Study finds increase in C difficile in cancer patients
Researchers with the University of Texas at Austin report that the incidence of Clostridium difficile infection (CDI) is increasing among cancer patients, according to a new study in BMC Infectious Diseases.
Using data from the US National Hospital Discharge Surveys, the researchers identified more than 30 million cancer discharges from US hospitals from 2001 to 2010. CDI was present in 260,219 (0.9%) of cancer patients. The overall CDI incidence for the study period was 8.6 per 1,000 adult discharges, with incidence increasing from 6.8 per 1,000 cancer discharges in 2001 to 12.8 in 2010. Incidence peaked in 2008 at 17.2 per 1,000 discharges. Increases were seen in both principal CDI and secondary CDI.
Patients with CDI were more likely to be older, male, residents of the Northeast, and Medicare users, and CDI was found to be over 2.5 times more common among patients with blood cancers than those with solid-organ cancers.
Death occurred in 7.4% of cancer patients during the study period. The mortality rate was significantly higher for cancer patients with CDI compared with those without (9.3% vs 7.4%). In addition, the median length of hospital stay was significantly longer for CDI patients compared with those without (9 days vs 4 days).
The authors of the study say that knowing the burden of CDI among cancer patients is important because cancer patients can now be identified as a high-risk population and a target for antimicrobial stewardship and infection control efforts.
Jun 23 BMC Infect Dis study
Editorial urges narrower use of contact precautions with MRSA, VRE
An editorial today in JAMA is calling for a rethinking of the use of contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus.
Under 2007 guidance from the US Centers for Disease Control and Prevention (CDC), which recommends the use of gloves and gowns for patients with target multidrug-resistant organisms (MDROs) and those who have previously been identified as colonized with target MDROs, patients infected or colonized with MRSA and VRE have become the most common focus of contact precautions. In addition, many states have passed laws mandating active culturing and contact precautions for MRSA patients.
But the authors of the editorial argue that no strong clinical trial evidence supports this policy. Observational data suggesting that contact precautions prevent MRSA or VRE infections, they say, come from reports of bundled approaches to outbreaks and not endemic MRSA or VRE, which are the more significant concern for hospitals. In addition, they cite higher-quality studies that have found no reduction in MRSA or VRE transmission rates associated with glove and gown use.
Furthermore, the authors argue that contact precautions can be burdensome when applied to an entire hospital, slowing the time it takes to move patients from the emergency room to hospital inpatient services and prolonging discharge time for patients being transferred to long-term care facilities, and result in less-satisfied patients. They also suggest that having to wear gloves and gowns for every patient visit could divert attention from other infection control activities, such as hand hygiene and chlorhexidine bathing.
One potential solution they offer is more selective use of contact precautions, given that MRSA or VRE contamination are more common when healthcare workers are performing high-risk patient care activities, such as bathing patients or dressing wounds, and caring for patients with clinical infections. Hospitals that have used such an approach, they say, have found no adverse effects on infection rates.
"Contact precautions are of unproven benefit and, at best, are low-value interventions that require significant personnel engagement," the authors write. "Reports of successful, alternative uses of gloves and gowns to prevent all infections while decreasing the health care worker, institutional, and environmental burden of personal protective equipment use are encouraging."
Jun 26 JAMA viewpoint
Antibiotic resistance in acne
A synopsis of clinical evidence suggests that the use of topical and systemic antibiotics for acne is associated with the formation of resistance in Propionibacterium acnes and other bacteria, with clinical consequences.
The synopsis, published in JAMA Dermatology, encompasses five trials conducted from 1987 to 2002 and 2007 to 2008 and including more than 120,000 patients in the United States, United Kingdom, Greece, Hungary, Italy, Spain, and Sweden. The primary outcomes were prevalence of antibiotic-resistant P acnes among patients and untreated contacts, nasal/pharyngeal colonization with S aureus, diagnosis of upper respiratory or urinary tract infection, and self-reported pharyngitis.
A summary of the findings showed that multiple countries have reported resistance in more than half of P acnes isolates, predominantly to topical erythromycin and clindamycin, and that resistant P acnes is found on the skin of untreated contacts of acne patients prescribed antibiotics. In addition, the reviewers found that use of topical antibiotics is associated with resistance in S aureus, that acne patients treated with topical and/or oral antibiotics for at least 6 weeks were more likely to develop upper respiratory infections during 1 year of follow-up than those who had not received antibiotics, and that university students receiving oral antibiotics for acne were four times more likely to report pharyngitis during 1 year of follow-up.
To reduce resistance, current guidelines from the American Academy of Dermatology recommend benzoyl peroxide, a topical bactericidal agent not reported to cause resistance, alongside topical and oral antibiotics. Benzoyl peroxide is thought to impede the formation of resistance, but evidence of its ability to limit resistance is stronger with topical antibiotics than with oral antibiotics.
The authors say additional studies are needed to address multiple evidence gaps.
Jun 21 JAMA Dermatol clinical evidence synopsis