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Bandelj P, Harmanus C, Blagus R, Cotman M, Kuijper EJ, Ocepek M, Vengust M. Quantification of Clostridioides (Clostridium) difficile in feces of calves of different age and determination of predominant Clostridioides difficile ribotype 033 relatedness and transmission between family dairy farms using multilocus variable-number tandem-repeat analysis. BMC Vet Res 2018; 14:298. [PMID: 30285751 PMCID: PMC6167908 DOI: 10.1186/s12917-018-1616-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 09/16/2018] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Community acquired Clostridioides (Clostridium) difficile infection (CA-CDI) is a significant health problem in human and veterinary medicine. Animals are often considered as potential reservoirs for CA-CDI. In Europe, family farming is the most predominant farming operation, with a complex interaction between animals and the community. Therefore, it is pertinent to evaluate transmission patterns of C. difficile on such prominent European farming model. Fecal samples from calves (n = 2442) were collected biweekly over a period of one year on 20 mid-size family dairy farms. Environmental samples (n = 475) were collected in a three month interval. Clostridioides difficile was detected using qPCR in 243 fecal samples (243/2442); positive samples were then quantified. Association between prevalence/load of C. difficile and age of the calves was estimated with logistic regression model. Most common C. difficile isolate from calves (n = 76) and the environment (n = 14) was C. difficile ribotype 033, which was further analyzed using multilocus variable-number tandem-repeat analysis (MLVA) to assess intra- and between-farm relatedness. RESULTS Clostridioides difficile was detected in feces of calves less than 24 h old. Results showed a non-linear statistically significant decrease in shedding load of C. difficile with age (P < 0.0001). A nonlinear relationship was also established between the number of calves and the farm C. difficile prevalence, whereas the prevalence of C. difficile ribotype 033 increased linearly with the number of calves. MLVA revealed close intra-farm relatedness among C. difficile ribotypes 033. It also revealed that the between-farms close relatedness of C. difficile ribotypes 033 can be a direct result of farm to farm trade of calves. CONCLUSIONS Implementation of better hygiene and management measures on farms may help decrease the risk of spreading CA-CDI between animals and the community. Trading calves older than 3 weeks would decrease the possibility C. difficile dissemination in the community because of lower prevalence and lower load of C. difficile in feces.
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Affiliation(s)
- Petra Bandelj
- 0000 0001 0721 6013grid.8954.0Veterinary faculty, University of Ljubljana, Cesta v Mestni log 47, SI-1115 Ljubljana, Slovenia
| | - Céline Harmanus
- 0000000089452978grid.10419.3dDepartment of Medical Microbiology, Center of Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - Rok Blagus
- 0000 0001 0721 6013grid.8954.0Institute for biostatistics and Medical informatics, University of Ljubljana, Vrazov trg 2, SI-1104 Ljubljana, Slovenia
| | - Marko Cotman
- 0000 0001 0721 6013grid.8954.0Veterinary faculty, University of Ljubljana, Cesta v Mestni log 47, SI-1115 Ljubljana, Slovenia
| | - Ed J. Kuijper
- 0000000089452978grid.10419.3dDepartment of Medical Microbiology, Center of Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - Matjaz Ocepek
- 0000 0001 0721 6013grid.8954.0Veterinary faculty, University of Ljubljana, Cesta v Mestni log 47, SI-1115 Ljubljana, Slovenia
| | - Modest Vengust
- 0000 0001 0721 6013grid.8954.0Veterinary faculty, University of Ljubljana, Cesta v Mestni log 47, SI-1115 Ljubljana, Slovenia
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Thornton CS, Rubin JE, Greninger AL, Peirano G, Chiu CY, Pillai DR. Epidemiological and genomic characterization of community-acquired Clostridium difficile infections. BMC Infect Dis 2018; 18:443. [PMID: 30170546 PMCID: PMC6119286 DOI: 10.1186/s12879-018-3337-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 08/16/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a major cause of morbidity and mortality in North America and Europe. The aim of this study was to identify epidemiologically-confirmed cases of community-acquired (CA)-CDI in a large North American urban center and analyze isolates using multiple genetic and phenotypic methods. METHODS Seventy-eight patients testing positive for C. difficile from outpatient clinics were further investigated by telephone questionnaire. CA-CDI isolates were characterized by antibiotic susceptibility, pulsed-field gel electrophoresis and whole genome sequencing. CA-CDI was defined as testing positive greater than 12 weeks following discharge or no previous hospital admission in conjunction with positive toxin stool testing. RESULTS 51.3% (40/78) of the patients in this study were found to have bona fide CA-CDI. The majority of patients were female (71.8% vs. 28.2%) with 50-59 years of age being most common (21.8%). Common co-morbidities included ulcerative colitis (1/40; 2.5%), Crohn's disease (3/40; 7.5%), celiac disease (2/40; 5.0%) and irritable bowel syndrome (8/40; 20.0%). However, of 40 patients with CA-CDI, 9 (29.0%) had been hospitalized between 3 and 6 months prior and 31 (77.5%) between 6 and 12 months prior. The hypervirulent North American Pulostype (NAP) 1-like (9/40; 22.5%) strain was the most commonly identified pulsotype. Whole genome sequencing of CA-CDI isolates confirmed that NAP 1-like pulsotypes are commonplace in CA-CDI. From a therapeutic perspective, there was universal susceptibility to metronidazole and vancomycin. CONCLUSIONS All CA-CDI cases had some history of hospitalization if the definition were modified to health care facility exposure in the last 12 months and is supported by the genomic analysis. This raises the possibility that even CA-CDI may have nosocomial origins.
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Affiliation(s)
- Christina S Thornton
- Department of Microbiology and Infectious Diseases, University of Calgary, Calgary, AB, Canada.,Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Joseph E Rubin
- Calgary Laboratory Services, Calgary, AB, Canada.,Department of Veterinary Microbiology, University of Saskatchewan, Regina, Canada
| | - Alexander L Greninger
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA.,Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | | | - Charles Y Chiu
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA.,Department of Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, CA, USA
| | - Dylan R Pillai
- Department of Microbiology and Infectious Diseases, University of Calgary, Calgary, AB, Canada. .,Department of Medicine, University of Calgary, Calgary, AB, Canada. .,Calgary Laboratory Services, Calgary, AB, Canada. .,Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada. .,Diagnostic and Scientific Center, Room 1W-416, 9-3535 Research Road NW, Calgary, AB, T2L 2K8, Canada.
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53
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van Dorp SM, Hensgens MPM, Dekkers OM, Demeulemeester A, Buiting A, Bloembergen P, de Greeff SC, Kuijper EJ. Spatial clustering and livestock exposure as risk factor for community-acquired Clostridium difficile infection. Clin Microbiol Infect 2018; 25:607-612. [PMID: 30076972 DOI: 10.1016/j.cmi.2018.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/17/2018] [Accepted: 07/18/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Clostridium difficile infections (CDI) account for 1.5% of diarrhoeic episodes in patients attending a general practitioner in the Netherlands, but its sources are unknown. We searched for community clusters to recognize localized point sources of CDI. METHODS Between October 2010 and February 2012, a community-based prospective nested case-control study was performed in three laboratories in the Netherlands with a study population of 2 810 830 people. Bernoulli spatial scan and space-time permutation models were used to detect spatial and/or temporal clusters of CDI. In addition, a multivariate conditional logistic regression model was constructed to test livestock exposure as a supposed risk factor in CDI patients without hospital admission within the previous 12 weeks (community-acquired (CA) CDI). RESULTS In laboratories A, B and C, 1.3%, 1.8% and 2.1% of patients with diarrhoea tested positive for CDI, respectively. The mean age of CA-CDI patients (n = 124) was 49 years (standard deviation, 22.6); 64.5% were female. No spatial or temporal clusters of CDI cases were detected compared to C. difficile-negative diarrhoeic controls. Except for one false-positive signal, no spatiotemporal interaction amongst CDI cases was found. Livestock exposure was not related to CA-CDI (odds ratio, 0.99; 95% confidence interval, 0.44-2.24). Ten percent of CA-CDIs was caused by PCR ribotype 078, spatially dispersed throughout the study area. CONCLUSIONS The absence of clusters of CDI cases in a community cohort of diarrhoeic patients suggests a lack of localized point sources of CDI in the living environment of these patients.
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Affiliation(s)
- S M van Dorp
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands.
| | - M P M Hensgens
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - O M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - A Demeulemeester
- Center for Diagnostic Support in Primary Care (SHL-Groep), Etten-Leur, The Netherlands
| | - A Buiting
- Laboratory for Medical Microbiology and Immunology of the St Elisabeth Hospital, Tilburg, The Netherlands
| | - P Bloembergen
- Laboratory of Clinical Microbiology and Infectious Diseases, Isala klinieken, Zwolle, The Netherlands
| | - S C de Greeff
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - E J Kuijper
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
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Ofori E, Ramai D, Dhawan M, Mustafa F, Gasperino J, Reddy M. Community-acquired Clostridium difficile: epidemiology, ribotype, risk factors, hospital and intensive care unit outcomes, and current and emerging therapies. J Hosp Infect 2018; 99:436-442. [DOI: 10.1016/j.jhin.2018.01.015] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 01/23/2018] [Indexed: 02/06/2023]
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Horvat S, Rupnik M. Interactions Between Clostridioides difficile and Fecal Microbiota in in Vitro Batch Model: Growth, Sporulation, and Microbiota Changes. Front Microbiol 2018; 9:1633. [PMID: 30087660 PMCID: PMC6066498 DOI: 10.3389/fmicb.2018.01633] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 06/29/2018] [Indexed: 12/14/2022] Open
Abstract
Disturbance in gut microbiota is crucial for the development of Clostridioides difficile infection (CDI). Different mechanisms through which gut microbiota influences C. difficile colonization are known. However, C. difficile could also affect gut microbiota balance as previously demonstrated by cultivation of fecal microbiota in C. difficile conditioned medium. In current study, the interactions of C. difficile cells with gut microbiota were addressed. Three different strains (ribotypes 027, 014/020, and 010) were co-cultivated with two types of fecal microbiota (healthy and dysbiotic) using in vitro batch model. While all strains showed higher sporulation frequency in the presence of dysbiotic fecal microbiota, the growth was strain dependent. C. difficile either proliferated to comparable levels in the presence of dysbiotic and healthy fecal microbiota or grew better in co-culture with dysbiotic microbiota. In co-cultures with any C. difficile strain fecal microbiota showed decreased richness and diversity. Dysbiotic fecal microbiota was more affected after co-culture with C. difficile than healthy microbiota. Altogether, 62 OTUs were significantly changed in co-cultures of dysbiotic microbiota/C. difficile and 45 OTUs in co-cultures of healthy microbiota/C. difficile. However, the majority of significantly changed OTUs in both types of microbiota belonged to the phylum Firmicutes with Lachnospiraceae and Ruminococcaceae origin.
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Affiliation(s)
- Sabina Horvat
- Department of Microbiology, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Maja Rupnik
- Department of Microbiology, Faculty of Medicine, University of Maribor, Maribor, Slovenia.,Centre for Medical Microbiology, National Laboratory for Health, Environment and Food, Maribor, Slovenia
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56
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Quantitative Thresholds Enable Accurate Identification of Clostridium difficile Infection by the Luminex xTAG Gastrointestinal Pathogen Panel. J Clin Microbiol 2018; 56:JCM.01885-17. [PMID: 29643194 DOI: 10.1128/jcm.01885-17] [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] [Received: 11/29/2017] [Accepted: 03/26/2018] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile colonizes the gastrointestinal (GI) tract, resulting in either asymptomatic carriage or a spectrum of diarrheal illness. If clinical suspicion for C. difficile is low, stool samples are often submitted for analysis by multiplex molecular assays capable of detecting multiple GI pathogens, and some institutions do not report this organism due to concerns for high false-positive rates. Since clinical disease correlates with organism burden and molecular assays yield quantitative data, we hypothesized that numerical cutoffs could be utilized to improve the specificity of the Luminex xTAG GI pathogen panel (GPP) for C. difficile infection. Analysis of cotested liquid stool samples (n = 1,105) identified a GPP median fluorescence intensity (MFI) value cutoff of ≥1,200 to be predictive of two-step algorithm (2-SA; 96.4% concordance) and toxin enzyme immunoassay (EIA) positivity. Application of this cutoff to a second cotested data set (n = 1,428) yielded 96.5% concordance. To determine test performance characteristics, concordant results were deemed positive or negative, and discordant results were adjudicated via chart review. Test performance characteristics for the MFI cutoff of ≥150 (standard), MFI cutoff of ≥1,200, and 2-SA were as follows (respectively): concordance, 95, 96, and 97%; sensitivity, 93, 78, and 90%; specificity, 95, 98, and 98%; positive predictive value, 67, 82, and 81%;, and negative predictive value, 99, 98, and 99%. To capture the high sensitivity for organism detection (MFI of ≥150) and high specificity for active infection (MFI of ≥1,200), we developed and applied a reporting algorithm to interpret GPP data from patients (n = 563) with clinician orders only for syndromic panel testing, thus enabling accurate reporting of C. difficile for 95% of samples (514 negative and 5 true positives) irrespective of initial clinical suspicion and without the need for additional testing.
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The Epidemiology of Community Clostridium difficile Infection: A Five-Year Population-Based Study on the Bailiwick of Jersey, Channel Islands. Infect Control Hosp Epidemiol 2018; 39:603-607. [DOI: 10.1017/ice.2018.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We studied healthcare-associated and community-associated Clostridium difficile infection (CDI) in Jersey, Channel Islands (2008–2012). The Island’s stable population has reliable denominator data, a clearly defined at-risk population, and healthcare contact that is easily followed. The vast majority of CDI cases had had recent healthcare contact, and true community-associated disease is extremely rare.Infect Control Hosp Epidemiol 2018;39:603–607
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58
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Janezic S, Mlakar S, Rupnik M. Dissemination ofClostridium difficilespores between environment and households: Dog paws and shoes. Zoonoses Public Health 2018; 65:669-674. [DOI: 10.1111/zph.12475] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Sandra Janezic
- National Laboratory for Health, Environment and Food; Maribor Slovenia
- Faculty of Medicine; University of Maribor; Maribor Slovenia
| | - Sabina Mlakar
- National Laboratory for Health, Environment and Food; Maribor Slovenia
| | - Maja Rupnik
- National Laboratory for Health, Environment and Food; Maribor Slovenia
- Faculty of Medicine; University of Maribor; Maribor Slovenia
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Cunha BA, Sessa J, Blum S. Enhanced Efficacy of High Dose Oral Vancomycin Therapy in Clostridium difficile Diarrhea for Hospitalized Adults Not Responsive to Conventional Oral Vancomycin Therapy: Antibiotic Stewardship Implications. J Clin Med 2018; 7:E75. [PMID: 29642570 PMCID: PMC5920449 DOI: 10.3390/jcm7040075] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 04/02/2018] [Accepted: 04/05/2018] [Indexed: 02/07/2023] Open
Abstract
Current therapy of Clostridium difficile diarrhea (CDD) is problematic. Optimal treatment for CDD remains oral vancomycin, but there is little data on oral vancomycin dosing regimens. The objective of this C. difficile diarrhea study was to compare the efficacy of "high dose" vancomycin, 500 mg (PO) q6h, as sole treatment and in those who after 72 h failed to respond to conventional doses of oral vancomycin, 125-250 mg (PO) q6h. Hospitalized adults with CDD were evaluated by various oral vancomycin regimens, i.e., a conventional dose group (125-250 mg (PO) q6h), a "high dose escalation" dose group (250 mg → 500 mg (PO) q6h), and a "high dose" group (500 mg (PO) q6h). Oral vancomycin treatment groups were compared by time to improvement, i.e., decrease in >50% of watery stools/day and duration of therapy. The high dose escalation and high dose oral vancomycin groups showed the most rapid resolution of diarrhea. There was marked decrease in stools/day after "high dose" vancomycin escalation from conventional dosing, i.e., 250 mg (PO) q6h → 500 mg (PO) q6h. This study demonstrated that "high dose" escalation or initial high dose oral vancomycin, i.e., 500 mg (PO) q6h was the most efficacious regimen for CDD.
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Affiliation(s)
- Burke A Cunha
- Infectious Disease Division, NYU Winthrop Hospital, Mineola, NY 11501, USA.
- State University of New York, School of Medicine, Stony Brook, NY 11794, USA.
| | - Julia Sessa
- Department of Pharmacy, Winthrop-University Hospital, Mineola, NY 11501, USA.
| | - Sharon Blum
- Department of Pharmacy, Winthrop-University Hospital, Mineola, NY 11501, USA.
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Kleinman L, Talbot GH, Hunsche E, Schüler R, Nord CE. The CDI-DaySyms: Content Development of a New Patient-Reported Outcome Questionnaire for Symptoms of Clostridium difficile Infection. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:441-448. [PMID: 29680101 DOI: 10.1016/j.jval.2017.08.3017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 06/30/2017] [Accepted: 08/19/2017] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To develop a patient-reported outcome (PRO) questionnaire for symptoms of Clostridium difficile infection (CDI) following the US Food and Drug Administration PRO guidelines. METHODS Patients' experiences of CDI symptoms were elicited in open-ended discussions with patients and nurses at five US sites (stage 1). A draft PRO measure was developed after demonstration of concept saturation. Two rounds of cognitive interviews were conducted with patients at three US sites (stage 2), with revision of the draft measure after each round. All patients were 18 years or older, with confirmed CDI. The study was conducted with input from a panel of five CDI experts in Europe and North America. RESULTS Stage 1 included interviews with 18 patients and supplementary interviews with 6 nurses; 16 additional patients were interviewed in stage 2. Patients were representative of the general CDI population and were diverse in age, sex, and disease severity. Concept saturation was reached in stage 1. Items were organized in a draft conceptual framework with five hypothesized domains: diarrhea, abdominal discomfort, tiredness, lightheadedness, and other symptoms. Stage 2 demonstrated initial content validity of the 13-item draft daily diary (CDI-DaySyms). Participants reported that the questions were clear, relevant, and comprehensive. They were able to use the instructions to complete the diary correctly and considered the 24-hour recall period appropriate. CONCLUSIONS The CDI-DaySyms captures symptoms relevant to patients undergoing CDI, demonstrating initial content validity. Final content and psychometric validity are being evaluated in a substudy comprising patients from two ongoing international clinical trials (ClinicalTrials.gov identifiers NCT01987895 and NCT01983683).
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Affiliation(s)
| | | | - Elke Hunsche
- Actelion Pharmaceuticals Ltd., Allschwil, Switzerland
| | - René Schüler
- Actelion Pharmaceuticals Ltd., Allschwil, Switzerland
| | - Carl Erik Nord
- Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
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Clostridium difficile Exposures, Colonization, and the Microbiome: Implications for Prevention. Infect Control Hosp Epidemiol 2018; 39:596-602. [PMID: 29553000 DOI: 10.1017/ice.2018.36] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
New studies have been published regarding the epidemiology of Clostridium difficile in topics such as asymptomatic C. difficile colonization, community-associated C. difficile infection, environmental contamination outside healthcare settings, animal colonization, and the interactions between C. difficile and the gut microbiome. In addition to summarizing these findings, this review offers a perspective on the potential impact of high-throughput sequencing and other potential techniques on the prevention of C. difficile.Infect Control Hosp Epidemiol 2018;39:596-602.
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McDonald LC, Gerding DN, Johnson S, Bakken JS, Carroll KC, Coffin SE, Dubberke ER, Garey KW, Gould CV, Kelly C, Loo V, Shaklee Sammons J, Sandora TJ, Wilcox MH. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2018; 66:e1-e48. [PMID: 29462280 PMCID: PMC6018983 DOI: 10.1093/cid/cix1085] [Citation(s) in RCA: 1266] [Impact Index Per Article: 211.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.
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Affiliation(s)
| | | | - Stuart Johnson
- Edward Hines Jr Veterans Administration Hospital, Hines
- Loyola University Medical Center, Maywood, Illinois
| | | | - Karen C Carroll
- Johns Hopkins University School of Medicine, Baltimore, Maryl
| | | | - Erik R Dubberke
- Washington University School of Medicine, St Louis, Missouri
| | | | - Carolyn V Gould
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ciaran Kelly
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Vivian Loo
- McGill University Health Centre, McGill University, Montréal, Québec, Canada
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Liao F, Li W, Gu W, Zhang W, Liu X, Fu X, Xu W, Wu Y, Lu J. A retrospective study of community-acquired Clostridium difficile infection in southwest China. Sci Rep 2018; 8:3992. [PMID: 29507300 PMCID: PMC5838233 DOI: 10.1038/s41598-018-21762-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 02/09/2018] [Indexed: 12/22/2022] Open
Abstract
To identify the prevalence and characteristics of community-acquired Clostridium difficile infection (CA-CDI) in southwest China, we conducted a cross-sectional study. 978 diarrhea patients were enrolled and stool specimens’ DNA was screened for virulence genes. Bacterial culture was performed and isolates were characterized by PCR ribotyping and multilocus sequence typing. Toxin genes tcdA and/or tcdB were found in 138/978 (14.11%) cases for fecal samples. A total of 55 C. difficile strains were isolated (5.62%). The positive rate of toxin genes and isolation results had no statistical significance between children and adults groups. However, some clinical features, such as fecal property, diarrhea times before hospital treatment shown difference between two groups. The watery stool was more likely found in children, while the blood stool for adults; most of children cases diarrhea ≤3 times before hospital treatment, and adults diarrhea >3 times. Independent risk factor associated with CA-CDI was patients with fever. ST35/RT046 (18.18%), ST54/RT012 (14.55%), ST3/RT001 (14.55%) and ST3/RT009 (12.73%) were the most distributed genotype profiles. ST35/RT046, ST3/RT001 and ST3/RT009 were the commonly found in children patients but ST54/RT012 for adults. The prevalence of CA-CDI in Yunnan province was relatively high, and isolates displayed heterogeneity between children and adults groups.
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Affiliation(s)
- Feng Liao
- Department of Respiratory Medicine, the First People's Hospital of Yunnan province, 650022, Kunming, China
| | - Wenge Li
- State Key Laboratory of Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 102206, Beijing, China
| | - Wenpeng Gu
- Department of Acute Infectious Diseases Control and Prevention, Yunnan Provincial Centre for Disease Control and Prevention, 650022, Kunming, China
| | - Wenzhu Zhang
- State Key Laboratory of Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 102206, Beijing, China
| | - Xiaoshu Liu
- State Key Laboratory of Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 102206, Beijing, China
| | - Xiaoqing Fu
- Department of Acute Infectious Diseases Control and Prevention, Yunnan Provincial Centre for Disease Control and Prevention, 650022, Kunming, China
| | - Wen Xu
- Department of Acute Infectious Diseases Control and Prevention, Yunnan Provincial Centre for Disease Control and Prevention, 650022, Kunming, China
| | - Yuan Wu
- State Key Laboratory of Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 102206, Beijing, China.
| | - Jinxing Lu
- State Key Laboratory of Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 102206, Beijing, China.
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Wiuff C, Banks AL, Fitzpatrick F, Cottom L. The Need for European Surveillance of CDI. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1050:13-25. [PMID: 29383661 DOI: 10.1007/978-3-319-72799-8_2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Since the turn of the millennium, the epidemiology of Clostridium difficile infection (CDI) has continued to challenge. Over the last decade there has been a growing awareness that improvements to surveillance are needed. The increasing rate of CDI and emergence of ribotype 027 precipitated the implementation of mandatory national surveillance of CDI in the UK. Changes in clinical presentation, severity of disease, descriptions of new risk factors and the occurrence of outbreaks all emphasised the importance of early diagnosis and surveillance.However a lack of consensus on case definitions, clinical guidelines and optimal laboratory diagnostics across Europe has lead to the underestimation of CDI and impeded comparison between countries. These inconsistencies have prevented the true burden of disease from being appreciated.Acceptance that a multi-country surveillance programme and optimised diagnostic strategies are required not only to detect and control CDI in Europe, but for a better understanding of the epidemiology, has built the foundations for a more robust, unified surveillance. The concerted efforts of the European Centre for Disease Prevention and Control (ECDC) CDI networks, has lead to the development of an over-arching long-term CDI surveillance strategy for 2014-2020. Fulfilment of the ECDC priorities and targets will no doubt be challenging and will require significant investment however the hope is that both a national and Europe-wide picture of CDI will finally be realised.
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Affiliation(s)
- Camilla Wiuff
- Strategic Lead Microbiology, NHS National Services Scotland, Health Protection Scotland, HAI & IC Section, Glasgow, UK.
| | - A-Lan Banks
- Strategic Lead Microbiology, NHS National Services Scotland, Health Protection Scotland, HAI & IC Section, Glasgow, UK
| | - Fidelma Fitzpatrick
- Department of Clinical Microbiology, The Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
| | - Laura Cottom
- Department of Microbiology, Glasgow Royal Infirmary, Glasgow, UK
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Couturier J, Davies K, Gateau C, Barbut F. Ribotypes and New Virulent Strains Across Europe. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1050:45-58. [PMID: 29383663 DOI: 10.1007/978-3-319-72799-8_4] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Clostridium difficile is a major bacterial cause of post-antibiotic diarrhoea. The epidemiology of C. difficile infections (CDI) has dramatically changed since the early 2000s, with an increasing incidence and severity across Europe. This trend is partly due to the emergence and rapid worldwide spread of the hypervirulent and epidemic PCR ribotype 027. Profiles of patients with CDI have also evolved, with description of community-acquired (CA) infections in patients with no traditional risk factors for CDI. However, recent epidemiological studies indicated that some European countries have successfully controlled the dissemination of the 027 clone whereas other countries recently reported the emergence of other virulent or unusual strains. The aims of this review are to summarize the current European CDI epidemiology and to describe the new virulent C. difficile strains circulating in Europe, as well as other potential emerging strains described elsewhere. Standardized typing methods and surveillance programmes are mandatory for a better understanding and monitoring of CDI in Europe.
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Affiliation(s)
- Jeanne Couturier
- National Reference Laboratory for C. difficile, Hôpital Saint-Antoine, Paris, France. .,Université Paris Descartes, Faculté de Pharmacie, Paris, France.
| | - Kerrie Davies
- Healthcare Associated Infections Research Group, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, UK
| | - Cécile Gateau
- National Reference Laboratory for C. difficile, Hôpital Saint-Antoine, Paris, France
| | - Frédéric Barbut
- National Reference Laboratory for C. difficile, Hôpital Saint-Antoine, Paris, France.,Université Paris Descartes, Faculté de Pharmacie, Paris, France
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66
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Nagy E. What do we know about the diagnostics, treatment and epidemiology of Clostridioides (Clostridium) difficile infection in Europe? J Infect Chemother 2017; 24:164-170. [PMID: 29289484 DOI: 10.1016/j.jiac.2017.12.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 11/28/2017] [Accepted: 12/05/2017] [Indexed: 12/17/2022]
Abstract
Clostridium difficile, recently reclassified as Clostridioides difficile is responsible for a significant part of diarrheal diseases in the hospitals and in the community. Besides the main pathogenic factors, toxin A, toxin B and the binary toxin, several other putative virulence factors have been investigated. This manuscript summarize recent findings in Europe concerning source of infection, epidemiology of CDI, the changing pattern of PCR ribotypes of C. difficile strains in different European countries, recommendations for diagnosis and treatment of CDI.
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Affiliation(s)
- Elisabeth Nagy
- Institute of Clinical Microbiology, University of Szeged, Szeged, Hungary.
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67
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Guh AY, Adkins SH, Li Q, Bulens SN, Farley MM, Smith Z, Holzbauer SM, Whitten T, Phipps EC, Hancock EB, Dumyati G, Concannon C, Kainer MA, Rue B, Lyons C, Olson DM, Wilson L, Perlmutter R, Winston LG, Parker E, Bamberg W, Beldavs ZG, Ocampo V, Karlsson M, Gerding DN, McDonald LC. Risk Factors for Community-Associated Clostridium difficile Infection in Adults: A Case-Control Study. Open Forum Infect Dis 2017; 4:ofx171. [PMID: 29732377 PMCID: PMC5903408 DOI: 10.1093/ofid/ofx171] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 08/08/2017] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND An increasing proportion of Clostridium difficile infections (CDI) in the United States are community-associated (CA). We conducted a case-control study to identify CA-CDI risk factors. METHODS We enrolled participants from 10 US sites during October 2014-March 2015. Case patients were defined as persons age ≥18 years with a positive C. difficile specimen collected as an outpatient or within 3 days of hospitalization who had no admission to a health care facility in the prior 12 weeks and no prior CDI diagnosis. Each case patient was matched to one control (persons without CDI). Participants were interviewed about relevant exposures; multivariate conditional logistic regression was performed. RESULTS Of 226 pairs, 70.4% were female and 52.2% were ≥60 years old. More case patients than controls had prior outpatient health care (82.1% vs 57.9%; P < .0001) and antibiotic (62.2% vs 10.3%; P < .0001) exposures. In multivariate analysis, antibiotic exposure-that is, cephalosporin (adjusted matched odds ratio [AmOR], 19.02; 95% CI, 1.13-321.39), clindamycin (AmOR, 35.31; 95% CI, 4.01-311.14), fluoroquinolone (AmOR, 30.71; 95% CI, 2.77-340.05) and beta-lactam and/or beta-lactamase inhibitor combination (AmOR, 9.87; 95% CI, 2.76-340.05),-emergency department visit (AmOR, 17.37; 95% CI, 1.99-151.22), white race (AmOR 7.67; 95% CI, 2.34-25.20), cardiac disease (AmOR, 4.87; 95% CI, 1.20-19.80), chronic kidney disease (AmOR, 12.12; 95% CI, 1.24-118.89), and inflammatory bowel disease (AmOR, 5.13; 95% CI, 1.27-20.79) were associated with CA-CDI. CONCLUSIONS Antibiotics remain an important risk factor for CA-CDI, underscoring the importance of appropriate outpatient prescribing. Emergency departments might be an environmental source of CDI; further investigation of their contribution to CDI transmission is needed.
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Affiliation(s)
- Alice Y Guh
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Susan Hocevar Adkins
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Qunna Li
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sandra N Bulens
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Monica M Farley
- Emory University Department of Medicine, Atlanta, Georgia
- Georgia Emerging Infections Program, Decatur, Georgia
- Atlanta Veterans Affairs Medical Center, Atlanta, Georgia
| | - Zirka Smith
- Georgia Emerging Infections Program, Decatur, Georgia
- Atlanta Veterans Affairs Medical Center, Atlanta, Georgia
- Atlanta Research and Education Foundation, Decatur, Georgia
| | - Stacy M Holzbauer
- Minnesota Department of Health, St Paul, Minnesota
- Career Epidemiology Field Officer Program, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Tory Whitten
- Minnesota Department of Health, St Paul, Minnesota
| | - Erin C Phipps
- University of New Mexico, New Mexico Emerging Infections Program, Albuquerque, New Mexico
| | - Emily B Hancock
- University of New Mexico, New Mexico Emerging Infections Program, Albuquerque, New Mexico
| | - Ghinwa Dumyati
- New York Emerging Infections Program and University of Rochester Medical Center, Rochester, New York
| | - Cathleen Concannon
- New York Emerging Infections Program and University of Rochester Medical Center, Rochester, New York
| | | | - Brenda Rue
- Tennessee Department of Health, Nashville, Tennessee
| | - Carol Lyons
- Yale School of Public Health, Connecticut Emerging Infections Program, New Haven, Connecticut
| | - Danyel M Olson
- Yale School of Public Health, Connecticut Emerging Infections Program, New Haven, Connecticut
| | - Lucy Wilson
- Maryland Department of Health and Mental Hygiene, Baltimore, Maryland
| | | | - Lisa G Winston
- University of California, San Francisco, School of Medicine, San Francisco, California
| | - Erin Parker
- California Emerging Infections Program, Oakland, California
| | - Wendy Bamberg
- Colorado Department of Public Health and Environment, Denver, Colorado
| | | | | | - Maria Karlsson
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Dale N Gerding
- Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
- Edward Hines, Jr. Veterans Affairs Hospital, Hines, Illinois
| | - L Clifford McDonald
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Clostridium difficile in Inflammatory Bowel Disease: A Retrospective Study. Gastroenterol Res Pract 2017; 2017:4803262. [PMID: 29109735 PMCID: PMC5646328 DOI: 10.1155/2017/4803262] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 07/24/2017] [Indexed: 01/03/2023] Open
Abstract
Aim To investigate the epidemiology and risk factors of Clostridium difficile infections (CDI) in patients with inflammatory bowel disease (IBD). Methods This is a retrospective study of patients diagnosed with IBD. 1006 charts were screened and 654 patients met the inclusion criteria. Patients were divided into 2 cohorts based on the presence of prior diagnosis of CDI. Statistical analysis with Pearson's chi-squared and two-sample t-test was performed. Results The incidence of CDI among IBD patients was 6.7%. There was equal prevalence of CDI among Crohn's disease (CD) (n = 21, 49%) and ulcerative colitis (UC) (n = 22, 51%). IBD patients acquired CDI at a mean age of 42.7 years, with 56% of infections acquired in the community and only 28% associated with healthcare. Only 30% of IBD patients with CDI had prior antibiotic use, and 16% had prior steroid use. IBD patients were significantly more likely to require biologic therapy (57% versus 37%, p < 0.01) and have extraintestinal manifestations of IBD (43% versus 28%, p < 0.02). Conclusions IBD patients are more susceptible to CDI at a younger age and often lack traditional risk factors. IBD patients with at least one CDI were more likely to require biologic therapy and had greater rates of extraintestinal manifestations.
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Al Otaibi H, Ahmed AE, Alammari M. Association between omeprazole use and Clostridium difficile infection among hospitalized patients: A case-control study of the Saudi population. Qatar Med J 2017; 2017:2. [PMID: 28785535 PMCID: PMC5522975 DOI: 10.5339/qmj.2017.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 06/06/2017] [Indexed: 12/18/2022] Open
Abstract
Background: While few international studies have assessed the association between omeprazole use and the risk of Clostridium difficile infection (CDI), research into this is lacking in Saudi Arabia and the Middle East region. The aim of this study was to determine whether exposure to omeprazole is associated with the risk of Clostridium difficile infection in a sample of hospitalized Saudi patients. Methodology: A retrospective matched case–control study was conducted at the King Abdulaziz Medical City in Riyadh, Saudi Arabia, from 1 August 2010 through 31 July 2015. The analysis included a total of 200 patients: 100 CDI cases and 100 matched controls. Results: The majority (60%, 120 out of 200) of patients had received proton pump inhibitors (PPIs), and a minority (18.5%, 37 out of 200) had received omeprazole. The PPI use was insignificantly higher in CDI cases than in controls. However, the use of omeprazole was significantly higher in CDI cases compared with controls. Specifically, patients receiving omeprazole were two times more likely to develop CDI compared with controls (aOR = 2.1, 95% confidence interval (CI) = (1.007–4.437)). After adjusting for potential predictors of CDI, watery diarrhea (aOR = 59.1, 95% CI = 19.831–175.974) and abdominal pain (aOR = 7.5, 95% CI = 2.184–25.445) were found to be independent predictors of CDI. Conclusions: The data suggests that PPIs were commonly used in patients admitted to King Abdulaziz Medical City in Riyadh: six out of ten patients received PPIs. The findings support a possible association between the use of omeprazole and a high risk of CDI. To confirm causality, the link between omeprazole and CDI should be assessed in a large interventional study.
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Affiliation(s)
| | - Anwar E Ahmed
- College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Maha Alammari
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Pharmaceutical Care Services, King Abdulaziz Medical City-Riyadh, Ministry of National Guard, Riyadh, Saudi Arabia
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Abrahamian FM, Talan DA, Krishnadasan A, Citron DM, Paulick AL, Anderson LJ, Goldstein EJ, Moran GJ, Abrahamian F, Moore J, Femling J, Chiang W, LoVecchio F, Jui J, Garg M, Steele M, Sullivan D, Rothman R. Clostridium difficile Infection Among US Emergency Department Patients With Diarrhea and No Vomiting. Ann Emerg Med 2017; 70:19-27.e4. [DOI: 10.1016/j.annemergmed.2016.12.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 12/04/2016] [Accepted: 12/08/2016] [Indexed: 12/24/2022]
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Incidence and Risk Factors for Community and Hospital Acquisition of Clostridium difficile Infection in the Tel Aviv Sourasky Medical Center. Infect Control Hosp Epidemiol 2017; 38:912-920. [DOI: 10.1017/ice.2017.82] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVESTo estimate the incidence and identified risk factors for community-acquired (CA) and hospital-acquired (HA) Clostridium difficile infection (CDI)METHODSWe conducted 2 parallel case-control studies at Tel Aviv Sourasky Medical Center from January 1, 2011, to December 31, 2014. We identified persons with CDI, determined whether infection was community or hospital acquired, and calculated incidence rates from 2007 to 2014. We collected demographic, clinical, and epidemiological information for CDI cases and hospitalized control cases and estimated the odds ratio with 95% confidence interval using conditional logistic regression.RESULTSIn total, 1,563 CDI cases were identified in the study. The incidence rate of CA-CDI and HA-CDI increased by 1.6-fold and 1.2-fold, respectively, during 2012–2014. However, the incidence rate of CA-CDI was 0.84 per 100,000 (95% CI, 0.52–1.30), the rate for HA-CDI was 4.7 per 10,000 patient days (95% CI, 4.08–5.38), respectively, in 2014. We identified several factors as independent variables significantly associated with HA-CDI: functional disability, presence of nasogastric tube, antibiotic use, chemotherapy, infection by extended-spectrum β-lactamases, and mean of albumin values. Risk factors independently associated with CA-CDI were close contact with a family member who had been hospitalized in the previous 6 months, inflammatory bowel disease, and home density index (adjusted odds ratio, 25.7; 95% confidence interval, 3.99–165.54; P=.001).CONCLUSIONSThe identification of the main modifiable risk factors for HA-CDI (antibiotic exposure and hypoalbuminemia) and for CA-CDI (close contact with a family member who had been hospitalized in the previous 6 months) is likely to optimize prevention efforts; these factors are critical in preventing the spread of CDI.Infect Control Hosp Epidemiol 2017;38:912–920
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72
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Investigation of community carriage rates of Clostridium difficile and Hungatella hathewayi in healthy volunteers from four regions of England. J Hosp Infect 2017; 97:153-155. [PMID: 28549779 DOI: 10.1016/j.jhin.2017.05.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 05/18/2017] [Indexed: 02/07/2023]
Abstract
Faecal samples from 1365 healthy asymptomatic volunteers from four regions in England were screened for the presence of Clostridium difficile between December 2013 and July 2014. The carriage rate of C. difficile in healthy patients was 0.5%, which is lower than reported previously. This study demonstrates that the true community reservoir of C. difficile in the healthy UK population is very low and is, therefore, unlikely to be a reservoir for infections diagnosed in the hospital setting.
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73
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Identification of novel risk factors for community-acquired Clostridium difficile infection using spatial statistics and geographic information system analyses. PLoS One 2017; 12:e0176285. [PMID: 28510584 PMCID: PMC5433765 DOI: 10.1371/journal.pone.0176285] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 04/07/2017] [Indexed: 02/04/2023] Open
Abstract
Background The rate of community-acquired Clostridium difficile infection (CA-CDI) is increasing. While receipt of antibiotics remains an important risk factor for CDI, studies related to acquisition of C. difficile outside of hospitals are lacking. As a result, risk factors for exposure to C. difficile in community settings have been inadequately studied. Main objective To identify novel environmental risk factors for CA-CDI Methods We performed a population-based retrospective cohort study of patients with CA-CDI from 1/1/2007 through 12/31/2014 in a 10-county area in central North Carolina. 360 Census Tracts in these 10 counties were used as the demographic Geographic Information System (GIS) base-map. Longitude and latitude (X, Y) coordinates were generated from patient home addresses and overlaid to Census Tracts polygons using ArcGIS; ArcView was used to assess “hot-spots” or clusters of CA-CDI. We then constructed a mixed hierarchical model to identify environmental variables independently associated with increased rates of CA-CDI. Results A total of 1,895 unique patients met our criteria for CA-CDI. The mean patient age was 54.5 years; 62% were female and 70% were Caucasian. 402 (21%) patient addresses were located in “hot spots” or clusters of CA-CDI (p<0.001). “Hot spot” census tracts were scattered throughout the 10 counties. After adjusting for clustering and population density, age ≥ 60 years (p = 0.03), race (<0.001), proximity to a livestock farm (0.01), proximity to farming raw materials services (0.02), and proximity to a nursing home (0.04) were independently associated with increased rates of CA-CDI. Conclusions Our study is the first to use spatial statistics and mixed models to identify important environmental risk factors for acquisition of C. difficile and adds to the growing evidence that farm practices may put patients at risk for important drug-resistant infections.
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Borren NZ, Ghadermarzi S, Hutfless S, Ananthakrishnan AN. The emergence of Clostridium difficile infection in Asia: A systematic review and meta-analysis of incidence and impact. PLoS One 2017; 12:e0176797. [PMID: 28463987 PMCID: PMC5413003 DOI: 10.1371/journal.pone.0176797] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 04/17/2017] [Indexed: 12/18/2022] Open
Abstract
Background Clostridium difficile infection (CDI) is the most common healthcare associated infection and is highly prevalent in Europe and North America. Limited data is available on the prevalence of CDI in Asia. However, secular increases in prevalence of risk factors for CDI suggest that it may be emerging as a major cause of morbidity, highlighting the urgent need for a systematic study of the prevalence of CDI in Asia. Methods We systematically searched PubMed/Medline and Embase for publications from Asia between 2000–16 examining prevalence of CDI. A random-effects meta-analysis was performed to calculate the pooled prevalence of CDI in Asia and to identify subgroups and regions at high risk. Results Our meta-analysis included 51 studies from throughout Asia including 37,663 patients at risk among whom confirmed CDI was found in 4,343 patients. The pooled proportion of confirmed CDI among all patients with diarrhea was 14.8% with a higher prevalence in East Asia (19.5%), compared with South Asia (10.5%) or the Middle East (11.1%). There were an estimated 5.3 episodes of CDI per 10,000 patient days, similar to rates reported from Europe and North America. Infections due to hypervirulent strains were rare. CDI-related mortality was 8.9%. Conclusions In a meta-analysis of 51 studies, we observed similar rates of CDI in Asia in comparison to Europe and North America. Increased awareness and improved surveillance of Clostridium difficile is essential to reduce incidence and morbidity.
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Affiliation(s)
- Nienke Z. Borren
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- University of Groningen, Groningen, The Netherlands
| | - Shadi Ghadermarzi
- Division of Gastroenterology & Hepatology, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Susan Hutfless
- Division of Gastroenterology & Hepatology, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Ashwin N. Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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75
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Kavanagh K, Pan J, Marwick C, Davey P, Wiuff C, Bryson S, Robertson C, Bennie M. Cumulative and temporal associations between antimicrobial prescribing and community-associated Clostridium difficile infection: population-based case-control study using administrative data. J Antimicrob Chemother 2017; 72:1193-1201. [PMID: 27999064 DOI: 10.1093/jac/dkw528] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 11/10/2016] [Indexed: 12/11/2022] Open
Abstract
Background Community-associated Clostridium difficile infection (CA-CDI; defined as cases without prior hospitalization in the previous 12 weeks who were either tested outside of hospital or tested within 2 days of admission to hospital) is a major public health problem. This study estimates the magnitude of the association between temporal and cumulative prescribing of antimicrobials in primary care and CA-CDI. Methods Three national patient-level datasets, covering CDI cases, community prescriptions and hospitalizations, were linked by the NHS Scotland unique patient identifier, the Community Health Index (CHI). All validated cases of CDI from August 2010 to July 2013 were extracted and up to six population-based controls were matched to each case from the CHI register for Scotland. Statistical analysis used conditional logistic regression. Results The 1446 unique cases of CA-CDI were linked with 7964 age-, sex- and location-matched controls. Cumulative exposure to any antimicrobial in the previous 6 months has a monotonic dose-response association with CA-CDI. Individuals with more than 28 DDDs to any antimicrobial (19.9% of cases) had an OR of 4.4 (95% CI 3.4-5.6) compared with those unexposed. Individuals exposed to 29+ DDDs of high-risk antimicrobials (cephalosporins, clindamycin, co-amoxiclav or fluoroquinolones) had an OR of 17.9 (95% CI 7.6-42.2). Elevated CA-CDI risk following high-risk antimicrobial exposure was greatest in the first month (OR = 12.5, 95% CI 8.9-17.4), but was still present 4-6 months later (OR = 2.6, 95% CI 1.7-3.9). Cases exposed to 29+ DDDs had prescription patterns more consistent with repeated therapeutic courses, using different antimicrobials, than long-term prophylactic use. Conclusions This analysis demonstrated temporal and dose-response associations between CA-CDI risk and antimicrobials, with an impact of exposure to high-risk antimicrobials remaining 4-6 months later.
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Affiliation(s)
- Kimberley Kavanagh
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK
- Information Services Division, NHS National Services Scotland, Edinburgh, UK
| | - Jiafeng Pan
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK
| | - Charis Marwick
- Population Health Sciences, School of Medicine, University of Dundee, Dundee, UK
| | - Peter Davey
- Population Health Sciences, School of Medicine, University of Dundee, Dundee, UK
| | - Camilla Wiuff
- Health Protection Scotland, NHS National Services Scotland, Glasgow, UK
| | - Scott Bryson
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Chris Robertson
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK
- Health Protection Scotland, NHS National Services Scotland, Glasgow, UK
- International Prevention Research Institute, Lyon, France
| | - Marion Bennie
- Information Services Division, NHS National Services Scotland, Edinburgh, UK
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
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Kola A, Wiuff C, Akerlund T, van Benthem BH, Coignard B, Lyytikäinen O, Weitzel-Kage D, Suetens C, Wilcox MH, Kuijper EJ, Gastmeier P. Survey of Clostridium difficile infection surveillance systems in Europe, 2011. ACTA ACUST UNITED AC 2017; 21:30291. [PMID: 27469420 DOI: 10.2807/1560-7917.es.2016.21.29.30291] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 06/03/2016] [Indexed: 01/03/2023]
Abstract
To develop a European surveillance protocol for Clostridium difficile infection (CDI), existing national CDI surveillance systems were assessed in 2011. A web-based electronic form was provided for all national coordinators of the European CDI Surveillance Network (ECDIS-Net). Of 35 national coordinators approached, 33 from 31 European countries replied. Surveillance of CDI was in place in 14 of the 31 countries, comprising 18 different nationwide systems. Three of 14 countries with CDI surveillance used public health notification of cases as the route of reporting, and in another three, reporting was limited to public health notification of cases of severe CDI. The CDI definitions published by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the European Centre for Disease Prevention and Control (ECDC) were widely used, but there were differing definitions to distinguish between community- and healthcare-associated cases. All CDI surveillance systems except one reported annual national CDI rates (calculated as number of cases per patient-days). Only four surveillance systems regularly integrated microbiological data (typing and susceptibility testing results). Surveillance methods varied considerably between countries, which emphasises the need for a harmonised European protocol to allow consistent monitoring of the CDI epidemiology at European level. The results of this survey were used to develop a harmonised EU-wide hospital-based CDI surveillance protocol.
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Affiliation(s)
- Axel Kola
- Charité - Universitätsmedizin Berlin, Germany
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Khanafer N, Vanhems P, Barbut F, Luxemburger C, Demont C, Hulin M, Dauwalder O, Vandenesch F, Argaud L, Badet L, Barth X, Bertrand M, Burillon C, Chapurlat R, Chuzeville M, Comte B, Disant F, Fessy MH, Gouillat C, Juillard L, Lermusiaux P, Monneuse O, Morelon E, Ninet J, Ponchon T, Poulet E, Rimmele T, Tazarourte K. Factors associated with Clostridium difficile infection: A nested case-control study in a three year prospective cohort. Anaerobe 2017; 44:117-123. [PMID: 28279859 DOI: 10.1016/j.anaerobe.2017.03.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 02/27/2017] [Accepted: 03/03/2017] [Indexed: 02/09/2023]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a serious medical condition that is associated with substantial morbidity and mortality. Identification of risk factors associated with CDI and prompt recognition of patients at risk is key to successfully preventing CDI. METHODS A 3-year prospective, observational, cohort study was conducted in a French university hospital and a nested case-control study was performed to identify risk factors for CDI. Inpatients aged 18 years or older, suffering from diarrhea suspected to be related to CDI, were asked to participate. RESULTS A total of 945 patients were included, of which 233 cases had a confirmed CDI. CDI infection was more common in men (58.4%) (P = 0.04) compared with patients with diarrhea not related to C. difficile. Previous hospitalization (P < 0.001), prior treatment with antibiotics (P = 0.001) or antiperistaltics (P = 0.002), liver disease (P = 0.003), malnutrition (P < 0.001), and previous CDI (P < 0.001) were significantly more common in patients with CDI. Multivariate logistic regression analysis showed that exposure to antibiotics in the last 60 days (especially third generation cephalosporins and penicillins with β-lactamase inhibitor), chronic renal or liver disease, malnutrition or previous CDI, were associated with an independent high risk of CDI. Age was not related with CDI. CONCLUSIONS This study showed that antibiotics and some comorbid conditions were predictors of CDI. Patients at high risk of acquiring CDI at the time of admission may benefit from careful monitoring of antibiotic prescriptions and early attention to infection control issues. In future, these "high-risk" patients may benefit from novel agents being developed to prevent CDI.
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Affiliation(s)
- Nagham Khanafer
- Epidemiology and Infection Control Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France; University of Lyon, Lyon, France.
| | - Philippe Vanhems
- Epidemiology and Infection Control Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France; University of Lyon, Lyon, France
| | - Frédéric Barbut
- Pierre and Marie Curie University, Paris, France; National Reference Laboratory for C. difficile, Saint Antoine Hospital, Paris, France
| | - Christine Luxemburger
- Epidemiology and Infection Control Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France; University of Lyon, Lyon, France.
| | | | | | - Monique Hulin
- Epidemiology and Infection Control Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France; University of Lyon, Lyon, France.
| | - Olivier Dauwalder
- Laboratory of Micro-biology Est, Hospices Civils de Lyon, Bron, France
| | | | | | - Laurent Argaud
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Lionel Badet
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Xavier Barth
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Malik Bertrand
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Carole Burillon
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Roland Chapurlat
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Michel Chuzeville
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Brigitte Comte
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - François Disant
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Michel Henry Fessy
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Christian Gouillat
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Laurent Juillard
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Patrick Lermusiaux
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Olivier Monneuse
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Emmanuel Morelon
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Jacques Ninet
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Thierry Ponchon
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Emmanuel Poulet
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Thomas Rimmele
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Karim Tazarourte
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
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Othman F, Crooks CJ, Card TR. The risk of Clostridium difficile infection in patients with pernicious anaemia: a retrospective cohort study using primary care database. United European Gastroenterol J 2017; 5:959-966. [PMID: 29163961 DOI: 10.1177/2050640617695697] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 01/31/2017] [Indexed: 01/05/2023] Open
Abstract
Background Studies have found an association between proton pump inhibitor (PPI) use and Clostridium difficile infection. The purpose of this study was to determine whether the mechanism by which PPIs induce an increased risk of C. difficile infection is supported by the same mechanism acting in another cause of achlorhydria, pernicious anaemia. Methods Using a database of anonymised primary care records between 1990 and 2013, we selected exposed patients with a diagnosis of pernicious anaemia treated with vitamin B12 therapy. Each exposed patient was matched by age, gender and general practice to up to 10 controls. Cox regression analysis was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) for C. difficile infection with pernicious anaemia, adjusted for potential confounders. Results We identified 45,467 exposed patients matched to 449,635 controls. The crude incidence rate of C. difficile infection was 1.85/1000 person-years for the exposed cohort and 1.09/1000 person-years for controls. Patients with pernicious anaemia had a greater risk of C. difficile infection than the controls (adjusted HR 1.57, 95% CI 1.40-1.76). Conclusions Pernicious anaemia patients have an increased risk of C. difficile infection. This supports the theory that severe achlorhydria is the mechanism that increases the risk of C. difficile infection in long-term PPI users.
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Affiliation(s)
- Fatmah Othman
- Department of Epidemiology and Public Health, University of Nottingham, Nottingham, UK.,Department of Basic Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Colin J Crooks
- Department of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | - Timothy R Card
- Department of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
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79
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Tang YM, Stone CD. Clostridium difficile infection in inflammatory bowel disease: challenges in diagnosis and treatment. Clin J Gastroenterol 2017; 10:112-123. [PMID: 28210836 DOI: 10.1007/s12328-017-0719-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 02/02/2017] [Indexed: 12/12/2022]
Abstract
The problem of Clostridium difficile infection (CDI) has reached epidemic proportions, particularly in industrialized nations. The pathophysiology, disease course and the potential complications are well appreciated in the general hospitalized patient. However, when CDI occurs in the setting of inflammatory bowel disease (IBD), a number of distinct differences in the diagnosis and clinical management of the infection in this population should be appreciated by gastroenterologists, hospitalists and other care providers. This review highlights the unique aspects of CDI when it occurs in IBD patients with an emphasis on the challenge of distinguishing persistent infection from exacerbation of underlying chronic colitis. An understanding of how CDI may differ in presentation and how management should be altered can prevent serious and life-threatening complications.
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Affiliation(s)
- Ying M Tang
- Section of Gastroenterology and Hepatology, Division of Gastroenterology and Hepatology, University of Nevada School of Medicine, 1701 W. Charleston Blvd, Suite 230, Las Vegas, NV, 89102, USA
| | - Christian D Stone
- Comprehensive Digestive Institute of Nevada, 8530 W. Sunset Rd, Suite 230, Las Vegas, NV, 89113, USA.
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80
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Makristathis A, Zeller I, Mitteregger D, Kundi M, Hirschl AM. Comprehensive evaluation of chemiluminescent immunoassays for the laboratory diagnosis of Clostridium difficile infection. Eur J Clin Microbiol Infect Dis 2017; 36:1253-1259. [PMID: 28181032 PMCID: PMC5495843 DOI: 10.1007/s10096-017-2916-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 01/24/2017] [Indexed: 01/05/2023]
Abstract
For the microbiological diagnosis of a Clostridium (C.) difficile infection (CDI), a two-test algorithm consisting of a C. difficile glutamate dehydrogenase (GDH)-immunoassay followed by a toxin-immunoassay in positive cases is widely used. In this study, two chemiluminescent immunoassays (CLIAs), one for GDH and the other for the toxins A and B, have been evaluated systematically using appropriate reference methods. Three-hundred diarrhoeal stool specimens submitted for CDI diagnosis were analysed by the LIAISON CLIAs (DiaSorin). Toxigenic culture (TC) and cell cytotoxicity assay (CCTA) were used as "gold standard" reference methods. In addition, GDH and toxin A and B enzyme immunoassays (EIAs), C. diff Chek-60 and toxin A/B II (TechLab), and the Cepheid Xpert C. difficile polymerase chain reaction (PCR) were performed. C. difficile was grown in 42 (14%), TC was positive in 35 (11.7%) and CCTA in 25 (8.3%) cases. CLIAs were more sensitive but less specific than the respective EIAs. Using culture as reference, the sensitivity of the GDH CLIA was 100%. In comparison to CCTA sensitivity, specificity, positive predictive value and negative predictive value of the two-test algorithm were 88, 99.3, 91.7 and 98.9% by CLIAs and 72, 99.6, 94.7 and 97.5% by EIAs. Discrepant results by CLIAs were more frequent than that by EIAs (9% vs. 6.3%); in those cases, PCR allowed for the accurate detection of toxigenic strains. Due to performance characteristics and testing comfort, CLIAs in combination with PCR represent a favourable option for the rapid laboratory C. difficile diagnostics.
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Affiliation(s)
- A Makristathis
- Division of Clinical Microbiology, Department of Laboratory Medicine, Medical University Vienna, Vienna, Austria.
| | - I Zeller
- Division of Clinical Microbiology, Department of Laboratory Medicine, Medical University Vienna, Vienna, Austria
| | - D Mitteregger
- Division of Clinical Microbiology, Department of Laboratory Medicine, Medical University Vienna, Vienna, Austria
| | - M Kundi
- Department of Environmental Hygiene, Medical University Vienna, Vienna, Austria
| | - A M Hirschl
- Division of Clinical Microbiology, Department of Laboratory Medicine, Medical University Vienna, Vienna, Austria
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81
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Wei L, Ratnayake L, Phillips G, McGuigan CC, Morant SV, Flynn RW, Mackenzie IS, MacDonald TM. Acid-suppression medications and bacterial gastroenteritis: a population-based cohort study. Br J Clin Pharmacol 2017; 83:1298-1308. [PMID: 28054368 PMCID: PMC5427234 DOI: 10.1111/bcp.13205] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 10/25/2016] [Accepted: 11/21/2016] [Indexed: 12/12/2022] Open
Abstract
Aims To investigate whether acid‐suppression medicines (ASMs) increase the risk of bacterial gastroenteritis. Methods A population‐based, propensity‐score matched cohort study using a record‐linkage database in Tayside, UK. The study consisted of 188 323 exposed to ASMs (proton‐pump inhibitors and histamine‐2 receptor antagonists) and 376 646 controls (a propensity‐score matched cohort from the rest of population who were not exposed to ASMs) between 1999 and 2013. The main outcome measure was a positive stool test for Clostridiumdifficile, Campylobacter, Salmonella, Shigella or Escherichia coli O157. The association between ASMs and risk of bacterial gastroenteritis was assessed by a Cox regression model. Results There were 22 705 positive test results (15 273 C. difficile [toxin positive], 6590 Campylobacter, 852 Salmonella, 129 Shigella and 193 E. coli O157, not mutually exclusive) with a total of 5 729 743 person‐years follow up time in Tayside, 1999–2013. The adjusted hazard ratios for culture positive diarrhoea for the proton‐pump inhibitors and histamine‐2 receptor antagonists exposed vs. unexposed cohort were 2.72 (95% confidence interval [CI] 2.33, 3.17) during follow–up time for samples submitted from the community and 1.28 (95% CI 1.08, 1.52) for samples submitted from hospitals. Compared with the unexposed cohort, patients in the exposed group had increased risks of C. difficile and Campylobacter [adjusted hazard ratios of 1.70 (95% CI 1.28, 2.25), 3.71 (95% CI 3.04, 4.53) for community samples, and 1.42 (95% CI 1.17, 1.71), 4.53 (95% CI 1.75, 11.8) for hospital samples, respectively]. Conclusions The results suggest that community prescribed ASMs were associated with increased rates of C. difficile and Campylobacter positive gastroenteritis in both the community and hospital settings.
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Affiliation(s)
- Li Wei
- Department of Practice and Policy, School of Pharmacy, University College London, 29-39 Brunswick Square, London, WC1N 1AX, UK
| | - Lasantha Ratnayake
- James Paget University Hospitals NHS Foundation Trust, Lowestoft Road, Gorleston-on-Sea. Norfolk, NR31 6LA, UK
| | - Gabby Phillips
- Medical Microbiology, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - Chris C McGuigan
- NHS Tayside, Directorate of Public Health, King's Cross, 350 Clepington Road, Dundee, DD3 8EA, UK
| | - Steve V Morant
- Medicines Monitoring Unit, Division of Medical Sciences, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - Robert W Flynn
- Medicines Monitoring Unit, Division of Medical Sciences, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - Isla S Mackenzie
- Medicines Monitoring Unit, Division of Medical Sciences, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - Thomas M MacDonald
- Medicines Monitoring Unit, Division of Medical Sciences, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
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82
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Bauer MP, Kuijper J. Clostridium difficile Infections in Hospitals and Community. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00040-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Comparison of Clostridium difficile Ribotypes Circulating in Australian Hospitals and Communities. J Clin Microbiol 2016; 55:216-225. [PMID: 27807147 DOI: 10.1128/jcm.01779-16] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/26/2016] [Indexed: 01/05/2023] Open
Abstract
Clostridium difficile infection (CDI) is becoming less exclusively a health care-associated CDI (HA-CDI). The incidence of community-associated CDI (CA-CDI) has increased over the past few decades. It has been postulated that asymptomatic toxigenic C. difficile (TCD)-colonized patients may play a role in the transfer of C. difficile between the hospital setting and the community. Thus, to investigate the relatedness of C. difficile across the hospital and community settings, we compared the characteristics of symptomatic and asymptomatic host patients and the pathogens from these patients in these two settings over a 3-year period. Two studies were simultaneously conducted; the first study enrolled symptomatic CDI patients from two tertiary care hospitals and the community in two Australian states, while the second study enrolled asymptomatic TCD-colonized patients from the same tertiary care hospitals. A total of 324 patients (96 with HA-CDI, 152 with CA-CDI, and 76 colonized with TCD) were enrolled. The predominant C. difficile ribotypes isolated in the hospital setting corresponded with those isolated in the community, as it was found that for 79% of the C. difficile isolates from hospitals, an isolate with a matching ribotype was isolated in the community, suggesting that transmission between these two settings is occurring. The toxigenic C. difficile strains causing symptomatic infection were similar to those causing asymptomatic infection, and patients exposed to antimicrobials prior to admission were more likely to develop a symptomatic infection (odds ratio, 2.94; 95% confidence interval, 1.20 to 7.14). Our findings suggest that the development of CDI symptoms in a setting without establishment of hospital epidemics with binary toxin-producing C. difficile strains may be driven mainly by host susceptibility and exposure to antimicrobials, rather than by C. difficile strain characteristics.
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84
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Tsai CS, Hung YP, Lee JC, Lee NY, Chen PL, Syue LS, Li MC, Li CW, Ko WC. Community-onset Clostridium difficile infection at a tertiary medical center in southern Taiwan, 2007-2015. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2016; 51:243-250. [PMID: 28089100 DOI: 10.1016/j.jmii.2016.08.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 08/22/2016] [Accepted: 08/23/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is well-known as the major cause of infectious diarrhea in hospitalized patients. Community-onset CDI (CO-CDI) is an emerging threat. However, clinical information of CO-CDI in Taiwan remains scarce. METHODS A retrospective study was conducted at a medical center in southern Taiwan. Symptomatic patients between 2007 and 2015 with C. difficile toxin or tcdB detected in stool were identified as CDI, and were classified as CO-CDI [including community-associated CDI (CA-CDI) and community-onset health care facility-associated CDI (CO-HCFA-CDI)] and health care facility-onset CDI (HCFO-CDI). RESULTS Of 427 patients, 15 (3.5%) were CA-CDI, 49 (11.5%) CO-HCFA-CDI, and 363 (85.0%) HCFO-CDI. Despite major involvement of the elderly (mean age: 66.1 years vs. 69.9 years, p = 0.46), no significant differences were noted between CA-CDI and CO-HCFA-CDI groups, except that solid organ cancer was more common in the CO-HCFA-CDI group. The CO-CDI group more often presented with abdominal pain but had shorter hospital stays and less exposure of proton-pump inhibitors or broad-spectrum antibiotics than the HCFO-CDI group did. The mortality rate related to CDI was 4.7% (3 patients) in the CO-CDI group. Despite a lower in-hospital mortality rate in the CO-CDI group (10.9% vs. 22.0%; p = 0.04), the recurrence rate was similar (10.9% vs. 7.2%; p = 0.3). CONCLUSIONS CO-CDI is not common but associated with substantial morbidity and mortality. Physicians should put CDI into consideration among patients who present community-onset fever, diarrhea, or abdominal pain alone or in combination.
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Affiliation(s)
- Chin-Shiang Tsai
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yuan-Pin Hung
- Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan; Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Executive Yuan, Tainan, Taiwan
| | - Jen-Chieh Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Nan-Yao Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan
| | - Po-Lin Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan
| | - Ling-Shan Syue
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ming-Chi Li
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chia-Wen Li
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan.
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85
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Clostridium-difficile-Infektion bei geriatrischen Patienten. Z Gerontol Geriatr 2016; 49:743-761. [DOI: 10.1007/s00391-016-1143-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 08/24/2016] [Accepted: 09/22/2016] [Indexed: 02/07/2023]
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86
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Hussain I, Borah P, Sharma R, Rajkhowa S, Rupnik M, Saikia D, Hasin D, Hussain I, Deka N, Barkalita L, Nishikawa Y, Ramamurthy T. Molecular characteristics of Clostridium difficile isolates from human and animals in the North Eastern region of India. Mol Cell Probes 2016; 30:306-311. [DOI: 10.1016/j.mcp.2016.08.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 08/18/2016] [Accepted: 08/25/2016] [Indexed: 11/15/2022]
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87
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Community-acquired Clostridium difficile infections in emergency departments. Med Mal Infect 2016; 46:372-379. [DOI: 10.1016/j.medmal.2016.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 03/27/2016] [Accepted: 06/07/2016] [Indexed: 12/15/2022]
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88
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The Cost-efficiency and Care Effectiveness of Probiotic Administration with Antibiotics to Prevent Hospital-Acquired Clostridium difficile Infection. Qual Manag Health Care 2016; 25:238-243. [DOI: 10.1097/qmh.0000000000000110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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89
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Wilcox MH, Chalmers JD, Nord CE, Freeman J, Bouza E. Role of cephalosporins in the era of Clostridium difficile infection. J Antimicrob Chemother 2016; 72:1-18. [PMID: 27659735 PMCID: PMC5161048 DOI: 10.1093/jac/dkw385] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The incidence of Clostridium difficile infection (CDI) in Europe has increased markedly since 2000. Previous meta-analyses have suggested a strong association between cephalosporin use and CDI, and many national programmes on CDI control have focused on reducing cephalosporin usage. Despite reductions in cephalosporin use, however, rates of CDI have continued to rise. This review examines the potential association of CDI with cephalosporins, and considers other factors that influence CDI risk. EUCLID (the EUropean, multicentre, prospective biannual point prevalence study of CLostridium difficile Infection in hospitalized patients with Diarrhoea) reported an increase in the annual incidence of CDI from 6.6 to 7.3 cases per 10 000 patient bed-days from 2011-12 to 2012-13, respectively. While CDI incidence and cephalosporin usage varied widely across countries studied, there was no clear association between overall cephalosporin prescribing (or the use of any particular cephalosporin) and CDI incidence. Moreover, variations in the pharmacokinetic and pharmacodynamic properties of cephalosporins of the same generation make categorization by generation insufficient for predicting impact on gut microbiota. A multitude of additional factors can affect the risk of CDI. Antibiotic choice is an important consideration; however, CDI risk is associated with a range of antibiotic classes. Prescription of multiple antibiotics and a long duration of treatment are key risk factors for CDI, and risk also differs across patient populations. We propose that all of these are factors that should be taken into account when selecting an antibiotic, rather than focusing on the exclusion of individual drug classes.
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Affiliation(s)
- Mark H Wilcox
- Leeds Institute of Biomedical and Clinical Sciences, Faculty of Medicine and Health, University of Leeds, and Microbiology, Leeds Teaching Hospitals, Leeds, UK
| | - James D Chalmers
- Tayside Respiratory Research Group, University of Dundee, Dundee, UK
| | - Carl E Nord
- Department of Laboratory Medicine, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Jane Freeman
- Leeds Institute of Biomedical and Clinical Sciences, Faculty of Medicine and Health, University of Leeds, and Microbiology, Leeds Teaching Hospitals, Leeds, UK
| | - Emilio Bouza
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Longitudinal Investigation of Carriage Rates, Counts, and Genotypes of Toxigenic Clostridium difficile in Early Infancy. Appl Environ Microbiol 2016; 82:5806-14. [PMID: 27451451 DOI: 10.1128/aem.01540-16] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 07/13/2016] [Indexed: 01/15/2023] Open
Abstract
UNLABELLED Asymptomatic infant carriers of toxigenic Clostridium difficile are suggested to play a role in the transmission of C. difficile infection (CDI) in adults. However, the mode of C. difficile carriage in infants remains to be fully elucidated. We investigated longitudinal changes in carriage rates, counts, and strain types of toxigenic C. difficile in infants. Stools collected from 111 healthy infants in Belgium periodically from birth until the age of 6 months were examined by quantitative PCR targeting 16S rRNA and toxin genes. Toxigenic C. difficile was detected in 18 of 111 infants (16%) in the period up to the age of 6 months. The carriage rate of toxigenic C. difficile remained below 5% until the age of 3 months. The carriage rate increased to 13% 1 week after weaning (average age, 143 days) and reached 16% at the age of 6 months. Counts of toxigenic C. difficile bacteria ranged from 10(4) to 10(8) cells/g of stool. Notably, two infants retained >10(8) cells/g of stool for at least several weeks. Average counts in the 18 infants hovered around 10(7) cells/g of stool from the age of 3 days until the age of 6 months, showing no age-related trend. Genotyping of toxigenic C. difficile isolates from the 18 infants revealed that 11 infants each retained a particular monophyletic strain for at least a month. The genotype most frequently identified was the same as that frequently identified in symptomatic adult CDI patients. Thus, toxigenic C. difficile strains-potential causes of CDI in adults-colonized the infants' intestines. IMPORTANCE Our study provides longitudinal data on counts and strain types of toxigenic C. difficile in infants. We found that considerable numbers of toxigenic C. difficile bacteria colonized the infants' intestines. The results of strain typing suggest that toxigenic C. difficile carried by healthy infants could be potentially pathogenic to adults. These results and findings are informative not only for ecological studies but also for efforts to prevent or control the spread of CDI in adults.
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Bloomfield LE, Riley TV. Epidemiology and Risk Factors for Community-Associated Clostridium difficile Infection: A Narrative Review. Infect Dis Ther 2016; 5:231-51. [PMID: 27370914 PMCID: PMC5019973 DOI: 10.1007/s40121-016-0117-y] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Indexed: 12/13/2022] Open
Abstract
Clostridium difficile infection (CDI) was once considered a primarily nosocomial concern. Emerging evidence from the last 20 years has highlighted a drastic shift in the known epidemiology of CDI, with disease outside of hospitals apparently occurring more frequently and causing severe disease in populations that were thought to be at low risk. This narrative review summarises potential pathways for infection outside of the hospital environment and highlights likely routes of transmission. Further, evidence is presented on potential risk factors for development of disease. Understanding the epidemiology of CDI outside of hospitals is essential to the ability to prevent and control disease in vulnerable populations.
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Affiliation(s)
- Lauren E Bloomfield
- School of Health Sciences, Flinders University, Bedford Park, SA, Australia
- Western Australian Department of Health, Communicable Diseases Control Directorate, Shenton Park, WA, Australia
| | - Thomas V Riley
- Department of Microbiology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Nedlands, WA, Australia.
- School of Medical and Health Sciences, Edith Cowan University, Joondalup Drive, Joondalup, 6027, WA, Australia.
- School of Veterinary and Life Sciences, Murdoch University, South Street, Murdoch, 6150, WA, Australia.
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92
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Vickers RJ, Tillotson G, Goldstein EJC, Citron DM, Garey KW, Wilcox MH. Ridinilazole: a novel therapy for Clostridium difficile infection. Int J Antimicrob Agents 2016; 48:137-43. [PMID: 27283730 DOI: 10.1016/j.ijantimicag.2016.04.026] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 04/22/2016] [Accepted: 04/23/2016] [Indexed: 12/15/2022]
Abstract
Clostridium difficile infection (CDI) is the leading cause of infectious healthcare-associated diarrhoea. Recurrent CDI increases disease morbidity and mortality, posing a high burden to patients and a growing economic burden to the healthcare system. Thus, there exists a significant unmet and increasing medical need for new therapies for CDI. This review aims to provide a concise summary of CDI in general and a specific update on ridinilazole (formerly SMT19969), a novel antibacterial currently under development for the treatment of CDI. Owing to its highly targeted spectrum of activity and ability to spare the normal gut microbiota, ridinilazole provides significant advantages over metronidazole and vancomycin, the mainstay antibiotics for CDI. Ridinilazole is bactericidal against C. difficile and exhibits a prolonged post-antibiotic effect. Furthermore, treatment with ridinilazole results in decreased toxin production. A phase 1 trial demonstrated that oral ridinilazole is well tolerated and specifically targets clostridia whilst sparing other faecal bacteria. Phase 2 and 3 trials will hopefully further our understanding of the clinical utility of ridinilazole for the treatment of CDI.
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Affiliation(s)
- Richard J Vickers
- Summit Therapeutics plc, 85b Park Drive, Milton Park, Abingdon, Oxford OX14 4RY, UK.
| | | | - Ellie J C Goldstein
- R.M. Alden Research Laboratory, Culver City, CA, USA; David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Kevin W Garey
- University of Houston College of Pharmacy, Houston, TX, USA
| | - Mark H Wilcox
- Microbiology, Leeds Teaching Hospitals and University of Leeds, Old Medical School, Leeds General Infirmary, Leeds, UK
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93
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Crobach MJT, Planche T, Eckert C, Barbut F, Terveer EM, Dekkers OM, Wilcox MH, Kuijper EJ. European Society of Clinical Microbiology and Infectious Diseases: update of the diagnostic guidance document for Clostridium difficile infection. Clin Microbiol Infect 2016; 22 Suppl 4:S63-81. [PMID: 27460910 DOI: 10.1016/j.cmi.2016.03.010] [Citation(s) in RCA: 362] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 03/02/2016] [Accepted: 03/10/2016] [Indexed: 12/14/2022]
Abstract
In 2009 the first European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guideline for diagnosing Clostridium difficile infection (CDI) was launched. Since then newer tests for diagnosing CDI have become available, especially nucleic acid amplification tests. The main objectives of this update of the guidance document are to summarize the currently available evidence concerning laboratory diagnosis of CDI and to formulate and revise recommendations to optimize CDI testing. This update is essential to improve the diagnosis of CDI and to improve uniformity in CDI diagnosis for surveillance purposes among Europe. An electronic search for literature concerning the laboratory diagnosis of CDI was performed. Studies evaluating a commercial laboratory test compared to a reference test were also included in a meta-analysis. The commercial tests that were evaluated included enzyme immunoassays (EIAs) detecting glutamate dehydrogenase, EIAs detecting toxins A and B and nucleic acid amplification tests. Recommendations were formulated by an executive committee, and the strength of recommendations and quality of evidence were graded using the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system. No single commercial test can be used as a stand-alone test for diagnosing CDI as a result of inadequate positive predictive values at low CDI prevalence. Therefore, the use of a two-step algorithm is recommended. Samples without free toxin detected by toxins A and B EIA but with positive glutamate dehydrogenase EIA, nucleic acid amplification test or toxigenic culture results need clinical evaluation to discern CDI from asymptomatic carriage.
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Affiliation(s)
- M J T Crobach
- Department of Medical Microbiology, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - T Planche
- Department of Medical Microbiology, St. George's Hospital, London, UK
| | - C Eckert
- National Reference Laboratory for Clostridium difficile, Paris, France
| | - F Barbut
- National Reference Laboratory for Clostridium difficile, Paris, France
| | - E M Terveer
- Department of Medical Microbiology, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - O M Dekkers
- Departments of Clinical Epidemiology and Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands; Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - M H Wilcox
- Department of Microbiology, Leeds Teaching Hospitals & University of Leeds, Leeds, UK
| | - E J Kuijper
- Department of Medical Microbiology, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands.
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94
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Fawley WN, Davies KA, Morris T, Parnell P, Howe R, Wilcox MH. Enhanced surveillance of Clostridium difficile infection occurring outside hospital, England, 2011 to 2013. Euro Surveill 2016; 21:30295. [DOI: 10.2807/1560-7917.es.2016.21.29.30295] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 03/18/2016] [Indexed: 12/20/2022] Open
Abstract
There are limited national epidemiological data for community-associated (CA)-Clostridium difficile infections (CDIs). Between March 2011 and March 2013, laboratories in England submitted to the Clostridium difficile Ribotyping Network (CDRN) up to 10 diarrhoeal faecal samples from successive patients with CA-CDI, defined here as C. difficile toxin-positive diarrhoea commencing outside hospital (or less than 48 hours after hospital admission), including those cases associated with community-based residential care, with no discharge from hospital within the previous 12 weeks. Patient demographics and C. difficile PCR ribotypes were compared for CA-CDIs in our study and presumed healthcare-associated (HA) CDIs via CDRN. Ribotype diversity indices, ranking and relative prevalences were very similar in CA- vs HA-CDIs, although ribotypes 002 (p ≤ 0.0001),020 (p = 0.009) and 056 (p < 0.0001) predominated in CA-CDIs; ribotype 027 (p = 0.01) predominated in HA-CDIs. Epidemic ribotypes 027 and 078 predominated in institutional residents with CDI (including care/nursing homes) compared with people with CDI living at home. Ribotype diversity decreased with increasing age in HA-CDIs, but not in CA-CDIs. Ribotype 078 CA-CDIs were significantly more common in elderly people (3.4% (6/174) vs 8.7% (45/519) in those aged < 65 and ≥ 65 years, respectively; p = 0.019). No antibiotics were prescribed in the previous four weeks in about twofold more CA-CDI vs HAs (38.6% (129/334) vs 20.3% (1,226/6,028); p < 0.0001). We found very similar ribotype distributions in CA- and HA-CDIs, although a few ribotypes significantly predominated in one setting. These national data emphasise the close interplay between, and likely common reservoirs for, CDIs, particularly when epidemic strains are not dominant.
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Affiliation(s)
- Warren N Fawley
- Public Health Laboratory Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Kerrie A Davies
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Trefor Morris
- UK Anaerobe Reference Unit (UKARU), Public Health Wales, Cardiff, United Kingdom
| | - Peter Parnell
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Robin Howe
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom
| | - Mark H Wilcox
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
- Public Health Laboratory Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
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95
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Miller AC, Polgreen LA, Cavanaugh JE, Polgreen PM. Hospital Clostridium difficile infection (CDI) incidence as a risk factor for hospital-associated CDI. Am J Infect Control 2016; 44:825-9. [PMID: 26944007 DOI: 10.1016/j.ajic.2016.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 12/23/2015] [Accepted: 01/04/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Environmental risk factors for Clostridium difficile infections (CDIs) have been described at the room or unit level but not the hospital level. To understand the environmental risk factors for CDI, we investigated the association between institutional- and individual-level CDI. METHODS We performed a retrospective cohort study using the Healthcare Cost and Utilization Project state inpatient databases for California (2005-2011). For each patient's hospital stay, we calculated the hospital CDI incidence rate corresponding to the patient's quarter of discharge, while excluding each patient's own CDI status. Adjusting for patient and hospital characteristics, we ran a pooled logistic regression to determine individual CDI risk attributable to the hospital's CDI rate. RESULTS There were 10,329,988 patients (26,086 cases and 10,303,902 noncases) who were analyzed. We found that a percentage point increase in the CDI incidence rate a patient encountered increased the odds of CDI by a factor of 1.182. CONCLUSIONS As a point of comparison, a 1-percentage point increase in the CDI incidence rate that the patient encountered had roughly the same impact on their odds of acquiring CDI as a 55.8-day increase in their length of stay or a 60-year increase in age. Patients treated in hospitals with a higher CDI rate are more likely to acquire CDI.
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96
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Lees EA, Miyajima F, Pirmohamed M, Carrol ED. The role of Clostridium difficile in the paediatric and neonatal gut - a narrative review. Eur J Clin Microbiol Infect Dis 2016; 35:1047-57. [PMID: 27107991 PMCID: PMC4902830 DOI: 10.1007/s10096-016-2639-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 03/22/2016] [Indexed: 01/15/2023]
Abstract
Clostridium difficile is an important nosocomial pathogen in adults. Its significance in children is less well defined, but cases of C. difficile infection (CDI) appear to be increasingly prevalent in paediatric patients. This review aims to summarize reported Clostridium difficile carriage rates across children of different age groups, appraise the relationship between CDI and factors such as method of delivery, type of infant feed, antibiotic use, and co-morbidities, and review factors affecting the gut microbiome in children and the host immune response to C. difficile. Searches of PubMed and Google Scholar using the terms 'Clostridium difficile neonates' and 'Clostridium difficile children' were completed, and reference lists of retrieved publications screened for further papers. In total, 88 papers containing relevant data were included. There was large inter-study variation in reported C. difficile carriage rates. There was an association between CDI and recent antibiotic use, and co-morbidities such as immunosuppression and inflammatory bowel disease. C. difficile was also found in stools of children with diarrhoea attributed to other pathogens (e.g. rotavirus). The role of C. difficile in the paediatric gut remains unclear; is it an innocent bystander in diarrhoeal disease caused by other organisms, or a pathogen causing subclinical to severe symptoms? Further investigation of the development of serological and local host response to C. difficile carriage may shed new light on disease mechanisms. Work is underway on defining a framework for diagnosis and management of paediatric CDI.
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Affiliation(s)
- E A Lees
- University of Liverpool Institute of Translational Medicine, Wolfson Centre, Block A: Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL, UK.
| | - F Miyajima
- University of Liverpool Institute of Translational Medicine, Wolfson Centre, Block A: Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - M Pirmohamed
- University of Liverpool Institute of Translational Medicine, Wolfson Centre, Block A: Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - E D Carrol
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, Ronald Ross Building, West Derby Street, Liverpool, L69 7BE, UK
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97
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Gupta A, Pardi DS, Baddour LM, Khanna S. Outcomes in children with Clostridium difficile infection: results from a nationwide survey. Gastroenterol Rep (Oxf) 2016; 4:293-298. [PMID: 27081152 PMCID: PMC5193063 DOI: 10.1093/gastro/gow007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 02/14/2016] [Accepted: 02/23/2016] [Indexed: 01/12/2023] Open
Abstract
Objective: Hospital- and population-based studies demonstrate an increasing incidence of Clostridium difficile infection (CDI) in adults and children; although pediatric CDI outcomes are incompletely understood. We analysed United States National Hospital Discharge Survey (NHDS) data to study CDI in hospitalized children. Methods: NHDS data for 2005–2009 (demographics, diagnoses and discharge status) were obtained; cases and comorbidities were identified using ICD-9 codes. Weighted univariate and multivariate analyses were performed to ascertain incidence of CDI; associations between CDI and outcomes [length of stay (LOS), colectomy, all-cause in-hospital mortality and discharge to a care facility (DTCF)]. Results: Of an estimated 13.8 million pediatric inpatients; 46 176 had CDI; median age was 3 years; overall incidence was 33.5/10 000 hospitalizations. The annual frequency of CDI did not vary from 2005 to 2009 (0.24–0.43%; P = 0.64). On univariate analyses, children with CDI had a longer median LOS (6 vs 2 days), higher rates of colectomy [odds ratio (OR) 2.0; 95% confidence interval (CI) 1.7–2.4], mortality (OR 2.5; 95% CI 2.3–2.7), and DTCF (OR 1.6; 95% CI 1.6–1.7) (all P < 0.0001). After adjusting for age, sex and comorbidities, CDI was an independent and the strongest predictor of increased LOS (adjusted mean difference, 6.4 days; 95% CI 5.4–7.4), higher rates of colectomy (OR 2.1; 95% CI 1.8–2.5), mortality (OR 2.3; 95% CI 2.2–2.5), and DTCF (OR 1.7; 95% CI 1.6–1.8) (all P < 0.0001). On excluding infants from the analysis, children with CDI had higher rates of mortality, DTCF and longer LOS than children without CDI. Conclusions: Despite increased awareness and advancements in management, CDI remains a significant problem and is associated with increased LOS, colectomy, in-hospital mortality and DTCF in hospitalized children.
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Affiliation(s)
- Arjun Gupta
- Divisions of Infectious Diseases, Mayo Clinic, Rochester, MN, USA.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Darrell S Pardi
- Divisions of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Larry M Baddour
- Divisions of Infectious Diseases, Mayo Clinic, Rochester, MN, USA
| | - Sahil Khanna
- Divisions of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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98
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Abstract
Infection of the colon with the Gram-positive bacterium Clostridium difficile is potentially life threatening, especially in elderly people and in patients who have dysbiosis of the gut microbiota following antimicrobial drug exposure. C. difficile is the leading cause of health-care-associated infective diarrhoea. The life cycle of C. difficile is influenced by antimicrobial agents, the host immune system, and the host microbiota and its associated metabolites. The primary mediators of inflammation in C. difficile infection (CDI) are large clostridial toxins, toxin A (TcdA) and toxin B (TcdB), and, in some bacterial strains, the binary toxin CDT. The toxins trigger a complex cascade of host cellular responses to cause diarrhoea, inflammation and tissue necrosis - the major symptoms of CDI. The factors responsible for the epidemic of some C. difficile strains are poorly understood. Recurrent infections are common and can be debilitating. Toxin detection for diagnosis is important for accurate epidemiological study, and for optimal management and prevention strategies. Infections are commonly treated with specific antimicrobial agents, but faecal microbiota transplants have shown promise for recurrent infections. Future biotherapies for C. difficile infections are likely to involve defined combinations of key gut microbiota.
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Affiliation(s)
- Wiep Klaas Smits
- Section Experimental Bacteriology, Department of Medical Microbiology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Dena Lyras
- Infection and Immunity Program, Monash Biomedicine Discovery Institute, and Department of Microbiology, Monash University, Victoria, Australia
| | - D. Borden Lacy
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, and The Veterans Affairs Tennessee Valley Healthcare System, Nashville Tennessee, USA
| | - Mark H. Wilcox
- Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Ed J. Kuijper
- Section Experimental Bacteriology, Department of Medical Microbiology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
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99
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Esteban-Vasallo MD, Naval Pellicer S, Domínguez-Berjón MF, Cantero Caballero M, Asensio Á, Saravia G, Astray-Mochales J. Age and gender differences in Clostridium difficile-related hospitalization trends in Madrid (Spain) over a 12-year period. Eur J Clin Microbiol Infect Dis 2016; 35:1037-44. [PMID: 27056555 DOI: 10.1007/s10096-016-2635-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 03/21/2016] [Indexed: 02/08/2023]
Abstract
This study aimed to analyze temporal trends by gender and age in Clostridium difficile infection (CDI)-related hospitalization rates in the Autonomous Community of Madrid (Spain) over a 12-year period. A population-based cross-sectional study of all hospital admissions with a CDI diagnosis from 2003 to 2014 was carried out. Annual age-specific hospitalization rates were calculated by gender. All the analyses were performed separately for total hospitalizations and hospitalizations with CDI as the primary diagnosis. Joinpoint regression models were used to analyze time trends. A total of 13,526 hospital discharges were identified (26.8 % with CDI as the primary diagnosis). In both sexes, a gradient in age-specific rates was observed, ranging in 2014 from 5.92 hospitalizations per 100,000 person-years in patients <15 years of age to 378.96 in patients ≥85 years of age. Since 2009, in the age group of 15-44 years, both men and women presented an increasing trend of around 18 %. A significantly increasing trend was detected in women of age 45-84 years, with an estimated annual percentage of change of 7.6 % in the age group of 45-64 years, and rounding with 4.5 % in the age group of 65-84 years. In men of age 45-64 years, the average annual percentage of increase was 4.7 %, and it was 21.1 % between 2010 and 2014 in the age group of 65-74 years. No trends were identified in the 85 years and over age group. Surveillance methods to assess trends by age group should be implemented. Preventive and therapeutic initiatives should remain a priority.
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Affiliation(s)
- M D Esteban-Vasallo
- Public Health Directorate, Madrid Regional Health Authority, San Martín de Porres, 6, 28035, Madrid, Spain.
| | - S Naval Pellicer
- Public Health Directorate, Madrid Regional Health Authority, San Martín de Porres, 6, 28035, Madrid, Spain
| | - M F Domínguez-Berjón
- Public Health Directorate, Madrid Regional Health Authority, San Martín de Porres, 6, 28035, Madrid, Spain
| | - M Cantero Caballero
- Preventive Medicine Service, Puerta de Hierro-Majadahonda Hospital, Manuel de Falla, 1, 28222, Majadahonda, Madrid, Spain
| | - Á Asensio
- Preventive Medicine Service, Puerta de Hierro-Majadahonda Hospital, Manuel de Falla, 1, 28222, Majadahonda, Madrid, Spain
| | - G Saravia
- Public Health Directorate, Madrid Regional Health Authority, San Martín de Porres, 6, 28035, Madrid, Spain
| | - J Astray-Mochales
- Public Health Directorate, Madrid Regional Health Authority, San Martín de Porres, 6, 28035, Madrid, Spain
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100
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Clostridium difficile infection: epidemiology, diagnosis and understanding transmission. Nat Rev Gastroenterol Hepatol 2016; 13:206-16. [PMID: 26956066 DOI: 10.1038/nrgastro.2016.25] [Citation(s) in RCA: 219] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Clostridium difficile infection (CDI) continues to affect patients in hospitals and communities worldwide. The spectrum of clinical disease ranges from mild diarrhoea to toxic megacolon, colonic perforation and death. However, this bacterium might also be carried asymptomatically in the gut, potentially leading to 'silent' onward transmission. Modern technologies, such as whole-genome sequencing and multi-locus variable-number tandem-repeat analysis, are helping to track C. difficile transmission across health-care facilities, countries and continents, offering the potential to illuminate previously under-recognized sources of infection. These typing strategies have also demonstrated heterogeneity in terms of CDI incidence and strain types reflecting different stages of epidemic spread. However, comparison of CDI epidemiology, particularly between countries, is challenging due to wide-ranging approaches to sampling and testing. Diagnostic strategies for C. difficile are complicated both by the wide range of bacterial targets and tests available and the need to differentiate between toxin-producing and non-toxigenic strains. Multistep diagnostic algorithms have been recommended to improve sensitivity and specificity. In this Review, we describe the latest advances in the understanding of C. difficile epidemiology, transmission and diagnosis, and discuss the effect of these developments on the clinical management of CDI.
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