Clostridium difficile is a leading cause of infectious diarrhea in hematopoietic stem cell transplant (HSCT) recipients. Asymptomatic colonization of the gastrointestinal tract occurs before development of C. difficile infection (CDI). This prospective study examines the rates, risk factors, and outcomes of colonization with toxigenic and nontoxigenic strains of C. difficile in HSCT patients. This 18-month study was conducted in the HSCT unit at the Karmanos Cancer Center and Wayne State University in Detroit. Stool samples from the patients who consented for the study were taken at admission and weekly until discharge. Anaerobic culture for C. difficile and identification of toxigenic strains by PCR were performed on the stool samples. Demographic information and clinical and laboratory data were collected. Of the 150 patients included in the study, 29% were colonized with C. difficile at admission; 12% with a toxigenic strain and 17% with a nontoxigenic strain. Over a 90-day follow-up, 12 of 44 (26%) patients colonized with any C. difficile strain at admission developed CDI compared with 13 of 106 (12%) of patients not colonized (odds ratio [OR], 2.70; 95% confidence interval [95% CI], 1.11 to 6.48; P = .025). Eleven of 18 (61%) patients colonized with the toxigenic strain and 1 of 26 (4%) of those colonized with nontoxigenic strain developed CDI (OR, 39.30; 95% CI, 4.30 to 359.0; P < .001) at a median of 12 days. On univariate and multivariate analyses, none of the traditional factors associated with high risk for C. difficile colonization or CDI were found to be significant. Recurrent CDI occurred in 28% of cases. Asymptomatic colonization with C. difficile at admission was high in our HSCT population. Colonization with toxigenic C. difficile was predictive of CDI, whereas colonization with a nontoxigenic C. difficile appeared protective. These findings may have implications for infection control strategies and for novel approaches for the prevention and preemptive treatment of CDI in the HSCT patient population.

Acute respiratory distress syndrome (ARDS) is a clinically and biologically heterogeneous disorder associated with a variety of disease processes that lead to acute lung injury with increased non-hydrostatic extravascular lung water, reduced compliance, and severe hypoxemia. Despite significant advances, mortality associated with this syndrome remains high. Mechanical ventilation remains the most important aspect of managing patients with ARDS. An in-depth knowledge of lung protective ventilation, optimal PEEP strategies, modes of ventilation and recruitment maneuvers are essential for ventilatory management of ARDS. Although, the management of ARDS is constantly evolving as new studies are published and guidelines being updated; we present a detailed review of the literature including the most up-to-date studies and guidelines in the management of ARDS. We believe this review is particularly helpful in the current times where more than half of the acute care hospitals lack in-house intensivists and the burden of ARDS is at large.

Background: Immune checkpoint inhibitors (ICIs) are the newest class of anticancer drugs. Pneumonitis is increasingly being recognized as a potential complication of these agents. Methods: We conducted a retrospective study of patients who received ICIs at a comprehensive cancer center. We collected data on demographics, type of malignancy, type of ICI agent, incidence of pneumonitis up to 6 weeks after receiving ICI agent, clinical characteristics, and risk factors for overall survival in patients who develop pneumonitis. Results: A total of 654 patients received ICIs during the study period. The most common type of cancer for which ICI was given was adenocarcinoma of the lung (29%), followed by renal cell cancer (12%) and squamous cell lung cancer (12%). Among the study patients, 41% received nivolumab and 32% received pembrolizumab. Other patients in the study received combination of ICIs or ICI plus chemotherapeutic agent, or were part of clinical trial involving ICI. Overall 42 (6.4%) patients developed pneumonitis within 6 weeks after the last dose of treatment of any ICI agent. Of these, 81% of patients had Grade ≥ 2 pneumonitis and 45% of these required hospital admission for pneumonitis, with 10% of them requiring admission to intensive care unit. Overall, patients who received pembrolizumab-containing regimen, had prior chemotherapy, or who never had cancer-related surgery had increased risk of death. Conclusion: Our large retrospective study shows real-life data of incidence of pneumonitis in patients who are treated with ICIs for cancer treatment. Our data indicate that the incidence of pneumonitis is overall lower than that reported previously with relatively good outcomes.

The Birmingham Hip Resurfacing procedure (BHR) is metal-on-metal resurfacing procedure for hip arthritis. BHR was associated with low risk of surgical site infection (SSI; 0.6%). In addition to antimicrobials, superficial SSIs were treated with incision and drainage, whereas deep incisional or organ-space SSIs required removal of prosthesis. Infect Control Hosp Epidemiol 2016;1-4.

Background Clostridium difficile (CD) is the leading cause of nosocomial diarrhea. After acquisition of CD, some patients (pts) remain colonized whereas others develop symptomatic CD infection (CDI). Hematopoietic stem cell transplant (HSCT) recipients are at higher risk of CDI than the general population. Rates of colonization and risk factors for CD colonization in the HSCT population are unknown. The goals of this study were to determine the rates and predictors of colonization with CD in HSCT pts at our institution. Methods We conducted a 16-month prospective study starting in December 2010 in the HSCT unit at the Karmanos Cancer Center. Pts who signed informed consent had stool samples collected within 72 hours of admission and weekly thereafter until discharge. Pts were followed up for 90 days after enrollment. Stool samples were cultured for CD and culture positive samples were tested by PCR for confirmation of toxigenic CD. Demographic information, risk factors and outcomes were examined. Results 154 patients who underwent allogeneic HSCT were enrolled in the study. Mean age for both CD colonized and non-colonized pts was 51 ±12.8 years, 59% were males. Overall, 47/154 (30%) pts were colonized with CD at admission; 23/154 (15%) with toxigenic CD. 8/23 (34%) pts colonized with toxigenic CD developed symptomatic CDI. Of the pts colonized with non-toxigenic CD, 7/24 (29%) acquired CD during the hospital stay. The median time to acquisition was week 2 of hospitalization. On bivariate analysis, underlying comorbid conditions and traditional risk factors for CDI like prior hospitalization, length-of-stay, antibiotic use, nasogastric tube and gastrointestinal tract procedures were found to be equally prevalent in both colonized and non-colonized population. The outcome in terms of graft versus host disease (GVHD) was also similar in both groups. The use of proton pump inhibitors was more prevalent in non-colonizers (56%) vs. colonizers (43%). However, it was not statistically significant (p=0.16). Similarly, lymphopenia seemed common amongst colonizers vs. non-colonizers (67% vs. 58%) but was not statistically significant (p=0.2). Conclusion Colonization with toxigenic CD is high in our HSCT recipients at hospital admission. Symptomatic CDI occurs in a third of pts colonized with toxigenic CD. Unlike in the general population, traditional risk factors for CD colonization are not predictive of colonization in our allogeneic HSCT pts. Novel approaches such as active surveillance to detect colonized patients to guide infection control measures and to direct “pre-emptive” therapy should be evaluated in this population. Disclosures: No relevant conflicts of interest to declare.