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To determine the role of unit-based transmission that accounts for cases of early Clostridium difficile infection (CDI) during hospitalization for allogeneic stem cell transplant.
Stem cell transplant unit at a tertiary care cancer center.
Serially collected stool from patients admitted for transplant was screened for toxigenic C. difficile through the hospital stay and genotyping was performed by multilocus sequence typing. In addition, isolates retrieved from cases of CDI that occurred in other patients hospitalized on the same unit were similarly characterized. Transmission links were established by time-space clustering of cases and carriers of shared toxigenic C. difficile strains.
During the 27-month period, 1,099 samples from 264 patients were screened, 69 of which had evidence of toxigenic C. difficile; 52 patients developed CDI and 17 were nonsymptomatic carriers. For the 52 cases, 41 had evidence of toxigenic C. difficile on the first study sample obtained within a week of admission, among which 22 were positive within the first 48 hours. A total of 24 sequence types were isolated from this group; 1 patient had infection with the NAP1 strain. A total of 11 patients had microbiologic evidence of acquisition; donor source could be established in half of these cases.
Most cases of CDI after stem cell transplant represent delayed onset disease in nonsymptomatic carriers. Transmission on stem cell transplant unit was confirmed in 19% of early CDI cases in our cohort with a probable donor source established in half of the cases.
Innate immunity is an ancient and highly conserved system that provides the first line of defense upon encounter with pathogenic organisms. Activation of innate immune responses is a complex process involving multiple components and distinct steps. The cellular components of innate immunity include neutrophils, monocytes, macrophages and dendritic cells (DCs). These cells are capable of direct microbicidal activity that partially depends on inducible nitric synthase (iNOS) and NADPH oxidase complex that catalyze production of toxic anti-microbial compounds. Additionally, they secrete a vast array of pro-inflammatory mediators such as cytokines and chemokines and can recruit and activate other inflammatory cells, thus amplifying the immune cascade. Apart from their role in restricting microbial growth, innate immune responses also provide the inflammatory context in which adaptive T- and B-cell immune responses develop.
Dendritic cells are derived from hematopoietic progenitor cells in the bone marrow and are found in the peripheral circulation as well as in the lymphoid and non-lymphoid tissues. Dendritic cells can be subdivided into several subsets based on the expression of the cell surface markers and different subsets have been ascribed distinct functions during the immune response. Since their discovery, dendritic cells have been studied extensively with regard to their role as antigen-presenting cells. However, it is becoming increasingly clear that dendritic cells also play an important role during the innate immune responses to microbial pathogens.
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