Brandon P. Verdoorn

High prevalence of tcdC deletion-carrying Clostridium difficile and lack of association with disease severity

We assessed the prevalence of tcdC deletion-carrying Clostridium difficile using a stool polymerase chain reaction (PCR) assay that detects previously described 18- and 39-bp deletions (J. Clin. Microbiol. 2008;46:1996). We divided inpatients into 2 groups, those for whom the assay detected a deletion in tcdC and those for whom no deletion was detected. We compared risk factors (antibiotic use, hospitalization, nursing home stay, immunocompromise, age >65 years), complications (pseudomembranous colitis, toxic megacolon, colonic perforation, colectomy, and intensive care unit admission), duration of antibiotic treatment, and 30-day mortality between the groups. Forty-two of 141 patients had deletion-positive C. difficile. Prior nursing home stay and age >65 years were significantly more common in the deletion-positive group. Other risk factors, complications, antibiotic duration, and mortality did not differ significantly. Deletion-carrying C. difficile was commonly present but not associated with more severe disease and not markedly different in terms of risk factor profile. Severity of disease was relatively low, regardless of the presence or absence of a deletion.

Effect of Telephoned Notification of Positive Clostridium difficile Test Results on the Time to the Ordering of Antimicrobial Therapy

The time between electronic-medical-record reporting of a positive result of a test for Clostridium difficile toxin in stool and the ordering of antimicrobial therapy was compared during consecutive periods when results were not telephoned (n = 274) and when results were telephoned (n = 90) to the clinical service. The mean times to the ordering of antimicrobial therapy were 11.9 and 3.6 hours, respectively (P < .001).

Improved Resident Physician Confidence With Advance Care Planning After an Ambulatory Clinic Intervention

Many primary care providers feel uncomfortable discussing end-of-life care. The aim of this intervention was to assess internal medicine residents’ advance care planning (ACP) practices and improve residents’ ACP confidence. Residents participated in a facilitated ACP quality improvement workshop, which included an interactive presentation and chart audit of their own patients. Pre- and postintervention surveys assessed resident ACP-related confidence. Only 24% of the audited patients had an advance directive (AD), and 28% of the ACP-documentation was of no clinical utility. Terminally ill patients (odds ratio 2.8, P < .001) were more likely to have an AD. Patients requiring an interpreter were less likely to have participated in ACP. Residents reported significantly improved confidence with ACP and identified important training gaps. Future studies examining the impact on ACP quality are needed.

62-year-old woman with fever, dyspnea, pleuritic chest pain, and weight loss.

A 62-year-old woman with rheumatoid arthritis (RA) presented for evaluation of chronic pleuritic chest pain, dyspnea, cough, odynophagia, fatigue, weight loss of 16.6 kg (30 lb), and migratory joint pains. Ten years earlier, RA had been diagnosed on the basis of polyarticular inflammatory arthritis. Rheumatoid factor (RF) had subsequently been positive and anticyclic citrullinated peptide (anti-CCP) antibodies negative. No signs or symptoms of underlying connective tissue disease (CTD) had been reported, and no serologic testing for CTD performed. For the past 6 years, the patient had been taking etanercept, methotrexate, and prednisone. Five months before presentation, findings on computed tomography (CT) of the chest reportedly were consistent with RA-associated interstitial lung disease (RA-ILD) or methotrexate-induced lung injury. Pulmonary function testing displayed a restrictive pattern. Methotrexate use was discontinued. One month before presentation, use of etanercept was discontinued because of leukopenia and perioral “fever blisters,” presumed to be adverse effects of medication. On arrival to our institution, her medication regimen was prednisone at 7.5 mg/d, sitagliptin-metformin, levothyroxine, lisinopril, pantoprazole, and simvastatin, as well as nonsteroidal anti-inflammatory drugs as needed.