series. SETTING: Two Veterans Affairs hospitals in which methicillin-resistant S aureus (MRSA) is endemic. PATIENTS: Five employees presenting to employee health or infectious disease clinic. RESULTS: All employees had had direct exposure to patients colonized with MRSA. Employee infections included cellulitis, impetigo, folliculitis, paronychia, and conjunctivitis. MRSA was isolated from all clinically infected sites and from the anterior nares of two employees. Three employees received a variety of ineffective oral antimicrobials before MRSA was recognized as the causative agent. All infections responded to appropriate therapy. CONCLUSIONS: Employees of hospitals with endemic MRSA may acquire MRSA infection. Presentation in our employees was that of relatively uncomplicated soft tissue infection, but several employees received inappropriate therapy before bacteriologic diagnosis. We recommend that culture and susceptibility testing be obtained prior to institution of therapy when hospital employees present with soft tissue infection.

Choosing appropriate criteria for tuberculin positivity and conversion in a long-term care facility.

OBJECTIVES: The Centers for Disease Control and Prevention has issued new criteria for conversion of the tuberculin skin test; in persons over 35 years of age, an increase in induration of at least 15 mm is considered indicative of new tuberculous infection. We reviewed our experience in a tuberculosis control program in a long-term care facility to assess the applicability of the new criteria to our patient population. DESIGN: Retrospective review of seven years of tuberculosis control records and outbreak investigation. SETTING: Long-term care Veterans Affairs hospital. PATIENTS: All patients in the facility between 1985 and June 1992 who received routine admission and annual tuberculin skin testing or who were evaluated for possible exposure to active tuberculosis. A total of 2,342 skin tests were performed. RESULTS: Mean increase in skin test diameter in patients with at least two prior negative tests and known exposure to active tuberculosis was 13.9 +/- 4.7 mm. Frequency distribution histograms of skin test sizes of initial tuberculin testing in the entire population indicated 10 mm induration as a reasonable criterion for initial positivity. CONCLUSIONS: In our long-term care population, an increase in skin test induration of 10 mm may indicate new tuberculous infection. Criteria for skin test conversion derived from ambulatory populations in other geographic areas may not apply in all situations. Prevalence of infection with Mycobacterium tuberculosis and prevalence of skin test reactivity due to nontuberculous mycobacteria are likely to influence the predictive value of criteria for tuberculin conversion in a given population.