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Objective To describe the use of Lactobacillus by hospitalized patients and to examine its relationship with various Clostridium difficile infection (CDI) related outcomes. Methods The characteristics of Lactobacillus users and non-users and the initiation of Lactobacillus with respect to initiation of antibiotic therapy and CDI treatment were described using national hospital discharge database. The relationships between Lactobacillus use and post-CDI length of stay, mortality, switch of CDI therapy, and readmission were analyzed. Results Lactobacillus users and non-users were different in most characteristics. Metronidazole and fluoroquinolones were the most frequently used antibiotics by Lactobacillus users. They were mainly CDI cases, used multiple antibiotics, extremely ill, and started Lactobacillus five or more days after initiation of antibiotics or CDI treatment. Lactobacillus use was associated with increased length of stay and switching of CDI therapy. Conclusions The true association between Lactobacillus use and CDI remains unclear. This study provides foundation for future research.

Clostridium difficile is the most common antibiotic related diarrhéa disease in Sweden. New recommendations from the Swedish public health authority and European Society of Clinical Microbiology and Infectious Diseases (ESCMID) had led to that a more advanced diagnostic algorithm is of priority. Hence this study, whose purpose was to investigate whether the performance of the rapid test C. diff Quik Chek Complete® could enable the introduction of a new diagnostic algorithm for detection of toxin-forming C. difficile in laboratory medicine in Sundsvall, according to these new recommendations. In the study 119 patient stool-samples were analysed with both GeneXpert and C. diff Quik Chek Complete® and these two combined fulfils these new recommendations of detecting toxin A and B from toxigenic C. difficile together with the enzyme Glutamate Dehydrogenase (GDH) which is produced by all C. difficile stems. The results shows that C. diff Quik Chek Complete® is well matched with GeneXpert and that most of the samples would come to be answered immediately after analysis with C. diff Quik Chek Complete®. The laboratory will save both time and money to establish C. diff Quik Chek Complete® in their algorithm for diagnosing C. difficile infection.

There is a pandemic of low-value clinical care that threatens the sustainability of our publicly funded healthcare systems. Over 30% of the health services provided to patients provide no benefit or may actually result in harm. Health services research is needed to critically evaluate our clinical practices and programs to ensure we create systems that consistently deliver high-value care. Unlike drug trials, health services research is complicated by enormous heterogeneity across cultures, environments, behaviours and systems. Ideally, local research communities should devise and conduct health services research to ensure that both the research questions and outcomes are relevant to community members, and thus more likely to result in sustainable healthcare systems. Embedded researcher models are emerging as a viable approach to supporting local research activities. Embedded researchers are part of the community they serve, provide research expertise to local investigators and community members, and help develop local research systems that facilitate health services research activities. While they may still collaborate with academic partners, this is not necessary for their research success. This thesis documents the transformation of a large community hospital in Ontario into a learning health centre through the use of an embedded researcher model. The first part of the thesis is focused on the results of incorporating an embedded research plan into the hospital’s new antimicrobial stewardship program. The research that emerges from this work contributes new knowledge about the value of antimicrobial stewardship to important patient outcomes such as reduced lengths of hospital stay and rates of Clostridium difficile infections. The thesis concludes with a discussion of the implementation of all the necessary components needed to support a learning health centre and how an embedded researcher model facilitated this transformation and could be used by any similar organization to achieve the same result. / Thesis / Doctor of Philosophy (PhD) / Over 30% of the health services provided by our healthcare systems does not benefit and may actually harm patients. Health services research is therefore a necessary activity required to reduce this waste. In Ontario, over 65% of patients receive their acute care in large community-based hospitals, and yet, these hospitals have minimal research activity and capacity despite repeated attempts by the academic research community to engage these institutions through a variety of collaborative models such as integrated knowledge translation. This thesis provides a blueprint for the transformation of a large community hospital into a learning health centre through the use of a locally created, locally relevant, embedded researcher model. Starting with a proof of concept through the systematic evaluation of an antimicrobial stewardship program, the thesis ends with a ‘how to’ guide for the implementation of the foundational elements needed to support health services research in similar organizations.

Multiorgan dysfunction syndrom is the major driving pathophysiological mechanism of morbidity and mortality in critically ill patients. Gastrointestinal dysfunction usually develops as a result critical illness and it is believed to play a key role in the development and progression of multiple organ dysfunction. Moreover, any primary disorder of the gastrointestinal tract, if severe enough, can lead to a critical state and secondary multiorgan dyfunction. Despite intensive experimental and clinical research, reliable tools for monitoring and evaluation of the severity of gastrointestinal dysfunction remain unknown. In the same line, therapy of this complex pathology remains largely supportive. The aim of this thesis was first to explain the severity of the most common and most serious nosocomial infection of the digestive tract, second to elucidate the safety and effectiveness of the endoscopic dual enteral probe insertion in ventilated critically ill patients, and, third to evaluate new diagnostic tools of the gastrointestinal dysfunction. Finally, we present an ongoing project aimed at investigating esophageal dysfunction in mechanically ventilated critically ill patients.

<p>Over three million infections were reported in the United States of America in 2019. These infections were caused by either antibiotic-resistant pathogens or <i>Clostridioides difficile</i> and resulted in more than 50,000 deaths. Unfortunately, antibacterial agents are rapidly losing their ability to treat infections and the process of discovering new antibiotics is too slow to cope up with bacterial evolution. Repurposing FDA-approved drugs of well-studied safety, pharmacology and pharmacokinetics represents a faster alternative method of antibacterial drug discovery. Repurposing is more successful and less depleting method of drug discovery than classical de novo method in regard to both cost and time. In the following studies, two major pathogens are targeted, vancomycin-resistant <i>Enterococcus</i> (VRE) and <i>C. difficile</i>. Both bacteria are more prevalent in healthcare settings were more vulnerable population of elderly and immunocompromised individuals reside. In addition, healthcare settings are usually associated with higher frequency of receiving antibiotics which in turn, compromises the integrity of normal microbiota responsible for protection against invading pathogens. Furthermore, hospital stays are associated with exposure to bacterial shedding from other patients. Our aim was to identify FDA-approved drugs with novel ability to eradicate these two bacterial pathogens in the gastrointestinal tract (GIT). Notably, the GIT is considered the actual site of infection in case of <i>C. difficile while it is only a transition site for VRE where the bacteria colonize before causing true infections in other tissues. Studies against both bacteria started with an <i>in vitro</i> screening of FDA-approved drugs and clinical molecules to identify potential candidates for further investigation.</i></p><p><i>For VRE, two drugs where identified with potent inhibitory activity and favorable pharmacokinetic profiles, auranofin and ebselen. Auranofin was approved in the 1960s for the treatment of rheumatoid arthritis due to its anti-inflammatory activity. Auranofin was found to exert potent bacteriostatic activity against both vancomycin-sensitive and vancomycin-resistant <i>Enterococcus</i> strains (minimum inhibitory concentration against 90% of the strains, MIC90 = 1 µg/mL). In addition, bacteria could not develop resistant mutants against auranofin upon prolonged exposure. On the other hand, ebselen is an organoselenium compounds currently in clinical trials for several indications. Similarly, ebselen was found to be a potent inhibitor of VRE growth (MIC90 = 2 µg/mL). In addition, ebselen successfully inhibited bacterial biofilm formation and eradicated mature biofilms. In a mouse model of VRE colonization, both drugs inhibited bacterial shedding and reduced bacterial counts in the GIT of the colonized animals.</i></p><p><i>For <i>C. difficile</i>, auranofin was also found to exert potent inhibitory activity against bacterial growth (MIC90 = 2 µg/mL), toxin production and spore formation. Additionally, it was beneficial in protecting colon cells against <i>C. difficile</i> toxin-induced inflammation. Further, auranofin was found to not promote growth of VRE as seen with the current anticlostridial agents. In addition to auranofin, two more antiprotozoal drugs were found to potently inhibit <i>C. difficile</i> growth, ronidazole and secnidazole. Both drugs are 5-nitroimidazoles approved for human (secnidazole) or veterinary (ronidazole) applications. Secnidazole and ronidazole halted <i>C. difficile</i> growth at very low concentrations (MIC90 = 0.5 and 0.125 µg/mL, respectively). Furthermore, both drugs were superior to metronidazole in bacterial killing and had favorable activities against protective gut microbiota. In addition, they demonstrated efficient protection to mice in a <i>C. difficile</i> infection model. </i></p><p><i>Overall, several drugs were presented to possess favorable activities against <i>C. difficile</i> or VRE. These drugs merit more evaluation as potential candidates for the treatment of infection caused by either bacteria. </i></p><div><i><br></i></div>

Multiorgan dysfunction syndrom is the major driving pathophysiological mechanism of morbidity and mortality in critically ill patients. Gastrointestinal dysfunction usually develops as a result critical illness and it is believed to play a key role in the development and progression of multiple organ dysfunction. Moreover, any primary disorder of the gastrointestinal tract, if severe enough, can lead to a critical state and secondary multiorgan dyfunction. Despite intensive experimental and clinical research, reliable tools for monitoring and evaluation of the severity of gastrointestinal dysfunction remain unknown. In the same line, therapy of this complex pathology remains largely supportive. The aim of this thesis was first to explain the severity of the most common and most serious nosocomial infection of the digestive tract, second to elucidate the safety and effectiveness of the endoscopic dual enteral probe insertion in ventilated critically ill patients, and, third to evaluate new diagnostic tools of the gastrointestinal dysfunction. Finally, we present an ongoing project aimed at investigating esophageal dysfunction in mechanically ventilated critically ill patients.