Invasive scedosporiosis in lung transplant recipients: A nine-year retrospective study in a tertiary care hospital

BackgroundScedosporium species and Lomentospora prolificans (Sc/Lp) are emerging molds that cause invasive disease associated with a high mortality rate. After Aspergillus, these molds are the second filamentous fungi recovered in lung transplant (LT) recipients.AimsOur objective was to evaluate the incidence, risk factors and outcome of Sc/Lp infections in LT recipients at a tertiary care hospital with a national reference LT program.MethodsA nine-year retrospective study was conducted.ResultsDuring this period, 395 LT were performed. Positive cultures for Sc/Lp were obtained from twenty-one LT recipients. Twelve patients (incidence 3.04%) developed invasive scedosporiosis (IS). In 66.7% of the patients with IS the invasive infection was defined as a breakthrough one. The main sites of infection were lungs and paranasal sinuses. Most of the patients received combination antifungal therapy. The IS crude mortality rate after 30 days was 16.7%, and 33.3% after a year.ConclusionsOur study highlights improved survival rates associated with combination antifungal therapy in LT recipients and underlines the risk of breakthrough infections in patients with allograft dysfunction on nebulized lipidic amphotericin B prophylaxis. In addition to pretransplant colonization, acute or chronic organ dysfunctions seem to be the main risk factors for IS.     

Prevalence and predictors of non-alcoholic fatty liver disease in tertiary care hospital of Taif,Saudi Arabia: A retrospective study

BackgroundThe prevalence of nonalcoholic fatty liver disease (NAFLD) in Saudi Arabia is predicted to exceed 30% by 2030. NAFLD leads to liver fibrosis, thus increasing morbidity and health care burden. Obesity and diabetes have been strongly associated with NAFLD in different cities in Saudi Arabia.ObjectivesTherefore, we aim to determine the prevalence rate of NAFLD and specific risk factors for NAFLD among patients of tertiary care hospital of Taif city.Material and methodsWe retrospectively analyzed the medical records of patients for two years, between Feb 2017 and Feb 2019, (n = 100) referred to the hepatology clinic at King Abdulaziz Specialist Hospital in Taif. The diagnosis of NAFLD was based on the radiology report for patients who were aged >20 years old. Other parameters including fasting blood glucose (FBG), platelets count, alanine transaminase (ALT), aspartate transaminase (AST) and total bilirubin were statistically analyzed.ResultsWe found that 40% (P < 0.05) of all patients had NAFLD. The results revealed that a significantly high number of patients with NAFLD have high FBG levels (75%, P < 0.0001) and total bilirubin (P < 0.05). Meanwhile, platelet count was significantly reduced in patients with NAFLD (P < 0.05).ConclusionNAFLD can be a serious health problem in the Taif region. In addition, high FBG is a significant specific risk factor for NAFLD. Health care providers should pay more attention to limiting the prevalence of NAFLD and its risk factors.     

Moyamoya disease: A clinical spectrum, literature review and case series from a tertiary care hospital in Pakistan

Background  

Moyamoya is a rare cerebrovascular disease of unknown etiology. The data on moyamoya disease from Pakistan is sparse. We report a case series of 13 patients who presented with moyamoya disease to a tertiary care hospital in Pakistan with a national referral base.     

Surveillance of patients attending a diarrhoeal disease hospital in Bangladesh

In October 1979 a surveillance system was set up at the International Centre for Diarrhoeal Disease Research, Bangladesh, Hospital at Dacca to study a 4% systematic sample of the 100 000 patients with diarrhoea who come to the hospital for care each year. From December 1979 to November 1980 inclusive, 3550 patients were studied. A recognised pathogenic organism was identified for 66% of patients screened for all pathogens, one-third of whom had a mixed infection with two or more agents. Enterotoxigenic Escherichia coli was the most common enteropathogen detected in all age groups (detection rate 20%), followed by rotavirus (19%), Campylobacter jejuni (14%), and Shigella (12%). Infants and young children (up to 5 years) were most often infected with rotavirus, enterotoxigenic E coli, and C jejuni and older children (5-14 years) had more infections with enterotoxigenic E coli, Shigella, and E histolytica. Surveillance has helped to define the range of disease among patients attending the Dacca Hospital. Sixty-five per cent of patients complained of watery diarrhoea, a presentation that was significantly more common in patients with Vibrio cholerae 0:1 (91%), enterotoxigenic E coli (78%), rotavirus (77%), and C jejuni (71%) than in all patients studied. Dysentery, defined as a history of diarrhoea with blood, was the presenting complaint of 20% of all patients but 55% of those with Shigella. Only patients with V cholerae 0:1 and enterotoxigenic E coli were at increased risk for severe dehydration. In addition surveillance has been used to identify areas where patient care can be improved and to generate new ideas for research.     

Risk factors and outcomes of candidemia caused by biofilm-forming isolates in a tertiary care hospital

Background

Very few data exist on risk factors for developing biofilm-forming Candida bloodstream infection (CBSI) or on variables associated with the outcome of patients treated for this infection.

Methods and Findings

We identified 207 patients with CBSI, from whom 84 biofilm-forming and 123 non biofilm-forming Candida isolates were recovered. A case-case-control study to identify risk factors and a cohort study to analyze outcomes were conducted. In addition, two sub-groups of case patients were analyzed after matching for age, sex, APACHE III score, and receipt of adequate antifungal therapy. Independent predictors of biofilm-forming CBSI were presence of central venous catheter (odds ratio [OR], 6.44; 95% confidence interval [95% CI], 3.21–12.92) or urinary catheter (OR, 2.40; 95% CI, 1.18–4.91), use of total parenteral nutrition (OR, 5.21; 95% CI, 2.59–10.48), and diabetes mellitus (OR, 4.47; 95% CI, 2.03–9.83). Hospital mortality, post-CBSI hospital length of stay (LOS) (calculated only among survivors), and costs of antifungal therapy were significantly greater among patients infected by biofilm-forming isolates than those infected by non-biofilm-forming isolates. Among biofilm-forming CBSI patients receiving adequate antifungal therapy, those treated with highly active anti-biofilm (HAAB) agents (e.g., caspofungin) had significantly shorter post-CBSI hospital LOS than those treated with non-HAAB antifungal agents (e.g., fluconazole); this difference was confirmed when this analysis was conducted only among survivors. After matching, all the outcomes were still favorable for patients with non-biofilm-forming CBSI. Furthermore, the biofilm-forming CBSI was significantly associated with a matched excess risk for hospital death of 1.77 compared to non-biofilm-forming CBSI.

Conclusions

Our data show that biofilm growth by Candida has an adverse impact on clinical and economic outcomes of CBSI. Of note, better outcomes were seen for those CBSI patients who received HAAB antifungal therapy.     

Psychosocial effects of SARS on hospital staff: survey of a large tertiary care institution

BackgroundThe outbreak of SARS in 2003 had a dramatic effect on the health care system in Toronto. The main objective of this study was to investigate the psychosocial effects associated with working in a hospital environment during this outbreak.MethodsQuestionnaires were distributed to all willing employees of Sunnybrook and Women''s College Health Sciences Centre between Apr. 10 and 22, 2003. The survey included questions regarding concern about SARS, precautionary measures, personal well-being and sociodemographic characteristics; a subsample also received the 12-item version of the General Health Questionnaire (GHQ-12).ResultsOf the 4283 questionnaires distributed, 2001 (47%) were returned, representing 27% of the total hospital employee population of 7474. The proportions of respondents who were allied health care professionals, nurses and doctors and who worked in areas other than patient care were representative of the hospital staff population as a whole. Of the 2001 questionnaires, 510 contained the GHQ-12. Two-thirds of the respondents reported SARS-related concern for their own or their family''s health. A total of 148 respondents (29%) scored above the threshold point on the GHQ-12, indicating probable emotional distress; the rate among nurses was 45%. Masks were reported to be the most bothersome infection control precaution. Logistic regression analysis identified 4 factors as being significantly associated with increased levels of concern for personal or family health: perception of a greater risk of death from SARS (adjusted odds ratio [OR] 5.0, 95% confidence interval [CI] 2.6–9.6), living with children (adjusted OR 1.8, 95% CI 1.5–2.3), personal or family lifestyle affected by SARS outbreak (adjusted OR 3.3, 95% CI 2.5–4.3) and being treated differently by people because of working in a hospital (adjusted OR 1.6, 95% CI 1.2–2.1). Four factors were identified as being significantly associated with the presence of emotional distress: being a nurse (adjusted OR 2.8, 95% CI 1.5–5.5), part-time employment status (adjusted OR 2.6, 95% CI 1.2–5.4), lifestyle affected by SARS outbreak (adjusted OR 2.2, 95% CI 1.4–3.5) and ability to do one''s job affected by the precautionary measures (adjusted OR 2.9, 95% CI 1.9–4.6).InterpretationOur findings indicate that the SARS outbreak had significant psychosocial effects on hospital staff. These effects differed with respect to occupation and risk perception. The effect on families and lifestyle was also substantial. These findings highlight the need for interventions to address psychosocial distress and concern and to provide support for employees during such crises.During the spring of 2003, Toronto was in the midst of the first of 2 phases of a SARS outbreak. As the principal tertiary referral hospital, Sunnybrook and Women''s College Health Sciences Centre (SWC) admitted 71 patients with SARS, of whom 23 were health care workers, between Mar. 14 and May 24. Over 1000 patients were seen at the SWC SARS assessment clinic.The effect of SARS on the health care system in the greater Toronto area was dramatic.^1,2,3,4,5,6 At various times during the outbreak, 3 hospitals were closed. Health care workers were at increased risk and many were quarantined, which resulted in severe staff shortages. On Mar. 28, following the closure of a second hospital, new and intensive infection control directives were issued for all hospitals in the greater Toronto area and surrounding area. At SWC the directives included cancellation of all hospital-based outpatient clinics, significant visitor restrictions, mandatory wearing of surgical masks by all staff at all times (and N95 masks in patient care areas), limited hospital entrance and mandatory screening of everyone entering the building (symptom/exposure questionnaire and temperature reading). Health care workers were instructed to work at 1 health care institution only, and off-work contact between health care workers from different institutions was discouraged. The SWC SARS Management Team met daily to implement Ministry of Health directives, organize care of patients with and without SARS and deal with staffing issues. With clinic and operating room closures and quarantined staff, staff redeployment to screening at entrances and other essential services became necessary. After Apr. 17, staff not involved in patient care no longer had to wear masks; however, most of the other infection control directives were kept in place well into the summer months.Little is known about the psychological effects of this type of disease outbreak on health care and other hospital workers. Maunder and colleagues¹ described the experiences of a small number of patients and staff at a Toronto hospital during the initial SARS outbreak. They observed that the staff were fearful for their own and their family''s health and found caring for colleagues as patients emotionally difficult. Mitchell and associates⁷ reported increased feelings of stigmatization among nurses during an outbreak of vancomycin-resistant enterococci in a hospital in Australia; feelings of alienation and isolation were also noted. A literature review revealed no large, systematic studies of the effect of a disease outbreak on hospital staff, particularly in cases with a high risk of nosocomial spread, as is the case with SARS.^2,4,8,9,10The main objectives of this study were (a) to determine the self-reported psychosocial effects associated with working in a hospital environment during the peak of a disease outbreak, specifically psychological distress and effects on the work and personal lives of employees, and (b) to examine the determinants of these effects.     

Nocardiosis in a tertiary care hospital in North India and review of patients reported from India

Nocardiosis, an uncommon infection of the past, is being increasingly reported in recent years with rise of immunosuppressed patients. In India, very few centers have reported this disease. The present report describes twelve consecutive cases of nocardiosis reported over a period of 26 months (January 2004 to March 2006) from a tertiary care center in north India. The patients were predominantly males (75%) with age range of 8–65 years and mean age of 38.4 years. Eleven patients had known underlying illness including renal transplantation, human immunodeficiency virus infection, and long-term steroid therapy. One patient with cerebral nocardiosis had no detectable predisposing factor. Infection involved central nervous system (3 cases), lungs (5 cases), subcutaneous tissue (1 case), and anterior mediastinum (1 case). Disseminated infection was documented in two patients. Nocardia asteroides complex was incriminated in six patients, N. brasiliensis in five and N. otitidiscaviarum in one patient. All the isolates were sensitive to co-trimoxazole, amikacin, cefotaxime and imipenem. Good therapeutic response was observed in 10 (90.9%) of 11 patients treated with antibiotics including co-trimaxazole, cephalosporins, amikacin, and imipenem alone or in combination. The series of nocardiosis reported from India has also been reviewed.     

Isolation of Candida in the blood cultures of patients admitted to the Emergency Room in a tertiary care hospital

BackgroundIn Spain, data of candidemia are limited to surveys conducted in specific areas or tertiary care centers. Also, in recent years, attention has shifted toward episodes of candidemia in non-ICU wards.AimsWe reviewed the cases of Candida isolates recovered from the blood of patients admitted to the Emergency Room (ER) in our tertiary care hospital.MethodsThe patients selected for this study had an isolation of Candida in the blood culture. All data were collected retrospectively from the clinical records of a 11-year period.ResultsCandida albicans and other species of the genus were present in 10 and 18 patients, respectively. The patients did not present different clinical features in comparison with other reports of hospitalized patients. All patients had several risk factors for candidemia. Only two patients had received previous antifungal therapy before admission. All the isolates of C. albicans, Candida glabrata and the only isolate of Candida tropicalis were susceptible to all the antifungal agents tested. Only one isolate of Candida parapsilosis was susceptible dose-dependent to fluconazole, and the only isolate of Candida metapsilosis was resistant to fluconazole.ConclusionsIt is essential to evaluate the risk factors, underlying conditions and clinical features in non-hospitalized patients in order to determine whether an empirical treatment for candidemia is appropriate.     

Frequency and susceptibility patterns of non-fermenting gram-negative rods isolated from patients hospitalised in intensive care units of a tertiary care hospital

The aim of the study was to assess frequency and susceptibility to antimicrobial agents of non-fermenting gram-negative rods isolated from clinical specimens obtained from patients requiring intensive care, with emphasis on profile of the unit. Identification of cultured isolates was done using automated VITEK and API systems (bioMerieux, France). Susceptibility to antimicrobial agents was tested by a disk-diffusion method according to the NCCLS recommendations. In total the analysis comprised 425 strains of non-fermenting gram-negative rods, constituting 58.9% of all isolates of gram-negative bacteria. In blood cultures predominated strains of A. baumannii (46.8%) and P. aeruginosa (40.4%), while in cultures of other clinical specimens these bacteria comprised 42.9% and 43.9% of isolates. Major differences were observed in frequency of these species on both ICU units. Strains of non-fermenting rods isolated from blood cultures comprised a lower percentage of strains susceptible to antimicrobials (particularly cefepime and carbapenems) than isolates cultured from other specimens. Strains of A. baumannii resistant to imipenem and meropenem were detected with a frequency of 12.5% and 26.7%, respectively. Resistance of P. aeruginosa strains to carbapenems was 62.2% and 44.3%, respectively. There was a relatively high percentage of strains susceptible to cefepime (82.0%), ceftazidime (78.9%), amikacin (77.8%) and piperacillin/tazobactam (69.7%). Conclusions: 1. There was a predominance (58.9%) of strains of gram-negative non-fermenting rods. 2. Isolates from blood cultures were characterised by a much higher percentage of resistant strains in comparison to other specimens. 3. Strains of A. baumannii resistant to carbapenems were recorded. 4. There were differences in frequency and antimicrobial susceptibility among the strains of P. aeruginosa and A. baumannii depending on the type of clinical specimen and ICU profile.     

Emergence and spread of carbapenem-resistant Acinetobacter baumannii in a tertiary care hospital in Turkey

An intensive care unit (ICU)-based OXA-23-producing multiple-drug resistant Acinetobacter baumannii (MDRAB) outbreak was detected between October 2005 and October 2006. A total of 47 patients were infected/colonized with the outbreak strain. Clinical data were available from 37 patients. The all-cause mortality rate among the patients exposed to the epidemic strain was 35% (13/37). The outbreak strain and the resistance determinants were characterized both by microbiological methods and by molecular techniques. Cloning and sequencing experiments identified ISAbaI-associated bla(oxa-23) on the chromosome. Screening of imipenem-resistant Acinetobacter isolated from the ICU during the outbreak period with PCR identified 97 isolates as positive for the ISAbaI-bla(oxa-23) structure. Pulsed-field gel electrophoresis and plasmid analyses with selected nonrepetitive isolates revealed the clonality. Disk diffusion on cloxacillin-supplemented agar media and the real-time PCR experiments showed that outbreak isolates are overexpressing the ampC enzyme. This study highlights the occurrence of OXA-23-producing and ampC-overexpressing MDRAB in ICUs.     

Consultation patterns and clinical correlates of consultation in a tertiary care setting

Background

Chronic diarrhoea is one of the most debilitating consequences of HIV infection in sub-Saharan Africa and it carries a high mortality rate. We report unexpectedly low concentrations of circulating aldosterone in 12 patients (6 men, 6 women) in the University Teaching Hospital, Lusaka, who all had diarrhoea for over one month. Changes in serum electrolytes, blood pressure, Karnofsky score and serum aldosterone concentration were being monitored during a short study of responses to saline infusion (3 litres/24 h) over 72 hours.

Findings

At baseline, 9/12 (75%) of the patients were hyponatraemic, 10/11 (91%) were hypokalaemic, and 6/12 (50%) had undetectable aldosterone concentrations. Blood pressure and Karnofsky score rose and creatinine concentration fell in response to the infusion.

Conclusion

Circulating aldosterone concentrations were inappropriately low and complicate the profound electrolyte deficiencies resulting from chronic diarrhoea. Management of these deficiencies needs to be more aggressive than is currently practised and consideration should be given to a formal clinical trial of mineralocorticoid replacement in these severely ill patients. If the inappropriately low aldosterone reflects a general adrenal failure, it may explain a considerable proportion of the high mortality seen both before and after initiation of anti-retroviral therapy.     

Prevalence of depression in tuberculosis patients in comparison with non-tuberculosis family contacts visiting the DOTS clinic in a Nigerian tertiary care hospital and its correlation with disease pattern

Background Individuals with chronic diseases such as tuberculosis often have comorbid de-pression that requires frequent hospitalisations. This poses great challenges to the care of such patients.Objective This study aimed at determining the prevalence of depression in tuberculosis patients in comparison with non-tuberculosis controls, and its correlation with disease pattern.Method Eighty-eight patients with tuberculosis and 81 family members visiting the DOTS Centre at University College Hospital Ibadan Centre were screened for depression. Severity of depression was assessed using the Hamilton Depression Scale and was compared with severity of pulmonary tuberculosis.Results The prevalence of depression was 45.5% among patients and 13.4% among family members. Depression was more prevalent among patients that were elderly (P = 0.001), with extensive disease (P = 0.01), of long duration (P = 0.03), those with category 2 tuberculosis (P = 0.003), those from a nuclear family (P = 0.01) and patients that were unmarried (P = 0.02).Conclusion The impact of chronic diseases such as tuberculosis extends beyond physical impairment. It includes behavioural consequences, in this instance depression, for both the patient and the primary care givers. Thus, the care of patients with tuberculosis should be comprehensive and include consultative–liaison psychiatric care.     

Long term effects of an integrated care intervention on hospital utilization in patients with severe COPD: a single centre controlled study

Abstract

Chronic obstructive pulmonary disease (COPD) is one of the main causes of morbidity and mortality globally. In Trondheim in 2008 an integrated care model (COPD-Home) consisting of an education program, self-management plan, home visits and a call centre for patient support and communication was developed. The objective was to determine the efficacy of an intervention according to the COPD-Home model in reducing hospital utilization among patients with COPD stage III and IV (GOLD 2007) discharged after hospitalization for acute exacerbations of COPD (AECOPD).

Methods

A single centre, prospective, open, controlled clinical study comparing COPD-Home integrated care (IC) with usual care (UC).

Results

Ninety-one versus 81 patients mean age 73.4 ± 9.3 years (57% women) were included in the IC group (ICG) and the UC group (UCG) respectively, and after 2 years 51 and 49 patients were available for control in the respective groups. During the year prior to study start there were 71 hospital admissions (HA) in the ICG and 84 in the UCG. There was a 12.6% reduction in HA in the ICG during the first year of follow-up and a 46.5% reduction during the second year (p = 0.01) compared to an 8.3% increase during the first year and no change during the second year in the ICG. During the year prior to study start, the number of hospital days (HD) was 468 in the ICG and 479 in the UCG. In the IC group, the number of HD was reduced by 48.3% during the first year (p = 0.01), and remained low during the second year of follow-up (p=0.02). In the UC group, the number of HD remained unchanged during the follow-up period. There was a trend towards a shorter survival time among patients in the ICG compared to the UCG, hazard ratio 1.33 [95% CI 0.77 to 2.33].

Conclusion

Intervention according to the COPD-Home model reduced hospital utilization in patients with COPD III and IV with a persisting effect throughout the 2 years of follow-up. However, there was a trend towards a shorter survival time in the intervention group.