Community-associated Clostridium difficile infection: experience of a veteran affairs medical center in southeastern USA.

BACKGROUND: There is increasing recognition of the importance of community-associated Clostridium difficile infection (CA-CDI) despite little being known about its epidemiology. METHODS: We performed routine, active laboratory surveillance for CDI at the Durham Veterans Affairs Medical Center between January and December 2005 and extracted data from the electronic medical record for this investigation. Bivariable analyses were performed using the chi-square test, and continuous variables were compared using two sample t test and Wilcoxon rank sums. RESULTS: We identified 108 CDI cases during the study period; 38 (35%) had onset of disease in the community and, of these, 31 (82%) met the definition for CA-CDI. A comparison of CA- versus healthcare facility-associated (HCFA)-CDI revealed that CA-CDI patients were younger (median age 58 vs. 69 years, respectively; p = 0.01), with the majority being <65 years, but had similar co-morbidities to HCFA-CDI patients. CA-CDI patients were reportedly exposed less frequently to an antimicrobial or a proton pump inhibitor than HCFA-CDI patients, while the latter showed a trend towards a higher 60-day all-cause mortality (3 vs. 17%, respectively; p = 0.06). CONCLUSIONS: CA-CDI is the primary reason for community-onset CDI in our community. Compared to patients with HCFA-CDI, those with CA-CDI were younger, had fewer reported exposures to antimicrobials or PPIs, and had lower mortality. Further study is needed to identify unrecognized risk factors of CDI in the community.

Mycobacterial infections in patients with chronic renal disease.

In this article, the authors have provided a comprehensive review of TB and MOTT infections in patients on renal dialysis and receiving kidney transplants. Because most published series are small retrospective studies or case reports, there are several uncertainties still involved in the diagnosis and treatment of such patients. Unanswered questions include selection of optimal dosage and duration of therapeutic agents; the best tests for screening and diagnosis, especially in high prevalence areas; and the best management of MOTT infections because of unavailability of highly effective therapy.

Angiostrongylus cantonensis eosinophilic meningitis.

In the past 50 years, Angiostrongylus cantonensis, the most common cause of eosinophilic meningitis, has spread from Southeast Asia to the South Pacific, Africa, India, the Caribbean, and recently, to Australia and North America, mainly carried by cargo ship rats. Humans are accidental, "dead-end" hosts infected by eating larvae from snails, slugs, or contaminated, uncooked vegetables. These larvae migrate to the brain, spinal cord, and nerve roots, causing eosinophilia in both spinal fluid and peripheral blood. Infected patients present with severe headache, vomiting, paresthesias, weakness, and occasionally visual disturbances and extraocular muscular paralysis. Most patients have a full recovery; however, heavy infections can lead to chronic, disabling disease and even death. There is no proven treatment for this disease. In the authors' experience, corticosteroids have been helpful in severe cases to relieve intracranial pressure as well as neurologic symptoms due to inflammatory responses to migrating and eventually dying worms.

Rifampin, a useful drug for nonmycobacterial infections.

Rifampin has clinical efficacy against a wide variety of organisms, including Staphylococcus aureus, Legionella pneumophila, group A Streptococcus, Brucella sp, Haemophilus influenzae, and Neisseria meningitidis, as well as in vitro activity against penicillin-resistant Streptococcus pneumoniae, Neisseria gonorrhoeae, Chlamydia trachomatis, Haemophilus ducreyi, and many gram-negative rods. Rifampin is a useful drug for several types of bacterial infections because of its broad spectrum of activity, excellent tissue penetration, and low side effect profile. In combination with other antibiotics, it may be effective when conventional therapies are not.