Clostridium difficile and inflammatory bowel disease

My treatment approach to the management of ulcerative colitis

Ulcerative colitis diagnosis and management represent a challenge for clinicians. The disguises of ischemia and acute infectious colitis continue to confound the diagnosis. The therapeutic options have remarkably expanded in the way of immunomodulators, biologics, or ileoanal pouch surgery, yet all carry potential considerable risks. These risks can confuse and impair patient acceptance, particularly elderly patients and men younger than 30 years. Predictors of outcome of medical and surgical therapy have improved but are far from complete. Nevertheless, therapies focused on the specific patient's condition continue to offer hope.

Review article: strategies for the management of chronic unremitting ulcerative colitis

BACKGROUND

Chronic active ulcerative colitis (UC) is associated with significant morbidity, loss of productivity, increased colorectal cancer risk and cost. Up to 18% of patients suffer chronic active disease, with 30% requiring colectomy at 10 years. The management remains challenging given the relatively few clinical trials in this area.

AIM

To summarise the evidence regarding optimal management strategies for patients with chronic active UC of differing disease extents and degrees of treatment refractoriness.

METHOD

A literature search using the PubMed and Medline databases was performed. No time limit was set on article publication for inclusion.

RESULTS

The principles of management should focus on confirming disease activity, exclusion of alternative diagnoses, adherence and treatment escalation. Infliximab and topical tacrolimus are options in refractory proctitis, although the evidence for these therapies is limited. Both infliximab and adalimumab are effective in corticosteroid-refractory disease, although the proportions of patients achieving corticosteroid-free remission remain modest (24% at 30 weeks and 16.9% at 8 weeks respectively). Alternatives include ciclosporin and tacrolimus, and possibly methotrexate. Colectomy often leads to an improved quality of life; medical strategies unlikely to provide durable corticosteroid-free remission should not be pursued.

CONCLUSIONS

No current pharmacological treatment delivers mucosal healing in the majority of patients. Newer treatments such as vedolizumab and tofacitinib may represent valuable future therapies. Available medical options should be discussed with patients at every step of their management, with an honest appraisal of the evidence. Surgery should always be considered in patients with chronic refractory disease of any extent.

Total colectomy for ulcerative colitis in children: when are we operating?

PURPOSE

Ulcerative colitis (UC) in children is frequently severe and treatment-refractory. While medical therapy is well standardized, little is known regarding factors that contribute to surgical indications. Our aim was to identify factors associated with progression to colectomy in a large cohort of pediatric UC patients.

METHODS

We conducted a retrospective cohort study using the Pediatric Health Information System database. We identified all patients under age 18 discharged between January 1, 2004 and September 30, 2011 with a primary diagnosis of UC. Primary outcome was odds of total colectomy.

RESULTS

Of 8,688 patients, 240 (2.8 %) underwent colectomy. Compared with non-operative patients, a greater proportion of colectomy patients received advanced therapies during admission, including corticosteroids (84.2 vs. 71.3 %) and biological therapy (25.4 vs. 13.6 %). Odds of colectomy were increased with malnutrition (OR 1.86), anemia (OR 2.17), electrolyte imbalance (OR 2.31), and Clostridium difficile infection (OR 1.69). TPN requirement also independently predicted colectomy (OR 3.86). Each successive UC admission significantly increased the odds of colectomy (OR 1.08).

CONCLUSION

These data identify factors associated with progression to colectomy in children hospitalized with UC. Our findings help to identify factors that should be incorporated into future studies aiming to reduce the variability in surgical treatment of childhood UC.

Clostridium difficile Infection

Clostridium difficile is emerging as a common cause of infectious diarrhea. Incidence has increased dramatically since 2000, associated with a new strain that features both increased toxin production and increased resistance to antibiotics. For patients with mild to moderate disease, oral metronidazole is usually the first choice of treatment, and those with severe disease should be treated with vancomycin, with additional intravenous metronidazole in some cases. Fecal microbiota transplantation is a potentially promising therapy for patients with multiple recurrences of C difficile infection. Prevention of nosocomial transmission is crucial to reducing disease outbreaks in health care settings.

Health care burden of Clostridium difficile infection in hospitalized children with inflammatory bowel disease

BACKGROUND

Children with inflammatory bowel disease (IBD), similar to adults, are at increased risk of acquiring a Clostridium difficile infection (CDI). Our objective was to characterize the health care burden associated with CDI in hospitalized pediatric patients with IBD.

METHODS

We extracted and analyzed cases with a discharge diagnosis of IBD or CDI from the U.S. Healthcare Cost and Utilization Project Kids' Inpatient Database.

RESULTS

In our primary analysis, we evaluated pediatric cases with a principal diagnosis of IBD or CDI. For the year 2009, we identified 12,610 weighted cases with IBD of which 3.5% had CDI. In children with IBD, CDI was independently associated with lengthier hospital stays (8.0 versus 6.0 days; adjusted regression coefficient, 2.1 days; 95% confidence interval [CI], 1.4-2.8), higher charges ($45,126 versus $34,703; adjusted regression coefficient, $11,506; 95% CI, 6192-16,820), and greater need for parenteral nutrition (15.9% versus 12.1%; adjusted odds ratio, 1.5; 95% CI, 1.1-2.0) and blood transfusion (17.7% versus 9.8%; adjusted odds ratio, 1.8; 95% CI, 1.4-2.4). There were no deaths. We made similar observations in a subanalysis of cases with principal or secondary diagnoses of IBD or CDI. The incidence of CDI in patients with IBD increased between 2000 and 2009 from 21.7 to 28.0 cases per 1000 IBD cases per year (P < 0.001). There was a significant increase in CDI complicating ulcerative colitis (28.1 versus 42.2, P < 0.001) but not for Crohn's disease (18.3 versus 20.3).

CONCLUSIONS

CDI represents a significant health care burden in hospitalized children with IBD.

Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections

Clostridium difficile infection (CDI) is a leading cause of hospital-associated gastrointestinal illness and places a high burden on our health-care system. Patients with CDI typically have extended lengths-of-stay in hospitals, and CDI is a frequent cause of large hospital outbreaks of disease. This guideline provides recommendations for the diagnosis and management of patients with CDI as well as for the prevention and control of outbreaks while supplementing previously published guidelines. New molecular diagnostic stool tests will likely replace current enzyme immunoassay tests. We suggest treatment of patients be stratified depending on whether they have mild-to-moderate, severe, or complicated disease. Therapy with metronidazole remains the choice for mild-to-moderate disease but may not be adequate for patients with severe or complicated disease. We propose a classification of disease severity to guide therapy that is useful for clinicians. We review current treatment options for patients with recurrent CDI and recommendations for the control and prevention of outbreaks of CDI.

Rifaximin in the treatment of irritable bowel syndrome: is there a high risk for development of antimicrobial resistance?

Irritable bowel syndrome (IBS), a chronic, nonfatal illness is commonly encountered in clinical practice; however, treatment options are limited and often ineffectual. Despite this, there is increasing evidence that bacterial overgrowth in the bowel (dysbiosis) may be an etiological factor in IBS. This has lead to studies in which the antibiotic agent rifaximin has been used to reduce the microbial burden in the bowel, to some extent alleviating the symptoms of IBS. Rifaximin is a member of the rifamycin class of antibiotics, which when administered orally has the distinctions of being gut specific coupled with poor systemic absorption, characteristics that are suggested to limit the development of bacterial resistance. The rifamycins are currently used to treat serious human diseases including tuberculosis, meningococcal disease, methicillin-resistant Staphylococcus aureus and Clostridium difficile infections. The use of rifamycins in the treatment of these diseases is associated with the development of antibiotic resistance over time. When considering the importance of the rifamycins in the treatment of serious human diseases, the large number of patients affected by IBS, and the lack of scientific evidence available on the development of antibiotic resistance to rifaximin over the long-term when used in the gut, it is advisable that the use of rifaximin as a therapy for IBS should be limited to single, acute, short-term treatment.

Infection-related hospitalizations are associated with increased mortality in patients with inflammatory bowel diseases

INTRODUCTION

Serious infections are an important side effect of immunosuppressive therapy used to treat Crohn's disease (CD) and ulcerative colitis (UC). There have been no nationally representative studies examining the spectrum of infection related hospitalizations in patients with IBD.

METHODS

Our study consisted of all adult CD and UC related hospitalizations from the Nationwide Inpatient Sample 2007, a national hospitalization database in the United States. We then identified all infection-related hospitalizations through codes for either the specific infections or disease processes (sepsis, pneumonia, etc.). Predictors of infections as well as the excess morbidity associated with infections were determined using multivariate regression models.

RESULTS

There were an estimated 67,221 hospitalizations related to infections in IBD patients, comprising 27.5% of all IBD hospitalizations. On multivariate analysis, infections were independently associated with age, co-morbidity, malnutrition, TPN, and bowel surgery. Infection-related hospitalizations had a four-fold greater mortality (OR 4.4, 95% CI 3.7-5.2). However, this varied by type of infection with the strongest effect seen for sepsis (OR 15.3, 95% CI 12.4-18.6), pneumonia (OR 3.6, 95% CI 2.9-4.5) and C. difficile (OR 3.2, 95% CI 2.6-4.0), and weaker effects for urinary infections (OR 1.4, 95%CI 1.1-1.7). Infections were also associated with an estimated 2.3 days excess hospital stay (95% CI 2.2-2.5) and $12,482 in hospitalization charges.

CONCLUSION

Infections account for significant morbidity and mortality in patients with IBD and disproportionately impact older IBD patients with greater co-morbidity. Pneumonia, sepsis and C difficile infection are associated with the greatest excess mortality risk.

The surgical management of active ulcerative colitis complicated by Clostridium difficile infection

INTRODUCTION

Clostridium difficile stool toxin is detected in 5-20 % of patients with acute exacerbations of ulcerative colitis (UC). There is little data regarding the safety of surgery for UC with concurrent C. difficile.

METHODS

A retrospective review was performed of 23 patients undergoing colectomy for refractory UC complicated by C. difficile infection between January 2002 and June 2012. Patients were stratified into those who completed a full antibiotic course for C. difficile infection prior to surgery (group A, n = 7) and those who proceeded directly to surgery (group B, n = 16). The primary endpoints of perioperative mortality, ICU requirement, reoperation, readmission, and surgical site infection were assessed within 30 days after surgery.

RESULTS

Postoperatively, no mortalities, ICU admissions, readmission, or reoperations occurred. One group A patient developed a superficial wound infection, which resolved with a course of outpatient antibiotics (14 vs. 0 %, p = 0.12). Average days until return of bowel function and average length of postoperative stay were comparable between group A and B (3.9 vs. 3.6 days, p = 0.70; 7.0 vs. 6.9 days, p = 0.87; respectively). Ninety-one percent of patients subsequently underwent ileal pouch-anal anastomosis.

CONCLUSION

Colectomy for ulcerative colitis complicated by C. difficile can be performed safely without completing a course of antibiotic therapy.

Risk factors and outcome of PCR-detected Clostridium difficile infection in ileal pouch patients

BACKGROUND

The clinical implication of Clostridium difficile infection (CDI) in patients with ileal pouch-anal anastomosis (IPAA) for underlying inflammatory bowel disease (IBD) has not been well studied. This study was designed to investigate the cumulative incidence, risk factors, and outcome of CDI in patients with ileal pouches.

METHODS

Consecutive IPAA patients (n = 196) from the subspecialty Pouchitis Clinic with an increase of at least three stools per day more from the postoperative baseline for more than 4 weeks were enrolled from October 2010 to December 2011. CDI was diagnosed based on the presence of symptoms and positive polymerase chain reaction (PCR)-based stool test for C. difficile toxin B. Risk factors for CDI were assessed with univariate and multivariate analyses. All patients with CDI (n = 21) were treated with oral vancomycin (500 - 1000 mg/day) for 2-4 weeks. The treatment outcome of these patients was documented.

RESULTS

Twenty-one patients (10.7%) were diagnosed with CDI. On univariate analysis, patients with CDI had more stool frequency (P = 0.014) and significant current weight loss (P = 0.003) than patients with no CDI. In logistic regression analysis, there was a trend that recent hospitalization (odds ratio [OR] = 4.00, 95% confidence interval [CI], 0.95-16.84) might be associated with CDI. Of the 14 CDI patients with follow-up data, eight (57.1%) had either recurrent (n = 5) or refractory (n = 3) CDI after oral vancomycin therapy.

CONCLUSIONS

A high index of suspicion for CDI in pouch patients should be given to those with recent hospitalization or constitutional symptoms, such as weight loss. Recurrent or refractory CDI is common, even with standard oral vancomycin therapy.

Strategies for the care of adults hospitalized for active ulcerative colitis

Ulcerative colitis is a chronic inflammatory disease of the colon; as many as 25% of patients with this disease require hospitalization. The goals of hospitalization are to assess disease severity, exclude infection, administer rapidly acting and highly effective medication regimens, and determine response. During hospitalization, patients should be given venous thromboembolism prophylaxis and monitored for the development of toxic megacolon. Patients who do not respond to intravenous corticosteroids should be considered for rescue therapy with infliximab or cyclosporine. Patients who are refractory to medical therapies or who develop toxic megacolon should be evaluated promptly for colectomy. Patients who do respond to medical therapies should be discharged on an appropriate maintenance regimen when they meet discharge criteria. We review practical evidence-based management principles and propose a day-by-day algorithm for managing patients hospitalized for ulcerative colitis.

Predictors of first recurrence of Clostridium difficile infection: implications for initial management

Symptomatic recurrence of Clostridium difficile infection (CDI) occurs in approximately 20% of patients and is challenging to treat. Identifying those at high risk could allow targeted initial management and improve outcomes. Adult toxin enzyme immunoassay–positive CDI cases in a population of approximately 600 000 persons from September 2006 through December 2010 were combined with epidemiological/clinical data. The cumulative incidence of recurrence ≥14 days after the diagnosis and/or onset of first-ever CDI was estimated, treating death without recurrence as a competing risk, and predictors were identified from cause-specific proportional hazards regression models. A total of 1678 adults alive 14 days after their first CDI were included; median age was 77 years, and 1191 (78%) were inpatients. Of these, 363 (22%) experienced a recurrence ≥14 days after their first CDI, and 594 (35%) died without recurrence through March 2011. Recurrence risk was independently and significantly higher among patients admitted as emergencies, with previous gastrointestinal ward admission(s), last discharged 4–12 weeks before first diagnosis, and with CDI diagnosed at admission. Recurrence risk also increased with increasing age, previous total hours admitted, and C-reactive protein level at first CDI (all P < .05). The 4-month recurrence risk increased by approximately 5% (absolute) for every 1-point increase in a risk score based on these factors. Risk factors, including increasing age, initial disease severity, and hospital exposure, predict CDI recurrence and identify patients likely to benefit from enhanced initial CDI treatment.

Therapeutic modulation of intestinal dysbiosis

The human gastrointestinal tract is home to an extremely numerous and diverse collection of microbes, collectively termed the "intestinal microbiota". This microbiota is considered to play a number of key roles in the maintenance of host health, including aiding digestion of otherwise indigestible dietary compounds, synthesis of vitamins and other beneficial metabolites, immune system regulation and enhanced resistance against colonisation by pathogenic microorganisms. Conversely, the intestinal microbiota is also a potent source of antigens and potentially harmful compounds. In health, humans can therefore be considered to exist in a state of natural balance with their microbial inhabitants. A shift in the balance of microbiota composition such that it may become deleterious to host health is termed "dysbiosis". Dysbiosis of the gut microbiota has been implicated in numerous disorders, ranging from intestinal maladies such as inflammatory bowel diseases and colorectal cancer to disorders with more systemic effects such as diabetes, metabolic syndrome and atopy. Given the far reaching influence of the intestinal microbiota on human health a clear future goal must be to develop reliable means to alter the composition of the microbiota and restore a healthy balance of microbial species. While it is clear that much fundamental research remains to be done, potentially important therapeutic options include narrow spectrum antibiotics, novel probiotics, dietary interventions and more radical techniques such as faecal transplantation, all of which aim to suppress clinical dysbiosis, restore intestinal microbiota diversity and improve host health.

Systematic review and meta-analysis of outcomes following emergency surgery for Clostridium difficile colitis

BACKGROUND

Only a small proportion of patients with severe Clostridium difficile infection (CDI) undergo emergency surgery, the timing and nature of which is unclear. The aim of this study was to describe the operations performed and to identify factors predictive of death following emergency surgery for CDI.

METHODS

A systematic review of published literature was performed for studies comparing survivors and non-survivors of emergency surgery for CDI. Meta-analysis was carried out for 30-day and in-hospital mortality.

RESULTS

Overall 31 studies were included, which presented data on a total of 1433 patients undergoing emergency surgery for CDI. Some 1·1 per cent of all patients with CDI and 29·9 per cent with severe CDI underwent emergency surgery, although rates varied between studies (0·2-7·6 and 2·2-86 per cent respectively). The most commonly performed operation was total colectomy with end ileostomy (89·0 per cent, 1247 of 1401 detailed surgical procedures). When total colectomy with end ileostomy was not performed, reoperation to resect further bowel was needed in 15·9 per cent (20 of 126). Where described, the 30-day mortality rate was 41·3 per cent (160 of 387). Meta-analysis of high-quality studies revealed that the strongest predictors of postoperative death were those relating to preoperative physiological status: preoperative intubation, acute renal failure, multiple organ failure and shock requiring vasopressors.

CONCLUSION

This systematic review supports total colectomy with end ileostomy as the primary surgical treatment for patients with severe CDI; other surgical procedures are associated with high rates of reoperation and mortality. Less extensive surgery may have a role in selected patients with earlier-stage disease.

Health supervision in the management of children and adolescents with IBD: NASPGHAN recommendations

Ulcerative colitis (UC) and Crohn disease (CD), collectively referred to as inflammatory bowel disease (IBD), are chronic inflammatory disorders that can affect the gastrointestinal tract of children and adults. Like other autoimmune processes, the cause(s) of these disorders remain unknown but likely involves some interplay between genetic vulnerability and environmental factors. Children, in particular with UC or CD, can present to their primary care providers with similar symptoms, including abdominal pain, diarrhea, weight loss, and bloody stool. Although UC and CD are more predominant in adults, epidemiologic studies have demonstrated that a significant percentage of these patients were diagnosed during childhood. The chronic nature of the inflammatory process observed in these children and the waxing and waning nature of their clinical symptoms can be especially disruptive to their physical, social, and academic development. As such, physicians caring for children must consider these diseases when evaluating patients with compatible symptoms. Recent research efforts have made available a variety of more specific and effective pharmacologic agents and improved endoscopic and radiologic assessment tools to assist clinicians in the diagnosis and interval assessment of their patients with IBD; however, as the level of complexity of these interventions has increased, so too has the need for practitioners to become familiar with a wider array of treatments and the risks and benefits of particular diagnostic testing. Nonetheless, in most cases, and especially when frequent visits to subspecialty referral centers are not geographically feasible, primary care providers can be active participants in the management of their pediatric patients with IBD. The goal of this article is to educate and assist pediatricians and adult gastroenterology physicians caring for children with IBD, and in doing so, help to develop more collaborative care plans between primary care and subspecialty providers.

Detecting and treating Clostridium difficile infections in patients with inflammatory bowel disease

The prevalence of CDI in patients with IBD has increased over the last decade. The excess morbidity and mortality associated with CDI appears to be greater in patients with IBD than in those without preexisting bowel disease. The risk factors for CDI in IBD and non-IBD populations appear similar; unique IBD-related risk factors are use of maintenance immunosuppression and extent and severity of prior colitis. Nevertheless, a significant proportion of CDI-IBD patients may have the disease without traditional risk factors (ie, antibiotic use, recent hospitalization). The absence of such risk factors must not preclude considering CDI in the differential diagnosis of IBD patients presenting with a disease flare. Vancomycin and metronidazole appear to have similar efficacy with vancomycin being the preferred agent for severe disease. Early surgical consultation is key for improving outcomes of patients with severe disease. Several gaps in research exist; prospective multicenter cohorts of CDI-IBD are essential to improve our understanding of the impact of CDI on IBD patients and define appropriate therapeutic regimens to improve patient outcomes.

Detection, treatment, and prevention of Clostridium difficile infection

Clostridium difficile is a gram-positive anaerobic bacillus responsible for approximately 1 of 5 cases of antibiotic-associated diarrhea. C difficile infection (CDI) is defined by at least 3 unformed stools in a 24-hour period and stool, endoscopic, or histopathologic test results that indicate the presence of this bacteria. The history of CDI research can be divided into early (before 2000) and modern eras (after 2000). C difficile was first described in 1935, and the characteristics and causes of CDI as well as therapies were identified during the early era of research. During the modern era, CDI has become a more common, aggressive nosocomial infection. Our understanding of the epidemiology, diagnosis, treatment, and prevention of CDI has increased at a rapid pace. We review features of CDI diagnosis, treatment, and prevention.

Clostridium difficile infection in a patient with Crohn disease

Crohn disease is a chronic inflammatory disorder, which is rare in pediatric patients. The definite etiology and mechanism to induce an acute exacerbation of Crohn disease remains mostly unknown. The authors report on a 14-year-old girl with Crohn disease who has acute gastrointestinal symptoms caused by toxin A-producing Clostridium difficile, which mimicked a flare-up of Crohn disease. There was no preceding antibiotic prescription before the episode. The disease activity did not improve after steroid treatment, which is unusual for Crohn disease. However, all symptoms were dramatically relieved after eradication of C difficile, and led to a symptom-free period for more than 3 years. This case report aims to address the unusual presentation of a usual pathogen, C difficile, in a pediatric patient with Crohn disease.

Standardized frozen preparation for transplantation of fecal microbiota for recurrent Clostridium difficile infection

OBJECTIVES

While fecal microbiota transplantation (FMT) is historically known to be an effective means to treat recurrent Clostridium difficile infection (CDI) refractory to standard antibiotic therapies, the procedure is rarely performed. At least some of the reasons for limited availability are those of practicality, including aesthetic concerns and costs of donor screening. The objective of this study was to overcome these barriers in our clinical FMT program.

METHODS

We report clinical experience with 43 consecutive patients who were treated with FMT for recurrent CDI since inception of this program at the University of Minnesota. During this time, we simplified donor identification and screening by moving from patient-identified individual donors to standard volunteer donors. Material preparation shifted from the endoscopy suite to a standardized process in the laboratory, and ultimately to banking frozen processed fecal material that is ready to use when needed.

RESULTS

Standardization of material preparation significantly simplified the practical aspects of FMT without loss of apparent efficacy in clearing recurrent CDI. Approximately 30% of the patients had underlying inflammatory bowel disease, and FMT was equally effective in this group.

CONCLUSIONS

Several key steps in the standardization of donor material preparation significantly simplified the clinical practice of FMT for recurrent CDI in patients failing antibiotic therapy.

Clostridium difficile infection in newly diagnosed pediatric patients with inflammatory bowel disease: prevalence and risk factors

BACKGROUND

Epidemiological and microbiological data suggest that Clostridium difficile infection (CDI) plays a substantial role in the clinical initiation of inflammatory bowel disease (IBD). The aim of the present study was to investigate the prevalence and risk factors of CDI in newly diagnosed pediatric patients with IBD.

METHODS

The current investigation was a retrospective study. All patients newly diagnosed with IBD in the pediatric gastroenterology clinic in Warsaw between 2007 and 2010 were included in the present study. The patients were diagnosed according to Porto criteria and microbiology evaluation screening tests for CDI were conducted. Risk factors including prior hospitalization, use of antibiotics within 2 months of CDI detection, colonic involvement, and the duration of symptoms were evaluated. CDI diagnosis was based on a positive stool enzyme immunoassay.

RESULTS

In the present study, 134 patients were evaluated (54 patients with Crohn's disease, and 80 with ulcerative colitis; 87% of the patients had colonic disease). The average age of the patients was 12.3 years, and the prevalence of CDI was 47% (95% confidence interval [CI], 38%-56%). Significant differences in the prevalence of CDI between patients with Crohn's disease and ulcerative colitis (P = 0.72; odds ratio [OR] = 1.187, 95% CI, 0.56-2.52) were not observed. The risk of CDI was associated with an increase in the age of the patient and the severity of the disease.

CONCLUSIONS

The prevalence of CDI in newly diagnosed IBD patients was high and was independent of the type of disease.

Trends in antimicrobial resistance in intensive care units in the United States

PURPOSE OF REVIEW

Antimicrobial resistance and a paucity of new antimicrobial agents are ongoing challenges. This review focuses on the major epidemiologic trends and novel treatments, when available, for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus, Clostridium difficile, and multidrug-resistant Gram-negative bacilli in the United States during 2010-2011.

RECENT FINDINGS

MRSA bloodstream infection rates have declined, primarily due to interventions aimed at decreasing vascular catheter infections. The proportion of MRSA due to the community-associated strain USA300 continues to increase. Recent studies of active surveillance and contact isolation for MRSA prevention provide conflicting views of efficacy. Two novel treatments for recurrent C. difficile infection, monoclonal antibodies and fidaxomicin, show promising results. Antimicrobial resistance among Gram-negative bacilli has become widespread; extended-spectrum beta-lactamases are now commonly found among Escherichia coli causing community-acquired infections in the United States. Klebsiella pneumoniae carbapenemases have spread beyond the northeast, and the New Delhi metallo-beta-lactamase has been reported in multiple countries within a few years of its discovery.

SUMMARY

Antimicrobial resistance, particularly among Gram-negative bacilli, continues to increase at a rapid rate. Given the frequent transfer of patients between outpatient and acute care settings, as well as between different geographic regions, coordinated infection control interventions are warranted.

Fecal transplantation, through colonoscopy, is effective therapy for recurrent Clostridium difficile infection

BACKGROUND & AIMS

Treatment of recurrent Clostridium difficile infection (CDI) with antibiotics leads to recurrences in up to 50% of patients. We investigated the efficacy of fecal transplantation in treatment of recurrent CDI.

METHODS

We reviewed records from 70 patients with recurrent CDI who had undergone fecal transplantation. Fecal transplantation was performed at colonoscopy by infusing fresh donor feces into cecum. Before transplantation, the patients had whole-bowel lavage with polyethylene glycol solution. Clinical failure was defined as persistent or recurrent symptoms and signs, and a need for new therapy.

RESULTS

During the first 12 weeks after fecal transplantation, symptoms resolved in all patients who did not have strain 027 C difficile infections. Of 36 patients with 027 C difficile infection, 32 (89%) had a favorable response; all 4 nonresponders had a pre-existing serious condition, caused by a long-lasting diarrheal disease or comorbidity and subsequently died of colitis. During the first year after transplantation, 4 patients with an initial favorable response had a relapse after receiving antibiotics for unrelated causes; 2 were treated successfully with another fecal transplantation and 2 with antibiotics for CDI. Ten patients died of unrelated illnesses within 1 year after transplantation. No immediate complications of fecal transplantation were observed.

CONCLUSIONS

Fecal transplantation through colonoscopy seems to be an effective treatment for recurrent CDI and also for recurrent CDI caused by the virulent C difficile 027 strain.

Clostridium difficile infection after allogeneic hematopoietic stem cell transplantation: incidence, risk factors, and outcome

Clostridium difficile (C. difficile) infection was observed in 13% of recipients after hematopoietic stem cell transplantation (HSCT), mainly in the first month posttransplantation. Risk factors were cord blood as the source of stem cells, acute graft-versus-host disease (GVHD), and total body irradiation (TBI). No association was found with an increased risk of mortality. The purpose of this study was to evaluate the incidence, risk factors, and outcome of C. difficile infection (CDI) after HSCT. We conducted a single-center, retrospective, cohort study on all patients who received an allogeneic HSCT from January 2004 to December 2007. All patients with diarrhea in the first year after HSCT were tested for the presence of C. difficile in stools. Among the 407 assessable patients, 53 presented at least 1 CDI in the first year post-HSCT. The total incidence rate was 5.6 cases of CDI per 10,000 patient-days. Fifty percent of cases were diagnosed in the first month after HSCT, and 95% occurred during the first 6 months. Fewer than 5% of patients with CDI had severe diarrhea and severe complications were never observed. TBI in the conditioning regimen, cord blood as the source of stem cells, and acute graft-versus-host disease (aGVHD) were independently associated with CDI. Six patients (11%) had a recurrence of CDI. Four patients required second-line treatment with vancomycin. With a median follow-up of 22 months, the 2-year overall survival rates were similar between patients who presented a CDI and those who did not. CDI was observed in approximately 13% of recipients after HSCT, mainly in the first month posttransplantation and was associated with CB, aGVHD, and TBI. CDI was not associated either with severe complications or with an increased risk of mortality in this large cohort of patients.

Clostridium difficile prevalence rates in a large healthcare system stratified according to patient population, age, gender, and specimen consistency

We evaluated Clostridium difficile prevalence rates in 2,807 clinically indicated stool specimens stratified by inpatient (IP), nursing home patient (NH), outpatient (OP), age, gender, and specimen consistency using bacterial culture, toxin detection, and polymerase chain reaction (PCR) ribotyping. Rates were determined based on the detection of toxigenic C. difficile isolates. We identified significant differences in the rates between patient populations and with age. Specimens from NH had a higher rate (46%) for toxigenic C. difficile than specimens from IP (18%) and OP (17%). There were no gender-related differences in the rates. Liquid specimens had a lower rate (15%) than partially formed and soft specimens (25%) and formed specimens (18%) for the isolation of toxigenic C. difficile. The nontoxigenic rate was lowest for NH (4%) and highest for patients<20 years of age (23%). We identified 31 different toxigenic ribotypes from a sampling of 190 isolates that showed the lowest diversity in NH. Fluoroquinolone resistance was observed in 93% of the 027 isolates, all of the 053 isolates, and in four other ribotypes. We observed different rates for toxigenic C. difficile in stratified patient populations, with the highest rate for NH, a low overall nontoxigenic rate, and fluoroquinolone resistance.

Clostridium difficile infection: clinical spectrum and approach to management

Clostridium difficile is recognized globally as an important enteric pathogen associated with considerable morbidity and mortality due to the widespread use of antibiotics. The overall incidence of C. difficile-associated diarrhea (CDAD) is increasing due to the emergence of a hypervirulent strain known as NAP1/BI/027. C. difficile acquisition by a host can result in a varied spectrum of clinical conditions inclusive of both colonic and extracolonic manifestations. Repeated occurrence of CDAD, manifested by the sudden re-appearance of diarrhea and other symptoms usually within a week of stopping treatment, makes it a difficult clinical problem. C. difficile infection has also been reported to be involved in exacerbation of inflammatory bowel diseases. The first step in the management of a suspected CDAD case is the withdrawal of the offending agent and changing the antibiotic regimens. Antimicrobial therapy directed against C. difficile viz. metronidazole for mild cases and vancomycin for severe cases is needed. For patients with ileus, oral vancomycin with simultaneous intravenous (IV) metronidazole and intracolonic vancomycin may be given. Depending on the severity of disease, the further line of management may include surgery, IV immunoglobulin treatment or high dose of vancomycin. Adjunctive measures used for CDAD are probiotics and prebiotics, fecotherapy, adsorbents and immunoglobulin therapy. Among the new therapies fidaxomicin has recently been approved by the American Food and Drugs Administration for treatment of CDAD.

Frequent hospital readmissions for Clostridium difficile infection and the impact on estimates of hospital-associated C. difficile burden

OBJECTIVE

Clostridium difficile infection (CDI) is associated with hospitalization and may cause readmission following admission for any reason. We aimed to measure the incidence of readmissions due to CDI.

DESIGN

Retrospective cohort study.

PATIENTS

Adult inpatients in Orange County, California, who presented with new-onset CDI within 12 weeks of discharge.

METHODS

We assessed mandatory 2000-2007 hospital discharge data for trends in hospital-associated CDI (HA-CDI) incidence, with and without inclusion of postdischarge CDI (PD-CDI) events resulting in rehospitalization within 12 weeks of discharge. We measured the effect of including PD-CDI events on hospital-specific CDI incidence, a mandatory reporting measure in California, and on relative hospital ranks by CDI incidence.

RESULTS

From 2000 to 2007, countywide hospital-onset CDI (HO-CDI) incidence increased from 15 per 10,000 to 22 per 10,000 admissions. When including PD-CDI events, HA-CDI incidence doubled (29 per 10,000 in 2000 and 52 per 10,000 in 2007). Overall, including PD-CDI events resulted in significantly higher hospital-specific CDI incidence, although hospitals had disproportionate amounts of HA-CDI occurring postdischarge. This resulted in substantial shifts in some hospitals' rankings by CDI incidence. In multivariate models, both HO and PD-CDI were associated with increasing age, higher length of stay, and select comorbidities. Race and Hispanic ethnicity were predictive of PD-CDI but not HO-CDI.

CONCLUSIONS

PD-CDI events associated with rehospitalization are increasingly common. The majority of HA-CDI cases may be occurring postdischarge, raising important questions about both accurate reporting and effective prevention strategies. Some risk factors for PD-CDI may be different than those for HO-CDI, allowing additional identification of high-risk groups before discharge.

Clostridium difficile Infection and Inflammatory Bowel Disease: A Review

The incidence of Clostridium difficile infection (CDI) has significantly increased in the last decade in the United States adding to the health care burden of the country. Patients with inflammatory bowel disease (IBD) have a higher prevalence of CDI and worse outcomes. In the past, the traditional risk factors for CDI were exposure to antibiotics and hospitalizations in elderly people. Today, it is not uncommon to diagnose CDI in a pregnant women or young adult who has no risk factors. C. difficile can be detected at the initial presentation of IBD, during a relapse or in asymptomatic carriers. It is important to keep a high index of suspicion for CDI in IBD patients and initiate prompt treatment to minimize complications. We summarize here the changing epidemiology, pathogenesis, risk factors, clinical features, and treatment of CDI in IBD.

A practical, evidence-based guide to the use of adalimumab in Crohn's disease

BACKGROUND

Anti-tumor necrosis factor (anti-TNF) agents are important therapies for treating Crohn's disease (CD) because they may induce and maintain remission, reduce the need for corticosteroids, decrease hospitalizations and surgeries, and heal the mucosa. Here we provide a practical, evidence-based guide to help clinicians optimize the use of adalimumab in patients with CD.

SCOPE

A literature search in the MEDLINE, EMBASE, and BIOSIS databases was performed for articles published between 1996 and 2010 describing adalimumab use in CD. Abstracts presented at the ACG, DDW, UEGW, ECCO, and SGNA congresses, references from review articles and published randomized clinical trials, and the manufacturer's prescribing information also were reviewed.

FINDINGS

When selecting an anti-TNF agent, factors such as efficacy, safety, immunogenicity, patient preference, and the timing and sequencing of therapies should be considered. Important considerations for patient management include dosage selection, use of combination therapy, timing of monitoring treatment response, and evaluation of recurrent CD symptoms in a previously responding patient. We recommend that patients initiating adalimumab receive a loading dose of 160/80 mg subcutaneously at Week 0/Week 2, followed by up to 8 weeks of 40 mg every-other-week maintenance therapy prior to determining if there is non-response. During therapy, recurrent or new symptoms should be fully evaluated to ensure that they are indeed related to underlying inflammation versus other causes (e.g., intercurrent infection, bile acid diarrhea, or irritable bowel). Patients experiencing attenuation of response or inflammatory-mediated symptoms during maintenance therapy may benefit from dosage intensification to weekly adalimumab.

CONCLUSION

Considerations for the use of anti-TNF agents in CD, with an emphasis on adalimumab, are reviewed and practical patient management recommendations are presented.

[Left-sided ulcerative colitis reactivated and aggravated during clostridium difficile infection]

Clostridium difficile (C. difficile) infection appears to be closely related to reactivation, diagnostic delay, and disease progression in patients with inflammatory bowel disease. However, whether C. difficile infection triggers the reactivation of inflammatory bowel disease or vice versa is not certain. We report a case of reactivated and progressed left ulcerative colitis following C. difficile infection in a 56-year-old woman. A series of endoscopic findings in this case report strongly supports a causative role of C. difficile infection on the reactivation and progression of ulcerative colitis.

Old-age inflammatory bowel disease onset: A different problem?

Inflammatory bowel disease (IBD) in patients aged > 60 accounts for 10%-15% of cases of the disease. Diganostic methods are the same as for other age groups. Care has to be taken to distinguish an IBD colitis from other forms of colitis that can mimick clinically, endoscopically and even histologically the IBD entity. The clinical pattern in ulcerative colitis (UC) is proctitis and left-sided UC, while granulomatous colitis with an inflammatory pattern is more common in Crohn’s disease (CD). The treatment options are those used in younger patients, but a series of considerations related to potential pharmacological interactions and side effects of the drugs must be taken into account. The safety profile of conventional immunomodulators and biological therapy is acceptable but more data are required on the safety of use of these drugs in the elderly population. Biological therapy has risen question on the possibility of increased side effects, however this needs to be confirmed. Adherence to performing all the test prior to biologic treatment administration is very important. The overall response to treatment is similar in the different patient age groups but elderly patients have fewer recurrences. The number of hospitalizations in patients > 65 years is greater than in younger group, accounting for 25% of all admissions for IBD. Mortality is similar in UC and slightly higher in CD, but significantly increased in hospitalized patients. Failure of medical treatment continues to be the most common indication for surgery in patients aged > 60 years. Age is not considered a contraindication for performing restorative proctocolectomy with an ileal pouch-anal anastomosis. However, incontinence evaluation should be taken into account an individualized options should be considered

Increased health burden associated with Clostridium difficile diarrhoea in patients with inflammatory bowel disease

BACKGROUND

Clostridium difficile (C. difficile) infection in hospitals in developed countries continues to be a major public health hazard despite increased control measures including review of antibiotic policies and hygiene measures. Patients with colitis are thought to be particularly vulnerable to C. difficile associated diarrhoea (CDAD). Identifying the clinical burden among hospitalised patients admitted with inflammatory bowel disease is an essential first step towards identifying and treating severe C. difficile infection in such individuals.

AIM

To determine excess morbidity and in-hospital mortality associated with hospital acquired CDAD in patients with inflammatory bowel disease (IBD-CDAD-HAI) admitted to NHS hospitals in England compared with those admitted for inflammatory bowel disease alone.

METHODS

Time trends study of all admissions to NHS hospitals between 2002/03 and 2007/08. We developed case definitions for IBD-CDAD-HAI patients. The primary outcomes were in-hospital mortality and length of stay. The secondary outcome was gastrointestinal surgery.

RESULTS

Patients in the IBD-CDAD-HAI group were more likely to die in hospital (adjusted OR 6.32), had 27.9 days longer in-patient stays and higher gastrointestinal surgery rates (adjusted OR 1.87) than patients admitted for inflammatory bowel disease alone.

CONCLUSION

Patients with inflammatory bowel disease admitted to NHS hospitals in England with co-existent C. difficile infection are at risk of greater in-hospital mortality and morbidity than patients admitted for inflammatory bowel disease alone.

Temporal trends in disease outcomes related to Clostridium difficile infection in patients with inflammatory bowel disease

BACKGROUND

Clostridium difficile has emerged as an important pathogen in patients with inflammatory bowel disease (IBD) and is associated with increased morbidity and mortality. No studies have examined the temporal change in severity of C. difficile infection (CDI) complicating IBD.

METHODS

Using data from the Nationwide Inpatient Sample, we identified all IBD-related hospitalizations during the years 1998, 2004, and 2007 and examined hospitalizations with a coexisting diagnosis of C. difficile. We compared the absolute outcomes of in-hospital mortality and colectomy in the C. difficile-IBD cohort during these timepoints, and also examined these outcomes relative to non-C. difficile IBD controls during each corresponding year.

RESULTS

During 1998, 2004, and 2007, approximately 1.4%, 2.3%, and 2.9% of all IBD hospitalizations nationwide were complicated by CDI (P < 0.001). The absolute mortality in the C. difficile-IBD cohort increased from 5.9%-7.2% (P = 0.052) with a nonsignificant increase in colectomy rate from 3.8%-4.5% between 1998 and 2007. Compared to non-C. difficile IBD controls, there was an increase in the relative mortality risk associated with C. difficile from 1998 (odds ratio [OR] 2.38, 95% confidence interval [CI]: 1.52-3.72) to 2007 (OR 3.38, 95% CI: 2.66-4.29) (P = 0.15) with a significant increase in total colectomy odds from 1998 (OR 1.39, 95% CI: 0.81-2.37) to 2007 (OR 2.51, 95% CI: 1.90-3.34) (P = 0.03).

CONCLUSION

There has been a temporal increase nationwide in CDI complicating IBD hospitalizations. The excess morbidity associated with C. difficile infection in hospitalized IBD patients has increased between 1998 and 2007.

Clostridium difficile infection in patients with ulcerative colitis: investigations of risk factors and efficacy of antibiotics for steroid refractory patients

BACKGROUND AND OBJECTIVE

The incidence of Clostridium difficile infection (CDI) has increased throughout the world and patients with ulcerative colitis (UC) are at a high risk for CDI. Potentially, CDI can exacerbate UC. Therefore, knowledge on the prevalence of CDI should contribute to better management of UC patients.

METHODS

The presence of toxin A antigen was defined as CDI, and the outcome of the test in patients with active UC during 2006-2009 was reviewed for identifying patients with CDI. Demographic data (disease profile, clinical response to medications and the need for colectomy) in UC patients with CDI were compared with the data from CDI free UC patients.

RESULTS

Fifty-five of 137 patients (40.1%) were CDI positive. Univariate and multivariate analyses revealed that CDI was not associated with any demographic factor. Intensive antibiotic therapy spared five of 17 (29.4%) steroid refractory patients with CDI from steroids. CDI was not a predictor of colectomy although this could be an outcome of efficient eradication strategy.

CONCLUSION

CDI was not associated with any demographic factor or colectomy rate. However, CDI eradication therapy allowed some refractory patients to withdraw from steroids. Patients with active UC benefit from regular CDI test and eradication treatment for CDI.

Systematic review: Clostridium difficile and inflammatory bowel disease

BACKGROUND

There is increasing concern about the apparently rising incidence and worsening outcome of Clostridium difficile infection (CDI) associated with inflammatory bowel disease (IBD). We have systematically reviewed the literature to evaluate the incidence, risk factors, endoscopic features, treatment and outcome of CDI complicating IBD.

AIM

To systematically review: clostridium difficile & inflammatory bowel disease.

METHODS

Structured searches of Pubmed up to September 2010 for original, cross-sectional, cohort and case-controlled studies were undertaken.

RESULTS

Of 407 studies, 42 met the inclusion criteria: their heterogeneity precluded formal meta-analysis. CDI is commoner in active IBD, particularly ulcerative colitis, than in controls. Certainty about a temporal trend to its increasing incidence in IBD is compromised by possible detection bias and miscoding. Risk factors include immunosuppressants and antibiotics, the latter less commonly than in controls. Endoscopy rarely shows pseudomembranes and is unhelpful for diagnosing CDI in IBD. There are no controlled therapeutic trials of CDI in IBD. In large studies, outcome of CDI in hospitalised IBD patients appears worse than in controls.

CONCLUSIONS

The complication of IBD by Clostridium difficile infection has received increasing attention in the past decade, but whether its incidence is really increasing or its outcome worsening remains unproven. Therapeutic trials of Clostridium difficile infection in IBD are lacking and are needed urgently.

Recurrence rate of clostridium difficile infection in hospitalized pediatric patients with inflammatory bowel disease

BACKGROUND

The incidence and associated morbidity of Clostridium difficile (CD) infection has been increasing at an alarming rate in North America. Clostridium difficile-associated diarrhea (CDAD) is the leading cause of nosocomial diarrhea in the USA. Patients with CDAD have longer average hospital admissions and additional hospital costs. Evidence has demonstrated that patients with inflammatory bowel disease (IBD) have a higher incidence of CD in comparison to the general population. The aim of this study was to compare the rate of recurrence of CD in hospitalized pediatric patients with IBD compared to hospitalized controls. The secondary aim was to evaluate whether infection with CD resulted in a more severe disease course of IBD.

METHODS

This was a nested case control retrospective study of hospitalized pediatric patients. Diagnosis of CD was confirmed with stool Toxin A and B analysis. The following data were obtained from the medical records: demographic information, classification of IBD including location of disease, IBD therapy, and prior surgeries. In addition, prior hospital admissions within 1 year and antibiotic exposure were recorded. The same information was recorded following CD infection. Cases were patients with IBD and CD; two control populations were also studied: patients with CD but without IBD, and patients with IBD but without CD.

RESULTS

For aim 1, a total of 111 eligible patients with IBD and CD infection and 77 eligible control patients with CD infection were included. The rate of recurrence of CD in the IBD population was 34% compared to 7.5% in the control population (P < 0.0001). In evaluating the effect of CD infection on IBD disease severity, we compared the 111 IBD patients with CD to a second control population of 127 IBD patients without CD. 57% of IBD-CD patients were readmitted with an exacerbation of disease within 6 months of infection with CD and 67% required escalation of therapy following CD infection, compared to 30% of IBD patients without CD (P < 0.001). Of the patients with IBD and CD, 44% of the cases were new-onset IBD, 63% were on immunosuppression therapy, and 33% were on gastric acid suppression prior to infection. In comparing the IBD-CD and control CD populations, there was no significant difference in antibiotic exposure: 33% of IBD patients and 26% of control patients were on antibiotics (P < 0.2). With regard to prior hospitalization, 10% of patients with IBD were hospitalized in the 30 days prior to infection in comparison to 27% of the control CD patients (P < 0.002).

CONCLUSIONS

CD infection in patients with IBD results in a higher rate of recurrence and is associated with higher morbidity than the general population. Patients with IBD often required hospitalization and escalation of therapy following infection with CD, suggesting that CD resulted in increased severity of IBD disease. In addition, IBD patients were more likely develop community-acquired CD, while the control patients developed nosocomial infections, indicating a higher susceptibility to CD infection in patients with IBD.

Dysbiosis of fecal microbiota in Crohn's disease patients as revealed by a custom phylogenetic microarray

BACKGROUND

A custom phylogenetic microarray composed of small subunit ribosomal RNA probes, representing ≈500 bacterial species from the human and animal gut, was developed and evaluated for analysis of gut microbial diversity using fecal samples from healthy subjects and Crohn's disease (CD) patients.

METHODS

Oligonucleotide probes (≈40 mer) used on the microarray were selected from published articles or designed with the "GoArray" microarray probe design program using selected bacterial 16S rRNA sequences. Fecal 16S rDNA from individual samples of six healthy subjects and six CD patients were used as template to generate fluorescently labeled cRNA that was hybridized to the microarray. Differences revealed by the microarray in relative abundance of microbial populations between healthy and diseased patients were verified using quantitative real-time polymerase chain reaction (PCR) with species-specific primer sets.

RESULTS

The microarray analyses showed that Eubacterium rectale, Bacteroides fragilis group, B. vulgatus, Ruminococcus albus, R. callidus, R. bromii, and Faecalibacterium prausnitzii were 5-10-fold more abundant in the healthy subjects than in the CD patients, while Enterococcus sp., Clostridium difficile, Escherichia coli, Shigella flexneri, and Listeria sp. were more abundant in the CD group.

CONCLUSIONS

The microarray detected differences in abundance of bacterial populations within the phylum Firmicutes that had been reported previously for the same samples based on phylogenetic analysis of metagenomic clone libraries. In addition, the microarray showed that Enterococcus sp. was in higher abundance in the CD patients. This microarray should be another useful tool to examine the diversity and abundance of human intestinal microbiota.

Increased mortality and length of stay among patients with inflammatory bowel disease and hospital-acquired infections

BACKGROUND & AIMS

Hospitalized patients with inflammatory bowel disease (IBD) could be at increased risk for hospital-acquired infections (HAIs). By using HAI outcome data from Pennsylvania, we examined the influence of HAIs on in-patient mortality and length of stay (LOS) in the hospital among patients with IBD.

METHODS

Data were generated by linking the Clinical Research Databases from CareFusion (formerly MediQual), which includes all acute care hospitals in Pennsylvania, with publicly reported HAI data from Pennsylvania. The study population included all patients discharged in 2004 with International Classification of Diseases, 9th Clinical Modification codes of 555.x or 556.x (2324 IBD cases from 161 hospitals). Controls were selected using risk-score matching with a 5:1 ratio. Mortality and LOS end points were estimated and corroborated with regression methods.

RESULTS

Among the IBD patients studied, there were 20 deaths and 22 reported cases of HAI. The mortality from HAI among patients with IBD was 13.6%, compared with 0.9% among controls (P = .0146, Fisher exact test). The odds ratio for mortality was 17.2 (95% confidence interval, 1.7-174.3). The median LOS for patients with IBD and HAI was 22 days, versus 6 days for controls (P < .001, Wilcoxon). Of the 22 cases with HAIs, 15 were urinary tract infections, 5 were blood stream infections, and 2 were from multiple sources.

CONCLUSIONS

Results from a population-based data set indicate that mortality and LOS are increased among IBD patients who develop HAIs. A majority of the HAIs were from urinary sources. Although HAIs are low-frequency events, increased vigilance to avoid HAI among patients with IBD could improve outcomes.

Identification of a genetic locus responsible for antimicrobial peptide resistance in Clostridium difficile

Clostridium difficile causes chronic intestinal disease, yet little is understood about how the bacterium interacts with and survives in the host. To colonize the intestine and cause persistent disease, the bacterium must circumvent killing by host innate immune factors, such as cationic antimicrobial peptides (CAMPs). In this study, we investigated the effect of model CAMPs on growth and found that C. difficile is not only sensitive to these compounds but also responds to low levels of CAMPs by expressing genes that lead to CAMP resistance. By plating the bacterium on medium containing the CAMP nisin, we isolated a mutant capable of growing in three times the inhibitory concentration of CAMPs. This mutant also showed increased resistance to the CAMPs gallidermin and polymyxin B, demonstrating tolerance to different types of antimicrobial peptides. We identified the mutated gene responsible for the resistance phenotype as CD1352. This gene encodes a putative orphan histidine kinase that lies adjacent to a predicted ABC transporter operon (CD1349 to CD1351). Transcriptional analysis of the ABC transporter genes revealed that this operon was upregulated in the presence of nisin in wild-type cells and was more highly expressed in the CD1352 mutant. The insertional disruption of the CD1349 gene resulted in significant decreases in resistance to the CAMPs nisin and gallidermin but not polymyxin B. Because of their role in cationic antimicrobial peptide resistance, we propose the designation cprABC for genes CD1349 to CD1351 and cprK for the CD1352 gene. These results provide the first evidence of a C. difficile gene associated with antimicrobial peptide resistance.

Clostridium difficile infection and inflammatory bowel disease: Understanding the evolving relationship

Clostridium difficile (C. difficile) infection (CDI) is the leading identifiable cause of antibiotic-associated diarrhea. While there is an alarming trend of increasing incidence and severity of CDI in the United States and Europe, superimposed CDI in patients with inflammatory bowel disease (IBD) has drawn considerable attention in the gastrointestinal community. The majority of IBD patients appear to contract CDI as outpatients. C. difficile affects disease course of IBD in several ways, including triggering disease flares, sustaining activity, and in some cases, acting as an “innocent” bystander. Despite its wide spectrum of presentations, CDI has been reported to be associated with a longer duration of hospitalization and a higher mortality in IBD patients. IBD patients with restorative proctocolectomy or with diverting ileostomy are not immune to CDI of the small bowel or ileal pouch. Whether immunomodulator or corticosteroid therapy for IBD should be continued in patients with superimposed CDI is controversial. It appears that more adverse outcomes was observed among patients treated by a combination of immunomodulators and antibiotics than those treated by antibiotics alone. The use of biologic agents does not appear to increase the risk of acquisition of CDI. For CDI in the setting of underlying IBD, vancomycin appears to be more efficacious than metronidazole. Randomized controlled trials are required to clearly define the appropriate management for CDI in patients with IBD.

Clostridium difficile infection in Polish pediatric outpatients with inflammatory bowel disease

The prevalence of Clostridium difficile infection (CDI) in pediatric patients with inflammatory bowel disease (IBD) is still not sufficiently recognized. We assessed the prevalence of CDI and recurrences in outpatients with IBD. In addition, the influence of IBD therapy on CDI and antimicrobial susceptibility of the potentially causative C. difficile strains was assessed. This was a prospective, single-center, observational study. All specimens were obtained between January 2005 and January 2007 from the IBD outpatient service and screened for C. difficile and its toxins. C. difficile isolates were genotyped by PCR ribotyping. Diagnosis of Crohn’s disease (CD) and ulcerative colitis (UC) was based on Porto criteria. Severity of disease was assessed using the Hyams scale (for Crohn’s disease) and the Truelove–Witts scale (for ulcerative colitis). One hundred and forty-three fecal samples from 58 pediatric IBD patients (21 with Crohn’s disease and 37 with ulcerative colitis) were screened. The risk of C. difficile infection was 60% and was independent of disease type (CD or UC) (χ2 = 2.5821, df = 3, p = 0.4606). About 17% of pediatric IBD patients experienced a recurrence of CDI. All C. difficile strains were susceptible to metronidazole, vancomycin and rifampin. A high prevalence of C. difficile infection and recurrences in pediatric outpatients with IBD was observed, independent of disease type. There was no significant correlation between C. difficile infection and IBD therapy. PCR ribotyping revealed C. difficile re-infection and relapses during episodes of IBD in pediatric outpatients.

Review of medical and surgical management of Clostridium difficile infection

Clostridium difficile infection (CDI) has become an important area in our daily clinical practice. C. difficile is known to cause a broad spectrum of conditions ranging from asymptomatic carriage, through mild or moderately severe disease with watery diarrhoea, to the life-threatening pseudomembranous colitis (PMC), with toxic megacolon and ileus. Peoples who have been treated with broad-spectrum antibiotics, patients with serious underlying co-morbidities and the elderly are at greatest risk. Over 80% of CDIs reported are in people aged over 65. Due to the alarming increase in its frequency, appearance of more virulent strains and occasional need for life-saving surgical intervention, a more coherent multidisciplinary approach is needed. Combination of rapid turn round time and accurate diagnosis will result in a better management of CDI and a timely implementation of infection control measure. Discontinuation of causative agents such as antibiotic treatment is often curative. In more serious cases, oral administration of metronidazole or vancomycin is the treatment of choice. Relapses of CDI have been reported in about 20-25% of cases, this may increase to 45-60% after the first recurrence. Patients should be treated as soon as possible when the diagnosis of Clostridium difficile colitis is made to avoid sepsis or bowel perforation. Colectomy may improve the outcome of the patient with systemic or complicated Clostridium difficile colitis. This article reviews the changing epidemiological picture, microbiology, histopathology and both medical and surgical managements.

Similar geographic variations of mortality and hospitalization associated with IBD and Clostridium difficile colitis

BACKGROUND

Superinfection with Clostridium difficile can aggravate the symptoms of preexisting inflammatory bowel disease (IBD). The study served to assess whether the geographic variation of IBD within the United States might be influenced by C. difficile infection.

METHODS

Hospitalization data of the Healthcare Cost and Utilization Project (HCUP) from 2001-2006 and mortality data from 1979-2005 of the US were analyzed by individual states. Hospitalization and mortality associated with Crohn's disease (CD), ulcerative colitis (UC), and C. difficile colitis were correlated with each other, using weighted least square linear regression with the population size of individual states as weight.

RESULTS

Among the hospitalization rates, there were strong correlations between both types of IBD, as well as each type of IBD with C. difficile colitis. Similarly, among the mortality rates there were strong correlations between both types of IBD, as well as each type of IBD with C. difficile colitis. Lastly, each type of hospitalization rate was also strongly correlated with each type of mortality rate. In general, hospitalization and mortality associated with IBD tended to be frequent in many of the northern states and infrequent in the Southwest and several southern states.

CONCLUSIONS

The similarity in the geographic distribution of the 3 diseases could indicate the influence of C. difficile colitis in shaping the geographic patterns of IBD. It could also indicate that shared environmental risk factors influence the occurrence of IBD, as well as C. difficile colitis.

Clostridium difficile infection and inflammatory bowel disease

The importance of Clostridium difficile (C. difficile) infection amongst patients with inflammatory bowel disease (IBD) is increasingly being recognized. Recent studies have demonstrated a concerning trend towards increased rates of infection, morbidity, mortality and health costs, and guidelines now promote testing for C. difficile in IBD patients experiencing a relapse. This critical review focuses on the epidemiology, risk factors, pathogenesis, treatment options and outcomes associated with C. difficile infection in patients with IBD.

Proposed changes to management of lower respiratory tract infections in response to the Clostridium difficile epidemic

Clostridium difficile infection (CDI) remains a major healthcare problem associated with antibiotic use in hospitals. Recent years have seen a dramatic increase in the incidence of CDI in the UK and internationally. Lower respiratory tract infections (LRTIs) are the leading indication for antibiotic prescription in hospitals and are therefore a critical battleground in the fight against inappropriate antibiotic use and healthcare-associated infections. This article reviews the evidence for interventions to reduce CDI in hospitalized patients with LRTIs. Reducing prescriptions of cephalosporins and fluoroquinolones in favour of penicillin-based regimens and increased use of tetracyclines have been proposed. Expanding outpatient management of LRTIs and reducing length of hospital stay will limit patient exposure to the healthcare environment in which C. difficile is most easily acquired. Intravenous (iv) broad-spectrum antibiotics are often prescribed when narrower spectrum, oral antimicrobials would be equally effective and, in a proportion of patients, antibiotic therapy is used unnecessarily. Shorter antibiotic regimes may be as effective as prolonged therapy and reduce antibiotic-related complications. Early switch from iv to oral therapy allows simpler antibiotic regimens and facilitates early discharge from hospital. Simple improvements in the management of LRTIs have the potential to reduce the incidence of healthcare-associated infections.

Human intestinal epithelial response(s) to Clostridium difficile

Clostridium difficile is a gram-positive, spore-forming, toxin-producing anaerobic bacillus that is being increasingly implicated as the leading cause of diarrhea and colitis, particularly in hospitalized, elderly patients. Studies to date suggest that C. difficile toxins A and B play a major role in the observed colonic inflammation and associated disease pathogenesis; however, the role of other potential bacterial factors at present remains unknown. Early effects of C. difficile on host intestinal epithelia include modest induction of innate immune responses with progressive loss of intestinal epithelial cell barrier function and cell death.

Clostridium difficile and inflammatory bowel disease

The past decade has seen an alarming increase in the burden of disease associated with Clostridium difficile. Several studies have now demonstrated an increasing incidence of C difficile infection in patients with inflammatory bowel disease (IBD) with a more severe course of disease compared with the non-IBD population. This article summarizes the available literature on the impact of C difficile infection on IBD and discusses the various diagnostic testing and treatment options available. Also reviewed are clinical situations specific to patients with IBD that are important for the treating physician to recognize.