Clostridium Difficile Associated Disease: Burden of and Predictors for in Hospital Fatal Outcome. Results of a Hospital-Based Study, Bucharest, Romania.

INTRODUCTION: In the last 15 years Clostridium difficile infection became a typical new emergent threat worldwide. Our aim was to describe the risk factors associated with fatal outcome of Clostridium difficile associated disease (CDAD) cases treated in 2012 in "Dr Victor Babes" Infectious and Tropical Diseases Hospital, a 450 beds teaching clinic from Bucharest, Romania. MATERIAL AND METHODS: Retrospective cohort study - the case records of hospitalized patients in the year 2012, presenting with diarrhea and that tested positive for C difficile through toxin A and B assays were reviewed. Data collected through chart review of CDAD were demographic and clinical. A Charlson comorbidities index score was allocated to each case. An EpiInfo data base was fed with demo and clinical data - software's facilities were used for univariate analysis (Chi square) and also for logistic regression. RESULTS: In study were included all 326 hospitalization episodes with a discharge diagnosis of CDAD in 2012. Overall, 30 of the 326 CDAD patients (9.2%) versus 289 of the 18636 non-CDAD patients (1.55%) died during their hospital stay, resulting in a relative risk of pre-discharge death of 5.93 (4.14- 8.50) for CDAD patients, a CDAD attributable risk of death of 7.65 per 100 patients and a CDAD attributable fraction of 83.15 % (70.1-86%). Unconditional logistic regression retained as fatal outcome predictors the following: (a) a Charlson comorbidity index score >3: (OR: 3.03; CI 95%: 1.21-7.54), (b) ICU stay: (OR: 15.81; CI 95%: 4.47- 55.89) and (c) age >64 years: (OR: 2.95; CI 95%: 1.15-7.69). CONCLUSION: Our findings add to the understanding of Clostridium difficile fatal outcome and they have implications for prevention and therapy - the case fatality of 9.2% underlines the importance of the increased efforts in CDAD prevention.

Plasma triglyceride levels may modulate hepatitis C viral replication.

BACKGROUND: Plasma and hepatic lipid abnormalities are frequent in hepatitis C infected individuals. METHODS: Plasma lipid and medical records profiles were prospectively obtained in 130 consecutive individuals seen by a single hepatologist in a university liver disease clinic. The relationships between viral load, genotype, plasma lipid fractions, HDL, LDL particle number and particle size were examined. RESULTS: Of 130 individuals studied, 74 had hepatitis C while 15 had NAFLD/NASH and 30 had alcohol related liver disease. The LDL particle number and LDL-C levels did not differ between those with and without hepatitis C although the number of small LDL particles was greater in those with hepatitis C infection. The HDL-C and total cholesterol levels were greater in those without hepatitis C than those with hepatitis C (P = 0.009). In contrast, the serum triglyceride level was greater in the hepatitis C viral group (P = 0.013). Importantly, the hepatitis C viral load regardless of the genotype correlated directly with the triglyceride and VLDL levels with r values of 0.73 and 0.84, respectively. CONCLUSIONS: There are: (1) important differences in lipid classes, number and the size of lipid particles exist between hepatitis C virus infected and noninfected liver disease groups, (2) the serum total triglyceride and the LDL levels correlate significantly with the hepatitis C viral load and, (3) Serum triglyceride level may play an important role in viral replication. These data further suggest that therapies directed at lowering plasma triglyceride levels may enhance the efficacy of current antiviral treatment regimens.

[Risk of hospital death in nosocomial infection with multi-drug resistant A. baumanii or P. aeruginosa]. / Riscul de deces în infectia nosocomiala cu A. baumanii sau P. aeruginosa multipluantibioticorezistenti.

OBJECTIVE: assessment of the in hospital death among the patients with healthcare associated infection (HA1) provoked by multi drug resistant strains (MDR) ofP. aeruginosa or A. baumanii. METHODS: enrolled in the study were patients with bloodstream, surgical site and urinary tract HAI infection, reported during 2006-2009 in the ICU for adults and general surgery wards of two large teaching clinics for emergencies in Bucharest municipality. Associations between fatal outcome and relevant demographic and clinical characteristics were analyzed both through cohort and also by case-control studies. RESULTS: in the cohort analysis both the severity of the underlying disease and also the presence of HAl with MDR strains of P. aeruginosa or A. baumanii were statistical significant (p < 0.05) and independently associated with fatal outcome; the presence of HAI with MDR strains of P. aeruginosa or A. baumanii remained significant associated with fatal outcome even after controlling of the underlying disease's severity by case-control design (Match OR: 5.89; 95% IC: 1.39-40.77; p = 0.011). CONCLUSIONS: the study's results demonstrate that the precautions to prevent the in hospital transmission of the MDR germs are pertinent because the HAI induced by these bugs is obviously associated with unfavorable clinical outcome of the patient.

[Effect of systematic vaccination on the epidemiology of urlian parotiditis in the population of Bucharest]. / Efectul vaccinarii sistematice asupra epidemiologiei parotiditei urliene în populatia municipiului Bucuresti.

OBJECTIVE: describe the mumps evolution during the time period that immediately followed the introduction of routine mumps vaccine into the Bucharest municipality's population. METHODS: observational, descriptive, and retrospective study. The temporal frequencies were taken from official reports of clinically confirmed mumps cases with annually sequence during the 1951-2001 period and monthly sequence during the 2002-2009 period of time respectively. The temporal frequencies were graphically represented in semilogarithmic scale; the temporal trend of the frequencies was estimated through linear regression. RESULTS: in the time period of 5 years subsequently to the introduction of mumps routine vaccination with two doses of measles-mumps-rubella triple vaccine, the following events intervened in the evolution of mumps in the population of Bucharest municipality: (a) starting with the year of 2006 the annual frequency of cases became constantly placed under the lower limit of 1000 cases of the prevaccine era's distribution, (b) starting with September 2005 the monthly frequency of mumps cases decreased under the lower limit of 100 cases of the prevaccine era's distribution, (c) the decline rhythm of the annual frequency account for 1156 units (r2 = 0.76; p = 0.03) and, (d) due to the herd protection effect induced by vaccine, decreasing affected all age groups. CONCLUSIONS: although late implemented (in European context) the routine vaccination determined a fairly consistent declining of the mumps morbidity and very probably of the serious complications and/or sequels associated to natural disease, being in this way an outstanding achievement of preventive medicine

[Frequency and severity of rotavirus acute gastroenteritis hospitalized in Bucharest, Romania. Results of a case-control study]. / Frecventa si severitatea gastroenteritei acute rotavirale spitalizate în Bucuresti, România. Rezultatele unui studiu case-control.

BACKGROUND: rotavirus gastroenteritis is an emergent condition of morbidity at global level; WHO is currently recommending integration of rotavirus vaccination into the regions and states where rotavirus infection is identified as a public health priority problem. OBJECTIVE: analyzing the frequency and clinical severity of rotavirus gastroenteritis in pediatric inpatients and commenting the programmatic signification of the analysis' results. METHODS: descriptive retrospective study followed by case-control study upon the cohort of patients hospitalized in the year 2008, for acute diarrhoeal disease (ADD) of infectious nature in the biggest university clinic for children from Bucharest municipality. Rotavirus etiology was sustained on the ground of rotavirus antigen's detection, through immune chromatography assay, in the feces of patients with ADD clinical syndrome. The predictor factor for clinical severity was prolonged hospitalization, defined as any duration of hospitalization longer then the value calculated at 75 percentile, in the studied cohort. For the case-control study each case of rotavirus enteritis (Code ICD-10: A08.0) has been matched by age and gender with one control, selected at random from the list of patients with ADD of different etiology than the case. RESULTS: in 2008 in our clinic, a lot of 684 of children was hospitalized for at least 24 hours, for infectious ADD, in which the median age was 8 months and the prevalence of male gender was 49%. In this lot, the prevalence of rotavirus enteritis was 12.7%. Cases of rotavirus enteritis have been admitted all year round, monthly highest prevalence being of 40%. The risk of prolonged hospitalization in patients discharged with the diagnosis of rotavirus enteritis was 2.36 higher (95% Confidence Interval: 1.17-4.78; p < 0.01) than in the same age and gender children hospitalized for ADD of other etiologies. CONCLUSIONS: our study found an annual prevalence of 2.7%, a monthly maximum prevalence of 40% and a risk of prolonged hospitalization of rotavirus enteritis of 2.36 times higher then in ADD cases of other etiologies. In our opinion, these findings encompass objective arguments sustaining that in Bucharest, the rotavirus infection represents a public health problem, with high priority in allocation of health resources, mainly for surveillance and routine immunization.

[Factors influencing the use of systemic antibiotics in hospitalized pediatric patients in Bucharest, Romania]. / Modulatori ai densitatii ratei de consum a agentilor antimicrobieni sistemici la pacientii pediatrici spitalizati în Bucuresti, România.

BACKGROUND: Formulation of effective strategies for prudent usage of antibacterial agents involves knowing of the factors that are modulating the variability of usage rate. OBJECTIVE: analysis of the factors what modulate the usage rate's variability of antimicrobials prescribed to hospitalized children from Bucharest municipality. METHODS: A statistically representative sample (n=895) has been extracted from the cohort of children discharged during October 2008 from the Bucharest's main pediatric university clinic. Demographic, clinic and pharmacological relevant data, captured by reviewing the subjects' medical charts were entered in an Epi Info database. For each enrolled subject the density rate of antimicrobial consumption has been calculated by dividing the pooled number of hospital days in which the subject received at least one dose of each individual antimicrobial agent, by the number of days of hospitalization. For the analysis of antimicrobials usage rate's variability, a rate higher the value calculated at 75 percentile has been defined as overuse. Personal, clinical and prescription characteristics significantly associated, in univariate analysis, with overuse status, were analyzed lately for independent association, by unconditional logistic regression. RESULTS: to the sample's subjects up to 31 individual antimicrobials owning to the J01 group (antimicrobials for systemic use) of the ATC (Anatomical Therapeutic Chemical) classification promoted by World Health Organization were prescribed. In total, in the sample a number of 2607 days of antimicrobial therapy was cumulated, in 60% of these 5 antimicrobials agents were administered: ceftriaxone, gentamicine, cefoperazone, cefazolin and cefuroxime. Antimicrobials overuse was observed in 37% of subjects. By univariate analysis the overuse was significantly associated (p < 0,05) with the following characteristics of the subjects: age under one, with a trip in ICU, diagnosed with LRTI, with a hospitalization longer than 5 days, exposed to more than two antimicrobials agents during the same hospitalization episode and treated with 3rd generation cephalosporins. However, by multivariate analysis, only factors related to antimicrobials prescribing style remained independently associated with overuse status. CONCLUSIONS: In children hospitalized in Bucharest, the antimicrobial agents' consumption is modulated by factors which are specific for this category of patients, factors broadly internationally recognized. Particularly, through multivariate analysis, we found that the factors related with antimicrobials prescription's style explained with the most fidelity the variation of usage density rate in the child hospitalized in Bucharest. The analysis of the modulators of the usage rate's variability is essential for issuing and evaluation of effective interventions focused on antimicrobials' prudent use.

[Use of systemic antibacterial agents at a university emergency clinic in Bucharest, in the year 2008]. / Observatii privind utilizarea agentilor antibacterieni sistemici într-o clinica universitara de urgenta din municipiul Bucuresti în anul 2008.

OBJECTIVE: use of ATC/DDD (Anatomic Therapeutic Classification/Daily Defined Dose) methodology promoted by World Health Organization for calculating and analysis of systemic antimicrobial agents' annual rates of usage among the adult patients hospitalized in Bucharest municipality. METHODS: descriptive retrospective study conducted in the main university clinic for medical emergencies from Bucharest municipality. Consumption of systemic antimicrobial agents, taken from the clinic pharmacy's records, regarding the 2008 year, has been transformed in defined daily doses and aggregated by ATC subgroups. The number of patient days from 2008 was obtained from clinic administrative service. Antimicrobial agents' usage was expressed as consumption density rate by dividing the defined daily doses counts to the correspondent number of patient days. Analysis of consumption rates has been performed both by whole clinic and also stratified by departments of medical specialties: surgery, internal medicine and intensive care. RESULTS: In the year 2008, the patients carried in the clinic totalized 255,600 days of hospitalization; during the respective time in clinic there were used 36 of individual antibacterial agents that made up 184,857 defined daily doses. At the level of entire clinic the consumption rate of all systemic antimicrobial agents was 72.6 defined daily doses per 100 de patient days (DDD/PD); by medical specialties the indicator's values were 61.2 DDD/100 PD in the department of internal medicine specialties, 62.8 DDD/100 PD in the departament of surgical specialties and 126 DDD/100 PD in the medical/surgical intensive care unit, respectively. Almost 70% of the defined daily doses' total included five antimicrobial agents: co-amoxiclav, cefuroxim, cefoperazone + sulbactam, ciprofloxacine si metronidazol. By ATC subgroups, the top three consumption rates included penicillin plus beta-lactamase inhibitors, 2nd generation cefalosporines and fluorochinolons, respectively. Comparing the own rate with the distributions of NNIS (National Nosocomial Infection Surveillance) system form USA, demonstrated that the usage was into the expected limits for the majority of antimicrobial agents groups considered, excess usage being detected only in the case of 2nd generation cefalosporins (in non-intensive care sector) and in the case of carbapenems in the intensive care units, respectively. CONCLUSIONS: At the whole clinic level, the study detected a rate of systemic antimicrobial agents' usage similar with the correspondent values recently reported even from the South European states or form USA. Excessive usage (against the NNIS standard) might be mitigated through augmentation of the compliance with guidelines for prudent utilization of antimicrobial agents.

[Prevalence of risk factors and mechanisms of transmission of acute viral hepatitis type B and C in Bucharest municipality: 2001-2008]. / Prevalenta factorilor de risc si a mecanismelor de transmitere a hepatitei acute virale tip B si C în municipiul Bucuresti: 2001-2008.

OBJECTIVE: Analysis of risk factors for achieving clinically overt hepatitis B and hepatitis C in the population of Bucharest municipality. METHODS: retrospective and descriptive study on hospital patients cohort. Cases - in the study have been enrolled all acute viral hepatitis B and C confirmed by the two infectious diseases university clinics of Bucharest municipality, during the time interval 2001-2008, among the residents of the municipality. Infection risk factors - for every case of hepatitis B and hepatitis C with the simptoms onset placed during the time interval 2001-2008, it was associated "the most plausible" risk factor, detected by case investigation. For contemplation of control strategies the risk factors were stratified by mechanisms of virus transmission and by age groups. The analysis consists mainly in statistical comparing of cases prevalence in each etiology by risk factors and mechanisms of visus transmission. RESULTS: Patients cohort included 1440 hepatitis B cases and 227 hepatitis C cases, respectively. The most prevalent individual risk factor in hepatitis B was the sexual contact with multiple partners (51,0%) while in hepatitis C the use of ilegal injectable drugs (46,3%). The prevalences of hepatitis B and hepatitis C cases by the four mechanisms of virus transmmission were similar (p = 0,52). For both etiologies the high risk behaviours represented the principal mechanism of virus transmission (64,1% in hepatitis B and 63,4% in hepatitis C, respectively); additionaly, for both etiologies the most prevalent mechanisms of virus transmission by age groups were indentically, namely: (a) consumption of medical services in the age group 55+ years, (b) high risk behaviours in the age group 13-54 years and (c) contact with case or virus carrier in the age group 0-12 years, respectively. CONCLUSIONS: in the time period 2001 - 2008 the structure by mechanisms of virus transmission in hepatitis B and hepatitis C cases reported in the population of Bucharest municipaly was statistically similar, for both etiologies the most prevalent mechanism (> 60%) was represented by high risk behaviours. This reality strongly suggests that additionaly to the current strategies for prevention of the infection with hepatitic visuses B and C, the decisive strategy to control of the two infection needs to be extended with an effective education satelite focused on high risk groups.

[Effect of air pollution upon the hospitalization for acute lower respiratory tract infections among the Bucharest municipality's residents]. / Efectul poluarii aeriene asupra frecventei spitalizarii pentru infectii acute ale cailor respiratori inferioare în populatia municipiului Bucuresti.

OBJECTIVE: Assessment of the short-term association between exposure to outdoor air pollution and hospitalization for lower respiratory tract infections (LRTI) in the Bucharest municipality'spopulation. MATERIALS AND METHODS: Relation exposure--health effect has been explored through linear regression upon time series, where the independent variable was represented by daily levels of nitrogen dioxide (NO), carbon monoxide (CO), sulfur dioxide (SO2) and ozone (O3) from atmospheric air of Bucharest municipality whereas the dependent variable has been represented by daily frequency, by age groups, of Bucharest municipality residents, hospitalized during the year 2007for LRTI (ICD-10 codes: J12-J22). RESULTS: In the year 2007, through linear regression we found high correlations (p < 0.01) between the following variables: (a) daily atmospheric concentrations of NO2, CO and SO2, (b) daily frequencies of hospitalizations for LRTI by age group and (c) daily air levels of three of the above mentioned pollutants and the age-specific frequencies of patient hospitalization for LRTI. The O3 daily air levels have been correlated (p < 0.01) only with the daily air levels of SO2 and CO but wasn't correlated to NO2 air level or with the health effect studied CONCLUSIONS: in the Bucharest municipality, the study demonstrated robust associations between the atmospheric pollutants' levels and daily frequencies of hospital admissions for LRTI. Through inference the results suggests that the interventions for environment control which will result in decreasing of the pollution level with NO2, CO and SO2 might be associated with decreasing the frequency of hospitalization for LRTI and consequently with preserving the resources allocated for health.

[Nature and severity of the complications in the measles cases hospitalized during the epidemics in 2005-2006 in Bucharest]. / Natura si severitatea complicatiilor la cazurile de rujeola spitalizate în epidemia 2005-2006 din municipiul Bucuresti.

AIM: analysis of the nature and the severity of medical complications of the hospitalized cases associated to an measles outbreak which appeared after a period of consistent interruption of measles virus circulation in the Bucharest municipality population. METHODS: analytical study on the cohort of measles cases hospitalized during the main period of the 2005-2006 outbreak from Bucharest municipality: data source--medical records of the cases enrolled in the study. Enrolled cases were allocated to 5 classes, based on the first two discharging diagnosis. Epi Info software has been used in order to: (a) analyze cases' prevalence by diagnosis classes and demographic characteristics and (b) analysis the prevalence of severe cases defined as cases with duration of hospitalization higher the value calculated at the 75 percentile of the series. RESULTS: 63% of laboratory confirmed measles cases have been hospitalized, the prevalence of measles cases with specific complications decreased with age. Longer hospitalization was strictly associated (p < .05) with the need to care for cases with measles specifically complications. CONCLUSIONS: when cases severity was expressed in terms of resources allocate (days of hospital stay) it was found that severity is not depending on age group (OR: 1.57: IC 95%: 0.93-2.63; p = 0.09), the study produced solid arguments regarding the good medical strategy (rational resources use) practiced in the infectious diseases clinics of the Bucharest municipality, demonstrated through.: (a) hospitalization authorized with priority for complicated cases and (b) longer hospitalization associated in special with clinically severe cases.