Clostridium difficile is the leading cause of healthcare-associated infections in the United States. Clinically, C. difficile-associated disease can present as asymptomatic colonization, self-limited diarrheal illness or severe colitis (that may result in death). This variability in disease course and outcomes suggests that host factors play an important role as key determinants of disease severity. Currently, there are several scoring indices to estimate severity of C. difficile-associated disease. Leukocytosis and renal failure are considered to be the most important predictors of C. difficile disease severity in hosts with a normal immune system. The degree of leukocytosis which is considered significant for severe disease and how it is scored vary amongst scoring indices. None of the scores have been prospectively validated, and while total WBC count is useful to estimate the magnitude of the host response in most patient populations, in immune-compromised patients like those receiving chemotherapy, solid organ transplant patients or hematopoietic stem cell transplants the WBC response can be variable or even absent making this marker of severity difficult to interpret. Other cellular subsets like neutrophils, eosinophils and lymphocytes provide important information about the host immune status and play an important role in the immune response against C. difficile infection. However, under the current scoring systems the role of these cellular subsets have been underestimated and only total white blood cell counts are taken into account. In this review we highlight the role of host leukocyte response to C. difficile challenge in the normal and immunocompromised host, and propose possible ways that would allow for a better representation of the different immune cell subsets (neutrophils, lymphocytes and eosinophils) in the current scoring indices.
Background: Angiography negative perimesencephalic subarachnoid hemorrhage (SAH) is considered a relatively benign entity compared to aneurysmal SAH. However, some patients with angiography negative perimesencephalic subarachnoid hemorrhage with extension of hemorrhage beyond the perimesencephalic area are at increased risk for vasospasm. Here we present a series of 21 patients with angiography negative perimesencephalic pattern of SAH both with and without ventricular extension and describe their incidence of vasospasm and clinical outcomes. Methods: Retrospective chart review was performed among patients who underwent invasive angiography from 8/2007-6/2010. Inclusion criteria were presenting clinical symptoms typical of SAH, computed tomography (CT) evidence of perimesencephalic SAH with or without ventricular extension, no recent trauma or stroke, and cerebral angiography negative for aneurysm or arteriovenous malformation. 21 patients, 8 men and 13 women, with a mean age of 55.1 years met these criteria. The presenting CTs were examined and a modified Fisher Grade assigned. The patients’ clinical course was reviewed for incidence and treatment of vasospasm. The patients’ discharge summaries were evaluated and each patient given a modified Rankin Scale score. Results: The modified Fisher Scale score derived from the presenting CT was 1 for 29% (n=6), 2 for 5% (n=1), 3 for 19% (n=4), and 4 for 47% (n=10) of the patients. Amongst the 52% (n=11) of patients with intraventricular hemorrhage as defined by a modified Fisher Scale score of 2 or 4, 24% (n=5) developed angiographical evidence of vasospasm. 10% (n=2) of the patients required intra-arterial verapamil. 90% (n=9) of patients without intraventricular extension had good outcomes at discharge as defined by modified Rankin Scale score less than or equal to 2, while only 36% (n=4) of patients with angiography negative SAH with intraventricular extension had good outcomes. Conclusions: Although angiography negative perimesencephalic SAH is considered to have less associated morbidity and mortality than aneurysmal perimesencephalic SAH, patients with extension of hemorrhage into the ventricles are at increased risk for vasospasm and poor functional outcomes.
Background SSI is a devastating complication of spine surgery that results in significant morbidity as it requires prolonged antibiotic courses and multiple surgical debridements. It also increases the economic burden on the health care system. So, it becomes important to learn the microbiological profile and assess the current pro-op antibiotic prophylaxis policy. Methods All cases reported by the hospital infection control surveillance program based on CDC/NHSN Surveillance definitions between January 2017 and July 2019 were retrospectively reviewed for microbiological data and surgical characteristics using electronic medical record, and non-parametric test was used to assess the difference in proportional distribution of gram-negative organisms between upper and lower spine groups. Results Between January 2017 and July 2019, 3561 spine surgeries were performed, 51 cases of SSI were reported, and 50 patients have microbiological data available. The most commonly isolated organism was Staphylococcus aureus (38%), followed by Escherichia coli (12%). There was no statistical difference for the distribution of gram-negative organisms in upper spine (17) and lower spine (33) surgeries (29.4% vs 48.4%, P Value = 0.24). However total gram-negative organisms accounted for 42% cases and lower spine surgical procedures were more likely to be associated with mixed infections including both gram negative and gram-positive organisms (15.1% vs 0%). Cefazolin resistant gram-negative organisms accounted for 22% of all gram-negative infections. Our current pre-op antibiotic policy recommends cefazolin plus or minus vancomycin (If MRSA screen positive) and clindamycin plus vancomycin in patients with severe penicillin allergy. Table 1: Characteristics of the cultures Table: 2 Microorganisms isolated from 50 patients with post-surgical spine infections Figure 1: Proportional distribution of Micro-organisms between lower and upper spine (Percentage on left side and No. of positive cultures on right side) Conclusion Although gram-positive organism predominated, there was a substantial portion of gram-negative organisms in post-surgical spine infections. Cefazolin would cover at least half of the gram-negative organisms identified based on our antibiogram susceptibility pattern. However, in patients with penicillin allergy, our current recommended pre-operative antibiotic prophylaxis does not provide gram-negative coverage. We will therefore explore the value of adding an agent with gram negative coverage based on our institutional antibiogram. Disclosures All Authors: No reported disclosures
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