The prognostic value of red blood cell distribution width in patients with suspected infection in the emergency department

Background: Sepsis is a potential life threatening dysregulated immune response to an infection, which can result in multi-organ failure and death. Unfortunately, good prognostic markers are lacking in patients with suspected infection to identify those at risk. Red blood cell distribution width (RDW) is a common and inexpensive hematologic laboratory measurement associated with adverse prognosis in multiple diseases. The aim of this study was to determine the prognostic value of RDW for mortality and early clinical deterioration in patients with a suspected infection in the emergency department. Methods: In this single center prospective observational cohort study, consecutive patients with suspected infection presenting for internal medicine in the emergency department between September 2016 and March 2018 were included. For prognostic validation of bedside sepsis scores and RDW receiver operating characteristics were generated. Association between RDW and mortality and ICU admission was analyzed univariate and in a multivariate logistic regression model. Results: 1046 patients were included. In multivariate analyses, RDW was significantly associated with 30-day mortality (OR 1.15, 95% CI: 1.04-1.28) and early clinical deterioration (OR 1.09, 95% CI: 1.00-1.18). For 30-day mortality RDW had an AUROC of 0.66 (95% CI 0.59-0.72). Optimal cut-off value for RDW 2 was 12.95%. For early clinical deterioration RDW had an AUROC of 0.59 (95% CI 0.54-0.63) with an optimal cut-off value of 14.48%. Conclusions: RDW was found to be a significant independent prognostic factor of 30-day mortality and early clinical deterioration in patients with suspected infection. Therefore it can be a used as an extra marker besides bedside sepsis scores in identifying patients at risk for worse outcome in patients with suspected infection

Heart transplantation for end-stage heart failure combined with Q fever isolated to the heart: A case report

Background: Active infection is generally considered a contraindication for heart transplantation. The rare combination of a patient with an active Coxiella burnetii infection and a congenital corrected transposition of the great arteries requiring heart transplantation impose challenging treatment decisions. We would like to demonstrate that if Q fever is restricted to the heart only, heart transplantation is also beneficial from an infectious point of view, therefore treating two severe conditions simultaneously. Case summary: A patient with end-stage heart failure due to congenital corrected transposition of the great arteries and requiring heart transplantation developed chronic Q fever and endocarditis. Different antibiotic regimes were tried due to severe adverse reactions. Antibiotic treatment was precisely monitored by measuring Q fever polymerase chain reaction (PCRs) and phase I IgG antibody titres. A positron emission tomography scan revealed that Q fever was confined to the heart only after which it was decided to perform heart transplantation. Based on the results of PCR and antibody testing, antibiotic treatment was stopped after 1 year. After 5 years of follow-up, patient is still in an optimal condition. Discussion: In case of a patient with end-stage heart failure and chronic Q fever, a combined treatment with PCR-/antibody monitored antibiotics and heart transplantation can cure both conditions

Treatment of Chronic Q Fever: Clinical Efficacy and Toxicity of Antibiotic Regimens

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Treatment of chronic Q fever : Clinical efficacy and toxicity of antibiotic regimens

Background. Evidence on the effectiveness of first-line treatment for chronic Q fever, tetracyclines (TET) plus hydroxychloroquine (HCQ), and potential alternatives is scarce. Methods. We performed a retrospective, observational cohort study to assess efficacy of treatment with TET plus quinolones (QNL), TET plus QNL plus HCQ, QNL monotherapy, or TET monotherapy compared to TET plus HCQ in chronic Q fever patients. We used a time-dependent Cox proportional hazards model to assess our primary (all-cause mortality) and secondary outcomes (first disease-related event and therapy failure). Results. We assessed 322 chronic Q fever patients; 276 (86%) received antibiotics. Compared to TET plus HCQ (n = 254; 92%), treatment with TET plus QNL (n = 49; 17%), TET plus QNL plus HCQ (n = 29, 10%), QNL monotherapy (n = 93; 34%), or TET monotherapy (n = 54; 20%) were not associated with primary or secondary outcomes. QNL and TET monotherapies were frequently discontinued due to insufficient clinical response (n = 27, 29% and n = 32, 59%). TET plus HCQ, TET plus QNL, and TET plus QNL plus HCQ were most frequently discontinued due to side effects (n = 110, 43%; n = 13, 27%; and n = 12, 41%). Conclusions. Treatment of chronic Q fever with TET plus QNL appears to be a safe alternative for TET plus HCQ, for example, if TET plus HCQ cannot be tolerated due to side effects. Treatment with TET plus QNL plus HCQ was not superior to treatment with TET plus HCQ, although this may be caused by confounding by indication. Treatment with TET or QNL monotherapy should be avoided; switches due to subjective, insufficient clinical response were frequently observed

Effects of Probiotics on Acquisition and Spread of Multiresistant Enterococci▿

Ampicillin-resistant Enterococcus faecium (ARE) and vancomycin-resistant E. faecium (VRE) are important nosocomial pathogens. We quantified effects of probiotics and antibiotics on intestinal acquisition of ARE colonization in patients hospitalized in two non-intensive care unit (non-ICU) wards with high ARE prevalence. In a prospective cohort study with crossover design, all patients with a length of stay of >48 h were offered a multispecies probiotic product twice daily until discharge (4.5 months, intervention period) or not (4.5 months, control period). Perianal ARE carriage was determined <48 h after admission, twice weekly, and <48 h before discharge. The first isolates were genotyped by multiple-locus variable-number tandem repeat analysis (MLVA). Risk factors for acquisition were determined by Cox proportional hazards modeling, with special emphasis on ecological postantibiotic effects and delays between actual acquisition and culture positivity. Of 530 patients included, 94 (18%) were ARE colonized on admission. Of the remaining 436 noncolonized patients, 92 acquired ARE colonization: 28 (25%) of 110 probiotic users and 64 (20%) of 326 control patients (χ2 test, P = 0.325). In all, 661 ARE strains were isolated from 186 patients, of which 186 were genotyped. In both wards, two MLVA types (MTs; MT1 and MT159) were responsible for >80% of acquisitions. Both MTs were genetically different from the probiotic E. faecium strain. Antibiotics to which ARE is resistant (hazard ratio [HR], 7.73 [95% confidence interval (CI), 4.52 to 13.22]), an ecological postantibiotic effect (HR, 7.11 [95% CI, 3.10 to 16.30]), and age (HR, 1.01 [95% CI, 0.99 to 1.02]) were associated with ARE acquisition. The HR of probiotics was 1.43 (95% CI, 0.88 to 2.34). In a setting with high selective antibiotic pressure, probiotics failed to prevent acquisition of multiresistant enterococci

Low hepatitis C virus-viremia prevalence yet continued barriers to direct-acting antiviral treatment in people living with HIV in the Netherlands

Objective:To describe hepatitis C virus (HCV)-viremia prevalence and barriers to direct-acting antiviral (DAA) treatment during unrestricted access to DAA in a nationwide cohort of people with HIV (PWH).Design:Retrospective analysis of prospectively collected data.Methods:We calculated yearly HCV-viremia prevalence as proportion of HCV RNA-positive individuals ever HCV-tested. We then included HCV-viremic individuals with ≥1 visit during the era of universal DAA-access (database lock = December 31, 2018). Based on their last visit, individuals were grouped as DAA-treated or -untreated. Variables associated with lack of DAA-treatment were assessed using targeted maximum likelihood estimation. In November 2020, physicians of DAA-untreated individuals completed a questionnaire on barriers to DAA-uptake and onward HCV-transmission risk.Results:Among 25 196 PWH, HCV-viremia decreased from 4% to 5% between 2000 and 2014 to 0.6% in 2019. Being DAA-untreated was associated with HIV-transmission route other than men who have sex with men, older age, infrequent follow-up, severe alcohol use, detectable HIV-RNA, HCV-genotype 3, and larger hospital size. With universal DAA-access, 72 of 979 HCV-viremic individuals remained DAA-untreated at their last visit. Of these, 39 were no longer in care, 27 remained DAA-untreated in care, and six initiated DAA since database lock. Most common physician-reported barriers to DAA-uptake were patient refusal (20/72, 28%) and infrequent visit attendance (19/72, 26%). Only one DAA-untreated individual in care was engaging in activities associated with onward HCV-transmission.Conclusions:Prevalence of HCV-viremic PWH is low in the Netherlands, coinciding with widespread DAA-uptake. Barriers to DAA-uptake appear mostly patient-related, while HCV-transmission seems unlikely from the few DAA-untreated in care

Hospital and community ampicillin-resistant Enterococcus faecium are evolutionarily closely linked but have diversified through niche adaptation

BACKGROUND: Ampicillin-resistant Enterococcus faecium (ARE) has emerged as a nosocomial pathogen. Here, we quantified ARE carriage in different community sources and determined genetic relatedness with hospital ARE. METHODS AND RESULTS: ARE was recovered from rectal swabs of 24 of 79 (30%) dogs, 11 of 85 (13%) cats and 0 of 42 horses and from 3 of 40 (8%) faecal samples of non-hospitalized humans receiving amoxicillin. Multi-locus Sequence Typing revealed 21 sequence types (STs), including 5 STs frequently associated with hospital-acquired infections. Genes previously found to be enriched in hospital ARE, such as IS16, orf903, orf905, orf907, were highly prevalent in community ARE (≥79%), while genes with a proposed role in pathogenesis, such as esp, hyl and ecbA, were found rarely (≤5%) in community isolates. Comparative genome analysis of 2 representative dog isolates revealed that the dog strain of ST192 was evolutionarily closely linked to two previously sequenced hospital ARE, but had, based on gene content, more genes in common with the other, evolutionarily more distantly related, dog strain (ST266). CONCLUSION: ARE were detected in dogs, cats and sporadically in healthy humans, with evolutionary linkage to hospital ARE. Yet, their accessory genome has diversified, probably as a result of niche adaptation

Multilocus sequence types (STs) of recovered ARE isolates and previous occurrence among other sources.

a<p><a href="http://efaecium.mlst.net/" target="_blank">http://efaecium.mlst.net/</a> queried March 2010;</p>b<p>HAI = hospital-associated isolates (i.e., clinical isolates, hospital surveillance, hospital outbreak);</p>c<p>CI = clinical isolate; CS = Community human surveillance; LS = Livestock; D = dogs; C = cats.</p

Polymorphisms in the C-terminal region of <i>pbp5</i>^a.

a<p>Amino acid mutations that contribute to ampicillin resistance are indicated in bold <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0030319#pone.0030319-Rice1" target="_blank">[15]</a>. The one-letter abbreviation code is used to denote the amino acids. The – sign indicates no change in amino acid compared to the reference allele.</p>b<p>Source (and frequency) of the isolates carrying a particular allele: D = dog; C = cat; H = human.</p