Consequences of Clostridium difficile infection: understanding the healthcare burden

AbstractClostridium difficile is the leading cause of infectious nosocomial diarrhoea in developed countries, with a measured incidence of approximately five episodes per 10 000 days of hospital stay in Europe. Accurate diagnosis of C. difficile infection (CDI) is a prerequisite for obtaining reliable epidemiological data, but in many European countries diagnosis is probably suboptimal. A significant percentage of CDI cases are missed because clinicians often fail to request tests for C. difficile toxins in cases of unexplained diarrhoea. In addition, some laboratories continue to use tests of low sensitivity or apply them inappropriately. In one study in Spain, failure to request CDI testing in more than two-thirds of patients with unexplained diarrhoea led to significant underdiagnosis of cases. A recent pan-European survey revealed huge discrepancies in the rate of CDI testing across Europe, which suggests that epidemiological reports underestimate the true incidence of CDI in many parts of Europe. This is important because, as this review of the clinical and economic burden of CDI illustrates, infection with C. difficile imposes a significant burden not only on patients, owing to increased morbidity and mortality, but also on healthcare systems and society in general. On the basis of current incidence rates, annual costs for management of CDI amount to approximately $800 million in the USA and €3000 million in Europe. Moreover, estimates suggest that costs associated with recurrent CDI can exceed those of primary CDI. Measures to more effectively prevent CDI and reduce CDI recurrence rates may help to reduce this burden

A man from Morocco and chronic hip pain

The patient was a 52-year-old male, born in Morocco, and living in Spain for the last 25 years. He was diagnosed with Diabetes Mellitus more than 25 years before and was a heavy smoker until he quit 6 years ago.At the age of 25, he suffered a closed hip fracture after am uncertain intensity occupational accident while working as a farmer and required surgery with placement of osteosynthe-sis material that apparently consisted in an intramedullary nail. Hardware had to be removed after a short time (2-3 months) due to infection, as endorsed by the patient, although he did not provide any information on the nature of the infection or the antimicrobial treatment received.The patient was a native of northern Morocco, a shoe-maker by profession, in an inactive situation at the present time and awaiting a disability concession. He lived with a friend and receives habitual treatment with long-acting insu-lin glargine and acetaminophen.Chief complaint. He was admitted from the outpatient Orthopedic Clinic due to pain in the right hip that was point-ed at fingertips. The pain had intensified in recent years and the patient had progressive gait limitation that prevented him from walking without the help of a cane. Over the past 12-15 years, he had occasionally experienced “holes” that opened..

Introduction : analysing English syntax past and present

This book is an exploration of categories, constructions, and change in English syntax. A great many books are published on the syntax of English, both monographs and edited volumes, and yet another may seem unnecessary. However, we felt more than justified in adding to the sizeable literature here for two reasons. The first, to borrow from Richard M. Hogg and David Denison’s justification for A History of the English Language, is that ‘one of the beauties of the language is its ability to show continuous change and flexibility while in some sense remaining the same

A European perspective on nosocomial urinary tract infections II. Report on incidence, clinical characteristics and outcome (ESGINI–04 study)

ObjectivesTo estimate the incidence of nosocomially acquired urinary tract infections (NAUTI) in Europe and provide information on the clinical characteristics, underlying conditions, etiology, management and outcome of patients.Materials and methodsWe collected clinical information from NAUTI patients with a microbiology report on the named study day.ResultsA total of 141 hospitals from 25 European countries participated in the study. Written institutional bladder catheter guidelines were in place in 90.3% of EU hospitals and 55% of non-EU hospitals (P <0.05). The total number of new NAUTI episodes on the day of the study was 298, representing an incidence of 3.55 episodes/1000 patient-days and an estimated prevalence of 10.65/1000. The five most commonly isolated micro-organisms were Escherichia coli, Enterococcus sp., Candida sp., Klebsiella sp. and Pseudomonas aeruginosa. Patients from non-EU countries were younger, with more severe underlying diseases with a higher incidence of obstructive uropathy/lithiasis. Overall, 22.8% of patients had no ‘classic’ UTI-predisposing factors. Catheter-associated UTI (CAUTI) was present in 187 patients (62.8%). A closed drainage system was used in only 78.5% of catheterised patients. The indication for bladder catheterisation was not considered adequate in 7.6% of cases and continuation of bladder catheterisation was considered unnecessary in 31.3%. Opening of the closed drainage system was the most frequent major error in catheter management (16.8%). Antimicrobial treatment was not considered adequate in 19.8% of all cases.ConclusionsThe incidence of NAUTI in a large European population is 3.55/1000 patient-days. There is clearly room for improvement in the area of bladder catheterisation, catheter care and medical management of NAUTI. We recommend that European authorities draw up and implement practical and specific guidelines to reduce the incidence of this infection

Crotonaldehyde hydrogenation on Rh supported catalysts

The vapor-phase hydrogenation of crotonaldehyde on Rh supported catalysts has been studied. The effect of some variables of preparation in catalysts prepared by the sol-gel and impregnation methods on the surface and catalytic properties were analyzed. It was found, that the porosity of the support has a small effect on the selectivity to the unsaturated alcohol and the presence of partially reducible supports such as ZrO2 and TiO2, may increase the selectivity to crotyl alcohol via an enhancement of the polarization of the C=O bond as a result of surface decoration of the metal component. The presence of chlorine ions in the metal-support interfacial region, also allows, in a certain extension, a polarization of the carbonyl bond.Se estudió la hidrogenación en fase vapor de crotonaldehído sobre catalizadores de Rh soportados. Se analizó la influencia de diferentes variables de preparación de catalizadores obtenidos por el método sol-gel y por impregnación. Se encontró que la porosidad del soporte tiene sólo un pequeño efecto sobre la selectividad hacia el alcohol insaturado y que la presencia de soportes parcialmente reducibles como ZrO2 y TiO2 pueden incrementar la selectividad hacia el alcohol crotílico a través de un aumento de la polarización del enlace C=O como consecuencia de una decoración superficial del componente metálico. Adicionalmente, la presencia de iones cloruro en la interfase metal-soporte, también contribuyen en alguna medida a la polarización del enlace carbonílico.The authors thank CONICYT (Chile, FONDECYT Grants 1980345 and 2990065 and CSIC-CONICYT Collaboration Program) for their financial support.Peer reviewe

Catheter-related bloodstream infection caused by Enterococcus spp.

AbstractThe role of Enterococcus spp. as a cause of catheter-related bloodstream infections (CR-BSI) is almost unexplored. We assessed the incidence and clinical characteristics of enterococcal CR-BSI (ECR-BSI) over an 8-year period in our hospital. We performed a retrospective study (January 2003 to December 2010) in a large teaching institution. We recorded the incidence, and the microbiological and clinical data from patients with ECR-BSI. The incidence per 10 000 admissions for enterococcal BSI and ECR-BSI was 25 and 1.7, respectively. ECR-BSI was the fourth leading cause of CR-BSI in our institution (6%). A total of 75 episodes of ECR-BSI were detected in 73 patients (6% of all enterococcal BSI). The incidence of ECR-BSI increased by 17% annually (95% CI 19.0–21.0%) during the study period. Nineteen percent of ECR-BSI episodes were polymicrobial. Overall mortality was 33%. ECR-BSI is an emerging and increasingly common entity with a high mortality. This finding should be taken into account when selecting empirical treatment for presumptive CR-BSI

Linezolid therapy for infective endocarditis

AbstractLinezolid is not yet recognised as a standard therapy for infective endocarditis. This report describes nine patients with endocarditis treated with linezolid and 33 similar cases from the medical literature. The majority of cases involved multiresistant strains, and the reasons for administering linezolid were refractory disease (60%), intolerance (28%), sequential therapy (12%) and a resistant pathogen (1%). Linezolid was administered for a mean of 37 days, with a successful outcome in 79% of cases. Reversible adverse effects were described in ten cases. The mean follow-up period was 8.5 months. Further data from randomised controlled clinical trials are needed to determine the efficacy and safety of linezolid for treating endocarditis

Revealing hidden clonal complexity in Mycobacterium tuberculosis infection by qualitative and quantitative improvement of sampling

AbstractThe analysis of microevolution events, its functional relevance and impact on molecular epidemiology strategies, constitutes one of the most challenging aspects of the study of clonal complexity in infection by Mycobacterium tuberculosis. In this study, we retrospectively evaluated whether two improved sampling schemes could provide access to the clonal complexity that is undetected by the current standards (analysis of one isolate from one sputum). We evaluated in 48 patients the analysis by mycobacterial interspersed repetitive unit–variable number tandem repeat of M. tuberculosis isolates cultured from bronchial aspirate (BAS) or bronchoalveolar lavage (BAL) and, in another 16 cases, the analysis of a higher number of isolates from independent sputum samples. Analysis of the isolates from BAS/BAL specimens revealed clonal complexity in a very high proportion of cases (5/48); in most of these cases, complexity was not detected when the isolates from sputum samples were analysed. Systematic analysis of isolates from multiple sputum samples also improved the detection of clonal complexity. We found coexisting clonal variants in two of 16 cases that would have gone undetected in the analysis of the isolate from a single sputum specimen. Our results suggest that analysis of isolates from BAS/BAL specimens is highly efficient for recording the true clonal composition of M. tuberculosis in the lungs. When these samples are not available, we recommend increasing the number of isolates from independent sputum specimens, because they might not harbour the same pool of bacteria. Our data suggest that the degree of clonal complexity in tuberculosis has been underestimated because of the deficiencies inherent in a simplified procedure

Evaluation of bone marrow and blood cultures for the recovery of mycobacteria in the diagnosis of disseminated mycobacterial infections

AbstractThis study evaluated the validity of bone marrow (BM) and blood specimens for the diagnosis of disseminated mycobacterial infections (DMIs). From 1990 to February 1997, all specimens were processed with the lysis-centrifugation procedure; thereafter (until December 2001), they were processed with the BACTEC Myco/F Lytic system. Twenty-three paired BM-blood specimens with mycobacteria in at least one specimen were studied from 23 patients. The strains isolated were 14 Mycobacterium avium complex (MAC) and nine M. tuberculosis complex (MTBC). Blood specimens had a statistically significant greater sensitivity for the isolation of MAC than BM (100% vs. 57.1%, respectively), whereas sensitivity for the isolation of MTBC was equal for the two specimen types (66.7%). Although not statistically significant, the times required to detect mycobacteria from blood specimens were lower than those from BM in the MycoF/Lytic system. Overall, blood cultures represented a more sensitive and less invasive alternative to BM cultures for the diagnosis of disseminated mycobacteriosis caused by MAC, especially when the MycoF/Lytic system was used, but provided no advantage for the diagnosis of DMI caused by MTBC