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Nerber HN, Baloh M, Brehm JN, Sorg JA. The small acid-soluble proteins of Clostridioides difficile regulate sporulation in a SpoIVB2-dependent manner. PLoS Pathog 2024; 20:e1012507. [PMID: 39213448 PMCID: PMC11392383 DOI: 10.1371/journal.ppat.1012507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 09/12/2024] [Accepted: 08/14/2024] [Indexed: 09/04/2024] Open
Abstract
Clostridioides difficile is a pathogen whose transmission relies on the formation of dormant endospores. Spores are highly resilient forms of bacteria that resist environmental and chemical insults. In recent work, we found that C. difficile SspA and SspB, two small acid-soluble proteins (SASPs), protect spores from UV damage and, interestingly, are necessary for the formation of mature spores. Here, we build upon this finding and show that C. difficile sspA and sspB are required for the formation of the spore cortex layer. Moreover, using an EMS mutagenesis selection strategy, we identified mutations that suppressed the defect in sporulation of C. difficile SASP mutants. Many of these strains contained mutations in CDR20291_0714 (spoIVB2) revealing a connection between the SpoIVB2 protease and the SASPs in the sporulation pathway. This work builds upon the hypothesis that the small acid-soluble proteins can regulate gene expression.
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Affiliation(s)
- Hailee N Nerber
- Department of Biology, Texas A&M University, College Station, Texas, United States of America
| | - Marko Baloh
- Department of Biology, Texas A&M University, College Station, Texas, United States of America
| | - Joshua N Brehm
- Department of Biology, Texas A&M University, College Station, Texas, United States of America
| | - Joseph A Sorg
- Department of Biology, Texas A&M University, College Station, Texas, United States of America
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2
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Kunishima H, Ichiki K, Ohge H, Sakamoto F, Sato Y, Suzuki H, Nakamura A, Fujimura S, Matsumoto K, Mikamo H, Mizutani T, Morinaga Y, Mori M, Yamagishi Y, Yoshizawa S. Japanese Society for infection prevention and control guide to Clostridioides difficile infection prevention and control. J Infect Chemother 2024; 30:673-715. [PMID: 38714273 DOI: 10.1016/j.jiac.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 05/09/2024]
Affiliation(s)
- Hiroyuki Kunishima
- Department of Infectious Diseases. St. Marianna University School of Medicine, Japan.
| | - Kaoru Ichiki
- Department of Infection Control and Prevention, Hyogo Medical University Hospital, Japan
| | - Hiroki Ohge
- Department of Infectious Diseases, Hiroshima University Hospital, Japan
| | - Fumie Sakamoto
- Quality Improvement and Safety Center, Itabashi Chuo Medical Center, Japan
| | - Yuka Sato
- Department of Infection Control and Nursing, Graduate School of Nursing, Aichi Medical University, Japan
| | - Hiromichi Suzuki
- Department of Infectious Diseases, University of Tsukuba School of Medicine and Health Sciences, Japan
| | - Atsushi Nakamura
- Department of Infection Prevention and Control, Graduate School of Medical Sciences, Nagoya City University, Japan
| | - Shigeru Fujimura
- Division of Clinical Infectious Diseases and Chemotherapy, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Japan
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, Japan
| | - Hiroshige Mikamo
- Department of Clinical Infectious Diseases, Aichi Medical University, Japan
| | | | - Yoshitomo Morinaga
- Department of Microbiology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
| | - Minako Mori
- Department of Infection Control, Hiroshima University Hospital, Japan
| | - Yuka Yamagishi
- Department of Clinical Infectious Diseases, Kochi Medical School, Kochi University, Japan
| | - Sadako Yoshizawa
- Department of Laboratory Medicine/Department of Microbiology and Infectious Diseases, Faculty of Medicine, Toho University, Japan
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3
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Nerber HN, Baloh M, Brehm JN, Sorg JA. The small acid-soluble proteins of Clostridioides difficile regulate sporulation in a SpoIVB2-dependent manner. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2023.05.17.541253. [PMID: 37292792 PMCID: PMC10245694 DOI: 10.1101/2023.05.17.541253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Clostridioides difficile is a pathogen whose transmission relies on the formation of dormant endospores. Spores are highly resilient forms of bacteria that resist environmental and chemical insults. In recent work, we found that C. difficile SspA and SspB, two small acid-soluble proteins (SASPs), protect spores from UV damage and, interestingly, are necessary for the formation of mature spores. Here, we build upon this finding and show that C. difficile sspA and sspB are required for the formation of the spore cortex layer. Moreover, using an EMS mutagenesis selection strategy, we identified mutations that suppressed the defect in sporulation of C. difficile SASP mutants. Many of these strains contained mutations in CDR20291_0714 (spoIVB2) revealing a connection between the SpoIVB2 protease and the SASPs in the sporulation pathway. This work builds upon the hypothesis that the small acid-soluble proteins can regulate gene expression.
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Affiliation(s)
- Hailee N. Nerber
- Department of Biology, Texas A&M University, College Station, TX 77845
| | - Marko Baloh
- Department of Biology, Texas A&M University, College Station, TX 77845
| | - Joshua N. Brehm
- Department of Biology, Texas A&M University, College Station, TX 77845
| | - Joseph A. Sorg
- Department of Biology, Texas A&M University, College Station, TX 77845
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4
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Liang Y, Meng Z, Ding XL, Jiang M. Effects of proton pump inhibitors on inflammatory bowel disease: An updated review. World J Gastroenterol 2024; 30:2751-2762. [PMID: 38899331 PMCID: PMC11185295 DOI: 10.3748/wjg.v30.i21.2751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/26/2024] [Accepted: 05/15/2024] [Indexed: 06/03/2024] Open
Abstract
Inflammatory bowel disease (IBD) is believed to be caused by various factors, including abnormalities in disease susceptibility genes, environmental factors, immune factors, and intestinal bacteria. Proton pump inhibitors (PPIs) are the primary drugs used to treat acid-related diseases. They are also commonly prescribed to patients with IBD. Recent studies have suggested a potential association between the use of certain medications, such as PPIs, and the occurrence and progression of IBD. In this review, we summarize the potential impact of PPIs on IBD and analyze the underlying mechanisms. Our findings may provide insights for conducting further investigations into the effects of PPIs on IBD and serve as an important reminder for physicians to exercise caution when prescribing PPIs to patients with IBD.
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Affiliation(s)
- Yu Liang
- Department of Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Zhen Meng
- Department of Intervention, The Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Xue-Li Ding
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Man Jiang
- Department of Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
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5
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Wetzel D, Carter ZA, Monteiro MP, Edwards AN, Scharer CD, McBride SM. The pH-responsive SmrR-SmrT system modulates C. difficile antimicrobial resistance, spore formation, and toxin production. Infect Immun 2024; 92:e0046123. [PMID: 38345371 PMCID: PMC10929453 DOI: 10.1128/iai.00461-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/23/2024] [Indexed: 02/27/2024] Open
Abstract
Clostridioides difficile is an anaerobic gastrointestinal pathogen that spreads through the environment as dormant spores. To survive, replicate, and sporulate in the host intestine, C. difficile must adapt to a variety of conditions in its environment, including changes in pH, the availability of metabolites, host immune factors, and a diverse array of other species. Prior studies showed that changes in intestinal conditions, such as pH, can affect C. difficile toxin production, spore formation, and cell survival. However, little is understood about the specific genes and pathways that facilitate environmental adaptation and lead to changes in C. difficile cell outcomes. In this study, we investigated two genes, CD2505 and CD2506, that are differentially regulated by pH to determine if they impact C. difficile growth and sporulation. Using deletion mutants, we examined the effects of both genes (herein smrR and smrT) on sporulation frequency, toxin production, and antimicrobial resistance. We determined that SmrR is a repressor of smrRT that responds to pH and suppresses sporulation and toxin production through regulation of the SmrT transporter. Further, we showed that SmrT confers resistance to erythromycin and lincomycin, establishing a connection between the regulation of sporulation and antimicrobial resistance.IMPORTANCEClostridioides difficile is a mammalian pathogen that colonizes the large intestine and produces toxins that lead to severe diarrheal disease. C. difficile is a major threat to public health due to its intrinsic resistance to antimicrobials and its ability to form dormant spores that are easily spread from host to host. In this study, we examined the contribution of two genes, smrR and smrT, on sporulation, toxin production, and antimicrobial resistance. Our results indicate that SmrR represses smrT expression, while production of SmrT increases spore and toxin production, as well as resistance to antibiotics.
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Affiliation(s)
- Daniela Wetzel
- Department of Microbiology and Immunology, Emory University School of Medicine, Emory Antibiotic Resistance Center, Atlanta, Georgia, USA
| | - Zavier A. Carter
- Department of Microbiology and Immunology, Emory University School of Medicine, Emory Antibiotic Resistance Center, Atlanta, Georgia, USA
| | - Marcos P. Monteiro
- Department of Microbiology and Immunology, Emory University School of Medicine, Emory Antibiotic Resistance Center, Atlanta, Georgia, USA
| | - Adrianne N. Edwards
- Department of Microbiology and Immunology, Emory University School of Medicine, Emory Antibiotic Resistance Center, Atlanta, Georgia, USA
| | - Christopher D. Scharer
- Department of Microbiology and Immunology, Emory University School of Medicine, Emory Antibiotic Resistance Center, Atlanta, Georgia, USA
| | - Shonna M. McBride
- Department of Microbiology and Immunology, Emory University School of Medicine, Emory Antibiotic Resistance Center, Atlanta, Georgia, USA
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6
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Wetzel D, Carter ZA, Monteiro MP, Edwards AN, McBride SM. The pH-responsive SmrR-SmrT system modulates C. difficile antimicrobial resistance, spore formation, and toxin production. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.11.02.565354. [PMID: 37961610 PMCID: PMC10635087 DOI: 10.1101/2023.11.02.565354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Clostridioides difficile is an anaerobic gastrointestinal pathogen that spreads through the environment as dormant spores. To survive, replicate, and sporulate in the host intestine, C. difficile must adapt to a variety of conditions in its environment, including changes in pH, the availability of metabolites, host immune factors, and a diverse array of other species. Prior studies showed that changes in intestinal conditions, such as pH, can affect C. difficile toxin production, spore formation, and cell survival. However, little is understood about the specific genes and pathways that facilitate environmental adaptation and lead to changes in C. difficile cell outcomes. In this study, we investigated two genes, CD2505 and CD2506, that are differentially regulated by pH to determine if they impact C. difficile growth and sporulation. Using deletion mutants, we examined the effects of both genes (herein smrR and smrT ) on sporulation frequency, toxin production, and antimicrobial resistance. We determined that SmrR is a repressor of smrRT that responds to pH and suppresses sporulation and toxin production through regulation of the SmrT transporter. Further, we showed that SmrT confers resistance to erythromycin and lincomycin, establishing a connection between the regulation of sporulation and antimicrobial resistance. IMPORTANCE C. difficile is a mammalian pathogen that colonizes the large intestine and produces toxins that lead to severe diarrheal disease. C. difficile is a major threat to public health due to its intrinsic resistance to antimicrobials and its ability to form dormant spores that are easily spread from host to host. In this study, we examined the contribution of two genes, smrR and smrT on sporulation, toxin production, and antimicrobial resistance. Our results indicate that SmrR represses smrT expression, while production of SmrT increases spore and toxin production, as well as resistance to antibiotics.
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7
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Moore JH, Salahi A, Honrado C, Warburton C, Tate S, Warren CA, Swami NS. Correlating Antibiotic-Induced Dysbiosis to Clostridioides difficile Spore Germination and Host Susceptibility to Infection Using an Ex Vivo Assay. ACS Infect Dis 2023; 9:1878-1888. [PMID: 37756389 PMCID: PMC10581205 DOI: 10.1021/acsinfecdis.3c00192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Indexed: 09/29/2023]
Abstract
Antibiotic-induced microbiota disruption and its persistence create conditions for dysbiosis and colonization by opportunistic pathogens, such as those causing Clostridioides difficile (C. difficile) infection (CDI), which is the most severe hospital-acquired intestinal infection. Given the wide differences in microbiota across hosts and in their recovery after antibiotic treatments, there is a need for assays to assess the influence of dysbiosis and its recovery dynamics on the susceptibility of the host to CDI. Germination of C. difficile spores is a key virulence trait for the onset of CDI, which is influenced by the level of primary vs secondary bile acids in the intestinal milieu that is regulated by the microbiota composition. Herein, the germination of C. difficile spores in fecal supernatant from mice that are subject to varying degrees of antibiotic treatment is utilized as an ex vivo assay to predict intestinal dysbiosis in the host based on their susceptibility to CDI, as determined by in vivo CDI metrics in the same mouse model. Quantification of spore germination down to lower detection limits than the colony-forming assay is achieved by using impedance cytometry to count single vegetative bacteria that are identified based on their characteristic electrical physiology for distinction vs aggregated spores and cell debris in the media. As a result, germination can be quantified at earlier time points and with fewer spores for correlation to CDI outcomes. This sets the groundwork for a point-of-care tool to gauge the susceptibility of human microbiota to CDI after antibiotic treatments.
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Affiliation(s)
- John H. Moore
- Electrical
and Computer Engineering, University of
Virginia, Charlottesville, Virginia 22904, United States
| | - Armita Salahi
- Electrical
and Computer Engineering, University of
Virginia, Charlottesville, Virginia 22904, United States
| | - Carlos Honrado
- Electrical
and Computer Engineering, University of
Virginia, Charlottesville, Virginia 22904, United States
| | - Christopher Warburton
- Electrical
and Computer Engineering, University of
Virginia, Charlottesville, Virginia 22904, United States
| | - Steven Tate
- Electrical
and Computer Engineering, University of
Virginia, Charlottesville, Virginia 22904, United States
| | - Cirle A. Warren
- Infectious
Diseases, School of Medicine, University
of Virginia, Charlottesville, Virginia 22903, United States
| | - Nathan S. Swami
- Electrical
and Computer Engineering, University of
Virginia, Charlottesville, Virginia 22904, United States
- Chemistry, University
of Virginia, Charlottesville, Virginia 22904, United States
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Edinoff AN, Wu NW, Parker K, Dudossat E, Linquest L, Flanagan CJ, Dharani A, Patel H, Willett O, Cornett EM, Kaye AM, Kaye AD. Proton Pump Inhibitors, Kidney Damage, and Mortality: An Updated Narrative Review. Adv Ther 2023; 40:2693-2709. [PMID: 37140707 PMCID: PMC10157135 DOI: 10.1007/s12325-023-02476-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/20/2023] [Indexed: 05/05/2023]
Abstract
Since their approval by the Food and Drug Administration (FDA) in 1989, proton pump inhibitors (PPIs) have become one of the most highly utilized drugs in the United States, assuming a position as one of the top 10 most prescribed medications in the country. The purpose of PPIs is to limit the amount of gastric acid secreted by the parietal cells via irreversible inhibition of the H+/K+-ATPase pump, therefore maintaining an elevated gastric acid pH of greater than 4 for 15-21 h. Even though PPIs have many clinical uses, they are not without their adverse effects, mimicking achlorhydria. Besides electrolyte abnormalities and vitamin deficiencies, long-term use of PPIs has been linked to acute interstitial nephritis, bone fractures, poor COVID-19 infection outcomes, pneumonia, and possibly an increase in all-cause mortality. The causality between PPI use and increased mortality and disease risk can be questioned since most studies are observational. Confounding variables can greatly affect an observational study and explain the wide-ranging associations with the use of PPIs. Patients on PPIs are generally older, obese, sicker with a higher number of baseline morbidities, and on more medications than the compared PPI non-users. These findings suggest that PPI users are at a higher risk of mortality and complications based on pre-existing conditions. This narrative review aims to update readers on the concerning effects that proton pump inhibitor use can have on patients and give providers a resource to create informed decisions on appropriate PPI use.
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Affiliation(s)
- Amber N. Edinoff
- Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114 USA
| | - Natalie W. Wu
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA 71103 USA
| | - Katelyn Parker
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA 71103 USA
| | - Edwin Dudossat
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA 71103 USA
| | - Lauren Linquest
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA 71103 USA
| | - Chelsi J. Flanagan
- School of Osteopathic Medicine, University of the Incarnate Word, San Antonio, USA
| | - Anam Dharani
- School of Osteopathic Medicine, University of the Incarnate Word, San Antonio, USA
| | - Hirni Patel
- Louisiana State University Health Sciences Center at Shreveport, LSU New Orleans, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA 71130-3932, 71103 USA
| | - Olga Willett
- Louisiana State University Health Sciences Center at Shreveport, LSU New Orleans, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA 71130-3932, 71103 USA
| | - Elyse M. Cornett
- Louisiana State University Health Sciences Center at Shreveport, LSU New Orleans, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA 71130-3932, 71103 USA
| | - Adam M. Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA 95211 USA
| | - Alan D. Kaye
- Louisiana State University Health Sciences Center at Shreveport, LSU New Orleans, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA 71130-3932, 71103 USA
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Freier L, Zacharias N, Gemein S, Gebel J, Engelhart S, Exner M, Mutters NT. Environmental Contamination and Persistence of Clostridioides difficile in Hospital Wastewater Systems. Appl Environ Microbiol 2023; 89:e0001423. [PMID: 37071016 PMCID: PMC10231184 DOI: 10.1128/aem.00014-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/28/2023] [Indexed: 04/19/2023] Open
Abstract
Clostridioides difficile produces an environmentally resistant dormant spore morphotype that infected patients shed to the hospital environment. C. difficile spores persist in clinical reservoirs that are not targeted by hospital routine cleaning protocols. Transmissions and infections from these reservoirs present a hazard to patient safety. This study aimed to assess the impact of patients acutely suffering from C. difficile-associated diarrhea (CDAD) on C. difficile environmental contamination to identify potential reservoirs. Twenty-three hospital rooms accommodating CDAD inpatients with corresponding soiled workrooms of 14 different wards were studied in a German maximum-care hospital. Additionally, four rooms that never accommodated CDAD patients were examined as negative controls. Stagnant water and biofilms from sinks, toilets, and washer disinfector (WD) traps as well as swabs from cleaned bedpans and high-touch surfaces (HTSs) were sampled. For detection, a culture method was used with selective medium. A latex agglutination assay and a Tox A/B enzyme-linked immunosorbent assay were performed with suspect colonies. Stagnant water and biofilms in hospital traps (29%), WDs (34%), and HTSs (37%) were found to be reservoirs for large amounts of C. difficile during the stay of CDAD inpatients that decreased but could persist 13 ± 6 days after their discharge (13%, 14%, and 9.5%, respectively). Control rooms showed none or only slight contamination restricted to WDs. A short-term cleaning strategy was implemented that reduced C. difficile in stagnant water almost entirely. IMPORTANCE Wastewater pipes are microbial ecosystems. The potential risk of infection emanating from the wastewater for individuals is often neglected, since it is perceived to remain in the pipes. However, sewage systems start with siphons and are thus naturally connected to the outside world. Wastewater pathogens do not only flow unidirectionally to wastewater treatment plants but also retrogradely, e.g., through splashing water from siphons to the hospital environment. This study focused on the pathogen C. difficile, which can cause severe and sometimes fatal diarrheas. This study shows how patients suffering from such diarrheas contaminate the hospital environment with C. difficile and that contamination persists in siphon habitats after patient discharge. This might pose a health risk for hospitalized patients afterward. Since this pathogen's spore morphotype is very environmentally resistant and difficult to disinfect, we show a cleaning measure that can almost entirely eliminate C. difficile from siphons.
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Affiliation(s)
- Lia Freier
- Institute for Hygiene and Public Health, University Hospital Bonn, Bonn, Germany
| | - Nicole Zacharias
- Institute for Hygiene and Public Health, University Hospital Bonn, Bonn, Germany
| | - Stefanie Gemein
- Institute for Hygiene and Public Health, University Hospital Bonn, Bonn, Germany
- Reference Institute for Bioanalytics, Bonn, Germany
| | - Jürgen Gebel
- Institute for Hygiene and Public Health, University Hospital Bonn, Bonn, Germany
| | - Steffen Engelhart
- Institute for Hygiene and Public Health, University Hospital Bonn, Bonn, Germany
| | - Martin Exner
- Institute for Hygiene and Public Health, University Hospital Bonn, Bonn, Germany
| | - Nico T. Mutters
- Institute for Hygiene and Public Health, University Hospital Bonn, Bonn, Germany
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Soldavini Pelichotti PC, Cejas D, Fernández-Caniggia L, Trejo FM, Pérez PF. Characterization of a Clostridioides difficile ST-293 isolate from a recurrent infection in Argentina. Rev Argent Microbiol 2023:S0325-7541(22)00102-X. [PMID: 36599754 DOI: 10.1016/j.ram.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/30/2022] [Accepted: 09/27/2022] [Indexed: 01/03/2023] Open
Abstract
Clostridioides difficile is an opportunistic spore-forming pathogen responsible for antibiotic-associated diarrhea in humans. C. difficile produces two main toxins: TcdA and TcdB as well as a third toxin named binary toxin (CDT) that is also involved in virulence. The present study aimed at characterizing the C. difficile isolate ALCD3 involved in a relapse episode of nosocomial infection. Molecular characterization showed that isolate ALCD3 belongs to toxinotype 0/v and the MLST analysis demonstrated allelic profile adk:91, atpA:1, dxr:2, glyA: 1, recA:27, sodA: 1 and tpi:1 which corresponds to ST293 (MLST clade: 1). During growth, isolate ALCD3 showed an early increase in the sporulation ratio as well as maximal values of heat resistant forms after 2 days of incubation. Both sporulation kinetics and production of heat resistant forms were faster for isolate ALCD3 than for the reference strain VPI 10463. Germination in the presence of the natural germinant taurocholate was faster for isolate ALCD3 than for strain VPI 10463, which indicates that isolate ALCD3 starts cortex hydrolysis earlier than strain VPI 10463. Furthermore, the co-germinant glycine, induces rapid release of dipicolinic acid (DPA) in isolate ALCD3. These findings indicate that isolate ALCD3 is particularly efficient in both sporulation and germination. The present work represents the first report of the circulation of C. difficile ST293 in Argentina. The ability of isolate ALCD3 to produce toxins and its high sporulation/germination capacity are key features compatible with a microorganism with high dissemination potential and the possibility of inducing recurrent infections.
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Affiliation(s)
- P Cecilia Soldavini Pelichotti
- Cátedra de Microbiología, Facultad de Ciencias Exactas, Universidad Nacional de La Plata, Calle 47 y 115, La Plata, Argentina; Centro de Investigación y Desarrollo en Criotecnología de Alimentos, CCT La Plata, CONICET-UNLP, 47 y 116 (s/n), La Plata B1900AJI, Argentina
| | - Daniela Cejas
- Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Instituto de Investigaciones en Bacteriología y Virología Molecular (IBaViM), Ciudad Autónoma de Buenos Aires, Argentina; Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Argentina
| | - Liliana Fernández-Caniggia
- Laboratorio de Microbiología, Hospital Alemán, Av. Pueyrredón 1640, Ciudad Autónoma de Buenos Aires, Argentina
| | - Fernando M Trejo
- Cátedra de Microbiología, Facultad de Ciencias Exactas, Universidad Nacional de La Plata, Calle 47 y 115, La Plata, Argentina
| | - Pablo F Pérez
- Cátedra de Microbiología, Facultad de Ciencias Exactas, Universidad Nacional de La Plata, Calle 47 y 115, La Plata, Argentina; Centro de Investigación y Desarrollo en Criotecnología de Alimentos, CCT La Plata, CONICET-UNLP, 47 y 116 (s/n), La Plata B1900AJI, Argentina.
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11
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Aguirre AM, Adegbite AO, Sorg JA. Clostridioides difficile bile salt hydrolase activity has substrate specificity and affects biofilm formation. NPJ Biofilms Microbiomes 2022; 8:94. [PMID: 36450806 PMCID: PMC9712596 DOI: 10.1038/s41522-022-00358-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 11/14/2022] [Indexed: 12/02/2022] Open
Abstract
The Clostridioides difficile pathogen is responsible for nosocomial infections. Germination is an essential step for the establishment of C. difficile infection (CDI) because toxins that are secreted by vegetative cells are responsible for the symptoms of CDI. Germination can be stimulated by the combinatorial actions of certain amino acids and either conjugated or deconjugated cholic acid-derived bile salts. During synthesis in the liver, cholic acid- and chenodeoxycholic acid-class bile salts are conjugated with either taurine or glycine at the C24 carboxyl. During GI transit, these conjugated bile salts are deconjugated by microbes that express bile salt hydrolases (BSHs). Here, we surprisingly find that several C. difficile strains have BSH activity. We observed this activity in both C. difficile vegetative cells and in spores and that the observed BSH activity was specific to taurine-derived bile salts. Additionally, we find that this BSH activity can produce cholate for metabolic conversion to deoxycholate by C. scindens. The C. scindens-produced deoxycholate signals to C. difficile to initiate biofilm formation. Our results show that C. difficile BSH activity has the potential to influence the interactions between microbes, and this could extend to the GI setting.
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Affiliation(s)
| | | | - Joseph A Sorg
- Department of Biology, Texas A&M University, College Station, TX, 77843, USA.
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12
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Abstract
Clostridioides difficile spores are the infective form for this endospore-forming organism. The vegetative cells are intolerant to oxygen and poor competitors with a healthy gut microbiota. Therefore, in order for C. difficile to establish infection, the spores have to germinate in an environment that supports vegetative growth. To initiate germination, C. difficile uses Csp-type germinant receptors that consist of the CspC and CspA pseudoproteases as the bile acid and cogerminant receptors, respectively. CspB is a subtilisin-like protease that cleaves the inhibitory propeptide from the pro-SleC cortex lytic enzyme, thereby activating it and initiating cortex degradation. Though several locations have been proposed for where these proteins reside within the spore (i.e., spore coat, outer spore membrane, cortex, and inner spore membrane), these have been based, mostly, on hypotheses or prior data in Clostridium perfringens. In this study, we visualized the germination and outgrowth process using transmission electron microscopy (TEM) and scanning electron microscopy (SEM) and used immunogold labeling to visualize key germination regulators. These analyses localize these key regulators to the spore cortex region for the first time. IMPORTANCE Germination by C. difficile spores is the first step in the establishment of potentially life-threatening C. difficile infection (CDI). A deeper understanding of the mechanism by which spores germinate may provide insight for how to either prevent spore germination into a disease-causing vegetative form or trigger germination prematurely when the spore is either in the outside environment or in a host environment that does not support the establishment of colonization/disease.
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Gut Microbiota Composition Associated with Clostridioides difficile Colonization and Infection. Pathogens 2022; 11:pathogens11070781. [PMID: 35890026 PMCID: PMC9322938 DOI: 10.3390/pathogens11070781] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/01/2022] [Accepted: 07/05/2022] [Indexed: 12/12/2022] Open
Abstract
Clostridioides difficile is an anaerobic Gram-positive and spore-forming bacterium. The majority of C. difficile strains produce two toxins, A and B, associated with the development of acute diarrhea and/or colitis. In this review, two situations are distinguished: C. difficile infection (CDI) and asymptomatic colonization (AC). The main objective of this review is to explore the available data related to the link between the gut microbiota and the development of CDI. The secondary aim is to provide more information on why some people colonized with toxigenic C. difficile develop an infection while others show no signs of disease. Several factors, such as the use of antibiotics and proton pump inhibitors, hospitalization, and age, predispose individuals to C. difficile colonization and/or C. difficile infection. The gut microbiota of people with AC showed decreased abundances of Prevotella, Alistipes, Bacteroides, Bifidobacterium, Dorea, Coprococcus, and Roseburia. The gut microbiota of people suffering from CDI showed reductions in the abundances of Lachnospiraceae, Ruminococcaceae, Blautia spp., Prevotella spp., Dialister spp., Bifidobacterium spp., Roseburia spp., Anaerostipes spp., Faecalibacterium spp. and Coprococcus spp., in comparison with healthy people. Furthermore, increases in the abundances of Enterococcaceae and Enterococcus were associated with C. difficile infection.
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14
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Jabłońska-Trypuć A, Makuła M, Włodarczyk-Makuła M, Wołejko E, Wydro U, Serra-Majem L, Wiater J. Inanimate Surfaces as a Source of Hospital Infections Caused by Fungi, Bacteria and Viruses with Particular Emphasis on SARS-CoV-2. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:8121. [PMID: 35805776 PMCID: PMC9265696 DOI: 10.3390/ijerph19138121] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 02/01/2023]
Abstract
The carriers of nosocomial infections are the hands of medical personnel and inanimate surfaces. Both hands and surfaces may be contaminated as a result of contact with the patient, their body fluids, and touching contaminated surfaces in the patient's surroundings. Visually clean inanimate surfaces are an important source of pathogens. Microorganisms have properties thanks to which they can survive in unfavorable conditions, from a few days to several months. Bacteria, viruses and fungi are able to transmit from inanimate surfaces to the skin of the patient and the medical staff. These pathogens include SARS-CoV-2, which can survive on various types of inanimate surfaces, being a potential source of infection. By following the recommendations related to washing and disinfecting hands and surfaces, and using appropriate washing and disinfecting agents with a broad biocidal spectrum, high material compatibility and the shortest duration of action, we contribute to breaking the chain of nosocomial infections.
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Affiliation(s)
- Agata Jabłońska-Trypuć
- Department of Chemistry, Biology and Biotechnology, Faculty of Civil Engineering and Environmental Sciences, Bialystok University of Technology, Wiejska 45E Street, 15-351 Białystok, Poland; (E.W.); (U.W.)
| | - Marcin Makuła
- Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Traugutta sq.2, 41-800 Zabrze, Poland;
| | - Maria Włodarczyk-Makuła
- Faculty of Infrastructure and Environment, Częstochowa University of Technology, 69 Dabrowskiego Str., 42-201 Częstochowa, Poland;
| | - Elżbieta Wołejko
- Department of Chemistry, Biology and Biotechnology, Faculty of Civil Engineering and Environmental Sciences, Bialystok University of Technology, Wiejska 45E Street, 15-351 Białystok, Poland; (E.W.); (U.W.)
| | - Urszula Wydro
- Department of Chemistry, Biology and Biotechnology, Faculty of Civil Engineering and Environmental Sciences, Bialystok University of Technology, Wiejska 45E Street, 15-351 Białystok, Poland; (E.W.); (U.W.)
| | - Lluis Serra-Majem
- Research Institute of Biomedical and Health Sciences, University of Las Palmas de Gran Canaria, 35001 Las Palmas de Gran Canaria, Spain;
| | - Józefa Wiater
- Department of Agri-Food Engineering and Environmental Management, Faculty of Civil Engineering and Environmental Sciences, Bialystok University of Technology, Wiejska 45E Street, 15-351 Białystok, Poland;
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15
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Tan C, Zhu F, Xiao Y, Wu Y, Meng X, Liu S, Liu T, Chen S, Zhou J, Li C, Wu A. Immunoinformatics Approach Toward the Introduction of a Novel Multi-Epitope Vaccine Against Clostridium difficile. Front Immunol 2022; 13:887061. [PMID: 35720363 PMCID: PMC9204425 DOI: 10.3389/fimmu.2022.887061] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/05/2022] [Indexed: 11/13/2022] Open
Abstract
Clostridium difficile (C.difficile) is an exclusively anaerobic, spore-forming, and Gram-positive pathogen that is the most common cause of nosocomial diarrhea and is becoming increasingly prevalent in the community. Because C. difficile is strictly anaerobic, spores that can survive for months in the external environment contribute to the persistence and diffusion of C. difficile within the healthcare environment and community. Antimicrobial therapy disrupts the natural intestinal flora, allowing spores to develop into propagules that colonize the colon and produce toxins, thus leading to antibiotic-associated diarrhea and pseudomembranous enteritis. However, there is no licensed vaccine to prevent Clostridium difficile infection (CDI). In this study, a multi-epitope vaccine was designed using modern computer methods. Two target proteins, CdeC, affecting spore germination, and fliD, affecting propagule colonization, were chosen to construct the vaccine so that it could simultaneously induce the immune response against two different forms (spore and propagule) of C. difficile. We obtained the protein sequences from the National Center for Biotechnology Information (NCBI) database. After the layers of filtration, 5 cytotoxic T-cell lymphocyte (CTL) epitopes, 5 helper T lymphocyte (HTL) epitopes, and 7 B-cell linear epitopes were finally selected for vaccine construction. Then, to enhance the immunogenicity of the designed vaccine, an adjuvant was added to construct the vaccine. The Prabi and RaptorX servers were used to predict the vaccine's two- and three-dimensional (3D) structures, respectively. Additionally, we refined and validated the structures of the vaccine construct. Molecular docking and molecular dynamics (MD) simulation were performed to check the interaction model of the vaccine-Toll-like receptor (TLR) complexes, vaccine-major histocompatibility complex (MHC) complexes, and vaccine-B-cell receptor (BCR) complex. Furthermore, immune stimulation, population coverage, and in silico molecular cloning were also conducted. The foregoing findings suggest that the final formulated vaccine is promising against the pathogen, but more researchers are needed to verify it.
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Affiliation(s)
- Caixia Tan
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
| | - Fei Zhu
- Center of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Yuanyuan Xiao
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
| | - Yuqi Wu
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
| | - Xiujuan Meng
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
| | - Sidi Liu
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
| | - Ting Liu
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
| | - Siyao Chen
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
| | - Juan Zhou
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
| | - Chunhui Li
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders (XiangYa Hospital), Changsha, China
| | - Anhua Wu
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders (XiangYa Hospital), Changsha, China
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16
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Park NY, Koh A. From the Dish to the Real World: Modeling Interactions between the Gut and Microorganisms in Gut Organoids by Tailoring the Gut Milieu. Int J Stem Cells 2022; 15:70-84. [PMID: 35220293 PMCID: PMC8889331 DOI: 10.15283/ijsc21243] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/25/2022] [Accepted: 01/26/2022] [Indexed: 11/11/2022] Open
Abstract
The advent of human intestinal organoid systems has revolutionized the way we understand the interactions between the human gut and microorganisms given the host tropism of human microorganisms. The gut microorganisms have regionality (i.e., small versus large intestine) and the expression of various virulence factors in pathogens is influenced by the gut milieu. However, the culture conditions, optimized for human intestinal organoids, often do not fully support the proliferation and functionality of gut microorganisms. In addition, the regional identity of human intestinal organoids has not been considered to study specific microorganisms with regional preference. In this review we provide an overview of current efforts to understand the role of microorganisms in human intestinal organoids. Specifically, we will emphasize the importance of matching the regional preference of microorganisms in the gut and tailoring the appropriate luminal environmental conditions (i.e., oxygen, pH, and biochemical levels) for modeling real interactions between the gut and the microorganisms with human intestinal organoids.
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Affiliation(s)
- Na-Young Park
- Department of Life Sciences, Pohang University of Science and Technology, Pohang, Korea
| | - Ara Koh
- Department of Life Sciences, Pohang University of Science and Technology, Pohang, Korea
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17
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Piotrowski M, Wultańska D, Pituch H. Effect of prebiotics on Bacteroides sp. adhesion and biofilm formation and synbiotic effect on Clostridioides difficile. Future Microbiol 2022; 17:363-375. [PMID: 35172601 DOI: 10.2217/fmb-2021-0206] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Aim: The objective of this study was to determine the effect of standard and candidate prebiotics on the adhesion and biofilm formation of Bacteroides sp. in monoculture and co-culture with Clostridioides difficile. Materials & methods: The effect of seven prebiotics on the adhesion and biofilm formation of Bacteroides sp. to three human cell lines was determined. The effect of Bacteroides sp. and fructooligosaccharides (FOS) on the adhesion and biofilm formation of C. difficile was tested by the co-incubation assay. Results: Inulin, mannose and raffinose presented the best anti-adhesion properties against Bacteroides sp. Combination of Bacteroides sp. with FOS decreased the adhesion of C. difficile. Conclusion: The study shows the potential role of prebiotics and synbiotics in decreasing the burden of C. difficile infections.
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Affiliation(s)
- Michał Piotrowski
- Department of Medical Microbiology, Medical University of Warsaw, Warsaw, 02-091, Poland
| | - Dorota Wultańska
- Department of Medical Microbiology, Medical University of Warsaw, Warsaw, 02-091, Poland
| | - Hanna Pituch
- Department of Medical Microbiology, Medical University of Warsaw, Warsaw, 02-091, Poland
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18
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Aguirre AM, Sorg JA. Gut associated metabolites and their roles in Clostridioides difficile pathogenesis. Gut Microbes 2022; 14:2094672. [PMID: 35793402 PMCID: PMC9450991 DOI: 10.1080/19490976.2022.2094672] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/21/2022] [Indexed: 02/04/2023] Open
Abstract
The nosocomial pathogen Clostridioides difficile is a burden to the healthcare system. Gut microbiome disruption, most commonly by broad-spectrum antibiotic treatment, is well established to generate a state that is susceptible to CDI. A variety of metabolites produced by the host and/or gut microbiota have been shown to interact with C. difficile. Certain bile acids promote/inhibit germination while other cholesterol-derived compounds and amino acids used in the Stickland metabolic pathway affect growth and CDI colonization. Short chain fatty acids maintain intestinal barrier integrity and a myriad of other metabolic compounds are used as nutritional sources or used by C. difficile to inhibit or outcompete other bacteria in the gut. As the move toward non-antibiotic CDI treatment takes place, a deeper understanding of interactions between C. difficile and the host's gut microbiome and metabolites becomes more relevant.
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Affiliation(s)
| | - Joseph A. Sorg
- Department of Biology, Texas A&M University, College Station, TX, USA
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19
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Aguirre AM, Yalcinkaya N, Wu Q, Swennes A, Tessier ME, Roberts P, Miyajima F, Savidge T, Sorg JA. Bile acid-independent protection against Clostridioides difficile infection. PLoS Pathog 2021; 17:e1010015. [PMID: 34665847 PMCID: PMC8555850 DOI: 10.1371/journal.ppat.1010015] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 10/29/2021] [Accepted: 10/07/2021] [Indexed: 12/21/2022] Open
Abstract
Clostridioides difficile infections occur upon ecological / metabolic disruptions to the normal colonic microbiota, commonly due to broad-spectrum antibiotic use. Metabolism of bile acids through a 7α-dehydroxylation pathway found in select members of the healthy microbiota is regarded to be the protective mechanism by which C. difficile is excluded. These 7α-dehydroxylated secondary bile acids are highly toxic to C. difficile vegetative growth, and antibiotic treatment abolishes the bacteria that perform this metabolism. However, the data that supports the hypothesis that secondary bile acids protect against C. difficile infection is supported only by in vitro data and correlative studies. Here we show that bacteria that 7α-dehydroxylate primary bile acids protect against C. difficile infection in a bile acid-independent manner. We monoassociated germ-free, wildtype or Cyp8b1-/- (cholic acid-deficient) mutant mice and infected them with C. difficile spores. We show that 7α-dehydroxylation (i.e., secondary bile acid generation) is dispensable for protection against C. difficile infection and provide evidence that Stickland metabolism by these organisms consumes nutrients essential for C. difficile growth. Our findings indicate secondary bile acid production by the microbiome is a useful biomarker for a C. difficile-resistant environment but the microbiome protects against C. difficile infection in bile acid-independent mechanisms. Secondary bile acid production by the colonic microbiome strongly correlates with an environment that is resistant to C. difficile invasion. However, it remained unclear if these bile acids provided in vivo protection. Here, we show that members of the microbiome that generate secondary bile acids (e.g., C. scindens) protect against C. difficile disease independently of secondary bile acid generation. These results are important because efforts to restore colonization resistance (e.g., FMT or precision bacterial therapy) focus on restoring secondary bile acid generation. Instead, restoring the organisms that produce 5-aminovalerate or consume proline / glycine are more important.
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Affiliation(s)
- Andrea Martinez Aguirre
- Department of Biology, Texas A&M University, College Station, Texas, United States of America
| | - Nazli Yalcinkaya
- Baylor College of Medicine & Texas Children’s Hospital, Houston, Texas, United States of America
| | - Qinglong Wu
- Baylor College of Medicine & Texas Children’s Hospital, Houston, Texas, United States of America
| | - Alton Swennes
- Baylor College of Medicine & Texas Children’s Hospital, Houston, Texas, United States of America
| | - Mary Elizabeth Tessier
- Baylor College of Medicine & Texas Children’s Hospital, Houston, Texas, United States of America
| | - Paul Roberts
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom
| | - Fabio Miyajima
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom
- Oswaldo Cruz Foundation, Ceara branch, Fortaleza, Brazil
| | - Tor Savidge
- Baylor College of Medicine & Texas Children’s Hospital, Houston, Texas, United States of America
| | - Joseph A. Sorg
- Department of Biology, Texas A&M University, College Station, Texas, United States of America
- * E-mail:
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20
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Rosenberg V, Tzadok R, Chodick G, Kariv R. Proton pump inhibitors long term use-trends and patterns over 15 years of a large health maintenance organization. Pharmacoepidemiol Drug Saf 2021; 30:1576-1587. [PMID: 34453456 DOI: 10.1002/pds.5352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 08/05/2021] [Accepted: 08/25/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Proton pump inhibitors (PPI) are used for a variety of indications. Despite reported associations with undesirable effects, their long-term use is on the rise, while appropriate indications, dose, and treatment duration may deviate from guideline recommendations. OBJECTIVES Primary to examine the annual patterns of PPI use. Secondary- to assess indications for initiating PPI treatment, long-term use, and factors associated with long-term use in a large Israeli health maintenance organization. METHODS A historical cohort study of 528 420 eligible PPI users during 2000-2015, analyzed PPI use using defined daily doses and the proportion of patients covered method. Data on indications for treatment initiation, clinical and socio-demographic parameters were captured as well. A multivariable logistic-regression model was used to identify factors associated with long-term use of PPI. RESULTS The annual incidence rates of patients initiating PPI treatment were relatively constant, ranging between 2.4% and 3.1% of the adult population, with a monotonic increase in annual consumption and prevalence (reaching 12.7% in 2015). Reflux, functional symptoms, and Helicobacter pylori eradication were the most common indications for initiating PPI therapy. However, 27% of patients had no recorded indication for treatment. Fifteen percent of patients used PPI for over 6 months, especially in older age groups. CONCLUSIONS Utilization of PPI increases steadily, mainly due to chronic use. Prolonged consumption is associated with specific clinical indications and older age. Health organizations should encourage awareness of appropriate use among physicians, specifically in the elderly, patients with reflux, and those with functional disorders.
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Affiliation(s)
- Vered Rosenberg
- Kahn-Sagol-Maccabi Research and Innovation Institute, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Roie Tzadok
- Department of Internal Medicine H, Sourasky Medical Center, Tel Aviv, Israel
| | - Gabriel Chodick
- Kahn-Sagol-Maccabi Research and Innovation Institute, Maccabi Healthcare Services, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Revital Kariv
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Gastroenterology, Sourasky Medical Center, Tel Aviv, Israel
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21
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Opportunities for Nanomedicine in Clostridioides difficile Infection. Antibiotics (Basel) 2021; 10:antibiotics10080948. [PMID: 34438998 PMCID: PMC8388953 DOI: 10.3390/antibiotics10080948] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 07/30/2021] [Accepted: 08/03/2021] [Indexed: 12/19/2022] Open
Abstract
Clostridioides difficile, a spore-forming bacterium, is a nosocomial infectious pathogen which can be found in animals as well. Although various antibiotics and disinfectants were developed, C. difficile infection (CDI) remains a serious health problem. C. difficile spores have complex structures and dormant characteristics that contribute to their resistance to harsh environments, successful transmission and recurrence. C. difficile spores can germinate quickly after being exposed to bile acid and co-germinant in a suitable environment. The vegetative cells produce endospores, and the mature spores are released from the hosts for dissemination of the pathogen. Therefore, concurrent elimination of C. difficile vegetative cells and inhibition of spore germination is essential for effective control of CDI. This review focused on the molecular pathogenesis of CDI and new trends in targeting both spores and vegetative cells of this pathogen, as well as the potential contribution of nanotechnologies for the effective management of CDI.
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22
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Persistence of Pathogens on Inanimate Surfaces: A Narrative Review. Microorganisms 2021; 9:microorganisms9020343. [PMID: 33572303 PMCID: PMC7916105 DOI: 10.3390/microorganisms9020343] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/27/2021] [Accepted: 02/01/2021] [Indexed: 12/21/2022] Open
Abstract
For the prevention of infectious diseases, knowledge about transmission routes is essential. In addition to respiratory, fecal-oral, and sexual transmission, the transfer of pathogens via surfaces plays a vital role for human pathogenic infections-especially nosocomial pathogens. Therefore, information about the survival of pathogens on surfaces can have direct implications on clinical measures, including hygiene guidelines and disinfection strategies. In this review, we reviewed the existing literature regarding viral, bacterial, and fungal persistence on inanimate surfaces. In particular, the current knowledge of the survival time and conditions of clinically relevant pathogens is summarized. While many pathogens persist only for hours, common nosocomial pathogens can survive for days to weeks under laboratory conditions and thereby potentially form a continuous source of transmission if no adequate inactivation procedures are performed.
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23
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Dharmasena M, Wang H, Wei T, Bridges WC, Jiang X. Survival of Clostridioides difficile in finished dairy compost under controlled conditions. J Appl Microbiol 2021; 131:996-1006. [PMID: 33450103 DOI: 10.1111/jam.15001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/01/2020] [Accepted: 01/07/2021] [Indexed: 12/01/2022]
Abstract
AIM The survival of Clostridioides difficile (previously Clostridium difficile) vegetative cells and endospores was compared at different levels of indigenous microflora using autoclaved and unautoclaved dairy composts with different moisture contents (MCs). METHODS AND RESULTS Both types of composts adjusted to 20, 30 and 40% MCs were inoculated with a suspension of C. difficile that contained both vegetative cells (c. 5-6 log CFU per gram) and endospores (c. 5·0 CFU per gram), and then stored aerobically inside a humidity-controlled chamber at room temperature 22·5 ± 0·8°C for 1 year. The level of indigenous microflora was very stable during the storage after day 7 in both types of compost. The greatest reductions of C. difficile vegetative cell counts occurred during the first 24 h of storage in autoclaved and unautoclaved composts, which had 4·7 and 5·5 log CFU per gram with 20% MC, 1·8 and 2·1 log CFU per gram with 30% MC, and 2·3 and 1·3 log CFU per gram with 40% MC, respectively. Both MC and the duration of storage have significant (P < 0·05) effects on the survival of vegetative cells for first 120 days of storage. The slow inactivation of C. difficile vegetative cells at higher MCs during aerobic storage was confirmed by exponentially decaying modelling data during the early stage of aerobic exposure. The reduction of endospore counts (<1·0 log CFU per gram) during the storage for both types of compost at all MCs was not significant (P > 0·05) except for the autoclaved compost with 30% MC. CONCLUSION The highly resistant C. difficile endospores to the unfavourable environmental conditions survived for more than a year while vegetative cells died off exponentially upon the initial aerobic exposure. SIGNIFICANCE AND IMPACT OF THE STUDY The long-term survival of C. difficile endospores in contaminated compost may transmit the pathogen to fresh produce, animals or water in pre-harvest conditions.
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Affiliation(s)
- M Dharmasena
- Department of Food, Nutrition, and Packaging Sciences, Clemson University, Clemson, SC, USA
| | - H Wang
- Department of Food, Nutrition, and Packaging Sciences, Clemson University, Clemson, SC, USA
| | - T Wei
- Department of Mathematical Sciences, Clemson University, Clemson, SC, USA
| | - W C Bridges
- Department of Mathematical Sciences, Clemson University, Clemson, SC, USA
| | - X Jiang
- Department of Food, Nutrition, and Packaging Sciences, Clemson University, Clemson, SC, USA
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Skinner AM, Petrella L, Siddiqui F, Sambol SP, Gulvik CA, Gerding DN, Donskey CJ, Johnson S. Unique Clindamycin-Resistant Clostridioides difficile Strain Related to Fluoroquinolone-Resistant Epidemic BI/RT027 Strain. Emerg Infect Dis 2021; 26:247-254. [PMID: 31961290 PMCID: PMC6986856 DOI: 10.3201/eid2602.181965] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
During a surveillance study of patients in a long-term care facility and the affiliated acute care hospital in the United States, we identified a Clostridioides difficile strain related to the epidemic PCR ribotype (RT) 027 strain associated with hospital outbreaks of severe disease. Fifteen patients were infected with this strain, characterized as restriction endonuclease analysis group DQ and RT591. Like RT027, DQ/RT591 contained genes for toxin B and binary toxin CDT and a tcdC gene of identical sequence. Whole-genome sequencing and multilocus sequence typing showed that DQ/RT591 is a member of the same multilocus sequence typing clade 2 as RT027 but in a separate cluster. DQ/RT591 produced a similar cytopathic effect as RT027 but showed delayed toxin production in vitro. DQ/RT591 was susceptible to moxifloxacin but highly resistant to clindamycin. Continued surveillance is warranted for this clindamycin-resistant strain that is related to the fluoroquinolone-resistant epidemic RT027 strain.
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25
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McSharry S, Koolman L, Whyte P, Bolton D. An investigation of the survival and/or growth of Clostridioides (Clostridium) difficile in beef stored under aerobic, anaerobic and commercial vacuum packaging conditions at 2 °C and 20 °C. Food Control 2021. [DOI: 10.1016/j.foodcont.2020.107475] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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26
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Werner M, Suchodolski JS, Lidbury JA, Steiner JM, Hartmann K, Unterer S. Diagnostic value of fecal cultures in dogs with chronic diarrhea. J Vet Intern Med 2020; 35:199-208. [PMID: 33277779 PMCID: PMC7848338 DOI: 10.1111/jvim.15982] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/15/2020] [Accepted: 11/20/2020] [Indexed: 12/23/2022] Open
Abstract
Background Culture‐based assessment of the fecal microbiome using fecal culture profiles frequently is performed in dogs with chronic diarrhea, but the diagnostic value of this approach has not been determined. Objectives To compare the reported results of fecal culture profiles and the polymerase chain reaction‐based dysbiosis index (DI) between dogs with chronic diarrhea and healthy dogs; to assess interlaboratory variability in bacterial and fungal cultures among 3 veterinary diagnostic laboratories (diagnostic laboratory 1 [L1], diagnostic laboratory 2 [L2], diagnostic laboratory 3 [L3]); and to compare the reported interpretation of culture profiles (normobiosis versus dysbiosis) with those of the DI. Animals Eighteen dogs with chronic diarrhea (CDG) and 18 healthy control dogs (HG). Methods In this prospective, case‐control study, fecal samples were submitted to 3 commercial laboratories for fecal culture. The microbiota was assessed using PCR assays. Dogs receiving antimicrobials were excluded. Results Dysbiosis index was significantly increased in CDG (mean, 0.9; SD, 3.8; 95% confidence interval [CI], −1.0; 2.8) compared to HG (mean, −3.0; SD, 2.8; CI, −4.3; −1.6; P = .0002), whereas cultures from all laboratories failed to detect significant differences (P = .66, .18, and .66, respectively). Hemolytic Escherichia coli was the only potential enteropathogen on culture, but no significant difference was found between CDG and HG. For diagnosis of dysbiosis, culture showed no agreement with DI (L1, κ = −0.21; CI, −0.44; −0.02; L2, κ = −0.33; CI, −0.58; −0.08; L3, κ = −0.25; CI, −0.39; −0.11). Furthermore, variability among the 3 laboratories was high (L1/L2, κ = 0.15; CI, −0.05; 0.35; L1/L3, κ = −0.08; CI, −0.01; −0.16; L2/L3, κ = −0.06; CI, −0.33; −0.20). Conclusions and clinical importance Fecal cultures failed to distinguish between diseased and healthy dogs, and a high level of interlaboratory variation for culture was found.
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Affiliation(s)
- Melanie Werner
- Clinic of Small Animal Internal Medicine, Centre for Clinical Veterinary Medicine, LMU, Munich, Germany
| | - Jan S Suchodolski
- Gastrointestinal Laboratory, Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Jonathan A Lidbury
- Gastrointestinal Laboratory, Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Jörg M Steiner
- Gastrointestinal Laboratory, Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Katrin Hartmann
- Clinic of Small Animal Internal Medicine, Centre for Clinical Veterinary Medicine, LMU, Munich, Germany
| | - Stefan Unterer
- Clinic of Small Animal Internal Medicine, Centre for Clinical Veterinary Medicine, LMU, Munich, Germany
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Principi N, Gnocchi M, Gagliardi M, Argentiero A, Neglia C, Esposito S. Prevention of Clostridium difficile Infection and Associated Diarrhea: An Unsolved Problem. Microorganisms 2020; 8:E1640. [PMID: 33114040 PMCID: PMC7690700 DOI: 10.3390/microorganisms8111640] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/18/2020] [Accepted: 10/19/2020] [Indexed: 02/08/2023] Open
Abstract
For many years, it has been known that Clostridium difficile (CD) is the primary cause of health-care-associated infectious diarrhea, afflicting approximately 1% of hospitalized patients. CD may be simply carried or lead to a mild disease, but in a relevant number of patients, it can cause a very severe, potentially fatal, disease. In this narrative review, the present possibilities of CD infection (CDI) prevention will be discussed. Interventions usually recommended for infection control and prevention can be effective in reducing CDI incidence. However, in order to overcome limitations of these measures and reduce the risk of new CDI episodes, novel strategies have been developed. As most of the cases of CDI follow antibiotic use, attempts to rationalize antibiotic prescriptions have been implemented. Moreover, to reconstitute normal gut microbiota composition and suppress CD colonization in patients given antimicrobial drugs, administration of probiotics has been suggested. Finally, active and passive immunization has been studied. Vaccines containing inactivated CD toxins or components of CD spores have been studied. Passive immunization with monoclonal antibodies against CD toxins or the administration of hyperimmune whey derived from colostrum or breast milk from immunized cows has been tried. However, most advanced methods have significant limitations as they cannot prevent colonization and development of primary CDI. Only the availability of vaccines able to face these problems can allow a resolutive approach to the total burden due to this pathogen.
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Affiliation(s)
| | - Margherita Gnocchi
- Pediatric Clinic, Pietro Barilla Children’s Hospital, University of Parma, 43126 Parma, Italy; (M.G.); (M.G.); (A.A.); (C.N.)
| | - Martina Gagliardi
- Pediatric Clinic, Pietro Barilla Children’s Hospital, University of Parma, 43126 Parma, Italy; (M.G.); (M.G.); (A.A.); (C.N.)
| | - Alberto Argentiero
- Pediatric Clinic, Pietro Barilla Children’s Hospital, University of Parma, 43126 Parma, Italy; (M.G.); (M.G.); (A.A.); (C.N.)
| | - Cosimo Neglia
- Pediatric Clinic, Pietro Barilla Children’s Hospital, University of Parma, 43126 Parma, Italy; (M.G.); (M.G.); (A.A.); (C.N.)
| | - Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children’s Hospital, University of Parma, 43126 Parma, Italy; (M.G.); (M.G.); (A.A.); (C.N.)
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Li S, Yang Z, Hu D, Cao L, He Q. Understanding building-occupant-microbiome interactions toward healthy built environments: A review. FRONTIERS OF ENVIRONMENTAL SCIENCE & ENGINEERING 2020; 15:65. [PMID: 33145119 PMCID: PMC7596174 DOI: 10.1007/s11783-020-1357-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 08/30/2020] [Accepted: 09/16/2020] [Indexed: 06/11/2023]
Abstract
Built environments, occupants, and microbiomes constitute a system of ecosystems with extensive interactions that impact one another. Understanding the interactions between these systems is essential to develop strategies for effective management of the built environment and its inhabitants to enhance public health and well-being. Numerous studies have been conducted to characterize the microbiomes of the built environment. This review summarizes current progress in understanding the interactions between attributes of built environments and occupant behaviors that shape the structure and dynamics of indoor microbial communities. In addition, this review also discusses the challenges and future research needs in the field of microbiomes of the built environment that necessitate research beyond the basic characterization of microbiomes in order to gain an understanding of the causal mechanisms between the built environment, occupants, and microbiomes, which will provide a knowledge base for the development of transformative intervention strategies toward healthy built environments. The pressing need to control the transmission of SARS-CoV-2 in indoor environments highlights the urgency and significance of understanding the complex interactions between the built environment, occupants, and microbiomes, which is the focus of this review.
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Affiliation(s)
- Shuai Li
- Department of Civil and Environmental Engineering, University of Tennessee, Knoxville, TN 37996 USA
| | - Zhiyao Yang
- Lyles School of Civil Engineering, Purdue University, West Lafayette, IN 47907 USA
| | - Da Hu
- Department of Civil and Environmental Engineering, University of Tennessee, Knoxville, TN 37996 USA
| | - Liu Cao
- Department of Civil and Environmental Engineering, University of Tennessee, Knoxville, TN 37996 USA
| | - Qiang He
- Department of Civil and Environmental Engineering, University of Tennessee, Knoxville, TN 37996 USA
- Institute for a Secure & Sustainable Environment, University of Tennessee, Knoxville, TN 37996 USA
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29
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Horve PF, Dietz LG, Ishaq SL, Kline J, Fretz M, Van Den Wymelenberg KG. Viable bacterial communities on hospital window components in patient rooms. PeerJ 2020; 8:e9580. [PMID: 33194331 PMCID: PMC7391968 DOI: 10.7717/peerj.9580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/30/2020] [Indexed: 01/04/2023] Open
Abstract
Previous studies demonstrate an exchange of bacteria between hospital room surfaces and patients, and a reduction in survival of microorganisms in dust inside buildings from sunlight exposure. While the transmission of microorganisms between humans and their local environment is a continuous exchange which generally does not raise cause for alarm, in a hospital setting with immunocompromised patients, these building-source microbial reservoirs may pose a risk. Window glass is often neglected during hospital disinfection protocols, and the microbial communities found there have not previously been examined. This pilot study examined whether living bacterial communities, and specifically the pathogens Methicillin-resistant Staphylococcus aureus (MRSA) and Clostridioides difficile (C. difficile), were present on window components of exterior-facing windows inside patient rooms, and whether relative light exposure (direct or indirect) was associated with changes in bacterial communities on those hospital surfaces. Environmental samples were collected from 30 patient rooms in a single ward at Oregon Health & Science University (OHSU) in Portland, Oregon, USA. Sampling locations within each room included the window glass surface, both sides of the window curtain, two surfaces of the window frame, and the air return grille. Viable bacterial abundances were quantified using qPCR, and community composition was assessed using Illumina MiSeq sequencing of the 16S rRNA gene V3/V4 region. Viable bacteria occupied all sampled locations, but was not associated with a specific hospital surface or relative sunlight exposure. Bacterial communities were similar between window glass and the rest of the room, but had significantly lower Shannon Diversity, theorized to be related to low nutrient density and resistance to bacterial attachment of glass compared to other surface materials. Rooms with windows that were facing west demonstrated a higher abundance of viable bacteria than those facing other directions, potentially because at the time of sampling (morning) west-facing rooms had not yet been exposed to sunlight that day. Viable C. difficile was not detected and viable MRSA was detected at very low abundance. Bacterial abundance was negatively correlated with distance from the central staff area containing the break room and nursing station. In the present study, it can be assumed that there is more human traffic in the center of the ward, and is likely responsible for the observed gradient of total abundance in rooms along the ward, as healthcare staff both deposit more bacteria during activities and affect microbial transit indoors. Overall, hospital window components possess similar microbial communities to other previously identified room locations known to act as reservoirs for microbial agents of hospital-associated infections.
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Affiliation(s)
- Patrick F Horve
- Biology and the Built Environment Center, University of Oregon, Eugene, OR, United States of America
| | - Leslie G Dietz
- Biology and the Built Environment Center, University of Oregon, Eugene, OR, United States of America
| | - Suzanne L Ishaq
- Biology and the Built Environment Center, University of Oregon, Eugene, OR, United States of America.,School of Food and Agriculture, University of Maine, Orono, ME, United States of America
| | - Jeff Kline
- Biology and the Built Environment Center, University of Oregon, Eugene, OR, United States of America
| | - Mark Fretz
- Institute for Health in the Built Environment, University of Oregon, Portland, OR, United States of America
| | - Kevin G Van Den Wymelenberg
- Biology and the Built Environment Center, University of Oregon, Eugene, OR, United States of America.,Institute for Health in the Built Environment, University of Oregon, Portland, OR, United States of America
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Moore JH, Salahi A, Honrado C, Warburton C, Warren CA, Swami NS. Quantifying bacterial spore germination by single-cell impedance cytometry for assessment of host microbiota susceptibility to Clostridioides difficile infection. Biosens Bioelectron 2020; 166:112440. [PMID: 32745926 DOI: 10.1016/j.bios.2020.112440] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/18/2020] [Accepted: 07/08/2020] [Indexed: 12/11/2022]
Abstract
The germination of ingested spores is often a necessary first step required for enabling bacterial outgrowth and host colonization, as in the case of Clostridioides difficile (C. difficile) infection. Spore germination rate in the colon depends on microbiota composition and its level of disruption by antibiotic treatment since secretions by commensal bacteria modulate primary to secondary bile salt levels to control germination. Assessment of C. difficile spore germination typically requires measurement of colony-forming units, which is labor intensive and takes at least 24 h to perform but is regularly required due to the high recurrence rates of nosocomial antibiotic-associated diarrhea. We present a rapid method to assess spore germination by using high throughput single-cell impedance cytometry (>300 events/s) to quantify live bacterial cells, by gating for their characteristic electrophysiology versus spores, so that germination can be assessed after just 4 h of culture at a detection limit of ~100 live cells per 50 μL sample. To detect the phenotype of germinated C. difficile bacteria, we utilize its characteristically higher net conductivity versus that of spore aggregates and non-viable C. difficile forms, which causes a distinctive high-frequency (10 MHz) impedance phase dispersion within moderately conductive media (0.8 S/m). In this manner, we can detect significant differences in spore germination rates within just 4 h, with increasing primary bile salt levels in vitro and using ex vivo microbiota samples from an antibiotic-treated mouse model to assess susceptibility to C. difficile infection. We envision a rapid diagnostic tool for assessing host microbiota susceptibility to bacterial colonization after key antibiotic treatments.
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Affiliation(s)
- John H Moore
- Electrical & Computer Engineering, University of Virginia, Charlottesville, VA, 22904, USA
| | - Armita Salahi
- Electrical & Computer Engineering, University of Virginia, Charlottesville, VA, 22904, USA
| | - Carlos Honrado
- Electrical & Computer Engineering, University of Virginia, Charlottesville, VA, 22904, USA
| | | | - Cirle A Warren
- Infectious Diseases, School of Medicine, University of Virginia, VA, 22904, USA
| | - Nathan S Swami
- Electrical & Computer Engineering, University of Virginia, Charlottesville, VA, 22904, USA.
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Sasaki T, Mori S, Kishi S, Fujiwara-Tani R, Ohmori H, Nishiguchi Y, Hojo Y, Kawahara I, Nakashima C, Fujii K, Luo Y, Kuniyasu H. Effect of Proton Pump Inhibitors on Colorectal Cancer. Int J Mol Sci 2020; 21:ijms21113877. [PMID: 32485921 PMCID: PMC7312442 DOI: 10.3390/ijms21113877] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/19/2020] [Accepted: 05/20/2020] [Indexed: 02/07/2023] Open
Abstract
Proton pump inhibitors (PPIs) are administered commonly to aged people; however, their effect on colorectal cancer (CRC) has still not been fully elucidated. Here, we examined the effect of PPIs and consequent alkalization on CRC cells. PPI administration alkalized the fecal pH and increased serum gastrin concentration. PPI and pH8 treatment (alkalization) of CMT93 mouse colon cancer cells inhibited cell growth and invasion, increased oxidative stress and apoptosis, and decreased mitochondrial volume and protein levels of cyclin D1 and phosphorylated extracellular signal-regulated kinase (pERK) 1/2. In contrast, gastrin treatment enhanced growth and invasion, decreased oxidative stress and apoptosis, and increased mitochondrial volume and cyclin D1 and pERK1/2 levels. Concurrent treatment with a PPI, pH8, and gastrin increased aldehyde dehydrogenase activity and also enhanced liver metastasis in the BALB/c strain of mice. PPI administration was associated with Clostridiumperfringens enterotoxin (CPE) in CRC lesions. CPE treatment activated yes-associated protein (YAP) signals to enhance proliferation and stemness. The orthotopic colon cancer model of CMT93 cells with long-term PPI administration showed enhanced tumor growth and liver metastasis due to gastrin and YAP activation, as indicated by gastrin receptor knockdown and treatment with a YAP inhibitor. These findings suggest that PPI promotes CRC growth and metastasis by increasing gastrin concentration and YAP activation, resulting in gut flora alteration and fecal alkalization. These findings suggest that PPI use in colorectal cancer patients might create a risk of cancer promotion.
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Affiliation(s)
- Takamitsu Sasaki
- Department of Molecular Pathology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8521, Japan; (T.S.); (S.M.); (S.K.); (R.F.-T.); (H.O.); (Y.N.); (Y.H.); (I.K.); (C.N.); (K.F.)
| | - Shiori Mori
- Department of Molecular Pathology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8521, Japan; (T.S.); (S.M.); (S.K.); (R.F.-T.); (H.O.); (Y.N.); (Y.H.); (I.K.); (C.N.); (K.F.)
| | - Shingo Kishi
- Department of Molecular Pathology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8521, Japan; (T.S.); (S.M.); (S.K.); (R.F.-T.); (H.O.); (Y.N.); (Y.H.); (I.K.); (C.N.); (K.F.)
| | - Rina Fujiwara-Tani
- Department of Molecular Pathology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8521, Japan; (T.S.); (S.M.); (S.K.); (R.F.-T.); (H.O.); (Y.N.); (Y.H.); (I.K.); (C.N.); (K.F.)
| | - Hitoshi Ohmori
- Department of Molecular Pathology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8521, Japan; (T.S.); (S.M.); (S.K.); (R.F.-T.); (H.O.); (Y.N.); (Y.H.); (I.K.); (C.N.); (K.F.)
| | - Yukiko Nishiguchi
- Department of Molecular Pathology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8521, Japan; (T.S.); (S.M.); (S.K.); (R.F.-T.); (H.O.); (Y.N.); (Y.H.); (I.K.); (C.N.); (K.F.)
| | - Yudai Hojo
- Department of Molecular Pathology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8521, Japan; (T.S.); (S.M.); (S.K.); (R.F.-T.); (H.O.); (Y.N.); (Y.H.); (I.K.); (C.N.); (K.F.)
| | - Isao Kawahara
- Department of Molecular Pathology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8521, Japan; (T.S.); (S.M.); (S.K.); (R.F.-T.); (H.O.); (Y.N.); (Y.H.); (I.K.); (C.N.); (K.F.)
| | - Chie Nakashima
- Department of Molecular Pathology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8521, Japan; (T.S.); (S.M.); (S.K.); (R.F.-T.); (H.O.); (Y.N.); (Y.H.); (I.K.); (C.N.); (K.F.)
| | - Kiyomu Fujii
- Department of Molecular Pathology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8521, Japan; (T.S.); (S.M.); (S.K.); (R.F.-T.); (H.O.); (Y.N.); (Y.H.); (I.K.); (C.N.); (K.F.)
| | - Yi Luo
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Nantong University, Nantong 226001, China
- Correspondence: (Y.L.); (H.K.); Tel.: +86-0513-85051805 (Y.L.); +81-744-22-3051 (H.K.); Fax: +81-744-25-7308 (H.K.)
| | - Hiroki Kuniyasu
- Department of Molecular Pathology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8521, Japan; (T.S.); (S.M.); (S.K.); (R.F.-T.); (H.O.); (Y.N.); (Y.H.); (I.K.); (C.N.); (K.F.)
- Correspondence: (Y.L.); (H.K.); Tel.: +86-0513-85051805 (Y.L.); +81-744-22-3051 (H.K.); Fax: +81-744-25-7308 (H.K.)
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Engevik MA, Danhof HA, Chang-Graham AL, Spinler JK, Engevik KA, Herrmann B, Endres BT, Garey KW, Hyser JM, Britton RA, Versalovic J. Human intestinal enteroids as a model of Clostridioides difficile-induced enteritis. Am J Physiol Gastrointest Liver Physiol 2020; 318:G870-G888. [PMID: 32223302 PMCID: PMC7272722 DOI: 10.1152/ajpgi.00045.2020] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Clostridioides difficile is an important nosocomial pathogen that produces toxins to cause life-threatening diarrhea and colitis. Toxins bind to epithelial receptors and promote the collapse of the actin cytoskeleton. C. difficile toxin activity is commonly studied in cancer-derived and immortalized cell lines. However, the biological relevance of these models is limited. Moreover, no model is available for examining C. difficile-induced enteritis, an understudied health problem. We hypothesized that human intestinal enteroids (HIEs) express toxin receptors and provide a new model to dissect C. difficile cytotoxicity in the small intestine. We generated biopsy-derived jejunal HIE and Vero cells, which stably express LifeAct-Ruby, a fluorescent label of F-actin, to monitor actin cytoskeleton rearrangement by live-cell microscopy. Imaging analysis revealed that toxins from pathogenic C. difficile strains elicited cell rounding in a strain-dependent manner, and HIEs were tenfold more sensitive to toxin A (TcdA) than toxin B (TcdB). By quantitative PCR, we paradoxically found that HIEs expressed greater quantities of toxin receptor mRNA and yet exhibited decreased sensitivity to toxins when compared with traditionally used cell lines. We reasoned that these differences may be explained by components, such as mucins, that are present in HIEs cultures, that are absent in immortalized cell lines. Addition of human-derived mucin 2 (MUC2) to Vero cells delayed cell rounding, indicating that mucus serves as a barrier to toxin-receptor binding. This work highlights that investigation of C. difficile infection in that HIEs can provide important insights into the intricate interactions between toxins and the human intestinal epithelium.NEW & NOTEWORTHY In this article, we developed a novel model of Clostridioides difficile-induced enteritis using jejunal-derived human intestinal enteroids (HIEs) transduced with fluorescently tagged F-actin. Using live-imaging, we identified that jejunal HIEs express high levels of TcdA and CDT receptors, are more sensitive to TcdA than TcdB, and secrete mucus, which delays toxin-epithelial interactions. This work also optimizes optically clear C. difficile-conditioned media suitable for live-cell imaging.
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Affiliation(s)
- Melinda A. Engevik
- 1Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas,2Department of Pathology, Texas Children’s Hospital, Houston, Texas
| | - Heather A. Danhof
- 3Alkek Center for Metagenomic and Microbiome Research, Baylor College of Medicine, Houston, Texas,4Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas
| | | | - Jennifer K. Spinler
- 1Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas,2Department of Pathology, Texas Children’s Hospital, Houston, Texas
| | - Kristen A. Engevik
- 3Alkek Center for Metagenomic and Microbiome Research, Baylor College of Medicine, Houston, Texas,4Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas
| | - Beatrice Herrmann
- 1Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas,2Department of Pathology, Texas Children’s Hospital, Houston, Texas
| | - Bradley T. Endres
- 5Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas
| | - Kevin W. Garey
- 5Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas
| | - Joseph M. Hyser
- 1Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas,2Department of Pathology, Texas Children’s Hospital, Houston, Texas
| | - Robert A. Britton
- 3Alkek Center for Metagenomic and Microbiome Research, Baylor College of Medicine, Houston, Texas,4Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas
| | - James Versalovic
- 1Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas,2Department of Pathology, Texas Children’s Hospital, Houston, Texas
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Schnoll-Sussman F, Niec R, Katz PO. Proton Pump Inhibitors: The Good, Bad, and Ugly. Gastrointest Endosc Clin N Am 2020; 30:239-251. [PMID: 32146944 DOI: 10.1016/j.giec.2019.12.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Proton pump inhibitors (PPIs) continue to be the medication of choice for treatment of acid-related disease, with few if any overt side effects seen with daily use. They are often prescribed empirically, often in high doses and with many patients being treated with multiple PPIs without an objective diagnosis. Therefore, they are believed to be overprescribed and used without indication. In this article we discuss the appropriate clinical indications for PPIs, review in detail the major associated adverse events, and put in perspective key issues in balancing benefits and risk of this exceptional (and safe) class of drug.
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Affiliation(s)
- Felice Schnoll-Sussman
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, 1315 York Avenue, New York City, NY 10021, USA
| | - Rachel Niec
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, 1315 York Avenue, New York City, NY 10021, USA
| | - Philip O Katz
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, 1315 York Avenue, New York City, NY 10021, USA.
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Kim HS, Kang JH, Kim HG, Kim YH, Bae H, Kim NK. Clostridium difficile Infection After Ileostomy Reversal. Ann Coloproctol 2020; 37:S4-S6. [PMID: 32178491 PMCID: PMC8359696 DOI: 10.3393/ac.2019.09.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 09/24/2019] [Indexed: 11/03/2022] Open
Abstract
Clostridium difficile infection (CDI) after ileostomy reversal is rare, with few reports available in the available literature describing this condition. The diagnosis of CDI after ileostomy reversal is challenging because symptoms such as diarrhea observed in these patients can occur frequently after surgery. However, CDI can be fatal, so early diagnosis and prompt treatment are important. We discuss 2 patients with positive C. difficile toxin assay results on stool cultures performed after ileostomy reversal. Clinical progression differed between these patients: one patient who presented with severe CDI and shock was successfully treated following a prolonged intensive care unit stay for the management of vital signs and underwent hemodialysis, while another patient showed symptoms of mild colitis but we could not confirm whether diarrhea was associated with CDI or with the usual postoperative state. To our knowledge, these represent 2 of just a few cases reported in the literature describing CDI after ileostomy reversal.
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Affiliation(s)
- Ho Seung Kim
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hyun Kang
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Han-Gil Kim
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Hun Kim
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyeonwoo Bae
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Nam Kyu Kim
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Horve PF, Lloyd S, Mhuireach GA, Dietz L, Fretz M, MacCrone G, Van Den Wymelenberg K, Ishaq SL. Building upon current knowledge and techniques of indoor microbiology to construct the next era of theory into microorganisms, health, and the built environment. JOURNAL OF EXPOSURE SCIENCE & ENVIRONMENTAL EPIDEMIOLOGY 2020; 30:219-235. [PMID: 31308484 PMCID: PMC7100162 DOI: 10.1038/s41370-019-0157-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 06/23/2019] [Accepted: 06/30/2019] [Indexed: 05/06/2023]
Abstract
In the constructed habitat in which we spend up to 90% of our time, architectural design influences occupants' behavioral patterns, interactions with objects, surfaces, rituals, the outside environment, and each other. Within this built environment, human behavior and building design contribute to the accrual and dispersal of microorganisms; it is a collection of fomites that transfer microorganisms; reservoirs that collect biomass; structures that induce human or air movement patterns; and space types that encourage proximity or isolation between humans whose personal microbial clouds disperse cells into buildings. There have been recent calls to incorporate building microbiology into occupant health and exposure research and standards, yet the built environment is largely viewed as a repository for microorganisms which are to be eliminated, instead of a habitat which is inexorably linked to the microbial influences of building inhabitants. Health sectors have re-evaluated the role of microorganisms in health, incorporating microorganisms into prevention and treatment protocols, yet no paradigm shift has occurred with respect to microbiology of the built environment, despite calls to do so. Technological and logistical constraints often preclude our ability to link health outcomes to indoor microbiology, yet sufficient study exists to inform the theory and implementation of the next era of research and intervention in the built environment. This review presents built environment characteristics in relation to human health and disease, explores some of the current experimental strategies and interventions which explore health in the built environment, and discusses an emerging model for fostering indoor microbiology rather than fearing it.
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Affiliation(s)
- Patrick F Horve
- Biology and the Built Environment Center, University of Oregon, Eugene, OR, 97403, USA
| | - Savanna Lloyd
- Biology and the Built Environment Center, University of Oregon, Eugene, OR, 97403, USA
| | - Gwynne A Mhuireach
- Biology and the Built Environment Center, University of Oregon, Eugene, OR, 97403, USA
| | - Leslie Dietz
- Biology and the Built Environment Center, University of Oregon, Eugene, OR, 97403, USA
| | - Mark Fretz
- Institute for Health and the Built Environment, University of Oregon, Portland, OR, 97209, USA
| | - Georgia MacCrone
- Biology and the Built Environment Center, University of Oregon, Eugene, OR, 97403, USA
| | - Kevin Van Den Wymelenberg
- Biology and the Built Environment Center, University of Oregon, Eugene, OR, 97403, USA
- Institute for Health and the Built Environment, University of Oregon, Portland, OR, 97209, USA
| | - Suzanne L Ishaq
- Biology and the Built Environment Center, University of Oregon, Eugene, OR, 97403, USA.
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Shen A. Clostridioides difficile Spores: Bile Acid Sensors and Trojan Horses of Transmission. Clin Colon Rectal Surg 2020; 33:58-66. [PMID: 32104157 DOI: 10.1055/s-0040-1701230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The Gram-positive, spore-forming bacterium, Clostridioides difficile is the leading cause of healthcare-associated infections in the United States, although it also causes a significant number of community-acquired infections. C. difficile infections, which range in severity from mild diarrhea to toxic megacolon, cost more to treat than matched infections, with an annual treatment cost of approximately $6 billion for almost half-a-million infections. These high-treatment costs are due to the high rates of C. difficile disease recurrence (>20%) and necessity for special disinfection measures. These complications arise in part because C. difficile makes metabolically dormant spores, which are the major infectious particle of this obligate anaerobe. These seemingly inanimate life forms are inert to antibiotics, resistant to commonly used disinfectants, readily disseminated, and capable of surviving in the environment for a long period of time. However, upon sensing specific bile salts in the vertebrate gut, C. difficile spores transform back into the vegetative cells that are responsible for causing disease. This review discusses how spores are ideal vectors for disease transmission and how antibiotics modulate this process. We also describe the resistance properties of spores and how they create challenges eradicating spores, as well as promote their spread. Lastly, environmental reservoirs of C. difficile spores and strategies for destroying them particularly in health care environments will be discussed.
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Affiliation(s)
- Aimee Shen
- Department of Molecular Biology and Microbiology, Tufts University School of Medicine, Boston, Massachusetts
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The Phylogeny and Biological Function of Gastric Juice-Microbiological Consequences of Removing Gastric Acid. Int J Mol Sci 2019; 20:ijms20236031. [PMID: 31795477 PMCID: PMC6928904 DOI: 10.3390/ijms20236031] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 11/24/2019] [Accepted: 11/25/2019] [Indexed: 12/15/2022] Open
Abstract
Gastric juice is a unique combination of hydrochloric acid (HCl), lipase, and pepsin. Acidic gastric juice is found in all vertebrates, and its main function is to inactivate microorganisms. The phylogenetic preservation of this energy-consuming and, at times, hazardous function (acid-related diseases) reflects its biological importance. Proton pump inhibitors (PPIs) are one of the most widely used drugs in the world. Due to the reduced prevalence of Helicobacter pylori infection as well as the increased use of inhibitors of gastric acid secretion, the latter has become the most important cause of gastric hypoacidity. In the present manuscript, we review the microbiological consequences of removing gastric acidity. The resulting susceptibility to infections has not been studied extensively, and focus has mainly been restricted to bacterial and parasitic agents only. The strongest evidence concerning the relationship between hypochlorhydria and predisposition to infections relates to bacterial infections affecting the gastrointestinal tract. However, several other clinical settings with increased susceptibility to infections due to inhibited gastric acidity are discussed. We also discuss the impact of hypochlorhydria on the gut microbiome.
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Maeda S, Yamaguchi M, Maeda K, Kobayashi N, Izumi N, Nagai M, Obayashi T, Ohashi W, Katsuno T, Nobata H, Ito Y. Proton pump inhibitor use increases the risk of peritonitis in peritoneal dialysis patients. PLoS One 2019; 14:e0224859. [PMID: 31697753 PMCID: PMC6837385 DOI: 10.1371/journal.pone.0224859] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/23/2019] [Indexed: 12/30/2022] Open
Abstract
Peritonitis is a major and the most significant complication of peritoneal dialysis (PD). Although some predictors of peritonitis in PD patients are known, the association between proton pump inhibitor (PPI) use and peritonitis has not been characterized. Here, we examined whether PPI use is a risk factor for the development of peritonitis, based on a single-center retrospective analysis of 230 consecutive Japanese PD patients at Narita Memorial Hospital. We assessed the association between PPI use and subsequent first episode of peritonitis using multivariate Cox proportional hazards models, following adjustment for clinically relevant factors. The median follow-up period was 36 months (interquartile range, 19–57 months). In total, 86 patients (37.4%) developed peritonitis. Analysis with multivariate Cox proportional hazards models revealed the following significant predictors of peritonitis: PPI use (adjusted hazard ratio [HR] = 1.72, 95% confidence interval [CI]: 1.11–2.66; P = 0.016) and low serum albumin level (per g/dl adjusted HR = 0.59, 95% CI: 0.39–0.90; P = 0.014). Thus, PPI use was independently associated with PD-related peritonitis. The results suggest that nephrology physicians should exercise caution when prescribing PPIs for PD patients.
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Affiliation(s)
- Sayaka Maeda
- Department of Nephrology, Narita Memorial Hospital, Toyohashi, Japan
| | - Makoto Yamaguchi
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Kunihiro Maeda
- Department of Nephrology, Narita Memorial Hospital, Toyohashi, Japan
| | - Naoto Kobayashi
- Department of Nephrology, Narita Memorial Hospital, Toyohashi, Japan
| | - Naoki Izumi
- Department of Nephrology, Narita Memorial Hospital, Toyohashi, Japan
| | - Masaaki Nagai
- Department of Nephrology, Narita Memorial Hospital, Toyohashi, Japan
| | - Takaaki Obayashi
- Department of Nephrology, Narita Memorial Hospital, Toyohashi, Japan
| | - Wataru Ohashi
- Division of Biostatistics, Clinical Research Center, Aichi Medical University, Nagakute, Japan
| | - Takayuki Katsuno
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Hironobu Nobata
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Yasuhiko Ito
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
- * E-mail:
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Spore Production of Toxigenic and Non-toxigenic Clostridium difficile Isolates in Sub-MIC of Vancomycin, Clindamycin, and Ceftazidime. Jundishapur J Microbiol 2019. [DOI: 10.5812/jjm.57905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Rodriguez C, Taminiau B, Bouchafa L, Romijn S, Rajamäki M, Van Broeck J, Delmée M, Clercx C, Daube G. Clostridium difficile beyond stools: dog nasal discharge as a possible new vector of bacterial transmission. Heliyon 2019; 5:e01629. [PMID: 31193177 PMCID: PMC6520566 DOI: 10.1016/j.heliyon.2019.e01629] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/10/2019] [Accepted: 04/30/2019] [Indexed: 12/14/2022] Open
Abstract
Zoonotic transmission of Clostridium difficile has been largely hypothesised to occur after direct or indirect contact with contaminated animal faeces. Recent studies have reported the presence of the bacterium in the natural environment, including in soils and rivers. If C. difficile spores are scattered in the environment, they can easily enter the respiratory tract of dogs, and therefore, dog nasal discharge could be a direct route of transmission not previously investigated. This study reports for the first time the presence of C. difficile in the respiratory tracts of dogs. The bacterium was isolated from 6 (17.1%) out of 35 nasal samples, with a total of 4 positive dogs (19%). C. difficile was recovered from both proximal and distal nasal cavities. All isolates were toxigenic and belonged to PCR-ribotype 014, which is one of the most predominant types in animals and in community-acquired C. difficile infections in recent years. The findings of this study demonstrate that the nasal cavity of dogs is contaminated with toxigenic C. difficile, and therefore, its secretions could be considered as a new route by which bacteria are spread and transmitted.
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Affiliation(s)
- C. Rodriguez
- Fundamental and Applied Research for Animal & Health (FARAH), Department of Food Microbiology, Faculty of Veterinary Medicine, University of Liège, Sart-Tilman 4000, Liège, Belgium
- Corresponding author.
| | - B. Taminiau
- Fundamental and Applied Research for Animal & Health (FARAH), Department of Food Microbiology, Faculty of Veterinary Medicine, University of Liège, Sart-Tilman 4000, Liège, Belgium
| | - L. Bouchafa
- Fundamental and Applied Research for Animal & Health (FARAH), Department of Food Microbiology, Faculty of Veterinary Medicine, University of Liège, Sart-Tilman 4000, Liège, Belgium
| | - S. Romijn
- Fundamental and Applied Research for Animal & Health (FARAH), Department of Veterinary Clinical Sciences, Division of Companion Animal Internal Medicine, Faculty of Veterinary Medicine, University of Liège, Sart-Tilman 4000, Liège, Belgium
| | - M.M. Rajamäki
- Small Animal Internal Medicine University of Helsinki, Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, Agnes Sjöberginkatu 2 P.O. Box 66, Finland
| | - J. Van Broeck
- National Reference Center Clostridium difficile, Microbiology Unit, Catholic University of Louvain, Avenue Hippocrate 54, Bte B1. 5405, 1200, Brussels, Belgium
| | - M. Delmée
- National Reference Center Clostridium difficile, Microbiology Unit, Catholic University of Louvain, Avenue Hippocrate 54, Bte B1. 5405, 1200, Brussels, Belgium
| | - C. Clercx
- Fundamental and Applied Research for Animal & Health (FARAH), Department of Veterinary Clinical Sciences, Division of Companion Animal Internal Medicine, Faculty of Veterinary Medicine, University of Liège, Sart-Tilman 4000, Liège, Belgium
| | - G. Daube
- Fundamental and Applied Research for Animal & Health (FARAH), Department of Food Microbiology, Faculty of Veterinary Medicine, University of Liège, Sart-Tilman 4000, Liège, Belgium
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Vaishnavi C, Gupta PK, Sharma M, Kochhar R. Pancreatic disease patients are at higher risk for Clostridium difficile infection compared to those with other co-morbidities. Gut Pathog 2019; 11:17. [PMID: 31044014 PMCID: PMC6480607 DOI: 10.1186/s13099-019-0300-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 04/13/2019] [Indexed: 12/29/2022] Open
Abstract
Background Surveillance of Clostridium difficile infection (CDI) in patients with underlying diseases is important because use of prophylactic antibiotics makes them prone to CDI. Epidemiology of CDI in this high-risk population is poorly understood. A study was conducted to evaluate the impact of CDI in patients with specific underlying co-morbidities. Method A total of 2036 patients, whose fecal samples were processed for C. difficile toxin A and B assay by ELISA formed the basis of study. Patients with underlying diseases were classified based on the organ/kind of disease as pancreatic (n = 340), renal (n = 408), hepatic (n = 245), malignant (n = 517) and miscellaneous disease (n = 526). Laboratory records of clinical and demographic details were reviewed. The association of CDI with age, gender, antibiotic receipt, clinical symptoms and underlying co-morbidities was analyzed. Variation in CDI cases based on age groups was also investigated. Result Clostridium difficile toxin positivity was 21.6% in general, whereas it was 30.6% in the pancreatic, 17.9% in the renal, 19.6%, in the hepatic, 21.3% in the malignancy and 20.0% in the miscellaneous disease groups. Toxin positivity was the lowest (14.8%) for female gender under renal disease and the highest (31.8%) for patients aged 40 to < 60 years, under pancreatic disease. Bloody diarrhea was a significant predictor for C. difficile toxin positivity. C. difficile toxin status irrespective to the underlying diseases was neither dependent on gender, age-groups or the number of antibiotics used. Association between patients’ gender, age and antibiotics receipt with underlying disease conditions, respective to C. difficile toxin status showed significance in relation to male gender (p < 0.05), age 40 to < 60 years (p = 0.03) and those receiving single (p = 0.09) or multiple antibiotics (p = 0.07). Conclusion Pancreatic disease patients are at a higher risk for developing CDI, and particularly male gender, age 40 to < 60 years and those receiving antibiotics are at significant risk.
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Affiliation(s)
- Chetana Vaishnavi
- 1Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Pramod K Gupta
- 2Department of Biostatistics, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Megha Sharma
- 1Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Rakesh Kochhar
- 1Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012 India
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Touchette MH, Benito de la Puebla H, Ravichandran P, Shen A. SpoIVA-SipL Complex Formation Is Essential for Clostridioides difficile Spore Assembly. J Bacteriol 2019; 201:e00042-19. [PMID: 30692174 PMCID: PMC6436350 DOI: 10.1128/jb.00042-19] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 01/23/2019] [Indexed: 01/05/2023] Open
Abstract
Spores are the major infectious particle of the Gram-positive nosocomial pathogen Clostridioides difficile (formerly Clostridium difficile), but the molecular details of how this organism forms these metabolically dormant cells remain poorly characterized. The composition of the spore coat in C. difficile differs markedly from that defined in the well-studied organism Bacillus subtilis, with only 25% of the ∼70 spore coat proteins being conserved between the two organisms and with only 2 of 9 coat assembly (morphogenetic) proteins defined in B. subtilis having homologs in C. difficile We previously identified SipL as a clostridium-specific coat protein essential for functional spore formation. Heterologous expression analyses in Escherichia coli revealed that SipL directly interacts with C. difficile SpoIVA, a coat-morphogenetic protein conserved in all spore-forming organisms, through SipL's C-terminal LysM domain. In this study, we show that SpoIVA-SipL binding is essential for C. difficile spore formation and identify specific residues within the LysM domain that stabilize this interaction. Fluorescence microscopy analyses indicate that binding of SipL's LysM domain to SpoIVA is required for SipL to localize to the forespore while SpoIVA requires SipL to promote encasement of SpoIVA around the forespore. Since we also show that clostridial LysM domains are functionally interchangeable at least in C. difficile, the basic mechanism for SipL-dependent assembly of clostridial spore coats may be conserved.IMPORTANCE The metabolically dormant spore form of the major nosocomial pathogen Clostridioides difficile is its major infectious particle. However, the mechanisms controlling the formation of this resistant cell type are not well understood, particularly with respect to its outermost layer, the spore coat. We previously identified two spore-morphogenetic proteins in C. difficile: SpoIVA, which is conserved in all spore-forming organisms, and SipL, which is conserved only in the clostridia. Both SpoIVA and SipL are essential for heat-resistant spore formation and directly interact through SipL's C-terminal LysM domain. In this study, we demonstrate that the LysM domain is critical for SipL and SpoIVA function, likely by helping recruit SipL to the forespore during spore morphogenesis. We further identified residues within the LysM domain that are important for binding SpoIVA and, thus, functional spore formation. These findings provide important insight into the molecular mechanisms controlling the assembly of infectious C. difficile spores.
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Affiliation(s)
- Megan H Touchette
- Department of Molecular Biology and Microbiology, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Hector Benito de la Puebla
- Department of Molecular Biology and Microbiology, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Priyanka Ravichandran
- Department of Microbiology and Molecular Genetics, University of Vermont, Burlington, Vermont, USA
| | - Aimee Shen
- Department of Molecular Biology and Microbiology, Tufts University School of Medicine, Boston, Massachusetts, USA
- Department of Microbiology and Molecular Genetics, University of Vermont, Burlington, Vermont, USA
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Shrestha R, Cochran AM, Sorg JA. The requirement for co-germinants during Clostridium difficile spore germination is influenced by mutations in yabG and cspA. PLoS Pathog 2019; 15:e1007681. [PMID: 30943268 PMCID: PMC6464247 DOI: 10.1371/journal.ppat.1007681] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 04/15/2019] [Accepted: 03/05/2019] [Indexed: 12/13/2022] Open
Abstract
Clostridium difficile spore germination is critical for the transmission of disease. C. difficile spores germinate in response to cholic acid derivatives, such as taurocholate (TA), and amino acids, such as glycine or alanine. Although the receptor with which bile acids are recognized (germinant receptor) is known, the amino acid co-germinant receptor has remained elusive. Here, we used EMS mutagenesis to generate mutants with altered requirements for the amino acid co-germinant, similar to the strategy we used previously to identify the bile acid germinant receptor, CspC. Surprisingly, we identified strains that do not require co-germinants, and the mutant spores germinated in response to TA alone. Upon sequencing these mutants, we identified different mutations in yabG. In C. difficile, yabG expression is required for the processing of key germination components to their mature forms (e.g., CspBA to CspB and CspA). A defined yabG mutant exacerbated the EMS mutant phenotype. Building upon this work, we found that small deletions in cspA resulted in spores that germinated in the presence of TA alone without the requirement of a co-germinant. cspA encodes a pseudoprotease that was previously shown to be important for incorporation of the CspC germinant receptor. Herein, our study builds upon the role of CspA during C. difficile spore germination by providing evidence that CspA is important for recognition of co-germinants during C. difficile spore germination. Our work suggests that two pseudoproteases (CspC and CspA) likely function as the C. difficile germinant receptors. Germination by C. difficile spores is one of the very first steps in the pathogenesis of this organism. The transition from the metabolically dormant spore form to the actively-growing, toxin-producing vegetative form is initiated by certain host-derived bile acids and amino acid signals. Despite near universal conservation in endospore-forming bacteria of the Ger-type germinant receptors, C. difficile and related organisms do not encode these proteins. In prior work, we identified the C. difficile bile acid germinant receptor as the CspC pseudoprotease. In this manuscript, we implicate the CspA pseudoprotease as the C. difficile co-germinant receptor. C. difficile cspA is encoded as a translational fusion to cspB. The resulting CspBA protein is processed post-translationally by the YabG protease. Inactivation of yabG resulted in strains whose spores no longer responded to amino acids or divalent cations as co-germinants and germinated in response to bile acid alone. Building upon this, we found that small deletions in the cspA portion of cspBA resulted in spores that could germinate in response to bile acids alone. Our results suggest that two pseudoproteases regulate C. difficile spore germination and provide further evidence that C. difficile spore germination proceeds through a novel spore germination pathway.
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Affiliation(s)
- Ritu Shrestha
- Department of Biology, Texas A&M University, College Station, United States of America
| | - Alicia M. Cochran
- Department of Biology, Texas A&M University, College Station, United States of America
| | - Joseph A. Sorg
- Department of Biology, Texas A&M University, College Station, United States of America
- * E-mail:
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Yong C, Lim J, Kim B, Park D, Oh S. Suppressive effect ofLactobacillus fermentumLim2 onClostridioides difficile027 toxin production. Lett Appl Microbiol 2019; 68:386-393. [DOI: 10.1111/lam.13124] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 01/24/2019] [Accepted: 01/28/2019] [Indexed: 01/05/2023]
Affiliation(s)
- C.C. Yong
- Division of Animal Science Chonnam National University Gwangju Korea
| | - J. Lim
- Division of Animal Science Chonnam National University Gwangju Korea
| | - B.‐K. Kim
- Korea Food Research Institute Jeollabuk‐do Korea
| | - D.‐J. Park
- Korea Food Research Institute Jeollabuk‐do Korea
| | - S. Oh
- Division of Animal Science Chonnam National University Gwangju Korea
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Risk factors for Clostridium difficile infection in pediatric inpatients: A meta-analysis and systematic review. Infect Control Hosp Epidemiol 2019; 40:420-426. [DOI: 10.1017/ice.2019.23] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AbstractObjective:To summarize risk factors for Clostridioides (formerly Clostridium) difficile infection (CDI) in hospitalized pediatric patients as determined by previous observational studies.Design:Meta-analysis and systematic review.Patients:Studies evaluating risk factors for CDI in pediatric inpatients were eligible for inclusion.Method:We systematically searched MEDLINE, Web of Science, Scopus, and EMBASE for subject headings and text words related to CDI and pediatrics from 1975 to 2017. Two of the investigators independently screened studies, extracted and compiled data, assessed study quality, and performed the meta-analysis.Results:Of the 2,033 articles screened, 14 studies reporting 10,531,669 children met the inclusion criteria. Prior antibiotic exposure (odds ratio [OR], 2.14; 95% confidence interval [CI], 1.31–3.52) and proton pump inhibitor (PPI) use (OR, 1.33; 95% CI, 1.07–1.64) were associated with an increased risk of CDI in children. Subgroup analyses using studies reporting only adjusted results suggested that prior antibiotic exposure is not a significant risk factor for CDI. H2 receptor antagonist (H2RA) use (OR, 1.36; 95% CI, 0.31–5.98) and that female gender (OR, 0.87; 95% CI, 0.74–1.03) did not play a significant role as a risk factor for developing CDI.Conclusion:Prior antibiotic exposure appears to be an important risk factor for CDI based on the combined analysis but not significant using adjusted studies. PPI use was associated with an increased risk of CDI. Judicious and appropriate use of antibiotics and PPIs may help reduce the risk of CDI in this vulnerable population.
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Candel-Pérez C, Ros-Berruezo G, Martínez-Graciá C. A review of Clostridioides [Clostridium] difficile occurrence through the food chain. Food Microbiol 2019; 77:118-129. [DOI: 10.1016/j.fm.2018.08.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 08/01/2018] [Accepted: 08/21/2018] [Indexed: 12/18/2022]
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ASID/ACIPC position statement - Infection control for patients with Clostridium difficile infection in healthcare facilities. Infect Dis Health 2018; 24:32-43. [PMID: 30691583 DOI: 10.1016/j.idh.2018.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 10/08/2018] [Accepted: 10/08/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND In 2011, the Australasian Society for Infectious Diseases (ASID) and the Australian Infection Control Association (AICA), now known as the Australasian College of Infection Prevention and Control (ACIPC), produced a position statement on infection control requirements for preventing and controlling Clostridium difficile infection (CDI) in healthcare settings. METHODS The statement updated in 2017 to reflect new literature available .The authors reviewed the 2011 position statement and critically appraised new literature published between 2011 and 2017 and relevant current infection control guidelines to identify where new evidence had become available or best practice had changed. RESULTS The position statement was updated incorporating the new findings. A draft version of the updated position statement was circulated for consultation to members of ASID and ACIPC. The authors responded to all comments received and updated the position statement. CONCLUSIONS This updated position statement emphasizes the importance of health service organizations having evidence-based infection prevention and control programs and comprehensive antimicrobial stewardship programs, to ensure the risk of C. difficile acquisition, transmission and infection is minimised.
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Lawry BM, Johnson CL, Flanagan K, Spoors JA, McNeil CJ, Wipat A, Keegan N. Species-Specific Detection of C. difficile Using Targeted Antibody Design. Anal Chem 2018; 90:13475-13482. [DOI: 10.1021/acs.analchem.8b03349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- B. M. Lawry
- School of Biomedical Sciences, Faculty of Medical Sciences, Newcastle University, Newcastle-Upon-Tyne, NE2 4HH, United Kingdom
| | - C. L. Johnson
- Diagnostic and Therapeutic Technologies, Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, NE2 4HH, United Kingdom
| | - K. Flanagan
- School of Computing, Urban Sciences Building, Newcastle University, Newcastle-Upon-Tyne, NE4 5TG, United Kingdom
| | - J. A. Spoors
- Diagnostic and Therapeutic Technologies, Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, NE2 4HH, United Kingdom
| | - C. J. McNeil
- Diagnostic and Therapeutic Technologies, Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, NE2 4HH, United Kingdom
| | - A. Wipat
- School of Computing, Urban Sciences Building, Newcastle University, Newcastle-Upon-Tyne, NE4 5TG, United Kingdom
| | - N. Keegan
- Diagnostic and Therapeutic Technologies, Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, NE2 4HH, United Kingdom
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49
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Fuchs BB, Tharmalingam N, Mylonakis E. Vulnerability of long-term care facility residents to Clostridium difficile infection due to microbiome disruptions. Future Microbiol 2018; 13:1537-1547. [PMID: 30311778 DOI: 10.2217/fmb-2018-0157] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Aging presents a significant risk factor for Clostridium difficile infection (CDI). A disproportionate number of CDIs affect individuals in long-term care facilities compared with the general population, likely due to the vulnerable nature of the residents and shared environment. Review of the literature cites a number of underlying medical conditions such as the use of antibiotics, proton pump inhibitors, chemotherapy, renal disease and feeding tubes as risk factors. These conditions alter the intestinal environment through direct bacterial killing, changes to pH that influence bacterial stabilities or growth, or influence nutrient availability that direct population profiles. In this review, we examine some of the contributing risk factors for elderly associated CDI and the toll they take on the microbiome.
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Affiliation(s)
- Beth Burgwyn Fuchs
- Rhode Island Hospital, Alpert Medical School & Brown University, Providence, Rhode Island 02903
| | - Nagendran Tharmalingam
- Rhode Island Hospital, Alpert Medical School & Brown University, Providence, Rhode Island 02903
| | - Eleftherios Mylonakis
- Rhode Island Hospital, Alpert Medical School & Brown University, Providence, Rhode Island 02903
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50
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Chang TH, Hsu WY, Yang TI, Lu CY, Hsueh PR, Chen JM, Lee PI, Huang LM, Chang LY. Increased age and proton pump inhibitors are associated with severe Clostridium difficile infections in children. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2018; 53:578-584. [PMID: 30287184 DOI: 10.1016/j.jmii.2018.09.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 08/24/2018] [Accepted: 09/02/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is increasing in children. We aimed to compare the clinical characteristics between CDI and colonization and to identify the risk factors for severe diseases of CDI in children. METHOD We retrospectively reviewed 124 children (1-18 years old) from 2011 to 2018. CDI was defined as diarrhea (≥3 loose stool in the past 24 h) with confirmed toxigenic strain. Colonization was defined as presence of C. difficile without clinical symptoms. Severe diseases included ileus, acute kidney injury, gastrointestinal bleeding or mortality. Patients younger than 1 year old and coinfections with other enteric pathogens were excluded. RESULTS Among 124 patients with C. difficile identified, 49 of them fulfilled CDI definition and 75 had C. difficile colonization. Children with CDI were more likely to present with watery (74% vs. 1%, p < 0.01) and mucoid stool (25% vs. 7%, p < 0.01) and occult blood in stool (67% vs. 33%, p < 0.01) than children with colonization. In CDI cases, elevated age-adjusted creatinine (18% vs. 0%, p = 0.03) and hyponatremia (134 mEq/L vs. 137 mEq/L, p = 0.04) were found. Also, they had more complicated diseases (27% vs. 0%, p < 0.01). On multivariate analysis, age older than 4 years (adjusted odds ratio: 5.83; 95% confidence interval: 1.05-32.27) and proton pump inhibitor use (PPI) (adjusted odds ratio: 7.25; 95% confidence interval: 1.07-49.07) were the independent factors for severe diseases. CONCLUSIONS Watery diarrhea, mucoid stool and occult blood in stool could differentiate CDI from colonization. Patients with increased age and previous PPI use were the independent risk factors for severe diseases in children.
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Affiliation(s)
- Tu-Hsuan Chang
- Department of Pediatrics, Chi-Mei Medical Center, Tainan, Taiwan; Division of Pediatric Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wei-Yun Hsu
- Department of Pediatrics, Chi-Mei Medical Center, Tainan, Taiwan; Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tzu-I Yang
- Division of Pediatric Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chun-Yi Lu
- Division of Pediatric Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Po-Ren Hsueh
- Department of Laboratory Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jong-Min Chen
- Department of Laboratory Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ping-Ing Lee
- Division of Pediatric Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Li-Min Huang
- Division of Pediatric Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Luan-Yin Chang
- Division of Pediatric Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.
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