Rhonda L. Stuart

Emergence of a Ribotype 244 Strain of Clostridium difficile Associated With Severe Disease and Related to the Epidemic Ribotype 027 Strain

BACKGROUND We identified 12 patients with Clostridium difficile infection between July 2011 and March 2012 from whom an unusual C. difficile strain was isolated. This strain had a single-nucleotide deletion of the tcdC gene at position 117 and binary toxin genes, which are characteristic of the hypervirulent ribotype (RT) 027 strain. METHODS A retrospective cohort study of 12 patients infected with C. difficile RT244 and 24 patients infected with non-RT244/non-RT027 strains matched for place of diagnosis and time of collection of specimen was performed. We performed whole-genome sequencing to understand the relationship of the RT244 strain to other C. difficile strains and further understand its virulence potential. RESULTS Clostridium difficile RT244 was associated with more severe disease and a higher mortality rate. Phylogenomic analysis using core genome single-nucleotide polymorphisms showed that RT244 is in the same genetic clade (clade 2) as RT027 but is distinct from all RT027 strains. The pathogenicity locus of the RT244 strain encodes a variant toxin B, and this was confirmed by demonstration of Clostridium sordellii-like cytopathic effect on Vero cells. Toxin B production in culture supernatants was lower than that seen with a RT027 strain. CONCLUSIONS Our findings demonstrate the pathogenic potential of this RT244 C. difficile strain and emphasize the importance of ongoing surveillance for emergent strains.

An outbreak of necrotizing enterocolitis associated with norovirus genotype GII.3.

Background: Necrotizing enterocolitis (NEC) is an acute abdominal emergency of unknown etiology predominantly affecting preterm infants. We describe a cluster of NEC in a level III NICU involving 15 infants over a 6-month period. Cohorting and stringent infection control measures were associated with termination of the cluster. A case-control study was used to investigate potential risk factors associated with development of NEC. Methods: Stool samples were collected from 55 infants (10 of 15 NEC and 45 non-NEC controls). Enteric pathogens were identified by culture and/or molecular diagnostic techniques. For the case-control study, controls were selected from admitted neonates during the same time and in the preceding 6-month period, matched for gestation and birthweight. Results: Forty percent (4/10) of NEC infants had norovirus RNA detected compared with 9% (4/45) of non-NEC infants (OR: 6.83, 95% CI: 1.3–34.9, P = 0.021). A lower rate of prolonged rupture of membranes and a higher rate of maternal smoking was also observed in NEC infants than in controls. No significant differences in incidences of chorioamnionitis, intrapartum antibiotics, volume of feedings, time of first formula feeding, and rates of patent ductus arteriosus or intrauterine growth retardation were detected. Conclusions: Infants who developed NEC had an increased incidence of norovirus detection in their stool following diagnosis. This further strengthens the case for an etiologic role of norovirus in the pathogenesis of NEC.

Down the drain:carbapenem-resistant bacteria in intensive care unit patients and handwashing sinks

Objectives: Clinical utility of carbapenem antibiotics is under threat because of the emergence of acquired metallo‐β‐lactamase (MBL) genes. We describe an outbreak in an intensive care unit (ICU) possibly associated with contaminated sinks.

Prevalence of antimicrobial-resistant organisms in residential aged care facilities.

Objective: To assess the frequency of, and risk factors for, colonisation with vancomycin‐resistant enterococci (VRE), Clostridium difficile and extended‐spectrum β‐lactamase (ESBL)‐producing organisms in residential aged care facilities (RACFs).

Half of All Peripheral Intravenous Lines in an Australian Tertiary Emergency Department Are Unused: Pain With No Gain?

STUDY OBJECTIVE Our study aims to determine the incidence of unused peripheral intravenous cannulas inserted in the emergency department (ED). METHODS A retrospective cohort study using a structured electronic medical record review was performed in a 640-bed tertiary care hospital in Melbourne, Australia. During a 30-day period, all patients who had a peripheral intravenous cannula recorded as a procedure on their electronic medical record in the ED were included in this study. RESULTS Fifty percent of peripheral intravenous cannulas inserted in the ED were unused. Patients presenting with obstetric and gynecologic and neurologic symptoms were significantly more likely to have an unused cannula. Forty-three percent of patients admitted to the hospital with unused peripheral intravenous cannulas in the ED continued to have them unused 72 hours later. CONCLUSION There is a high incidence of unused peripheral intravenous cannulas inserted in the ED. The risk of having an unused peripheral intravenous cannula is associated with the patients presenting complaint. Efforts should be directed to reduce this rate of unused peripheral intravenous cannula insertion, especially in patients being admitted, to minimize the risk of complications.

Peripheral intravenous catheter-associated Staphylococcus aureus bacteraemia: more than 5 years of prospective data from two tertiary health services.

Objectives: To determine the incidence, risk factors for and outcomes of Staphylococcus aureus bacteraemia (SAB) associated with peripheral intravenous catheters (PIVCs).

Microbiological monitoring of endoscopes : 5-year review

Periodic microbiological monitoring of endoscopes is a recommendation of the Gastroenterological Society of Australia (GENSA). The aim of monitoring has been to provide quality assurance of the cleaning and disinfection of endoscopes; however, there is controversy regarding its frequency. This lack of consensus stimulated a review of the experience within our health service. At Southern Health, routine microbiological sampling has involved 4‐weekly monitoring of bronchoscopes, duodenoscopes and automated flexible endoscope reprocessors (AFER), and 3‐monthly monitoring of all other gastrointestinal endoscopes. Records of testing were reviewed from 1 January 2002 until 31 December 2006. A literature review was conducted, cost analysis performed and positive cultures investigated. There were 2374 screening tests performed during the 5‐year period, including 287 AFER, 631 bronchoscopes for mycobacteria and 1456 endoscope bacterial screens. There were no positive results of the AFER or bronchoscopes for mycobacteria. Of the 1456 endoscopic bacterial samples, six were positive; however, retesting resulted in no growth. The overall cost of tests performed and cost in time for nursing staff to collect the samples was estimated at

Influenza vaccination uptake amongst pregnant women and maternal care providers is suboptimal

AUD 100 400. Periodic monitoring of endoscopes is both time‐consuming and costly. Our review demonstrates that AFER (Soluscope) perform well in cleaning endoscopes. Based on our 5‐year experience, assurance of quality for endoscopic use could be achieved through process control as opposed to product control. Maintenance of endoscopes and AFER should be in accordance with the manufacturers instructions and microbiological testing performed on commissioning, annually and following repair. Initial prompt manual leak testing and manual cleaning followed by mechanical leak testing, cleaning and disinfection should be the minimum standard in reprocessing of endoscopes.

Emergence and spread of predominantly community-onset Clostridium difficile PCR ribotype 244 infection in Australia, 2010 to 2012

OBJECTIVE To assess the uptake of influenza vaccination by pregnant women and maternity care providers and explore their attitudes towards influenza vaccination. DESIGN, SETTING AND PARTICIPANTS Cross-sectional survey administered in a Victorian tertiary level public hospital to 337 pregnant women and 96 maternity care providers. RESULTS 31.3% of patients planned to or had received influenza vaccination this year, but only a quarter had received education about influenza. Women were more likely to receive influenza vaccination if they had been vaccinated in the last two years (RR 4.5, 95% CI: 3.1-6.4, p<0.001), received education about influenza (RR 2.3, 95% CI: 1.6-3.2, p<0.001) or believed that they were at high risk of influenza-related complications while pregnant (RR 2.0, 95% CI: 1.4-2.7, p<0.001). While only 56.8% of maternity care providers believed pregnant women were at high risk of influenza-related complications, 72.9% would recommend influenza vaccination to all pregnant women. Of the maternity care providers studied, 69% planned to or had been vaccinated in 2011, with this group more likely to recommend vaccination to their patients (RR 2.0, 95% CI: 1.3-3.0, p<0.001). Significantly more maternity care providers indicated that they would routinely recommend influenza vaccination than the proportion of patients who reported receiving education. CONCLUSIONS Influenza vaccination rates in pregnant women are low, reflecting inadequate patient education despite most maternity care providers indicating that they would routinely recommend influenza vaccination. Increasing influenza vaccination uptake by women in pregnancy will require better education of both women and maternity care providers.

Treatment and outcome of 104 hospitalized patients with legionnaires’ disease

We describe an Australia-wide Clostridium difficile outbreak in 2011 and 2012 involving the previously uncommon ribotype 244. In Western Australia, 14 of 25 cases were community-associated, 11 were detected in patients younger than 65 years, 14 presented to emergency/outpatient departments, and 14 to non-tertiary/community hospitals. Using whole genome sequencing, we confirm ribotype 244 is from the same C. difficile clade as the epidemic ribotype 027. Like ribotype 027, it produces toxins A, B, and binary toxin, however it is fluoroquinolone-susceptible and thousands of single nucleotide variants distinct from ribotype 027. Fifteen outbreak isolates from across Australia were sequenced. Despite their geographic separation, all were genetically highly related without evidence of geographic clustering, consistent with a point source, for example affecting the national food chain. Comparison with reference laboratory strains revealed the outbreak clone shared a common ancestor with isolates from the United States and United Kingdom (UK). A strain obtained in the UK was phylogenetically related to our outbreak. Follow-up of that case revealed the patient had recently returned from Australia. Our data demonstrate new C. difficile strains are an on-going threat, with potential for rapid spread. Active surveillance is needed to identify and control emerging lineages.