Non-epidemic Setting Research Articles

Leptospirosis-induced transverse myelitis and multiorgan failure: an uncommon manifestation in non-epidemic setting

Leptospirosis is a disease that can be transmitted from animals to humans. It is caused by a bacterium called Leptospira interrogans and is more common in tropical and subtropical regions. Despite being the most neglected tropical disease, it is a significant emerging and re-emerging disease, according to recent reports and reviews by the World Health Organization (WHO). Leptospirosis is widespread among humans and animals globally, and it is estimated that there are 1.03 million cases and 58,900 deaths annually, with a case fatality rate of 6.85%. Acute transverse myelitis (TM) is a rare neurological disease that affects the spinal cord. It is caused by various autoimmune reactions and is usually limited to several spinal cord segments. It has a poor prognosis. Our case report presents a unique situation where a patient developed multiorgan failure due to leptospirosis and also had a rare co-presentation of transverse myelitis.

Transmission Patterns of Clostridioides difficile in a Non-Epidemic Setting Based on WGS Analysis

Clostridioides difficile is a major nosocomial pathogen and has a considerable burden on healthcare systems. Our objective was to determine the transmission patterns of C. difficile in a non-epidemic setting using whole-genome multi-locus sequence typing (wgMLST) and core-genome single-nucleotide polymorphism (cgSNP) analyses. A retrospective study was conducted in a 650-bed university hospital between January 2016 and February 2017. In total, 191 strains isolated from 169 symptomatic C. difficile infection (CDI) patients were analyzed by WGS. Sequences were compared using wgMLST and cgSNP analyses. Genetic data and ward movements were then combined to identify the transmission rate and the type of transmission. The transmission rate varied from 55/169 (19.5%) (wgMLST) to 33/169 (32.5%) (cgSNP). Most transmission was considered cryptic, irrespective of the genetic analysis (38/55 [69.1%] by wgMLST to 25/33 [75.8%] by cgSNP). No transmission within the same ward was observed. In a non-epidemic setting, most C. difficile transmission occurs from sources other than symptomatic CDI patients.

Environmental shedding of toxigenic Clostridioides difficile by asymptomatic carriers: A prospective observational study

ObjectivesThe aim was to compare the burden of environmental shedding of toxigenic Clostridioides difficile among asymptomatic carriers, C. difficile-infected (CDI) patients and non-carriers in an inpatient non-epidemic setting. MethodsC. difficile carriage was determined by positive toxin-B PCR from rectal swabs of asymptomatic patients. Active CDI was defined as a positive two-step enzyme immunoassay/polymerase chain reaction (EIA/PCR) test in patients with more than three unformed stools/24 hr. C. difficile environmental contamination was assessed by obtaining specimens from ten sites in the patients' rooms. Toxigenic strains were identified by PCR. We created a contamination scale to define the overall level of room contamination that ranged from clean to heavy contamination. ResultsOne hundred and seventeen rooms were screened: 70 rooms inhabited by C. difficile carriers, 30 rooms by active CDI patients and 17 rooms by non C. difficile -carriers (control). In the carrier rooms 29 (41%) had more than residual contamination, from which 17 (24%) were heavily contaminated. In the CDI rooms 12 (40%) had more than residual contamination from which three (10%) were heavily contaminated, while in the control rooms, one room (6%) had more than residual contamination and none were heavily contaminated. In a multivariate analysis, the contamination score of rooms inhabited by carriers did not differ from rooms of CDI patients, yet both were significantly more contaminated than those of non-carriers odd ratio 12.23 and 11.16 (95% confidence interval 1.5–99.96 p 0.0195, and 1.19–104.49 p 0.035), respectively. DiscussionHere we show that the rooms of C. difficile carriers are as contaminated as those of patients with active CDI and significantly more than those of non-carriers.

1120. Clostridium difficile Infection Risk Factors, Severity, and Outcomes in Patients Infected with NAP1/027 Strain in a Non-Epidemic Setting

BackgroundEvidence surrounding outcomes with the North American pulsed-field gel electrophoresis type 1 (NAP1) Clostridium difficile (CDI) strain remains conflicting. We compared risk factors, severity of illness, and mortality of patients infected with NAP1 strain compared with patients with non-NAP1 strains in our multihospital health system.MethodsThis is a retrospective case–control analysis of patients admitted to one of five hospitals (one academic and four community hospitals) and diagnosed with CDI from April 2014 through July 2017. CDI definition included three or more stools per day with positive stool sample polymerase chain reaction (PCR) testing for C. difficile.ResultsA total of 490 patients met inclusion, of which 155 had the NAP1 strain and 335 patients were infected with non-NAP1 strains. More patients with NAP1 were older, female, had CHF, and presented from a healthcare facility as opposed to from the community (all P < 0.05). No difference in 90-day antibiotic class use was found. NAP1 patients had increased ICU admission (12.3 vs. 6.0%, P = 0.016), a shorter length of stay (10.8 vs. 13.4 days, P = 0.037), abnormal CT findings (P < 0.023), and trend toward more ID consults (P = 0.067). Per IDSA classification, 61.9% in the NAP1 CDI group had severe CDI as opposed to 49.6% in the non-NAP1 study group. (P ≤ 0.038). There was no observed difference in inpatient mortality (7.7 vs. 5.7%, P = 0.381).ConclusionCDI caused by NAP1 strain did result in increased severity but did not result in increased mortality compared with CDI caused by non-NAP1 strains. Evidence continues to mount that while the NAP1 strain may affect severity, its effect on mortality remains in question.Disclosures All authors: No reported disclosures.

Toxigenic Clostridium difficile colonization among hospitalised adults; risk factors and impact on survival

SummaryObjectivesTo establish risk factors for Clostridium difficile colonization among hospitalized patients in England.MethodsPatients admitted to elderly medicine wards at three acute hospitals in England were recruited to a prospective observational study. Participants were asked to provide a stool sample as soon as possible after enrolment and then weekly during their hospital stay. Samples were cultured for C. difficile before ribotyping and toxin detection by PCR. A multivariable logistic regression model of risk factors for C. difficile colonization was fitted from univariable risk factors significant at the p < 0.05 level.Results410/727 participants submitted ≥1 stool sample and 40 (9.8%) carried toxigenic C. difficile in the first sample taken. Ribotype 106 was identified three times and seven other ribotypes twice. No ribotype 027 strains were identified. Independent predictors of colonization were previous C. difficile infection (OR 4.53 (95% C.I. 1.33–15.48) and malnutrition (MUST score ≥2) (OR 3.29 (95% C.I. 1.47–7.35)). Although C. difficile colonised patients experienced higher 90-day mortality, colonization was not an independent risk for death.ConclusionsIn a non-epidemic setting patients who have previously had CDI and have a MUST score of ≥2 are at increased risk of C. difficile colonization and could be targeted for active surveillance to prevent C. difficile transmission.

Clostridium difficile infection (CDI) severity and outcome among patients infected with the NAP1/BI/027 strain in a non-epidemic setting.

Determine whether the NAP1 strain identified by polymerase chain reaction (PCR)-based stool assay is correlated with CDI severity and clinical outcomes. Medical records of adult patients with positive stool Xpert® Clostridium difficile PCR assay for an initial episode of CDI between January 2012 and January 2013 at a tertiary care hospital in Chicago were reviewed. Two patients diagnosed with CDI caused by a non-NAP1 strain (positive Xpert® C. difficile assay but negative Xpert® C. difficile Epi assay) were included for each patient diagnosed with CDI caused by a NAP1 strain (positive Epi assay). Patient charts were reviewed for markers of severity, risk factors, treatment regimens, and outcomes. Of 494 stool specimens, 90 (18%) that were positive for C. difficile by PCR were positive for NAP1 strain. In total, 37 patients with CDI due to NAP1 were matched with 74 patients with CDI due to non-NAP1 strains. Multivariable model revealed individuals ≥65 years old were 3 times more likely to have NAP1 strain than individuals <65 (P=.02). Residents of a nursing home prior to hospitalization were 10 times more likely to have NAP1 strain than patients residing in their homes (P=.001). More NAP1 cases had a change in treatment from metronidazole to oral vancomycin plus intravenous metronidazole (P=.01). The severity of CDI, incidence of mortality and recurrent CDI were similar between groups. In a nonepidemic setting, NAP1 strains were more common in older patients and individuals admitted from nursing homes. Identification of NAP1 by PCR of stool specimens was associated in a change of therapy but did not predict worse outcomes. Reporting strain results may not be clinically useful in routine settings.

Rate of Transmission of Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae Without Contact Isolation

Extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae are emerging worldwide. Contact isolation is recommended; however, little is known about the rate of transmission without contact isolation in the non-epidemic setting. Therefore, we aimed to estimate the rate of spread (R(0)) of ESBL-producing Enterobacteriaceae in a tertiary care center with 5 intensive care units. In this observational cohort study performed from June 1999 through April 2011, all patients at the University Hospital Basel, Switzerland, who were hospitalized in the same room as a patient colonized or infected with an ESBL-producing Enterobacteriaceae for at least 24 hours (index case) were screened for ESBL carriage by testing of rectal swab samples, swab samples from open wounds or drainages, and urine samples from patients with foley catheters. Strains with phenotypic evidence for ESBL were confirmed by polymerase chain reaction. Nosocomial transmission was assumed when the result of screening for ESBL carriage in a contact patient was positive and molecular typing by pulsed-field gel electrophoresis (PFGE) revealed clonal relatedness with the strain from the index patient. Active screening for ESBL carriage could be performed in 133 consecutive contact patients. Transmission confirmed by PFGE occurred in 2 (1.5%) of 133 contact patients, after a mean exposure to the index case of 4.3 days. The estimated rate of spread of ESBL-producing Enterobacteriaceae-in particular, Escherichia coli-was low in a tertiary care university-affiliated hospital with high levels of standard hygiene precautions. The low level of nosocomial transmission and the rapid emergence of community-acquired ESBL challenge the routine use of contact isolation in a non-epidemic setting, saving resources and potentially improving patient care.

Epidemiology and Clinical Characteristics ofClostridium difficileInfection in a Korean Tertiary Hospital

In order to investigate the incidence, clinical and microbiologic characteristics of Clostridium difficile infection (CDI) in Korea, a prospective observational study was performed. From September 2008 through January 2010, all patients whose stool was tested for toxin assay A&B and/or C. difficile culture were studied for clinical characteristics. Toxin types of the isolates from stool were tested. The mean incidence of CDI per 100,000 patient-days was 71.6 by month (range, 52.5-114.0), and the ratio of CDI to antibiotic-associated diarrhea was 0.23. Among 200 CDI patients, 37.5% (75/200) was severe CDI based on severity score. Clinical outcome of 189 CDI was as followed; 25.9% (49/189) improved without treatment, 84.3% (118/140) achieved clinical cure and attributed mortality was 0.7% (1/140) with the treatment. Recurrence rate was 21.4% (30/140) and cure without recurrence was 66.4% (93/140). The most common type of toxin was toxin A-positive/toxin B-positive strain (77.5%), toxin A-negative/toxin B-positive strains or binary toxin-producing strains comprised 15.4% or 7.1%, respectively. In conclusion, the incidence of CDI in Korea is a little higher than other reports during the non-epidemic setting. We expect that the change of epidemiology and clinical severity in CDI can be evaluated based on these results.

Clostridium difficile Strain NAP-1 Is Not Associated With Severe Disease in a Nonepidemic Setting

Recent outbreaks of Clostridium difficile infection (CDI) in North America and in Europe with very high case-fatality rates have been associated with infection by North American Pulsed Field Type I (NAP-1) isolates. This study examined whether NAP-1 strains are associated with worse outcomes of CDI in a nonepidemic, nosocomial setting. All cases of CDI that occurred over a 13-month period at a tertiary medical center were examined for risk factors associated with increased severity of CDI and other outcomes. Stool samples from each patient were cultured for C difficile and the resulting isolates were strain-typed by pulsed-field gel electrophoresis. Strain types were obtained from 236 of 272 CDI samples; the NAP-1 strain was identified in 59 (25%). In this inpatient cohort of patients with CDI, the incidence of in hospital death was 12.1% and of death caused by CDI was 4.0%. Of the patients with CDI, 22.1% met the combined outcome end point of severe CDI. In both univariate and multivariate analyses, patients infected with the NAP-1 strain did not have worse outcomes compared with those infected with non-NAP-1 strains. Infection with the NAP-1 strain was correlated with admission from outside health care facilities regardless of whether symptoms of CDI began before or after admission to the study hospital. The NAP-1 strain of C difficile was found to cause 25% of cases of CDI in the hospital where the study was performed. However, compared with non-NAP-1 strains, CDI was not associated with increased severity of disease in this nonepidemic setting.

W1278 Clostridium difficile NaP-1 Strain Is Not Associated with Severe Disease in a Non-Epidemic Setting

W1278 Clostridium difficile NaP-1 Strain Is Not Associated with Severe Disease in a Non-Epidemic Setting

Risk-factors for acquisition of extended-spectrum β-lactamase-producing Escherichia coli among hospitalised patients

Between 1996 and 2002, 103 hospitalised patients yielding one or more clinical isolates of extended-spectrum beta-lactamase-producing Escherichia coli (ESBL-EC) were identified. A significant increase was observed in the incidence of ESBL-EC colonisation or infection during the study period (1.65 episodes/100 000 patient-days in 1996 to 12.6 episodes/100 000 patient-days in 2002; p 0.01). Infection developed in 70 (68%) patients (75 episodes), with surgical site (44%) and urinary tract (17%) infections being the most frequent. Pulsed-field gel electrophoresis showed extensive clonal diversity among the isolates. A case-control study and multivariate analysis identified female gender (OR 2.1; p 0.01), use of a nasogastric tube (OR 3.5; p 0.001) and previous antibiotic therapy (OR 3.9; p < 0.001) as independent variables associated with acquisition of ESBL-EC. The study demonstrated a progressive increase in the number of ESBL-EC isolates in a non-epidemic setting. Most cases of ESBL-EC colonisation or infection occurred in hospitalised patients exposed to invasive procedures and antibiotic pressure.

Relationship between environmental fungal contamination and the incidence of invasive aspergillosis in haematology patients

Invasive aspergillosis (IA) is a major opportunistic infection in haematology patients. Spore inhalation is the usual route of Aspergillus infection, suggesting a determining role of environmental contamination by spores in the epidemiology of IA. We prospectively examined the relationship between environmental contamination by Aspergillus and other fungal species and the incidence of invasive nosocomial aspergillosis (INA) in a bone marrow transplantation unit and two haematology wards. During a four-year period, levels of air and surface fungal contamination were determined bi-monthly in patients' rooms(some equipped with HEPA filters and LAF systems), and various common sites in each ward (corridors, nursing stations, etc.). Results were compared to the incidence of INA. A total of 3100 air and 9800 surface samples were collected, and 79 cases of IA were diagnosed, of which 64 were probably or possibly INA. Patterns of fungal contamination were comparable in the three wards, with a gradient ranging fromhigh levels in common sites to a virtual absence in rooms equipped with HEPA filters and LAF systems. Using a regression model, a significant relationship was found between the incidence of INA and the degree of fungal contamination of air and surfaces in conventional patient rooms (not equipped with HEPA) and common sites. This study shows that in a non-epidemic setting, there is a significant relationship between environmental fungal contamination in haematology wards and the incidence of INA. Ourfindings underline the importance of environmental surveillance and strict application of preventivemeasures.

Hospital carpeting and epidemiology of Clostridium difficile

Background:Clostridium difficile is the usual and most important cause of antibiotic-associated pseudomembranous enterocolitis. The source of nosocomial acquisition of the organism in nonepidemic settings has not been determined. Methods: Epidemiologic and microbiologic studies were conducted in a community-teaching hospital complex to assess the impact of carpeting in patient rooms on environmental contamination with C. difficile, along with the prevalence of pseudomembranous enterocolitis. All C. difficile isolates were typed by means of a bacteriophage-bacteriocin typing scheme. Results: No clear evidence of environmental acquisition of C. difficile in a nonepidemic setting of pseudomembranous enterocolitis was found. Carpeted floors were significantly more heavily contaminated for prolonged periods with clinical strains of C. difficile than were noncarpeted floors. Conclusion: There was no evidence that contamination of carpeting resulted in increased frequency of pseudomembranous enterocolitis in patients residing in carpeted rooms. Because there is strong evidence of exogenous acquisition of C. difficile during outbreaks, however, room carpeting should be considered a potential reservoir of this organism.