2402. Clinical Outcomes Associated with an Emerging Clostridioides difficile Ribotype 255 in Texas

Abstract Background PCR ribotyping of Clostridioides difficile strains is commonly used to describe the epidemiology of C. difficile infection (CDI). Certain ribotypes (RT) have been associated with more severe disease and clinical outcomes, such as RT 027, while others are considered less virulent, such as RT 014-020. Texas statewide surveillance identified the emergence of a rarely-described RT 255 beginning in 2015, which now represents the fifth most common ribotype across the state. Here we describe clinical outcomes associated with an emergent RT 255 in Texas. Methods A retrospective cohort study was conducted including patients from two tertiary care centers in Houston, Texas. Patients infected with C. difficile strains of either RT 255, 014-020, or 027 between 2016–18 were included. The primary outcome was disease severity as classified by the 2017 IDSA guidelines. Multivariable logistic regression analysis was done to control for other patient factors. Results were significant at P < 0.05, and all statistical analyses were completed using SPSS, version 25. Results A total of 150 patients were included (50 patients infected with each RT). Overall, 53% of the patients had severe or fulminant disease most commonly due to RT 027 (80%) followed by RT 014-020 (40%) and RT 255 (38%). Patients infected with RT 255 or 014-020 had a 75% relative reduction in the odds of severe disease compared with RT 027 after controlling for patient age and serum albumin level (OR, 0.25; 95% CI, 0.86–0.74; P = 0.12;). No differences were seen in the rates of 30- or 90-day recurrence between RTs. Conclusion Although RT 255 is becoming increasingly common across Texas, it does not appear to be associated with more severe disease when compared with other common ribotypes. Further studies are warranted to determine contributing factors for its increasing prevalence. Disclosures All authors: No reported disclosures.

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Comparison of Clinical Outcomes With Drug Coated Balloons Versus Plain Balloon Angioplasty In Chronic Limb-Threatening Ischemia

Vascular and Endovascular Surgery ◽

10.1177/15385744211022598 ◽

2021 ◽

pp. 153857442110225

Author(s):

Joel Mathew John ◽

Vimalin Samuel ◽

Dheepak Selvaraj ◽

Prabhu Premkumar ◽

Albert A Kota ◽

...

Keyword(s):

Clinical Outcomes ◽

Interventional Procedure ◽

Tertiary Care ◽

Arterial Disease ◽

Multivariable Logistic Regression Analysis ◽

Tertiary Care Centre ◽

Chi Square ◽

Exact Test ◽

Institutional Review ◽

Chi Square Test

Objective: The use of drug coated balloon (DCB) for angioplasty has shown superior efficacy against plain balloons for treating complex infrainguinal arterial disease. We report and compare the clinical outcomes following application of DCB(Paclitaxel) and plain angioplasty (POBA) in our tertiary care centre. Methods: A retrospective, single centre analysis of 301 patients with chronic limb-threatening ischemia involving the infrainguinal segment was conducted between September 2014 and September 2018, after approval from the Institutional review board. We analyzed clinical outcomes by measuring postoperative ABI improvement, restenosis requiring reintervention procedure, minor and major amputations at the end of 18 months. . To find the association between the group variables (POBA and DCB) and other risk variables, Chi-square test/Fisher’s exact test was used. Multivariable logistic regression analysis was used. Results: Patients who underwent treatment with plain balloon (POBA) and DCB(Paclitaxel) angioplasty were 246(81.7%) and 55(18.3%) respectively. Our study group was predominantly male (Male: Female = 6.7:1), most patients were more than 50 years of age (n = 251, 83.4%). Smoking (n = 199, 66.1%) and diabetes (n = 210, 69.8%) were the most common atherosclerotic risk factors. Postoperative Ankle Brachial Pressure Index (ABI) improvement were similar in both groups (POBA = 57.7%; DCB = 69.8%; p = 0.103). Minor and major amputations following POBA were 26% and 22%; and DCB were 12.7% and 16.4% respectively. Re-stenosis requiring a re-interventional procedure within 18 months was 15%, (n = 37) following POBA; and 12.7% (n = 7) following DCB (p = 0.661). Conclusions: This retrospective study shows similar clinical limb related outcomes following POBA and DCB at 18 months. However, our comparative analysis between the POBA and DCB groups was totally unadjusted and not adjusted for common confounders such as age and sex. Hence, for one to draw definitive conclusions leading to changes in clinical practice; a randomized, prospective study with a larger patient cohort is needed.

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Platelet Count in Patients with Mild Disease at Admission is Associated with Progression to Severe Hantavirus Cardiopulmonary Syndrome

Viruses ◽

10.3390/v11080693 ◽

2019 ◽

Vol 11 (8) ◽

pp. 693 ◽

Cited By ~ 1

Author(s):

René López ◽

Cecilia Vial ◽

Jerónimo Graf ◽

Mario Calvo ◽

Marcela Ferrés ◽

...

Keyword(s):

Mechanical Ventilation ◽

Platelet Count ◽

Severe Disease ◽

Tertiary Care ◽

Curve Analysis ◽

Roc Curve Analysis ◽

Mild Disease ◽

Laboratory Variables ◽

Advanced Support ◽

Tertiary Care Centers

Background: Hantavirus cardiopulmonary syndrome (HCPS) has a mortality up to 35–40% and its treatment is mainly supportive. A variable to predict progression from mild to severe disease is unavailable. This study was performed in patients with documented infection by Andes orthohantavirus, and the aim was to find a simple variable to predict progression to moderate/severe HCPS in patients with mild disease at admission. Methods: We performed a retrospective analysis of 175 patients between 2001 and 2018. Patients were categorized into mild, moderate, and severe disease according to organ failure and advanced support need at hospital admission (e.g., mechanical ventilation, vasopressors). Progression to moderate/severe disease was defined accordingly. Clinical and laboratory variables associated with progression were explored. Results: Forty patients with mild disease were identified; 14 of them progressed to moderate/severe disease. Only platelet count was different between those who progressed versus those that did not (37 (34–58) vs. 83 (64–177) K/mm3, p < 0.001). A ROC curve analysis showed an AUC = 0.889 (0.78–1.0) p < 0.001, with a platelet count greater than 115K /mm3 ruling out progression to moderate/severe disease. Conclusions: In patients with mild disease at presentation, platelet count could help to define priority of evacuation to tertiary care centers.

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2398. Effect of Eosinopenia and Binary Toxin on Clostridioides difficile Infection Clinical Outcomes

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.2076 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S828-S828

Author(s):

Travis J Carlson ◽

Bradley T Endres ◽

Julie Le Pham ◽

Anne J Gonzales-Luna ◽

Faris S Alnezary ◽

...

Keyword(s):

Immune Response ◽

Clinical Outcomes ◽

Eosinophil Count ◽

Toxin Production ◽

Albumin Level ◽

Binary Toxin ◽

Inpatient Mortality ◽

Healthcare Facilities ◽

Clostridioides Difficile

Abstract Background The ability of Clostridioides difficile to cause clinical disease in humans is dependent on toxin production. Significantly fewer eosinophils are seen in the peripheral blood of mice infected with a binary toxin positive (CDT+) C. difficile strain. Furthermore, the presence of CDT and eosinopenia have separately been associated with increased mortality in humans with C. difficile infection (CDI). We hypothesized that CDI due to a CDT+ C. difficile strain accompanied by peripheral eosinopenia would be associated with higher odds of inpatient mortality. Methods This multicenter, retrospective cohort study included all patients ≥ 18 years of age with toxigenic CDI in which specimen ribotype data were available as part of our ongoing surveillance study. The cohort was stratified by eosinophil count (0.0 cells/μL vs. > 0.0 cells/μL). The primary outcome was inpatient mortality. A logistic regression model was developed modeling inpatient mortality as a function of the available patient covariates. All P-values were from 2-sided tests, and results were deemed statistically significant at P < 0.05. Results A total of 688 patients from 13 institutions in six cities were included. Of those, 132 had a baseline eosinophil count of 0.0 cells/µL and 556 had a baseline eosinophil count > 0.0 cells/µL. While the odds of inpatient mortality were higher among patients with eosinopenia and those infected with a CDT+ ribotype, the combination of these variables remained an independent predictor of inpatient mortality after adjusting for CCI score, WBC count, and serum albumin level (OR, 7.84; 95% CI, 1.85–33.20; P = 0.005). Conclusion This is the first attempt to study the in vivo relationship between CDT presence, human immune response, and CDI clinical outcome. We identified an association between CDT presence with concomitant eosinopenia and worsened CDI outcomes. Healthcare facilities should consider identifying this important subset of patients at the time of CDI diagnosis. Future CDI drug development might benefit from targeting C. difficile properties that impair host immune response, which may in turn decrease adverse clinical outcomes associated with this disease. Disclosures All authors: No reported disclosures.

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Outcome of Thalassemia Intermedia Mothers and Newborns in Two Tertiary Care Centers, Beirut and Milan.

Blood ◽

10.1182/blood.v110.11.3827.3827 ◽

2007 ◽

Vol 110 (11) ◽

pp. 3827-3827

Author(s):

A. Taher ◽

A. Nassar ◽

M. Naja ◽

C. Cesaretti ◽

R. Fasulo ◽

...

Keyword(s):

Cesarean Delivery ◽

Preterm Delivery ◽

Post Partum ◽

Care Center ◽

Severe Disease ◽

Tertiary Care ◽

Adult Life ◽

Close Monitoring ◽

Thalassemia Intermedia ◽

Tertiary Care Centers

Abstract Introduction: β-thalassemia intermedia (TI) patients either present with a severe disease between the ages of 2–6 years, or remain asymptomatic until they present with a milder disease during adult life. With the advances in assisted reproductive technology and medical management, pregnancy has become possible in most TI cases. Spontaneous abortions, intrauterine growth restriction (IUGR), and preterm labor are complications that face women with TI. This study aimed at evaluating the pregnancy outcome of women with TI in two tertiary care centers, one in Lebanon and another in Italy. Methods: Patient databases at the Chronic Care Center, Lebanon and at the Hereditary Anemia Center in Milan, Italy were reviewed. Maternal and neonatal charts of women with TI and documented pregnancy were identified and reviewed using a specially formulated questionnaire that focused on demographic characteristics (maternal age, gestational age (GA), parity, and abortions), past medical history related to thalassemia, course of pregnancy and complications, intrapartum events and neonatal outcome. Patients were then contacted by phone for any missing information. Results: A total of 44 pregnant TI patients, 11 in Lebanon and 33 in Italy were identified. Mean age at diagnosis of TI was 9.2 ± 9.7 years (range 1–42 years) with 34 (77.3%) splenectomized patients identified. Fourteen patients (31.8%) were frequently transfused, 25 (56.8%) occasionally transfused and only 4 (9.1%) never transfused. Mean age at pregnancy was 29.5 ± 3.9 years (range 21–38 years) with 11 patients (28.2%) receiving the first transfusion during pregnancy. Twenty eight patients were on chelation therapy: 21 (48.8%) received deferioxamine, 4 (9.3%) deferiprone and 3 (7%) deferasirox. After excluding 4 women with ongoing pregnancies, information on 79 pregnancies, all spontaneous, were available, 30 from Lebanon and 49 from Italy. These resulted in 60 live births (75.9%), 17 abortions (21.5%), and 2 intrauterine fetal deaths (2.5%), at 26 and 36 weeks of gestation, respectively. Three patients (7.5%) had recurrent abortions (≥3 abortions). Of women whose pregnancies progressed beyond 20 weeks of gestation (n=62), the following obstetrical complications were encountered: preterm delivery <37 weeks of gestation (18, 29.0%), IUGR (14, 22.6%), preeclampsia (1, 1.6%), placental abruption (2, 3.2%) and cholestasis of pregnancy (1, 1.6%). Mean GA at delivery was 36.8 ±2.8 weeks. Thrombotic events were encountered during 4/79 (5.1%) pregnancies: deep vein thrombosis (DVT) ante- and post-partum (n=2), antepartum DVT (n=1) and placental thrombosis (n=1). Two women had postpartum splenectomy. Cesarean delivery was performed in 44 pregnancies (70.9%). No significant differences were noted when the course of pregnancy and obstetrical outcomes of women in Lebanon and Milan were compared. Conclusions: Preterm delivery complicates 29% of pregnancies with TI which are at a 23% risk of IUGR. Cesarean delivery is the most common route of delivery in these patients (70.9%). As with any chronic disease affecting different organs, TI presents a challenge for pregnant patients, their fetuses and physicians and requires close monitoring for any events that might compromise the patient or the newborn. Further studies comprising more patients need to be carried out to determine the effects of splenectomy and transfusions during pregnancy and on the outcome of those pregnancies.

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A Randomized Assessment of a Laxative-Based Clostridioides difficile Diagnostic Stewardship Intervention

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.604 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s102-s103

Author(s):

Chelsea E. Lau ◽

Rena G. Morse ◽

Costi Sifri ◽

Gregory Madden

Keyword(s):

Statistical Significance ◽

Tertiary Care ◽

Clinical Decision ◽

Relative Reduction ◽

Patient Identification ◽

Clostridioides Difficile ◽

Additional Costs ◽

Care Health ◽

Polymerase Chain ◽

Healthcare Associated

Background:Clostridiodes difficile is the leading healthcare-associated pathogen, with significant morbidity associated with acute C. difficile infection (CDI). However, polymerase chain reaction stool testing is unable to differentiate colonization from infection, leading to frequent overdiagnosis, unnecessary iatrogenesis, and additional costs. As a result, IDSA guidelines do not recommend C. difficile testing in patients with diarrheal symptoms attributed to other causes, including laxatives. Our group has previously investigated the use of a computerized clinical decision support (CCDS) tool to reduce inappropriate C. difficile testing in a single tertiary-care health system, with a subsequent 41% reduction in testing. We investigated the reduction in proportion of inappropriately completed tests with the randomized addition of a laxative alert to our existing CCDS. Methods: An existing electronic medical record-based CCDS tool was augmented by the addition of an automatic alert that notified the user if a patient received any of a set of identified laxative medications within 48 hours. During the 78-day pilot period, users encountered the existing CCDS or the CCDS with laxative alert (CCDS-LA), randomized by patient identification number. A proportional χ2 analysis was used to compare the proportion of aborted to completed tests among patients who met laxative criteria in the CCDS versus CCDS-LA groups. Results: In total, 187 test orders were attempted during the pilot period in 119 patients meeting the laxative alert criteria, with 43.3% order attempts randomized to the existing CCDS and 56.7% to the CCDS-LA. Of order attempts via the CCDS-LA, 50.0% were completed, compared to 64.2% of orders completed via the existing CCDS (22.1% relative reduction in test completion; P = .0525). Conclusions: We demonstrated substantially fewer completed C. difficile tests among patients receiving laxatives who were randomized to modified laxative-alert CCDS. Although our result did not reach statistical significance, the trend toward reduced inappropriate testing prompted the CCDS-LA alert to be adopted hospital-wide following completion of the test period. Further analyses of the pre- and postintervention periods are required to determine whether this intervention significantly impacts testing rates over time, as well as to determine the durability and safety of the CCDS-LA. Additional analyses are also needed to assess the impacts on hospital-onset CDI rate and the associated costs.Funding: NoneDisclosures: None

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Binary toxin expression by Clostridioides difficile is associated with worse disease

10.1101/2021.07.30.21261256 ◽

2021 ◽

Author(s):

Mary K Young ◽

Jhansi L Leslie ◽

Gregory R Madden ◽

David M Lyerly ◽

Robert J Carman ◽

...

Keyword(s):

Clinical Outcomes ◽

Disease Severity ◽

Severe Disease ◽

Patient Treatment ◽

Binary Toxin ◽

Enzyme Linked Immunosorbent Assay ◽

Rrna Gene ◽

Clostridioides Difficile ◽

Cell Counts ◽

Significant Difference

Background. The incidence of Clostridioides difficile infection (CDI) has increased over the past two decades and is considered an urgent threat by the Centers for Disease Control. Hypervirulent strains such as ribotype 027, that possess genes for an additional toxin C. difficile binary toxin (CDT) are contributing to increased morbidity and mortality. In the mouse model, CDT activates Toll-like receptor 2 resulting in suppression of a protective type 2 innate immune response mediated by eosinophils. Methods. We retrospectively tested stool from 215 CDI patients for CDT by enzyme-linked immunosorbent assay (ELISA). Stratifying patients by CDT status, we assessed if disease severity and clinical outcomes correlated with CDT positivity. Additionally, we performed 16 S rRNA gene sequencing to examine if CDT positive samples had an altered fecal microbiota. Results. We found that patients with CdtB, the pore forming component of CDT, detected in their stool were more likely to have severe disease and had higher 90-day mortality compared to CDT negative patients. CDT positive patients also had higher C. difficile bacterial burden and white blood cell counts. There was no significant difference in gut microbiome diversity between CDT positive and negative patients. Conclusions. Patients with fecal samples that were positive for CDT had increased disease severity and worse clinical outcomes. Utilization of PCR and C. difficile Toxins A and B testing may not reveal the entire picture when diagnosing CDI and the detection of CDT-expressing strains may be valuable during patient treatment.

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Multilocus Variable-Number Tandem-Repeat Analysis of Clostridioides difficile Clusters in Ribotype 027 Isolates and Lack of Association with Clinical Outcomes

Journal of Clinical Microbiology ◽

10.1128/jcm.01724-18 ◽

2019 ◽

Vol 57 (5) ◽

Cited By ~ 2

Author(s):

Julian R. Garneau ◽

Claire Nour Abou Chakra ◽

Louis-Charles Fortier ◽

Annie-Claude Labbé ◽

Andrew E. Simor ◽

...

Keyword(s):

Clinical Outcomes ◽

Tandem Repeat ◽

Variable Number Tandem Repeat ◽

Variable Number ◽

Content Type ◽

Repeat Analysis ◽

Ribotype 027 ◽

Clostridioides Difficile ◽

Significant Difference ◽

Pcr Ribotyping

ABSTRACT The epidemiology of Clostridioides difficile infection (CDI) has drastically changed since the emergence of the epidemic strain BI/NAP1/027, also known as ribotype 027 (R027). However, the relationship between the infecting C. difficile strain and clinical outcomes is still debated. We hypothesized that certain subpopulations of R027 isolates could be associated with unfavorable outcomes. We applied high-resolution multilocus variable-number tandem-repeat analysis (MLVA) to characterize C. difficile R027 isolates collected from confirmed CDI patients recruited across 10 Canadian hospitals from 2005 to 2008. PCR ribotyping was performed first to select R027 isolates that were then analyzed by MLVA (n = 450). Complicated CDI (cCDI) was defined by the occurrence of any of admission to an intensive care unit, colonic perforation, toxic megacolon, colectomy, and if CDI was the cause or contributed to death within 30 days after enrollment. Three major MLVA clusters were identified, MC-1, MC-3, and MC-10. MC-1 and MC-3 were exclusive to Quebec centers, while MC-10 was found only in Ontario. Fewer cases infected with MC-1 developed cCDI (4%) than those infected with MC-3 and MC-10 (15% and 16%, respectively), but a statistically significant difference was not reached. Our data did not identify a clear association between subpopulations of R027 and different clinical outcomes; however, the data confirmed the utility of MLVA’s higher discrimination potential to better characterize CDI populations in an epidemiological analysis. For a patient with CDI, the progression toward an unfavorable outcome is a complex process that probably includes several interrelated strain and host characteristics.

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Binary toxin expression by Clostridioides difficile is associated with worse disease

Open Forum Infectious Diseases ◽

10.1093/ofid/ofac001 ◽

2022 ◽

Author(s):

Mary K Young ◽

Jhansi L Leslie ◽

Gregory R Madden ◽

David M Lyerly ◽

Robert J Carman ◽

...

Keyword(s):

Clinical Outcomes ◽

Disease Severity ◽

Severe Disease ◽

Fecal Microbiota ◽

Binary Toxin ◽

Enzyme Linked Immunosorbent Assay ◽

Rrna Gene ◽

Clostridioides Difficile ◽

Cell Counts ◽

Significant Difference

Abstract Background The incidence of Clostridioides difficile infection (CDI) has increased over the past two decades and is considered an urgent threat by the Centers for Disease Control. Hypervirulent strains such as ribotype 027, that possess genes for the additional toxin C. difficile binary toxin (CDT), are contributing to increased morbidity and mortality. Methods We retrospectively tested stool from 215 CDI patients for CDT by enzyme-linked immunosorbent assay (ELISA). Stratifying patients by CDT status, we assessed if disease severity and clinical outcomes correlated with CDT positivity. Additionally, we completed qPCR DNA extracted from patient stool to detect cdtB gene. Lastly, we performed 16 S rRNA gene sequencing to examine if CDT positive samples had an altered fecal microbiota. Results We found that patients with CdtB, the pore forming component of CDT, detected in their stool by ELISA were more likely to have severe disease with a higher 90-day mortality. CDT positive patients also had higher C. difficile bacterial burden and white blood cell counts. There was no significant difference in gut microbiome diversity between CDT positive and negative patients. Conclusions Patients with fecal samples that were positive for CDT had increased disease severity and worse clinical outcomes. Utilization of PCR and C. difficile Toxins A and B testing may not reveal the entire picture when diagnosing CDI, with the detection of CDT-expressing strains valuable in identifying patients at risk of more severe disease.

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A menace to human health: rhino-orbital cerebral mucormycosis

International Journal of Community Medicine and Public Health ◽

10.18203/2394-6040.ijcmph20212623 ◽

2021 ◽

Vol 8 (7) ◽

pp. 3597

Author(s):

Arvind Sharma ◽

Aditi Bharti ◽

Tej Pratap Singh ◽

Richa Sharma

Keyword(s):

Diabetes Mellitus ◽

Corticosteroid Therapy ◽

Fungal Infections ◽

Severe Disease ◽

Tertiary Care ◽

Case Series ◽

Care Centre ◽

Contributing Factors ◽

Tertiary Care Centre ◽

Cross Sectional

Collate and interpret data on rhino-orbital-cerebral mucormycosis (ROCM) infections admitted at the tertiary care centre and investigate the common contributing factors leading to such infections and highlighting the relationship of this upsurge seen in patients infected with COVID-19. We conducted a cross-sectional study in Central India, in the period of eleven days (from 9 May to 18 May). A total of ten patients with ROCM was investigated, admitted to the separate ward for mucormycosis in the tertiary care centre. A self-pre-designed questionnaire was used for the evaluation. Verbal consent was obtained from the patients before the start of the study and also ensured the confidentiality of their respective details. Among ten of the patients, six patients were known cases of diabetes mellitus, two of the patients were diagnosed with diabetes mellitus after the initiation of corticosteroid therapy during their treatment and two of them were non-diabetic. All the patients in this case series were on corticosteroid therapy and on oxygen supplementation. Majority of the patients showing mild to moderate disease with unilateral symptoms, although only 10% showed the severe disease with bilateral eye involvement. It is evident that the poor or impaired immune functioning is the leading cause of the upsurge in mucormycosis cases. Therefore, early diagnosis and treatment of fungal infections can substantially reduce morbidity and mortality.

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CIScoSI Study [Children Immunization Status and cases of Systemic Illness]

Medical & Clinical Research ◽

10.33140/mcr.03.03.02 ◽

2018 ◽

Vol 3 (3) ◽

Keyword(s):

Infectious Diseases ◽

East Asia ◽

Pediatric Patients ◽

Severe Disease ◽

Tertiary Care ◽

Immunization Coverage ◽

South East Asia ◽

Immunization Status ◽

Tertiary Care Hospitals ◽

Total Coverage

To determine the immunization status of pediatric patients under age of 5 years visiting pediatric department of tertiary care hospitals in South East Asia. The aim of this study was to appreciate the awareness and implementation of vaccination in pediatric patients who came into pediatric outpatient Department with presenting complain other than routine vaccination. we can also know the count of patients who do not complete their vaccination after birth. we can differentiate between vaccinated and unvaccinated patients and incidence of severe disease in both groups. Immunization is a protective process which makes a person resistant to the harmful diseases prevailing in the community, typically by vaccine administration either orally or intravenously. It is proven for controlling and eliminating many threatening diseases from the community. WHO report that licensed vaccines are available for the prevention of many infectious diseases. After the implementation of effective immunization the rate of many infectious diseases have declined in many countries of the world. South-East Asia is far behind in the immunization coverage. An estimated total coverage is 56%-88% for a fully immunized child, which is variable between countries. Also the coverage is highest for BCG and lowest for Polio.

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