51
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Roshan N, Riley T, Hammer K. Effects of natural products on several stages of the spore cycle ofClostridium difficile in vitro. J Appl Microbiol 2018; 125:710-723. [DOI: 10.1111/jam.13889] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 03/29/2018] [Accepted: 04/12/2018] [Indexed: 02/06/2023]
Affiliation(s)
- N. Roshan
- School of Biomedical Sciences (M504); The University of Western Australia; Crawley WA Australia
| | - T.V. Riley
- School of Biomedical Sciences (M504); The University of Western Australia; Crawley WA Australia
- Department of Microbiology; PathWest Laboratory Medicine; Queen Elizabeth II Medical Centre; Nedlands WA Australia
- School of Veterinary & Life Sciences; Murdoch University; Murdoch WA Australia
- School of Medical & Health Sciences; Edith Cowan University; Joondalup WA Australia
| | - K.A. Hammer
- School of Biomedical Sciences (M504); The University of Western Australia; Crawley WA Australia
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Lee E, Song KH, Bae JY, Yoon D, Hwang JH, Choe PG, Park WB, Bang JH, Kim ES, Park SW, Kim NJ, Oh MD, Kim HB. Risk factors for poor outcome in community-onset Clostridium difficile infection. Antimicrob Resist Infect Control 2018; 7:75. [PMID: 29946450 PMCID: PMC6003152 DOI: 10.1186/s13756-018-0365-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 06/04/2018] [Indexed: 01/19/2023] Open
Abstract
Background A substantial portion of Clostridium difficile infection (CDI) cases occur in communities, and community-onset CDI (CO-CDI) can lead to serious complications including mortality. This study aimed to identify the risk factors for a poor outcome in CO-CDI. Methods We performed a retrospective review of all inpatients with CDI, in a 1300-bed tertiary-care hospital in Korea, from 2008 through 2015. CO-CDI was defined as CDI occurring within 48 h of admission. Poor outcome was defined as follows: 1) all-cause 30-day mortality, 2) in-hospital mortality, or 3) surgery due to CDI. Results Of a total 1256 CDIs occurring over 8 years, 152 (12.1%) cases were classified as CO-CDI and 23 (15.1%) had a poor outcome, including 22 (14.5%) cases of mortality and 2 (1.3%) cases of surgery. Patients with a poor outcome had a higher mean age than those without a poor outcome (75.8 vs. 69.6 years, p = 0.03). The proportion of men and prior proton pump inhibitor (PPI) use were significantly higher in the poor outcome group (65.2% vs. 41.9%, p = 0.04; 39.1% vs. 17.6%, p = 0.02, respectively). Multivariate binary logistic model showed that PPI use and anemia (hemoglobin < 10 g/dL) at presentation were significantly associated with a poor outcome (adjusted odds ratio [aOR], 3.76; 95% confidence interval [95CI], 1.26-11.21, aOR, 4.67; 95CI, 1.52-14.34, respectively). Conclusions Clinicians should not only be aware of the possibility of CDI in the community setting but also pay more attention to PPI-using elderly patients with anemia in consideration of a poor outcome.
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Affiliation(s)
- Eunyoung Lee
- 1Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 463-707 Republic of Korea.,2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyoung-Ho Song
- 1Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 463-707 Republic of Korea.,2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Yun Bae
- 2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Doran Yoon
- 2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Joo-Hee Hwang
- 2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Pyoeng Gyun Choe
- 2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Wan Beom Park
- 2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Hwan Bang
- 2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eu Suk Kim
- 1Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 463-707 Republic of Korea.,2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sang Won Park
- 2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Nam Joong Kim
- 2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Myoung-Don Oh
- 2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hong Bin Kim
- 1Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 463-707 Republic of Korea.,2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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53
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Abstract
Each year in the United States, billions of dollars are spent combating almost half a million Clostridium difficile infections (CDIs) and trying to reduce the ∼29,000 patient deaths in which C. difficile has an attributed role. In Europe, disease prevalence varies by country and level of surveillance, though yearly costs are estimated at €3 billion. One factor contributing to the significant health care burden of C. difficile is the relatively high frequency of recurrent CDIs. Recurrent CDI, i.e., a second episode of symptomatic CDI occurring within 8 weeks of successful initial CDI treatment, occurs in ∼25% of patients, with 35 to 65% of these patients experiencing multiple episodes of recurrent disease. Using microbial communities to treat recurrent CDI, either as whole fecal transplants or as defined consortia of bacterial isolates, has shown great success (in the case of fecal transplants) or potential promise (in the case of defined consortia of isolates). This review will briefly summarize the epidemiology and physiology of C. difficile infection, describe our current understanding of how fecal microbiota transplants treat recurrent CDI, and outline potential ways that knowledge can be used to rationally design and test alternative microbe-based therapeutics.
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54
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Nourian A, Mohammadi M, Beigmohammadi MT, Taher M, Dadvar Z, Malekolkottab M, Ramezani M, Khalili H. Comparing efficacy of enteral nutrition plus ranitidine and enteral nutrition alone as stress ulcer prophylaxis. J Comp Eff Res 2018; 7:493-501. [DOI: 10.2217/cer-2017-0098] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Adequacy of enteral nutrition (EN) alone as stress ulcer prophylaxis (SUP) is controversial. The aim of this study was to compare efficacy of EN alone and ranitidine plus EN as SUP. Method: Critically ill adults with indications to receive SUP were randomized to ranitidine 50 mg IV every 8 h plus EN (SUP) or EN alone (non-SUP) group for 7 days. Besides, endoscopy was performed at the time of recruitment and on day 7. Results: During the study period, only one patient in each group of SUP and non-SUP experienced gastrointestinal bleeding. At the time of recruitment, gastric erosion and erythema were the most endoscopic findings in the SUP and non-SUP groups. These findings did not significantly change at the end of the study (p = 0.21). Conclusion: EN was at least effective as ranitidine plus EN as SUP.
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Affiliation(s)
- Anahid Nourian
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mostafa Mohammadi
- Department of Intensive Care Unit, Imam Khomeini Hospital, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad-Taghi Beigmohammadi
- Department of Intensive Care Unit, Imam Khomeini Hospital, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Taher
- Department of Internal Medicine, Imam Khomeini Hospital, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Zohreh Dadvar
- Department of Internal Medicine, Imam Khomeini Hospital, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoume Malekolkottab
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Ramezani
- Department of Intensive Care Unit, Imam Khomeini Hospital, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Khalili
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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55
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Schäffler H, Breitrück A. Clostridium difficile - From Colonization to Infection. Front Microbiol 2018; 9:646. [PMID: 29692762 PMCID: PMC5902504 DOI: 10.3389/fmicb.2018.00646] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 03/19/2018] [Indexed: 12/19/2022] Open
Abstract
Clostridium difficile is the most frequent cause of nosocomial antibiotic-associated diarrhea. The incidence of C. difficile infection (CDI) has been rising worldwide with subsequent increases in morbidity, mortality, and health care costs. Asymptomatic colonization with C. difficile is common and a high prevalence has been found in specific cohorts, e.g., hospitalized patients, adults in nursing homes and in infants. However, the risk of infection with C. difficile differs significantly between these cohorts. While CDI is a clear indication for therapy, colonization with C. difficile is not believed to be a direct precursor for CDI and therefore does not require treatment. Antibiotic therapy causes alterations of the intestinal microbial composition, enabling C. difficile colonization and consecutive toxin production leading to disruption of the colonic epithelial cells. Clinical symptoms of CDI range from mild diarrhea to potentially life-threatening conditions like pseudomembranous colitis or toxic megacolon. While antibiotics are still the treatment of choice for CDI, new therapies have emerged in recent years such as antibodies against C. difficile toxin B and fecal microbial transfer (FMT). This specific therapy for CDI underscores the role of the indigenous bacterial composition in the prevention of the disease in healthy individuals and its role in the pathogenesis after alteration by antibiotic treatment. In addition to the pathogenesis of CDI, this review focuses on the colonization of C. difficile in the human gut and factors promoting CDI.
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Affiliation(s)
- Holger Schäffler
- Division of Gastroenterology, Department of Medicine II, University of Rostock, Rostock, Germany
| | - Anne Breitrück
- Extracorporeal Immunomodulation Unit, Fraunhofer Institute for Cell Therapy and Immunology, Rostock, Germany.,Institute of Medical Microbiology, Virology and Hygiene, University of Rostock, Rostock, Germany
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56
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Abstract
This study was to optimize the detection methods for Clostridium difficile from the animal manure-based composts. Both autoclaved and unautoclaved dairy composts were inoculated with a 12-h old suspension of a non-toxigenic C. difficile strain (ATCC 43593) and then plated on selected agar for vegetative cells and endospores. Six types of enrichment broths supplemented with taurocholate and l-cysteine were assessed for detecting a low level of artificially inoculated C. difficile (ca. 5 spores/g) from dairy composts. The efficacy of selected enrichment broths was further evaluated by isolating C. difficile from 29 commercial compost samples. Our results revealed that using heat-shock was more effective than using ethanol-shock for inducing endospore germination, and the highest endospore count (p < 0.05) was yielded at 60 °C for 25 min. C. difficile agar base, supplemented with 0.1% l-cysteine, 7% defibrinated horse blood, and cycloserine-cefoxitin (CDA-CYS-H-CC agar) was the best medium (p < 0.05) for recovering vegetative cells from compost. C. difficile endospore populations from both types of composts enumerated on both CDA-CYS-H-CC agar supplemented with 0.1% sodium taurocholate (CDA-CYS-H-CC-T agar) and brain heart infusion agar supplemented with 0.5% yeast extract, 0.1% l-cysteine, cycloserine-cefoxitin, and 0.1% sodium taurocholate (BHIA-YE-CYS-CC-T agar) media were not significantly different from each other (p > 0.05). Overall, enrichment of inoculated compost samples in broths containing moxalactam-norfloxacin (MN) produced significantly higher (p < 0.05) spore counts than in non-selective broths or broths supplemented with CC. Enrichment in BHIB-YE-CYS-MN-T broth followed by culturing on an agar containing 7% horse blood and 0.1% taurocholate provided a more sensitive and selective combination of media for detecting a low population of C. difficile from environmental samples with high background microflora.
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Affiliation(s)
- Muthu Dharmasena
- Department of Food, Nutrition, and Packaging Sciences, Clemson University, Clemson, SC 29634, USA
| | - Xiuping Jiang
- Department of Food, Nutrition, and Packaging Sciences, Clemson University, Clemson, SC 29634, USA.
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57
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Abstract
This narrative review summarises the benefits, risks and appropriate use of acid-suppressing drugs (ASDs), proton pump inhibitors and histamine-2 receptor antagonists, advocating a rationale balanced and individualised approach aimed to minimise any serious adverse consequences. It focuses on current controversies on the potential of ASDs to contribute to infections-bacterial, parasitic, fungal, protozoan and viral, particularly in the elderly, comprehensively and critically discusses the growing body of observational literature linking ASD use to a variety of enteric, respiratory, skin and systemic infectious diseases and complications (Clostridium difficile diarrhoea, pneumonia, spontaneous bacterial peritonitis, septicaemia and other). The proposed pathogenic mechanisms of ASD-associated infections (related and unrelated to the inhibition of gastric acid secretion, alterations of the gut microbiome and immunity), and drug-drug interactions are also described. Both probiotics use and correcting vitamin D status may have a significant protective effect decreasing the incidence of ASD-associated infections, especially in the elderly. Despite the limitations of the existing data, the importance of individualised therapy and caution in long-term ASD use considering the balance of benefits and potential harms, factors that may predispose to and actions that may prevent/attenuate adverse effects is evident. A six-step practical algorithm for ASD therapy based on the best available evidence is presented.
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58
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Oshima T, Wu L, Li M, Fukui H, Watari J, Miwa H. Magnitude and direction of the association between Clostridium difficile infection and proton pump inhibitors in adults and pediatric patients: a systematic review and meta-analysis. J Gastroenterol 2018; 53:84-94. [PMID: 28744822 DOI: 10.1007/s00535-017-1369-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 07/10/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a cause of increased morbidity and health care costs among hospitalized patients. Proton pump inhibitors (PPIs) are mainly used for the treatment of acid-related upper gastrointestinal diseases. The aim of the study was to assess the risks associated with initial and recurrent CDI in adult and pediatric patients treated with PPIs. METHODS A systematic search was performed using PubMed (Medline), Embase, and Web of Science with the following search terms: ("proton pump inhibitor," "PPI," or "acid suppression") AND ("infection," "diarrhea," "diarrhoea," "colitis," or "disease") AND ("Clostridium difficile"). Meta-analysis was performed using Revman5.3 software. Pooled odds ratios (ORs) presented as standard plots with 95% confidence intervals (CIs) were determined. RESULTS Sixty-seven eligible studies were selected. PPI use was significantly associated with risk of CDI (OR 2.34, 95% CI 1.94-2.82; P < 0.00001). Pooled data from twelve studies demonstrated a significant association between PPI use and recurrent CDI (OR 1.73, 95% CI 1.39-2.15; P = 0.02). Subgroup analysis revealed significant associations between PPI use and an increased incidence of CDI among adult (OR 2.30, 95% CI 1.89-2.80; P < 0.00001) and pediatric (OR 3.00, 95% CI 1.44-6.23; P < 0.00001) patients. CONCLUSIONS PPI use was associated with CDI in adult and pediatric patients, and with recurrent CDI. Although many risk factors are associated with the occurrence and recurrence of CDI, consideration should be given to not administering PPIs at any age if they are unnecessary.
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Affiliation(s)
- Tadayuki Oshima
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan.
| | - Liping Wu
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan.,Department of Gastroenterology, The Third People's Hospital of Chengdu, Chengdu, China
| | - Min Li
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan.,Department of Gastroenterology, The Third People's Hospital of Chengdu, Chengdu, China
| | - Hirokazu Fukui
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Jiro Watari
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Hiroto Miwa
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
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59
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Lázaro-Pacheco IB, Servín-Caamaño AI, Pérez-Hernández JL, Rojas-Loureiro G, Servín-Abad L, Tijera FHDELA. PROTON PUMP INHIBITORS INCREASE THE OVERALL RISK OF DEVELOPING BACTERIAL INFECTIONS IN PATIENTS WITH CIRRHOSIS. ARQUIVOS DE GASTROENTEROLOGIA 2018; 55:28-32. [PMID: 29561973 DOI: 10.1590/s0004-2803.201800000-09] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 11/28/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acid suppression has been associated with adverse events; such as, enteric infections. Proton pump inhibitors (PPI) are frequently prescribed in patients with cirrhosis, but is unclear if PPI are associated with the development of bacterial infections in these patients. OBJECTIVE To assess the impact of PPI intake on the development of bacterial, viral and fungal infections in patients with cirrhosis. METHODS An observational, retrospective, historic cohort study. The exposed cohort included patients with cirrhosis with chronic use of PPI. The non-exposed cohort had not been using PPI. The follow-up period was 3 years, searching in the medical records for any events of bacterial infection confirmed by bacteriological culture. RESULTS One hundred and thirteen patients met the selection criteria, 44 (39%) had chronic use of PPI; of them, 28 (63.6%) patients had not a clear clinical indication to justify the prescription of PPI. Twenty four (21.2%) patients developed bacterial infections during the follow-up period. In the univariate analysis, decompensated cirrhosis (Child B/C), presence of ascites, history of variceal bleeding, and chronic consumption of PPI were risk factors related to the development of infections. But, in the adjusted multivariate analysis only the chronic use of PPI was associated with development of infections (RR=3.6; 95% CI=1.1-12.3; P=0.04). CONCLUSION There is an over-prescription of PPI without a justified clinical indication. The long-term consumption of PPI in patients with cirrhosis is associated with the development of bacterial infections; therefore these drugs must be carefully prescribed in this specific population.
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Affiliation(s)
- Illce B Lázaro-Pacheco
- Gastroenterology and Hepatology Department, Hospital General de México Dr. Eduardo Liceaga, Mexico City, Mexico
| | - Alfredo I Servín-Caamaño
- Internal Medicine Department, Hospital General de México Dr. Eduardo Liceaga, Mexico City, Mexico
| | - José L Pérez-Hernández
- The Liver Clinic´s Research Group from Gastroenterology and Hepatology Department, Hospital General de México Dr. Eduardo Liceaga, Mexico City, Mexico
| | - Gabriela Rojas-Loureiro
- Gastroenterology and Hepatology Department, Hospital General de México Dr. Eduardo Liceaga, Mexico City, Mexico
| | - Luis Servín-Abad
- Gastroenterology Department, Lakeland Regional Medical Center, United States of America
| | - Fátima Higuera-DE LA Tijera
- The Liver Clinic´s Research Group from Gastroenterology and Hepatology Department, Hospital General de México Dr. Eduardo Liceaga, Mexico City, Mexico
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60
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Abstract
Clostridium difficile is the most frequent cause of nosocomial antibiotic-associated diarrhea. The incidence of C. difficile infection (CDI) has been rising worldwide with subsequent increases in morbidity, mortality, and health care costs. Asymptomatic colonization with C. difficile is common and a high prevalence has been found in specific cohorts, e.g., hospitalized patients, adults in nursing homes and in infants. However, the risk of infection with C. difficile differs significantly between these cohorts. While CDI is a clear indication for therapy, colonization with C. difficile is not believed to be a direct precursor for CDI and therefore does not require treatment. Antibiotic therapy causes alterations of the intestinal microbial composition, enabling C. difficile colonization and consecutive toxin production leading to disruption of the colonic epithelial cells. Clinical symptoms of CDI range from mild diarrhea to potentially life-threatening conditions like pseudomembranous colitis or toxic megacolon. While antibiotics are still the treatment of choice for CDI, new therapies have emerged in recent years such as antibodies against C. difficile toxin B and fecal microbial transfer (FMT). This specific therapy for CDI underscores the role of the indigenous bacterial composition in the prevention of the disease in healthy individuals and its role in the pathogenesis after alteration by antibiotic treatment. In addition to the pathogenesis of CDI, this review focuses on the colonization of C. difficile in the human gut and factors promoting CDI.
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Affiliation(s)
- Holger Schäffler
- Division of Gastroenterology, Department of Medicine II, University of Rostock, Rostock, Germany
| | - Anne Breitrück
- Extracorporeal Immunomodulation Unit, Fraunhofer Institute for Cell Therapy and Immunology, Rostock, Germany
- Institute of Medical Microbiology, Virology and Hygiene, University of Rostock, Rostock, Germany
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61
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Harries RL, Ansell J, Codd RJ, Williams GL. A systematic review of Clostridium difficile infection following reversal of ileostomy. Colorectal Dis 2017; 19:881-887. [PMID: 28872758 DOI: 10.1111/codi.13873] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 08/14/2017] [Indexed: 02/08/2023]
Abstract
AIM The incidence of Clostridium difficile infection (CDI) has been reported to be as high as 4% following ileostomy reversal. CDI can be associated with significant morbidity. A systematic review on this subject has not been previously reported; our aim was to review the literature to establish incidence and to evaluate the factors that may contribute to an increased risk of CDI following ileostomy reversal. METHOD A systematic review of Ovid, Embase and Medline was undertaken. Search terms included C. difficile, reversal of ileostomy and ileostomy closure. Articles were included where at least one case of C. difficile-associated diarrhoea following reversal of defunctioning ileostomy was reported. Data extraction for articles was performed by two authors, using predefined data fields. The primary outcome measure was incidence of CDI amongst patients undergoing ileostomy reversal. Secondary outcomes were defunctioning time, antibiotic regime, acid suppression, time to onset of symptoms and study conclusions including colectomy and mortality rate. RESULTS Eleven articles were included (five case reports and six cohort studies). The overall incidence of CDI was 1.8% (242/13 728). The mean defunctioning time was 8.7 months (range 6-12). A variety of antibiotic regimes were described. Mean time to onset of symptoms was 6 days (range 3-14). Use of acid suppression, colectomy or mortality rate were frequently not reported. CONCLUSION CDI should be recognized as a potentially life-threatening complication of ileostomy closure. Careful consideration should be given to peri-operative antibiotic regime, acid suppression, timing of reversal and appropriate preoperative counselling of patients.
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Affiliation(s)
- R L Harries
- Department of Colorectal Surgery, Royal Gwent Hospital, Newport, UK
| | - J Ansell
- Department of Colorectal Surgery, Royal Gwent Hospital, Newport, UK
| | - R J Codd
- Department of Colorectal Surgery, Royal Gwent Hospital, Newport, UK
| | - G L Williams
- Department of Colorectal Surgery, Royal Gwent Hospital, Newport, UK
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62
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Zheng Y, Luo Y, Lv Y, Huang C, Sheng Q, Zhao P, Ye J, Jiang W, Liu L, Song X, Tong Z, Chen W, Lin J, Tang YW, Jin D, Fang W. Clostridium difficile colonization in preoperative colorectal cancer patients. Oncotarget 2017; 8:11877-11886. [PMID: 28060753 PMCID: PMC5355311 DOI: 10.18632/oncotarget.14424] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 12/20/2016] [Indexed: 01/05/2023] Open
Abstract
The entire process of Clostridium difficile colonization to infection develops in large intestine. However, the real colonization pattern of C. difficile in preoperative colorectal cancer patients has not been studied. In this study, 33 C. difficile strains (16.1%) were isolated from stool samples of 205 preoperative colorectal cancer patients. C. difficile colonization rates in lymph node metastasis patients (22.3%) were significantly higher than lymph node negative patients (10.8%) (OR=2.314, 95%CI=1.023-5.235, P =0.025). Meanwhile, patients positive for stool occult blood had lower C. difficile colonization rates than negative patients (11.5% vs. 24.0%, OR=0.300, 95%CI=0.131-0.685, P =0.019). A total of 16 sequence types were revealed by multilocus sequence typing. Minimum spanning tree and time-space cluster analysis indicated that all C. difficile isolates were epidemiologically unrelated. Antibiotic susceptibility testing showed all isolates were susceptible to vancomycin and metronidazole. The results suggested that the prevalence of C. difficile colonization is high in preoperative colorectal cancer patients, and the colonization is not acquired in the hospital. Since lymph node metastasis colorectal cancer patients inevitably require adjuvant chemotherapy and C. difficile infection may halt the ongoing treatment, the call for sustained monitoring of C. difficile in those patients is apparently urgent.
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Affiliation(s)
- Yi Zheng
- Cancer Biotherapy Center, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yun Luo
- Department of Microbiology, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
| | | | - Chen Huang
- Department of Microbiology, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
| | - Qinsong Sheng
- Department of Colorectal Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Peng Zhao
- Cancer Biotherapy Center, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Julian Ye
- Department of Microbiology, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
| | - Weiqin Jiang
- Cancer Biotherapy Center, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Lulu Liu
- Cancer Biotherapy Center, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaojun Song
- Department of Microbiology, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
| | - Zhou Tong
- Cancer Biotherapy Center, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wenbin Chen
- Department of Colorectal Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jianjiang Lin
- Department of Colorectal Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yi-Wei Tang
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center; Department of Pathology and Medicine, Weill Medical College of Cornell University, New York, NY, USA
| | - Dazhi Jin
- Department of Microbiology, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
| | - Weijia Fang
- Cancer Biotherapy Center, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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63
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Lee WT, Wu YN, Chen YH, Wu SR, Shih TM, Li TJ, Yang LX, Yeh CS, Tsai PJ, Shieh DB. Octahedron Iron Oxide Nanocrystals Prohibited Clostridium difficile Spore Germination and Attenuated Local and Systemic Inflammation. Sci Rep 2017; 7:8124. [PMID: 28811642 PMCID: PMC5558001 DOI: 10.1038/s41598-017-08387-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 07/12/2017] [Indexed: 01/27/2023] Open
Abstract
Clinical management of Clostridium difficile infection is still far from satisfactory as bacterial spores are resistant to many chemical agents and physical treatments. Certain types of nanoparticles have been demonstrated to exhibit anti-microbial efficacy even in multi-drug resistance bacteria. However, most of these studies failed to show biocompatibility to the mammalian host cells and no study has revealed in vivo efficacy in C. difficile infection animal models. The spores treated with 500 µg/mL Fe3-δO4 nanoparticles for 20 minutes, 64% of the spores were inhibited from transforming into vegetative cells, which was close to the results of the sodium hypochlorite-treated positive control. By cryo-electron micro-tomography, we demonstrated that Fe3-δO4 nanoparticles bind on spore surfaces and reduce the dipicolinic acid (DPA) released by the spores. In a C. difficile infection animal model, the inflammatory level triple decreased in mice with colonic C. difficile spores treated with Fe3-δO4 nanoparticles. Histopathological analysis showed a decreased intense neutrophil accumulation in the colon tissue of the Fe3-δO4 nanoparticle-treated mice. Fe3-δO4 nanoparticles, which had no influence on gut microbiota and apparent side effects in vivo, were efficacious inhibitors of C. difficile spore germination by attacking its surface and might become clinically feasible for prophylaxis and therapy.
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Affiliation(s)
- Wei-Ting Lee
- Institute of Basic Medical Sciences, National Cheng Kung University, 1 University Road, Tainan, 701, Taiwan
| | - Ya-Na Wu
- Institute of Oral Medicine, National Cheng Kung University, 1 University Road, Tainan, 701, Taiwan
| | - Yi-Hsuan Chen
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, 1 University Road, Tainan, 701, Taiwan
| | - Shang-Rung Wu
- Institute of Oral Medicine, National Cheng Kung University, 1 University Road, Tainan, 701, Taiwan
| | - Tsai-Miao Shih
- Institute of Oral Medicine, National Cheng Kung University, 1 University Road, Tainan, 701, Taiwan
| | - Tsung-Ju Li
- Institute of Basic Medical Sciences, National Cheng Kung University, 1 University Road, Tainan, 701, Taiwan
| | - Li-Xing Yang
- Institute of Basic Medical Sciences, National Cheng Kung University, 1 University Road, Tainan, 701, Taiwan
| | - Chen-Sheng Yeh
- Department of Chemistry, National Cheng Kung University, 1 University Road, Tainan, 701, Taiwan
| | - Pei-Jane Tsai
- Institute of Basic Medical Sciences, National Cheng Kung University, 1 University Road, Tainan, 701, Taiwan. .,Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, 1 University Road, Tainan, 701, Taiwan. .,Center of Infectious Disease and Signaling Research, National Cheng Kung University, 1 University Road, Tainan, 701, Taiwan.
| | - Dar-Bin Shieh
- Institute of Basic Medical Sciences, National Cheng Kung University, 1 University Road, Tainan, 701, Taiwan. .,Institute of Oral Medicine, National Cheng Kung University, 1 University Road, Tainan, 701, Taiwan. .,Department of Stomatology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138 Sheng-Li Road, Tainan, 704, Taiwan. .,Advanced Optoelectronic Technology Center and Center for Micro/Nano Science and Technology, National Cheng Kung University, 1 University Road, Tainan, 701, Taiwan.
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Abstract
To survive adverse conditions, some bacterial species are capable of developing into a cell type, the "spore," which exhibits minimal metabolic activity and remains viable in the presence of multiple environmental challenges. For some pathogenic bacteria, this developmental state serves as a means of survival during transmission from one host to another. Spores are the highly infectious form of these bacteria. Upon entrance into a host, specific signals facilitate germination into metabolically active replicating organisms, resulting in disease pathogenesis. In this article, we will review spore structure and function in well-studied pathogens of two genera, Bacillus and Clostridium, focusing on Bacillus anthracis and Clostridium difficile, and explore current data regarding the lifestyles of these bacteria outside the host and transmission from one host to another.
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Vaezi MF, Yang YX, Howden CW. Complications of Proton Pump Inhibitor Therapy. Gastroenterology 2017; 153:35-48. [PMID: 28528705 DOI: 10.1053/j.gastro.2017.04.047] [Citation(s) in RCA: 291] [Impact Index Per Article: 41.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 04/21/2017] [Accepted: 04/24/2017] [Indexed: 02/08/2023]
Abstract
Safety issues associated with proton pump inhibitors (PPIs) have recently attracted widespread media and lay attention. Gastroenterologists are frequently asked about the appropriateness of PPI therapy for specific patients. Furthermore, some patients may have had PPI therapy discontinued abruptly or inappropriately due to safety concerns. Faced with such a wide variety of potentially serious adverse consequences, prescribers need to evaluate the evidence objectively to discern the likelihood that any reported association might actually be causal. Here, we review many of the proposed adverse consequences of PPI therapy and apply established criteria for the determination of causation. We also consider the potential contribution of residual confounding in many of the reported studies. Evidence is inadequate to establish causal relationships between PPI therapy and many of the proposed associations. Residual confounding related to study design and the overextrapolation of quantitatively small estimates of effect size have probably led to much of the current controversy about PPI safety. In turn, this has caused unnecessary concern among patients and prescribers. The benefits of PPI therapy for appropriate indications need to be considered, along with the likelihood of the proposed risks. Patients with a proven indication for a PPI should continue to receive it in the lowest effective dose. PPI dose escalation and continued chronic therapy in those unresponsive to initial empiric therapy is discouraged.
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Affiliation(s)
- Michael F Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Yu-Xiao Yang
- Division of Gastroenterology and Center for Clinical Epidemiology and Biostatistics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Colin W Howden
- Division of Gastroenterology and Hepatology, University of Tennessee Health Science Center, Memphis, Tennessee
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Johnson DA, Katz PO, Armstrong D, Cohen H, Delaney BC, Howden CW, Katelaris P, Tutuian RI, Castell DO. The Safety of Appropriate Use of Over-the-Counter Proton Pump Inhibitors: An Evidence-Based Review and Delphi Consensus. Drugs 2017; 77:547-561. [PMID: 28233274 PMCID: PMC5357248 DOI: 10.1007/s40265-017-0712-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The availability of over-the-counter (OTC) proton pump inhibitors (PPIs) for the short-term (2 weeks) management of frequent heartburn (≥2 days/week) has increased markedly, yet evidence-based recommendations have not been developed. A panel of nine international experts in gastroesophageal reflux disease developed consensus statements regarding the risks and benefits of OTC PPIs using a modified Delphi process. Consensus (based on ≥80% approval) was reached through multiple rounds of remote voting and a final round of live voting. To identify relevant data, the available literature was searched and summarized. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system terminology was used to rate the quality of evidence and strength of recommendations; consensus was based on ≥2/3 agreement. After 4 rounds of review, consensus was achieved for 18 statements. Notably, the available data did not directly reflect OTC use, but instead, prescription use; therefore, extrapolations to the OTC setting were often necessary. This limitation is regrettable, but it justifies performing this exercise to provide evidence-based expert opinion on a widely used class of drugs. The panel determined that using OTC PPIs according to label instructions is unlikely to mask the symptoms of esophageal or gastric cancer or adversely impact the natural history of related precursor conditions. OTC PPIs are not expected to substantially affect micronutrient absorption or bone mineral density or cause community-acquired pneumonia, Clostridium difficile infection, or cardiovascular adverse events. However, OTC PPI use may be associated with slightly increased risks for infectious diarrhea, certain idiosyncratic reactions, and cirrhosis-related spontaneous bacterial peritonitis. The available evidence does not suggest that OTC PPI use consistent with label instructions is associated with substantial health risks. To minimize potential risks, healthcare professionals and consumers must actively participate in decision making when managing reflux-related symptoms in the self-care setting.
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Affiliation(s)
- David A Johnson
- Department of Gastroenterology, Eastern Virginia Medical School, 885 Kempsville Rd, Suite 114, Norfolk, VA, 23505, USA.
| | - Philip O Katz
- Division of Gastroenterology, Einstein Medical Center, 5401 Old York Rd, Suite 363 Klein Building, Philadelphia, PA, 19141, USA.
| | - David Armstrong
- Division of Gastroenterology, McMaster University, HSC-3V3, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | - Henry Cohen
- Department of Gastroenterology, National University of Uruguay, Av. Italia 2370, 11600, Montevideo, Uruguay
| | - Brendan C Delaney
- Department of Surgery and Cancer, Imperial College, Kensington, London, SW7 2AZ, UK
| | - Colin W Howden
- Division of Gastroenterology, University of Tennessee Health Science Center, 956 Court Avenue, Suite H210, Memphis, TN, 38163, USA
| | - Peter Katelaris
- Department of Gastroenterology, University of Sydney, Concord, Sydney, 2139, Australia
| | - Radu I Tutuian
- Department of Gastroenterology, University of Bern School of Medicine, Freiburgerstr 10, Bern, Switzerland
| | - Donald O Castell
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, 11 Harleston Place, Charleston, SC, 29401, USA
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Abstract
Clostridium difficile infections (CDIs) have emerged as one of the principal threats to the health of hospitalized and immunocompromised patients. The importance of C difficile colonization is increasingly recognized not only as a source for false-positive clinical testing but also as a source of new infections within hospitals and other health care environments. In the last five years, several new treatment strategies that capitalize on the increasing understanding of the altered microbiome and host defenses in patients with CDI have completed clinical trials, including fecal microbiota transplantation. This article highlights the changing epidemiology, laboratory diagnostics, pathogenesis, and treatment of CDI.
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68
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Clinical Implications of Emerging Data on the Safety of Proton Pump Inhibitors. ACTA ACUST UNITED AC 2017; 15:1-9. [DOI: 10.1007/s11938-017-0115-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Cole HL, Pennycook S, Hayes PC. The impact of proton pump inhibitor therapy on patients with liver disease. Aliment Pharmacol Ther 2016; 44:1213-1223. [PMID: 27774677 DOI: 10.1111/apt.13827] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 08/21/2016] [Accepted: 09/21/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Proton pump inhibitor (PPI) therapy has been reported to be an independent mortality risk factor in patients with cirrhosis. AIM To identify the prevalence of PPI prescription, the appropriateness of this therapy and to investigate the relationship between PPI therapy and overall survival in patients with liver disease. METHODS This retrospective cohort study used patient data for 2012 to 2014 collected from the Scottish Liver Transplant Unit and the Hepatology Ward at the New Royal Infirmary of Edinburgh. RESULTS A total of 64% of the 198 patients discharged from the Hepatology ward were prescribed a PPI. Of the 206 patients assessed and listed for orthotopic liver transplant (OLT), 55% were prescribed a PPI. These percentages are significant, particularly as the majority had no recorded appropriate indication for this therapy. For patients listed for OLT, a logistic regression model revealed significant associations between PPI treatment and male sex, higher model of end-stage liver disease (MELD) scores and patient encephalopathy. A multivariate Cox regression model showed that MELD and UK model for end-stage liver disease scores were independent predictors of patient mortality, while alcoholic liver disease aetiology was a protective factor. There was no statistically significant difference in survival between patients who were prescribed a PPI at assessment and those who were not. CONCLUSION Associations between PPI use, encephalopathy and higher MELD scores imply caution should be exercised in prescribing gastric acid suppressants to patients with cirrhosis, particularly in the absence of clear indications.
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Affiliation(s)
- H L Cole
- University of Edinburgh, Edinburgh, UK
| | | | - P C Hayes
- University of Edinburgh, Edinburgh, UK
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Ciricillo J, Haslam D, Blum S, Kim MO, Liu C, Paulsen G, Courter J, Danziger-Isakov L. Frequency and risks associated withClostridium difficile-associated diarrhea after pediatric solid organ transplantation: a single-center retrospective review. Transpl Infect Dis 2016; 18:706-713. [DOI: 10.1111/tid.12584] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 05/04/2016] [Accepted: 05/22/2016] [Indexed: 01/04/2023]
Affiliation(s)
- J. Ciricillo
- Cincinnati Children's Hospital Medical Center; Cincinnati Ohio USA
| | - D. Haslam
- Cincinnati Children's Hospital Medical Center; Cincinnati Ohio USA
| | - S. Blum
- Cincinnati Children's Hospital Medical Center; Cincinnati Ohio USA
| | - M.-O. Kim
- Cincinnati Children's Hospital Medical Center; Cincinnati Ohio USA
| | - C. Liu
- Cincinnati Children's Hospital Medical Center; Cincinnati Ohio USA
| | - G. Paulsen
- Cincinnati Children's Hospital Medical Center; Cincinnati Ohio USA
| | - J. Courter
- Cincinnati Children's Hospital Medical Center; Cincinnati Ohio USA
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de Brito-Ashurst I, Preiser JC. Diarrhea in Critically Ill Patients: The Role of Enteral Feeding. JPEN J Parenter Enteral Nutr 2016; 40:913-23. [PMID: 27271709 DOI: 10.1177/0148607116651758] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/26/2016] [Indexed: 12/20/2022]
Abstract
This tutorial presents a systematic approach to the management of diarrhea in the critical care setting. Diarrhea is a common and prevalent problem in critically ill patients. Despite the high prevalence, its management is far from simple. Professionals are confronted with a myriad of definitions based on frequency, consistency, and volume. The causes are complex and multifactorial, yet enteral tube feeding formula is believed to be the perpetrator. Potential causes for diarrhea are discussed, and 3 case reports provide context to examine the treatment from a nutrition perspective. Each scenario is comprehensively addressed discussing potential causes and providing specific clinical strategies contributing to improved bowel function in this patient group. The approach used for diarrhea management is based on a complete understanding of enteral tube formula, their composition, and their impact in the presence of gut dysfunction. Choosing the right feeding formula may positively influence bowel function and contribute to improved nutrition.
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High morbidity and mortality of Clostridium difficile infection and its associations with ribotype 002 in Hong Kong. J Infect 2016; 73:115-22. [PMID: 27246801 DOI: 10.1016/j.jinf.2016.05.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 04/15/2016] [Accepted: 05/23/2016] [Indexed: 02/06/2023]
Abstract
OBJECTIVES We aim to study the disease burden, risk factors and severity of Clostridium difficile infection (CDI) in Hong Kong. METHODS We conducted a prospective, case-control study in three acute-care hospitals in Hong Kong. Adult inpatients who developed CDI diarrhoea confirmed by PCR (n = 139) were compared with the non-CDI controls (n = 114). Ribotyping of isolates and antimicrobial susceptibility testing were performed. RESULTS The estimated crude annual incidence of CDI was 23-33/100,000 population, and 133-207/100,000 population among those aged ≥65 years. The mean age of CDI patients was 71.5. Nursing home care, recent hospitalization, antibiotics exposure (adjusted OR 3.0, 95% CI 1.3-7.1) and proton-pump inhibitors use (adjusted OR 2.2, 95% CI 1.2-3.9) were risk factors. Severe CDI occurred in 41.7%. Overall mortality was 16.5% (among severe CDI, 26.5%). The commonest ribotypes were 002 (22.8%), 014 (14.1%), 012 and 046; ribotype 027 was absent. Ribotype 002 was associated with fluoroquinolone resistance and higher mortality (47.6% vs. 12.7%; adjusted HR 2.8, 95% CI 1.1-7.0). CONCLUSIONS Our findings show high morbidity and mortality of CDI in the older adults, and identify ribotype 002 as a possible virulent strain causing serious infections in this cohort.
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Pappas M, Jolly S, Vijan S. Defining Appropriate Use of Proton-Pump Inhibitors Among Medical Inpatients. J Gen Intern Med 2016; 31:364-71. [PMID: 26553337 PMCID: PMC4803704 DOI: 10.1007/s11606-015-3536-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 08/12/2015] [Accepted: 09/23/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Proton-pump inhibitors (PPIs) are commonly used among medical inpatients, both for prophylaxis against upper gastrointestinal bleeding (UGIB) and continuation of outpatient use. While PPIs reduce the risk of UGIB, they also appear to increase the risk of hospital-acquired pneumonia (HAP) and Clostridium difficile infection (CDI). Depending upon the underlying risks of these conditions and the changes in those risks with PPIs, use of proton-pump inhibitors may lead to a net benefit or net harm among medical inpatients. OBJECTIVE We aimed to determine the net impact of PPIs on hospital mortality among medical inpatients. DESIGN A microsimulation model, using literature-derived estimates of the risks of UGIB, HAP, and CDI among medical inpatients, along with the changes in risk associated with PPI use for each of these outcomes. The primary outcome was change in inpatient mortality. PARTICIPANTS Simulated general medical inpatients outside the intensive care unit (ICU). MAIN MEASURE Change in overall mortality during hospitalization. KEY RESULTS New initiation of PPI therapy led to an increase in hospital mortality in about 90% of simulated patients. Continuation of outpatient PPI therapy on admission led to net increase in hospital mortality in 79% of simulated patients. Results were robust to both one-way and multivariate sensitivity analyses, with net harm occurring in at least two-thirds of patients in all scenarios. CONCLUSIONS For the majority of medical inpatients outside the ICU, use of PPIs likely leads to a net increase in hospital mortality. Even in patients at particularly high risk of UGIB, only those at the very lowest risk of HCAP and CDI should be considered for prophylactic PPI use. Continuation of outpatient PPIs may also increase expected hospital mortality. Apart from patients with active UGIB, use of PPIs in hospitalized patients should be discouraged.
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Affiliation(s)
- Matt Pappas
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Rd., NCRC Bldg. 16, Ann Arbor, MI, 48105, USA. .,Department of Internal Medicine, Division of General Internal Medicine, The University of Michigan Health System, Ann Arbor, MI, USA. .,The University of Michigan, Ann Arbor, MI, USA.
| | | | - Sandeep Vijan
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Rd., NCRC Bldg. 16, Ann Arbor, MI, 48105, USA.,Department of Internal Medicine, Division of General Internal Medicine, The University of Michigan Health System, Ann Arbor, MI, USA
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Pereira FL, Oliveira Júnior CA, Silva ROS, Dorella FA, Carvalho AF, Almeida GMF, Leal CAG, Lobato FCF, Figueiredo HCP. Complete genome sequence of Peptoclostridium difficile strain Z31. Gut Pathog 2016; 8:11. [PMID: 28828039 PMCID: PMC5562067 DOI: 10.1186/s13099-016-0095-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 03/03/2016] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Peptoclostridium (Clostridium) difficile is a spore-forming bacterium responsible for nosocomial infections in humans. It is recognized as an important agent of diarrhea and colitis in several animal species and a possible zoonotic agent. Despite the known importance of P. difficile infection in humans and animals, no vaccine or other effective measure to control the disease is commercially available. A possible alternative treatment for P. difficile infection is the use of a nontoxigenic strain of P. difficile as a competitive exclusion agent. However, a thorough knowledge of this strain is necessary for this purpose. We selected P. difficile Z31, a nontoxigenic strain (PCR ribotype 009), for investigation because it prevents P. difficile infection in a hamster model. RESULTS The genome sequence of P. difficile Z31 is a circular chromosome of 4298,263 bp, with a 29.21 % GC content, encoding 4128 proteins, and containing 78 pseudogenes. This strain belongs to ST 3, clade 1, and has five phage regions in its genome. Genes responsible for resistance to tetracycline and erythromycin were detected and more importantly, Z31 also contains genes that promote spore production and stability, cell attachment, intestinal adherence, and biofilm formation. CONCLUSION In this study, we present the first complete genome sequence of nontoxigenic P. difficile strain Z31. When the Z31 genome was compared with those of other isolates available in GenBank, including a draft genome of a nontoxigenic strain, several unique regions were evident. Z31 contains no toxin genes, but encodes several non-toxin virulence factors, which may favor host colonization.
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Affiliation(s)
- Felipe L. Pereira
- National Reference Laboratory for Aquatic Animal Diseases (AQUACEN), Ministry of Fisheries and Aquaculture, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | - Rodrigo O. S. Silva
- Veterinary School, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Fernanda A. Dorella
- National Reference Laboratory for Aquatic Animal Diseases (AQUACEN), Ministry of Fisheries and Aquaculture, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Alex F. Carvalho
- National Reference Laboratory for Aquatic Animal Diseases (AQUACEN), Ministry of Fisheries and Aquaculture, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Gabriel M. F. Almeida
- National Reference Laboratory for Aquatic Animal Diseases (AQUACEN), Ministry of Fisheries and Aquaculture, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Carlos A. G. Leal
- National Reference Laboratory for Aquatic Animal Diseases (AQUACEN), Ministry of Fisheries and Aquaculture, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | - Henrique C. P. Figueiredo
- National Reference Laboratory for Aquatic Animal Diseases (AQUACEN), Ministry of Fisheries and Aquaculture, Federal University of Minas Gerais, Belo Horizonte, Brazil
- Department of Preventive Veterinary Medicine, School of Veterinary, Federal University of Minas Gerais, Av. Antônio Carlos 6627, Pampulha, 30161-970 Belo Horizonte, MG Brazil
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Rane PP, Guha S, Chatterjee S, Aparasu RR. Prevalence and predictors of non-evidence based proton pump inhibitor use among elderly nursing home residents in the US. Res Social Adm Pharm 2016; 13:358-363. [PMID: 27033427 DOI: 10.1016/j.sapharm.2016.02.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 02/26/2016] [Accepted: 02/26/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) can lead to several adverse effects among the elderly, particularly when used inappropriately or in contrast to evidence suggested protocols. OBJECTIVE The aim of this study was to examine the prevalence and predictors of non-evidence based PPI use in elderly nursing home residents. METHODS A cross-sectional study was conducted using data from the 2004 National Nursing Home Survey (NNHS). The study sample included nursing home residents 65 years and older. Descriptive statistics were used to examine the prevalence of non-evidence based PPI use. Multivariable logistic regression was used to evaluate the patient and facility-level factors associated with non-evidence based PPI use among the elderly nursing home residents. RESULTS A total of 355,600 elderly nursing home residents received at least one PPI for an overall prevalence of 26.99%. Among those elderly receiving PPIs, 48.59% of the use was not evidence based. Multivariable logistic regression revealed that residents with osteoporosis (Odds Ratio (OR): 0.55, 95% CI: 0.45-0.68), SSRI users (OR: 0.81, 95% CI: 0.68-0.97) and those residing in micropolitan area (OR: 0.79, 95% CI: 0.63-0.98) were negatively associated with prescription of PPIs without an indication. Patients with chronic cough (OR: 2.10, 95% CI: 1.12-3.96) and Medicare insurance (OR: 1.23, 95% CI: 1.01-1.50) were positively associated with prescription of PPIs without an indication. CONCLUSIONS The current study found that almost half of the elderly nursing home residents used PPIs for non-evidence based indications. Given the safety concerns and high non-evidence based use of PPIs in nursing homes, there is an urgent need to optimize PPI use in the elderly.
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Affiliation(s)
- Pratik P Rane
- Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, 1441 Moursund St., Houston, TX, USA
| | - Sushovan Guha
- Division of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Satabdi Chatterjee
- Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, 1441 Moursund St., Houston, TX, USA; Health Economics and Outcomes Research, Novartis Healthcare Pvt. Ltd., Hyderabad, India
| | - Rajender R Aparasu
- Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, 1441 Moursund St., Houston, TX, USA.
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Kevorkian Y, Shirley DJ, Shen A. Regulation of Clostridium difficile spore germination by the CspA pseudoprotease domain. Biochimie 2016; 122:243-54. [PMID: 26231446 PMCID: PMC4732931 DOI: 10.1016/j.biochi.2015.07.023] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 07/24/2015] [Indexed: 12/18/2022]
Abstract
Clostridium difficile is a spore-forming obligate anaerobe that is a leading cause of healthcare-associated infections. C. difficile infections begin when its metabolically dormant spores germinate in the gut of susceptible individuals. Binding of bile salt germinants to the Csp family pseudoprotease CspC triggers a proteolytic signaling cascade consisting of the Csp family protease CspB and the cortex hydrolase SleC. Conserved across many of the Clostridia, Csp proteases are subtilisin-like serine proteases that activate pro-SleC by cleaving off its inhibitory pro-peptide. Active SleC degrades the protective cortex layer, allowing spores to resume metabolism and growth. This signaling pathway, however, is differentially regulated in C. difficile, since CspC functions both as a germinant receptor and regulator of CspB activity. CspB is also produced as a fusion to a catalytically inactive CspA domain that subsequently undergoes interdomain processing during spore formation. In this study, we investigated the role of the CspA pseudoprotease domain in regulating C. difficile spore germination. Mutational analyses revealed that the CspA domain controls CspC germinant receptor levels in mature spores and is required for optimal spore germination, particularly when CspA is fused to the CspB protease. During spore formation, the YabG protease separates these domains, although YabG itself is dispensable for germination. Bioinformatic analyses of Csp family members suggest that the CspC-regulated signaling pathway characterized in C. difficile is conserved in related Peptostreptococcaceae family members but not in the Clostridiaceae or Lachnospiraceae. Our results indicate that pseudoproteases play critical roles in regulating C. difficile spore germination and highlight that diverse mechanisms control spore germination in the Clostridia.
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Affiliation(s)
- Yuzo Kevorkian
- Department of Microbiology and Molecular Genetics, University of Vermont, Burlington, VT, 05405, USA
| | - David J Shirley
- Department of Microbiology and Molecular Genetics, University of Vermont, Burlington, VT, 05405, USA
| | - Aimee Shen
- Department of Microbiology and Molecular Genetics, University of Vermont, Burlington, VT, 05405, USA.
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Buendgens L, Koch A, Tacke F. Prevention of stress-related ulcer bleeding at the intensive care unit: Risks and benefits of stress ulcer prophylaxis. World J Crit Care Med 2016; 5:57-64. [PMID: 26855894 PMCID: PMC4733456 DOI: 10.5492/wjccm.v5.i1.57] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Revised: 11/13/2015] [Accepted: 01/07/2016] [Indexed: 02/06/2023] Open
Abstract
Stress-related mucosal disease is a typical complication of critically ill patients in the intensive care unit (ICU). It poses a risk of clinically relevant upper gastrointestinal (GI) bleeding. Therefore, stress ulcer prophylaxis (SUP) is recommended in high-risk patients, especially those mechanically ventilated > 48 h and those with a manifest coagulopathy. Proton pump inhibitors (PPI) and, less effectively, histamine 2 receptor antagonists (H2RA) prevent GI bleeding in critically ill patients in the ICU. However, the routine use of pharmacological SUP does not reduce overall mortality in ICU patients. Moreover, recent studies revealed that SUP in the ICU might be associated with potential harm such as an increased risk of infectious complications, especially nosocomial pneumonia and Clostridium difficile-associated diarrhea. Additionally, special populations such as patients with liver cirrhosis may even have an increased mortality rate if treated with PPI. Likewise, PPI can be toxic for both the liver and the bone marrow, and some PPI show clinically relevant interactions with important other drugs like clopidogrel. Therefore, the agent of choice, the specific balance of risks and benefits for individual patients as well as the possible dose of PPI has to be chosen carefully. Alternatives to PPI prophylaxis include H2RA and/or sucralfate. Instead of routine SUP, further trials should investigate risk-adjusted algorithms, balancing benefits and threats of SUP medication in the ICU.
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78
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Shen A, Fimlaid KA, Pishdadian K. Inducing and Quantifying Clostridium difficile Spore Formation. Methods Mol Biol 2016; 1476:129-42. [PMID: 27507338 DOI: 10.1007/978-1-4939-6361-4_10] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The Gram-positive nosocomial pathogen Clostridium difficile induces sporulation during growth in the gastrointestinal tract. Sporulation is necessary for this obligate anaerobe to form metabolically dormant spores that can resist antibiotic treatment, survive exit from the mammalian host, and transmit C. difficile infections. In this chapter, we describe a method for inducing C. difficile sporulation in vitro. This method can be used to study sporulation and maximize spore purification yields for a number of C. difficile strain backgrounds. We also describe procedures for visualizing spore formation using phase-contrast microscopy and for quantifying the efficiency of sporulation using heat resistance as a measure of functional spore formation.
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Affiliation(s)
- Aimee Shen
- Department of Microbiology and Molecular Genetics, University of Vermont, 95 Carrigan Drive, Burlington, VT, 05405, USA.
| | - Kelly A Fimlaid
- Department of Microbiology and Molecular Genetics, University of Vermont, 95 Carrigan Drive, Burlington, VT, 05405, USA.,Program in Cellular, Molecular & Biomedical Sciences, University of Vermont, Burlington, VT, 05405, USA
| | - Keyan Pishdadian
- Department of Microbiology and Molecular Genetics, University of Vermont, 95 Carrigan Drive, Burlington, VT, 05405, USA
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79
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Reexamining the Germination Phenotypes of Several Clostridium difficile Strains Suggests Another Role for the CspC Germinant Receptor. J Bacteriol 2015; 198:777-86. [PMID: 26668265 DOI: 10.1128/jb.00908-15] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 12/09/2015] [Indexed: 12/17/2022] Open
Abstract
UNLABELLED Clostridium difficile spore germination is essential for colonization and disease. The signals that initiate C. difficile spore germination are a combination of taurocholic acid (a bile acid) and glycine. Interestingly, the chenodeoxycholic acid class (CDCA) bile acids competitively inhibit taurocholic acid-mediated germination, suggesting that compounds that inhibit spore germination could be developed into drugs that prophylactically prevent C. difficile infection or reduce recurring disease. However, a recent report called into question the utility of such a strategy to prevent infection by describing C. difficile strains that germinated in the apparent absence of bile acids or germinated in the presence of the CDCA inhibitor. Because the mechanisms of C. difficile spore germination are beginning to be elucidated, the mechanism of germination in these particular strains could yield important information on how C. difficile spores initiate germination. Therefore, we quantified the interaction of these strains with taurocholic acid and CDCA, the rates of spore germination, the release of DPA from the spore core, and the abundance of the germinant receptor complex (CspC, CspB, and SleC). We found that strains previously observed to germinate in the absence of taurocholic acid correspond to more potent 50% effective concentrations (EC50 values; the concentrations that achieve a half-maximum germination rate) of the germinant and are still inhibited by CDCA, possibly explaining the previous observations. By comparing the germination kinetics and the abundance of proteins in the germinant receptor complex, we revised our original model for CspC-mediated activation of spore germination and propose that CspC may activate spore germination and then inhibit downstream processes. IMPORTANCE Clostridium difficile forms metabolically dormant spores that persist in the health care environment. In susceptible hosts, C. difficile spores germinate in response to certain bile acids and glycine. Blocking germination by C. difficile spores is an attractive strategy to prevent the initiation of disease or to block recurring infection. However, certain C. difficile strains have been identified whose spores germinate in the absence of bile acids or are not blocked by known inhibitors of C. difficile spore germination (calling into question the utility of such strategies). Here, we further investigate these strains and reestablish that bile acid activators and inhibitors of germination affect these strains and use these data to suggest another role for the C. difficile bile acid germinant receptor.
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80
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Trifan A, Stoica O, Stanciu C, Cojocariu C, Singeap AM, Girleanu I, Miftode E. Clostridium difficile infection in patients with liver disease: a review. Eur J Clin Microbiol Infect Dis 2015; 34:2313-24. [PMID: 26440041 DOI: 10.1007/s10096-015-2501-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 09/28/2015] [Indexed: 02/05/2023]
Abstract
Over the past two decades, there has been a dramatic worldwide increase in both the incidence and severity of Clostridium difficile infection (CDI). Paralleling the increased incidence of CDI in the general population, there has been increased interest in CDI among patients with liver disease, particularly in those with liver cirrhosis and post liver transplantation. MEDLINE and several other electronic databases from January 1995 to December 2014 were searched in order to identify potentially relevant literature. Patients with cirrhosis and liver transplant recipients are at high risk for the development CDI because of antibiotics and proton pump inhibitors use, frequent and prolonged hospitalization, immunosuppressant therapy, and multiple comorbidities. Enzyme immunoassay to detect C. difficile toxins A and B in stool remains the most widely used test for CDI diagnosis, although, more recently, polymerase chain reaction (PCR)-based assays have become the preferred diagnostic test in many laboratories. Metronidazole and vancomycin, given orally, have proved to be effective in the treatment of CDI. Both cirrhotic patients and liver transplant recipients with CDI have longer length of hospital stay, increased mortality, and higher healthcare costs than those without CDI. A rapid diagnosis and adequate therapy of CDI are of paramount importance to improve liver disease patients' outcome. The aim of this review is to provide up-to-date information on the epidemiology, risk factors, pathogenesis, treatment, and outcomes in liver disease patients with CDI.
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Affiliation(s)
- A Trifan
- "Gr. T. Popa" University of Medicine and Pharmacy, 700111, Iasi, Romania
- Institute of Gastroenterology and Hepatology, "St. Spiridon" Emergency University Hospital, Independentei Street no. 1, 700111, Iasi, Romania
| | - O Stoica
- "Gr. T. Popa" University of Medicine and Pharmacy, 700111, Iasi, Romania
| | - C Stanciu
- Institute of Gastroenterology and Hepatology, "St. Spiridon" Emergency University Hospital, Independentei Street no. 1, 700111, Iasi, Romania.
| | - C Cojocariu
- "Gr. T. Popa" University of Medicine and Pharmacy, 700111, Iasi, Romania
- Institute of Gastroenterology and Hepatology, "St. Spiridon" Emergency University Hospital, Independentei Street no. 1, 700111, Iasi, Romania
| | - A-M Singeap
- "Gr. T. Popa" University of Medicine and Pharmacy, 700111, Iasi, Romania
- Institute of Gastroenterology and Hepatology, "St. Spiridon" Emergency University Hospital, Independentei Street no. 1, 700111, Iasi, Romania
| | - I Girleanu
- "Gr. T. Popa" University of Medicine and Pharmacy, 700111, Iasi, Romania
| | - E Miftode
- Hospital of Infectious Diseases, "Gr. T. Popa" University of Medicine and Pharmacy, 700111, Iasi, Romania
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81
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Furuya-Kanamori L, Marquess J, Yakob L, Riley TV, Paterson DL, Foster NF, Huber CA, Clements ACA. Asymptomatic Clostridium difficile colonization: epidemiology and clinical implications. BMC Infect Dis 2015; 15:516. [PMID: 26573915 PMCID: PMC4647607 DOI: 10.1186/s12879-015-1258-4] [Citation(s) in RCA: 137] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 10/31/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The epidemiology of Clostridium difficile infection (CDI) has changed over the past decades with the emergence of highly virulent strains. The role of asymptomatic C. difficile colonization as part of the clinical spectrum of CDI is complex because many risk factors are common to both disease and asymptomatic states. In this article, we review the role of asymptomatic C. difficile colonization in the progression to symptomatic CDI, describe the epidemiology of asymptomatic C. difficile colonization, assess the effectiveness of screening and intensive infection control practices for patients at risk of asymptomatic C. difficile colonization, and discuss the implications for clinical practice. METHODS A narrative review was performed in PubMed for articles published from January 1980 to February 2015 using search terms 'Clostridium difficile' and 'colonization' or 'colonisation' or 'carriage'. RESULTS There is no clear definition for asymptomatic CDI and the terms carriage and colonization are often used interchangeably. The prevalence of asymptomatic C. difficile colonization varies depending on a number of host, pathogen, and environmental factors; current estimates of asymptomatic colonization may be underestimated as stool culture is not practical in a clinical setting. CONCLUSIONS Asymptomatic C. difficile colonization presents challenging concepts in the overall picture of this disease and its management. Individuals who are colonized by the organism may acquire protection from progression to disease, however they also have the potential to contribute to transmission in healthcare settings.
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Affiliation(s)
- Luis Furuya-Kanamori
- Research School of Population Health, The Australian National University, Building 62 Mills Road, Canberra, ACT 2601, Australia.
| | - John Marquess
- School of Population Health, The University of Queensland, Herston, QLD, Australia.
- Queensland Department of Health, Communicable Diseases Unit, Herston, QLD, Australia.
| | - Laith Yakob
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK.
| | - Thomas V Riley
- Microbiology and Immunology, School of Pathology and Laboratory Medicine, The University of Western Australia, Nedlands, WA, Australia.
- PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Nedlands, WA, Australia.
| | - David L Paterson
- The University of Queensland, UQ Centre for Clinical Research, Herston, QLD, Australia.
| | - Niki F Foster
- PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Nedlands, WA, Australia.
| | - Charlotte A Huber
- The University of Queensland, UQ Centre for Clinical Research, Herston, QLD, Australia.
| | - Archie C A Clements
- Research School of Population Health, The Australian National University, Building 62 Mills Road, Canberra, ACT 2601, Australia.
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82
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Brown KE, Knoderer CA, Nichols KR, Crumby AS. Acid-Suppressing Agents and Risk for Clostridium difficile Infection in Pediatric Patients. Clin Pediatr (Phila) 2015; 54:1102-6. [PMID: 25644650 DOI: 10.1177/0009922815569201] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Acid-suppressing agents have been associated with increased Clostridium difficile infection (CDI) in adults. The objective of this study was to evaluate the association of acid-suppressing therapy with the development of CDI in the pediatric population. METHODS This was a retrospective case-control study. Children aged 1 through 17 years with a positive C difficile polymerase chain reaction (PCR) result obtained between June 1, 2008, and June 1, 2012, were randomly matched to a control population selected from patients with negative PCR. RESULTS A total of 458 children were included. No difference was observed in acid-suppressive therapy prior to PCR in CDI-positive versus -negative patients (n = 131 [57.2%] vs n = 121 [52.8%], P = .348). Among patients receiving acid-suppressing therapy prior to obtaining a PCR, no difference was observed in proton pump inhibitor use (45% vs 46.3%, P = .843), but histamine-2 receptor antagonist (H2RA) use was greater in the CDI-positive patients (32.8% vs 14.9%, P = .001). Logistic regression analysis demonstrated that H2RA therapy at home (odds ratio = 4.6; 95% confidence interval = 1.5-14.5) was an independent CDI predictor. CONCLUSION In this pediatric population, CDI risk in children receiving home acid-suppressive therapy with H2RAs is nearly 4.5 times greater than that of children not receiving H2RA therapy. These results suggest the need for continued monitoring and study of H2RA therapy in children.
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Affiliation(s)
| | | | | | - Ashley S Crumby
- University of Mississippi School of Pharmacy, University, MS, USA
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83
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Chang SS, Lai CC, Lee MTG, Lee YC, Tsai YW, Hsu WT, Lee CC. Risk of spontaneous bacterial peritonitis associated with gastric Acid suppression. Medicine (Baltimore) 2015; 94:e944. [PMID: 26039135 PMCID: PMC4616349 DOI: 10.1097/md.0000000000000944] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The primary objective of this study was to determine the association between the use of gastric acid suppressants (GAS) and the risk of developing spontaneous bacterial peritonitis (SBP) in patients with advanced liver cirrhosis (LC). A case-control study nested within a cohort of 480,000 representatives of Taiwan National Health Insurance beneficiaries was carried out. A case was matched with 100 controls on age, gender, and index date of SBP diagnosis. GAS use was identified from the 1-year period before the index date. Conditional logistic regression analysis was used to adjust for various unbalanced covariates between users and nonusers of GAS. A total of 947 cases of SBP were identified among the 86,418 patients with advanced LC. A significant increased risk of developing SBP was found to be associated with current (within 30 days), and recent (within 30-90 day) use of 2 different classes of GAS: proton pump inhibitors (PPIs) and histamine 2 receptor antagonists (H2RAs). The confounder adjusted rate ratio (aRR) for the current use of PPIs was 2.77 (95% CI: 1.90-4.04) and H2RAs was 2.62 (95% CI: 2.00-3.42). The risk of SBP attenuated for the recent use of PPIs (aRR: 2.20, 95%CI: 1.60-3.02) or H2RAs (aRR: 1.72, 95% CI: 1.25-2.37). In addition, sensitivity analysis using hospitalized SBP as the primary outcome showed a similar risk for the current use of PPIs (aRR, 3.24; 95% CI: 2.08-5.05) and H2RAs (aRR 2.43; 95% CI 1.71-3.46). Furthermore, higher cumulative days of gastric acid suppression were associated with a higher risk of SBP (trend P < 0.0001). To conclude, exposure to GAS was associated with an increased risk of SBP in patients with advanced LC. The association was more pronounced in current PPI users compared with nonusers.
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Affiliation(s)
- Shy-Shin Chang
- From the Department of Family Medicine, Chang Gung Memorial Hospital, Linkou, (S-SC, Y-CL, Y-WT); Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan City (S-SC); Chang Gung University College of Medicine, Taoyuan City (S-SC, Y-CL, Y-WT); Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying Dis., Tainan City (C-CLai); Department of Emergency Medicine, National Taiwan University Hospital, Taipei City (M-tGL, W-TH, C-CLee); and Department of Emergency Medicine and General Medicine, National Taiwan University Hospital Yunlin Branch, Douliou, Taiwan (R.O.C.) (C-CLee)
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84
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Hung YP, Lee JC, Lin HJ, Liu HC, Wu YH, Tsai PJ, Ko WC. Clinical impact of Clostridium difficile colonization. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2015; 48:241-8. [DOI: 10.1016/j.jmii.2014.04.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 04/12/2014] [Accepted: 04/21/2014] [Indexed: 01/05/2023]
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85
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Spore Cortex Hydrolysis Precedes Dipicolinic Acid Release during Clostridium difficile Spore Germination. J Bacteriol 2015; 197:2276-83. [PMID: 25917906 DOI: 10.1128/jb.02575-14] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 04/21/2015] [Indexed: 12/17/2022] Open
Abstract
UNLABELLED Bacterial spore germination is a process whereby a dormant spore returns to active, vegetative growth, and this process has largely been studied in the model organism Bacillus subtilis. In B. subtilis, the initiation of germinant receptor-mediated spore germination is divided into two genetically separable stages. Stage I is characterized by the release of dipicolinic acid (DPA) from the spore core. Stage II is characterized by cortex degradation, and stage II is activated by the DPA released during stage I. Thus, DPA release precedes cortex hydrolysis during B. subtilis spore germination. Here, we investigated the timing of DPA release and cortex hydrolysis during Clostridium difficile spore germination and found that cortex hydrolysis precedes DPA release. Inactivation of either the bile acid germinant receptor, cspC, or the cortex hydrolase, sleC, prevented both cortex hydrolysis and DPA release. Because both cortex hydrolysis and DPA release during C. difficile spore germination are dependent on the presence of the germinant receptor and the cortex hydrolase, the release of DPA from the core may rely on the osmotic swelling of the core upon cortex hydrolysis. These results have implications for the hypothesized glycine receptor and suggest that the initiation of germinant receptor-mediated C. difficile spore germination proceeds through a novel germination pathway. IMPORTANCE Clostridium difficile infects antibiotic-treated hosts and spreads between hosts as a dormant spore. In a host, spores germinate to the vegetative form that produces the toxins necessary for disease. C. difficile spore germination is stimulated by certain bile acids and glycine. We recently identified the bile acid germinant receptor as the germination-specific, protease-like CspC. CspC is likely cortex localized, where it can transmit the bile acid signal to the cortex hydrolase, SleC. Due to the differences in location of CspC compared to the Bacillus subtilis germinant receptors, we hypothesized that there are fundamental differences in the germination processes between the model organism and C. difficile. We found that C. difficile spore germination proceeds through a novel pathway.
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86
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Seifert CF, Brown AT. The reply. Am J Med 2015; 128:e15. [PMID: 25812638 DOI: 10.1016/j.amjmed.2014.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 11/13/2014] [Indexed: 11/18/2022]
Affiliation(s)
- Charles F Seifert
- Texas Tech University Health Sciences Center, School of Pharmacy, Lubbock
| | - Adam T Brown
- Texas Tech University Health Sciences Center, School of Pharmacy, Lubbock
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87
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Daniell HW. Proton pump inhibition may promote Clostridium difficile recurrences. Am J Med 2015; 128:e13. [PMID: 25812637 DOI: 10.1016/j.amjmed.2014.10.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 10/10/2014] [Indexed: 10/23/2022]
Affiliation(s)
- Harry W Daniell
- Department of Family Practice, University of California Medical School at Davis
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88
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Furuya-Kanamori L, Stone JC, Clark J, McKenzie SJ, Yakob L, Paterson DL, Riley TV, Doi SAR, Clements AC. Comorbidities, Exposure to Medications, and the Risk of Community-Acquired Clostridium difficile Infection: a systematic review and meta-analysis. Infect Control Hosp Epidemiol 2015; 36:132-41. [PMID: 25632995 DOI: 10.1017/ice.2014.39] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) has been extensively described in healthcare settings; however, risk factors associated with community-acquired (CA) CDI remain uncertain. This study aimed to synthesize the current evidence for an association between commonly prescribed medications and comorbidities with CA-CDI. METHODS A systematic search was conducted in 5 electronic databases for epidemiologic studies that examined the association between the presence of comorbidities and exposure to medications with the risk of CA-CDI. Pooled odds ratios were estimated using 3 meta-analytic methods. Subgroup analyses by location of studies and by life stages were conducted. RESULTS Twelve publications (n=56,776 patients) met inclusion criteria. Antimicrobial (odds ratio, 6.18; 95% CI, 3.80-10.04) and corticosteroid (1.81; 1.15-2.84) exposure were associated with increased risk of CA-CDI. Among the comorbidities, inflammatory bowel disease (odds ratio, 3.72; 95% CI, 1.52-9.12), renal failure (2.64; 1.23-5.68), hematologic cancer (1.75; 1.02-5.68), and diabetes mellitus (1.15; 1.05-1.27) were associated with CA-CDI. By location, antimicrobial exposure was associated with a higher risk of CA-CDI in the United States, whereas proton-pump inhibitor exposure was associated with a higher risk in Europe. By life stages, the risk of CA-CDI associated with antimicrobial exposure greatly increased in adults older than 65 years. CONCLUSIONS Antimicrobial exposure was the strongest risk factor associated with CA-CDI. Further studies are required to investigate the risk of CA-CDI associated with medications commonly prescribed in the community. Patients with diarrhea who have inflammatory bowel disease, renal failure, hematologic cancer, or diabetes are appropriate populations for interventional studies of screening.
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Affiliation(s)
- Luis Furuya-Kanamori
- 1Research School of Population Health,Australian National University,Canberra,Australia
| | - Jennifer C Stone
- 2School of Population Health,University of Queensland,Herston,Australia
| | | | | | - Laith Yakob
- 4Department of Disease Control,London School of Hygiene & Tropical Medicine,London,UK
| | - David L Paterson
- 5University of Queensland,UQ Centre for Clinical Research,Herston,Australia
| | - Thomas V Riley
- 6Microbiology & Immunology,University of Western Australia, andDepartment of Microbiology PathWest Laboratory Medicine,Queen Elizabeth II Medical Centre,Nedlands,Australia
| | - Suhail A R Doi
- 2School of Population Health,University of Queensland,Herston,Australia
| | - Archie C Clements
- 1Research School of Population Health,Australian National University,Canberra,Australia
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89
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Fraise A, Wilkinson M, Bradley C, Paton S, Walker J, Maillard JY, Wesgate R, Hoffman P, Coia J, Woodall C, Fry C, Wilcox M. Development of a sporicidal test method for Clostridium difficile. J Hosp Infect 2015; 89:2-15. [DOI: 10.1016/j.jhin.2014.09.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 09/22/2014] [Indexed: 01/19/2023]
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90
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Acid suppression therapy does not predispose to Clostridium difficile infection: the case of the potential bias. PLoS One 2014; 9:e110790. [PMID: 25343667 PMCID: PMC4208782 DOI: 10.1371/journal.pone.0110790] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 09/17/2014] [Indexed: 01/05/2023] Open
Abstract
Objective An adverse effect of acid-suppression medications on the occurrence of Clostridium difficile infection (CDI) has been a common finding of many, but not all studies. We hypothesized that association between acid-suppression medications and CDI is due to the residual confounding in comparison between patients with infection to those without, predominantly from non-tested and less sick subjects. We aimed to evaluate the effect of acid suppression therapy on incidence of CDI by comparing patients with CDI to two control groups: not tested patients and patients suspected of having CDI, but with a negative test. Methods We conducted a case-control study of adult patients hospitalized in internal medicine department of tertiary teaching hospital between 2005–2010 for at least three days. Controls from each of two groups (negative for CDI and non-tested) were individually matched (1∶1) to cases by primary diagnosis, Charlson comorbidity index, year of hospitalization and gender. Primary outcomes were diagnoses of International Classification of Diseases (ICD-9)–coded CDI occurring 72 hours or more after admission. Results Patients with CDI were similar to controls with a negative test, while controls without CDI testing had lower clinical severity. In multivariable analysis, treatment by acid suppression medications was associated with CDI compared to those who were not tested (OR = 1.88, p-value = 0.032). Conversely, use of acid suppression medications in those who tested negative for the infection was not associated with CDI risk as compared to the cases (OR = 0.66; p = 0.059). Conclusions These findings suggest that the reported epidemiologic associations between use of acid suppression medications and CDI risk may be spurious. The control group choice has an important impact on the results. Clinical differences between the patients with CDI and those not tested and not suspected of having the infection may explain the different conclusions regarding the acid suppression effect on CDI risk.
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91
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Abstract
PURPOSE OF REVIEW This article defines the risk factors for Clostridium difficile infection (CDI) in hospitalized children in light of recent studies demonstrating a change in the epidemiology of these infections in both adults and children. RECENT FINDINGS Antibiotic exposure within the past 4-12 weeks was noted in a majority of published cases of pediatric CDI, and that remains a key risk factor for infection. Past and/or prolonged hospitalization increase a child's risk for CDI as they increase potential contact with C. difficile spores. Of all CDI, hospital-acquired infection remains more common. Many comorbid conditions have been linked with CDI, with the strongest association existing in children with cancer and inflammatory bowel disease. Severe infections occur infrequently in pediatric patients. Markers established in adults for severe CDI resulting in colectomy or transfer to ICU have not been shown to correlate in pediatric patients. SUMMARY Recent antibiotic exposure and hospitalization remain key risk factors for CDI in the hospitalized pediatric patient. Patients with comorbid conditions such as malignancy and inflammatory bowel disease are at higher risk for CDI. Resistant infections and severe outcomes are not common in the pediatric population.
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92
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Rineh A, Kelso MJ, Vatansever F, Tegos GP, Hamblin MR. Clostridium difficile infection: molecular pathogenesis and novel therapeutics. Expert Rev Anti Infect Ther 2014; 12:131-50. [PMID: 24410618 DOI: 10.1586/14787210.2014.866515] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The Gram-positive anaerobic bacterium Clostridium difficile produces toxins A and B, which can cause a spectrum of diseases from pseudomembranous colitis to C. difficile-associated diarrhea. A limited number of C. difficile strains also produce a binary toxin that exhibits ADP ribosyltransferase activity. Here, the structure and the mechanism of action of these toxins as well as their role in disease are reviewed. Nosocomial C. difficile infection is often contracted in hospital when patients treated with antibiotics suffer a disturbance in normal gut microflora. C. difficile spores can persist on dry, inanimate surface for months. Metronidazole and oral vancomycin are clinically used for treatment of C. difficile infection but clinical failure and concern about promotion of resistance are motivating the search for novel non-antibiotic therapeutics. Methods for controlling both toxins and spores, replacing gut microflora by probiotics or fecal transplant, and killing bacteria in the anaerobic gut by photodynamic therapy are discussed.
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Affiliation(s)
- Ardeshir Rineh
- The Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA 02114, USA
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93
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Comparative nutritional and chemical phenome of Clostridium difficile isolates determined using phenotype microarrays. Int J Infect Dis 2014; 27:20-5. [PMID: 25130165 DOI: 10.1016/j.ijid.2014.06.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 06/11/2014] [Accepted: 06/22/2014] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES Clostridium difficile infection (CDI) is the leading cause of infectious diarrhea in North America and Europe. The risk of CDI increases significantly in the case where antimicrobial treatment reduces the number of competing bacteria in the gut, thus leading to the increased availability of nutrients and loss of colonization resistance. The objective of this study was to determine comprehensive nutritional utilization and the chemical sensitivity profile of historic and newer C. difficile isolates and to examine the possible role of the phenotype diversity in C. difficile virulence. METHODS Phenotype microarrays (PMs) were used to elucidate the complete nutritional and chemical sensitivity profile of six C. difficile isolates. RESULTS Of the 760 nutrient sources tested, 285 compounds were utilized by at least one strain. Among the C. difficile isolates compared, R20291, a recent hypervirulent outbreak-associated strain, appears to have an expanded nutrient utilization profile when compared to all other strains. CONCLUSIONS The expanded nutritional utilization profile of some newer C. difficile strains could be one of the reasons for infections in patients who are not exposed to the hospital environment or not undergoing antibiotic treatment. This nutritional profile could be used to design tube feeding formulas that reduce the risk of CDI.
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94
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Jump RLP, Polinkovsky A, Hurless K, Sitzlar B, Eckart K, Tomas M, Deshpande A, Nerandzic MM, Donskey CJ. Metabolomics analysis identifies intestinal microbiota-derived biomarkers of colonization resistance in clindamycin-treated mice. PLoS One 2014; 9:e101267. [PMID: 24988418 PMCID: PMC4079339 DOI: 10.1371/journal.pone.0101267] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 06/04/2014] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The intestinal microbiota protect the host against enteric pathogens through a defense mechanism termed colonization resistance. Antibiotics excreted into the intestinal tract may disrupt colonization resistance and alter normal metabolic functions of the microbiota. We used a mouse model to test the hypothesis that alterations in levels of bacterial metabolites in fecal specimens could provide useful biomarkers indicating disrupted or intact colonization resistance after antibiotic treatment. METHODS To assess in vivo colonization resistance, mice were challenged with oral vancomycin-resistant Enterococcus or Clostridium difficile spores at varying time points after treatment with the lincosamide antibiotic clindamycin. For concurrent groups of antibiotic-treated mice, stool samples were analyzed using quantitative real-time polymerase chain reaction to assess changes in the microbiota and using non-targeted metabolic profiling. To assess whether the findings were applicable to another antibiotic class that suppresses intestinal anaerobes, similar experiments were conducted with piperacillin/tazobactam. RESULTS Colonization resistance began to recover within 5 days and was intact by 12 days after clindamycin treatment, coinciding with the recovery bacteria from the families Lachnospiraceae and Ruminococcaceae, both part of the phylum Firmicutes. Clindamycin treatment caused marked changes in metabolites present in fecal specimens. Of 484 compounds analyzed, 146 (30%) exhibited a significant increase or decrease in concentration during clindamycin treatment followed by recovery to baseline that coincided with restoration of in vivo colonization resistance. Identified as potential biomarkers of colonization resistance, these compounds included intermediates in carbohydrate or protein metabolism that increased (pentitols, gamma-glutamyl amino acids and inositol metabolites) or decreased (pentoses, dipeptides) with clindamycin treatment. Piperacillin/tazobactam treatment caused similar alterations in the intestinal microbiota and fecal metabolites. CONCLUSIONS Recovery of colonization resistance after antibiotic treatment coincided with restoration of several fecal bacterial metabolites. These metabolites could provide useful biomarkers indicating intact or disrupted colonization resistance during and after antibiotic treatment.
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Affiliation(s)
- Robin L. P. Jump
- Geriatric Research Education and Clinical Center, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, United States of America
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University, Cleveland, Ohio, United States of America
- * E-mail:
| | - Alex Polinkovsky
- Research Service, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, United States of America
| | - Kelly Hurless
- Research Service, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, United States of America
| | - Brett Sitzlar
- Research Service, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, United States of America
| | - Kevin Eckart
- Research Service, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, United States of America
| | - Myreen Tomas
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Abhishek Deshpande
- Research Service, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, United States of America
| | - Michelle M. Nerandzic
- Research Service, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, United States of America
| | - Curtis J. Donskey
- Geriatric Research Education and Clinical Center, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, United States of America
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University, Cleveland, Ohio, United States of America
- Research Service, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, United States of America
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95
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Arsic B, Pavlovic M, Berenji K. Risk Factors for Relapse and Mortality of Clostridium Difficile-Associated Diarrhea. Open Access Maced J Med Sci 2014. [DOI: 10.3889/oamjms.2014.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
AIM: The aim of the present paper was to identify prognostic factors for relapse and mortality in patients with hospital-acquired infections caused by Clostridium difficile.MATERIAL AND METHODS: This study included 133 patients with healthcare facility-associated disease caused by C. difficile. The medical records of all patients with their clinical history and laboratory data were analyzed.RESULTS: Patients with one onset of disease were 105 (78.9%), 28 (21.1%) experienced a relapse and seven (5.2%) patients not survived infection. The average age in our patients was over 65 years (64.5 years in the survived patients and 78.8 in patient who died, p = 0.01). All of patients had received antibiotic treatment (cephalosporins – 83.4%, aminoglycosides – 21.5% and penicillins – 20.3%) and 40.6% of patients received acid-reducing therapy. There was no difference between patients with one onset of disease/patients with relaps; and survived/died in number of administered antibiotics, duration of administration, administration of acid-reducing treatment or length of hospital stay (p > 0.05). CRP levels were significantly higher in the group of patients who died compared with recovered (p < 0.001). CONCLUSION: C. difficile-associated diarrhea is a common nosocomial disease with high relapse, and significant mortality rate particularly in the elderly.
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96
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Clostridium difficile spore biology: sporulation, germination, and spore structural proteins. Trends Microbiol 2014; 22:406-16. [PMID: 24814671 DOI: 10.1016/j.tim.2014.04.003] [Citation(s) in RCA: 287] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Revised: 03/27/2014] [Accepted: 04/07/2014] [Indexed: 02/06/2023]
Abstract
Clostridium difficile is a Gram-positive, spore-forming obligate anaerobe and a major nosocomial pathogen of worldwide concern. Owing to its strict anaerobic requirements, the infectious and transmissible morphotype is the dormant spore. In susceptible patients, C. difficile spores germinate in the colon to form the vegetative cells that initiate Clostridium difficile infections (CDI). During CDI, C. difficile induces a sporulation pathway that produces more spores; these spores are responsible for the persistence of C. difficile in patients and horizontal transmission between hospitalized patients. Although important to the C. difficile lifecycle, the C. difficile spore proteome is poorly conserved when compared to members of the Bacillus genus. Further, recent studies have revealed significant differences between C. difficile and Bacillus subtilis at the level of sporulation, germination, and spore coat and exosporium morphogenesis. In this review, the regulation of the sporulation and germination pathways and the morphogenesis of the spore coat and exosporium will be discussed.
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97
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Abstract
There has been dramatic change in the epidemiology of Clostridium difficile infection (CDI) since the turn of the 21st century noted by a marked increase in incidence and severity, occurring at a disproportionately higher frequency in older patients. Historically considered a nosocomial infection associated with antibiotic exposure, CDI has now also emerged in the community in populations previously considered low risk. Emerging risk factors and disease recurrence represent continued challenges in the management of CDI. The increased incidence and severity associated with CDI has coincided with the emergence and rapid spread of a previously rare strain, ribotype 027. Recent data from the United States and Europe suggest that the incidence of CDI may have reached a crescendo in the recent years and is perhaps beginning to plateau. The acute care direct costs of CDI were estimated to be US$4.8 billion in 2008. However, nearly all the published studies have focused on CDI diagnosed and treated in the acute care hospital setting and fail to measure the burden outside the hospital, including recently discharged patients, outpatients, and those in long-term care facilities. Enhanced surveillance methods are needed to monitor the incidence, to identify populations at risk, and to characterize the molecular epidemiology of strains causing CDI.
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98
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Cunningham R, Mustoe E, Spiller L, Lewis S, Benjamin N. Acidified nitrite: a host defence against colonization with C. difficile spores? J Hosp Infect 2014; 86:155-7. [DOI: 10.1016/j.jhin.2013.12.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 12/10/2013] [Indexed: 11/25/2022]
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99
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Patil R, Blankenship L. Proton Pump Inhibitors and Clostridium Difficile Infection: Are We Propagating an Already Rapidly Growing Healthcare Problem? Gastroenterology Res 2013; 6:171-173. [PMID: 27785249 PMCID: PMC5051091 DOI: 10.4021/gr575w] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2013] [Indexed: 12/15/2022] Open
Abstract
Proton pump inhibitors (PPIs) have been associated with Clostridium difficile infection (CDI) in several recent studies. The exact mechanism through which PPIs may cause Clostridium difficile infection is not well understood. One potential mechanism to explain this association may be that elevated gastric pH levels facilitate the growth of potentially pathogenic upper and lower gastrointestinal tract flora. Although Clostridium difficile spores are acid resistant, vegetative forms are susceptible to acidity. Higher gastric PH therefore increases vegetative bacteria counts in the small and large intestine. Other potential mechanisms include impairment of leukocytes and other immune responses and antimicrobial properties of PPIs. In recent years, much research has been contributed to prove the relationship between PPIs and CDI as causal. Most studies however, fail to prove causality due to the use of antibiotics and other medications during time of initial diagnosis of CDI. PPIs continue to also be one of the most heavily prescribed drugs in our country. As primary and recurrent infection caused by Clostridium difficile continues to rise, more data must be collected to determine better treatment, overall management, and the role that PPIs may play in its propagation.
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Affiliation(s)
- Rashmee Patil
- Department of Internal Medicine, Lutheran HealthCare, 150 55th Street, Brooklyn, NY, USA
| | - LeAnn Blankenship
- Department of Internal Medicine, Lutheran HealthCare, 150 55th Street, Brooklyn, NY, USA
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100
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Abstract
There has been dramatic change in the epidemiology of Clostridium difficile infection (CDI) since the turn of the 21st century noted by a marked increase in incidence and severity, occurring at a disproportionately higher frequency in older patients. Historically considered a nosocomial infection associated with antibiotic exposure, CDI has now also emerged in the community in populations previously considered low risk. Emerging risk factors and disease recurrence represent continued challenges in the management of CDI. The increased incidence and severity associated with CDI has coincided with the emergence and rapid spread of a previously rare strain, ribotype 027. Recent data from the United States and Europe suggest that the incidence of CDI may have reached a crescendo in the recent years and is perhaps beginning to plateau. The acute care direct costs of CDI were estimated to be US$4.8 billion in 2008. However, nearly all the published studies have focused on CDI diagnosed and treated in the acute care hospital setting and fail to measure the burden outside the hospital, including recently discharged patients, outpatients, and those in long-term care facilities. Enhanced surveillance methods are needed to monitor the incidence, to identify populations at risk, and to characterize the molecular epidemiology of strains causing CDI.
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Affiliation(s)
- Daryl D. DePestel
- Clinical Scientific Director, Medical Affairs, Cubist Pharmaceuticals, Inc., 65 Hayden Ave, Lexington, MA 02421
| | - David M. Aronoff
- Division of Infectious Diseases, Department of Internal Medicine, Department of Microbiology & Immunology, University of Michigan Medical School, Ann Arbor, MI, 48109
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