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Dennie J, Vandell AG, Inoue S, Gajee R, Pav J, Zhang G, Zamora C, Masuda N, Uchiyama M, Yamada M, Senaldi G. A Phase I, Single-Ascending-Dose Study in Healthy Subjects to Assess the Safety, Tolerability, Pharmacokinetics, and Pharmacodynamics of DS-2969b, a Novel GyrB Inhibitor. J Clin Pharmacol 2018; 58:1557-1565. [DOI: 10.1002/jcph.1151] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/04/2018] [Indexed: 12/17/2022]
Affiliation(s)
- Justin Dennie
- Daiichi Sankyo Pharma Development; Basking Ridge NJ USA
| | | | | | - Roohi Gajee
- Daiichi Sankyo Pharma Development; Basking Ridge NJ USA
| | - Joseph Pav
- Daiichi Sankyo Pharma Development; Basking Ridge NJ USA
| | - George Zhang
- Daiichi Sankyo Pharma Development; Basking Ridge NJ USA
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Vandell AG, Inoue S, Dennie J, Nagasawa Y, Gajee R, Pav J, Zhang G, Zamora C, Masuda N, Senaldi G. Phase 1 Study To Assess the Safety, Tolerability, Pharmacokinetics, and Pharmacodynamics of Multiple Oral Doses of DS-2969b, a Novel GyrB Inhibitor, in Healthy Subjects. Antimicrob Agents Chemother 2018; 62:e02537-17. [PMID: 29439973 PMCID: PMC5923173 DOI: 10.1128/aac.02537-17] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 02/07/2018] [Indexed: 12/29/2022] Open
Abstract
DS-2969b is a novel GyrB inhibitor in development for the treatment of Clostridium difficile infection (CDI). The aim of this study was to assess the safety, tolerability, pharmacokinetics, and effects on the normal gastrointestinal microbiota of multiple daily oral ascending doses of DS-2969b in healthy subjects. The study enrolled three sequential ascending-dose cohorts (60 mg, 200 mg, and 400 mg). In each cohort, subjects received an oral dose of DS-2969b or placebo (six subjects received DS-2969b, and two received placebo) each morning for 14 days. DS-2969b was safe and well tolerated at all dose levels examined. All adverse events related to DS-2969b were mild and predominantly related to the gastrointestinal tract. DS-2969a (free form of DS-2969b) plasma concentrations increased with increasing doses; however, both the maximum concentration of drug in serum (Cmax) and the area under the concentration-time curve (AUC) increased less than dose proportionally. In all cohorts, sufficient fecal levels of DS-2969a were achieved within 24 h following the administration of the first dose and maintained for at least 17 days. Following treatment with DS-2969b, clear reductions in the populations of Clostridium coccoides and Bifidobacterium groups were observed. However, populations of three other bacterial groups examined (Bacteroides fragilis, Clostridium leptum, and Prevotella) were not affected. Data from this study support and encourage the further development of DS-2969b as a novel treatment for CDI.
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Affiliation(s)
| | | | - Justin Dennie
- Daiichi Sankyo Pharma Development, Basking Ridge, New Jersey, USA
| | | | - Roohi Gajee
- Daiichi Sankyo Pharma Development, Basking Ridge, New Jersey, USA
| | - Joe Pav
- Daiichi Sankyo Pharma Development, Basking Ridge, New Jersey, USA
| | - George Zhang
- Daiichi Sankyo Pharma Development, Basking Ridge, New Jersey, USA
| | | | | | - Giorgio Senaldi
- Daiichi Sankyo Pharma Development, Basking Ridge, New Jersey, USA
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103
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Dow DE, Seed PC. Clostridium difficile cure with fecal microbiota transplantation in a child with Pompe disease: a case report. J Med Case Rep 2018; 12:112. [PMID: 29703246 PMCID: PMC5924470 DOI: 10.1186/s13256-018-1659-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 03/20/2018] [Indexed: 12/30/2022] Open
Abstract
Background Recurrent Clostridium difficile infection is a growing problem among children due to both the increasing survival of medically fragile children with complicated chronic medical conditions resulting in prolonged antibiotic exposure and hospitalization and the emergence of strains of Clostridium difficile that are hypervirulent and associated with high rates of relapse. Case presentation This case describes a medically complex 21-month-old Hispanic girl with Pompe disease and B cell immunodeficiency with recurrent Clostridium difficile infection refractory to antimicrobial management. She presented with nine recurrent episodes of Clostridium difficile infection including fever, foul smelling diarrhea, and respiratory distress with failed sustained responses to compliant treatment using metronidazole and pulsed vancomycin therapy. Maternal donor fecal microbiota transplantation was performed with complete symptom resolution and produced a sustained cure, now 5 years in duration. Conclusions This patient presented with symptomatic Clostridium difficile at an early age causing significant morbidity and reduced quality of life. After nearly one year of failed medical management, fecal microbiota transplantation provided a cure. Further evidence-based research is necessary to test the safety and efficacy of this low technology, low cost, and morbidity-sparing therapy in children.
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Affiliation(s)
- D E Dow
- Division of Infectious Diseases, Department of Pediatrics, Duke University Medical Center, Box 3499, Durham, NC, 27710, USA.
| | - P C Seed
- Division of Infectious Diseases, Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Evanston, USA
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104
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Type IV Pili Promote Clostridium difficile Adherence and Persistence in a Mouse Model of Infection. Infect Immun 2018; 86:IAI.00943-17. [PMID: 29483294 DOI: 10.1128/iai.00943-17] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 02/21/2018] [Indexed: 12/16/2022] Open
Abstract
Cyclic diguanylate (c-di-GMP) is a second messenger that regulates the transition from motile to sessile lifestyles in numerous bacteria and controls virulence factor production in a variety of pathogens. In Clostridium difficile, c-di-GMP negatively regulates flagellum biosynthesis and swimming motility and promotes the production of type IV pili (TFP), biofilm formation, and surface motility in vitro Flagella have been identified as colonization factors in C. difficile, but the role of TFP in adherence to host cells and in colonization of the mammalian gut is unknown. Here we show that c-di-GMP promotes adherence to epithelial cells in vitro, which can be partly attributed to the loss of flagella. Using TFP-null mutants, we demonstrate that adherence to epithelial cells is partially mediated by TFP and that this TFP-mediated adherence requires c-di-GMP regulation. In a mouse model of colonization, the TFP-null mutants initially colonized the intestine as well as the parental strain but were cleared more quickly. Moreover, compared to the parent strain, C. difficile strains lacking TFP were particularly deficient in association with the cecal mucosa. Together these data indicate that TFP and their positive regulation by c-di-GMP promote attachment of C. difficile to the intestinal epithelium and contribute to persistence of C. difficile in the host intestine.
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105
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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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106
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Gil F, Calderón IL, Fuentes JA, Paredes-Sabja D. Clostridioides (Clostridium) difficile infection: current and alternative therapeutic strategies. Future Microbiol 2018; 13:469-482. [PMID: 29464969 DOI: 10.2217/fmb-2017-0203] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Clostridioides difficile (C. difficile) has become a pathogen of worldwide importance considering that epidemic strains are disseminated in hospitals of several countries, where community-acquired infections act as a constant source of new C. difficile strains into hospitals. Despite the advances in the treatment of infections, more effective therapies against C. difficile are needed but, at the same time, these therapies should be less harmful to the resident gastrointestinal microbiota. The purpose of this review is to present a description of issues associated to C. difficile infection, a summary of current therapies and those in developmental stage, and a discussion of potential combinations that may lead to an increased efficacy of C. difficile infection treatment.
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Affiliation(s)
- Fernando Gil
- Microbiota-Host Interactions & Clostridia Research Group, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andres Bello, Santiago, 8370035, Chile
| | - Iván L Calderón
- Laboratorio de Genética y Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andres Bello, Santiago, 8370035, Chile
| | - Juan A Fuentes
- Laboratorio de Genética y Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andres Bello, Santiago, 8370035, Chile
| | - Daniel Paredes-Sabja
- Microbiota-Host Interactions & Clostridia Research Group, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andres Bello, Santiago, 8370035, Chile
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107
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Marsh JW, Curry SR. Therapeutic Approaches for
Clostridium difficile
Infections. ACTA ACUST UNITED AC 2018; 30:9A.3.1-9A.3.9. [DOI: 10.1002/9780471729259.mc09a03s30] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Jane W. Marsh
- Epidemiology Research Unit, University of Pittsburgh Pittsburgh Pennsylvania
| | - Scott R. Curry
- Epidemiology Research Unit, University of Pittsburgh Pittsburgh Pennsylvania
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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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109
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Fitzpatrick F, Skally M, Brady M, Burns K, Rooney C, Wilcox MH. European Practice for CDI Treatment. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1050:117-135. [PMID: 29383667 DOI: 10.1007/978-3-319-72799-8_8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Clostridium difficile infection (CDI) remains a significant cause of morbidity and mortality worldwide. Historically, two antibiotics (metronidazole and vancomycin) and a recent third (fidaxomicin) have been used routinely for CDI treatment; convincing data are now available showing that metronidazole is the least efficacious agent. The European Society of Clinical Microbiology and Infectious Diseases CDI treatment guidelines outline the treatment options for a variety of CDI clinical scenarios, including use of the more traditional anti-CDI therapies (e.g., metronidazole, vancomycin), the role of newer anti-CDI agents (e.g., fidaxomicin), indications for surgical intervention and for non-antimicrobial management (e.g., faecal microbiota transplantation, FMT). A 2017 survey of 20 European countries found that while the majority (n = 14) have national CDI guidelines that provide a variety of recommendations for CDI treatment, only five have audited guideline implementation. A variety of restrictions are in place in 13 (65%) countries prior to use of new anti-CDI treatments, including committee/infection specialist approval or economic review/restrictions. Novel anti-CDI agents are being evaluated in Phase III trials; it is not yet clear what will be the roles of these agents. Prophylaxis is an optimum approach to reduce the impact of CDI especially in high-risk populations; monoclonal antibodies, antibiotic blocking approaches and multiple vaccines are currently in advanced clinical trials. The treatment of recurrent CDI is particularly troublesome, and several different live bio therapeutics are being developed, in addition to FMT.
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Affiliation(s)
- Fidelma Fitzpatrick
- Department of Clinical Microbiology, The Royal College of Surgeons in Ireland, Dublin, Ireland.
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland.
| | - Mairead Skally
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
| | - Melissa Brady
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
| | - Karen Burns
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
- Health Protection Surveillance Centre, Dublin, Ireland
| | - Christopher Rooney
- Microbiology, Leeds Teaching Hospitals and University of Leeds, Leeds, UK
| | - Mark H Wilcox
- Microbiology, Leeds Teaching Hospitals and University of Leeds, Leeds, UK.
- Leeds Teaching Hospitals and University of Leeds, Leeds, UK.
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110
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Antibiotic Resistances of Clostridium difficile. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1050:137-159. [PMID: 29383668 DOI: 10.1007/978-3-319-72799-8_9] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The rapid evolution of antibiotic resistance in Clostridium difficile and the consequent effects on prevention and treatment of C. difficile infections (CDIs) are matter of concern for public health. Antibiotic resistance plays an important role in driving C. difficile epidemiology. Emergence of new types is often associated with the emergence of new resistances and most of epidemic C. difficile clinical isolates is currently resistant to multiple antibiotics. In particular, it is to worth to note the recent identification of strains with reduced susceptibility to the first-line antibiotics for CDI treatment and/or for relapsing infections. Antibiotic resistance in C. difficile has a multifactorial nature. Acquisition of genetic elements and alterations of the antibiotic target sites, as well as other factors, such as variations in the metabolic pathways and biofilm production, contribute to the survival of this pathogen in the presence of antibiotics. Different transfer mechanisms facilitate the spread of mobile elements among C. difficile strains and between C. difficile and other species. Furthermore, recent data indicate that both genetic elements and alterations in the antibiotic targets can be maintained in C. difficile regardless of the burden imposed on fitness, and therefore resistances may persist in C. difficile population in absence of antibiotic selective pressure.
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111
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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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112
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Camacho-Ortiz A, Gutiérrez-Delgado EM, Garcia-Mazcorro JF, Mendoza-Olazarán S, Martínez-Meléndez A, Palau-Davila L, Baines SD, Maldonado-Garza H, Garza-González E. Randomized clinical trial to evaluate the effect of fecal microbiota transplant for initial Clostridium difficile infection in intestinal microbiome. PLoS One 2017; 12:e0189768. [PMID: 29261736 PMCID: PMC5738078 DOI: 10.1371/journal.pone.0189768] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 11/10/2017] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the impact of fecal donor-unrelated donor mix (FMT-FURM) transplantation as first-line therapy for C. difficile infection (CDI) in intestinal microbiome. METHODS We designed an open, two-arm pilot study with oral vancomycin (250mg every 6 h for 10-14 days) or FMT-FURM as treatments for the first CDI episode in hospitalized adult patients in Hospital Universitario "Dr. Jose Eleuterio Gonzalez". Patients were randomized by a closed envelope method in a 1: 1 ratio to either oral vancomycin or FMT-FURM. CDI resolution was considered when there was a reduction on the Bristol scale of at least 2 points, a reduction of at least 50% in the number of bowel movements, absence of fever, and resolution of abdominal pain (at least two criteria). From each patient, a fecal sample was obtained at days 0, 3, and 7 after treatment. Specimens were cultured to isolate C. difficile, and isolates were characterized by PCR. Susceptibility testing of isolates was performed using the agar dilution method. Fecal samples and FMT-FURM were analyzed by 16S rRNA sequencing. RESULTS We included 19 patients; 10 in the vancomycin arm and 9 in the FMT-FURM arm. However, one of the patients in the vancomycin arm and two patients in the FMT-FURM arm were eliminated. Symptoms resolved in 8/9 patients (88.9%) in the vancomycin group, while symptoms resolved in 4/7 patients (57.1%) after the first FMT-FURM dose (P = 0.26) and in 5/7 patients (71.4%) after the second dose (P = 0.55). During the study, no adverse effects attributable to FMT-FURM were observed in patients. Twelve isolates were recovered, most isolates carried tcdB, tcdA, cdtA, and cdtB, with an 18-bp deletion in tcdC. All isolates were resistant to ciprofloxacin and moxifloxacin but susceptible to metronidazole, linezolid, fidaxomicin, and tetracycline. In the FMT-FURM group, the bacterial composition was dominated by Firmicutes, Bacteroidetes, and Proteobacteria at all-time points and the microbiota were remarkably stable over time. The vancomycin group showed a very different pattern of the microbial composition when comparing to the FMT-FURM group over time. CONCLUSION The results of this preliminary study showed that FMT-FURM for initial CDI is associated with specific bacterial communities that do not resemble the donors' sample.
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Affiliation(s)
- Adrián Camacho-Ortiz
- Coordinación de Epidemiología Hospitalaria, Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León, Monterrey, Nuevo Leon, Mexico
- Servicio de Infectología, Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León, Monterrey, Nuevo Leon, Mexico
| | - Eva María Gutiérrez-Delgado
- Servicio de Infectología, Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León, Monterrey, Nuevo Leon, Mexico
| | - Jose F. Garcia-Mazcorro
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Medico-Biológicas, Universidad Veracruzana, Veracruz, México
| | - Soraya Mendoza-Olazarán
- Servicio de Gastroenterología, Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León, Monterrey, Nuevo Leon, Mexico
| | - Adrián Martínez-Meléndez
- Departamento de Microbiología e Inmunología, Facultad de Ciencias Biológicas, Universidad Autónoma de Nuevo León, San Nicolás de los Garza, Nuevo León, Mexico
| | - Laura Palau-Davila
- Coordinación de Epidemiología Hospitalaria, Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León, Monterrey, Nuevo Leon, Mexico
| | - Simon D. Baines
- Department of Biological and Environmental Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom
| | - Héctor Maldonado-Garza
- Servicio de Gastroenterología, Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León, Monterrey, Nuevo Leon, Mexico
| | - Elvira Garza-González
- Servicio de Gastroenterología, Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León, Monterrey, Nuevo Leon, Mexico
- * E-mail:
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113
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Verbeke F, Janssens Y, Wynendaele E, De Spiegeleer B. Faecal microbiota transplantation: a regulatory hurdle? BMC Gastroenterol 2017; 17:128. [PMID: 29179687 PMCID: PMC5704511 DOI: 10.1186/s12876-017-0687-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 11/17/2017] [Indexed: 02/06/2023] Open
Abstract
During faecal microbiota transplantation, stool from a healthy donor is transplanted to treat a variety of dysbiosis-associated gut diseases. Competent authorities are faced with the challenge to provide adequate regulation. Currently, regulatory harmonization is completely lacking and authorities apply non-existing to most stringent requirements. A regulatory approach for faecal microbiota transplantation could be inserting faecal microbiota transplantation in the gene-, cell- and tissue regulations, including the hospital exemption system in the European Advanced Therapy Medicinal Products regulation, providing a pragmatic and efficacy-risk balanced approach and granting all patients as a matter of principle access to this therapy.
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Affiliation(s)
- Frederick Verbeke
- Drug Quality and Registration (DruQuaR) group, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, B-9000, Ghent, Belgium
| | - Yorick Janssens
- Drug Quality and Registration (DruQuaR) group, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, B-9000, Ghent, Belgium
| | - Evelien Wynendaele
- Drug Quality and Registration (DruQuaR) group, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, B-9000, Ghent, Belgium
| | - Bart De Spiegeleer
- Drug Quality and Registration (DruQuaR) group, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, B-9000, Ghent, Belgium.
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Pakpour S, Bhanvadia A, Zhu R, Amarnani A, Gibbons SM, Gurry T, Alm EJ, Martello LA. Identifying predictive features of Clostridium difficile infection recurrence before, during, and after primary antibiotic treatment. MICROBIOME 2017; 5:148. [PMID: 29132405 PMCID: PMC5684761 DOI: 10.1186/s40168-017-0368-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 11/01/2017] [Indexed: 05/03/2023]
Abstract
BACKGROUND Colonization by the pathogen Clostridium difficile often occurs in the background of a disrupted microbial community. Identifying specific organisms conferring resistance to invasion by C. difficile is desirable because diagnostic and therapeutic strategies based on the human microbiota have the potential to provide more precision to the management and treatment of Clostridium difficile infection (CDI) and its recurrence. METHODS We conducted a longitudinal study of adult patients diagnosed with their first CDI. We investigated the dynamics of the gut microbiota during antibiotic treatment, and we used microbial or demographic features at the time of diagnosis, or after treatment, to predict CDI recurrence. To check the validity of the predictions, a meta-analysis using a previously published dataset was performed. RESULTS We observed that patients' microbiota "before" antibiotic treatment was predictive of disease relapse, but surprisingly, post-antibiotic microbial community is indistinguishable between patients that recur or not. At the individual OTU level, we identified Veillonella dispar as a candidate organism for preventing CDI recurrence; however, we did not detect a corresponding signal in the conducted meta-analysis. CONCLUSION Although in our patient population, a candidate organism was identified for negatively predicting CDI recurrence, results suggest the need for larger cohort studies that include patients with diverse demographic characteristics to generalize species that robustly confer colonization resistance against C. difficile and accurately predict disease relapse.
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Affiliation(s)
- Sepideh Pakpour
- Genome Sequencing and Analysis Program, Broad Institute, Cambridge, MA USA
- Department of Biological Engineering, Massachusetts Institute of Technology (MIT), Cambridge, MA USA
- MIT Center for Microbiome Informatics and Therapeutics, Cambridge, MA USA
| | - Amit Bhanvadia
- Division of Digestive Diseases, Lenox Hill Hospital/Northwell Health, New York, NY USA
- Medicine, SUNY Downstate Medical Center, Brooklyn, NY USA
| | - Roger Zhu
- Surgery, NewYork-Presbyterian/Queens, Flushing, NY USA
- Medicine, SUNY Downstate Medical Center, Brooklyn, NY USA
| | | | - Sean M. Gibbons
- Genome Sequencing and Analysis Program, Broad Institute, Cambridge, MA USA
- Department of Biological Engineering, Massachusetts Institute of Technology (MIT), Cambridge, MA USA
- MIT Center for Microbiome Informatics and Therapeutics, Cambridge, MA USA
| | - Thomas Gurry
- Genome Sequencing and Analysis Program, Broad Institute, Cambridge, MA USA
- Department of Biological Engineering, Massachusetts Institute of Technology (MIT), Cambridge, MA USA
- MIT Center for Microbiome Informatics and Therapeutics, Cambridge, MA USA
| | - Eric J. Alm
- Genome Sequencing and Analysis Program, Broad Institute, Cambridge, MA USA
- Department of Biological Engineering, Massachusetts Institute of Technology (MIT), Cambridge, MA USA
- MIT Center for Microbiome Informatics and Therapeutics, Cambridge, MA USA
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Jeon N, Sorokina M, Henriksen C, Staley B, Lipori GP, Winterstein AG. Measurement of selected preventable adverse drug events in electronic health records: Toward developing a complexity score. Am J Health Syst Pharm 2017; 74:1865-1877. [PMID: 29118045 DOI: 10.2146/ajhp160911] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The defining of a select number of high-priority preventable adverse drug events (pADEs) for measurement in the electronic health record (EHR) and the estimation of pADE incidences in two tertiary care facilities are described. METHODS This study was part of a larger effort aimed at developing an automated electronic health record (EHR)-based complexity-score (C-score) that ranks hospitalized patients according to their risk for pADEs for clinical intervention. We developed measures for 16 high-priority pADEs often deemed preventable using discrete clinical and administrative EHR data. For each pADE we specified inclusion and exclusion criteria that were used to define risk populations for each specific pADE. The incidence of each type of pADE was then measured during a designated follow-up period considering all adult admissions to 2 large academic tertiary care hospitals, who were eligible for the pADE-specific risk populations during any of their first 5 hospital days. RESULTS Utilizing the data from 83,787 admissions who were at risk for at least one pADE during at least one of their first five hospital days, we found that 27,193 admissions (32.5%) developed at least one pADE. Uncontrolled postsurgical pain, uncontrolled pneumonia, and drug-associated hypotension had the highest incidences with the following number of days with pADE per number of patients at risk: 13,484 of 19,640; 527 of 1,530; and 13,394 of 43,630, while drug-associated falls (446 of 75,036), drug-associated acute mental status changes (262 of 66,875) and venous thromboembolism (214 of 74,283) had the lowest incidence rates. CONCLUSION EHR-based definitions of clinically important pADEs were developed, and the incidence of the pADEs was estimated. These definitions will be advanced for the creation of prediction models to develop a C-score for identifying patients at risk for pADEs to prioritize pharmacist intervention.
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Affiliation(s)
- Nakyung Jeon
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
| | - Magarita Sorokina
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
| | - Carl Henriksen
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
| | - Ben Staley
- Department of Pharmacy Service, UF Health Shands Hospital, Gainesville, FL
| | | | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, and Department of Epidemiology, College of Public Health and Health Professions, University of Florida, Gainesville, FL
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Burton HE, Mitchell SA, Watt M. A Systematic Literature Review of Economic Evaluations of Antibiotic Treatments for Clostridium difficile Infection. PHARMACOECONOMICS 2017; 35:1123-1140. [PMID: 28875314 PMCID: PMC5656734 DOI: 10.1007/s40273-017-0540-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Clostridium difficile infection (CDI) is associated with high management costs, particularly in recurrent cases. Fidaxomicin treatment results in lower recurrence rates than vancomycin and metronidazole, but has higher acquisition costs in Europe and the USA. This systematic literature review summarises economic evaluations (EEs) of fidaxomicin, vancomycin and metronidazole for treatment of CDI. METHODS Electronic databases (MEDLINE®, Embase, Cochrane Library) and conference proceedings (ISPOR, ECCMID, ICAAC and IDWeek) were searched for publications reporting EEs of fidaxomicin, vancomycin and/or metronidazole in the treatment of CDI. Reference bibliographies of identified manuscripts were also reviewed. Cost-effectiveness was evaluated according to the overall population of patients with CDI, as well as in subgroups with severe CDI or recurrent CDI, or those at higher risk of recurrence or mortality. RESULTS Overall, 27 relevant EEs, conducted from the perspective of 12 different countries, were identified. Fidaxomicin was cost-effective versus vancomycin and/or metronidazole in 14 of 24 EEs (58.3%), vancomycin was cost-effective versus fidaxomicin and/or metronidazole in five of 27 EEs (18.5%) and metronidazole was cost-effective versus fidaxomicin and/or vancomycin in two of 13 EEs (15.4%). Fidaxomicin was cost-effective versus vancomycin in most of the EEs evaluating specific patient subgroups. Key cost-effectiveness drivers were cure rate, recurrence rate, time horizon, drug costs and length and cost of hospitalisation. CONCLUSIONS In most EEs, fidaxomicin was demonstrated to be cost-effective versus metronidazole and vancomycin in patients with CDI. These results have relevance to clinical practice, given the high budgetary impact of managing CDI and increasing restrictions on healthcare budgets. OTHER This analysis was initiated and funded by Astellas Pharma Inc.
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Affiliation(s)
| | | | - Maureen Watt
- Astellas Pharma Inc., 2000 Hillswood Drive, Chertsey, KT16 0RS UK
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117
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Asempa TE, Nicolau DP. Clostridium difficile infection in the elderly: an update on management. Clin Interv Aging 2017; 12:1799-1809. [PMID: 29123385 PMCID: PMC5661493 DOI: 10.2147/cia.s149089] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The burden of Clostridium difficile infection (CDI) is profound and growing. CDI now represents a common cause of health care–associated diarrhea, and is associated with significant morbidity, mortality, and health care costs. CDI disproportionally affects the elderly, possibly explained by the following risk factors: age-related impairment of the immune system, increasing antibiotic utilization, and frequent health care exposure. In the USA, recent epidemiological studies estimate that two out of every three health care–associated CDIs occur in patients 65 years or older. Additionally, the elderly are at higher risk for recurrent CDI. Existing therapeutic options include metronidazole, oral vancomycin, and fidaxomicin. Choice of agent depends on disease severity, history of recurrence, and, increasingly, the drug cost. Bezlotoxumab, a recently approved monoclonal antibody targeting C. difficile toxin B, offers an exciting advancement into immunologic therapies. Similarly, fecal microbiota transplantation is gaining popularity as an effective option mainly for recurrent CDI. The challenge of decreasing CDI burden in the elderly involves adopting preventative strategies, optimizing initial treatment, and decreasing the risk of recurrence. Expanded strategies are certainly needed to improve outcomes in this high-risk population. This review considers available data from prospective and retrospective studies as well as case reports to illustrate the merits and gaps in care related to the management of CDI in the elderly.
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Affiliation(s)
- Tomefa E Asempa
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
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118
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Vinner GK, Vladisavljević GT, Clokie MRJ, Malik DJ. Microencapsulation of Clostridium difficile specific bacteriophages using microfluidic glass capillary devices for colon delivery using pH triggered release. PLoS One 2017; 12:e0186239. [PMID: 29023522 PMCID: PMC5638336 DOI: 10.1371/journal.pone.0186239] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 09/27/2017] [Indexed: 12/14/2022] Open
Abstract
The prevalence of pathogenic bacteria acquiring multidrug antibiotic resistance is a global health threat to mankind. This has motivated a renewed interest in developing alternatives to conventional antibiotics including bacteriophages (viruses) as therapeutic agents. The bacterium Clostridium difficile causes colon infection and is particularly difficult to treat with existing antibiotics; phage therapy may offer a viable alternative. The punitive environment within the gastrointestinal tract can inactivate orally delivered phages. C. difficile specific bacteriophage, myovirus CDKM9 was encapsulated in a pH responsive polymer (Eudragit® S100 with and without alginate) using a flow focussing glass microcapillary device. Highly monodispersed core-shell microparticles containing phages trapped within the particle core were produced by in situ polymer curing using 4-aminobenzoic acid dissolved in the oil phase. The size of the generated microparticles could be precisely controlled in the range 80 μm to 160 μm through design of the microfluidic device geometry and by varying flow rates of the dispersed and continuous phase. In contrast to free 'naked' phages, those encapsulated within the microparticles could withstand a 3 h exposure to simulated gastric fluid at pH 2 and then underwent a subsequent pH triggered burst release at pH 7. The significance of our research is in demonstrating that C. difficile specific phage can be formulated and encapsulated in highly uniform pH responsive microparticles using a microfluidic system. The microparticles were shown to afford significant protection to the encapsulated phage upon prolonged exposure to an acid solution mimicking the human stomach environment. Phage encapsulation and subsequent release kinetics revealed that the microparticles prepared using Eudragit® S100 formulations possess pH responsive characteristics with phage release triggered in an intestinal pH range suitable for therapeutic purposes. The results reported here provide proof-of-concept data supporting the suitability of our approach for colon targeted delivery of phages for therapeutic purposes.
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Affiliation(s)
- Gurinder K. Vinner
- Chemical Engineering Department, Loughborough University, Loughborough, United Kingdom
| | | | - Martha R. J. Clokie
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, United Kingdom
| | - Danish J. Malik
- Chemical Engineering Department, Loughborough University, Loughborough, United Kingdom
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Cobo J, Merino E, Martínez C, Cózar-Llistó A, Shaw E, Marrodán T, Calbo E, Bereciartúa E, Sánchez-Muñoz LA, Salavert M, Pérez-Rodríguez MT, García-Rosado D, Bravo-Ferrer JM, Gálvez-Acebal J, Henríquez-Camacho C, Cuquet J, Pino-Calm B, Torres L, Sánchez-Porto A, Fernández-Félix BM. Prediction of recurrent clostridium difficile infection at the bedside: the GEIH-CDI score. Int J Antimicrob Agents 2017; 51:393-398. [PMID: 28939450 DOI: 10.1016/j.ijantimicag.2017.09.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 09/01/2017] [Accepted: 09/12/2017] [Indexed: 01/05/2023]
Abstract
Recurrence of Clostridium difficile infection (CDI) has major consequences for both patients and the health system. The ability to predict which patients are at increased risk of recurrent CDI makes it possible to select candidates for treatment with new drugs and therapies (including fecal microbiota transplantation) that have proven to reduce the incidence of recurrence of CDI. Our objective was to develop a clinical prediction tool, the GEIH-CDI score, to determine the risk of recurrence of CDI. Predictors of recurrence of CDI were investigated using logistic regression in a prospective cohort of 274 patients diagnosed with CDI. The model was calibrated using the Hosmer-Lemeshow test. The tool comprises four factors: age (70-79 years and ≥80 years), history of CDI during the previous year, direct detection of toxin in stool, and persistence of diarrhea on the fifth day of treatment. The functioning of the GEIH-CDI score was validated in a prospective cohort of 183 patients. The area under the ROC curve was 0.72 (0.65-0.79). Application of the tool makes it possible to select patients at high risk (>50%) of recurrence and patients at low risk (<10%) of recurrence. GEIH-CDI score may be useful for clinicians treating patients with CDI.
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Affiliation(s)
- Javier Cobo
- Servicio de Enfermedades Infecciosas, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain.
| | - Esperanza Merino
- Unidad de Enfermedades Infecciosas, Hospital General Universitario de Alicante, ISABIAL-FISABIO, Alicante, Spain
| | - Cristina Martínez
- Servicio de Enfermedades Infecciosas, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Alberto Cózar-Llistó
- Unidad de Enfermedades Infecciosas, Servicio de Medicina Interna, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Evelyn Shaw
- Servicio de Enfermedades infecciosas, Hospital Universitario de Bellvitge, IDIBELL, Barcelona, Spain
| | - Teresa Marrodán
- Servicio de Microbiología Clínica, Hospital de León, León, Spain
| | - Esther Calbo
- Servicio de Medicina Interna, Unidad de Control de la Infección, Hospital Universitario MútuaTerrasssa, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Elena Bereciartúa
- Unidad de Enfermedades infecciosas, Hospital Universitario Cruces, Bilbao, Spain
| | - Luis A Sánchez-Muñoz
- Servicio de Medicina Interna, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Miguel Salavert
- Unidad de Enfermedades infecciosas, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - M Teresa Pérez-Rodríguez
- Unidad de Patología Infecciosa, Servicio de Medicina Interna, Complejo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Dácil García-Rosado
- Sección de Infecciones, Servicio de Medicina Interna Hospital universitario de Canarias, Vigo, Tenerife, Spain
| | | | - Juan Gálvez-Acebal
- Instituto de Biomedicina de Sevilla, IBiS/Hospital universitario Virgen Macarena/Unidad de Enfermedades infecciosas/CSIC/Universidad de Sevilla, Sevilla, Spain
| | | | - Jordi Cuquet
- Proceso de Infecciones, Servicio de Medicina Interna, Hospital General de Granollers, Barcelona, Spain
| | - Berta Pino-Calm
- Servicio de Microbiología, Hospital Nuestra Señora de Candelaria, Sta, Cruz de Tenerife, Spain
| | - Luis Torres
- Servicio de Microbiología, Hospital San Jorge de Huesca, Huesca, Spain
| | - Antonio Sánchez-Porto
- Unidad de Enfermedades infecciosas y Microbiología, Hospital del SAS de La Línea de la Concepción, Cádiz, Spain
| | - Borja M Fernández-Félix
- Unidad de Bioestadística Clínica, Hospital Universitario Ramón y Cajal, Madrid, Spain; IRYCIS, CIBER Epidemiología y Salud Pública (CIBERESP)
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120
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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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121
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Safety, Tolerability, Systemic Exposure, and Metabolism of CRS3123, a Methionyl-tRNA Synthetase Inhibitor Developed for Treatment of Clostridium difficile, in a Phase 1 Study. Antimicrob Agents Chemother 2017; 61:AAC.02760-16. [PMID: 28584140 DOI: 10.1128/aac.02760-16] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 05/13/2017] [Indexed: 01/25/2023] Open
Abstract
Clostridium difficile causes antibiotic-associated diarrhea and is a major public health concern. Current therapies disrupt the protective intestinal flora, do not reliably prevent recurrent infections, and will be decreasingly effective should less susceptible strains emerge. CRS3123 is an oral agent that inhibits bacterial methionyl-tRNA synthetase and has potent activity against C. difficile and aerobic Gram-positive bacteria but little activity against Gram-negative bacteria, including anaerobes. This first-in-human, double-blind, placebo-controlled, dose escalation study evaluated the safety and systemic exposure of CRS3123 after a single oral dose in healthy adults. Five cohorts of eight subjects each received CRS3123 or placebo in a 3:1 ratio. Doses for the respective active arms were 100 mg, 200 mg, 400 mg, 800 mg, and 1,200 mg. Blood and urine were collected for pharmacokinetic analysis. CRS3123 concentrations were measured with validated LC-MS/MS techniques. There were no serious adverse events or immediate allergic reactions during administration of CRS3123. In the CRS3123-treated groups, the most frequent adverse events were decreased hemoglobin, headache, and abnormal urine analysis; all adverse events in the active-treatment groups were mild to moderate, and their frequency did not increase with dose. Although CRS3123 systemic exposure increased at higher doses, the increase was less than dose proportional. The absorbed drug was glucuronidated at reactive amino groups on the molecule, which precluded accurate pharmacokinetic analysis of the parent drug. Overall, CRS3123 was well tolerated over this wide range of doses. This safety profile supports further investigation of CRS3123 as a treatment for C. difficile infections. (This study has been registered at ClinicalTrials.gov under identifier NCT01551004.).
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Ferrada P, Callcut R, Zielinski MD, Bruns B, Yeh DD, Zakrison TL, Meizoso JP, Sarani B, Catalano RD, Kim P, Plant V, Pasley A, Dultz LA, Choudhry AJ, Haut ER. Loop ileostomy versus total colectomy as surgical treatment for Clostridium difficile-associated disease: An Eastern Association for the Surgery of Trauma multicenter trial. J Trauma Acute Care Surg 2017; 83:36-40. [PMID: 28426557 PMCID: PMC5998809 DOI: 10.1097/ta.0000000000001498] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The mortality of patients with Clostridium difficile-associated disease (CDAD) requiring surgery continues to be very high. Loop ileostomy (LI) was introduced as an alternative procedure to total colectomy (TC) for CDAD by a single-center study. To date, no reproducible results have been published. The objective of this study was to compare these two procedures in a multicentric approach to help the surgeon decide what procedure is best suited for the patient in need. METHODS This was a retrospective multicenter study conducted under the sponsorship of the Eastern Association for the Surgery of Trauma. Demographics, medical history, clinical presentation, APACHE score, and outcomes were collected. We used the Research Electronic Data Capture tool to store the data. Mann-Whitney (continuous data) and Fisher exact (categorical data) were used to compare TC with LI. Logistic regression was performed to determine predictors of mortality. A propensity score analysis was done to control for potential confounders and determine adjusted mortality rates by procedure type. RESULTS We collected data from 10 centers of patients who presented with CDAD requiring surgery between July 1, 2010 and July 30, 2014. Two patients died during the surgical procedure, leaving 98 individuals in the study. The overall mortality was 32%, and 75% had postoperative complications. Median age was 64.5 years; 59% were male. Concerning preoperative patient conditions, 54% were on pressors, 47% had renal failure, and 36% had respiratory failure. When comparing TC and LI, there was no statistical difference regarding these conditions. Univariate preprocedure predictors of mortality were age, lactate, timing of operation, vasopressor use, and acute renal failure. There was no statistical difference between the APACHE score of patients undergoing either procedure (TC, 22 vs LI, 16). Adjusted mortality (controlled for preprocedure confounders) was significantly lower in the LI group (17.2% vs 39.7%; p = 0.002). CONCLUSIONS This is the first multicenter study comparing TC with LI for the treatment of CDAD. In this study, LI carried less mortality than TC. In patients without contraindications, LI should be considered for the surgical treatment of CDAD. LEVEL OF EVIDENCE Therapeutic study, level III.
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123
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Watt M, Dinh A, Le Monnier A, Tilleul P. Cost-effectiveness analysis on the use of fidaxomicin and vancomycin to treat Clostridium difficile infection in France. J Med Econ 2017; 20:678-686. [PMID: 28299963 DOI: 10.1080/13696998.2017.1302946] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Fidaxomicin is a macrocyclic antibiotic with proven efficacy against Clostridium difficile infection (CDI) in adults. It was licensed in France in 2012, but, due to higher acquisition costs compared with existing treatments, healthcare providers require information on its cost/benefit profile. OBJECTIVE To compare healthcare costs and health outcomes of fidaxomicin and vancomycin, as reference treatment for CDI. METHODS A Markov model was used to simulate the treatment pathway, over 1 year, of adult patients with CDI receiving fidaxomicin or vancomycin. Several patient sub-groups (severe CDI; recurrent CDI; concomitant antibiotics; cancer; renal failure; elderly) were evaluated. Cost-effectiveness was analyzed based on cure and recurrence rates derived from published randomized clinical trials comparing fidaxomicin and vancomycin, and costs calculated from the payer perspective using French hospitalization data and drug cost databases. Model outputs included costs in euros (reference year 2014) and health outcomes (recurrence; sustained cure rates). Alternative scenario and sensitivity analyses were performed using data from other clinical trials in CDI, including one conducted in real-life clinical practice in France. RESULTS Drug acquisition costs were €1,692 higher in fidaxomicin-treated patients, but this was offset by the lower hospitalization costs with fidaxomicin, which were reduced by €1,722. The reduction in the cost of hospitalization was driven by the significantly lower number of recurrences in fidaxomicin-treated patients, offsetting the acquisition cost of fidaxomicin in all sub-groups except recurrent CDI and concomitant antibiotics. CONCLUSION This study demonstrated that, despite higher acquisition costs, the lower recurrence rate with fidaxomicin resulted in cost savings or low incremental costs compared with vancomycin.
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Affiliation(s)
- Maureen Watt
- a Health Economics and Outcomes Research, Astellas Pharma EMEA , Chertsey , UK
| | - Aurélien Dinh
- b Département de Médecine Aiguë Spécialisée , Hopital Raymond Poincaré , Garches , France
| | - Alban Le Monnier
- c Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph , Paris , France
| | - Patrick Tilleul
- d Pharmacie à Usage Intérieur, Groupe Hospitalier Pitié-Salpêtrière AP-HP , Paris , France
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124
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Messick CA, Hammel JP, Hull T. Risk Factors that Predict Recurrent Clostridium difficile Infections in Surgical Patients. Am Surg 2017. [DOI: 10.1177/000313481708300633] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Clostridium difficile (C. difficile) infection (CDI) is a serious problem mostly studied during patients’ index infections. The aim of this study is to define the incidence of primary and recurrent postoperative (postop) CDI in a single institution's entire surgical population and to identify risk factors that influence disease recurrence. Using electronic medical records from 2002 to 2012, charts were reviewed from all patients with laboratory-proven (enzyme-linked immunosorbent assay or polymerase chain reaction methods) C. difficile-positive stool samples. Index postop CDI was defined as a positive C. difficile assay (CDA) within 30 days of surgery and recurrence was defined as a positive CDA within 30 days of any surgery in a patient with a previously documented positive CDA. Patient demographics, surgical diagnoses, and laboratory data were recorded. Approximately 342,000 surgeries were performed in the study period with a 0.6 per cent (2188 patients) incidence of index postop CDI. Patients undergoing musculoskeletal surgery had the highest recurrent CDI rate [odds ratio (OR) 3.09 (1.47–6.49), P = 0.003]. Use of any steroid (OR 2.45 [1.43–4.20], P = 0.002) or other immunosuppressant (OR 2.64 [1.09–6.38], P = 0.011) within six months of surgery was associated with an increased risk of the development of a recurrent CDI. Across surgical specialties at our institution, postop index CDI is low and patients have about a 5-fold increased risk for developing recurrent CDI. Patients undergoing musculoskeletal surgery are at greater risk for CDI recurrence and younger age, use of steroids and immune modulators, and surgery by organ system are independent risk factors for a recurrent CDI.
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Affiliation(s)
- Craig A. Messick
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeff P. Hammel
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
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Nelson RL, Suda KJ, Evans CT. Antibiotic treatment for Clostridium difficile-associated diarrhoea in adults. Cochrane Database Syst Rev 2017; 3:CD004610. [PMID: 28257555 PMCID: PMC6464548 DOI: 10.1002/14651858.cd004610.pub5] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Clostridium difficile (C. difficile) is recognized as a frequent cause of antibiotic-associated diarrhoea and colitis. This review is an update of a previously published Cochrane review. OBJECTIVES The aim of this review is to investigate the efficacy and safety of antibiotic therapy for C. difficile-associated diarrhoea (CDAD), or C. difficile infection (CDI), being synonymous terms. SEARCH METHODS We searched MEDLINE, EMBASE, CENTRAL and the Cochrane IBD Group Specialized Trials Register from inception to 26 January 2017. We also searched clinicaltrials.gov and clinicaltrialsregister.eu for ongoing trials. SELECTION CRITERIA Only randomised controlled trials assessing antibiotic treatment for CDI were included in the review. DATA COLLECTION AND ANALYSIS Three authors independently assessed abstracts and full text articles for inclusion and extracted data. The risk of bias was independently rated by two authors. For dichotomous outcomes, we calculated the risk ratio (RR) and corresponding 95% confidence interval (95% CI). We pooled data using a fixed-effect model, except where significant heterogeneity was detected, at which time a random-effects model was used. The following outcomes were sought: sustained symptomatic cure (defined as initial symptomatic response and no recurrence of CDI), sustained bacteriologic cure, adverse reactions to the intervention, death and cost. MAIN RESULTS Twenty-two studies (3215 participants) were included. The majority of studies enrolled patients with mild to moderate CDI who could tolerate oral antibiotics. Sixteen of the included studies excluded patients with severe CDI and few patients with severe CDI were included in the other six studies. Twelve different antibiotics were investigated: vancomycin, metronidazole, fusidic acid, nitazoxanide, teicoplanin, rifampin, rifaximin, bacitracin, cadazolid, LFF517, surotomycin and fidaxomicin. Most of the studies were active comparator studies comparing vancomycin with other antibiotics. One small study compared vancomycin to placebo. There were no other studies that compared antibiotic treatment to a placebo or a 'no treatment' control group. The risk of bias was rated as high for 17 of 22 included studies. Vancomycin was found to be more effective than metronidazole for achieving symptomatic cure. Seventy-two per cent (318/444) of metronidazole patients achieved symptomatic cure compared to 79% (339/428) of vancomycin patients (RR 0.90, 95% CI 0.84 to 0.97; moderate quality evidence). Fidaxomicin was found to be more effective than vancomycin for achieving symptomatic cure. Seventy-one per cent (407/572) of fidaxomicin patients achieved symptomatic cure compared to 61% (361/592) of vancomycin patients (RR 1.17, 95% CI 1.04 to 1.31; moderate quality evidence). Teicoplanin may be more effective than vancomycin for achieving a symptomatic cure. Eightly-seven per cent (48/55) of teicoplanin patients achieved symptomatic cure compared to 73% (40/55) of vancomycin patients (RR 1.21, 95% CI 1.00 to 1.46; very low quality evidence). For other comparisons including the one placebo-controlled study the quality of evidence was low or very low due to imprecision and in many cases high risk of bias because of attrition and lack of blinding. One hundred and forty deaths were reported in the studies, all of which were attributed by study authors to the co-morbidities of the participants that lead to acquiring CDI. Although many other adverse events were reported during therapy, these were attributed to the participants' co-morbidities. The only adverse events directly attributed to study medication were rare nausea and transient elevation of liver enzymes. Recent cost data (July 2016) for a 10 day course of treatment shows that metronidazole 500 mg is the least expensive antibiotic with a cost of USD 13 (Health Warehouse). Vancomycin 125 mg costs USD 1779 (Walgreens for 56 tablets) compared to fidaxomicin 200 mg at USD 3453.83 or more (Optimer Pharmaceuticals) and teicoplanin at approximately USD 83.67 (GBP 71.40, British National Formulary). AUTHORS' CONCLUSIONS No firm conclusions can be drawn regarding the efficacy of antibiotic treatment in severe CDI as most studies excluded patients with severe disease. The lack of any 'no treatment' control studies does not allow for any conclusions regarding the need for antibiotic treatment in patients with mild CDI beyond withdrawal of the initiating antibiotic. Nonetheless, moderate quality evidence suggests that vancomycin is superior to metronidazole and fidaxomicin is superior to vancomycin. The differences in effectiveness between these antibiotics were not too large and the advantage of metronidazole is its far lower cost compared to the other two antibiotics. The quality of evidence for teicoplanin is very low. Adequately powered studies are needed to determine if teicoplanin performs as well as the other antibiotics. A trial comparing the two cheapest antibiotics, metronidazole and teicoplanin, would be of interest.
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Affiliation(s)
- Richard L Nelson
- University of Illinois School of Public HealthEpidemiology/Biometry Division1603 West TaylorRoom 956ChicagoIllinoisUSA60612
| | | | - Charlesnika T Evans
- Northwestern UniversityDepartment of Preventive Medicine and Center for Healthcare Studies633 N. St. ClairChicagoILUSA60611
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Chen S, Sun C, Gu H, Wang H, Li S, Ma Y, Wang J. Salubrinal protects against Clostridium difficile toxin B-induced CT26 cell death. Acta Biochim Biophys Sin (Shanghai) 2017; 49:228-237. [PMID: 28119311 DOI: 10.1093/abbs/gmw139] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile (C. difficile) is considered to be the major cause of the antibiotic-associated diarrhea and pseudomembranous colitis in animals and humans. The prevalence of C. difficile infections (CDI) has been increasing since 2000. Two exotoxins of C. difficile, Toxin A (TcdA) and Toxin B (TcdB), are the main virulence factors of CDI, which can induce glucosylation of Rho GTPases in host cytosol, leading to cell morphological changes, cell apoptosis, and cell death. The mechanism of TcdB-induced cell death has been investigated for decades, but it is still not completely understood. It has been reported that TcdB induces endoplasmic reticulum stress via PERK-eIF2α signaling pathway in CT26 cell line (BALB/C mouse colon tumor cells). In this study, we found that salubrinal, a selective inhibitor of eIF2α dephosphorylation, efficiently protects CT26 cell line against TcdB-induced cell death and tried to explore the mechanism underlying in this protective effect. Our results demonstrated that salubrinal protects CT26 cells from TcdB-mediated cytotoxic and cytopathic effect, inhibits apoptosis and death of the toxin-exposed cells via caspase-9-dependent pathway, eIF2α signaling pathway, and autophagy. These findings will be helpful for the development of CDI therapies.
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Affiliation(s)
- Shuyi Chen
- School of Bioscience and Bioengineering, South China University of Technology, Guangzhou 510006, China
| | - Chunli Sun
- School of Bioscience and Bioengineering, South China University of Technology, Guangzhou 510006, China
| | - Huawei Gu
- School of Bioscience and Bioengineering, South China University of Technology, Guangzhou 510006, China
| | - Haiying Wang
- School of Bioscience and Bioengineering, South China University of Technology, Guangzhou 510006, China
| | - Shan Li
- School of Bioscience and Bioengineering, South China University of Technology, Guangzhou 510006, China
| | - Yi Ma
- School of Bioscience and Bioengineering, South China University of Technology, Guangzhou 510006, China
| | - Jufang Wang
- School of Bioscience and Bioengineering, South China University of Technology, Guangzhou 510006, China
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Diagnosis and treatment of Clostridium difficile (C. diff) colitis: Review of the literature and a perspective in gynecologic oncology. Gynecol Oncol 2017; 144:428-437. [DOI: 10.1016/j.ygyno.2016.11.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 11/08/2016] [Accepted: 11/12/2016] [Indexed: 12/16/2022]
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Trubiano JA, Cheng AC, Korman TM, Roder C, Campbell A, May MLA, Blyth CC, Ferguson JK, Blackmore TK, Riley TV, Athan E. Australasian Society of Infectious Diseases updated guidelines for the management of Clostridium difficile infection in adults and children in Australia and New Zealand. Intern Med J 2017; 46:479-93. [PMID: 27062204 DOI: 10.1111/imj.13027] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 01/19/2016] [Accepted: 01/19/2016] [Indexed: 12/16/2022]
Abstract
The incidence of Clostridium difficile infection (CDI) continues to rise, whilst treatment remains problematic due to recurrent, refractory and potentially severe nature of disease. The treatment of C. difficile is a challenge for community and hospital-based clinicians. With the advent of an expanding therapeutic arsenal against C. difficile since the last published Australasian guidelines, an update on CDI treatment recommendations for Australasian clinicians was required. On behalf of the Australasian Society of Infectious Diseases, we present the updated guidelines for the management of CDI in adults and children.
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Affiliation(s)
- J A Trubiano
- Infectious Diseases Department, Austin Health, Melbourne, Western Australia.,Infectious Diseases Department, Peter MacCallum Cancer Centre, Melbourne, Western Australia
| | - A C Cheng
- Infectious Diseases Department, Alfred Health, Melbourne, Western Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Western Australia.,Infection Prevention and Healthcare Epidemiology Unit, Alfred Hospital, Melbourne, Western Australia
| | - T M Korman
- Monash Infectious Diseases, Monash Health, Monash University, Melbourne, Western Australia
| | - C Roder
- School of Medicine, Deakin University, Geelong, Victoria, Western Australia.,Geelong Centre for Emerging Infectious Diseases, Barwon Health, Geelong, Victoria, Western Australia
| | - A Campbell
- Infectious Diseases Department, Princess Margaret Hospital for Children, Queen Elizabeth II Medical Centre, Perth, Western Australia
| | - M L A May
- Infection Management and Prevention Service, Lady Cilento Children's Hospital and Sullivan Nicolaides Pathology, Brisbane, Queensland
| | - C C Blyth
- Infectious Diseases Department, Princess Margaret Hospital for Children, Queen Elizabeth II Medical Centre, Perth, Western Australia.,School of Paediatrics and Child Health, The University of Western Australia, Queen Elizabeth II Medical Centre, Perth, Western Australia.,Department of Microbiology, PathWest Laboratory Medicine, Princess Margaret Hospital, Queen Elizabeth II Medical Centre, Perth, Western Australia
| | - J K Ferguson
- Pathology North, NSW Pathology, Wellington South, New Zealand.,Immunology and Infectious Diseases Unit, John Hunter Hospital, Wellington South, New Zealand.,Universities of New England and Newcastle, Newcastle, New South Wales, Australia
| | - T K Blackmore
- Laboratory Services, Wellington Regional Hospital, Wellington South, New Zealand
| | - T V Riley
- Microbiology and Immunology, School of Pathology and Laboratory Medicine, The University of Western Australia, Queen Elizabeth II Medical Centre, Perth, Western Australia.,Department of Microbiology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Perth, Western Australia
| | - E Athan
- School of Medicine, Deakin University, Geelong, Victoria, Western Australia.,Department of Infectious Disease, Barwon Health, Geelong, Victoria, Western Australia
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Complete Microbiota Engraftment Is Not Essential for Recovery from Recurrent Clostridium difficile Infection following Fecal Microbiota Transplantation. mBio 2016; 7:mBio.01965-16. [PMID: 27999162 PMCID: PMC5181777 DOI: 10.1128/mbio.01965-16] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Bacterial communities from subjects treated for recurrent Clostridium difficile infection (rCDI) by fecal microbiota transplantation (FMT), using either heterologous donor stool samples or autologous stool samples, were characterized by Illumina next-generation sequencing. As previously reported, the success of heterologous FMT (90%) was superior to that of autologous FMT (43%) (P = 0.019), and post-FMT intestinal bacterial communities differed significantly between treatment arms (P < 0.001). Subjects cured by autologous FMT typically had greater abundances of the Clostridium XIVa clade and Holdemania bacteria prior to treatment, and the relative abundances of these groups increased significantly after FMT compared to heterologous FMT and pre-FMT samples. The typical shift to post-FMT, donor-like assemblages, featuring high relative abundances of genera within the Bacteroidetes and Firmicutes phyla, was not observed in the autologous FMT subjects. Autologous FMT patient bacterial communities were significantly different in composition than those for heterologous FMT patients and donors (P < 0.001). The SourceTracker program, which employs a Bayesian algorithm to determine source contributions to sink communities, showed that patients initially treated by heterologous FMT had significantly higher percentages of engraftment (i.e., similarity to donor communities, mean value of 74%) compared to those who suffered recurrence following autologous FMT (1%) (P ≤ 0.013). The findings of this study suggest that complete donor engraftment may be not necessary if functionally critical taxa are present in subjects following antibiotic therapy. This study provides a detailed characterization of fecal bacterial communities in subjects who participated in a previously published randomized clinical trial to treat recurrent C. difficile infection (rCDI). Bacterial communities were characterized to determine differences between subjects who received fecal bacteria either from healthy donor stool samples or their own stool samples as “placebo” in order to determine which groups of bacteria were most important in achieving a cure. The results of this study suggested that bacteria associated with secondary bile acid metabolism could potentially provide resistance to infection and that complete transfer of healthy donor microorganisms was not necessary to resolve CDI following unsuccessful antibiotic treatment.
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Adenine and benzimidazole-based mimics of REP-3123 as antibacterial agents against Clostridium difficile and Bacillus anthracis: Design, synthesis and biological evaluation. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.bfopcu.2016.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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131
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Abstract
Clostridium difficile is a sporogenic, anaerobic, Gram-positive, emerging enteric pathogen. It represents the most common cause of health care-associated diarrhoea in the United States, with significantly associated morbidity, mortality, and health care costs. Historically regarded as a little more than an innocent coloniser bystander of the gastrointestinal tract of children, C difficile has increasingly demonstrated its behaviour as a true pathogen in the paediatric age groups. This organism may be responsible for a broad spectrum of diseases in children, ranging from self-limiting secretory diarrhoea to life-threatening conditions, such as pseudomembranous colitis, toxic megacolon, intestinal perforation, and septic shock. The incidence and severity of C difficile infection are, however, not completely understood in this population. In particular, although asymptomatic carriage remains high among infants, the clinical significance of detecting C difficile in children aged 1 to 3 years is not fully understood. Moreover, recent epidemiological surveillance has demonstrated a rise in the incidence of C difficile infection, particularly in the community and in low-risk settings. Interestingly, such cases may not show the disease pattern to be associated with typical risk factors, such as recent exposure to antimicrobial drugs or on-going contacts with the health care system.The purpose of the present review is to present the features of C difficile infection that are unique to paediatric patients and to update paediatricians on information and recommendations regarding C difficile infection in children.
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Fehlbaum S, Chassard C, Poeker SA, Derrien M, Fourmestraux C, Lacroix C. Clostridium difficile colonization and antibiotics response in PolyFermS continuous model mimicking elderly intestinal fermentation. Gut Pathog 2016; 8:63. [PMID: 27980686 PMCID: PMC5133761 DOI: 10.1186/s13099-016-0144-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 11/19/2016] [Indexed: 02/07/2023] Open
Abstract
Background Clostridium difficile (CD), a spore-forming and toxin-producing bacterium, is the main cause for antibiotic-associated diarrhea in the elderly. Here we investigated CD colonization in novel in vitro fermentation models inoculated with immobilized elderly fecal microbiota and the effects of antibiotic treatments. Methods Two continuous intestinal PolyFermS models inoculated with different immobilized elder microbiota were used to investigate selected factors of colonization of CD in proximal (PC, model 1) and transverse-distal (TDC, model 1 and 2) colon conditions. Colonization of two CD strains of different PCR ribotypes, inoculated as vegetative cells (ribotype 001, model 1) or spores (ribotypes 001 and 012, model 2), was tested. Treatments with two antibiotics, ceftriaxone (daily 150 mg L−1) known to induce CD infection in vivo or metronidazole (twice daily 333 mg L−1) commonly used to treat CD, were investigated in TDC conditions (model 2) for their effects on gut microbiota composition (qPCR, 16S pyrosequencing) and activity (HPLC), CD spore germination and colonization, and cytotoxin titer (Vero cell assay). Results CD remained undetected after inoculating vegetative cells in PC reactors of model 1, but was shown to colonize TDC reactors of both models, reaching copy numbers of up to log10 8 mL−1 effluent with stable production of toxin correlating with CD cell numbers. Ceftriaxone treatment in TDC reactors showed only small effects on microbiota composition and activity and did not promote CD colonization compared to antibiotic-free control reactor. In contrast, treatment with metronidazole after colonization of CD induced large modifications in the microbiota and decreased CD numbers below the detection limit of the specific qPCR. However, a fast CD recurrence was measured only 2 days after cessation of metronidazole treatment. Conclusions Using our in vitro fermentation models, we demonstrated that stable CD colonization in TDC reactors can be induced by inoculating CD vegetative cells or spores without the application of ceftriaxone. Treatment with metronidazole temporarily reduced the counts of CD, in agreement with CD infection recurrence in vivo. Our data demonstrate that CD colonized an undisturbed microbiota in vitro, in contrast to in vivo observations, thus suggesting an important contribution of host-related factors in the protection against CD infection. Electronic supplementary material The online version of this article (doi:10.1186/s13099-016-0144-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sophie Fehlbaum
- Laboratory of Food Biotechnology, Institute of Food, Nutrition and Health, ETH Zurich, Schmelzbergstrasse 7, 8092 Zurich, Switzerland
| | - Christophe Chassard
- Laboratory of Food Biotechnology, Institute of Food, Nutrition and Health, ETH Zurich, Schmelzbergstrasse 7, 8092 Zurich, Switzerland
| | - Sophie Annick Poeker
- Laboratory of Food Biotechnology, Institute of Food, Nutrition and Health, ETH Zurich, Schmelzbergstrasse 7, 8092 Zurich, Switzerland
| | | | | | - Christophe Lacroix
- Laboratory of Food Biotechnology, Institute of Food, Nutrition and Health, ETH Zurich, Schmelzbergstrasse 7, 8092 Zurich, Switzerland
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Lübbert C, Zimmermann L, Borchert J, Hörner B, Mutters R, Rodloff AC. Epidemiology and Recurrence Rates of Clostridium difficile Infections in Germany: A Secondary Data Analysis. Infect Dis Ther 2016; 5:545-554. [PMID: 27770261 PMCID: PMC5125138 DOI: 10.1007/s40121-016-0135-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Indexed: 01/05/2023] Open
Abstract
Introduction Clostridiumdifficile infection (CDI) is the most common cause of health-care-associated infectious diarrhea. Recurrence rates are as high as 20–30% after standard treatment with metronidazole or vancomycin, and appear to be reduced for patients treated with fidaxomicin. According to the literature, the risk of CDI recurrence increases after the second relapse to 30–65%. Accurate data for Germany are not yet available. Methods Based on the research database of arvato health analytics (Munich, Germany), a secondary data analysis for the incidence, treatment characteristics and course of CDI was performed. The database included high granular accounting information of about 1.46 million medically insured patients covering the period 2006–2013, being representative for Germany. The analysis was based on new-onset CDI in 2012 in patients which either received outpatient antibiotic therapy for CDI or were hospitalized. Results The ICD-10 coded incidence of CDI in 2012 was 83 cases per 100,000 population. Overall mortality rates within the follow-up period of 1 year were 13.5% in inpatients with primary diagnosis of CDI, compared to 24.3% in inpatients with secondary diagnosis of CDI (P < 0.001), and 7.1% in outpatients (P < 0.001). In the median, patients with secondary diagnosis of CDI remained significantly longer hospitalized (24 vs. 9 days, P < 0.001). First recurrence of CDI was observed in 18.2% of cases with index events. There was a significantly increased risk to suffer a second and third recurrence, reaching 28.4% (P < 0.001), and 30.2% (P = 0.017), respectively. Antibiotic therapy of CDI in outpatients was performed mainly with metronidazole (in 90.8% of index events, 60.0% of first recurrences, and 43.5% of second recurrences). Conclusion The reported incidence of CDI in Germany is higher than noted previously. The recurrence rates do increase with the number of relapses, but are lower than reported in the literature, despite dominance of metronidazole treatment in outpatients. Funding MSD Sharp & Dohme GmbH, Haar, Germany.
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Affiliation(s)
- Christoph Lübbert
- Division of Infectious Diseases and Tropical Medicine, Department of Gastroenterology and Rheumatology, Leipzig University Hospital, Liebigstr. 20, 04103, Leipzig, Germany. .,Interdisciplinary Center for Infectious Diseases, Leipzig University Hospital, 04103, Leipzig, Germany.
| | | | | | | | - Reinier Mutters
- Institute of Medical Microbiology and Hygiene, Philipps University Marburg, 35043, Marburg, Germany
| | - Arne C Rodloff
- Interdisciplinary Center for Infectious Diseases, Leipzig University Hospital, 04103, Leipzig, Germany.,Institute for Medical Microbiology and Epidemiology of Infectious Diseases, Leipzig University Hospital, 04103, Leipzig, Germany
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Utilization of Health Services Among Adults With Recurrent Clostridium difficile Infection: A 12-Year Population-Based Study. Infect Control Hosp Epidemiol 2016; 38:45-52. [PMID: 27760583 DOI: 10.1017/ice.2016.232] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Considerable efforts have been dedicated to developing strategies to prevent and treat recurrent Clostridium difficile infection (rCDI); however, evidence of the impact of rCDI on patient healthcare utilization and outcomes is limited. OBJECTIVE To compare healthcare utilization and 1-year mortality among adults who had rCDI, nonrecurrent CDI, or no CDI. METHODS We performed a nested case-control study among adult Kaiser Foundation Health Plan members from September 1, 2001, through December 31, 2013. We identified CDI through the presence of a positive laboratory test result and divided patients into 3 groups: patients with rCDI, defined as CDI in the 14-57 days after initial CDI; patients with nonrecurrent CDI; and patients who never had CDI. We conducted 3 matched comparisons: (1) rCDI vs no CDI; (2) rCDI vs nonrecurrent CDI; (3) nonrecurrent CDI vs no CDI. We followed patients for 1 year and compared healthcare utilization between groups, after matching patients on age, sex, and comorbidity. RESULTS We found that patients with rCDI consistently have substantially higher levels of healthcare utilization in various settings and greater 1-year mortality risk than both patients who had nonrecurrent CDI and patients who never had CDI. CONCLUSIONS Patients who develop an initial CDI are generally characterized by excess underlying, severe illness and utilization. However, patients with rCDI experience even greater adverse consequences of their disease than patients who do not experience rCDI. Our results further support the need for continued emphasis on identifying and using novel approaches to prevent and treat rCDI. Infect Control Hosp Epidemiol. 2016;1-8.
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Khanna S, Pardi DS. Clinical implications of antibiotic impact on gastrointestinal microbiota and Clostridium difficile infection. Expert Rev Gastroenterol Hepatol 2016; 10:1145-1152. [PMID: 26907220 DOI: 10.1586/17474124.2016.1158097] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The human gastrointestinal (GI) microbiota plays an important role in human health. Anaerobic bacteria prevalent in the normal colon suppress the growth of non-commensal microorganisms, thus maintaining colonic homeostasis. The GI microbiota is influenced by both patient-specific and environmental factors, particularly antibiotics. Antibiotics can alter the native GI microbiota composition, leading to decreased colonization resistance and opportunistic proliferation of non-native organisms. A common and potentially serious antibiotic-induced sequela associated with GI microbiota imbalance is Clostridium difficile infection (CDI), which may become recurrent if dysbiosis persists. This review focuses on the association between antibiotics and CDI, and the antibiotic-induced disruption leading to recurrent CDI. Promoting antibiotic stewardship is pivotal in protecting native microbiota and reducing the incidence of CDI and other GI infections.
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Affiliation(s)
- Sahil Khanna
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
| | - Darrell S Pardi
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
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Kullin B, Wojno J, Abratt V, Reid SJ. Toxin A-negative toxin B-positive ribotype 017 Clostridium difficile is the dominant strain type in patients with diarrhoea attending tuberculosis hospitals in Cape Town, South Africa. Eur J Clin Microbiol Infect Dis 2016; 36:163-175. [DOI: 10.1007/s10096-016-2790-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 09/13/2016] [Indexed: 12/12/2022]
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Recombinant Mucin-Type Fusion Proteins with a Galα1,3Gal Substitution as Clostridium difficile Toxin A Inhibitors. Infect Immun 2016; 84:2842-52. [PMID: 27456831 DOI: 10.1128/iai.00341-16] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 07/18/2016] [Indexed: 02/04/2023] Open
Abstract
The capability of a recombinant mucin-like fusion protein, P-selectin glycoprotein ligand-1/mouse IgG2b (PSGL-1/mIgG2b), carrying Galα1,3Galβ1,4GlcNAc determinants to bind and inhibit Clostridium difficile toxin A (TcdA) was investigated. The fusion protein, produced by a glyco-engineered stable CHO-K1 cell line and designated C-PGC2, was purified by affinity and gel filtration chromatography from large-scale cultures. Liquid chromatography-mass spectrometry was used to characterize O-glycans released by reductive β-elimination, and new diagnostic ions to distinguish Galα1,3Gal- from Galα1,4Gal-terminated O-glycans were identified. The C-PGC2 cell line, which was 20-fold more sensitive to TcdA than the wild-type CHO-K1, is proposed as a novel cell-based model for TcdA cytotoxicity and neutralization assays. The C-PGC2-produced fusion protein could competitively inhibit TcdA binding to rabbit erythrocytes, making it a high-efficiency inhibitor of the hemagglutination property of TcdA. The fusion protein also exhibited a moderate capability for neutralization of TcdA cytotoxicity in both C-PGC2 and CHO-K1 cells, the former with and the latter without cell surface Galα1,3Galβ1,4GlcNAc sequences. Future studies in animal models of C. difficile infection will reveal its TcdA-inhibitory effect and therapeutic potential in C. difficile-associated diseases.
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Chen S, Gu H, Sun C, Wang H, Wang J. Rapid detection of Clostridium difficile toxins and laboratory diagnosis of Clostridium difficile infections. Infection 2016; 45:255-262. [PMID: 27601055 DOI: 10.1007/s15010-016-0940-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 08/11/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Clostridium difficile is an anaerobic, spore-forming and Gram-positive bacillus. It is the major cause of antibiotic-associated diarrhea prevailing in hospital settings. The morbidity and mortality of C. difficile infection (CDI) has increased significantly due to the emergence of hypervirulent strains. Because of the poor clinical different between CDI and other causes of hospital-acquired diarrhea, laboratory test for C. difficile is an important intervention for diagnosis of CDI. OBJECTIVE Laboratory tests for CDI can broadly detect either the organisms or its toxins. Currently, several laboratory tests are used for diagnosis of CDI, including toxigenic culture, glutamate dehydrogenase detection, nucleic acid amplification testing, cell cytotoxicity assay, and enzyme immunoassay towards toxin A and/or B. This review focuses on the rapid testing of C. difficile toxins and currently available methods for diagnosis of CDI, giving an overview of the role that the toxins rapid detecting plays in clinical diagnosis of CDI.
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Affiliation(s)
- Shuyi Chen
- School of Bioscience and Bioengineering, South China University of Technology, Guangzhou, China
| | - Huawei Gu
- School of Bioscience and Bioengineering, South China University of Technology, Guangzhou, China
| | - Chunli Sun
- School of Bioscience and Bioengineering, South China University of Technology, Guangzhou, China
| | - Haiying Wang
- School of Bioscience and Bioengineering, South China University of Technology, Guangzhou, China
| | - Jufang Wang
- School of Bioscience and Bioengineering, South China University of Technology, Guangzhou, China.
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Vivancos-Gallego MJ, Jiménez-López MÁ, Gioia F, Ibañez-Segura D, Romero-Vivas J, Cobo J. A scoring system for prescribing fidaxomicin in Clostridium diffícile infection. Enferm Infecc Microbiol Clin 2016; 36:34-37. [PMID: 27601193 DOI: 10.1016/j.eimc.2016.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 07/25/2016] [Accepted: 07/29/2016] [Indexed: 01/27/2023]
Abstract
Recurrences of Clostridium difficile infections lead to hospital readmissions and high costs, in addition to the suffering and frustration for the patients. Fidaxomicin has recently been introduced as a new antibiotic that has been shown to significantly reduce the recurrence of this infection. Despite this superiority, its high cost has led to very restrictive policies in its use, as such that many institutions only use it in patients with multiple recurrences. While waiting for new predictive clinical tools, we propose the development of scoring systems that allow the more high-risk patients to be treated earlier.
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Affiliation(s)
| | | | - Francesca Gioia
- Servicio de Medicina Interna, Hospital Ramón y Cajal, Madrid, España
| | | | | | - Javier Cobo
- Servicio de Enfermedades Infecciosas, Hospital Ramón y Cajal, Madrid, España
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The Economic Burden of Hospital-Acquired Clostridium difficile Infection: A Population-Based Matched Cohort Study. Infect Control Hosp Epidemiol 2016; 37:1068-78. [PMID: 27322606 DOI: 10.1017/ice.2016.122] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND High-quality cost estimates for hospital-acquired Clostridium difficile infection (CDI) are vital evidence for healthcare policy and decision-making. OBJECTIVE To evaluate the costs attributable to hospital-acquired CDI from the healthcare payer perspective. METHODS We conducted a population-based propensity-score matched cohort study of incident hospitalized subjects diagnosed with CDI (those with the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Canada code A04.7) from January 1, 2003, through December 31, 2010, in Ontario, Canada. Infected subjects were matched to uninfected subjects (those without the code A04.7) on age, sex, comorbidities, geography, and other variables, and followed up through December 31, 2011. We stratified results by elective and nonelective admissions. The main study outcomes were up-to-3-year costs, which were evaluated in 2014 Canadian dollars. RESULTS We identified 28,308 infected subjects (mean annual incidence, 27.9 per 100,000 population, 3.3 per 1,000 admissions), with a mean age of 71.5 years (range, 0-107 years), 54.0% female, and 8.0% elective admissions. For elective admission subjects, cumulative mean attributable 1-, 2-, and 3-year costs adjusted for survival (undiscounted) were $32,151 (95% CI, $28,192-$36,005), $34,843 ($29,298-$40,027), and $37,171 ($30,364-$43,415), respectively. For nonelective admission subjects, the corresponding costs were $21,909 ($21,221-$22,609), $26,074 ($25,180-$27,014), and $29,944 ($28,873-$31,086), respectively. CONCLUSIONS Hospital-acquired CDI is associated with substantial healthcare costs. To the best of our knowledge, this study is the first CDI costing study to present longitudinal costs. New strategies may be warranted to mitigate this costly infectious disease. Infect Control Hosp Epidemiol 2016;37:1068-1078.
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Mathur H, Rea MC, Cotter PD, Hill C, Ross RP. The efficacy of thuricin CD, tigecycline, vancomycin, teicoplanin, rifampicin and nitazoxanide, independently and in paired combinations against Clostridium difficile biofilms and planktonic cells. Gut Pathog 2016; 8:20. [PMID: 27257437 PMCID: PMC4890490 DOI: 10.1186/s13099-016-0102-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 05/05/2016] [Indexed: 01/10/2023] Open
Abstract
Background Thuricin CD is a two-component antimicrobial, belonging to the recently designated sactibiotic subclass of bacteriocins. The aim of this study was to investigate the effects of thuricin CD, as well as the antibiotics, tigecycline, vancomycin, teicoplanin, rifampicin and nitazoxanide when used independently and when combined at low concentrations on the viability of Clostridium difficile 20291 R027, TL178 R002, Liv022 R106, DPC6350 and VPI10463 biofilms and planktonic cells. Results On the basis of XTT (2,3-bis[2-methyloxy-4-nitro-5-sulphophenyl]-2H-tetrazolium-5-carboxanilide)-menadione biofilm viability assays, we found that thuricin CD was effective against biofilms of R027, Liv022 R106 and DPC6350 when used independently while nitazoxanide and rifampicin were also potent against biofilms of R027 and DPC6350, when applied on their own. Tigecycline was found to be effective against R027 and DPC6350 biofilms, whereas teicoplanin and vancomycin when used independently were only effective against DPC6350 biofilms. The efficacies of the antibiotics rifampicin, tigecycline, vancomycin and teicoplanin against C. difficile 20291 R027 biofilms were significantly potentiated when combined with thuricin CD, indicating effective antimicrobial combinations with this sactibiotic against R027 biofilms. However, the potency of nitazoxanide against R027 biofilms was significantly diminished when combined with thuricin CD, indicating an ineffective combination with this sactibiotic against R027 biofilms. Paired combinations of thuricin CD along with these five antibiotics were effective at diminishing the viability of DPC6350 biofilms. However, such combinations were largely ineffective against biofilms of TL178 R002, Liv022 R106 and VPI10463. Conclusions To the best of our knowledge, this is the first study to highlight the activity of a sactibiotic bacteriocin against biofilms and the first to reveal the potency of the antibiotics tigecycline, teicoplanin and nitazoxanide against C. difficile biofilms. On the basis of this study, it is apparent that different strains of C. difficile possess varying abilities to form biofilms and that the sensitivities of these biofilms to different antimicrobials and antimicrobial combinations are strain-dependent. Since the formation of relatively strong biofilms by certain C. difficile strains may contribute to increased cases of antibiotic resistance and recurrence and relapse of C. difficile infection, the findings presented in this study could provide alternative strategies to target this pathogen.
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Affiliation(s)
- Harsh Mathur
- School of Microbiology, University College Cork, Cork, Ireland ; Teagasc Food Research Centre, Moorepark, Fermoy, County Cork Ireland
| | - Mary C Rea
- Teagasc Food Research Centre, Moorepark, Fermoy, County Cork Ireland ; Alimentary Pharmabiotic Centre Microbiome Institute, University College Cork, Cork, Ireland
| | - Paul D Cotter
- Teagasc Food Research Centre, Moorepark, Fermoy, County Cork Ireland ; Alimentary Pharmabiotic Centre Microbiome Institute, University College Cork, Cork, Ireland
| | - Colin Hill
- School of Microbiology, University College Cork, Cork, Ireland ; Alimentary Pharmabiotic Centre Microbiome Institute, University College Cork, Cork, Ireland
| | - R Paul Ross
- Alimentary Pharmabiotic Centre Microbiome Institute, University College Cork, Cork, Ireland ; College of Science, Engineering and Food Science, University College Cork, Cork, Ireland
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142
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Fidaxomicin versus Vancomycin in the Treatment of Clostridium difficile Infection: Canadian Outcomes. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2016; 2016:8048757. [PMID: 27366179 PMCID: PMC4904592 DOI: 10.1155/2016/8048757] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 12/28/2015] [Indexed: 12/31/2022]
Abstract
Background. This analysis examined the efficacy of fidaxomicin versus vancomycin in 406 Canadian patients with Clostridium difficile infection (CDI), based on data from 2 randomized, clinical trials. Methods. Patients received fidaxomicin or vancomycin 1. Patients were assessed for clinical response recurrence of infection and sustained clinical response for 28 days after treatment completion. Patients at increased risk of recurrence were subjected to subgroup analyses. Results. Clinical response rates for fidaxomicin (90.0%) were noninferior to those with vancomycin (92.2%; 95% confidence interval for difference: −7.7, 3.5). However, fidaxomicin-treated patients had lower recurrence (14.4% versus 28.0%, p = 0.001) and higher sustained clinical response (77.1% versus 66.3%, p = 0.016). Compared with vancomycin, fidaxomicin was associated with lower recurrence rates in all subgroups, reaching statistical significance in patients with age ≥ 65 years (16.0% versus 30.9%, p = 0.026), concomitant antibiotic use (16.2% versus 38.7%, p = 0.036), and non-BI strains (11.8% versus 28.3%, p = 0.004). Higher sustained clinical response rates were observed for fidaxomicin compared with vancomycin in all subgroups; this was statistically significant in the non-BI subgroup (82.8% versus 69.1%, p = 0.021). Conclusions. In Canadian patients, fidaxomicin was superior to vancomycin in sustaining clinical response and reducing CDI recurrence.
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143
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Di Bella S, Ascenzi P, Siarakas S, Petrosillo N, di Masi A. Clostridium difficile Toxins A and B: Insights into Pathogenic Properties and Extraintestinal Effects. Toxins (Basel) 2016; 8:E134. [PMID: 27153087 PMCID: PMC4885049 DOI: 10.3390/toxins8050134] [Citation(s) in RCA: 147] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 04/22/2016] [Accepted: 04/25/2016] [Indexed: 02/06/2023] Open
Abstract
Clostridium difficile infection (CDI) has significant clinical impact especially on the elderly and/or immunocompromised patients. The pathogenicity of Clostridium difficile is mainly mediated by two exotoxins: toxin A (TcdA) and toxin B (TcdB). These toxins primarily disrupt the cytoskeletal structure and the tight junctions of target cells causing cell rounding and ultimately cell death. Detectable C. difficile toxemia is strongly associated with fulminant disease. However, besides the well-known intestinal damage, recent animal and in vitro studies have suggested a more far-reaching role for these toxins activity including cardiac, renal, and neurologic impairment. The creation of C. difficile strains with mutations in the genes encoding toxin A and B indicate that toxin B plays a major role in overall CDI pathogenesis. Novel insights, such as the role of a regulator protein (TcdE) on toxin production and binding interactions between albumin and C. difficile toxins, have recently been discovered and will be described. Our review focuses on the toxin-mediated pathogenic processes of CDI with an emphasis on recent studies.
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Affiliation(s)
- Stefano Di Bella
- 2nd Infectious Diseases Division, National Institute for Infectious Diseases "L. Spallanzani", Rome 00149, Italy.
| | - Paolo Ascenzi
- Department of Science, Roma Tre University, Rome 00154, Italy.
| | - Steven Siarakas
- Department of Microbiology and Infectious Diseases, Concord Repatriation General Hospital, Sydney 2139, Australia.
| | - Nicola Petrosillo
- 2nd Infectious Diseases Division, National Institute for Infectious Diseases "L. Spallanzani", Rome 00149, Italy.
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144
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Vardakas KZ, Trigkidis KK, Boukouvala E, Falagas ME. Clostridium difficile infection following systemic antibiotic administration in randomised controlled trials: a systematic review and meta-analysis. Int J Antimicrob Agents 2016; 48:1-10. [PMID: 27216385 DOI: 10.1016/j.ijantimicag.2016.03.008] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 03/11/2016] [Accepted: 03/19/2016] [Indexed: 12/17/2022]
Abstract
Antibiotics have been the most important risk factor for Clostridium difficile infection (CDI). However, only data from non-randomised studies have been reviewed. We sought to evaluate the risk for development of CDI associated with the major antibiotic classes by analysing data from randomised controlled trials (RCTs). The PubMed, Cochrane and Scopus databases were searched and the references of selected RCTs were also hand-searched. Eligible studies should have compared only one antibiotic versus another administered systemically. Inclusion of studies comparing combinations of antibiotics was allowed only if the second antibiotic was the same or from the same class or if it was administered in a subset of the enrolled patients who were equally distributed in the two arms. Only a minority of the selected RCTs (79/1332; 5.9%) reported CDI episodes. Carbapenems were associated with more CDI episodes than fluoroquinolones [risk ratio (RR) = 2.44, 95% confidence interval (CI) 1.32-4.49] and cephalosporins (RR = 2.24, 95% CI 1.46-3.42), but not penicillins (RR = 2.53, 95% CI 0.87-7.41). Cephalosporins were associated with more CDIs than penicillins (RR = 2.36, 95% CI 1.32-4.23) and fluoroquinolones (RR = 2.84, 95% CI 1.60-5.06). There was no difference in CDI frequency between fluoroquinolones and penicillins (RR = 1.34, 95% CI 0.55-3.25). Finally, clindamycin was associated with more CDI episodes than cephalosporins and penicillins (RR = 3.92, 95% CI 1.15-13.43). In conclusion, data from RCTs showed that clindamycin and carbapenems were associated with more CDIs than other antibiotics.
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Affiliation(s)
- Konstantinos Z Vardakas
- Alfa Institute of Biomedical Sciences, Athens, Greece; Department of Internal Medicine-Infectious Diseases, IASO General Hospital, IASO Group, Athens, Greece.
| | | | - Eleni Boukouvala
- Department of Applied Mathematics and Physics, National Technical University of Athens, Athens, Greece
| | - Matthew E Falagas
- Alfa Institute of Biomedical Sciences, Athens, Greece; Department of Internal Medicine-Infectious Diseases, IASO General Hospital, IASO Group, Athens, Greece; Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
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145
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Marra F, Ng K. Controversies Around Epidemiology, Diagnosis and Treatment of Clostridium difficile Infection. Drugs 2016; 75:1095-118. [PMID: 26113167 DOI: 10.1007/s40265-015-0422-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Clostridium difficile infection is a major public health problem. However, in recent years the epidemiology, risk factors, diagnosis, and treatment of C. difficile infection have undergone a significant change. The incidence of C. difficile has increased, not only in the healthcare sector but also in the community. Hospital-acquired infection and community-acquired disease have different risk factors, with the latter occurring in children and younger individuals without a history of antibiotic use or previous infections. From a clinician's perspective, a quick efficient diagnosis is required for patient treatment; however, the old method of using enzyme immunoassays is insensitive and not very specific. Recent literature around diagnostic testing for C. difficile infection suggests using PCR or a two-step algorithm to improve sensitivity and specificity. More failures and recurrence with metronidazole have led to treatment algorithms suggesting its use for mild infections and switching to vancomycin if there is no clinical improvement. Alternatively, if signs and symptoms suggest severe infection, then oral vancomycin is recommended as a first-line agent. The addition of a new but costly agent, fidaxomicin, has seen some disparity between the European and North American guidelines with regard to when it should be used. Lastly, rapid developments and good results with fecal microbial transplantation have also left clinicians wondering about its place in therapy. This article reviews the literature around some of the recent controversies in the field of C. difficile infection.
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Affiliation(s)
- Fawziah Marra
- University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada,
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146
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Sandell S, Rashid MU, Jorup-Rönström C, Ellström K, Nord CE, Weintraub A. Clostridium difficile recurrences in Stockholm. Anaerobe 2016; 38:97-102. [PMID: 26802875 DOI: 10.1016/j.anaerobe.2016.01.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 01/11/2016] [Accepted: 01/19/2016] [Indexed: 02/07/2023]
Abstract
Sixty-eight hospital-admitted patients with a first episode of Clostridium difficile infection (CDI) were included and followed up during 1 year. Faeces samples were collected at 1, 2, 6 and 12 months after inclusion and analyzed for the presence of C. difficile toxin B, genes for toxin A, toxin B, binary toxin and TcdC deletion by PCR. All strains were also PCR-ribotyped and the MICs of the isolates were determined against eight antimicrobial agents. In 68 patients initially included, antibiotics, clinical signs and co-morbidities were analyzed and 56 were evaluable for recurrences. The mean number of different antibiotics given during 3 months prior to inclusion was 2.6 (range 0-6). Six patients had not received any antibiotics and three of them had diagnosed inflammatory bowel disease. Thirty-two patients (57%) had either a microbiological or clinical recurrence, 16 of whom had clinical recurrences that were confirmed microbiologically (13, 23%) or unconfirmed by culture (3, 5%). Twenty-nine patients were positive in at least one of the follow-up tests, 16 had the same ribotype in follow-up tests, i.e. relapse, and 13 a different ribotype, i.e., reinfection. Most common ribotypes were 078/126, 020, 023, 026, 014/077, 001 and 005. No strain of ribotype 027 was found. Strains ribotype 078/126 and 023 were positive for binary toxin and were the strains most prone to cause recurrence. All strains were sensitive to vancomycin and metronidazole. Patients with recurrences were significantly older (p = 0.02) and all patients had a high burden of comorbidities, which could explain the high fatality rate, 26 (38%) patients died during the 1-year follow-up.
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Affiliation(s)
- Staffan Sandell
- Karolinska Institutet, Department of Medicine, Division of Infectious Diseases, Södersjukhuset, SE-118 83 Stockholm, Sweden
| | - Mamun-Ur Rashid
- Karolinska Institutet, Department of Laboratory Medicine, Division of Clinical Microbiology, Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden
| | - Christina Jorup-Rönström
- Karolinska Institutet, Department of Medicine, Division of Infectious Diseases, Södersjukhuset, SE-118 83 Stockholm, Sweden
| | - Kristina Ellström
- Karolinska Institutet, Department of Medicine, Division of Infectious Diseases, Södersjukhuset, SE-118 83 Stockholm, Sweden
| | - Carl Erik Nord
- Karolinska Institutet, Department of Laboratory Medicine, Division of Clinical Microbiology, Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden.
| | - Andrej Weintraub
- Karolinska Institutet, Department of Laboratory Medicine, Division of Clinical Microbiology, Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden
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147
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McFarland LV, Ozen M, Dinleyici EC, Goh S. Comparison of pediatric and adult antibiotic-associated diarrhea and Clostridium difficile infections. World J Gastroenterol 2016; 22:3078-3104. [PMID: 27003987 PMCID: PMC4789985 DOI: 10.3748/wjg.v22.i11.3078] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 01/12/2016] [Accepted: 02/22/2016] [Indexed: 02/06/2023] Open
Abstract
Antibiotic-associated diarrhea (AAD) and Clostridum difficile infections (CDI) have been well studied for adult cases, but not as well in the pediatric population. Whether the disease process or response to treatments differs between pediatric and adult patients is an important clinical concern when following global guidelines based largely on adult patients. A systematic review of the literature using databases PubMed (June 3, 1978-2015) was conducted to compare AAD and CDI in pediatric and adult populations and determine significant differences and similarities that might impact clinical decisions. In general, pediatric AAD and CDI have a more rapid onset of symptoms, a shorter duration of disease and fewer CDI complications (required surgeries and extended hospitalizations) than in adults. Children experience more community-associated CDI and are associated with smaller outbreaks than adult cases of CDI. The ribotype NAP1/027/BI is more common in adults than children. Children and adults share some similar risk factors, but adults have more complex risk factor profiles associated with more co-morbidities, types of disruptive factors and a wider range of exposures to C. difficile in the healthcare environment. The treatment of pediatric and adult AAD is similar (discontinuing or switching the inciting antibiotic), but other treatment strategies for AAD have not been established. Pediatric CDI responds better to metronidazole, while adult CDI responds better to vancomycin. Recurrent CDI is not commonly reported for children. Prevention for both pediatric and adult AAD and CDI relies upon integrated infection control programs, antibiotic stewardship and may include the use of adjunctive probiotics. Clinical presentation of pediatric AAD and CDI are different than adult AAD and CDI symptoms. These differences should be taken into account when rating severity of disease and prescribing antibiotics.
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148
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Cost-Effectiveness Analysis of Six Strategies to Treat Recurrent Clostridium difficile Infection. PLoS One 2016; 11:e0149521. [PMID: 26901316 PMCID: PMC4769325 DOI: 10.1371/journal.pone.0149521] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 02/02/2016] [Indexed: 12/17/2022] Open
Abstract
Objective To assess the cost-effectiveness of six treatment strategies for patients diagnosed with recurrent Clostridium difficile infection (CDI) in Canada: 1. oral metronidazole; 2. oral vancomycin; 3.oral fidaxomicin; 4. fecal transplantation by enema; 5. fecal transplantation by nasogastric tube; and 6. fecal transplantation by colonoscopy. Perspective Public insurer for all hospital and physician services. Setting Ontario, Canada. Methods A decision analytic model was used to model costs and lifetime health effects of each strategy for a typical patient experiencing up to three recurrences, over 18 weeks. Recurrence data and utilities were obtained from published sources. Cost data was obtained from published sources and hospitals in Toronto, Canada. The willingness-to-pay threshold was $50,000/QALY gained. Results Fecal transplantation by colonoscopy dominated all other strategies in the base case, as it was less costly and more effective than all alternatives. After accounting for uncertainty in all model parameters, there was an 87% probability that fecal transplantation by colonoscopy was the most beneficial strategy. If colonoscopy was not available, fecal transplantation by enema was cost-effective at $1,708 per QALY gained, compared to metronidazole. In addition, fecal transplantation by enema was the preferred strategy if the probability of recurrence following this strategy was below 8.7%. If fecal transplantation by any means was unavailable, fidaxomicin was cost-effective at an additional cost of $25,968 per QALY gained, compared to metronidazole. Conclusion Fecal transplantation by colonoscopy (or enema, if colonoscopy is unavailable) is cost-effective for treating recurrent CDI in Canada. Where fecal transplantation is not available, fidaxomicin is also cost-effective.
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149
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Spigaglia P. Recent advances in the understanding of antibiotic resistance in Clostridium difficile infection. Ther Adv Infect Dis 2016; 3:23-42. [PMID: 26862400 DOI: 10.1177/2049936115622891] [Citation(s) in RCA: 145] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Clostridium difficile epidemiology has changed in recent years, with the emergence of highly virulent types associated with severe infections, high rates of recurrences and mortality. Antibiotic resistance plays an important role in driving these epidemiological changes and the emergence of new types. While clindamycin resistance was driving historical endemic types, new types are associated with resistance to fluoroquinolones. Furthermore, resistance to multiple antibiotics is a common feature of the newly emergent strains and, in general, of many epidemic isolates. A reduced susceptibility to antibiotics used for C. difficile infection (CDI) treatment, in particular to metronidazole, has recently been described in several studies. Furthermore, an increased number of strains show resistance to rifamycins, used for the treatment of relapsing CDI. Several mechanisms of resistance have been identified in C. difficile, including acquisition of genetic elements and alterations of the antibiotic target sites. The C. difficile genome contains a plethora of mobile genetic elements, many of them involved in antibiotic resistance. Transfer of genetic elements among C. difficile strains or between C. difficile and other bacterial species can occur through different mechanisms that facilitate their spread. Investigations of the fitness cost in C. difficile indicate that both genetic elements and mutations in the molecular targets of antibiotics can be maintained regardless of the burden imposed on fitness, suggesting that resistances may persist in the C. difficile population also in absence of antibiotic selective pressure. The rapid evolution of antibiotic resistance and its composite nature complicate strategies in the treatment and prevention of CDI. The rapid identification of new phenotypic and genotypic traits, the implementation of effective antimicrobial stewardship and infection control programs, and the development of alternative therapies are needed to prevent and contain the spread of resistance and to ensure an efficacious therapy for CDI.
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150
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Chopra T, Goldstein EJC. Clostridium difficile Infection in Long-term Care Facilities: A Call to Action for Antimicrobial Stewardship. Clin Infect Dis 2016; 60 Suppl 2:S72-6. [PMID: 25922404 DOI: 10.1093/cid/civ053] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Across the United States, the baby boomers are entering into their elderly years. As they are America's largest generation to do so to date, their need for care will greatly affect nursing homes, long-term care facilities, and long-term acute-care hospitals (LTACHs). Unfortunately, the rise of Clostridium difficile infection (CDI), particularly in extended-care facilities, might become the biggest obstacle in their care. Elderly extended-care-facility residents are at an elevated risk of CDI simply due to their advanced age and the fact that they are receiving care in an extended-care facility. LTACHs experience a high incidence rate of CDI, and these infections can lead to major complications for a patient's health. Other factors that contribute to higher risk for CDI include receiving multiple courses of antibiotics, longer length of antibiotic treatment, and previous CDI. Although this obstacle to proper care is great, some simple solutions are available to healthcare providers. Probiotics may help improve natural immunity in patients, and strict adherence to antimicrobial stewardship standards could help reduce this serious bacterial threat.
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Affiliation(s)
- Teena Chopra
- Division of Infectious Diseases, Wayne State University, Detroit, Michigan
| | - Ellie J C Goldstein
- R M Alden Research Laboratory, Santa Monica, California David Geffen School of Medicine at the University of California, Los Angeles
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