Etid ka-kontwòl nan enfeksyon Clostridium Innocuum, Taiwan Ⅱ
Jun 04, 2024
Rezilta yo
Patisipan yo ak enfòmasyon demografik yo
Pa MALDI-TOF mas spectrométrie sistèm lan, 180 echantiyon bay kwasans C. innocuum. Nou eskli 22 nan sa yo ki soti nan plis analiz paske yo pa gen aksè a enfòmasyon klinik ak 6 paske nan izolasyon koncomitan nan C. inoculum ak dosye C. dif nan menm echantiyon an (gwoup CI). Nou matche gwoup kontwòl la ak echantiyon C. inoculum pa kritè etid yo. Soti nan 1,134 ka C. difficile pandan peryòd etid la, nou te enskri 304 ka kòm kontwòl (gwoup CD). Tout ka kontwòl yo te matche jisteman sou ane dyagnostik ak laj (+2 ane); 25 kontwòl pa t matche sou sèks. Mwayèn laj pasyan an pou 456 ka yo te 66.7 ane, ak 58.3% nan pasyan yo te gason (Tablo 1). Tou de gwoup yo te menm jan an konsènan laj, sèks, ak nòt Charlson Komorbidite Index (5.7 + 3.2 pou CI ak 6.2 + 3.3 pou CD). Analiz sou gwoup chak gwoup laj (<50, 50–60, 60–70, 70–80, and >80 ane) tou devwale pa gen okenn diferans estatistik. An jeneral, 8 pasyan pedyatrik yo te rekrite, 3 nan gwoup CI ak 5 nan gwoup CD. Konsènan maladi sistemik ki kache, gwoup CD a te montre plis pasyan ki gen maladi ren kwonik (18.4% kont 30.9%; p=0.005) (Tablo 1). Nòt, plis pasyan te pran enfeksyon an nan kominote a nan gwoup CI (33.6% vs 16.8%; rapò chans [OR] 2.5, 95% CI 1.6-3.9; p<0.001) (Table 1).
Karakteristik maladi ak gravite
Nou te obsève diferans remakab nan karakteristik maladi ant 2 gwoup yo. Moun ki nan gwoup CI a te gen yon risk 6.5 fwa pi wo pou yo devlope EICI, ki gen ladan bakteriemi, enfeksyon nan vant, enfeksyon nan aparèy bili, enfeksyon nan po ak tisi mou, piospermi, ak vajinit bakteri (36.8% pou CI vs 8.2% pou CD). ; OSWA 6.5, 95% CI 3.9 -11.0;<0.001) (Table 1). On the contrary, most disease manifestations in the CD group were confined to the intestine and colon, mainly C. difficile–associated diarrhea. Most patients had antibiotic exposure 30 days before the CI or CD infection event. CD group showed a higher 30-day antibiotic exposure rate (95.1%) than the CI group (79.6%; p<0.001) (Table 2) and longer duration (mean 15.6 days, SD 8.3) than the CI group (mean 13.7 days, SD 8.6; p<0.001). Patients in the CD group received more penicillins, cephalosporins, carbapenems, and fluoroquinolones (Table 2).
Konsènan gravite maladi a, pi fò nan pasyan yo nan tou de gwoup yo te oblije entène lopital (93.4% nan gwoup CI a ak 97.7% nan gwoup CD a; p=0.03) (Tablo 1). Malgre ke pifò pasyan nan gwoup CD a te gen enfeksyon entesten, konplikasyon gastwoentestinal ki gen rapò ak ileus, pèforasyon entesten, sepsis klinik, ak chòk ki te fèt pi souvan nan gwoup CI a (26.3%) pase gwoup CD (11.2%; OSWA 2.8, 95%). CI 1.7–4.7;<0.001). CI group also showed a higher rate of intensive care unit (ICU) admission (23.6% vs. 9.5%; OR 2.9, 95% CI 1.7–5.0; p<0.001) (Table 1). All the data indicated that the disease severity at the acute stage was more severe and invasive in the C. innocuum–infected patients. Furthermore, we saw no recurrence of infection in the CI group but a recurrence of infection in 4.9% of the CD group (p = 0.005).
Nou te obsève okenn diferans estatistik enpòtan nan prezantasyon klinik yo, men pasyan ki gen enfeksyon C. inoculum te gen mwens sentòm dyare ak mwens lafyèv. Nan rezilta tès laboratwa yo, pasyan yo te fè eksperyans anemi pi souvan nan gwoup CD a pase nan gwoup CI; konte emoglobin yo te 9.8 (2.0) g/dL nan CD ak 10.7 (2.4) g/dL nan CI (p<0.001) (Table 3). We observed no difference in other systemic inflammatory markers. A limited number of patients received colonoscopy examination, and we found no pseudomembranous colitis in the CI group
Figi. Koub Kaplan-Meier nan 30-jou (A), 90-jou (B), ak total (C) pousantaj siviv pasyan ki gen Clostridioides difficile ak Clostridium innocuum, Taiwan. Nan gwoup C. inoculum la, 30-pousantaj siviv jou a te 85.5%, 90-pousantaj siviv jou a te 84.2%, ak pousantaj siviv jeneral la te 77.0%. Pousantaj siviv 90-jou a te yon ti kras pi wo pase gwoup C. difficile (valè p nan tès log-rank=0.05), tandiske 30-jou ak pousantaj siviv jeneral pa t '. montre yon diferans enpòtan ant 2 gwoup yo.
Rezilta ak Faktè Risk pou To mòtalite
{{0}}To mòtalite jou nan gwoup CI a te 14.5%; to 90-jou a, te 15.8%, ak to jeneral la, te 23.0%. Malgre ke to mòtalite 90-jou a te yon ti kras pi wo nan gwoup CD a ak yon diferans enpòtan (valè p nan tès log-rank=0.05) nan analiz siviv Kaplan-Meier, to mòtalite jeneral la te fè pa montre yon diferans estatistik enpòtan ant 2 gwoup yo (Figi). Sèvi ak regresyon lojistik, nou idantifye maladi ren kwonik (OSWA 8.6, 95% CI 2.6-28.4; p<0.001), solid tumor (OR 3.5, 95% CI 1.0–12.0; p = 0.051), ICU admission (OR 7.3, 95% CI 2.4–21.9; p<0.001), and shock status (odds ratio 8.0, 95% CI 2.4–27.2; p<0.001) as 4 independent risk factors for both 30-day and overall mortality rates in the patients with C. innocuous infection. We identified 7 bacteremias caused by C. innocuum in this study. Two of those patients experienced septic shock, and 1 needed ICU hospitalization. The 30-day mortality rate for the 7 patients was 42.9% (3/7) and the 90-day was 57.1% (4/7).
Rezilta mikwobyolojik ak sansiblite antimikwòb Pami 152 izolan C. inoculum yo, nou te refè 96 (63.2%) izolat nan espesimèn poupou; rès yo te soti nan san an (7), ascit (13), pi/absè (16), blesi / tisi gwo twou san fon (16), ji kòlè (2), endo kòl matris (1), ak espèm (1). Nou te detekte 18 enfeksyon mikwòb polymère nan gwoup CI a, pi fò nan yo te soti nan echantiyon ascit ak pi / absè. Plis izolan C. inoculum (36.8%) pase izolat C. difficile (8.2%) te soti nan espesimèn ekstraentestinal (p<0.001) (Table 3), which is compatible with our clinical observation. We performed antimicrobial susceptibility testing on limited isolates. In the C. inoculum isolates, we observed the highest susceptibility rate for metronidazole (20/20, 100%) and ampicillin/sulbactam (21/21, 100%), followed by penicillin (35/44, 79.5%) and clindamycin 30/44 (68.2%).
Diskisyon
Genus Clostridium se gwo ak etewojèn; li gen ladann<200 species. Accurate species identification has been difficult. In recent years, several new species have been recognized and others reclassified using newer molecular diagnostic methods, such as 16S rRNA gene sequencing (24). Among the medically important Clostridium spp., C. perfringens is the predominant species isolated from cases of bacteremia. The severity of EICI varies; for bacteremia, the mortality rate was found to be 48%–52% by different studies (25–27). The risk factors for disease acquisition and death were related to an underlying immunocompromised condition such as hemodialysis, malignancy, immunosuppressant use, and Crohn's disease (25). The main portal of entry is the hepatobiliary and gastrointestinal tract. We believe this is also the case in C. innocuum because stool was a common source for the C. innocuum isolates and gastrointestinal tract–related complications were not uncommon in C. innocuum–infected patients.
Yon etid resan pa Ha et al. (28) te jwenn tou ke C. inoculum se youn nan bakteri ki pi komen ki ta ka transloke soti nan trip la nan tisi mesenteric nan pasyan ki gen maladi Crohn a ak plis pwovoke adipogenèz ak fibwoz lokal yo, ke yo rekonèt ansanm kòm grès trennen sou vant. Nou te jwenn ke nan mitan espès clostridial anaerobik, C. inoculum te neglije depi lontan kòm yon patojèn imen. Etid nou an se jodi a etid obsèvasyon ki pi konplè pou dekri manifestasyon klinik yo ak rezilta enfeksyon C. inoculum; non sèlman li pi anvayisan pase pifò espès Clostridium, men li ka lakòz plis konplikasyon nan aparèy gastwoentestinal apre enfeksyon entesten. Yo te pibliye ka rapò sou EICI ki gen rapò ak enfeksyon C. inoculum nan Etazini, Espay, Japon, ak Taiwan (10,29-32) (Tablo 4). Bakterimi ak enfeksyon nan vant sete manifestasyon ki pi komen yo, ki se konpatib ak obsèvasyon nou yo. Tout enfeksyon yo te fèt nan pasyan ki gen kondisyon kache; terapi antimikwòb pwolonje te oblije trete pasyan sa yo, ki gen to mòtalite (20%) te menm jan ak sa yo obsève nan etid nou an (23%). Konpare ak C. difficile, ke yo rekonèt kòm yon patojèn nosocomial, prèske yon tyè nan enfeksyon C. inoculum yo te fèt nan kominote a. Obsèvasyon sa a endike ke C. inoculum ta ka pi virulan ak konpetitif pase C. difficile.
Among the EICI, bacteremia is the most severe form of infection. In a recent study by Morel et al. (33), non–C. difficile Clostridium bacteremia requiring ICU hospitalization showed an aggressive clinical course and was usually life-threatening. The 28-day mortality rate was 55% and the 90-day mortality rate was 71% (33). This report is compatible with our findings of 30-day (42.9%) and 90-day (57.1%) mortality rates in CI bacteremic patients. Identifying C. inoculum infection is important because the microorganism expresses intrinsic resistance to vancomycin, because of the synthesis of peptidoglycan precursors with low affinity for vanvancomycin (MIC 4–16 mg/L) (8,26). Moreover, highly vancomycin-resistant strains (MIC >16 mg / L) ta ka devlope si bakteri yo te deja ekspoze a vancomycin (34). Paske vancomycin oral yo te rekòmande kòm terapi premye liy pou enfeksyon C. difficile, distenge C. inoculum ak lòt espès clostridial vin esansyèl pou evite echèk tretman ki te koze pa itilizasyon antimikwòb ki pa apwopriye. Metronidazol ak clindamycin parèt kòm chwa apwopriye pou trete enfeksyon C. inoculum, dapre rezilta tès sansiblite antimikwòb nou yo.
Limit prensipal etid nou an se konsepsyon etid retrospektiv ak done inevitab ki manke yo. Mank fòma dosye medikal estanda a te anpeche nou defini egzakteman chak ka-pasyan dyagnostik, espesyalman dyare ki asosye ak antibyotik, ak kolit egi, ki gen deskripsyon klinik ki sanble nan dosye medikal yo. Gen kèk done objektif ki pa t disponib, ki ka potansyèlman konpwomèt presizyon nan to yo estime nan prezantasyon ak dyagnostik nan mitan pasyan yo. Sepandan, pwopòsyon done ki manke yo te parèt piti epi yo pa ta dwe afekte anpil rezilta etid la. Dezyèmman, se pa tout izole C. inoculum ki soti nan pasyan ki enskri yo te teste pou sansiblite antimikwòb, e tès sa a pa t gen ladann van vini. Twazyèmman, etid la pa avanse konpreyansyon nou sou mekanis virulans C. nan vakyòm. C. inoculum ka posede yon mekanis virulans inik ki lakòz enfeksyon gastwoentestinal kòm byen ke ekstraentestinal, tankou estrikti nan lipopolysaccharide ki tankou nou dekri nan etid anvan nou an (9). C. difficile gen ladan tou idrat kabòn lipo sur face, ki gen yon aktivite byolojik ki sanble ak lipopolysaccharide nan bakteri gram-negatif (35); ipotèz sa a bezwen plis verifikasyon eksperimantal. An konklizyon, C. inoculum ta dwe konsidere kòm yon espès Clostridium enpòtan ki lakòz EICI ak enfeksyon gastwoentestinal ki gen yon risk pou konplikasyon grav ak yon to mòtalite segondè nan pasyan iminitè; doktè yo ta dwe rekonèt li kòm yon patojèn pou trete klinikman. Yo bezwen plis etid pou konprann mekanis virulans C. innocuum. Idantifikasyon egzak nan C. inoculum pral gide terapi antimikwòb apwopriye ak alè pou pasyan yo paske nan rezistans intrinsèques vancomycin li yo.
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