Positive Stool Test Research Articles

The yield of stool testing in hospital-onset diarrhea: Has evidence changed practice?

Introduction: Aside from examination for Clostridium difficile, the yield of stool testing in hospital-onset diarrhea is poor. Clinical practice guidelines discourage overzealous stool testing in patients with diarrhea that develops after the third hospital day. However, the adoption of this recommendation into clinical practice is limited. Furthermore, the effect of microbiology laboratory improvements on hospital-onset diarrhea testing is largely unknown. Methods: A retrospective cohort study was conducted in a university-affiliated community-hospital and included all adult inpatients who developed diarrhea after hospitalization. Results: 132 adult patients (53% female) developed diarrhea after hospitalization in 2013. The cohort’s mean age was 55.6 years. 46.2% of patients developed diarrhea in the first 3 days of hospitalization. Testing for parasites was negative in all examined 67 samples. Testing for C. difficile was positive in 13 cases (10.8%) out of 120 tested samples. Testing for other pathogens was positive in 1 sample (Campylobacter) out of 129 samples. Stool samples tested in the first 3 days of hospitalization were more likely to be positive (64.3 vs 35.7%, p = 0.1). Change in management was reported in 9 out of 14 patients (64.3%) with positive stool testing compared with 31 out of 118 patients (26.3%) with negative stool testing, p = 0.01. Conclusion: Despite improvements in stool samples’ testing, the yield continues to be low, especially in hospital-onset diarrhea past the third hospital day. Physicians’ embracement of the ‘3-day rule’ continues to be poor.

Clostridium difficile ribotype 027: relationship to age, detectability of toxins A or B in stool with rapid testing, severe infection, and mortality.

Clostridium difficile infection (CDI) can cause severe disease and death, especially in older adults. A better understanding of risk factors for adverse outcomes is needed. This study tests the hypotheses that infection with specific ribotypes and presence of stool toxins independently associate with severity and constructs predictive models of adverse outcomes. Cases of non-recurrent CDI were prospectively included after positive stool tests for toxins A and/or B by enzyme immunoassay (EIA) or tcdB by polymerase chain reaction. Outcomes included severe CDI (intensive care unit admission, colectomy, or death attributable to CDI within 30 days of diagnosis) and 30-day all-cause mortality. Adjusted models were developed to test hypotheses and predict outcomes. In total, 1144 cases were included. The toxin EIA was positive in 37.2% and 35.6% of patients were of age >65 years. One of the 137 unique ribotypes was ribotype 027 (16.2%). Detectable stool toxin did not associate with outcomes. Adjusting for covariates, including age, Ribotype 027 was a significant predictor of severe CDI (90 cases; odds ratio [OR], 1.73; 95% confidence interval [CI], 1.03-2.89; P = .037) and mortality (89 cases; OR, 2.02; 95% CI, 1.19-3.43; P = .009). Concurrent antibiotic use associated with both outcomes. Both multivariable predictive models had excellent performance (area under the curve >0.8). Detection of stool toxin A and/or B by EIA does not predict severe CDI or mortality. Infection with ribotype 027 independently predicts severe CDI and mortality. Use of concurrent antibiotics is a potentially modifiable risk factor for severe CDI.

Risk of Clostridium Difficile Infection in Leukemia and Lymphoma Patients

Background: Clostridium difficile is the most important cause of nosocomial infectious diarrhea. The prevelance of C. difficile infection (CDI) has been poorly investigated in patients with hematologic malignancies such as leukemia and lymphoma.Purpose: To evaluate the clostridium difficile infection (CDI) incidence, severity, recurrence, developing sepsis and 30-days mortality among hospitalized patients with Leukemia and lymphoma.Methods: IRB approved retrospective case control study. 2020 patients were admitted for >48 hours in our institution between July 2007 and December 2013 with CDI, and had adequate follow up. CDI was defined as more than 3 episodes of loose stools in less than 24 hrs with a positive CD stool toxin assay. Recurrent CDI (RCDI) defined as readmission for recurrent diarrhea with 2nd positive stool test 15 days following complete resolution of previous diarrheal episode and cessation of CDI treatment.Computerized medical records to investigate demographics, laboratory blood work, Carlson Co-morbidity index, and medication used. Patients were divided into leukemia lymphoma group and control group. Group-1 included all patients with Leukemia lymphoma; AML, CML, ALL CML.Univariate predictors of CDI and multiple logistic regressions were used to assess whether patients with leukemia lymphoma had higher incidence of severity, recurrence and mortality. Controlling for Age, Serum Albumin, modified Carlson Co-morbidity index (CCI), PPI, antibiotics, and CDI treatment.Results: 2020 patients had been identified; in group-1 19 out of 95 patients (25%) had RCDI. In the control group, 364 out of 1655 patients (18%) had RCDI (p=0.614). 30-days mortality 7 out of 95 patients died within group-1 versus 157 out of 1924 in control group (p=0.799). Criteria for sepsis was fulfilled in 37 out of 95 in group-1 versus 482 out of 1924 in control group (p=0.003)Conclusion: We conclude that hospitalized patient with Leukemia and lymphoma had higher incidence of developing sepsis from CDI. There was no difference in the incidence of recurrence and 30-days mortality between patients with Leukemia lymphoma than control group. Physicians should have high suspicious for CDI in Leukemia lymphoma patients. Depend on this study we suggest early diagnosis and starting second line stronger treatment may help in decrease the incidence of CDI related sepsis. DisclosuresNo relevant conflicts of interest to declare.

Recurrent Clostridium difficile Infection in Patients With Chronic Kidney Disease

Introduction: To evaluate the impact of chronic kidney disease (CKD) on recurrent Clostridium difficile infection (RCDI) in hospitalized patients. Methods: This is a retrospective case control study of 2,020 patients admitted for >48 hours to our institution between 1/2007 and 11/2013 with Clostridium difficile infection (CDI). CDI was defined as >3 episodes of loose stools in <24 h with a positive CD stool toxin assay. Recurrent CDI (RCDI) defined as readmission for recurrent diarrhea with second positive stool test 15-90 days following complete resolution of previous diarrheal episode and cessation of CDI treatment. Computerized medical records to investigate demographics, laboratory blood work, Carlson comorbidity index, and medication used. Patients were divided accordingly into stages 1, 2, 3, 4 and 5 CKD by measuring glomerular filtration rate (GFR). Univariate predictors of RCDI and multiple logistic regression to assess whether CKD is an independent risk factor for developing CD, controlling for age, serum albumin, modified CCI, PPI, antibiotics, and CDI treatment. Results: Two thousand six patients had complete data. RCDI was identified in 209 patients <90 days and 154 patients >90 days. One thousand forty-five patients had normal kidney function, 537 had CKD stage 3, 261 patients had stage 4 CKD, and 163 had stage 5 CKD. Recurrence rate was 11% in normal kidney function patients, 8% in CKD 3, 8% in CKD 4, and 17% in CKD 5 patients. In univariate and multivariate model CKD was significantly associated with RCDI (p=0.039). In univariate and multivariate model CKD was significantly associated with RCDI (p=0.039). In univariate and multivariate model CKD was significantly associated with RCDI (p=0.039). Conclusion: CKD, PPIs use, high CCI score, and the type of treatment used for previous CDI are significantly associated with RCDI. CKD is an independent predictor of RCDI in our study.Table

Outcomes for Severe Complicated Clostridium difficile Infection Treated with Vancomycin Enemas

Introduction: The prevalence of Clostridium difficile infection (CDI) is increasing. Serious, complicated infections have been linked to a virulent strain (BI/NAP1), which produces elevated levels of toxin and can lead to colectomy or death. For these infections, standard of care is now concomitant treatment with IV metronidazole (IVM) and per oral vancomycin (POV). Some institutions use add-on therapy with vancomycin per rectum (VPR) to increase colonic drug delivery when there is a concern about delayed transit. Our purpose was to look at clinical outcomes of consecutive patients with CDI treated with VPR at our hospital. Methods: Using pharmacy records and manual chart review, we identified inpatients prescribed VPR from 1/2003 to 12/2013. Included patients had diarrhea, a positive stool test for Clostridium difficile toxin by ELISA, and no alternative cause for symptoms. Patients were required to have been in the ICU at the initiation of treatment and to have received ≥4 doses of VPR. Patients were followed to discharge or death. Results: We identified 43 CDI patients who received VPR during the study period. We excluded 18 patients because they did not receive ≥4 doses of VPR and 1 patient who received VPR after colonic surgery. There were 11 males and 13 females, mean age was 61.8±15.9 years (range: 21-93). The dose of VPR (IV solution mixed in 100 cc of tap water) ranged from 125 to 250 mg Q 6-8 hrs. Most patients received concomitant therapy with POV (n=17) and/or IVM (n=20). Four patients (16.7%) underwent colectomy and 3 died post-op. Mortality was 11/24 (45.8%) including the 3 post-op deaths. The mean number of doses of VPR in those who survived versus died was 22.3±6.9 vs. 19.3±19.4 (P=0.62). Similarly, there were no significant differences (all P>0.05) in age (64.5±16.7 vs. 59.1±15.3 years), WBC (24.6±11.5 vs. 25.7±17.9K), or interval rise in creatinine (91.6% vs. 100%) between those who survived versus died or those who survived versus the combined endpoint of surgery/death. There was notably a shorter median time interval between initiation of CDI treatment and initiation of VPR for those who survived and avoided surgery (3.5 days; IQR 1-15.25 vs. 8.5 days; IQR 2-19.5), but this was not statistically significant (P=0.47). Conclusion: In our study, the largest case series reported to date on the use of VPR for severe, complicated CDI, 50.0% of patients ultimately died or had a colectomy. Based on our modest sample size and high rate of morbidity and mortality we cannot strongly advocate for the use of VPR at this time. It appeared that earlier initiation of VPR may be beneficial. Controlled trials are needed to better assess this therapy.

The Effect of Statins on the Risk of Recurrent Clostridium difficile Infection

Introduction: To assess the effect of statins on recurrent Clostridium difficile infection (RCDI) among hospitalized patients. Methods: An IRB-approved retrospective case control study in which 2,020 patients were admitted for >48 hours in our institution between January 2007 and November 2013 with CDI, and had adequate follow-up. CDI was defined as >3 episodes of loose stools in <24 hours with a positive CD stool toxin assay. RCDI was defined as readmission for recurrent diarrhea with second positive stool test 15 days following complete resolution of previous diarrheal episode and cessation of CDI treatment. Computerized medical records to investigate demographics, laboratory blood work, Carlson comorbidity index, and medication used. Patients were divided statins group (patients using statins) and control group. Statin exposure was defined as a history of statin use for at least one year prior to developing CD. Statins considered include simvastatin, atorvastatin, pravastatin, lovastatin, fluvastatin, and rosuvastatin. Univariate predictors of CD and multiple logistic regression was used to assess whether statins use had impact on RCDI, controlling for age, serum albumin, modified Carlson comorbidity index (CCI), PPI, antibiotics, and CDI treatment. Results: Two thousand twenty patients had been identified; in statins group 122 out of 674 patients (18.1%) had RCDI. In the control group 242 out of 1345 patients (17.9%) had RCDI. Statins did not have any impact on RCDI in univariate or in multivariate model (Table 1). Conclusion: Contrary to the previous reports, our study did not show any protective effect of statin on RCDI.Table 1: Multiple Logistic Regressions and Risk Factors for RCDITable 2: Demographic and Clinical Characteristics of the Study Population

Single Nucleotide Polymorphisms of the tcdC Gene and Presence of the Binary Toxin Gene Predict Recurrent Episodes of Clostridium difficile Infection

To identify Clostridium difficile genotypes, which are associated with recurrent C difficile infection (RCDI). Reliable bacterial genetic factors predicting RCDI are currently lacking. Inpatients and outpatients 18 years or older treated at our institution for C difficile infection (CDI) of any severity were consecutively enrolled. CDI was defined as symptoms of colitis with a positive PCR stool test. Each bacterial isolate was studied for virulence factors: tcdC mutations, including single nucleotide polymorphisms (SNPs) via PCR, the presence of genes for toxins A, B and binary toxin using restriction fragment length polymorphism, and identification of ribotype by PCR. χ tests, t tests, and logistic and linear regression were used to determine which virulence factors predicted RCDI and the need for hospital admission, with corrections made for multiple statistical comparisons. Seventy-three patients (male: 52%; mean age: 66 ± 15 years) were studied. Binary toxin gene (P = 0.03) was associated with at least 1 episode of RCDI, as was the presence of SNPs C184T (P = 0.006) and A117T (P = 0.003). The presence of the binary toxin gene with either of these tcdC SNPs increased RCDI by 80% (P = 0.0002) but did not predict the need for hospital admission. None of the other virulence factors, including ribotype 027, were predictive of RCDI. The presence of the binary toxin gene and tcdC SNPs C184T and A117T strongly predict RCDI. The presence of both tcdC SNPs and the binary toxin gene significantly increased the risk of RCDI, which might warrant longer antibiotic courses to eradicate the infection.

Single Donor-Derived Strongyloidiasis in Three Solid Organ Transplant Recipients: Case Series and Review of the Literature

Donor-derived Strongyloides stercoralis infections in transplant recipients are a rare but recognized complication. In this case series, we report donor-derived allograft transmission of Strongyloides in three solid organ transplant recipients. Following detection of infection in heart and kidney-pancreas recipients at two different transplant centers, a third recipient from the same donor was identified and diagnosed. S. stercoralis larvae were detected in duodenal aspirates, bronchial washings, cerebrospinal fluid, urine and stool specimens. Treatment with ivermectin and albendazole was successful in two of the three patients identified. The Centers for Disease Control and Prevention was contacted and performed an epidemiologic investigation. Donor serology was strongly positive for S. stercoralis antibodies on retrospective testing while all pretransplant recipient serum was negative. There should be a high index of suspicion for parasitic infection in transplant recipients and donors from endemic regions of the world. This case series underscores the need for expanded transplant screening protocols for Strongyloides. Positive serologic or stool tests should prompt early treatment or prophylaxis in donors and recipients as well as timely notification of organ procurement organizations and transplant centers.

A neglected cause for chronic spontaneous urticaria in children: Helicobacter pylori

BackgroundThe aetiology of chronic urticaria is usually considered idiopathic. There is a paucity of research both on the prevalence of Helicobacter pylori infection in the aetiology of chronic spontaneous urticaria (CU) in children and also on which patients H. pylori should be investigated. MethodsAll paediatric and adult patients who presented to the allergy outpatient clinic due to CU between January 2011 and July 2012 were included in this prospective, randomised study. Stool samples from all patients were examined for the H. pylori antigen. Paediatric and adult patients who had a positive stool test for the H. pylori antigen were reassessed following eradication therapy. ResultsThirty-two children with CU and 35 adults with CU were enrolled in the study. Ten of the 32 (31.2%) children and 18 of the 35 (51.4%) adults were H. pylori positive (p=0.09). All children with positive-H. pylori were older than eight years of age. There was a significant positive correlation between age and the frequency of H. pylori infection (p<0.001; r=0.61). The presence of H. pylori was not significantly associated with the presence of GI (gastrointestinal) symptoms (p>0.05). Following H. pylori eradication, urticarial symptoms recovered in 15 of the adults (83.3%) and 10 of the paediatric (100%) patients (p=0.172). ConclusionIn the current study we found that H. pylori is common among children with CU, particularly after eight years of age. We suggest that CU patients with an unknown aetiology should be routinely screened for H. pylori even if they do not present with GI symptoms and that those with H. pylori-positive results may receive treatment.

Blastocystis sp. frequency and sources among children from 0 to 5 years of age attending public day care centers in Calarcá, Colombia

There are no reports of the potential sources of Blastocystis sp . in Colombia. To estimate the frequency of Blastocystis sp . and explore possible associations among infection, clinical manifestations and environmental sources. A descriptive study was conducted; a representative sample was calculated from a population of 1,993 children less than 5 years old of the lowest socioeconomic levels (1 and 2) attending day care centers in Calarcá, Colombia. The calculated sample size was 275 children, who were selected randomly in 10 % of the centers. Stool testing, questionnaires and sampling to identify the parasite in feces, nails, pets and environmental sources, were performed. Fresh preparations were made with 1% iodine solution, and a concentration technique with formalin-ether was used. Prevalence and odd ratios were estimated; the chi-square test was utilized for qualitative variables, and Student's t for the quantitative ones. The prevalence of infection in children was of 57.5%. A statistically significant association was found between the Blastocystis sp . positive stool tests and the presence of the parasite in containers of sugar cane beverage (OR=1.70; 95% CI: 1.05-2.79), wood or ground floors (OR=3.43; 95% CI: 1.12-10.48) and in foods other than bottled milk (OR=3.23; 95% CI: 1.41-4.41). A non-significant high prevalence was found in nails (OR=1.62; 95% CI: 0.99-2.67), as well as a significantly higher prevalence of diarrhea (OR=1.95; 95% CI: 0.99-2.77) in children with Blastocystis sp . (45%) as compared with those without the parasite (33%; p<0.05). Blastocystis sp . showed a significant association with diarrhea symptoms in children 0 to 5 years old and was widely distributed in the environment and in water. It is necessary to determine if there are specific hosts with pathogenic potential through molecular techniques.

Frecuencia y fuentes de Blastocystis sp. en niños urbanos de 0 a 5 años de hogares infantiles del estado del municipio de Calarcá, Colombia

There are no reports of the potential sources of Blastocystis sp . in Colombia.To estimate the frequency of Blastocystis sp . and explore possible associations among infection, clinical manifestations and environmental sources.A descriptive study was conducted; a representative sample was calculated from a population of 1,993 children less than 5 years old of the lowest socioeconomic levels (1 and 2) attending day care centers in Calarcá, Colombia. The calculated sample size was 275 children, who were selected randomly in 10 % of the centers. Stool testing, questionnaires and sampling to identify the parasite in feces, nails, pets and environmental sources, were performed. Fresh preparations were made with 1% iodine solution, and a concentration technique with formalin-ether was used. Prevalence and odd ratios were estimated; the chi-square test was utilized for qualitative variables, and Student's t for the quantitative ones.The prevalence of infection in children was of 57.5%. A statistically significant association was found between the Blastocystis sp . positive stool tests and the presence of the parasite in containers of sugar cane beverage (OR=1.70; 95% CI: 1.05-2.79), wood or ground floors (OR=3.43; 95% CI: 1.12-10.48) and in foods other than bottled milk (OR=3.23; 95% CI: 1.41-4.41). A non-significant high prevalence was found in nails (OR=1.62; 95% CI: 0.99-2.67), as well as a significantly higher prevalence of diarrhea (OR=1.95; 95% CI: 0.99-2.77) in children with Blastocystis sp . (45%) as compared with those without the parasite (33%; p<0.05).Blastocystis sp . showed a significant association with diarrhea symptoms in children 0 to 5 years old and was widely distributed in the environment and in water. It is necessary to determine if there are specific hosts with pathogenic potential through molecular techniques.

Imported strongyloidiasis in Spain

The objective of this study was to assess the epidemiological, laboratory, and clinical features of imported strongyloidiasis in a tropical medicine referral unit in Madrid, Spain. This was a retrospective study based on a review of medical records. A patient was diagnosed with strongyloidiasis when the infection could be detected by conventional stool analysis and/or serology against Strongyloides stercoralis, regardless of the presence of symptoms. One hundred and seventy-eight cases of strongyloidiasis were included in the study. Stool tests were performed in all patients, and serology in 160 patients (89.9%). The diagnosis of strongyloidiasis was based on serology only in four patients; 21 patients only had positive stool tests. A third of the total strongyloidiasis cases in this study were travel-related, mainly associated with short trips (<2 months). Only 47.8% of total cases were symptomatic. We found no differences in clinical presentation between immigrants and travelers with strongyloidiasis. Not only should strongyloidiasis be suspected in symptomatic travelers and immigrants, but it should also be ruled out when elevated IgE levels or eosinophilia are present. Strongyloidiasis can be asymptomatic in HIV patients, but it should be diagnosed and treated before a possible hyperinfection develops.

Proton Pump Inhibitors and Risk for Recurrent Clostridium difficile Infection Among Inpatients

Observational studies suggest that proton pump inhibitors (PPIs) are a risk factor for incident Clostridium difficile infection (CDI). Data also suggest an association between PPIs and recurrent CDI, although large-scale studies focusing solely on hospitalized patients are lacking. We therefore performed a retrospective cohort analysis of inpatients with incident CDI to assess receipt of PPIs as a risk factor for CDI recurrence in this population. Using electronic medical records, we identified hospitalized adult patients between 1 December 2009 and 30 June 2012 with incident CDI, defined as a first positive stool test for C. difficile toxin B and who received appropriate treatment. Electronic records were parsed for clinical factors including receipt of PPIs, other acid suppression, non-CDI antibiotics, and comorbidities. The primary exposure was in-hospital PPIs given concurrently with C. difficile treatment. Recurrence was defined as a second positive stool test 15-90 days after the initial positive test. C. difficile recurrence rates in the PPI exposed and unexposed groups were compared with the log-rank test. Multivariable Cox proportional hazards modeling was performed to control for demographics, comorbidities, and other clinical factors. We identified 894 inpatients with incident CDI. The cumulative incidence of CDI recurrence in the cohort was 23%. Receipt of PPIs concurrent with CDI treatment was not associated with C. difficile recurrence (hazard ratio (HR)=0.82; 95% confidence interval (CI)=0.58-1.16). Black race (HR=1.66, 95% CI=1.05-2.63), increased age (HR=1.02, 95% CI=1.01-1.03), and increased comorbidities (HR=1.09, 95% CI=1.04-1.14) were associated with CDI recurrence. In light of a higher 90-day mortality seen among those who received PPIs (log-rank P=0.02), we also analyzed the subset of patients who survived to 90 days of follow-up. Again, there was no association between PPIs and CDI recurrence (HR=0.87; 95% CI=0.60-1.28). Finally, there was no association between recurrent CDI and increased duration or dose of PPIs. Among hospitalized adults with C. difficile, receipt of PPIs concurrent with C. difficile treatment was not associated with CDI recurrence. Black race, increased age, and increased comorbidities significantly predicted recurrence. Future studies should test interventions to prevent CDI recurrence among high-risk inpatients.

The impact of aspirin, statins and ACE-inhibitors on the presentation of colorectal neoplasia in a colorectal cancer screening programme

Background:There is increasing evidence that aspirin, statins and ACE-inhibitors can reduce the incidence of colorectal cancer. The aim of the present study was to assess the impact of these medications on an individual's risk of advanced neoplasia in a colorectal cancer screening programme.Methods:A prospectively maintained database of the first round of screening in our geographical area was analysed. The outcome measure was advanced neoplasia (cancer or intermediate or high risk adenomata).Results:Of the 4188 individuals who underwent colonoscopy following a positive occult blood stool test, colorectal pathology was present in 3043(73%). Of the 3043 patients with colorectal pathology, 1704(56%) had advanced neoplasia. Patients with advanced neoplasia were more likely to be older (OR 1.38; 95% CI 1.19–1.59) and male (OR 1.66; 95% CI 1.43–1.94) (both P<0.001). In contrast, those on aspirin (OR 0.68; 95% CI 0.56–0.83), statins (OR 0.65; 95% CI 0.55–0.78) or ACE inhibitors (OR 0.71; 95% CI 0.57–0.89) were less likely to have advanced neoplasia at colonoscopy (all P<0.05).Conclusion:In patients undergoing colonoscopy following a positive occult blood stool test with documented evidence of aspirin, statin or ACE-inhibitor usage, advanced neoplasia is less likely, suggesting that the usage of these medications may have a chemopreventative effect.

Endoscopic colorectal cancer screening provides long-lasting effect.

Endoscopic colorectal cancer screening provides long-lasting effect.

Polysaccharide hemostatic system for hemostasis management in colorectal endoscopic mucosal resection

A new polysaccharide hemostatic system (EndoClot(TM) ) was recently developed for bleeding control in gastrointestinal tract endoscopy; however, its efficacy and safety is not yet well established in colorectal endoscopic mucosal resection (EMR). The aim of the present study was to observe the bleeding control effect after EMR in the colorectum. EndoClot(TM) was applied immediately to mucosal defects after resection whether or not there was post-resection bleeding. Bleeding was monitored post-procedurally by clinical findings including positive stool occult blood test and by second-look endoscopy. Hemostasis, rebleeding rates and treatment-related complications were observed. In total, 82 patients were enrolled, totaling 181 lesions. Among them, 20 lesions in 18 cases showed bleeding immediately after the procedure. Among them, two lesions were treated by combined hot biopsy forceps, and complete hemostasis was achieved in all cases without surgery. It took 1.1 min (0.4-2.1) tocarry out hemostasis treatment. Rebleeding with positive stool test and colonoscopy recurred in three of 18 patients with immediate post-procedural bleeding. In patients without immediate post-procedural bleeding, three patients were confirmed with delayed bleeding. No major adverse events of treatment or procedure-related serious adverse events were reported during a 30-day follow up. Colonoscopy was done in selected patients at 30 days and full recovery of mucosal defect was achieved in all cases. Polysaccharide hemostatic system effectively achieves hemostasis in controlling and preventing EMR-related bleeding with the advantage of simple application; thus it might be a useful alternative in treating bleeding endoscopically.

Secular trends in the epidemiology of Clostridium difficile infection (CDI): relationship with alcohol gel and antimicrobial usage in a hospital

Clostridium difficile-associated diarrhea (CDAD) has shown increasing incidence, morbidity, and mortality in recent years. We assessed the number of CDAD tests requested, CDAD positivity rates, the use of alcohol-based hand rubs, and antimicrobial utilization. We collected information on every adult patient (>18 years) who developed diarrhea and had a positive stool test for C. difficile toxin from June 2005 to December 2009 at a tertiary care hospital. A time-series analysis was performed using monthly data on the incidence of C. difficile infection (CDI) (i.e., cases of infection per 1000 patient-days), as well as the consumption of alcohol-based hand rubs (in liters/1000-patient days) and antibiotics (in defined daily doses per 1000 patient-days). The mean number of annual requests for C. difficile tests was 1031, and the rates per 1000 patient-days for each year from 2005 to 2009 were 0.30, 0.46, 0.39, 0.31, and 0.40 overall in the hospital, and 0.18, 0.10, 0.53, 0.38, and 0.37 in the intensive care unit (ICU). The use of alcohol-based hand rubs per 1000 patient-days increased from 37.4 to 73.0, and from 41.5 to 129.4 in the hospital and in the ICU, respectively. The incidence of CDI in the hospital and ICU remained low, despite the increased use of alcohol-based hand rubs and antimicrobials.

Underwater Snare Cautery Polypectomy Can Be Safely Executed During Water Exchange Colonoscopy

Purpose: Worries over inability to re-identify polyps seen on insertion during scope withdrawal has led to recommendations to remove them when first encountered. In water exchange colonoscopy, water is used to lavage and clean the bowel while dirty water is suctioned from the colon during insertion. Concerns have been expressed that polypectomy may be difficult under water. Here we report a case of underwater polypectomy and retrieval during water exchange colonoscopy. Case: A 77-year-old man underwent diagnostic colonoscopy for FIT positive stool test. The patient was fully sedated for the supervised trainee. Using the water exchange method, the scope was advanced to the cecum. In the cecum, two pedunculated polyps (1 cm and 1.5 cm) were encountered (A). With the cecum still distended with water, underwater snare cautery polypectomy was successfully carried out on these two polyps (B). The polyps were successfully recovered via the suction channel (C, D). The patient experienced no pain. Upon withdrawal of the scope back through the colon, an additional 12 polyps were removed. At a follow-up appointment, the patient had no signs or symptoms of serositis or post-polypectomy syndrome. Discussion: This patient received full sedation dictated by the conventional approach in our training program. Whereas traditional colonoscopy uses air insufflation to dilate the colon, this patient was examined by the trainee using the water exchange method supervised by an attending experienced in this method as a learning exercise. To date, routine polypectomy under water with successful retrieval of the resected polyp has not been reported. The current case details how successful polypectomy and retrieval can occur even with the cecum filled with water. Conclusion: Underwater polypectomy in conjunction with the water exchange method is safe. Proficiency in the water exchange method improves the ability to recover polyps underwater, should the need arise, e.g., removal of polyps encountered during insertion.Figure: [1339] Figure A: Polyp encountered with cecum filled with water. B: Underwater snare cautery polypectomy. C: Retrieval of polyp. D: Following underwater polypectomy.

The role of an independent entity in equitable access of vaccines in developing countries: A case from Pakistan

Background: This study is the first to examine the effect of otavirusvaccinationon rotavirusgastroenteritis inThailand. Itwas onducted by determining the results of stool specimens tested for otavirus antigen before and after the introduction of the vaccine. Methods: The study was undertaken at Samitivej Hospital, one f Thailand’s leading private hospitals located in Bangkok, where otavirus vaccination has been introduced since March 2006. The ospital’s database between 2005 and 2010 were retrospectively eviewed in order to identify children aged 5 years) and themonthly distribution of rotavirus activty before and after the vaccination were analyzed. The number of reakthrough rotavirus gastroenteritis among vaccinated children as also tallied. Results: During the 6-year period, a total of 3,052 stool specienswere tested for rotavirus antigen. In 2005 (before vaccination tarted), 110 (47%) of 232 stool specimens in all the children were ested positive, and 52.7%, 33.6%, and 13.6% of the positive tests ere found in the children aged 5 years, espectively. Between 2007 and 2009, there was a gradual decline n the percentage of the overall positive stool tests. More interestngly, the percentage of positive stool tests in the children aged 5 years, respectively. Despite these hanges, the seasonal peak in November to February remained the ame. Among 2,162 vaccinated children, there were 29 children 1.3%) having breakthrough rotavirus gastroenteritis. Conclusion: After introducing rotavirus vaccination, there was remarkable decline in the positive rate of stool specimens tested or rotavirus antigen in all the age groups, notably in children aged 2 years. However, there was an increase in rotavirus infection in hildren aged >5 years. Despite these, the monthly distribution of otavirus activity remained unchanged during the study period.

P418 Extraintestinal manifestations in inflammatory bowel disease; the prevalence in tertiary referral center

Background: CDI is the main cause of antibiotic associated infectious diarrhea. Incidence, severity and burden on the healthcare system related to CDI have increased in last decade in many industrialized countries. Epidemiological data of CDI are scarce in Southern Europe. Aims: To evaluate incidence and secular trend of nosocomial CDI between 2000 and 2009 in two Spanish referral hospitals. To analyze the highest incidence rates across specialties. Methods: Setting: Two referral hospitals in the Barcelona metropolitan area. Design: Retrospective surveillance study. Laboratory CDI diagnosis: Positive toxigenic culture and/or toxin detection in fecal samples using cell citoxicity neutralization assay. Patients: All in-patients from whom an appropriate fecal sample was submitted for CDI study between January 2000 and December 2009 were included. Nosocomial CDI case definition: A nosocomial CDI case was defined by the presence of either a positive stool test for C. difficile toxin or toxigenic C. difficile more than 48 hours after admission and that not have been diagnosed of CDI within the previous 28 days. Results: We identified 278 cases. Between 2000 and 2005 CDI incidence remained stable (0.52 and 0.54 cases/10.000 inpatient days in 2000 and 2005 respectively). During second half of this decade a four fold increase in incidence occurred (0.79, 1.48, 1.95 y 2.33 cases/10.000 in-patient days in 2006, 2007, 2008 y 2009 respectively). During de same period there was an increased hospitalary antibiotics consumption (from 56 to 67 defined daily doses/100 in-patient days between 2000 and 2009) that correlated with nosocomial CDI incidence (r = 0.98, p < 0.001). Hematology, ICU, Infectious Diseases and Gastroenterology Departments had the highest CDI incidence rates. Conclusions: CDI incidence has quadruplicate during second half of last decade coinciding with an increased use of antibiotics. Our results highlight the importance of CDI surveillance in hospitals, specially among high risk departments.