Search

Background Clinical decision making and drug development for fibrostenosing Crohn disease is constrained by a lack of imaging definitions, scoring conventions, and validated end points. Purpose To assess the reliability of MR enterography features to describe Crohn disease strictures and determine correlation with stricture severity. Materials and Methods A retrospective study of patients with symptomatic terminal ileal Crohn disease strictures who underwent MR enterography at tertiary care centers (Cleveland Clinic: September 2013 to November 2020; Mayo Clinic: February 2008 to March 2019) was conducted by using convenience sampling. In the development phase, blinded and trained radiologists independently evaluated 26 MR enterography features from baseline and follow-up examinations performed more than 6 months apart, with no bowel resection performed between examinations. Follow-up examinations closest to 12 months after baseline were selected. Reliability was assessed using the intraclass correlation coefficient (ICC). In the validation phase, after five features were redefined, reliability was re-estimated in an independent convenience sample using baseline examinations. Multivariable linear regression analysis identified features with at least moderate interrater reliability (ICC ≥0.41) that were independently associated with stricture severity. Results Ninety-nine (mean age, 40 years ± 14 [SD]; 50 male) patients were included in the development group and 51 (mean age, 45 years ± 16 [SD]; 35 female) patients were included in the validation group. In the development group, nine features had at least moderate interrater reliability. One additional feature demonstrated moderate reliability in the validation group. Stricture length (ICC = 0.85 [95% CI: 0.75, 0.91] and 0.91 [95% CI: 0.75, 0.96] in development and validation phase, respectively) and maximal associated small bowel dilation (ICC = 0.74 [95% CI: 0.63, 0.80] and 0.73 [95% CI: 0.58, 0.87] in development and validation group, respectively) had the highest interrater reliability. Stricture length, maximal stricture wall thickness, and maximal associated small bowel dilation were independently (regression coefficients, 0.09-3.97; P < .001) associated with stricture severity. Conclusion MR enterography definitions and scoring conventions for reliably assessing features of Crohn disease strictures were developed and validated, and feature correlation with stricture severity was determined. © RSNA, 2024 Supplemental material is available for this article. See also the article by Rieder and Ma et al in this issue. See also the editorial by Galgano and Summerlin in this issue.

In an experimental study, the frequency of contamination of healthcare personnel during removal of contaminated personal protective equipment (PPE) was similar for bacteriophage MS2 and a novel reflective marker visualized using flash photography. The reflective marker could be a useful tool to visualize and document personnel contamination during PPE removal. Infect Control Hosp Epidemiol 2016;37:711-713.

Background: Systemic antibiotics vary widely in in vitro activity against Clostridium difficile. Some agents with activity against C. difficile (e.g., piperacillin/tazobactam) inhibit establishment of colonization in mice. We tested the hypothesis that piperacillin/tazobactam and other agents with activity against C. difficile achieve sufficient concentrations in the intestinal tract to inhibit colonization in patients., Methods: Point-prevalence culture surveys were conducted to compare the frequency of asymptomatic rectal carriage of toxigenic C. difficile among patients receiving piperacillin/tazobactam or other inhibitory antibiotics (e.g. ampicillin, linezolid, carbapenems) versus antibiotics lacking activity against C. difficile (e.g., cephalosporins, ciprofloxacin). For a subset of patients, in vitro inhibition of C. difficile (defined as a reduction in concentration after inoculation of vegetative C. difficile into fresh stool suspensions) was compared among antibiotic treatment groups., Results: Of 250 patients, 32 (13 %) were asymptomatic carriers of C. difficile. In comparison to patients receiving non-inhibitory antibiotics or prior antibiotics within 90 days, patients currently receiving piperacillin/tazobactam were less likely to be asymptomatic carriers (1/36, 3 versus 7/36, 19 and 15/69, 22 %, respectively; P = 0.024) and more likely to have fecal suspensions with in vitro inhibitory activity against C. difficile (20/28, 71 versus 3/11, 27 and 4/26, 15 %; P = 0.03). Patients receiving other inhibitory antibiotics were not less likely to be asymptomatic carriers than those receiving non-inhibitory antibiotics., Conclusions: Our findings suggest that piperacillin/tazobactam achieves sufficient concentrations in the intestinal tract to inhibit C. difficile colonization during therapy.

In an observational study, we found that healthcare personnel frequently acquired Clostridium difficile on their hands when caring for patients with recently resolved C. difficile infection (CDI) (<6 weeks after treatment) who were no longer under contact precautions. Continuing contact precautions after diarrhea resolves may be useful to reduce transmission.

In a quasi-experimental study, an educational intervention to improve the technique for personal protective equipment (PPE) removal in conjunction with disinfection of gloves before removal of PPE reduced acquisition of Clostridium difficile spores on the hands of health care personnel caring for patients with C difficile infection., (Published by Elsevier Inc.)

Importance: Contamination of the skin and clothing of health care personnel during removal of personal protective equipment (PPE) contributes to dissemination of pathogens and places personnel at risk for infection., Objectives: To determine the frequency and sites of contamination on the skin and clothing of personnel during PPE removal and to evaluate the effect of an intervention on the frequency of contamination., Design, Setting, and Participants: We conducted a point-prevalence study and quasi-experimental intervention from October 28, 2014, through March 31, 2015. Data analysis began November 17, 2014, and ended April 21, 2015. Participants included a convenience sample of health care personnel from 4 Northeast Ohio hospitals who conducted simulations of contaminated PPE removal using fluorescent lotion and a cohort of health care personnel from 7 study units in 1 medical center that participated in a quasi-experimental intervention that included education and practice in removal of contaminated PPE with immediate visual feedback based on fluorescent lotion contamination of skin and clothing., Main Outcomes and Measures: The primary outcomes were the frequency and sites of contamination on skin and clothing of personnel after removal of contaminated gloves or gowns at baseline vs after the intervention. A secondary end point focused on the correlation between contamination of skin with fluorescent lotion and bacteriophage MS2, a nonpathogenic, nonenveloped virus., Results: Of 435 glove and gown removal simulations, contamination of skin or clothing with fluorescent lotion occurred in 200 (46.0%), with a similar frequency of contamination among the 4 hospitals (range, 42.5%-50.3%). Contamination occurred more frequently during removal of contaminated gloves than gowns (52.9% vs 37.8%, P = .002) and when lapses in technique were observed vs not observed (70.3% vs 30.0%, P < .001). The intervention resulted in a reduction in skin and clothing contamination during glove and gown removal (60.0% before the intervention vs 18.9% after, P < .001) that was sustained after 1 and 3 months (12.0% at both time points, P < .001 compared with before the intervention). During simulations of contaminated glove removal, the frequency of skin contamination was similar with fluorescent lotion and bacteriophage MS2 (58.0% vs 52.0%, P = .45)., Conclusions and Relevance: Contamination of the skin and clothing of health care personnel occurs frequently during removal of contaminated gloves or gowns. Educational interventions that include practice with immediate visual feedback on skin and clothing contamination can significantly reduce the risk of contamination during removal of PPE.

We found that a majority of hospitalized patients were aware of the importance of hand hygiene, but observations indicated that performance of hand hygiene was uncommon. An intervention in which healthcare personnel facilitated hand hygiene at specific moments significantly increased performance of hand hygiene by patients.

Background: Due to their efficacy and convenience, alcohol-based hand sanitizers have been widely adopted as the primary method of hand hygiene in healthcare settings. However, alcohols lack activity against bacterial spores produced by pathogens such as Clostridium difficile and Bacillus anthracis. We hypothesized that sporicidal activity could be induced in alcohols through alteration of physical or chemical conditions that have been shown to degrade or allow penetration of spore coats., Principal Findings: Acidification, alkalinization, and heating of ethanol induced rapid sporicidal activity against C. difficile, and to a lesser extent Bacillus thuringiensis and Bacillus subtilis. The sporicidal activity of acidified ethanol was enhanced by increasing ionic strength and mild elevations in temperature. On skin, sporicidal ethanol formulations were as effective as soap and water hand washing in reducing levels of C. difficile spores., Conclusions: These findings demonstrate that novel ethanol-based sporicidal hand hygiene formulations can be developed through alteration of physical and chemical conditions.

No new acquisition of Clostridium difficile occurred among 12 hospitalised patients receiving tigecycline, and pre-existing colonisation was reduced to undetectable levels in 2 patients. Moreover, 91% of stool suspensions obtained during tigecycline therapy exhibited inhibitory activity against C. difficile. These results suggest that tigecycline achieves sufficient concentrations to inhibit intestinal colonisation by C. difficile., (Published by Elsevier B.V.)

Hand hygiene by patients may prevent acquisition and dissemination of health care-associated pathogens, but limited efforts have been made to engage patients in hand hygiene interventions. In a long-term care facility, we found that residents were aware of the importance of hand hygiene, but barriers, such as inaccessible products or difficult to use products, limited compliance. A dramatic and sustained improvement in meal time hand hygiene was achieved through engagement of staff and residents., (Published by Elsevier Inc.)

Background: One strategy to promote improved hand hygiene is to monitor health care workers' adherence to recommended practices and give feedback. For feasibility of monitoring, many health care facilities assess hand hygiene practices on room entry and exit (wash in-wash out). It is not known if the wash in-wash out method is comparable with a more comprehensive approach, such as the World Health Organization's My 5 Moments for Hand Hygiene method., Methods: During a 1-month period, a surreptitious observer monitored hand hygiene compliance simultaneously using the wash in-wash out and My 5 Moments for Hand Hygiene methods., Results: For 283 health care worker room entries, the methods resulted in similar rates of hand hygiene compliance (70% vs 72%, respectively). The wash in-wash out method required 148 hand hygiene events not required by the My 5 Moments for Hand Hygiene method (ie, before and after room entry with no patient or environmental contact) while not providing monitoring for 89 hand hygiene opportunities in patient rooms., Conclusion: The monitoring methods resulted in similar overall rates of hand hygiene compliance. Use of the wash in-wash out method should include ongoing education and intermittent assessment of hand hygiene before clean procedures and after body fluid exposure in patient rooms., (Published by Elsevier Inc.)

OxyCide Daily Disinfectant Cleaner, a novel peracetic acid/hydrogen peroxide-based sporicidal disinfectant, was as effective as sodium hypochlorite for in vitro killing of Clostridium difficile spores, methicillin-resistant Staphylococcus aureus, and vancomcyin-resistant enterococci. OxyCide was minimally affected by organic load and was effective in reducing pathogen contamination in isolation rooms.

A commercial PCR assay of perirectal swab specimens detected 17 (68%) of 25 asymptomatic carriers of toxigenic Clostridium difficile, including 93% with skin and/or environmental contamination. A clinical prediction rule, followed by PCR screening, could be used to identify carriers at high risk of C. difficile shedding.

Background: Clostridium difficile is an anaerobic, spore-forming bacterium that is the most common cause of healthcare-associated diarrhea in developed countries. A significant proportion of patients receiving oral vancomycin or metronidazole for treatment of Clostridium difficile infection (CDI) develop recurrences. However, the period of vulnerability to re-establishment of colonization by C. difficile after therapy is not well defined., Principal Findings: In a prospective study of CDI patients, we demonstrated that most vancomycin-treated patients maintained inhibitory concentrations of vancomycin in stool for 4 to 5 days after therapy, whereas metronidazole was only detectable during therapy. From the time of elimination of the antibiotics to 14 to 21 days after therapy, a majority of stool suspensions supported growth of C. difficile and deep 16S rRNA sequencing demonstrated persistent marked alteration of the indigenous microbiota. By 21 to 28 days after completion of CDI treatment, a majority of stool suspensions inhibited growth of C. difficile and there was evidence of some recovery of the microbiota., Conclusions: These data demonstrate that there is a vulnerable period for re-establishment of C. difficile colonization after CDI treatment that begins within a few days after discontinuation of treatment and extends for about 3 weeks in most patients.

For long-term care and spinal cord injury patients, the sensitivity, specificity, and positive and negative predictive values of perirectal versus rectal cultures for detection of asymptomatic carriers of Clostridium difficile were 95%, 100%, 100%, and 97%, respectively. Perirectal cultures provide an accurate method to detect asymptomatic carriers of C. difficile.

Contaminated environmental surfaces are an important source for transmission of Clostridium difficile. However, there are no efficient and easy methods to assess contamination. The performance of a commercial real-time polymerase chain reaction (PCR) assay was evaluated for detection of environmental toxigenic C. difficile in comparison with anaerobic culture followed by toxin testing of isolates. For 66 sites sampled, PCR had a sensitivity of 17.39%, specificity 100%, positive predictive value 100% and negative predictive value 69.35%. Increasing the PCR cycle threshold (CT) value to 45 increased sensitivity to 52% without decreasing specificity. The commercial PCR assay is not sufficiently sensitive for environmental monitoring, but improved sensitivity might be possible through CT value modification., (© 2013 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Objective: The objective of this study was to test the hypothesis that many patients with suspected Clostridium difficile infection (CDI) receive inappropriate empiric therapy and/or receive continued therapy despite negative test results., Methods: We performed a 3 month prospective cohort study at the Cleveland Veteran Affairs Medical Center to assess the appropriateness of empiric CDI therapy for all patients with stool samples submitted for CDI testing. Empiric therapy for CDI was considered appropriate if patients with suspected CDI had findings suggestive of severe or complicated illness., Results: Of 251 patients tested for CDI, 53 (21%) received empiric treatment, including 45 (85%) treated with metronidazole and 8 (15%) treated with vancomycin. Of the 53 empirical therapy regimens, only 20 (38%) were deemed appropriate based on criteria for severe or severe, complicated CDI and 39 (74%) had negative laboratory testing for CDI. Twenty-one of 39 (54%) patients with negative testing were continued on therapy for three or more days despite the negative results. The key limitations of the study are the fact that it was conducted in a single institution and had a small sample size., Conclusion: In our facility, empiric treatment for CDI was common and more than half of empirical treatment was deemed inappropriate because patients did not meet criteria for severe CDI. Because CDI therapy may be associated with adverse effects, there is a need for interventions to improve the appropriateness of empiric CDI treatment.

Background: Patients with suspected Clostridium difficile infection (CDI) often receive empirical therapy prior to collection of stool specimens for diagnostic testing. The likelihood that such empirical therapy might result in false-negative CDI test results is unknown., Methods: We conducted a prospective study of CDI patients to determine the time to conversion of CDI test results, including polymerase chain reaction (PCR) for toxin B genes, glutamate dehydrogenase, and toxigenic culture, from positive to negative during CDI therapy. We evaluated the frequency of and risk factors for persistence of positive CDI tests. For patients receiving empirical therapy, we assessed the frequency of conversion of positive CDI test results at the time of the test order to negative by the time clinical staff collected stool specimens for testing., Results: For 51 CDI patients, PCR, glutamate dehydrogenase, and toxigenic culture results converted to negative at similar rates. For PCR, 14%, 35%, and 45% of positive CDI tests converted to negative after 1, 2, and 3 days of treatment, respectively. Increased age and infection with North American pulsed-field gel electrophoresis strains were associated with persistent positive PCR results. For CDI patients diagnosed at the time of the test order, conversion to negative PCR results by the time clinical stool specimens were collected occurred in 4 of 9 (44%) patients who were prescribed empirical CDI therapy versus 0 of 23 (0%) who were not (P = .004)., Conclusions: Empirical treatment for suspected CDI cases may result in false-negative PCR results if there are delays in stool specimen collection.

Although rapid laboratory tests are available for diagnosis of Clostridium difficile infection (CDI), delays in completion of CDI testing are common in clinical practice. We conducted a cohort study of 242 inpatients tested for CDI to determine the timing of different steps involved in diagnostic testing and to identify modifiable factors contributing to delays in diagnosis. The average time from test order to test result was 1.8 days (range, 0.2 to 10.6), with time from order to stool collection accounting for most of the delay (mean, 1.0 day; range, 0 to 10). Several modifiable factors contributed to delays, including not providing stool collection supplies to patients in a timely fashion, rejection of specimens due to incorrect labeling or leaking from the container, and holding samples in the laboratory for batch processing. Delays in testing contributed to delays in initiation of treatment for patients diagnosed with CDI and to frequent prescription of empirical CDI therapy for patients with mild to moderate symptoms whose testing was ultimately negative. An intervention that addressed several easily modified factors contributing to delays resulted in a significant decrease in the time required to complete CDI testing. These findings suggest that health care facilities may benefit from a review of their processes for CDI testing to identify and address modifiable factors that contribute to delays in diagnosis and treatment of CDI.

In a prospective study of inpatients tested for Clostridium difficile infection (CDI), skin and environmental contamination were common at the time of the order for CDI testing, and there were often delays in completion of testing. Preemptive isolation of patients with suspected CDI may reduce the risk of transmission.

For 139 patients tested for Clostridium difficile infection by polymerase chain reaction, the sensitivity, specificity, positive predictive value, and negative predictive value of testing perirectal swabs vs stool specimens were 95.7%, 100%, 100%, and 99.1%, respectively. For selected patients, perirectal swabs provide an accurate toxigenic C. difficile detection strategy.