Archive for September 5, 2015

Trimethoprim-sulfamethoxazole vs vancomycin for severe infections caused by meticillin resistant Staphylococcus aureus: randomised controlled trial.

BMJ. MAY.14, 2015  V.350 .

Paul M1, Bishara J2, Yahav D3, Goldberg E4, Neuberger A5, Ghanem-Zoubi N6, Dickstein Y7, Nseir W8, Dan M9, Leibovici L3.

1Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel

2Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel.

3Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel Unit of Infectious Diseases, Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva.

4Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel Unit of Infectious Diseases, Medicine F, Rabin Medical Center, Beilinson Hospital, Petah-Tikva.

5Division of Infectious Diseases, Medicine B, Rambam Health Care Campus, Haifa, Israel Technion-Israel Institute of Technology and the Ruth & Bruce Rappaport Faculty of Medicine, Haifa.

6Division of Infectious Diseases, Rambam Health Care Campus, Haifa.

7Technion-Israel Institute of Technology and the Ruth & Bruce Rappaport Faculty of Medicine, Haifa Division of Infectious Diseases, Medicine A, Rambam Health Care Campus, Haifa.

8Internal Medicine Department, Holy Family Hospital, Nazareth, Faculty of Medicine in the Galilee, Bar-Ilan Univesity, Safed, Israel.

9Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel Infectious Diseases Unit, E Wolfson Hospital, Holon, Israel.



To show non-inferiority of trimethoprim-sulfamethoxazole compared with vancomycin for the treatment of severe infections due to meticillin resistant Staphylococcus aureus (MRSA).


Parallel, open label, randomised controlled trial.


Four acute care hospitals in Israel.


Adults with severe infections caused by MRSA susceptible to trimethoprim-sulfamethoxazole and vancomycin. Patients with left sided endocarditis, meningitis, chronic haemodialysis, and prolonged neutropenia were excluded.


Trimethoprim-sulfamethoxazole 320 mg/1600 mg twice daily versus vancomycin 1 g twice daily for a minimum of seven days and then by indication.


The primary efficacy outcome was treatment failure assessed at day 7, consisting of death, persistence of haemodynamic instability or fever, stable or worsening Sequential Organ Failure Assessment score, and persistence of bacteraemia. The primary safety outcome was all cause mortality at day 30. Non-inferiority was defined by a difference of less than 15% for treatment failure.


252 patients were included in the trial, of whom 91 (36%) had bacteraemia. No significant difference in treatment failure was seen for trimethoprim-sulfamethoxazole (51/135, 38%) versus vancomycin (32/117, 27%)-risk ratio 1.38 (95% confidence interval 0.96 to 1.99). However, trimethoprim-sulfamethoxazole did not meet the non-inferiority criterion-absolute difference 10.4% (95% confidence interval -1.2% to 21.5%). For patients with bacteraemia, the risk ratio was 1.40 (0.91 to 2.16). In a multivariable logistic regression analysis, trimethoprim-sulfamethoxazole was significantly associated with treatment failure (adjusted odds ratio 2.00, 1.09 to 3.65). The 30 day mortality rate was 32/252 (13%), with no significant difference between arms. Among patients with bacteraemia, 14/41 (34%) treated with trimethoprim-sulfamethoxazole and 9/50 (18%) with vancomycin died (risk ratio 1.90, 0.92 to 3.93).


High dose trimethoprim-sulfamethoxazole did not achieve non-inferiority to vancomycin in the treatment of severe MRSA infections. The difference was particularly marked for patients with bacteraemia. Trial registration Clinical trials NCT00427076.



September 5, 2015 at 11:06 pm

Perianal Abscess and Proctitis by Klebsiella pneumoniae.

Intest Res. 2015 Jan;13(1):85-9.

Jeong WS1, Choi SY1, Jeong EH1, Bang KB1, Park SS1, Lee DS1, Park DI1, Jung YS1.

1Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea.


Klebsiella pneumoniae (K. pneumoniae) can at times cause invasive infections, especially in patients with diabetes mellitus and a history of alcohol abuse.

A 61-year-old man with diabetes mellitus and a history of alcohol abuse presented with abdominal and anal pain for two weeks. After admission, he underwent sigmoidoscopy, which revealed multiple ulcerations with yellowish exudate in the rectum and sigmoid colon.

The patient was treated with ciprofloxacin and metronidazole. After one week, follow up sigmoidoscopy was performed owing to sustained fever and diarrhea.

The lesions were aggravated and seemed webbed in appearance because of damage to the rectal mucosa. Abdominal computed tomography and rectal magnetic resonance imaging were performed, and showed a perianal and perirectal abscess.

The patient underwent laparoscopic sigmoid colostomy and perirectal abscess incision and drainage. Extended-spectrum beta-lactamase-producing K. pneumoniae was identified in pus culture.

The antibiotics were switched to ertapenem. He improved after surgery and was discharged. K. pneumoniae can cause rapid invasive infection in patients with diabetes and a history of alcohol abuse.

We report the first rare case of proctitis and perianal abscess caused by invasive K. pneumoniae infection.


September 5, 2015 at 11:00 pm

Chlorhexidine bathing and health care-associated infections: a randomized clinical trial.

JAMA. JAN.27, 2015 V.313 N.4 P.369-78.

Noto MJ1, Domenico HJ2, Byrne DW2, Talbot T1, Rice TW1, Bernard GR1, Wheeler AP1.

1Department of Medicine, Vanderbilt University, Nashville, Tennessee.

2Department of Biostatistics, Vanderbilt University, Nashville, Tennessee.



Daily bathing of critically ill patients with the broad-spectrum, topical antimicrobial agent chlorhexidine is widely performed and may reduce health care-associated infections.


To determine if daily bathing of critically ill patients with chlorhexidine decreases the incidence of health care-associated infections.


A pragmatic cluster randomized, crossover study of 9340 patients admitted to 5 adult intensive care units of a tertiary medical center in Nashville, Tennessee, from July 2012 through July 2013.


Units performed once-daily bathing of all patients with disposable cloths impregnated with 2% chlorhexidine or nonantimicrobial cloths as a control. Bathing treatments were performed for a 10-week period followed by a 2-week washout period during which patients were bathed with nonantimicrobial disposable cloths, before crossover to the alternate bathing treatment for 10 weeks. Each unit crossed over between bathing assignments 3 times during the study.


The primary prespecified outcome was a composite of central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated pneumonia (VAP), and Clostridium difficile infections. Secondary outcomes included rates of clinical cultures that tested positive for multidrug-resistant organisms, blood culture contamination, health care-associated bloodstream infections, and rates of the primary outcome by ICU.


During the chlorhexidine bathing period, 55 infections occurred: 4 CLABSI, 21 CAUTI, 17 VAP, and 13 C difficile. During the control bathing period, 60 infections occurred: 4 CLABSI, 32 CAUTI, 8 VAP, and 16 C difficile. The primary outcome rate was 2.86 per 1000 patient-days during the chlorhexidine and 2.90 per 1000 patient-days during the control bathing periods (rate difference, -0.04; 95% CI, -1.10 to 1.01; P = .95). After adjusting for baseline variables, no difference between groups in the rate of the primary outcome was detected. Chlorhexidine bathing did not change rates of infection-related secondary outcomes including hospital-acquired bloodstream infections, blood culture contamination, or clinical cultures yielding multidrug-resistant organisms. In a prespecified subgroup analysis, no difference in the primary outcome was detected in any individual intensive care unit.


In this pragmatic trial, daily bathing with chlorhexidine did not reduce the incidence of health care-associated infections including CLABSIs, CAUTIs, VAP, or C difficile. These findings do not support daily bathing of critically ill patients with chlorhexidine.

TRIAL REGISTRATION: Identifier: NCT02033187.




September 5, 2015 at 4:00 pm

Transmission of infection by flexible gastrointestinal endoscopy and bronchoscopy.

Clin Microbiol Rev. APR 2013 V.26 N.2 P.231-54.

Kovaleva J1, Peters FT, van der Mei HC, Degener JE.

1Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.


Flexible endoscopy is a widely used diagnostic and therapeutic procedure. Contaminated endoscopes are the medical devices frequently associated with outbreaks of health care-associated infections.

Accurate reprocessing of flexible endoscopes involves cleaning and high-level disinfection followed by rinsing and drying before storage. Most contemporary flexible endoscopes cannot be heat sterilized and are designed with multiple channels, which are difficult to clean and disinfect.

The ability of bacteria to form biofilms on the inner channel surfaces can contribute to failure of the decontamination process. Implementation of microbiological surveillance of endoscope reprocessing is appropriate to detect early colonization and biofilm formation in the endoscope and to prevent contamination and infection in patients after endoscopic procedures.

This review presents an overview of the infections and cross-contaminations related to flexible gastrointestinal endoscopy and bronchoscopy and illustrates the impact of biofilm on endoscope reprocessing and postendoscopic infection.


September 5, 2015 at 10:25 am

A review of current disinfectants for gastrointestinal endoscopic reprocessing.

Clin Endosc. JUL 2013 V.46 N.4 P.337-41.

Park S1, Jang JY, Koo JS, Park JB, Lim YJ, Hong SJ, Kim SW, Chun HJ; Disinfection Management Committee, The Korean Society of Gastrointestinal Endoscopy.

1Department of Internal Medicine, KEPCO Medical Center, Seoul, Korea.


Gastrointestinal endoscopy is gaining popularity for diagnostic and therapeutic purposes. However, concerns over endoscope-related nosocomial infections are increasing, together with interest by the general public in safe and efficient endoscopy.

For this reason, reprocessing the gastrointestinal endoscope is an important step for effective performance of endoscopy. Disinfectants are essential to the endoscope reprocessing procedure. Before selecting an appropriate disinfectant, their characteristics, limitations and means of use must be fully understood.

Herein, we review the characteristics of several currently available disinfectants, including their uses, potency, advantages, and disadvantages.

Most disinfectants can be used to reprocess gastrointestinal endoscopes if the manufacturer’s guidelines are followed. The selection and use of a suitable disinfectant depends on the individual circumstances of each endoscopy suite.



September 5, 2015 at 10:23 am

Guidelines for safety in the gastrointestinal endoscopy unit.

Gastrointest Endosc. MAR 2014 V.79 N.3 P.363-72. .

ASGE Ensuring Safety in the Gastrointestinal Endoscopy Unit Task Force, Calderwood AH, Chapman FJ, Cohen J, Cohen LB, Collins J, Day LW, Early DS.


September 5, 2015 at 10:21 am

Risk of transmission of carbapenem-resistant Enterobacteriaceae and related “superbugs” during gastrointestinal endoscopy.

World J Gastrointest Endosc. OCT. 16, 2014 V.6 N.10 P.457-74.

Muscarella LF1.

1Lawrence F Muscarella, LFM Healthcare Solutions, LLC, Montgomeryville, PA 18936, United States.


To evaluate the risk of transmission of carbapenem-resistant Enterobacteriaceae (CRE) and their related superbugs during gastrointestinal (GI) endoscopy.

Reports of outbreaks linked to GI endoscopes contaminated with different types of infectious agents, including CRE and their related superbugs, were reviewed.

Published during the past 30 years, both prior to and since CRE’s emergence, these reports were obtained by searching the peer-reviewed medical literature (via the United States National Library of Medicine’s “MEDLINE” database); the Food and Drug Administration’s Manufacturer and User Facility Device Experience database, or “MAUDE”; and the Internet (via Google’s search engine).

This review focused on an outbreak of CRE in 2013 following the GI endoscopic procedure known as endoscopic retrograde cholangiopancreatography, or ERCP, performed at “Hospital X” located in the suburbs of Chicago (IL; United States).

Part of the largest outbreak of CRE in United States history, the infection and colonization of 10 and 28 of this hospital’s patients, respectively, received considerable media attention and was also investigated by the Centers for Disease Control and Prevention (CDC), which published a report about this outbreak in Morbidity and Mortality Weekly Report (MMWR), in 2014.

This report, along with the results of an independent inspection of Hospital X’s infection control practices following this CRE outbreak, were also reviewed. While this article focuses primarily on the prevention of transmissions of CRE and their related superbugs in the GI endoscopic setting, some of its discussion and recommendations may also apply to other healthcare settings, to other types of flexible endoscopes, and to other types of transmissible infectious agents.

This review found that GI endoscopy is an important risk factor for the transmission of CRE and their related superbugs, having been recently associated with patient morbidity and mortality following ERCP.

The CDC reported in MMWR that the type of GI endoscope, known as an ERCP endoscope, that Hospital X used to perform ERCP in 2013 on the 38 patients who became infected or colonized with CRE might be particularly challenging to clean and disinfect, because of the complexity of its physical design.

If performed in strict accordance with the endoscope manufacturer’s labeling, supplemented as needed with professional organizations’ published guidelines, however, current practices for reprocessing GI endoscopes, which include high-level disinfection, are reportedly adequate for the prevention of transmission of CRE and their related superbugs.

Several recommendations are provided to prevent CRE transmissions in the healthcare setting. CRE transmissions are not limited to contaminated GI endoscopes and also have been linked to other reusable flexible endoscopic instrumentation, including bronchoscopes and cystoscopes.

In conclusion, contaminated GI endoscopes, particularly those used during ERCP, have been causally linked to outbreaks of CRE and their related superbugs, with associated patient morbidity and mortality. Thorough reprocessing of these complex reusable instruments is necessary to prevent disease transmission and ensure patient safety during GI endoscopy.

Enhanced training and monitoring of reprocessing staffers to verify the proper cleaning and brushing of GI endoscopes, especially the area around, behind and near the forceps elevator located at the distal end of the ERCP endoscope, are recommended.

If the ERCP endoscope features a narrow and exposed channel that houses a wire connecting the GI endoscope’s control head to this forceps elevator, then this channel’s complete reprocessing, including its flushing with a detergent using a procedure validated for effectiveness, is also emphasized.


September 5, 2015 at 10:20 am


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