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Risk of antibiotics associated with Clostridioides difficile infection: Antibiotic stewardship in action. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e146. [PMID: 36483417 PMCID: PMC9726489 DOI: 10.1017/ash.2022.286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/15/2022] [Accepted: 07/18/2022] [Indexed: 02/08/2023]
Abstract
We examined risk associated with antibiotics used for Clostridioides difficile infection (CDI) at a single site from 2018 through 2020. Overall, 78 patients had nonrecurrent infections. Among inpatient antibiotics, intravenous meropenem had the highest CDI rate (3.56 per 1,000 days of therapy; n = 2 cases). Among outpatient antibiotics, metronidazole had the highest rate (0.071 per 1,000 pills dispensed; n = 3 cases).
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Squire N, Lux C, Tolbert K, Lidbury J, Sun X, Suchodolski JS. Characterization of the Fecal Microbiome in Dogs Receiving Medical Management for Congenital Portosystemic Shunts. Front Vet Sci 2022; 9:897760. [PMID: 35968011 PMCID: PMC9366551 DOI: 10.3389/fvets.2022.897760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 06/20/2022] [Indexed: 12/02/2022] Open
Abstract
Background The GI microbiome has not been characterized in dogs being medically managed for congenital portosystemic shunts (CPSS). Objectives To characterize the fecal microbiome in a population of dogs being medically managed for CPSS. Animals 27 client-owned dogs. Methods Prospective cohort study enrollment of fecal samples was performed with follow-up data collected retrospectively. The overall fecal dysbiosis index (DI) and individual bacterial abundances were determined using real-time qPCR. Medical management, clinical findings, clinicopathologic, and outcome variables were collected, and logistic regression analyses were performed to evaluate associations between these variables and overall DI and bacterial abundances. Numerical variables were evaluated with general linear models for normality and equal variance using Shapiro-Wilk test and Levene's test, respectively. Results All dogs were administered a hepatic diet and lactulose, while antibiotics were used in 22 (81.5%) and acid suppressants in 7 (25.9%). Seventeen dogs (63.0%) had a DI >2. The median DI in this population was 3.02 (range 4.23–8.42), and the median DI in dogs receiving and not receiving antibiotics was 4.3 (range −4.23–8.42) and 1.52 (range −1.62–5.43), respectively. No significant association between any of the analyzed variables and the DI was identified. There was a significant association between the use of metronidazole and a larger abundance of E. coli (p = 0.024). Conclusions and Clinical Importance Dysbiosis appears to be common in dogs that are being medically managed for CPSS, though the clinical significance remains unclear.
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Affiliation(s)
- Nathan Squire
- Department of Small Animal Clinical Sciences, University of Tennessee College of Veterinary Medicine, Knoxville, TN, United States
| | - Cassie Lux
- Department of Small Animal Clinical Sciences, University of Tennessee College of Veterinary Medicine, Knoxville, TN, United States
- *Correspondence: Cassie Lux
| | - Katie Tolbert
- Department of Veterinary Small Animal Clinical Sciences, Texas A&M College of Veterinary Medicine and Biomedical Sciences, College Station, TX, United States
| | - Jonathan Lidbury
- Department of Veterinary Small Animal Clinical Sciences, Texas A&M College of Veterinary Medicine and Biomedical Sciences, College Station, TX, United States
| | - Xiaocun Sun
- Office of Information and Technology, University of Tennessee Knoxville, Knoxville, TN, United States
| | - Jan S. Suchodolski
- Department of Veterinary Small Animal Clinical Sciences, Texas A&M College of Veterinary Medicine and Biomedical Sciences, College Station, TX, United States
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Poran I, Elbaz M, Turjeman A, Huberman Samuel M, Eliakim-Raz N, Nashashibi J, Paul M, Leibovici L. Predicting In-Hospital Antibiotic Use in the Medical Department: Derivation and Validation Study. Antibiotics (Basel) 2022; 11:antibiotics11060813. [PMID: 35740219 PMCID: PMC9219723 DOI: 10.3390/antibiotics11060813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/12/2022] [Accepted: 06/13/2022] [Indexed: 11/16/2022] Open
Abstract
Background: The rise of multi-drug-resistant pathogens and nosocomial infections among hospitalized patients is partially attributed to the increased use of antibiotic therapy. A prediction model for in-hospital antibiotic treatment could be valuable to target preventive strategies. Methods: This was a retrospective cohort study, including patients admitted in 2018 to medical departments and not treated with antibiotics during the first 48 h. Data available at hospital admission were used to develop a logistic model to predict the probability of antibiotic treatment during hospitalization. The performance of the model was evaluated in two independent validation cohorts. Results: In the derivation cohort, antibiotic treatment was initiated in 454 (8.1%) out of 5592 included patients. Male gender, lower functional capacity, prophylactic antibiotic treatment, medical history of atrial fibrillation, peripheral vascular disease, solid organ transplantation, chronic use of a central venous catheter, urinary catheter and nasogastric tube, albumin level, mental status and vital signs at presentation were identified as predictors for antibiotic use during hospitalization and were included in the prediction model. The area under the ROC curve (AUROC) was 0.72 (95% CI 0.70–0.75). In the highest probability group, the percentage of antibiotic treatment was 18.2% (238/1,307). In the validation cohorts, the AUROC was 0.73 (95% CI 0.68–0.77) and 0.75 (95% CI 0.72–0.78). In the highest probability group, the percentage of antibiotic treatment was 12.5% (66/526) and 20.7% (244/1179) of patients. Conclusions: Our prediction model performed well in the validation cohorts and was able to identify a subgroup of patients at high risk for antibiotic treatment.
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Affiliation(s)
- Itamar Poran
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petach Tikva 4941492, Israel; (M.E.); (A.T.); (M.H.S.); (N.E.-R.); (L.L.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Correspondence: ; Tel.: +972-524881870; Fax: +972-3-9376512
| | - Michal Elbaz
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petach Tikva 4941492, Israel; (M.E.); (A.T.); (M.H.S.); (N.E.-R.); (L.L.)
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah Tikva 4941492, Israel
| | - Adi Turjeman
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petach Tikva 4941492, Israel; (M.E.); (A.T.); (M.H.S.); (N.E.-R.); (L.L.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Maayan Huberman Samuel
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petach Tikva 4941492, Israel; (M.E.); (A.T.); (M.H.S.); (N.E.-R.); (L.L.)
| | - Noa Eliakim-Raz
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petach Tikva 4941492, Israel; (M.E.); (A.T.); (M.H.S.); (N.E.-R.); (L.L.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah Tikva 4941492, Israel
| | - Jeries Nashashibi
- Department of Medicine D, Rambam Health Care Campus, Haifa 3436212, Israel;
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa 3436212, Israel;
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3436212, Israel
| | - Leonard Leibovici
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petach Tikva 4941492, Israel; (M.E.); (A.T.); (M.H.S.); (N.E.-R.); (L.L.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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Tinelli M, Rossini A, Scudeller L, Zabzuni D, Errico G, Fogato E, D'Angelo R, Gentiloni Silverj F, Cesana E, Bergamaschini LC, Pasi F, Monaco M, Cerquetti M, Pantosti A, Giufrè M. Dynamics of carbapenemase-producing Enterobacterales intestinal colonisation in the elderly population after hospital discharge, Italy, 2018-2020. Int J Antimicrob Agents 2022; 59:106594. [PMID: 35483624 DOI: 10.1016/j.ijantimicag.2022.106594] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 04/12/2022] [Accepted: 04/17/2022] [Indexed: 02/03/2023]
Abstract
Carbapenemase-producing Enterobacterales (CPE) represent a serious threat to public health worldwide. Elderly patients are at increased risk of colonisation/infection with CPE. This study aimed to evaluate the persistence of CPE colonisation and the genotypic characteristics of persistent strains in elderly people discharged from Italian hospitals. A longitudinal study was conducted in two Italian cities (March 2018 to September 2020) enrolling 137 patients aged ≥65 years with CPE intestinal colonisation at hospital discharge. CPE colonisation was evaluated after 4, 8 and 12 months. Competing risk analysis was used to explore the association between baseline characteristics and persistence at 4 months. For all isolates, carbapenemase typing and multilocus sequence typing were performed. Persistent isolates underwent whole-genome sequencing. Of 137 patients, 91% carried carbapenemase-producing Klebsiella pneumoniae (CP-KP) and 8.8% carried carbapenemase-producing Escherichia coli. Although a large number of patients were lost to follow-up owing to death or withdrawal, 28/65 patients (43.1%) remained colonised at Month 4; 16/42 (38.1%) and 5/28 (17.9%) were found colonised up to Months 8 and 12, respectively. Colonisation persistence was more frequent in patients with bacteraemia or complicated urinary tract infection while in hospital and in those staying in long-term care facilities (LTCFs). Clonal characteristics of CP-KP isolates did not appear to influence persistence. Isolates obtained from each persistent carrier were identical or highly related by SNP phylogenetic analysis. Identification of patients at higher risk of persistent intestinal carriage after hospital discharge can prompt control measures to limit the transmission of CPE in the community, especially in LTCF settings.
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Affiliation(s)
- Marco Tinelli
- Italian Society of Infectious and Tropical Diseases (SIMIT), Prato, Italy; IRCCS Istituto Auxologico Italiano, San Luca Hospital, Milan, Italy
| | | | - Luigia Scudeller
- Research and Innovation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Dorjan Zabzuni
- IRCCS Istituto Auxologico Italiano, San Luca Hospital, Milan, Italy
| | - Giulia Errico
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Elena Fogato
- Laboratory of Clinical Microbiology, ASP 'Golgi-Redaelli', Milan, Italy
| | - Roberto D'Angelo
- Laboratory of Clinical Microbiology, ASP 'Golgi-Redaelli', Milan, Italy
| | | | | | | | - Francesca Pasi
- Medical Oncology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Monica Monaco
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Marina Cerquetti
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Annalisa Pantosti
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Maria Giufrè
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy.
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Waqas M, Mohib K, Saleem A, LNU M, Arjumand S, Khalil HHUR, Nosheen R, Abbas S, Maqsood KM, Abbas K. Rifaximin Therapy for Patients With Metronidazole-Unresponsive Clostridium difficile Infection. Cureus 2022; 14:e24140. [PMID: 35582554 PMCID: PMC9107305 DOI: 10.7759/cureus.24140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2022] [Indexed: 11/27/2022] Open
Abstract
Background Clostridium difficile infection (CDI) is a leading cause of hospital-acquired diarrhea. Rifaximin is an antibiotic that offers marginal resistance to C. difficile bacteria. This study was conducted to evaluate the efficacy of rifaximin in metronidazole non-responsive CDI patients. Methods A cross-sectional study was performed from August 2019 to May 2020 at the Lahore General Hospital, Lahore, Pakistan. A total of 200 cases were included. Patients who developed diarrhea after receiving antibiotics for seven days and a positive C. difficile toxin stool test as detected by the enzyme immunoassay (BioCheck, Inc., CA) were diagnosed with CDI. Only patients who were unresponsive to metronidazole therapy were enrolled in our analysis. Two groups were formed. The intervention group was administered 200 mg tablets of rifaximin three times a day for 10 days. For patients in the control group, no new treatment was started. The efficacy of rifaximin was defined in terms of the resolution of diarrhea after two weeks of therapy and a negative stool test. All data were recorded in a predefined pro forma. Results The mean age of 45.41 ± 8.54 years was found in the intervention group. The majority of the patients were aged 35-50 years. The majority of the patients had watery diarrhea, abdominal cramping, and loss of appetite on presentation. Rifaximin was found to be significantly effective in the resolution of symptoms of CDI, which was previously unresponsive to metronidazole (p<0.00001). it was found that the duration of diarrhea of more than three weeks was significantly associated with failure of therapy (p=0.03). Conclusion We concluded that rifaximin therapy is effective for patients of CDI non-responsive to metronidazole in more than 65% of the cases. Even though several new developments are made to address the concerned subject, such as microbiota transplantation, antibiotics, and immunotherapy, rifaximin can be considered for patients with metronidazole non-responsive CDI.
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Colonization of the live biotherapeutic product VE303 and modulation of the microbiota and metabolites in healthy volunteers. Cell Host Microbe 2022; 30:583-598.e8. [PMID: 35421353 DOI: 10.1016/j.chom.2022.03.016] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 12/22/2021] [Accepted: 03/10/2022] [Indexed: 11/20/2022]
Abstract
Manipulation of the gut microbiota via fecal microbiota transplantation (FMT) has shown clinical promise in diseases such as recurrent Clostridioides difficile infection (rCDI). However, the variable nature of this approach makes it challenging to describe the relationship between fecal strain colonization, corresponding microbiota changes, and clinical efficacy. Live biotherapeutic products (LBPs) consisting of defined consortia of clonal bacterial isolates have been proposed as an alternative therapeutic class because of their promising preclinical results and safety profile. We describe VE303, an LBP comprising 8 commensal Clostridia strains under development for rCDI, and its early clinical development in healthy volunteers (HVs). In a phase 1a/b study in HVs, VE303 is determined to be safe and well-tolerated at all doses tested. VE303 strains optimally colonize HVs if dosed over multiple days after vancomycin pretreatment. VE303 promotes the establishment of a microbiota community known to provide colonization resistance.
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In-hospital delay of surgery increases the rate of complicated appendicitis in patients presenting with short duration of symptoms: a retrospective cohort study. Eur J Trauma Emerg Surg 2022; 48:3879-3886. [PMID: 35211772 DOI: 10.1007/s00068-022-01912-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 01/29/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Current practice allows for surgery for acute appendicitis to be delayed up to 24 h in the belief that there will be no increase in complicated appendicitis rates. We evaluated the combined effect of Patient Time (between symptom onset and hospital admission) and Hospital Time (between hospital admission and surgery) on the surgical outcome. We hypothesized that in patients with a short Patient Time, increased Hospital Times will be associated with a higher rate of complicated appendicitis, even in patients operated within 24 h. METHODS Retrospective evaluation of medical files of patients operated for acute appendicitis between 12/2006 and 12/2016. RESULTS Of 2749 patients with acute appendicitis included in this analysis, 818 (29.8%) were admitted with symptom onset the same day as admission, 577 (21.0%) reported symptom onset had started the previous day but less than 24 h before admission, and 1354 (49.3%) had over 24 h of symptoms. In patients with symptom onset the same day, a gradual increase in the rate of complicated appendicitis was noted with increasing Hospital Times (≤ 6 h-6.3%; 6-12 h-9.9%; 12-18 h-14.7%; and 18-24 h-12.7%; p = 0.017). In all other patients no differences in the rate of complicated appendicitis were noted as long as the patients were operated within 24 h of admission. CONCLUSION In patients with a short Patient Time, delaying operation is associated with an increased rate of complicated appendicitis and this group of patients should be prioritized for early surgery. CLINICAL TRIALS Study registered as ClinicalTrials.gov Identifier: NCT04689906 ( https://clinicaltrials.gov/ct2/show/NCT04689906?term=ashkenazi+itamar&draw=2&rank=2 ).
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Whittle E, Yonkus JA, Jeraldo P, Alva-Ruiz R, Nelson H, Kendrick ML, Grys TE, Patel R, Truty MJ, Chia N. Optimizing Nanopore Sequencing for Rapid Detection of Microbial Species and Antimicrobial Resistance in Patients at Risk of Surgical Site Infections. mSphere 2022; 7:e0096421. [PMID: 35171692 PMCID: PMC8849348 DOI: 10.1128/msphere.00964-21] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Surgical site infections (SSI) are a significant burden to patients and health care systems. We evaluated the use of Nanopore sequencing (NS) to rapidly detect microbial species and antimicrobial resistance (AMR) genes present in intraoperative bile aspirates. Bile aspirates from 42 patients undergoing pancreatic head resection were included. Three methods of DNA extraction using mechanical cell lysis or protease cell lysis were compared to determine the optimum method of DNA extraction. The impact of host DNA depletion, sequence run duration, and use of different AMR gene databases was also assessed. To determine clinical value, NS results were compared to standard culture (SC) results. NS identified microbial species in all culture positive samples. Mechanical lysis improved NS detection of cultured species from 60% to 76%, enabled detection of fungal species, and increased AMR predictions. Host DNA depletion improved detection of streptococcal species and AMR correlation with SC. Selection of AMR database influenced the number of AMR hits and resistance profile of 13 antibiotics. AMR prediction using CARD and ResFinder 4.1 correctly predicted 79% and 81% of the bile antibiogram, respectively. Sequence run duration positively correlated with detection of AMR genes. A minimum of 6 h was required to characterize the biliary microbes, resulting in a turnaround time of 14 h. Rapid identification of microbial species and AMR genes can be achieved by NS. NS results correlated with SC, suggesting that NS may be useful in guiding early antimicrobial therapy postsurgery. IMPORTANCE Surgical site infections (SSI) are a significant burden to patients and health care systems. They increase mortality rates, length of hospital stays, and associated health care costs. To reduce the risk of SSI, surgical patients are administered broad-spectrum antibiotics that are later adapted to target microbial species detected at the site of surgical incision. Use of broad-spectrum antibiotics can be harmful to the patient. We wanted to develop a rapid method of detecting microbial species and their antimicrobial resistance phenotypes. We developed a method of detecting microbial species and predicting resistance phenotypes using Nanopore sequencing. Results generated using Nanopore sequencing were similar to current methods of detection but were obtained in a significantly shorter amount of time. This suggests that Nanopore sequencing could be used to tailor antibiotics in surgical patients and reduce use of broad-spectrum antibiotics.
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Affiliation(s)
- Emma Whittle
- Division of Surgical Research, Department of Surgery, Mayo Clinicgrid.66875.3a, Rochester, Minnesota, USA
| | - Jennifer A. Yonkus
- Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, Mayo Clinicgrid.66875.3a, Rochester, Minnesota, USA
| | - Patricio Jeraldo
- Division of Surgical Research, Department of Surgery, Mayo Clinicgrid.66875.3a, Rochester, Minnesota, USA
| | - Roberto Alva-Ruiz
- Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, Mayo Clinicgrid.66875.3a, Rochester, Minnesota, USA
| | - Heidi Nelson
- Division of Research and Optimal Patient Care, Cancer Programs, American College of Surgeonsgrid.417954.a, Chicago, Illinois, USA
| | - Michael L. Kendrick
- Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, Mayo Clinicgrid.66875.3a, Rochester, Minnesota, USA
| | - Thomas E. Grys
- Department of Laboratory Medicine and Pathology, Mayo Clinicgrid.66875.3a, Phoenix, Arizona, USA
| | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinicgrid.66875.3a, Rochester, Minnesota, USA
| | - Mark J. Truty
- Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, Mayo Clinicgrid.66875.3a, Rochester, Minnesota, USA
| | - Nicholas Chia
- Division of Surgical Research, Department of Surgery, Mayo Clinicgrid.66875.3a, Rochester, Minnesota, USA
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Carlson TJ, Gonzales-Luna AJ, Garey KW. Fulminant Clostridioides difficile Infection: A Review of Treatment Options for a Life-Threatening Infection. Semin Respir Crit Care Med 2022; 43:28-38. [PMID: 35172356 DOI: 10.1055/s-0041-1740973] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Fulminant Clostridioides difficile infection (FCDI) encompasses 3 to 5% of all CDI cases with associated mortality rates between 30 and 40%. Major treatment modalities include surgery and medical management with antibiotic and nonantibiotic therapies. However, identification of patients with CDI that will progress to FCDI is difficult and makes it challenging to direct medical management and identify those who may benefit from surgery. Furthermore, since it is difficult to study such a critically ill population, data investigating treatment options are limited. Surgical management with diverting loop ileostomy (LI) instead of a total abdominal colectomy (TAC) with end ileostomy has several appealing advantages, and studies have not consistently demonstrated a clinical benefit with this less-invasive strategy, so both LI and TAC remain acceptable surgical options. Successful medical management of FCDI is complicated by pharmacokinetic changes that occur in critically ill patients, and there is an absence of high-quality studies that included patients with FCDI. Recommendations accordingly include a combination of antibiotics administered via multiple routes to ensure adequate drug concentrations in the colon: intravenous metronidazole, high-dose oral vancomycin, and rectal vancomycin. Although fidaxomicin is now recommended as first-line therapy for non-FCDI, there are limited clinical data to support its use in FCDI. Several nonantibiotic therapies, including fecal microbiota transplantation and intravenous immunoglobulin, have shown success as adjunctive therapies, but they are unlikely to be effective alone. In this review, we aim to summarize diagnosis and treatment options for FCDI.
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Affiliation(s)
- Travis J Carlson
- Department of Clinical Sciences, High Point University Fred Wilson School of Pharmacy, High Point, North Carolina
| | - Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas
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Carayon P, Thuemling T, Parmasad V, Bao S, O'Horo J, Bennett NT, Safdar N. Implementation of An Antibiotic Stewardship Intervention to Reduce Prescription of Fluoroquinolones: A Human Factors Analysis in Two Intensive Care Units. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2022; 26:161-171. [PMID: 35146329 DOI: 10.1177/25160435211025417] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Antibiotic use is often the target of interventions in health care organizations that aim to decrease healthcare-associated infections (HAI) such as Clostridioides difficile (CDI); this is particularly important for fluoroquinolones (FQ), which are frequently used in critical care settings. In this study, using a multiple case study research approach, we conduct an in-depth analysis of an intervention aimed at limiting ICU prescriber access to FQ in two ICUs of two hospitals. The data collection and analysis were guided by a human factors engineering approach based on the SEIPS (Systems Engineering Initiative for Patient Safety) model and evidence-based implementation principles. Our results show some differences in the implementation of the FQ intervention between the two ICUs, such as level and method of FQ restriction, and training and communication with physicians and pharmacists. In both ICUs, several organizational learning mechanisms helped to quickly identify problems with the intervention and ensure that changes were made in a just-in-time manner (e.g. just-in-time training, removal of FQ in order set for pneumonia). Despite their organizational differences, both sites developed strategies to successfully implement the FQ intervention.
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Affiliation(s)
- Pascale Carayon
- Department of Industrial and Systems Engineering, Wisconsin Institute for Healthcare Systems Engineering; University of Wisconsin-Madison
| | - Teresa Thuemling
- Wisconsin Institute for Healthcare Systems Engineering; University of Wisconsin-Madison
| | | | - Songtao Bao
- School of Journalism and Mass Communication; University of Wisconsin-Madison
| | | | | | - Nasia Safdar
- Department of Medicine; University of Wisconsin-Madison
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Malick A, Wang Y, Axelrad J, Salmasian H, Freedberg D. Obesity is not associated with adverse outcomes among hospitalized patients with Clostridioides difficile infection. Gut Pathog 2022; 14:7. [PMID: 35093158 PMCID: PMC8799984 DOI: 10.1186/s13099-022-00479-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 01/06/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Obesity is associated with increased risk for death in most infections but has not been studied as a risk factor for mortality in Clostridioides difficile infection (CDI). This study tested obesity as a risk factor for death in patients hospitalized with CDI. This was a three-center retrospective study that included hospitalized adults with CDI at Columbia University Irving Medical Center, Brigham and Women’s Hospital, and NYU Langone from 2010 to 2018. Multivariate logistic regression was used to assess the relationship between obesity, measured by body mass index, and death from any cause within 30 days after the index CDI test.
Results
Data for 3851 patients were analyzed, including 373 (9.7%) who died within 30 days following a diagnosis of CDI. After adjusting for other factors, BMI was not associated with increased risk for death in any BMI category [adjusted OR (aOR) 0.96, 95% CI 0.69 to 1.34 for BMI > 30 vs BMI 20–30; aOR 1.02, 95% CI 0.53 to 1.87 for BMI > 40 vs BMI 20–30]. After stratifying into three groups by age, there were trends towards increased mortality with obesity in the middle-aged (56–75 vs ≤ 55 years old) yet decreased mortality with obesity in the old (> 75 vs ≤ 55) (p = NS for all). Advanced age and low albumin were the factors most strongly associated with death.
Conclusions
We found no association between obesity and death among patients with CDI, in contrast to most other infections. Obesity is not likely to be useful for risk-stratifying hospitalized patients with CDI.
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Giles J, Roberts A. Clostridioides difficile: Current overview and future perspectives. ADVANCES IN PROTEIN CHEMISTRY AND STRUCTURAL BIOLOGY 2022; 129:215-245. [PMID: 35305720 DOI: 10.1016/bs.apcsb.2021.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The most common world-wide cause of antibiotic-associated infectious diarrhea and colitis is the toxin producing bacterium, Clostridioides difficile (C. difficile). Here we review the background and characteristics of the bacterium and the toxins produced together with the epidemiology and the complex pathogenesis that leads to a broad clinical spectrum of disease. The review describes the difficulties faced in obtaining a quick and accurate diagnosis despite the range of sensitive and specific diagnostic tools available. We also discuss the problem of disease recurrence and the importance of disease prevention. The high rates of infection recurrence mean that treatment strategies are constantly under review and we outline the diverse treatment options that are currently in use and explore the emerging treatment options of pulsed antibiotic use, microbial replacement therapies and the use of monoclonal antibodies. We summarize the future direction of treatment strategies which include the development of novel antibiotics, the administration of oral polyclonal antibody formulations, the use of vaccines, the administration of competitive non-toxigenic spores and the neutralization of antibiotics at the microbiota level. Future successful treatments will likely involve a combination of therapies to provide the most effective and robust approach to C. difficile management.
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Affiliation(s)
- Joanna Giles
- MicroPharm Ltd, Newcastle Emlyn, United Kingdom.
| | - April Roberts
- Toxins Group, National Infection Service, Public Health England, Porton Down, United Kingdom
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Schranz E, Rappaport S, Groth C, Prasad P, Cooper K, Connor K. A Retrospective Characterization of Dexmedetomidine-Suspected Fever and Its Consequences in Adult Critically Ill Patients. Ann Pharmacother 2022; 56:1023-1029. [DOI: 10.1177/10600280211060082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background: Current evidence for dexmedetomidine-suspected fever (DSF) is limited. Lack of recognition may lead to costly or potentially harmful interventions for critically ill patients. Objective: The primary objective was to characterize escalations of care related to DSF. Secondary objectives were to describe the incidence, severity, and consequences associated with DSF. Methods: A retrospective review was conducted in critically ill adults who developed fever ≥39°C within 12 h from initiation of dexmedetomidine, with resolution of fever to <39°C within 12 h after discontinuation. The primary outcome was percentage of patients who received an escalation of care due to fever. Secondary outcomes included the percentage of patients who developed a multidrug-resistant organism or Clostridium difficile infection. Results: Eighteen of 3943 patients screened in 4099 encounters met criteria for DSF (0.4%). The majority were white (83.3%), male (66.7%), and underwent cardiac surgery (61.1%). Median (interquartile range [IQR]) time to fever onset and resolution were 5.5 (3.6-7.6) and 1.3 (1.0-2.9) h. Nine patients (50%) underwent infectious workup including antimicrobial initiation (n = 1, 5.6%), broadening of antimicrobials (n = 4, 22.2%), or culture collection (n = 9, 50%). Eleven patients (61.1%) underwent attempted temperature reduction. Twelve patients (66.7%) underwent diagnostic imaging. Incidence of multidrug-resistant organism and C. difficile infection were low (11.1 and 16.7% of fever patients, respectively). Conclusion and Relevance: Incidence of DSF was low and more common in cardiac surgery patients. Unrecognized DSF led to an escalation of care in most patients. Dexmedetomidine exposure should be considered as a potential cause of fever in critically ill adults.
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Affiliation(s)
| | | | | | | | - Kevin Cooper
- University of Rochester Medical Center, Rochester, NY, USA
| | - Kathryn Connor
- Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY, USA
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Karoli NA, Rebrov A. Some issues of safety of antimicrobial therapy in COVID-19 patients. CLINICAL MICROBIOLOGY AND ANTIMICROBIAL CHEMOTHERAPY 2022. [DOI: 10.36488/cmac.2022.3.226-235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Currently, there is a lack of evidence for empiric use of antimicrobial agents in most patients with COVID-19 in outpatient and hospital settings as the overall proportion of secondary bacterial infections in COVID-19 is quite low. This literature review summarizes data on changes in antimicrobial resistance over the course of COVID-19 pandemic, especially in nosocomial ESKAPE pathogens. The other significant consequences of excessive and unnecessary administration of antibiotics to COVID-19 patients including risk of Clostridioides difficile infection and adverse effects of antimicrobial agents are also discussed.
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Affiliation(s)
- Nina A. Karoli
- Saratov State Medical University named after V.I. Razumovsky (Saratov, Russia)
| | - A.P. Rebrov
- Saratov State Medical University named after V.I. Razumovsky (Saratov, Russia)
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65
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Nzabarushimana E, Tang H. Functional profile of host microbiome indicates Clostridioides difficile infection. Gut Microbes 2022; 14:2135963. [PMID: 36289064 PMCID: PMC9621045 DOI: 10.1080/19490976.2022.2135963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 09/28/2022] [Accepted: 10/03/2022] [Indexed: 02/04/2023] Open
Abstract
Clostridioides difficile infection (CDI) is a gastro-intestinal (GI) infection that illustrates how perturbations in symbiotic host-microbiome interactions render the GI tract vulnerable to the opportunistic pathogens. CDI also serves as an example of how such perturbations could be reversed via gut microbiota modulation mechanisms, especially fecal microbiota transplantation (FMT). However, microbiome-mediated diagnosis of CDI remains understudied. Here, we evaluated the diagnostic capabilities of the fecal microbiome on the prediction of CDI. We used the metagenomic sequencing data from ten previous studies, encompassing those acquired from CDI patients treated by FMT, CDI-negative patients presenting other intestinal health conditions, and healthy volunteers taking antibiotics. We designed a hybrid species/function profiling approach that determines the abundances of microbial species in the community contributing to its functional profile. These functionally informed taxonomic profiles were then used for classification of the microbial samples. We used logistic regression (LR) models using these features, which showed high prediction accuracy (with an average A U C ≥ 0.91 ), substantiating that the species/function composition of the gut microbiome has a robust diagnostic prediction of CDI. We further assessed the confounding impact of antibiotic therapy on CDI prediction and found that it is distinguishable from the CDI impact. Finally, we devised a log-odds score computed from the output of the LR models to quantify the likelihood of CDI in a gut microbiome sample and applied it to evaluating the effectiveness of FMT based on post-FMT microbiome samples. The results showed that the gut microbiome of patients exhibited a gradual but steady improvement after receiving successful FMT, indicating the restoration of the normal microbiome functions.
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Affiliation(s)
- Etienne Nzabarushimana
- Luddy School of Informatics, Computing and Engineering, Indiana University, Bloomington, Indiana, USA
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Haixu Tang
- Luddy School of Informatics, Computing and Engineering, Indiana University, Bloomington, Indiana, USA
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66
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Jordan S, Hui N, Doudle M, Von Papen M, Naik A, Lu CT, Nolan G, Cooper M. Incidence of Clostridioides difficile in patients post loop ileostomy reversal in an Australian tertiary hospital: a retrospective study. ANZ J Surg 2021; 92:403-408. [PMID: 34889019 DOI: 10.1111/ans.17411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 11/09/2021] [Accepted: 11/21/2021] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The purpose of a loop ileostomy is to temporarily divert faeces away from a distal anastomosis, to reduce the consequences of anastomotic leak. This ultimately requires a second procedure to restore bowel continuity, which confers risk of complications including the development of Clostridioides difficile infection (CDI). It is hypothesized that patients who undergo loop ileostomy reversal are at increased risk of CDI when compared with other patients undergoing elective colorectal surgical procedures, and that these patients also experience an increased length of stay (LOS). METHODS A retrospective cohort study was performed on all patients who underwent loop ileostomy reversal at the Gold Coast Hospital and Health Service between 1 January 2012 and 31 December 2019. RESULTS Two hundred and twenty-eight patients were identified. Eight tested positive for CDI on faecal PCR (3.51%), a higher incidence than that in patients who underwent an elective colorectal surgical procedure during the same period (0.83%) (RR = 4.23). Additionally, median LOS for ileostomy reversal patients was significantly increased in those who also had CDI when compared with those without CDI (11 versus 4 days; P = 0.0003). CONCLUSION The study confirmed that the incidence of CDI was higher in those who underwent ileostomy reversal when compared with an otherwise comparable hospital population (elective colorectal surgery patients). Additionally, those patients who underwent ileostomy reversal and had CDI experienced an increased LOS which translates to increased cost to the healthcare system. Further investigation into pre-operative screening and prophylactic antibiotics should be considered as a measure to mitigate this post-operative complication.
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Affiliation(s)
- Stephanie Jordan
- Department of General Surgery, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Nathan Hui
- Department of General Surgery, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Mark Doudle
- Department of General Surgery, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Michael Von Papen
- Department of General Surgery, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Arun Naik
- Department of General Surgery, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Cu Tai Lu
- Department of General Surgery, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Gregory Nolan
- Department of General Surgery, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Michelle Cooper
- Department of General Surgery, Gold Coast University Hospital, Southport, Queensland, Australia
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Rutten JJS, van Buul LW, Smalbrugge M, Geerlings SE, Gerritsen DL, Natsch S, Sloane PD, van der Wouden JC, Twisk JWR, Hertogh CMPM. An Electronic Health Record Integrated Decision Tool and Supportive Interventions to Improve Antibiotic Prescribing for Urinary Tract Infections in Nursing Homes: A Cluster Randomized Controlled Trial. J Am Med Dir Assoc 2021; 23:387-393. [PMID: 34896069 DOI: 10.1016/j.jamda.2021.11.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 11/01/2021] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To investigate whether an electronic health record (EHR)-integrated decision tool, combined with supportive interventions, results in more appropriate antibiotic prescribing in nursing home (NH) residents with suspected urinary tract infection (UTI), without negative consequences for residents. DESIGN Cluster randomized controlled trial with NHs as the randomization unit; intervention group NHs received the EHR-integrated decision tool and supportive interventions, and control group NHs provided care as usual. SETTING AND PARTICIPANTS 212 residents with suspected UTI, from 16 NHs in the Netherlands. METHODS Physicians collected data at index consultation (ie, UTI suspicion) and during a 21-day follow-up period (March 2019-March 2020). Overall antibiotic prescribing data at NH level, 12 months prior to and during the study, was derived from the electronic prescribing system. The primary study outcome was the percentage of antibiotic prescriptions for suspected UTI that was appropriate, at index consultation. Secondary study outcomes included changes in treatment decision, complications, UTI-related hospitalization, and mortality during follow-up; and pre-post study changes in antibiotic prescribing at the NH level. RESULTS 295 suspected UTIs were included (intervention group: 189; control group: 106). The between-group difference in appropriate antibiotic prescribing was 13% [intervention group: 62%, control group: 49%; adjusted odds ratio (OR) 1.43, 95% CI 0.57-3.62]. In both groups, complications (2% vs 3%), UTI-related hospitalization (2% vs 1%), and possible UTI-related mortality (2% vs 2%) were rare. The pre-post study difference in antibiotic prescriptions per 1000 resident-care days was -0.95 in the intervention group NHs and -0.05 in the control group NHs (P = .02). CONCLUSION AND IMPLICATIONS Although appropriate antibiotic prescribing improved in the intervention group, this does not provide sufficient evidence for our multidisciplinary intervention. Despite this inconclusive result, our intervention could potentially still be effective, because we established a large reduction in the number of antibiotic prescriptions in the intervention group.
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Affiliation(s)
- Jeanine J S Rutten
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Laura W van Buul
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Martin Smalbrugge
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Suzanne E Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Debby L Gerritsen
- Radboud Institute for Health Sciences, Radboudumc Alzheimer Center, Department of Primary and Community care, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Stephanie Natsch
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Philip D Sloane
- Department of Family Medicine, School of Medicine, and the Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Johannes C van der Wouden
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands; Department of General Practice, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jos W R Twisk
- Department of Epidemiology and Biostatistics, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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van Prehn J, Reigadas E, Vogelzang EH, Bouza E, Hristea A, Guery B, Krutova M, Norén T, Allerberger F, Coia JE, Goorhuis A, van Rossen TM, Ooijevaar RE, Burns K, Scharvik Olesen BR, Tschudin-Sutter S, Wilcox MH, Vehreschild MJGT, Fitzpatrick F, Kuijper EJ. European Society of Clinical Microbiology and Infectious Diseases: 2021 update on the treatment guidance document for Clostridioides difficile infection in adults. Clin Microbiol Infect 2021; 27 Suppl 2:S1-S21. [PMID: 34678515 DOI: 10.1016/j.cmi.2021.09.038] [Citation(s) in RCA: 248] [Impact Index Per Article: 82.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 09/23/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022]
Abstract
SCOPE In 2009, the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) published the first treatment guidance document for Clostridioides difficile infection (CDI). This document was updated in 2014. The growing literature on CDI antimicrobial treatment and novel treatment approaches, such as faecal microbiota transplantation (FMT) and toxin-binding monoclonal antibodies, prompted the ESCMID study group on C. difficile (ESGCD) to update the 2014 treatment guidance document for CDI in adults. METHODS AND QUESTIONS Key questions on CDI treatment were formulated by the guideline committee and included: What is the best treatment for initial, severe, severe-complicated, refractory, recurrent and multiple recurrent CDI? What is the best treatment when no oral therapy is possible? Can prognostic factors identify patients at risk for severe and recurrent CDI and is there a place for CDI prophylaxis? Outcome measures for treatment strategy were: clinical cure, recurrence and sustained cure. For studies on surgical interventions and severe-complicated CDI the outcome was mortality. Appraisal of available literature and drafting of recommendations was performed by the guideline drafting group. The total body of evidence for the recommendations on CDI treatment consists of the literature described in the previous guidelines, supplemented with a systematic literature search on randomized clinical trials and observational studies from 2012 and onwards. The Grades of Recommendation Assessment, Development and Evaluation (GRADE) system was used to grade the strength of our recommendations and the quality of the evidence. The guideline committee was invited to comment on the recommendations. The guideline draft was sent to external experts and a patients' representative for review. Full ESCMID endorsement was obtained after a public consultation procedure. RECOMMENDATIONS Important changes compared with previous guideline include but are not limited to: metronidazole is no longer recommended for treatment of CDI when fidaxomicin or vancomycin are available, fidaxomicin is the preferred agent for treatment of initial CDI and the first recurrence of CDI when available and feasible, FMT or bezlotoxumab in addition to standard of care antibiotics (SoC) are preferred for treatment of a second or further recurrence of CDI, bezlotoxumab in addition to SoC is recommended for the first recurrence of CDI when fidaxomicin was used to manage the initial CDI episode, and bezlotoxumab is considered as an ancillary treatment to vancomycin for a CDI episode with high risk of recurrence when fidaxomicin is not available. Contrary to the previous guideline, in the current guideline emphasis is placed on risk for recurrence as a factor that determines treatment strategy for the individual patient, rather than the disease severity.
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Affiliation(s)
- Joffrey van Prehn
- Department of Medical Microbiology, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Elena Reigadas
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Erik H Vogelzang
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Adriana Hristea
- University of Medicine and Pharmacy Carol Davila, National Institute for Infectious Diseases Prof Dr Matei Bals, Romania
| | - Benoit Guery
- Infectious Diseases Specialist, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Marcela Krutova
- Department of Medical Microbiology, Charles University in Prague and Motol University Hospital, Czech Republic
| | - Torbjorn Norén
- Faculty of Medicine and Health, Department of Laboratory Medicine, National Reference Laboratory for Clostridioides difficile, Clinical Microbiology, Örebro University Hospital, Örebro, Sweden
| | | | - John E Coia
- Department of Clinical Microbiology, Hospital South West Jutland and Department of Regional Health Research IRS, University of Southern Denmark, Esbjerg, Denmark
| | - Abraham Goorhuis
- Department of Infectious Diseases, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Tessel M van Rossen
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Rogier E Ooijevaar
- Department of Gastroenterology, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Karen Burns
- Departments of Clinical Microbiology, Beaumont Hospital & Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Sarah Tschudin-Sutter
- Department of Infectious Diseases and Infection Control, University Hospital Basel, University Basel, Universitatsspital, Basel, Switzerland
| | - Mark H Wilcox
- Department of Microbiology, Old Medical, School Leeds General Infirmary, Leeds Teaching Hospitals & University of Leeds, Leeds, United Kingdom
| | - Maria J G T Vehreschild
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany; Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Fidelma Fitzpatrick
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland; Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ed J Kuijper
- Department of Medical Microbiology, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands; National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands.
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Krishna A, Chopra T. Prevention of Infection due to Clostridium (Clostridioides) difficile. Infect Dis Clin North Am 2021; 35:995-1011. [PMID: 34752229 DOI: 10.1016/j.idc.2021.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Clostridium (Clostridioides) difficile infection (CDI) causes significant morbidity and mortality in the United States every year. Prevention of CDI is difficult because of spore durability and requires implementation of multipronged strategies. Two categories of prevention strategies are infection control and prevention and risk factor reduction. Hand hygiene, contact precautions, patient isolation, and environmental decontamination are cornerstones of infection control and prevention. Risk factor reduction should focus on antibiotic stewardship to reduce unnecessary antibiotic use. If CDI incidence remains higher than the institution's goal despite these measures, then special measures should be considered.
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Affiliation(s)
- Amar Krishna
- Internal Medicine, Norther Light AR Gould Hospital, 140 Academy Street, Presque Isle, ME 04769, USA.
| | - Teena Chopra
- Infectious Diseases, Wayne State University/Detroit Medical Center, UHC-2B, 4201 St Antoine, Detroit, MI 48201, USA
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Tougas SR, Lodha N, Vandermeer B, Lorenzetti DL, Tarr PI, Tarr GAM, Chui L, Vanderkooi OG, Freedman SB. Prevalence of Detection of Clostridioides difficile Among Asymptomatic Children: A Systematic Review and Meta-analysis. JAMA Pediatr 2021; 175:e212328. [PMID: 34338715 PMCID: PMC8329794 DOI: 10.1001/jamapediatrics.2021.2328] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
IMPORTANCE Detection of Clostridioides difficile has frequently been described in asymptomatic infants and children, but accurate estimates across the age spectrum are unavailable. OBJECTIVE To assess the prevalence of C difficile detection among asymptomatic children across the age spectrum. DATA SOURCES This systematic review and meta-analysis included a search of the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, Scopus, and Web of Science for articles published from January 1, 1990, to December 31, 2020. Search terms included Clostridium difficile, Peptoclostridium difficile, Clostridioides difficile, CDF OR CDI OR c diff OR c difficile, Clostridium infections OR cd positive diarrhea OR cd positive diarrhea OR Clostridium difficile OR Peptoclostridium difficile OR pseudomembranous colitis OR pseudomembranous enterocolitis, enterocolitis, and pseudomembranous. These were combined with the following terms: bacterial colonization and colonization OR colonized OR colonizing OR epidemiology OR prevalence OR seroprevalence. STUDY SELECTION Studies were screened independently by 2 authors. Studies were included if they reported testing for C difficile among asymptomatic children (ie, children without diarrhea) younger than 18 years. DATA EXTRACTION AND SYNTHESIS Data were extracted independently and in duplicate by 2 reviewers. Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) guidelines were used. Data were pooled using a random-effects model. MAIN OUTCOMES AND MEASURES The primary outcome was prevalence of C difficile detection among asymptomatic children. Secondary outcomes included prevalence of toxigenic vs nontoxigenic strains of C difficile and prevalence of C difficile detection stratified by geographic region, income status, testing method, and year of testing. RESULTS A total of 95 studies with 19 186 participants were included. Rates of detection of toxigenic or nontoxigenic C difficile were greatest among infants aged 6 to 12 months (41%; 95% CI, 32%-50%) and decreased to 12% (95% CI, 7%-18%) among children aged 5 to 18 years. The prevalence of toxigenic C difficile colonization was lower, peaking at 14% (95% CI, 8%-21%) among infants aged 6 to 12 months and decreasing to 6% (95% CI, 2%-11%) among children older than 5 years. Although prevalence differed by geographic region (ie, North and South America vs Europe: β, -0.151, P = .001; North and South America vs Western Pacific: β, 0.136, P = .007), there was no difference by testing method (ie, culture vs polymerase chain reaction: β, 0.069, P = .052; culture vs enzyme immunoassay: β, -0.178, P = .051), income class (low-middle income vs high income: β, -0.144, P = .23; upper-middle vs high income: β, -0.020, P = .64), or period (before 1990 vs 2010-2020: β, -0.125, P = .19; 1990-1999 vs 2010-2020: β, -0.037, P = .42; 2000-2009 vs 2010-2020: β, -0.006, P = .86). CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis, C difficile colonization rates among children were greatest at 6 to 12 months of age and decreased thereafter. These estimates may provide context for interpreting C difficile test results among young children.
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Affiliation(s)
- Sarah R Tougas
- Cumming School of Medicine, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Nidhi Lodha
- Cumming School of Medicine, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Ben Vandermeer
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Diane L Lorenzetti
- Department of Community Health Sciences and the Health Sciences Library, University of Calgary, Calgary, Alberta, Canada
| | - Phillip I Tarr
- Department of Pediatrics, Washington University in St Louis, St Louis, Missouri.,Department of Molecular Microbiology, Washington University in St Louis, St Louis, Missouri
| | - Gillian A M Tarr
- Division of Environmental Health Sciences, School of Public Health, University of Minnesota, Minneapolis
| | - Linda Chui
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Otto G Vanderkooi
- Alberta Children's Hospital, Division of Pediatric Infectious Disease, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, Microbiology, Immunology and Infectious Diseases, Community Health Sciences, and Pathology & Laboratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephen B Freedman
- Alberta Children's Hospital, Divisions of Pediatric Emergency Medicine and Gastroenterology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Hotinger JA, Morris ST, May AE. The Case against Antibiotics and for Anti-Virulence Therapeutics. Microorganisms 2021; 9:2049. [PMID: 34683370 PMCID: PMC8537500 DOI: 10.3390/microorganisms9102049] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 09/22/2021] [Accepted: 09/24/2021] [Indexed: 12/14/2022] Open
Abstract
Although antibiotics have been indispensable in the advancement of modern medicine, there are downsides to their use. Growing resistance to broad-spectrum antibiotics is leading to an epidemic of infections untreatable by first-line therapies. Resistance is exacerbated by antibiotics used as growth factors in livestock, over-prescribing by doctors, and poor treatment adherence by patients. This generates populations of resistant bacteria that can then spread resistance genes horizontally to other bacterial species, including commensals. Furthermore, even when antibiotics are used appropriately, they harm commensal bacteria leading to increased secondary infection risk. Effective antibiotic treatment can induce bacterial survival tactics, such as toxin release and increasing resistance gene transfer. These problems highlight the need for new approaches to treating bacterial infection. Current solutions include combination therapies, narrow-spectrum therapeutics, and antibiotic stewardship programs. These mediate the issues but do not address their root cause. One emerging solution to these problems is anti-virulence treatment: preventing bacterial pathogenesis instead of using bactericidal agents. In this review, we discuss select examples of potential anti-virulence targets and strategies that could be developed into bacterial infection treatments: the bacterial type III secretion system, quorum sensing, and liposomes.
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Affiliation(s)
| | | | - Aaron E. May
- Department of Medicinal Chemistry, School of Pharmacy, Virginia Commonwealth University, Richmond, VA 23219, USA; (J.A.H.); (S.T.M.)
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Medaglia AA, Buffa S, Gioè C, Bonura S, Rubino R, Iaria C, Colomba C, Cascio A. An emergent infectious disease: Clostridioides difficile infection hospitalizations, 10-year trend in Sicily. Infection 2021; 49:1221-1229. [PMID: 34495497 PMCID: PMC8613107 DOI: 10.1007/s15010-021-01683-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/09/2021] [Indexed: 11/30/2022]
Abstract
Background Clostridioides difficile is the most common cause of healthcare-associated diarrhoea worldwide and C. difficile infection is an emerging infectious disease. In the US, its rates are monitored trough an active surveillance system, but many European Union member states still lack this, and in Italy no epidemiological data on C. difficile infection are available except for a few single-centre data. Aim To provide data on the C. difficile infection incidence in Sicily (the biggest and 5th most populous region of Italy) during a 10-year period. Methods We revised all the regional standardized discharge forms between 2009 and June 2019 using the code ICD-9 00845 of the International Classification of Diseases, Ninth Revision Clinical Modification, which refers to C. difficile infection with or without complications. Results 1139 cases of CDI were identified. 97% were adults with a median age of 73.2 years and a male-to-female ratio of 1:1.4. Female patients were older than males and patients who died were older than patients who did not. The main comorbidities were renal disease, diabetes, pneumonia and hypertension. There were 65 reporting hospitals and 86% of cases were provided by level III and II hospitals. Between 2009 and 2019, the incidence increased 40-fold. 81.5% of cases were reported in Medicine Units, Infectious Diseases Units and long-term care facilities. The mean length of stay was 20 days. Mean case fatality rate was 8.3% over the 10-year period. Conclusion Clostridioides difficile infection is a dramatically increasing condition in Sicily. A high-quality surveillance system and shared diagnostic protocols are needed. Supplementary Information The online version contains supplementary material available at 10.1007/s15010-021-01683-w.
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Affiliation(s)
| | - Sergio Buffa
- Dipartimento per le Attività Sanitarie e Osservatorio Epidemiologico (DASOE), Palermo, Italy
| | - Claudia Gioè
- Infectious and Tropical Disease Unit, AOU Policlinico "P. Giaccone", Palermo, Italy
| | - Silvia Bonura
- Infectious and Tropical Disease Unit, AOU Policlinico "P. Giaccone", Palermo, Italy
| | - Raffaella Rubino
- Infectious and Tropical Disease Unit, AOU Policlinico "P. Giaccone", Palermo, Italy
| | - Chiara Iaria
- Infectious Diseases Unit, ARNAS Civico, Palermo, Italy
| | - Claudia Colomba
- Infectious and Tropical Disease Unit, AOU Policlinico "P. Giaccone", Palermo, Italy.,Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Infectious Diseases Unit, University of Palermo, Palermo, Italy
| | - Antonio Cascio
- Infectious and Tropical Disease Unit, AOU Policlinico "P. Giaccone", Palermo, Italy. .,Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Infectious Diseases Unit, University of Palermo, Palermo, Italy.
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73
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Jalava K, Sallinen V, Lampela H, Malmi H, Leppäniemi A, Mentula P. Role of delay and antibiotics on PERForation rate while waiting appendicECTomy (PERFECT): a protocol for a randomized non-inferiority trial. BJS Open 2021; 5:6377141. [PMID: 34580704 PMCID: PMC8477049 DOI: 10.1093/bjsopen/zrab089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 08/16/2021] [Indexed: 11/14/2022] Open
Abstract
Background Longer duration from symptom onset is associated with increased risk of perforation in appendicitis. In previous studies, in-hospital delay to surgery has had conflicting effects on perforation rates. Although preoperative antibiotics have been shown to reduce postoperative infections, there are no data showing that administration of antibiotics while waiting for surgery has any benefits. The aims of this study are to evaluate the role of both in-hospital delay to surgery and antibiotic treatment while waiting for surgery on the rate of appendiceal perforation. Methods This prospective, open-label, randomized, controlled non-inferiority trial compares the in-hospital delay to surgery of less than 8 hours versus less than 24 hours in adult patients with predicted uncomplicated acute appendicitis. Additionally, participants are randomized either to receive or not to receive antibiotics while waiting for surgery. The primary study endpoint is the rate of perforated appendicitis discovered during appendicectomy. The aim is to randomize 1800 patients, that is estimated to give a power of 90 per cent (χ2) for the non-inferiority margin of 5 percentage points for both layers (urgency and preoperative antibiotic). Secondary endpoints include length of hospital stay, 30-day complications graded using Clavien–Dindo classification, preoperative pain, conversion rate, histopathological diagnosis and Sunshine Appendicitis Grading System classification. Discussion There are no previous randomized controlled studies for either in-hospital delay or preoperative antibiotic treatment. The trial will yield new level 1 evidence. EU Clinical Trials Register, EudraCT Number: 2019–002348-26; registration number: NCT04378868 (http://www.clinicaltrials.gov)
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Affiliation(s)
- K Jalava
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - V Sallinen
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - H Lampela
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - H Malmi
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - A Leppäniemi
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - P Mentula
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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74
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Sahra S, Abureesh M, Amarnath S, Alkhayyat M, Badran R, Jahangir A, Gumaste V. Clostridioides difficile infection in liver cirrhosis patients: A population-based study in United States. World J Hepatol 2021; 13:926-938. [PMID: 34552699 PMCID: PMC8422922 DOI: 10.4254/wjh.v13.i8.926] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/11/2021] [Accepted: 07/22/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Clostridioides (formerly Clostridium) difficile infection (CDI) is an increasingly frequent cause of morbidity and mortality in hospitalized patients. Multiple risk factors are documented in the literature that includes, but are not limited to, antibiotics use, advanced age, and gastric acid suppression. Several epidemiological studies have reported an increased incidence of CDI in advanced liver disease patients. Some have also demonstrated a higher prevalence of nosocomial infections in cirrhotic patients.
AIM To use a large nationwide database, we sought to determine CDI’s risk among liver cirrhosis patients in the United States.
METHODS We queried a commercial database (Explorys IncTM, Cleveland, OH, United States), and obtained an aggregate of electronic health record data from 26 major integrated United States healthcare systems comprising 360 hospitals in the United States from 2018 to 2021. Diagnoses were organized into the Systematized Nomenclature of Medicine Clinical Terms (SNOMED–CT) hierarchy. Statistical analysis for the multivariable model was performed using Statistical Package for Social Sciences (SPSS version 25, IBM CorpTM). For all analyses, a two-sided P value of < 0.05 was considered statistically significant.
RESULTS There were a total of 19387760 patients in the database who were above 20 years of age between the years 2018-2021. Of those, 133400 were diagnosed with liver cirrhosis. The prevalence of CDI amongst the liver cirrhosis population was 134.93 per 100.000 vs 19.06 per 100.000 in non-cirrhotic patients (P < 0.0001). The multivariate analysis model uncovered that cirrhotic patients were more likely to develop CDI (OR: 1.857; 95%CI: 1.665-2.113, P < 0.0001) compared to those without any prior history of liver cirrhosis.
CONCLUSION In this large database study, we uncovered that cirrhotic patients have a significantly higher CDI prevalence than those without cirrhosis. Liver cirrhosis may be an independent risk factor for CDI. Further prospective studies are needed to clarify this possible risk association that may lead to the implementation of screening methods in this high-risk population.
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Affiliation(s)
- Syeda Sahra
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Mohammad Abureesh
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Shivantha Amarnath
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Motasem Alkhayyat
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Rawan Badran
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Abdullah Jahangir
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Vivek Gumaste
- Department of Gastroenterology, Staten Island University Hospital, Staten Island, NY 10305, United States
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75
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Bao H, Lighter J, Dubrovskaya Y, Merchan C, Siegfried J, Papadopoulos J, Jen SP. Oral Vancomycin as Secondary Prophylaxis for Clostridioides difficile Infection. Pediatrics 2021; 148:peds.2020-031807. [PMID: 34330867 DOI: 10.1542/peds.2020-031807] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Secondary oral vancomycin prophylaxis (OVP) has been used in adults with a history of Clostridioides difficile infection (CDI) while receiving systemic antibiotics to prevent CDI recurrence. However, this practice has not been studied in pediatric patients. The objective of this study was to assess the utility of secondary OVP in pediatric patients with previous CDI who received subsequent antibiotic exposure. METHODS A multicampus, retrospective cohort evaluation was conducted among patients aged ≤18 years with any history of clinical CDI and receiving systemic antibiotics in a subsequent encounter from 2013-2019. Patients who received concomitant OVP with antibiotics were compared with unexposed patients. The primary outcome was CDI recurrence within 8 weeks after antibiotic exposure. Infection with vancomycin-resistant enterococci and risk factors for CDI recurrence were assessed. RESULTS A total of 148 patients were screened, of which 30 and 44 patients received OVP and no OVP, respectively. Patients who received OVP had greater antibiotic use and hospital lengths of stay. The incidence of CDI recurrence within 8 weeks of antibiotic exposure was significantly lower in patients who received OVP (3% vs 25%; P = .02) despite this group having notably more risk factors for recurrence. There were no vancomycin-resistant enterococci infections in any patients within either group. After adjustment in a multivariable analysis, secondary OVP was associated with less risk of recurrence (odds ratio, 0.10; 95% confidence interval, 0.01-0.86; P = .04). CONCLUSIONS Secondary OVP while receiving systemic antibiotics reduces the risk of recurrent CDI in pediatric patients with a history of CDI.
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Affiliation(s)
- Hongkai Bao
- Department of Pharmacy, Montefiore Medical Center, The Bronx, New York
| | | | - Yanina Dubrovskaya
- Medicine, New York University School of Medicine, New York, New York.,Department of Pharmacy, NYU Langone Health, New York, New York
| | | | | | - John Papadopoulos
- Medicine, New York University School of Medicine, New York, New York.,Department of Pharmacy, NYU Langone Health, New York, New York
| | - Shin-Pung Jen
- Department of Pharmacy, Newark Beth Israel Medical Center, Newark, New Jersey
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76
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Butler AM, Durkin MJ, Keller MR, Ma Y, Powderly WG, Olsen MA. Association of Adverse Events with Antibiotic Treatment for Urinary Tract Infection. Clin Infect Dis 2021; 74:1408-1418. [PMID: 34279560 DOI: 10.1093/cid/ciab637] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Little is known about the relative harms of different antibiotic regimens prescribed to treat uncomplicated urinary tract infection (UTI). We sought to compare the risk of adverse events associated with commonly-used oral antibiotic regimens for the outpatient treatment of uncomplicated UTI. METHODS We identified 1,169,033 otherwise healthy, non-pregnant women aged 18-44 years with uncomplicated UTI who initiated an oral antibiotic with activity against common uropathogens from July 1, 2006 to September 30, 2015. We used propensity score-weighted Kaplan-Meier methods and Cox proportional hazards regression models to estimate the association between antibiotic agent and adverse events. RESULTS Of two first-line agents, TMP/SMX (versus nitrofurantoin) was associated with higher risk of several adverse drug events including hypersensitivity reaction (hazard ratio [HR] 2.62, 95% CI 2.30-2.98), acute renal failure (HR 2.56, 95% CI 1.55-4.25), skin rash (HR 2.42, 95% CI 2.13-2.75), urticaria (HR 1.37, 95% CI 1.19-1.57), abdominal pain (HR 1.14, 95% CI 1.09-1.19), and nausea / vomiting (HR 1.18, 95% CI 1.10-1.28), but similar risk of potential microbiome-related adverse events. Compared to nitrofurantoin, non-first-line agents were associated with higher risk of several adverse drug events and potential microbiome-related adverse events including non-C. difficile diarrhea, C. difficile infection, vaginitis / vulvovaginal candidiasis, and pneumonia. Treatment duration modified the risk of potential microbiome-related adverse events. CONCLUSIONS The risks of adverse drug events and potential microbiome-related events differ widely by antibiotic agent and duration. These findings underscore the utility of using real-world data to fill evidentiary gaps related to antibiotic safety.
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Affiliation(s)
- Anne M Butler
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA.,Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael J Durkin
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - Matthew R Keller
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - Yinjiao Ma
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - William G Powderly
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - Margaret A Olsen
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA.,Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
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77
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Slimings C, Riley TV. Antibiotics and healthcare facility-associated Clostridioides difficile infection: systematic review and meta-analysis 2020 update. J Antimicrob Chemother 2021; 76:1676-1688. [PMID: 33787887 DOI: 10.1093/jac/dkab091] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/01/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Antibiotic use is the most important modifiable risk factor for healthcare facility-associated Clostridioides difficile infection (HCFA-CDI). Previous systematic reviews cover studies published until 31 December 2012. OBJECTIVES To update the evidence for associations between antibiotic classes and HCFA-CDI to 31 December 2020. METHODS PubMed, Scopus, Web of Science Core Collection, WorldCat and Proquest Dissertations & Theses were searched for studies published since 1 January 2013. Eligible studies were those conducted among adult hospital inpatients, measured exposure to individual antibiotics or antibiotic classes, included a comparison group and measured the occurrence of HCFA-CDI as an outcome. The Newcastle-Ottawa Scale was used to appraise study quality. To assess the association between each antibiotic class and HCFA-CDI, a pooled random-effects meta-analysis was undertaken. Meta-regression and subgroup analysis was used to investigate study characteristics identified a priori as potential sources of heterogeneity. RESULTS Carbapenems and third- and fourth-generation cephalosporin antibiotics remain the most strongly associated with HCFA-CDI, with cases more than twice as likely to have recent exposure to these antibiotics prior to developing HCFA-CDI. Modest associations were observed for fluoroquinolones, clindamycin and β-lactamase inhibitor combination penicillin antibiotics. Individual study effect sizes were variable and heterogeneity was observed for most antibiotic classes. CONCLUSIONS This review provides the most up-to-date synthesis of evidence in relation to the risk of HCFA-CDI associated with exposure to specific antibiotic classes. Studies were predominantly conducted in North America or Europe and more studies outside of these settings are needed.
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Affiliation(s)
- Claudia Slimings
- Medical School, College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Western Australia
| | - Thomas V Riley
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia.,Department of Microbiology, PathWest Laboratory Medicine, Nedlands, Western Australia
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78
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Ghanem S, Kim CJ, Dutta D, Salifu M, Lim SH. Antimicrobial therapy during cancer treatment: Beyond antibacterial effects. J Intern Med 2021; 290:40-56. [PMID: 33372309 DOI: 10.1111/joim.13238] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/22/2020] [Accepted: 12/01/2020] [Indexed: 02/07/2023]
Abstract
Cancer treatment options have evolved to include immunotherapy and targeted therapy, in addition to traditional chemoradiation. Chemoradiation places the patient at a higher risk of infection through a myelosuppressive effect. High clinical suspicion and early use of antimicrobials play a major role in decreasing any associated morbidity and mortality. This has led to a widespread use of antimicrobials in cancer patients. Antimicrobial use, however, does not come without its perils. Dysbiosis caused by antimicrobial use affects responses to chemotherapeutic agents and is prognostic in the development and severity of certain cancer treatment-related complications such as graft-versus-host disease and Clostridioides difficile infections. Studies have also demonstrated that an intact gut microbiota is essential in the anticancer immune response. Antimicrobial use can therefore modulate responses and outcomes with immunotherapy targeting immune checkpoints. In this review, we highlight the perils associated with antimicrobial use during cancer therapy and the importance of a more judicious approach. We discuss the nature of the pathologic changes in the gut microbiota resulting from antimicrobial use. We explore the effect these changes have on responses and outcomes to different cancer treatment modalities including chemotherapy and immunotherapy, as well as potential adverse clinical consequences in the setting of stem cell transplant.
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Affiliation(s)
- S Ghanem
- From the, Division of Hematology and Oncology, Department of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - C J Kim
- From the, Division of Hematology and Oncology, Department of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - D Dutta
- From the, Division of Hematology and Oncology, Department of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - M Salifu
- From the, Division of Hematology and Oncology, Department of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - S H Lim
- From the, Division of Hematology and Oncology, Department of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
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79
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Heidebrecht HJ, Lagkouvardos I, Reitmeier S, Hengst C, Kulozik U, Pfaffl MW. Alteration of Intestinal Microbiome of Clostridioides difficile-Infected Hamsters during the Treatment with Specific Cow Antibodies. Antibiotics (Basel) 2021; 10:antibiotics10060724. [PMID: 34208527 PMCID: PMC8235726 DOI: 10.3390/antibiotics10060724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/10/2021] [Accepted: 06/10/2021] [Indexed: 01/04/2023] Open
Abstract
Clostridioides difficile infection (CDI) often develops after pretreatment with antibiotics, which can lead to damage of the intestinal microbiome. The approach of this study was to use specific polyclonal antibodies isolated from the milk of immunized cows to treat CDI, in contrast to the standard application of nonspecific antibiotics. To gain a deeper understanding of the role of the microbiome in the treatment of CDI with bovine antibodies, stool and intestinal fluid samples of hamsters were collected in large quantities from various treatments (>400 samples). The results show that the regeneration of the microbiome instantly begins with the start of the antibody treatment, in contrast to the Vancomycin-treated group where the diversity decreased significantly during the treatment duration. All antibody-treated hamsters that survived the initial phase also survived the entire study period. The results also show that the regeneration of the microbiome was not an antibody-induced regeneration, but a natural regeneration that occurred because no microbiota-inactivating substances were administered. In conclusion, the treatment with bovine antibodies is a functional therapy for both the acute treatment and the prevention of recurrence in hamsters and could meet the urgent need for CDI treatment alternatives in humans.
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Affiliation(s)
- Hans-Jürgen Heidebrecht
- Food- and Bioprocess Engineering, TUM School of Life Science, Technical University of Munich, Weihenstephaner Berg 1, 85354 Freising, Germany; (C.H.); (U.K.)
- Correspondence: ; Tel.: +49-8161713481
| | - Ilias Lagkouvardos
- ZIEL—Institute for Food & HealthCore Facility Microbiome, Technical University of Munich, Weihenstephaner Berg 3, 85354 Freising, Germany; (I.L.); (S.R.)
| | - Sandra Reitmeier
- ZIEL—Institute for Food & HealthCore Facility Microbiome, Technical University of Munich, Weihenstephaner Berg 3, 85354 Freising, Germany; (I.L.); (S.R.)
| | - Claudia Hengst
- Food- and Bioprocess Engineering, TUM School of Life Science, Technical University of Munich, Weihenstephaner Berg 1, 85354 Freising, Germany; (C.H.); (U.K.)
| | - Ulrich Kulozik
- Food- and Bioprocess Engineering, TUM School of Life Science, Technical University of Munich, Weihenstephaner Berg 1, 85354 Freising, Germany; (C.H.); (U.K.)
| | - Michael W. Pfaffl
- Animal Physiology and Immunology, TUM School of Life Science, Technical University of Munich, Weihenstephaner Berg 3, 85354 Freising, Germany;
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80
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Hiraki M, Suzuki R, Tanaka N, Fukunaga H, Kinoshita Y, Kimura H, Tsutsui S, Murata M, Morita S. Community-acquired fulminant Clostridioides (Clostridium) difficile infection by ribotype 027 isolate in Japan: a case report. Surg Case Rep 2021; 7:137. [PMID: 34101061 PMCID: PMC8187545 DOI: 10.1186/s40792-021-01220-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/29/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Clostridioides (Clostridium) difficile infection (CDI) has become an increasingly significant disease not only as healthcare-associated infection, but also as community-acquired (CA) infection worldwide. CDI caused by the NAP1/BI/027 strain is reported to be more severe, difficult to cure, and frequently associated with recurrences in North America and Europe. CASE PRESENTATION A 68-year-old woman was referred to our hospital for continuous lower abdominal pain 4 weeks after eradication therapy against Helicobacter pylori. While she was treated with fasting on the suspicion of ischemic colitis, she experienced septic shock. Emergent subtotal proctocolectomy revealed fulminant pseudomembranous C. difficile colitis. The C. difficile isolate recovered from the patient was identified as ribotype 027, which has been reported to be uncommon in Japan. CONCLUSION We report a rare case of CA fulminant pseudomembranous colitis caused by ribotype 027 C. difficile after H. pylori eradication therapy.
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Affiliation(s)
- Masayuki Hiraki
- Department of Surgery, Itami City Hospital, 1-100 Koyaike, Itami-shi, Hyogo, 664-8540, Japan. .,Department of Surgery, Kansai Rosai Hospital, Japan Organization of Occupational Health and Safety, 3-1-69 Inabaso, Amagasaki, Hyogo, 660-8511, Japan.
| | - Rei Suzuki
- Department of Surgery, Itami City Hospital, 1-100 Koyaike, Itami-shi, Hyogo, 664-8540, Japan
| | - Nobuo Tanaka
- Department of Surgery, Itami City Hospital, 1-100 Koyaike, Itami-shi, Hyogo, 664-8540, Japan
| | - Hiroki Fukunaga
- Department of Surgery, Itami City Hospital, 1-100 Koyaike, Itami-shi, Hyogo, 664-8540, Japan
| | - Yoshinori Kinoshita
- Department of Respiratory Medicine, Itami City Hospital, 1-100 Koyaike, Itami-shi, Hyogo, 664-8540, Japan
| | - Hayato Kimura
- Department of Diagnostic Pathology, Itami City Hospital, 1-100 Koyaike, Itami-shi, Hyogo, 664-8540, Japan
| | - Shusaku Tsutsui
- Department of Gastroenterology, Itami City Hospital, 1-100 Koyaike, Itami-shi, Hyogo, 664-8540, Japan
| | - Masaru Murata
- Department of Surgery, Itami City Hospital, 1-100 Koyaike, Itami-shi, Hyogo, 664-8540, Japan
| | - Shunji Morita
- Department of Surgery, Itami City Hospital, 1-100 Koyaike, Itami-shi, Hyogo, 664-8540, Japan
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81
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Jaffa RK, Hammer J, Medaris LA, Anderson WE, Heffner AC, Pillinger KE. Empiric aztreonam is associated with increased mortality compared to beta-lactams in septic shock. Am J Emerg Med 2021; 48:255-260. [PMID: 34004470 DOI: 10.1016/j.ajem.2021.04.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/10/2021] [Accepted: 04/27/2021] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To determine if aztreonam as initial empiric treatment of adult septic shock is associated with increased mortality compared to the use of anti-pseudomonal beta-lactam agents. METHODS This was a multicenter, retrospective cohort study of 582 adult emergency department patients admitted to 12 acute care facilities within a single health system from January 2014 to December 2017 with septic shock receiving either aztreonam or an anti-pseudomonal beta-lactam for empiric treatment and discharged with an infection-related ICD-9 or ICD-10 code. The primary endpoint was in-hospital mortality. RESULTS Initial exposure to aztreonam was associated with increased hospital mortality compared to treatment with an anti-pseudomonal beta-lactam agent (22.7% vs. 12.9%, OR = 1.98, 95% CI: 1.27-3.11). When adjusted for APACHE II score, the treatment group effect on mortality remained statistically significant (OR = 1.74, 95% CI: 1.08-2.80). Aztreonam use was also associated with increased utilization of aminoglycosides (28.9% vs. 12.4%, p < 0.0001) and fluoroquinolones (50.5% vs. 25.8%, p < 0.01). There was no difference in hospital or intensive care unit length of stay in surviving patients between the two groups. CONCLUSIONS Compared to anti-pseudomonal beta-lactams, empiric treatment with aztreonam is associated with increased mortality and greater antibiotic exposure among patients with acute septic shock. These findings suggest that treatment with anti-pseudomonal beta-lactams should be prioritized over allergy avoidance whenever feasible.
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Affiliation(s)
- Rupal K Jaffa
- Division of Pharmacy, Atrium Health's Carolinas Medical Center, United States of America.
| | - John Hammer
- Division of Pharmacy, Atrium Health's Carolinas Medical Center, United States of America.
| | - Leigh Ann Medaris
- Department of Infectious Diseases, Atrium Health's Carolinas Medical Center, United States of America.
| | - William E Anderson
- Center for Outcomes Research and Evaluation, Atrium Health's Carolinas Medical Center, United States of America
| | - Alan C Heffner
- Department of Internal Medicine, Division of Critical Care, Atrium Health's Carolinas Medical Center, United States of America; Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, United States of America.
| | - Kelly E Pillinger
- University of Rochester Medical Center - Strong Memorial Hospital, United States of America.
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82
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Johnson SW, Brown SV, Priest DH. Effectiveness of Oral Vancomycin for Prevention of Healthcare Facility-Onset Clostridioides difficile Infection in Targeted Patients During Systemic Antibiotic Exposure. Clin Infect Dis 2021; 71:1133-1139. [PMID: 31560051 DOI: 10.1093/cid/ciz966] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/26/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Limited retrospective data suggest prophylactic oral vancomycin may prevent Clostridioides difficile infection (CDI). We sought to evaluate the effectiveness of oral vancomycin for the prevention of healthcare facility-onset CDI (HCFO-CDI) in targeted patients. METHODS We conducted a randomized, prospective, open-label study at Novant Health Forsyth Medical Center in Winston-Salem, North Carolina, between October 2018 and April 2019. Included patients were randomized 1:1 to either oral vancomycin (dosed at 125 mg once daily while receiving systemic antibiotics and continued for 5 days postcompletion of systemic antibiotics [OVP]) or no prophylaxis. The primary endpoint was incidence of HCFO-CDI. Secondary endpoints included incidence of community-onset healthcare facility-associated CDI (CO-HCFA-CDI), incidence of vancomycin-resistant Enterococci (VRE) colonization after receiving OVP, adverse effects, and cost of OVP. RESULTS A total of 100 patients were evaluated, 50 patients in each arm. Baseline and hospitalization characteristics were similar, except antibiotic exposure. No events of HCFO-CDI were noted in the OVP group compared with 6 (12%) in the no-prophylaxis group (P = .03). CO-HCFA-CDI was identified in 2 patients who were previously diagnosed with HCFO-CDI. No patients developed new VRE colonization, with only 1 patient reporting mild gastrointestinal side effects to OVP. A total of 600 doses of OVP were given during the study, with each patient receiving an average of 12 doses. Total acquisition cost of OVP was $1302, $26.04 per patient. CONCLUSION OVP appears to protect against HCFO-CDI during in-patient stay in targeted patients during systemic antibiotic exposure. Further prospective investigation is warranted.
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Affiliation(s)
- Steven W Johnson
- Department of Pharmacy Practice, Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina, USA.,Department of Pharmacy, Novant Health Forsyth Medical Center, Winston-Salem, North Carolina, USA
| | - Shannon V Brown
- Department of Pharmacy Practice, Campbell University College of Pharmacy and Health Science, Buies Creek, North Carolina, USA
| | - David H Priest
- Novant Health Institute for Safety and Quality, Winston-Salem, North Carolina, USA.,Novant Health Infectious Disease Specialists, Winston-Salem, North Carolina, USA
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83
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Antimicrobial stewardship programs in adult intensive care units in Latin America: Implementation, assessments, and impact on outcomes. Infect Control Hosp Epidemiol 2021; 43:181-190. [PMID: 33829982 DOI: 10.1017/ice.2021.80] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To assess the impact of antimicrobial stewardship programs (ASPs) in adult medical-surgical intensive care units (MS-ICUs) in Latin America. DESIGN Quasi-experimental prospective with continuous time series. SETTING The study included 77 MS-ICUs in 9 Latin American countries. PATIENTS Adult patients admitted to an MS-ICU for at least 24 hours were included in the study. METHODS This multicenter study was conducted over 12 months. To evaluate the ASPs, representatives from all MS-ICUs performed a self-assessment survey (0-100 scale) at the beginning and end of the study. The impact of each ASP was evaluated monthly using the following measures: antimicrobial consumption, appropriateness of antimicrobial treatments, crude mortality, and multidrug-resistant microorganisms in healthcare-associated infections (MDRO-HAIs). Using final stewardship program quality self-assessment scores, MS-ICUs were stratified and compared among 3 groups: ≤25th percentile, >25th to <75th percentile, and ≥75th percentile. RESULTS In total, 77 MS-ICU from 9 Latin American countries completed the study. Twenty MS-ICUs reached at least the 75th percentile at the end of the study in comparison with the same number who remain within the 25th percentile (score, 76.1 ± 7.5 vs 28.0 ± 7.3; P < .0001). Several indicators performed better in the MS-ICUs in the 75th versus 25th percentiles: antimicrobial consumption (143.4 vs 159.4 DDD per 100 patient days; P < .0001), adherence to clinical guidelines (92.5% vs 59.3%; P < .0001), validation of prescription by pharmacist (72.0% vs 58.0%; P < .0001), crude mortality (15.9% vs 17.7%; P < .0001), and MDRO-HAIs (9.45 vs 10.96 cases per 1,000 patient days; P = .004). CONCLUSION MS-ICUs with more comprehensive ASPs showed significant improvement in antimicrobial utilization.
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84
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Clostridium difficile: Diagnosis and the Consequence of Over Diagnosis. Infect Dis Ther 2021; 10:687-697. [PMID: 33770398 PMCID: PMC8116462 DOI: 10.1007/s40121-021-00417-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 02/16/2021] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile infection (CDI) is a leading cause of healthcare-associated infections, accounting for significant disease burden and mortality. The clinical spectrum of C. difficile ranges from asymptomatic colonization to toxic megacolon and fulminant colitis. CDI is characterized by new onset of ≥ 3 unformed stools in 24 h and is confirmed by laboratory test for the presence of toxigenic C. difficile. Currently, laboratory tests to diagnose CDI include toxigenic culture, glutamate dehydrogenase (GDH), nucleic acid amplification test (NAAT), and toxins A/B enzyme immunoassay (EIA). The sensitivities of these tests are variable with toxin EIA ranging from 53 to 60% and with NAAT at about 95%. Overall, the specificity is > 90% for these methods. However, the positive predictive value (PPV) depends on the disease prevalence with lower CDI rates associated with lower PPVs. Notably, the widespread use of the highly sensitive NAAT and its relatively lower clinical specificity have led to overdiagnosis of C. difficile by identifying carriers when NAAT is used as the sole diagnostic method. Overdiagnosis of C. difficile has resulted in unwarranted treatment, possibly attributing to resistance to metronidazole and vancomycin, increased risk for overgrowth of vancomycin-resistant enterococci strains in stool specimens, and increased hospitalization thereby impacting patient safety and healthcare costs. Strategies to optimize the clinical sensitivity and specificity of current laboratory tests are critical to differentiate the clinical CDI from colonization. To achieve high diagnostic yield, if preagreed institutional criteria for stool submission are not used, a multistep approach to CDI diagnosis is recommended, such as either GDH or NAAT followed by toxins A/B EIA in conjunction with laboratory stewardship by evaluating C. difficile test orders for appropriateness and providing feedback. Furthermore, antimicrobial stewardship, along with provider education on appropriate testing for C. difficile, is vital to differentiate CDI from colonization.
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85
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Gaudreau S, Bourque G, Côté K, Nutu C, Beauchesne MF, Longpré AA, Beloin-Jubinville B, Legeleux L, Blaquière M, Martin P, Gilbert M. Resources Assessment for Penicillin Allergy Testing Performed by Pharmacists at the Patient's Bedside. Ann Pharmacother 2021; 55:1355-1362. [PMID: 33703922 PMCID: PMC8908455 DOI: 10.1177/10600280211002412] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: False penicillin allergies lead to increased antimicrobial resistance, adverse effects, and health care costs by promoting the use of broad-spectrum antibiotics. The Infectious Diseases Society of America recommends the implementation of allergy testing. Objectives: The primary objective of this research was to estimate the number of pharmacist full-time equivalents (FTEs) required for an intervention aimed at determining penicillin allergy in hospitalized patients. Acceptance of pharmacists’ suggestions on antibiotic therapy are described. Methods: A quasi-experimental study was conducted in a 712-bed university hospital involving hospitalized patients with a suspected penicillin allergy and an infection treatable with penicillin. The time required for the intervention, which included a questionnaire, penicillin allergy testing (skin-prick test, intradermal injection, and oral provocation test), and recommendations on antibiotic therapy were measured to calculate the number of pharmacist FTEs. Results: A total of 55 patients were included. Scarification allergy testing was performed on 37, intradermal allergy test on 33, and oral provocation test on 26 patients. The intervention ruled out penicillin allergy in 26 patients, with no serious adverse effects. The intervention was associated with a median weekly pharmacist FTE of 0.15 (interquartile range = 0.12-0.25). The acceptance of pharmacists’ suggestions was high and led to 9 patients being switched to an antibiotic with a narrower spectrum of activity. Conclusions and Relevance: This study describes penicillin allergy testing and the number of median weekly hospital pharmacist FTEs required, which was approximately 0.15. These data may aid in the implementation of this safe intervention that promotes narrower-spectrum antibiotherapy.
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Affiliation(s)
- Sophie Gaudreau
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Montréal, Montréal, QC, Canada
| | - Geneviève Bourque
- Centre intégré de santé et de services sociaux de la Montérégie-Centre, Saint-Jean-sur-Richelieu, QC, Canada
| | - Kevin Côté
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Montréal, Montréal, QC, Canada
| | | | - Marie-France Beauchesne
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Montréal, Montréal, QC, Canada.,Centre de recherche du CHUS, Sherbrooke, QC, Canada
| | - Audrey-Anne Longpré
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Montréal, Montréal, QC, Canada
| | - Bianca Beloin-Jubinville
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Montréal, Montréal, QC, Canada
| | - Lorraine Legeleux
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Montréal, Montréal, QC, Canada
| | - Martin Blaquière
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Philippe Martin
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Mélanie Gilbert
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Montréal, Montréal, QC, Canada
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86
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Alammari KM, Thabit AK. Characteristics of patients infected with Clostridioides difficile at a Saudi Tertiary Academic Medical Center and assessment of antibiotic duration. Gut Pathog 2021; 13:10. [PMID: 33593421 PMCID: PMC7887815 DOI: 10.1186/s13099-021-00405-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 02/10/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Clostridioides difficile infection (CDI) is a common hospital-associated diarrhea. Several antibiotics commonly associate with CDI; however, limited data are available on the duration of exposure prior to CDI. Moreover, studies on the characteristics of CDI patients in Saudi Arabia are limited. Therefore, this study aimed to characterize CDI patients identified over 10 years and assess antibiotic days of therapy (DOT) prior to CDI. METHODS This was a retrospective descriptive analysis of CDI patients at a Saudi tertiary academic medical center between December 2007 and January 2018. Patients characteristics, prior exposure to known CDI risk factors, and DOT of antibiotics prior to CDI incidence were assessed. RESULTS A total of 159 patients were included. Median age was 62 years. Most cases were hospital-acquired (71.1%), non-severe (44.7%), and admitted to medical wards (81.1%). Prior exposure to antibiotics and acid suppression therapy were reported with the majority (76.1 and 75.5%, respectively). The most frequently prescribed antibiotics were piperacillin/tazobactam, ceftriaxone, meropenem, and ciprofloxacin with median DOTs prior to CDI incidence of 14 days for the β-lactams and 26 days for ciprofloxacin. The distribution of DOT was significantly different for piperacillin/tazobactam in different units (P = 0.003) where its median DOT was the shortest in medical wards (11 days), and for ciprofloxacin among different severity groups (P = 0.013), where its median DOT was the shortest in severe CDI patients (11 days). CONCLUSION Most patients in this study had hospital-acquired non-severe CDI and were largely exposed to antibiotics and acid suppression therapy. Therefore, such therapies should be revised for necessity.
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Affiliation(s)
- Khadijah M Alammari
- Pharmacy Practice Department, Faculty of Pharmacy, King Abdulaziz University, 7027 Abdullah Al-Sulaiman Rd, Jeddah, 22254-2265, Saudi Arabia
| | - Abrar K Thabit
- Pharmacy Practice Department, Faculty of Pharmacy, King Abdulaziz University, 7027 Abdullah Al-Sulaiman Rd, Jeddah, 22254-2265, Saudi Arabia.
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87
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Ahmad O, Crawford TN, Arora V, Maskey MK. Laboratory markers predictive of fulminant Clostridioides difficile infection refractory to fluid resuscitation. Infect Prev Pract 2021; 3:100127. [PMID: 34368744 PMCID: PMC8336175 DOI: 10.1016/j.infpip.2021.100127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/08/2021] [Indexed: 11/26/2022] Open
Abstract
Background Old age, leucocytosis, hypoalbuminemia, and elevated creatinine have been identified as risk factors for fulminant Clostridioides difficile infection (CDI). High ATLAS scores have also been linked to fatal disease. The affiliated studies, however, involved patients prescribed metronidazole - a regimen no longer standard of care. The variables were thus reassessed in patients prescribed optimal therapy. Methods Adults hospitalized with CDI at University of Kentucky Medical Center were retrospectively reviewed. Enrolled subjects were separated according to disease classification i.e. non-severe/severe versus fulminant CDI. Fulminant patients were further subdivided into hypotensive persons responsive to fluid resuscitation, and those with sequent shock, ileus, or megacolon. Following partition, the cohorts underwent correlation analysis. Findings Forty-five subjects had non-severe/severe disease. Thirteen fulminant CDI patients responded to fluid resuscitation. Seventeen fulminant CDI patients developed shock, ileus, or megacolon. Median WBC counts, albumin values, and ATLAS scores varied among the cohorts. Although WBC counts were similar among the fulminant subsets, declining albumin values and increasing ATLAS scores mirrored disease worsening. Logistic regression revealed albumin values < 20 g/L (odds ratio [OR] 3.91) and ATLAS scores ≥ 6 (OR 5.03) to predict critical illness in hypotensive persons. Conclusion Median WBC counts, albumin values, and ATLAS scores differed in patients separated by CDI severity. A notable variance in albumin values and ATLAS scores between fluid responsive fulminant disease and critical illness was moreover seen. The finding suggests hypoalbuminemia and high ATLAS scores in hypotensive CDI patients may herald shock, ileus, or megacolon.
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Affiliation(s)
- Omar Ahmad
- Division of Infectious Diseases, University of Kentucky, 740 S. Limestone Street K512, Lexington, 40536, KY, USA
| | - Timothy N Crawford
- Department of Population and Public Health Sciences, Wright State University, 3123 Research Boulevard, Dayton, 45420, OH, USA
| | - Vaneet Arora
- Department of Pathology and Laboratory Medicine, University of Kentucky, 800 Rose Street MS 117, Lexington, 40536, KY, USA
| | - Mitu Karki Maskey
- Division of Infectious Diseases, University of Kentucky, 740 S. Limestone Street K512, Lexington, 40536, KY, USA
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88
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Karyal C, Hughes J, Kelly ML, Luckett JC, Kaye PV, Cockayne A, Minton NP, Griffin R. Colonisation Factor CD0873, an Attractive Oral Vaccine Candidate against Clostridioides difficile. Microorganisms 2021; 9:microorganisms9020306. [PMID: 33540694 PMCID: PMC7913071 DOI: 10.3390/microorganisms9020306] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/18/2021] [Accepted: 01/29/2021] [Indexed: 12/12/2022] Open
Abstract
Clostridioides difficile is the main cause of health-care-associated infectious diarrhoea. Toxins, TcdA and TcdB, secreted by this bacterium damage colonic epithelial cells and in severe cases this culminates in pseudomembranous colitis, toxic megacolon and death. Vaccines in human trials have focused exclusively on the parenteral administration of toxin-based formulations. These vaccines promote toxin-neutralising serum antibodies but fail to confer protection from infection in the gut. An effective route to immunise against gut pathogens and stimulate a protective mucosal antibody response (secretory immunoglobulin A, IgA) at the infection site is the oral route. Additionally, oral immunisation generates systemic antibodies (IgG). Using this route, two different antigens were tested in the hamster model: The colonisation factor CD0873 and a TcdB fragment. Animals immunised with CD0873 generated a significantly higher titre of sIgA in intestinal fluid and IgG in serum compared to naive animals, which significantly inhibited the adherence of C. difficile to Caco-2 cells. Following challenge with a hypervirulent isolate, the CD0873-immunised group showed a mean increase of 80% in time to experimental endpoint compared to naïve animals. Survival and body condition correlated with bacterial clearance and reduced pathology in the cecum. Our findings advocate CD0873 as a promising oral vaccine candidate against C. difficile.
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Affiliation(s)
- Cansu Karyal
- Synthetic Biology Research Centre, The University of Nottingham Biodiscovery Institute, University Park, Nottingham NG7 2RD, UK; (C.K.); (J.H.); (M.L.K.); (A.C.); (N.P.M.)
| | - Jaime Hughes
- Synthetic Biology Research Centre, The University of Nottingham Biodiscovery Institute, University Park, Nottingham NG7 2RD, UK; (C.K.); (J.H.); (M.L.K.); (A.C.); (N.P.M.)
| | - Michelle L. Kelly
- Synthetic Biology Research Centre, The University of Nottingham Biodiscovery Institute, University Park, Nottingham NG7 2RD, UK; (C.K.); (J.H.); (M.L.K.); (A.C.); (N.P.M.)
| | - Jeni C. Luckett
- The University of Nottingham Biodiscovery Institute, University Park, Nottingham NG7 2RD, UK;
| | - Philip V. Kaye
- Department of Histopathology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK;
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham NG7 2UH, UK
| | - Alan Cockayne
- Synthetic Biology Research Centre, The University of Nottingham Biodiscovery Institute, University Park, Nottingham NG7 2RD, UK; (C.K.); (J.H.); (M.L.K.); (A.C.); (N.P.M.)
| | - Nigel P. Minton
- Synthetic Biology Research Centre, The University of Nottingham Biodiscovery Institute, University Park, Nottingham NG7 2RD, UK; (C.K.); (J.H.); (M.L.K.); (A.C.); (N.P.M.)
| | - Ruth Griffin
- Synthetic Biology Research Centre, The University of Nottingham Biodiscovery Institute, University Park, Nottingham NG7 2RD, UK; (C.K.); (J.H.); (M.L.K.); (A.C.); (N.P.M.)
- Correspondence: ; Tel.: +44-0115-7486120
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89
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Clinical consequences of contaminated blood cultures in adult hospitalized patients at an institution utilizing a rapid blood-culture identification system. Infect Control Hosp Epidemiol 2020; 42:978-984. [PMID: 33298207 DOI: 10.1017/ice.2020.1337] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To assess the clinical impact of contaminated blood cultures in hospitalized patients during a period when rapid diagnostic testing using a FilmArray Blood Culture Identification (BCID) panel was in use. DESIGN Retrospective cohort study. SETTING Single academic medical center. PARTICIPANTS Patients who had blood culture(s) performed during an admission between June 2014 and December 2016. METHODS Length of hospital stay and days of antibiotic therapy were assessed in relation to blood-culture contamination using generalized linear models with univariable and multivariable analyses. RESULTS Among 11,474 patients who had blood cultures performed, the adjusted mean length of hospital stay for patients with contaminated blood-culture episodes (N = 464) was 12.3 days (95% confidence interval [CI], 11.4-13.2) compared to 11.5 days (95% CI, 11.0-11.9) for patients (N = 11,010) with negative blood-culture episodes (P = .032). The adjusted mean durations of antibiotic therapy for patients with contaminated and negative blood-culture episodes were 6.0 days (95% CI, 5.3-6.7) and 5.2 days (95% CI, 4.9-5.4), respectively (P = .011). CONCLUSIONS Despite the use of molecular-based, rapid blood-culture identification, contamination of blood cultures continues to result in prolonged hospital stay and unnecessary antibiotic therapy in hospitalized patients.
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90
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Kim B, Kim J, Pai H. Association between Antibiotic Consumption and Incidence of Clostridioides difficile Infection in a Hospital. J Korean Med Sci 2020; 35:e407. [PMID: 33289370 PMCID: PMC7721558 DOI: 10.3346/jkms.2020.35.e407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 11/10/2020] [Indexed: 11/20/2022] Open
Abstract
Previous exposure to antimicrobials is a major risk factor for Clostridioides difficile infection (CDI). Antibiotic prescription and C. difficile toxin assay records of patients admitted to a tertiary hospital in Korea from 2009 to 2013 were collected to investigate the association between antibiotic consumption and CDI incidence. A Spearman's correlation analysis between CDI incidence (positive result of toxin assay/10,000 admissions) and antibiotic consumption (defined daily dose/1,000 patient-days) was performed on a monthly basis. Using the matched month approach, we found a significant correlation between CDI rate and moxifloxacin consumption (Spearman's r = 0.351, P < 0.001). Furthermore, using the one-month delay approach, we found that the consumption of clindamycin (Spearman's r = 0.272, P = 0.037) and moxifloxacin (Spearman's r = 0.297, P = 0.022) was significantly correlated with CDI incidence. Extended-spectrum cephalosporins did not have any effect on CDI incidence.
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Affiliation(s)
- Bongyoung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Jieun Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Hyunjoo Pai
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea.
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91
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Panshin MS, Alnachoukati OK, Schroeppel TJ, Metzler M, McFann K, Dunn JA. Optimal Duration of Antibiotics Following Appendectomy for Patients With Complicated Appendicitis. Am Surg 2020; 87:480-485. [PMID: 33047976 DOI: 10.1177/0003134820947372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Complicated appendicitis patients typically undergo appendectomy followed by antibiotics. The optimal course of antibiotics for complicated appendicitis is poorly defined. METHODS Data were collected from patients presenting with acute appendicitis and underwent appendectomy at the index hospitalization (2015-2017). Primary outcomes were readmission rate, superficial surgical site infection (SSI), deep space infection (DSI), which includes abscess. Length of post-operative antibiotic use was recorded and an average intent-to-treat (ITT) by operative grade was calculated. RESULTS Two hundred seventy-two patients (23%) were diagnosed with complicated appendicitis. SSI occurred in 4% of patients (n = 11); SSI rates ranged from 0% to 14.6% by ITT group with 3-4 days being the lowest (0%) and <3 days the highest (14.6%) (P = .008). DSI including abscesses occurred in 27 (9.9%) patients; least frequently in the 5-6 day ITT group (7.4%). Length of stay (LOS) was significantly related to longer antibiotic use (P < .001) and increasing operative grade (P < .01). CONCLUSIONS Given the lower incidence of postoperative complications between 3 and 6 days and no added benefit for ITT >6 days, we recommend limiting antibiotic treatment to 3-6 days for all complicated appendicitis cases with additional workup warranted if infectious symptoms persist.
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Affiliation(s)
| | | | | | | | - Kim McFann
- UCHealth Medical Center of the Rockies, Loveland, CO, USA
| | - Julie A Dunn
- UCHealth Medical Center of the Rockies, Loveland, CO, USA
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92
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Carlson TJ, Gonzales-Luna AJ. Utilizing antibiotics to prevent Clostridioides difficile infection: does exposure to a risk factor decrease risk? A systematic review. J Antimicrob Chemother 2020; 75:2735-2742. [PMID: 32696044 DOI: 10.1093/jac/dkaa251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/04/2020] [Accepted: 05/11/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Antibiotic use is a major risk factor for Clostridioides difficile infection (CDI). However, antibiotics recommended for CDI treatment are being utilized in clinical practice as prophylactic agents. OBJECTIVES To comprehensively summarize and critically evaluate the published literature investigating the effectiveness of antibiotic CDI prophylaxis. METHODS A systematic search for relevant literature was conducted in PubMed and ClinicalTrials.gov. Two investigators independently screened each article for inclusion, and the references of the included articles were studied to identify additional relevant articles. Data extraction and an assessment of risk of bias was completed for all included studies. Unadjusted risk ratios and 95% CI were calculated for each study, with CDI being the outcome variable and prophylaxis (prophylaxis versus control) representing the exposure. RESULTS In total, 13 articles were identified in PubMed and 9 ongoing or unpublished trials were identified in ClinicalTrials.gov. The effect of antibiotic prophylaxis on CDI rates varied between studies; however, most favoured the use of antibiotic prophylaxis. CONCLUSIONS The authors of this review conclude that the current literature carries a high risk of bias and the results should be interpreted with caution.
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Affiliation(s)
- Travis J Carlson
- Department of Clinical Sciences, High Point University Fred Wilson School of Pharmacy, One University Parkway, High Point, NC 27268, USA
| | - Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, 4849 Calhoun Road, Houston, TX 77204, USA
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93
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Carius BM, Liang SY, Koyfman A, Long B. Clostridioides difficile infection evaluation and management in the emergency department. Am J Emerg Med 2020; 38:2203-2208. [DOI: 10.1016/j.ajem.2020.06.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/24/2020] [Accepted: 06/28/2020] [Indexed: 11/15/2022] Open
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Characterizing Clostridioides difficile infections and hospital exposures in California using surveillance and administrative data, 2014-2015. Infect Control Hosp Epidemiol 2020; 42:292-297. [PMID: 32993820 DOI: 10.1017/ice.2020.447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To evaluate a method to identify hospitals contributing to Clostridioides difficile infections (CDI) at subsequent hospitalizations. DESIGN Retrospective cohort study. METHODS We merged 2014-2015 National Healthcare Safety Network (NHSN) inpatient CDI laboratory-identified events with hospital patient discharge data. For patients with incident community-onset CDI (CO CDI), we identified immediately preceding admissions (within 12 weeks) unrelated to CDI at different (exposure) hospitals. We calculated an exposure rate, and we selected hospitals with the highest (90th-100th percentile) rates by hospital type and compared these rates with reported standardized infection ratios (SIR) for CDI. RESULTS We successfully matched 44,691 of 58,842 NHSN CDI records (76.0%) with a hospital discharge record. Among 36,215 unique matched records, 5,234 (14.5%) had an admission not related to CDI within 12 weeks prior to an incident CO CDI event, and 1,574 of these admissions (30.1%) occurred in a different hospital. For 33 hospitals with an exposure ranking within the 90th-100th percentile, CDI SIRs for 22 (66.7%) were not significantly different; 3 (9.1%) were lower; and 8 (24.2%) were higher than the national baseline. Also, 12 (36.4%) had an SIR ≤1.0. CONCLUSIONS The identification of high-ranked exposure hospitals presents an alternative to SIR for measuring the contribution of hospitals to the CDI burden across the continuum of care. Further exploration of the potential factors leading to high exposure rank, such as antibiotic use and infection control practices, is indicated and may inform CDI prevention outreach to healthcare facilities and provider networks in California and elsewhere.
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95
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Ferreira EDO, Penna B, Yates EA. Should We Be Worried About Clostridioides difficile During the SARS-CoV2 Pandemic? Front Microbiol 2020; 11:581343. [PMID: 33133048 PMCID: PMC7550402 DOI: 10.3389/fmicb.2020.581343] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 08/26/2020] [Indexed: 12/11/2022] Open
Affiliation(s)
- Eliane de Oliveira Ferreira
- Laboratório de Biologia de Anaeróbios, Departamento de Microbiologia Médica, Instituto de Microbiologia Paulo de Góes- IMPG, Universidade Federal Do Rio de Janeiro- UFRJ, Rio de Janeiro, Brazil
| | - Bruno Penna
- Laboratório de Cocos Gram Positivos, Departamento Do Microbiologia e Parasitologia, Instituto Biomédico, Universidade Federal Fluminense, Niteroi, Brazil
| | - Edwin A. Yates
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
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Khanna S. Defending against a difficult clostridioides with a vaccine. THE LANCET. INFECTIOUS DISEASES 2020; 21:157-158. [PMID: 32946837 DOI: 10.1016/s1473-3099(20)30356-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 04/17/2020] [Indexed: 12/31/2022]
Affiliation(s)
- Sahil Khanna
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA.
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Zhang W, Williams A, Griffith N, Gaskins J, Bookstaver PB. Online availability of fish antibiotics and documented intent for self-medication. PLoS One 2020; 15:e0238538. [PMID: 32881969 PMCID: PMC7470343 DOI: 10.1371/journal.pone.0238538] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 08/18/2020] [Indexed: 11/19/2022] Open
Abstract
Self-medication and antibiotic utilization without healthcare oversight may lead to delayed appropriate treatment, transmission of communicable infections, untoward adverse events, and contribute to antimicrobial resistance. Previous data suggest people obtain over-the-counter (OTC) animal antibiotics for their personal use. This study examined the availability of OTC fish antibiotics online and the documented intent for self-medication. The authors conducted a web-based cross-sectional study using Google search engine to identify vendor websites selling fish antibiotics in the United States. Vendor websites were included if product information, consumer reviews, and comments were publicly available. Nine fish antibiotics were chosen due to their possibility of having consequences to human misuse. The cost and availability of fish antibiotics was recorded. The proportion of reviews and comments related to human consumption was calculated. Consumer review traffic based on “likes” and “dislikes” received was compared between human- and non-human consumption-related reviews. Selected fish antibiotics were purchased and evaluated for physical appearance and compared to FDA-approved available equivalents. We found 24 website vendors with online ordering available for OTC fish antibiotics. Cost varied significantly by antibiotic and quantity ranging from USD $8.99 to $119.99. There were 2,288 reviews documented for the 9 selected antibiotics being sold. Among consumer reviews, 2.4% were potentially associated with human consumption. Human consumption-related reviews constituted 30.2% of all “likes” received and 37.5% of all “dislikes” received. Human consumption-related reviews received an average of 9.2 likes compared to 0.52 likes for non-human consumption-related reviews. The 8 fish antibiotics purchased were consistent with FDA-approved equivalents in physical appearance. Although infrequent, antibiotics intended for fish use are being purchased online without a prescription for self-medication to circumvent professional medical care. Reviews related to human consumption generate significant online traffic compared to reviews unrelated to human consumption.
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Affiliation(s)
- Weiwei Zhang
- Department of Clinical Pharmacy, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
- * E-mail: (PBB); (WZ)
| | - Austin Williams
- University of South Carolina College of Pharmacy, Columbia, South Carolina, United States of America
| | - Nicole Griffith
- University of Virginia Health, Charlottesville, Virginia, United States of America
| | - Jessica Gaskins
- South Carolina Aquarium, Charleston, South Carolina, United States of America
| | - P. Brandon Bookstaver
- University of South Carolina College of Pharmacy, Columbia, South Carolina, United States of America
- Prisma Health Richland, Columbia, South Carolina, United States of America
- * E-mail: (PBB); (WZ)
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98
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Ganesh R, Lucocq J, Ekpete NO, Ain NU, Lim SK, Alwash A, Bibi S, Alijani A. Management of appendicitis during COVID-19 pandemic; short-term outcomes. Scott Med J 2020; 65:144-148. [PMID: 32878574 PMCID: PMC7481653 DOI: 10.1177/0036933020956316] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background and aim COVID-19 pandemic has predisposed patients undergoing surgery to post-operative infection and resultant complications. Appendicitis is frequently managed by appendicectomy. After the onset of the pandemic, selected cases of appendicitis were managed with antibiotics which is a recognised treatment option. Our objective was to compare the management of appendicitis and post-operative outcomes between pre- and post-COVID-19. Methods Ninety-six patients were identified from before the onset of the pandemic (November 2019) to after the onset of the pandemic (May 2020). Data were collected retrospectively from electronic records including demographics, investigations, treatment, duration of inpatient stay, complications, readmissions and compared between pre- and post-COVID-19 groups. Results One hundred percent underwent surgical treatment before the onset of pandemic, compared with 56.3% from the onset of the pandemic. A greater percentage of patients were investigated with imaging post-COVID-19 (100% versus 60.9%; p < 0.00001). There was no significant difference in the outcomes between the two groups. Conclusion CT/MRI scan was preferred to laparoscopy in diagnosing appendicitis and conservative management of uncomplicated appendicitis was common practice after the onset of pandemic. Health boards can adapt their management of surgical conditions during pandemics without adverse short-term consequences. Long term follow-up of this cohort will identify patients suitable for conservative management.
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Affiliation(s)
| | - James Lucocq
- Specialty Registrar, Department of General Surgery, Ninewells Hospital, UK
| | | | - Noor Ul Ain
- Specialty Registrar, Department of General Surgery, Ninewells Hospital, UK
| | - Su Kwan Lim
- Specialty Registrar, Department of General Surgery, Ninewells Hospital, UK
| | - Al Alwash
- Specialty Registrar, Department of General Surgery, Ninewells Hospital, UK
| | - Saira Bibi
- Specialty Registrar, Department of General Surgery, Ninewells Hospital, UK
| | - Afshin Alijani
- Specialty Registrar, Department of General Surgery, Ninewells Hospital, UK
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99
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Kipnis M, Schwab F, Kramer TS, Stegemann MS, Isner C, Pilarski G, Märtin N, Bui MT, Boldt AC, Behnke M, Denkel LA, Wiese-Posselt M, Zweigner J, Gastmeier P, Rohde AM. Incidence of healthcare-associated Clostridioides difficile infections and association with ward-level antibiotic consumption in a German university hospital: an ecological study. J Antimicrob Chemother 2020; 74:2400-2404. [PMID: 31098633 DOI: 10.1093/jac/dkz195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/03/2019] [Accepted: 04/06/2019] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Clostridioides difficile infection (CDI) is one of the most important healthcare-associated infections. We aimed to describe the incidence density of healthcare-associated CDI (HA-CDI) in Germany's largest hospital and to identify associations with ward-level antimicrobial consumption. METHODS We used surveillance data on CDI and antimicrobial consumption from 2014 to 2017 and analysed a potential association by means of multivariable regression analysis. RESULTS We included 77 wards with 404998 admitted patients and 1850862 patient-days. Six hundred and seventy-one HA-CDI cases were identified, resulting in a pooled mean incidence density of 0.36/1000 patient-days (IQR = 0.34-0.39). HA-CDI incidence density on ICU and haematological-oncological wards was about three times higher than on surgical wards [incidence rate ratio (IRR) = 3.00 (95% CI = 1.96-4.60) and IRR = 2.78 (95% CI = 1.88-4.11), respectively]. Ward-level consumption of third-generation cephalosporins was the sole antimicrobial risk factor for HA-CDI. With each DDD/100 patient-days administered, a ward's HA-CDI incidence density increased by 2% [IRR = 1.02 (95% CI = 1.01-1.04)]. Other risk factors were contemporaneous community-associated CDI cases [IRR = 1.32 (95% CI = 1.07-1.63)] and CDI cases in the previous month [IRR = 1.27 (95% CI = 1.07-1.51)]. Furthermore, we found a significant decrease in HA-CDI in 2017 compared with 2014 [IRR = 0.68 (95% CI = 0.54-0.86)]. CONCLUSIONS We confirmed that ward-level antimicrobial use influences HA-CDI and specifically identified third-generation cephalosporin consumption as a risk factor.
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Affiliation(s)
- Marina Kipnis
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Frank Schwab
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Tobias S Kramer
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Miriam S Stegemann
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Infectious Diseases and Respiratory Medicine, Berlin, Germany
| | - Caroline Isner
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Infectious Diseases and Respiratory Medicine, Berlin, Germany
| | - Georg Pilarski
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Nayana Märtin
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Minh Trang Bui
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Anne-C Boldt
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Michael Behnke
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Luisa A Denkel
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Miriam Wiese-Posselt
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Janine Zweigner
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Petra Gastmeier
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany.,German Centre for Infection Research (DZIF), Braunschweig, Germany
| | - Anna M Rohde
- Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany.,German Centre for Infection Research (DZIF), Braunschweig, Germany
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100
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Tilkorn FKMT, Frickmann H, Simon IS, Schwanbeck J, Horn S, Zimmermann O, Groß U, Bohne W, Zautner AE. Antimicrobial Resistance Patterns in Clostridioides difficile Strains Isolated from Neonates in Germany. Antibiotics (Basel) 2020; 9:E481. [PMID: 32759868 PMCID: PMC7460221 DOI: 10.3390/antibiotics9080481] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/01/2020] [Accepted: 08/03/2020] [Indexed: 01/15/2023] Open
Abstract
Young children are frequently colonized with Clostridioides (C.) difficile. Depending on their resistance patterns, antibiotic treatment can facilitate gastrointestinal spreading in colonized individuals, potentially leading to transmission to others. C. difficile was isolated from stool samples from infants born in two hospitals in Göttingen and Darmstadt, Germany. All isolates were subjected to phenotypic antimicrobial resistance testing, PCR-based screening for toxin genes and mass spectrometry-based exclusion of ribotypes 027 and 176. Within an initial cohort of 324 neonates with a longitudinal survey of C. difficile, 137 strains were isolated from 48 individuals. Antimicrobial resistance was recorded against metronidazole in one (0.7%), erythromycin in 16 (11.7%) and moxifloxacin in 2 (1.5%) of the strains, whereas no resistance was observed against vancomycin (0.0%) or rifampicin (0.0%). Newly observed resistance against erythromycin in children with detection of previously completely sensitive isolates was reported for C. difficile isolates from 2 out of 48 children. In 20 children (42%), non-toxigenic strains were detected, and from 27 children (56%), toxigenic strains were isolated, while both toxigenic and non-toxigenic strains were recorded for 1 child (2%). Ribotypes 027 or 176 were not observed. In conclusion, the German C. difficile strains isolated from the children showed mild to moderate resistance with predominance of macrolide resistance, a substance class which is frequently applied in children. The observed switches to the dominance of macrolide-resistant isolates suggests likely selection of resistant C. difficile strains already in children.
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Affiliation(s)
- Friederike K. M. T. Tilkorn
- Institute for Medical Microbiology, University Medical Center Göttingen, 37075 Göttingen, Germany; (F.K.M.T.T.); (I.S.S.); (J.S.); (O.Z.); (U.G.); (W.B.)
| | - Hagen Frickmann
- Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg, 20359 Hamburg, Germany;
- Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, 18057 Rostock, Germany
| | - Isabel S. Simon
- Institute for Medical Microbiology, University Medical Center Göttingen, 37075 Göttingen, Germany; (F.K.M.T.T.); (I.S.S.); (J.S.); (O.Z.); (U.G.); (W.B.)
- Department of Pediatrics, University Medical Center Göttingen, 37075 Göttingen, Germany;
| | - Julian Schwanbeck
- Institute for Medical Microbiology, University Medical Center Göttingen, 37075 Göttingen, Germany; (F.K.M.T.T.); (I.S.S.); (J.S.); (O.Z.); (U.G.); (W.B.)
| | - Sebastian Horn
- Department of Pediatrics, University Medical Center Göttingen, 37075 Göttingen, Germany;
- Department of Pediatrics, SRH Central Hospital Suhl, 98527 Suhl, Germany
| | - Ortrud Zimmermann
- Institute for Medical Microbiology, University Medical Center Göttingen, 37075 Göttingen, Germany; (F.K.M.T.T.); (I.S.S.); (J.S.); (O.Z.); (U.G.); (W.B.)
| | - Uwe Groß
- Institute for Medical Microbiology, University Medical Center Göttingen, 37075 Göttingen, Germany; (F.K.M.T.T.); (I.S.S.); (J.S.); (O.Z.); (U.G.); (W.B.)
| | - Wolfgang Bohne
- Institute for Medical Microbiology, University Medical Center Göttingen, 37075 Göttingen, Germany; (F.K.M.T.T.); (I.S.S.); (J.S.); (O.Z.); (U.G.); (W.B.)
| | - Andreas E. Zautner
- Institute for Medical Microbiology, University Medical Center Göttingen, 37075 Göttingen, Germany; (F.K.M.T.T.); (I.S.S.); (J.S.); (O.Z.); (U.G.); (W.B.)
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