151
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King A, Mullish BH, Williams HRT, Aylin P. Comparative epidemiology of Clostridium difficile infection: England and the USA. Int J Qual Health Care 2018; 29:785-791. [PMID: 29025123 DOI: 10.1093/intqhc/mzx120] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 08/23/2017] [Indexed: 12/18/2022] Open
Abstract
Objective To examine whether there is an epidemiological difference between Clostridium difficile infection (CDI) inpatient populations in England and the United States. Design A cross-sectional study. Setting National administrative inpatient discharge data from England (Hospital Episode Statistics) and the USA (National Inpatient Sample) in 2012. Participants De-identifiable non-obstetric inpatient discharges from the national datasets were used to estimate national CDI incidence in the United States and England using ICD9-CM(008.45) and ICD10(A04.7) respectively. Main outcome measures The rate of CDI was calculated per 100 000 population using national population estimates. Rate per 100 000 inpatient discharges was also calculated separated by primary and secondary diagnosis of CDI. Age, sex and Elixhauser comorbidities profiles were examined. Results The USA had a higher rate of CDI compared to England: 115.1/100 000 vs. 19.3/100 000 population (P < 0.001). CDI age profiles differed between the countries (P < 0.001): in England, patients ≥75 years constitute a larger proportion of CDI cases, whilst those aged 25-70 constitute more cases in the US (P < 0.001). Overall adjusted odds of CDI in females compared to males was elevated in both England (odds ratios (OR) 1.26 95% CI [1.21,1.31] P < 0.001) and the USA (OR 1.20 95% CI [1.18,1.22] P < 0.001). The proportion of CDI patients with comorbidities was greater in the USA compared to England apart from dementia, which was greater in England (9.63% vs. 1.25%, P < 0.0001). Conclusions The 2012 inpatient CDI rate within the USA was much higher than in England. Age and comorbidity profiles also differed between CDI patients in both countries. The reasons for this are likely multi-factorial but may reflect national infection control policy.
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Affiliation(s)
- Alice King
- Dr Foster Unit at Imperial College London, 3 Dorset Rise, London EC4Y 8EN, UK
| | - Benjamin H Mullish
- Division of Digestive Diseases, Department of Surgery and Cancer, Faculty of Medicine, St Mary's Hospital Campus, Imperial College London, South Wharf Road, London W2 1NY, UK
| | - Horace R T Williams
- Division of Digestive Diseases, Department of Surgery and Cancer, Faculty of Medicine, St Mary's Hospital Campus, Imperial College London, South Wharf Road, London W2 1NY, UK
| | - Paul Aylin
- Dr Foster Unit at Imperial College London, 3 Dorset Rise, London EC4Y 8EN, UK
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152
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Vaustat D, Rollet R. Glutamato deshidrogenasa. Su valor diagnóstico en la diarrea por Clostridioides difficile. Rev Argent Microbiol 2018; 50:264-268. [DOI: 10.1016/j.ram.2017.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 07/20/2017] [Accepted: 08/29/2017] [Indexed: 11/16/2022] Open
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153
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McGovern AM, Androga GO, Moono P, Collins DA, Foster NF, Chang BJ, Riley TV. Evaluation of the Cepheid ® Xpert ® C. difficile binary toxin (BT) diagnostic assay. Anaerobe 2018. [DOI: 10.1016/j.anaerobe.2018.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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154
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Aljefri DM, Christensen AB, Gibson AK, Postelnick M. Role of Antimicrobial Stewardship Programs in Decreasing Hospital-Associated Clostridium difficile Infections. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018. [DOI: 10.1007/s40506-018-0151-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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155
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Quantitative Thresholds Enable Accurate Identification of Clostridium difficile Infection by the Luminex xTAG Gastrointestinal Pathogen Panel. J Clin Microbiol 2018; 56:JCM.01885-17. [PMID: 29643194 DOI: 10.1128/jcm.01885-17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 03/26/2018] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile colonizes the gastrointestinal (GI) tract, resulting in either asymptomatic carriage or a spectrum of diarrheal illness. If clinical suspicion for C. difficile is low, stool samples are often submitted for analysis by multiplex molecular assays capable of detecting multiple GI pathogens, and some institutions do not report this organism due to concerns for high false-positive rates. Since clinical disease correlates with organism burden and molecular assays yield quantitative data, we hypothesized that numerical cutoffs could be utilized to improve the specificity of the Luminex xTAG GI pathogen panel (GPP) for C. difficile infection. Analysis of cotested liquid stool samples (n = 1,105) identified a GPP median fluorescence intensity (MFI) value cutoff of ≥1,200 to be predictive of two-step algorithm (2-SA; 96.4% concordance) and toxin enzyme immunoassay (EIA) positivity. Application of this cutoff to a second cotested data set (n = 1,428) yielded 96.5% concordance. To determine test performance characteristics, concordant results were deemed positive or negative, and discordant results were adjudicated via chart review. Test performance characteristics for the MFI cutoff of ≥150 (standard), MFI cutoff of ≥1,200, and 2-SA were as follows (respectively): concordance, 95, 96, and 97%; sensitivity, 93, 78, and 90%; specificity, 95, 98, and 98%; positive predictive value, 67, 82, and 81%;, and negative predictive value, 99, 98, and 99%. To capture the high sensitivity for organism detection (MFI of ≥150) and high specificity for active infection (MFI of ≥1,200), we developed and applied a reporting algorithm to interpret GPP data from patients (n = 563) with clinician orders only for syndromic panel testing, thus enabling accurate reporting of C. difficile for 95% of samples (514 negative and 5 true positives) irrespective of initial clinical suspicion and without the need for additional testing.
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156
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Searching for a Potential Algorithm for Clostridium difficile Testing at a Tertiary Care Hospital: Does Toxin Enzyme Immunoassay Testing Help? J Clin Microbiol 2018; 56:JCM.00415-18. [PMID: 29743303 DOI: 10.1128/jcm.00415-18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 05/02/2018] [Indexed: 01/05/2023] Open
Abstract
Clostridium difficile is a major contributor to morbidity and mortality in the United States. Methods for identifying the organism in stool include molecular platforms, enzyme immunoassays (EIAs) for toxin, and culture. Controversy persists over whether molecular tests are too sensitive at identifying C. difficile, and there are questions about how additional laboratory information could inform clinical management and reduce over treatment. The aim of this study was to assess whether clinical factors are related to the toxin status of patients and whether information about toxin status could potentially inform clinical management of patients. A total of 201 PCR-positive C. difficile stool samples from adult patients at our institution underwent EIA toxin testing. Clinical and laboratory data were collected, and the percentage of PCR-positive/EIA-positive (PCR+/EIA+) patients and PCR+ and EIA-negative (PCR+/EIA-) patients was calculated. Of the 201 samples, 47% were EIA positive and 53% were EIA negative. Although PCR+/EIA+ patients were more likely to have had a prior C. difficile infection (P = 0.015), there was no statistical difference between the additional data collected that correlated with a positive EIA result. We were unable to show that patients with an EIA+ result had worse clinical parameters than those with EIA- results and concluded that establishing a testing algorithm that included both PCR and EIA testing would not change the clinical management of patients at our hospital.
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157
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Ortega L, Ryberg A, Johansson Å. HMW-profiling using MALDI-TOF MS: A screening method for outbreaks of Clostridioides difficile. Anaerobe 2018; 54:254-259. [PMID: 29698754 DOI: 10.1016/j.anaerobe.2018.04.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 04/20/2018] [Accepted: 04/20/2018] [Indexed: 02/02/2023]
Abstract
Clostridioides difficile (CD), previously known as Clostridium difficile, is an anaerobic Gram-positive rod-shaped bacterium that causes mild to severe diarrhea mainly in hospitalized patients. The bacteria are easily spread between patients and can persist in hospital wards due to its ability to form spores. An outbreak of CD causes great sufferings for patients and is in many aspects very expensive for the health care organization. Continuously monitoring circulating CD isolates in the hospital as well as being able to detect possible spread between patients at an early phase would be of great benefit. Recently a new method was published by Rizzardi et al. (2015) where CD can be typed to a High Molecular Weight (HMW)-profile using Matrix-Assisted Laser Desorption Ionization -Time of Flight Mass Spectrometry (MALDI-TOF MS). We analyzed 1000 isolates of toxin-positive CD with this method and compared the frequency of profiles within different hospitals as well as between two counties in the south-east part of Sweden. During the study period we could detect three outbreaks of CD in three different hospitals. One was an outbreak of CD with ribotype 027, resulting in severe consequences. The method was easily implemented at the clinical microbiology routine diagnostic laboratory and in collaboration with the hospitals Infection Control Units it is a very useful and cost-effective tool to detect outbreaks of CD at an early stage.
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Affiliation(s)
- Lucía Ortega
- Department of Clinical Microbiology Kronoberg and Blekinge, Central Hospital, Växjö, Sweden
| | - Anna Ryberg
- Department of Clinical Microbiology Kronoberg and Blekinge, Central Hospital, Växjö, Sweden
| | - Åsa Johansson
- Department of Clinical Microbiology Kronoberg and Blekinge, Central Hospital, Växjö, Sweden.
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158
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Reducing Clostridium difficile Colitis Rates Via Cost-Saving Diagnostic Stewardship. Infect Control Hosp Epidemiol 2018; 39:734-736. [DOI: 10.1017/ice.2018.51] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
We conducted a quality improvement project at a large public tertiary-care academic hospital to reduce reported hospital-acquired Clostridium difficile infection (CDI) rates. We introduced diagnostic stewardship and provider education, resulting in a 2-fold reduction in C. difficile nucleic acid amplification test (NAAT) orders and markedly lower hospital CDI rate.Infect Control Hosp Epidemiol 2018;39:734–736
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159
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McDonald LC, Gerding DN, Johnson S, Bakken JS, Carroll KC, Coffin SE, Dubberke ER, Garey KW, Gould CV, Kelly C, Loo V, Shaklee Sammons J, Sandora TJ, Wilcox MH. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2018; 66:e1-e48. [PMID: 29462280 PMCID: PMC6018983 DOI: 10.1093/cid/cix1085] [Citation(s) in RCA: 1248] [Impact Index Per Article: 208.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.
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Affiliation(s)
| | | | - Stuart Johnson
- Edward Hines Jr Veterans Administration Hospital, Hines
- Loyola University Medical Center, Maywood, Illinois
| | | | - Karen C Carroll
- Johns Hopkins University School of Medicine, Baltimore, Maryl
| | | | - Erik R Dubberke
- Washington University School of Medicine, St Louis, Missouri
| | | | - Carolyn V Gould
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ciaran Kelly
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Vivian Loo
- McGill University Health Centre, McGill University, Montréal, Québec, Canada
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160
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Reductions in Clostridium difficile Infection (CDI) Rates Using Real-Time Automated Clinical Criteria Verification to Enforce Appropriate Testing. Infect Control Hosp Epidemiol 2018; 39:625-627. [PMID: 29552992 DOI: 10.1017/ice.2018.32] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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161
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Abstract
Clostridium difficile is the main causative agent of antibiotic-associated and health care-associated infective diarrhea. Recently, there has been growing interest in alternative sources of C. difficile other than patients with Clostridium difficile infection (CDI) and the hospital environment. Notably, the role of C. difficile-colonized patients as a possible source of transmission has received attention. In this review, we present a comprehensive overview of the current understanding of C. difficile colonization. Findings from gut microbiota studies yield more insights into determinants that are important for acquiring or resisting colonization and progression to CDI. In discussions on the prevalence of C. difficile colonization among populations and its associated risk factors, colonized patients at hospital admission merit more attention, as findings from the literature have pointed to their role in both health care-associated transmission of C. difficile and a higher risk of progression to CDI once admitted. C. difficile colonization among patients at admission may have clinical implications, although further research is needed to identify if interventions are beneficial for preventing transmission or overcoming progression to CDI.
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162
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Dubberke ER, Reske KA, Olsen MA, Bommarito K, Cleveland AA, Silveira FP, Schuster MG, Kauffman CA, Avery RK, Pappas PG, Chiller TM. Epidemiology and outcomes of Clostridium difficile infection in allogeneic hematopoietic cell and lung transplant recipients. Transpl Infect Dis 2018; 20:e12855. [PMID: 29427356 DOI: 10.1111/tid.12855] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 09/29/2017] [Accepted: 11/07/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a common complication of lung and allogeneic hematopoietic cell (HCT) transplant, but the epidemiology and outcomes of CDI after transplant are poorly described. METHODS We performed a prospective, multicenter study of CDI within 365 days post-allogeneic HCT or lung transplantation. Data were collected via patient interviews and medical chart review. Participants were followed weekly in the 12 weeks post-transplant and while hospitalized and contacted monthly up to 18 months post-transplantation. RESULTS Six sites participated in the study with 614 total participants; 4 enrolled allogeneic HCT (385 participants) and 5 enrolled lung transplant recipients (229 participants). One hundred and fifty CDI cases occurred within 1 year of transplantation; the incidence among lung transplant recipients was 13.1% and among allogeneic HCTs was 31.2%. Median time to CDI was significantly shorter among allogeneic HCT than lung transplant recipients (27 days vs 90 days; P = .037). CDI was associated with significantly higher mortality from 31 to 180 days post-index date among the allogeneic HCT recipients (Hazard ratio [HR] = 1.80; P = .007). There was a trend towards increased mortality among lung transplant recipients from 120 to 180 days post-index date (HR = 4.7, P = .09). CONCLUSIONS The epidemiology and outcomes of CDI vary by transplant population; surveillance for CDI should continue beyond the immediate post-transplant period.
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Affiliation(s)
- E R Dubberke
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - K A Reske
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - M A Olsen
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - K Bommarito
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - A A Cleveland
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - F P Silveira
- Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, PA, USA
| | - M G Schuster
- University of Pennsylvania, Philadelphia, PA, USA
| | - C A Kauffman
- VA Ann Arbor Healthcare System, University of Michigan Medical School, Ann Arbor, MI, USA
| | - R K Avery
- Johns Hopkins University, Baltimore, MD, USA
| | - P G Pappas
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - T M Chiller
- Centers for Disease Control and Prevention, Atlanta, GA, USA
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163
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Dunwoody R, Steel A, Landy J, Simmonds N. Clostridium difficile and cystic fibrosis: management strategies and the role of faecal transplantation. Paediatr Respir Rev 2018; 26:16-18. [PMID: 28411069 DOI: 10.1016/j.prrv.2017.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 03/07/2017] [Indexed: 11/17/2022]
Abstract
Clostridium difficile is a bacterial infection that colonises the gut in susceptible hosts. It is associated with exposure to healthcare settings and antibiotic use. It could be assumed that cystic fibrosis (CF) patients are a high-risk group for C.difficile. However, despite high carriage rates, CF patients have low rates of active disease. There are guidelines for the treatment of C.difficile, however little is published specific to treating C.difficile in CF. This article provides an overview of the current management strategies for C.difficile in CF, including a description of the first faecal transplantation in this patient population.
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Affiliation(s)
- Roisin Dunwoody
- Adult Cystic Fibrosis Centre, Royal Brompton Hospital, London, SW3 6NP, United Kingdom
| | - Alan Steel
- Department of Gastroenterology, Chelsea and Westminster Hospital, London, United Kingdom
| | - Jonathan Landy
- Watford General Hospital, Vicarage Road, Watford, United Kingdom
| | - Nicholas Simmonds
- Adult Cystic Fibrosis Centre, Royal Brompton Hospital, London, SW3 6NP, United Kingdom.
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164
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Immunological Stability of Clostridium difficile Toxins in Clinical Specimens. Infect Control Hosp Epidemiol 2018; 39:434-438. [PMID: 29457584 DOI: 10.1017/ice.2018.20] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The impact of storage on stability and detection of Clostridium difficile toxins in feces is poorly understood. The objective of this study was to investigate the immunological stability of C. difficile toxins in clinical stool specimens under different storage conditions by evaluating this stability using toxin detection by enzyme immunoassay (EIA). METHODS Stool specimens positive for C. difficile infection (CDI) by quantitative polymerase chain reaction (qPCR) were used for EIA testing with the C. difficile Tox A/B II kit. The EIA-positive specimens were stored aerobically under refrigerated (4-10°C) and frozen (-30°C and -80°C) conditions. Measurement of toxin quantity was conducting using optical density (OD) on days 0, 14, 30, 60, 90, and 120 of storage. RESULTS Clostridium difficile toxins demonstrated good detection in undiluted stool specimens by EIA up to 120 days of storage. Good detection of the toxins was observed in diluted samples at refrigerated and -80°C temperatures. Dilution detrimentally affected toxin detection at -30°C. CONCLUSION Storage of undiluted clinical stool specimens at refrigerated, -30°C, and -80°C temperatures for up to 120 days has no discernible effect on the immunological stability of C. difficile cytotoxins. However, storage at -30°C has a detrimental effect on C. difficile toxin stability in diluted specimens. Infect Control Hosp Epidemiol 2018;39:434-438.
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165
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Peng Z, Ling L, Stratton CW, Li C, Polage CR, Wu B, Tang YW. Advances in the diagnosis and treatment of Clostridium difficile infections. Emerg Microbes Infect 2018; 7:15. [PMID: 29434201 PMCID: PMC5837143 DOI: 10.1038/s41426-017-0019-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 12/22/2017] [Accepted: 12/27/2017] [Indexed: 12/14/2022]
Abstract
Clostridium difficile is a leading cause of antibiotic-associated diarrhea worldwide. The diagnosis of C. difficile infection (CDI) requires both clinical manifestations and a positive laboratory test for C. difficile and/or its toxins. While antibiotic therapy is the treatment of choice for CDI, there are relatively few classes of effective antibiotics currently available. Therefore, the development of novel antibiotics and/or alternative treatment strategies for CDI has received a great deal of attention in recent years. A number of emerging agents such as cadazolid, surotomycin, ridinilazole, and bezlotoxumab have demonstrated activity against C. difficile; some of these have been approved for limited clinical use and some are in clinical trials. In addition, other approaches such as early and accurate diagnosis of CDI as well as disease prevention are important for clinical management. While the toxigenic culture and the cell cytotoxicity neutralization assay are still recognized as the gold standard for the diagnosis of CDI, new diagnostic approaches such as nucleic acid amplification methods have become available. In this review, we will discuss both current and emerging diagnostic and therapeutic modalities for CDI.
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Affiliation(s)
- Zhong Peng
- State Key Laboratory of Agricultural Microbiology, College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, 430070, Hubei, China
| | - Lifen Ling
- The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, 518000, Guangdong, China
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Charles W Stratton
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Chunhui Li
- Infection Control Center, Xiangya Hospital of Central South University, Changsha, 410008, Hunan, China
| | - Christopher R Polage
- Departments of Pathology and Laboratory Medicine and Internal Medicine, University of California Davis School of Medicine, Sacramento, CA, 95817, USA
| | - Bin Wu
- State Key Laboratory of Agricultural Microbiology, College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, 430070, Hubei, China
| | - Yi-Wei Tang
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.
- Department of Pathology and Laboratory Medicine, Weill Medical College of Cornell University, New York, NY, 10065, USA.
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166
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Hopkins RJ, Wilson RB. Treatment of recurrent Clostridium difficile colitis: a narrative review. Gastroenterol Rep (Oxf) 2018; 6:21-28. [PMID: 29479439 PMCID: PMC5806400 DOI: 10.1093/gastro/gox041] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 10/17/2017] [Accepted: 10/31/2017] [Indexed: 12/11/2022] Open
Abstract
Clostridium difficile is a gram-positive, spore-forming, obligate anaerobic bacillus that was originally isolated from the stool of a healthy neonate in 1935. In high-income countries, C. difficile is the most common cause of infectious diarrhoea in hospitalized patients. The incidence of C. difficile infection in the USA has increased markedly since 2000, with hospitalizations for C. difficile infections in non-pregnant adults doubling between 2000 and 2010. Between 20% and 35% of patients with C. difficile infection will fail initial antibiotic treatment and, of these, 40-60% will have a second recurrence. Recurrence of C. difficile infection after initial treatment causes substantial morbidity and is a major burden on health care systems. In this article, current treatments for recurrent C. difficile infection are reviewed and future directions explored. These include the use of antibiotics, probiotics, donor faecal transplants, anion resins, secondary bile acids or anti-toxin antibodies.
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Affiliation(s)
- Roy J Hopkins
- Department of Upper GI Surgery, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Robert B Wilson
- Department of Upper GI Surgery, Liverpool Hospital, Sydney, New South Wales, Australia
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167
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Muñoz M, Ríos-Chaparro DI, Herrera G, Soto-De Leon SC, Birchenall C, Pinilla D, Pardo-Oviedo JM, Josa DF, Patarroyo MA, Ramírez JD. New Insights into Clostridium difficile (CD) Infection in Latin America: Novel Description of Toxigenic Profiles of Diarrhea-Associated to CD in Bogotá, Colombia. Front Microbiol 2018; 9:74. [PMID: 29441053 PMCID: PMC5797639 DOI: 10.3389/fmicb.2018.00074] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 01/11/2018] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile (CD) produces antibiotic associated diarrhea and leads to a broad range of diseases. The source of CD infection (CDI) acquisition and toxigenic profile are factors determining the impact of CD. This study aimed at detecting healthcare facility onset- (HCFO) and community-onset (CO) CDI and describing their toxigenic profiles in Bogotá, Colombia. A total of 217 fecal samples from patients suffering diarrhea were simultaneously submitted to two CDI detection strategies: (i) in vitro culture using selective chromogenic medium (SCM; chromID, bioMérieux), followed verification by colony screening (VCS), and (ii) molecular detection targeting constitutive genes, using two conventional PCR tests (conv.PCR) (conv.16S y conv.gdh) and a quantitative test (qPCR.16s). The CD toxigenic profile identified by any molecular test was described using 6 tests independently for describing PaLoc and CdtLoc organization. High overall CDI frequencies were found by both SCM (52.1%) and conv.PCR (45.6% for conv.16S and 42.4% for conv.gdh), compared to reductions of up to half the frequency by VCS (27.2%) or qPCR.16S (22.6%). Infection frequencies were higher for SCM and conv.16S regarding HCFO but greater for CO concerning conv.gdh, such differences being statistically significant. Heterogeneous toxigenic profiles were found, including amplification with lok1/3 primers simultaneously with other PaLoc markers (tcdA, tcdB or tcdC). These findings correspond the first report regarding the differential detection of CDI using in vitro culture and molecular detection tests in Colombia, the circulation of CD having heterogeneous toxigenic profiles and molecular arrays which could affect the impact of CDI epidemiology.
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Affiliation(s)
- Marina Muñoz
- Universidad del Rosario, Facultad de Ciencias Naturales y Matemáticas, Programa de Biología, Grupo de Investigaciones Microbiológicas-UR (GIMUR), Bogotá, Colombia.,Posgrado Interfacultades Doctorado en Biotecnología, Facultad de Ciencias, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Dora I Ríos-Chaparro
- Universidad del Rosario, Facultad de Ciencias Naturales y Matemáticas, Programa de Biología, Grupo de Investigaciones Microbiológicas-UR (GIMUR), Bogotá, Colombia
| | - Giovanny Herrera
- Universidad del Rosario, Facultad de Ciencias Naturales y Matemáticas, Programa de Biología, Grupo de Investigaciones Microbiológicas-UR (GIMUR), Bogotá, Colombia
| | - Sara C Soto-De Leon
- Molecular Biology and Immunology Department, Fundación Instituto de Inmunología de Colombia, Bogotá, Colombia
| | | | - Darío Pinilla
- Hospital Universitario Mayor-Méderi, Bogotá, Colombia
| | | | | | - Manuel A Patarroyo
- Molecular Biology and Immunology Department, Fundación Instituto de Inmunología de Colombia, Bogotá, Colombia.,Universidad del Rosario, School of Medicine and Health Sciences, Bogotá, Colombia
| | - Juan D Ramírez
- Universidad del Rosario, Facultad de Ciencias Naturales y Matemáticas, Programa de Biología, Grupo de Investigaciones Microbiológicas-UR (GIMUR), Bogotá, Colombia
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168
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Diagnostic Guidance for C. difficile Infections. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1050:27-44. [PMID: 29383662 DOI: 10.1007/978-3-319-72799-8_3] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Diagnosis of Clostridium difficile infection (CDI) can be challenging. First of all, there has been debate on which of the two reference assays, cell cytotoxicity neutralization assay (CCNA) or toxigenic culture (TC) should be considered the gold standard for CDI detection. Although the CCNA suffers most from suboptimal storage conditions and subsequent toxin degradation, TC is reported to falsely increase CDI detection rates as it cannot differentiate CDI patients from patients asymptomatically colonised by toxigenic C. difficile. Several rapid assays are available for CDI detection and fall into three broad categories: (1) enzyme immunoassays for glutamate dehydrogenase, (2) enzyme immunoassays for toxins A/B and (3) nucleic acid amplification tests detecting toxin genes. All three categories have their own limitations, being suboptimal specificity and/or sensitivity or the inability to discern colonised patients from CDI patients. In light of these limitations, multi-step algorithmic testing has now been advocated by international guidelines in order to optimize diagnostic accuracy. Despite these recommendations, testing methods between hospitals vary widely, which impacts CDI incidence rates. CDI incidence rates are also influenced by sample selection criteria, as several studies have shown that if not all unformed stool samples are tested for CDI, many cases may be missed due to an absence of clinical suspicion. Since methods for diagnosing CDI remain imperfect, there has been a growing interest in alternative testing strategies like faecal biomarkers, immune modulating interleukins, cytokines and imaging methods. At the moment, these alternative methods might play an adjunctive role, but they are not suitable to replace conventional CDI testing strategies.
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169
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Piatti G, Bruzzone M, Fontana V, Mannini A, Ceppi M. Epidemiology of Clostridium Difficile Infection in a Large Hospital in Northern Italy: Questioning the Ward-Based Transmission. Open Microbiol J 2017; 11:360-371. [PMID: 29399217 PMCID: PMC5759130 DOI: 10.2174/1874285801711010360] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 11/30/2017] [Accepted: 12/10/2017] [Indexed: 02/07/2023] Open
Abstract
Background: Clostridium Difficile infection (CDI) is considered a ward-based nosocomial infection, due to contagion among patients. Molecular studies recently questioned ward-based contact for disease spread. Objective: To investigate whether it is plausible that CDI spread in San Martino Hospital of Genoa was due to a ward-based contact and patient-to-patient diffusion. Methods: We conducted a retrospective cohort study of CDI cases from April 2010 to March 2015. We referred to Hospital data set and Admission Service. Multilevel modelling approach and ecological analysis were used to assess C. difficile infection risk according to wards and time of occurrence. Six representative CD strains were ribotyped to assess a possible equivalence. Results: The assessment of 514 CDI cases showed that the risk of disease and rate of incidence in wards were independent, while frequency of cases and number of wards involved exhibited a positive relationship, excluding the typical epidemic pattern of contagious diffusion, i.e., many cases in few wards. The extra-binomial variability due to ward clustering was not significant, indicating homogeneity in the probability of CDI occurrence across all wards. Three hundred sixty-eight patients changed ward, without showing connection between the frequency of cases in new wards and incidence among new subjects. Trigonometric components described a significant contribution of seasonality, with excess of CDI cases during the winter months. Molecular analysis showed different ribotypes of CD strains from the same ward. Conclusion: From our results it seems unlikely that in our institution CDI occurrence is due to ward-based contact and inter-human contagion of the organism.
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Affiliation(s)
- Gabriella Piatti
- DISC, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Division of Microbiology, Ospedale Policlinico San Martino, Genoa, 10 Largo Benzi, 16132, Genoa, Italy
| | - Marco Bruzzone
- Unit of Clinical Epidemiology, Ospedale Policlinico San Martino, Genoa, 10 Largo Benzi, 16132, Genoa, Italy
| | - Vincenzo Fontana
- Unit of Clinical Epidemiology, Ospedale Policlinico San Martino, Genoa, 10 Largo Benzi, 16132, Genoa, Italy
| | - Alessandro Mannini
- Department of Science, Environment and Life, University of Genoa, Genoa, Italy
| | - Marcello Ceppi
- Unit of Clinical Epidemiology, Ospedale Policlinico San Martino, Genoa, 10 Largo Benzi, 16132, Genoa, Italy
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170
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Nagy E. What do we know about the diagnostics, treatment and epidemiology of Clostridioides (Clostridium) difficile infection in Europe? J Infect Chemother 2017; 24:164-170. [PMID: 29289484 DOI: 10.1016/j.jiac.2017.12.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 11/28/2017] [Accepted: 12/05/2017] [Indexed: 12/17/2022]
Abstract
Clostridium difficile, recently reclassified as Clostridioides difficile is responsible for a significant part of diarrheal diseases in the hospitals and in the community. Besides the main pathogenic factors, toxin A, toxin B and the binary toxin, several other putative virulence factors have been investigated. This manuscript summarize recent findings in Europe concerning source of infection, epidemiology of CDI, the changing pattern of PCR ribotypes of C. difficile strains in different European countries, recommendations for diagnosis and treatment of CDI.
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Affiliation(s)
- Elisabeth Nagy
- Institute of Clinical Microbiology, University of Szeged, Szeged, Hungary.
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171
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Zhou W, Chen Y, Roh T, Lin Y, Ling S, Zhao S, Lin JD, Khalil N, Cairns DM, Manousiouthakis E, Tse M, Kaplan DL. Multifunctional Bioreactor System for Human Intestine Tissues. ACS Biomater Sci Eng 2017; 4:231-239. [PMID: 29333491 PMCID: PMC5761048 DOI: 10.1021/acsbiomaterials.7b00794] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 12/08/2017] [Indexed: 12/24/2022]
Abstract
The three-dimensional (3D) cultivation of intestinal cells and tissues in dynamic bioreactor systems to represent in vivo intestinal microenvironments is essential for developing regenerative medicine treatments for intestinal diseases. We have previously developed in vitro human intestinal tissue systems using a 3D porous silk scaffold system with intestinal architectures and topographical features for the adhesion, growth, and differentiation of intestinal cells under static culture conditions. In this study, we designed and fabricated a multifunctional bioreactor system that incorporates pre-epithelialized 3D silk scaffolds in a dynamic culture environment for in vitro engineering of human intestine tissues. The bioreactor system allows for control of oxygen levels in perfusion fluids (aerobic simulated intestinal fluid (SIF), microaerobic SIF, and anaerobic SIF), while ensuring control over the mechanical and chemical microenvironments present in native human intestines. The bioreactor system also enables 3D cell culture with spatial separation and cultivation of cocultured epithelial and stromal cells. Preliminary functional analysis of tissues housed in the bioreactor demonstrated that the 3D tissue constructs survived and maintained typical phenotypes of intestinal epithelium, including epithelial tight junction formation, intestinal biomarker expression, microvilli formation, and mucus secretion. The unique combination of a dynamic bioreactor and 3D intestinal constructs offers utility for engineering human intestinal tissues for the study of intestinal diseases and discovery options for new treatments.
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Affiliation(s)
- Wenda Zhou
- Department of Biomedical Engineering, Tufts University, 4 Colby Street, Medford, Massachusetts 02155, United States.,National Engineering Laboratory for Modern Silk, College of Textile and Clothing Engineering, Soochow University, Suzhou 215021, People's Republic of China
| | - Ying Chen
- Department of Biomedical Engineering, Tufts University, 4 Colby Street, Medford, Massachusetts 02155, United States
| | - Terrence Roh
- Department of Biomedical Engineering, Tufts University, 4 Colby Street, Medford, Massachusetts 02155, United States
| | - Yinan Lin
- Department of Biomedical Engineering, Tufts University, 4 Colby Street, Medford, Massachusetts 02155, United States
| | - Shengjie Ling
- Department of Biomedical Engineering, Tufts University, 4 Colby Street, Medford, Massachusetts 02155, United States.,Department of Civil and Environmental Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, United States
| | - Siwei Zhao
- Department of Biomedical Engineering, Tufts University, 4 Colby Street, Medford, Massachusetts 02155, United States
| | - James D Lin
- Department of Biomedical Engineering, Tufts University, 4 Colby Street, Medford, Massachusetts 02155, United States
| | - Noor Khalil
- Department of Biomedical Engineering, Tufts University, 4 Colby Street, Medford, Massachusetts 02155, United States
| | - Dana M Cairns
- Department of Biomedical Engineering, Tufts University, 4 Colby Street, Medford, Massachusetts 02155, United States
| | - Eleana Manousiouthakis
- Department of Biomedical Engineering, Tufts University, 4 Colby Street, Medford, Massachusetts 02155, United States
| | - Megan Tse
- Department of Biomedical Engineering, Tufts University, 4 Colby Street, Medford, Massachusetts 02155, United States
| | - David L Kaplan
- Department of Biomedical Engineering, Tufts University, 4 Colby Street, Medford, Massachusetts 02155, United States
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172
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Kim HN, Kim H, Moon HW, Hur M, Yun YM. Toxin positivity and tcdB gene load in broad-spectrum Clostridium difficile infection. Infection 2017; 46:113-117. [PMID: 29218569 DOI: 10.1007/s15010-017-1108-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 12/04/2017] [Indexed: 12/18/2022]
Abstract
PURPOSE This study aimed to evaluate the clinical significance of toxin positivity and toxin gene load, and the relation between them in the broad spectrum of Clostridium difficile infection (CDI) including colonization, significant diarrhea, and severe disease. METHODS We included 2671 fecal samples submitted for CDI diagnosis and 180 samples from healthy individuals. The clinical spectrum was categorized as category I (toxigenic C. difficile positive without clinical CDI criteria), category II (mild CDI), and category III (severe CDI). Clinical parameters were compared based on toxin EIA and tcdB C t values. C t values of tcdB PCR for predicting toxin EIA positivity were assessed using receiver-operating characteristic (ROC) curves. RESULTS The median C t values of tcdB PCR and toxin positivity were not significantly correlated with clinical spectrum of CDI (27.5, 28.2, and 26.1 for tcdB C t and 55.0, 56.6, and 60.9% for toxin EIA positivity in category I, II, and III, respectively, P > 0.05). There were significant differences in the tcdB C t values between toxin EIA-positive and -negative groups (P < 0.001). Optimal cutoff for the tcdB C t value for estimating toxin EIA positivity was 26.3 with 79.3% sensitivity and 83.6% specificity with good area under the curves (AUC, 0.848). CONCLUSIONS The C t values successfully predicted toxin EIA positivity and could be used as a surrogate for toxin EIA positivity in the diagnostic algorithm and routine analysis. Further studies are needed to validate the clinical significance of tcdB PCR C t value in toxigenic C. difficile colonization and infection.
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Affiliation(s)
- Hyeong Nyeon Kim
- Department of Laboratory Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, 120-1, Neungdong-ro, Gwangjin-gu, Seoul, 05030, Korea
| | - Hanah Kim
- Department of Laboratory Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, 120-1, Neungdong-ro, Gwangjin-gu, Seoul, 05030, Korea
| | - Hee-Won Moon
- Department of Laboratory Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, 120-1, Neungdong-ro, Gwangjin-gu, Seoul, 05030, Korea.
| | - Mina Hur
- Department of Laboratory Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, 120-1, Neungdong-ro, Gwangjin-gu, Seoul, 05030, Korea
| | - Yeo-Min Yun
- Department of Laboratory Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, 120-1, Neungdong-ro, Gwangjin-gu, Seoul, 05030, Korea
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173
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Garg SK, Lu K, Duncan J, Peterson LR, Liesenfeld O. Equivalent Performance of the Cobas ® Cdiff Test for Use on the Cobas ® Liat ® System and the Cobas ® 4800 System. Eur J Microbiol Immunol (Bp) 2017; 7:310-318. [PMID: 29403660 PMCID: PMC5793701 DOI: 10.1556/1886.2017.00034] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 11/11/2017] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile infection is a significant health burden, and innovative solutions are needed to shorten time to diagnosis and improve infection control. We evaluated the performance of the cobas® Cdiff test for use on the cobas® Liat® System (cobas® Liat® Cdiff), a single-sample, on-demand, and automated molecular solution with a 20-min turnaround time. The limit of detection was 45-90 colony-forming units (CFUs)/swab for toxigenic strains that covered the most prevalent toxinotypes, including the hyper-virulent epidemic 027/BI/NAP1 strain. Using 442 prospectively collected clinical stool specimens, we compared the performance of the cobas® Liat® Cdiff to direct culture and to the cobas® Cdiff test on the cobas® 4800 System (cobas® 4800 Cdiff) - a medium-throughput molecular platform. The sensitivity and specificity of the cobas® Liat® Cdiff compared to direct culture were 93.1% and 95.1%, respectively, and this performance did not statistically differ from the cobas® 4800 Cdiff (P < 0.05). Direct correlation of the cobas® Liat® and cobas® 4800 Cdiff tests yielded overall percent agreement of 98.6%. The test performance, automation, and turnaround time of the cobas® Liat® Cdiff enable its use for on-demand and out-of-hours testing as a complement to existing batch testing solutions like the cobas® 4800 Cdiff.
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Affiliation(s)
- Sachin K Garg
- Medical and Scientific Affairs, Roche Molecular Diagnostics, Pleasanton, CA, USA
| | - Kyle Lu
- Development, Roche Molecular Diagnostics, Pleasanton, CA, USA
| | - John Duncan
- Medical and Scientific Affairs, Roche Molecular Diagnostics, Pleasanton, CA, USA
| | | | - Oliver Liesenfeld
- Medical and Scientific Affairs, Roche Molecular Diagnostics, Pleasanton, CA, USA
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174
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Guinta MM, Bunnell K, Harrington A, Bleasdale S, Danziger L, Wenzler E. Clinical and economic impact of the introduction of a nucleic acid amplification assay for Clostridium difficile. Ann Clin Microbiol Antimicrob 2017; 16:77. [PMID: 29202797 PMCID: PMC5713042 DOI: 10.1186/s12941-017-0252-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 11/23/2017] [Indexed: 01/03/2023] Open
Abstract
Background The clinical outcomes and cost implications of a diagnostic shift from an EIA- to PCR-based assay for Clostridium difficile infection (CDI) have not been completely described in the literature. Methods The impact of the PCR-based assay on the incidence and duration of CDI therapy was compared to the EIA assay for patients with a negative CDI diagnostic result. Secondary clinical and economic outcomes were also evaluated. Independent predictors of receipt of antibiotic therapy were assessed via logistic regression. Results 141 EIA and 140 PCR patients were included. Significantly more patients were started or continued on anti-CDI antibiotic therapy after a known negative assay result in the EIA group (26 patients vs. 8 patients, P = 0.002). Duration of antibiotic therapy after a known negative result was significantly shorter in the PCR group (1 vs. 4 days, P = 0.029) and a 23% reduction in the number of tests obtained per patient was observed (1.41 ± 0.86 vs. 1.82 ± 1.35, P = 0.007). The over fourfold difference in per-test cost of the EIA assay ($8.33 vs. $42.86, P < 0.0001) was offset by the overall medication costs required for the increased treatment in the EIA group ($546.60 vs. $188.96, P = 0.191). Utilization of the EIA-based CDI assay was associated with increased odds of CDI treatment after a negative test (aOR 4.71, 95% CI 1.93–11.46, P = 0.001). Conclusion The transition from an EIA to PCR-based assay for diagnosing CDI resulted in a significant decrease in the number of patients treated and the duration of treatment in response to a negative test result. This significant decrease in treatment resulted in decreased costs offsetting the utilization of a more expensive molecular test for patients with a negative CDI diagnostic result.
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Affiliation(s)
- Margaret M Guinta
- College of Pharmacy, University of Illinois at Chicago, 833 South Wood St. Room 164, Chicago, IL, USA
| | - Kristen Bunnell
- College of Pharmacy, University of Illinois at Chicago, 833 South Wood St. Room 164, Chicago, IL, USA
| | - Amanda Harrington
- Department of Pathology, University of Illinois at Chicago, Chicago, IL, USA
| | - Susan Bleasdale
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Larry Danziger
- College of Pharmacy, University of Illinois at Chicago, 833 South Wood St. Room 164, Chicago, IL, USA
| | - Eric Wenzler
- College of Pharmacy, University of Illinois at Chicago, 833 South Wood St. Room 164, Chicago, IL, USA.
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175
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Peterson LR, Young SA, Davis TE, Wang ZX, Duncan J, Noutsios C, Liesenfeld O, Osiecki JC, Lewinski MA. Evaluation of the cobas Cdiff Test for Detection of Toxigenic Clostridium difficile in Stool Samples. J Clin Microbiol 2017; 55:3426-3436. [PMID: 28954901 PMCID: PMC5703809 DOI: 10.1128/jcm.01135-17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 09/22/2017] [Indexed: 12/18/2022] Open
Abstract
Nucleic acid amplification tests (NAATs) are reliable tools for the detection of toxigenic Clostridium difficile from unformed (liquid or soft) stool samples. The objective of this study was to evaluate performance of the cobas Cdiff test on the cobas 4800 system using prospectively collected stool specimens from patients suspected of having C. difficile infection (CDI). The performance of the cobas Cdiff test was compared to the results of combined direct and broth-enriched toxigenic culture methods in a large, multicenter clinical trial. Additional discrepancy analysis was performed by using the Xpert C. difficile Epi test. Sample storage was evaluated by using contrived and fresh samples before and after storage at -20°C. Testing was performed on samples from 683 subjects (306 males and 377 females); 113 (16.5%) of 683 subjects were positive for toxigenic C. difficile by direct toxigenic culture, and 141 of 682 subjects were positive by using the combined direct and enriched toxigenic culture method (reference method), for a prevalence rate of 20.7%. The sensitivity and specificity of the cobas Cdiff test compared to the combined direct and enriched culture method were 92.9% (131/141; 95% confidence interval [CI], 87.4% to 96.1%) and 98.7% (534/541; 95% CI, 97.4% to 99.4%), respectively. Discrepancy analysis using results for retested samples from a second NAAT (Xpert C. difficile/Epi test; Cepheid, Sunnyvale, CA) found no false-negative and 4 false-positive cobas Cdiff test results. There was no difference in positive and negative results in comparisons of fresh and stored samples. These results support the use of the cobas Cdiff test as a robust aid in the diagnosis of CDI.
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Affiliation(s)
- Lance R Peterson
- Department of Laboratory Medicine and Pathology, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Stephen A Young
- Department of Pathology, University of New Mexico HSC, Albuquerque, New Mexico, USA
- TriCore Reference Laboratories, Albuquerque, New Mexico, USA
| | - Thomas E Davis
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Zi-Xuam Wang
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - John Duncan
- Medical and Scientific Affairs, Roche Molecular Diagnostics, Pleasanton, California, USA
| | - Christopher Noutsios
- Medical and Scientific Affairs, Roche Molecular Diagnostics, Pleasanton, California, USA
| | - Oliver Liesenfeld
- Medical and Scientific Affairs, Roche Molecular Diagnostics, Pleasanton, California, USA
| | - John C Osiecki
- Medical and Scientific Affairs, Roche Molecular Diagnostics, Pleasanton, California, USA
| | - Michael A Lewinski
- Medical and Scientific Affairs, Roche Molecular Diagnostics, Pleasanton, California, USA
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176
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Muñoz M, Camargo M, Ríos-Chaparro DI, Gómez P, Patarroyo MA, Ramírez JD. Community-acquired infection with hypervirulent Clostridium difficile isolates that carry different toxin and antibiotic resistance loci: a case report. Gut Pathog 2017; 9:63. [PMID: 29151897 PMCID: PMC5680771 DOI: 10.1186/s13099-017-0212-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 11/01/2017] [Indexed: 01/05/2023] Open
Abstract
Background Clostridium difficile infection (CDI) leads to the onset of antibiotic-associated diarrhea (AAD) and a wide range of gastrointestinal pathologies. Currently, CDI is one of the most important opportunistic infections at the intrahospital level and an exponential increase in community-acquired infections has been reported. Herein, we evaluated the relationships (at phylogenetic and genetic population structure levels), as well as the molecular toxigenic and antibiotic resistance profiles of a set of isolates established from a case of community acquired-CDI. Case presentation A 30-year-old woman with no history of hospitalization who was exposed to antibiotics (ampicillin/sulbactam and metronidazole) after a cat-bite wound was presented. The patient had a continuous episode of diarrhea; a stool sample was then collected and community acquired-CDI was confirmed by molecular tests and in vitro culture. Seven isolates were established and subsequently subjected to: (i) Multilocus sequence typing, all isolates belonging to ST-1 (associated with hypervirulent strain (027/BI/NAP1); (ii) description of their toxigenic profile: two of the isolates (Gcol.49 and Gcol.91) were positive for the genes coding for the major toxins (tcdA and tcdB) and their negative regulator (tcdC). All isolates were positive for the cdtB gene encoding one of the binary toxin subunits, while only two (Gcol.51 and Gcol.52) were positive for cdtA; and (iii) identification of antibiotic resistance molecular markers, where there was no difference in gyrA or gyrB gene polymorphisms (related to quinolone resistance), but rather at loci presence/absence, being just one isolate negative, whereas the others showed a differential presence of the tet, ermB and Tn916 regions. The former was associated with resistance to tetracycline and the other two for erythromycin/clindamycin. Conclusions This case represents the first report of community acquired-CDI in Colombia associated with hypervirulent strains and shows that isolates obtained from a single patient can carry different toxin and antibiotic resistance loci. Electronic supplementary material The online version of this article (10.1186/s13099-017-0212-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marina Muñoz
- Universidad del Rosario, Facultad de Ciencias Naturales y Matemáticas, Programa de Biología, Grupo de Investigaciones Microbiológicas-UR (GIMUR), Bogotá, Colombia.,Posgrado Interfacultades Doctorado en Biotecnología, Facultad de Ciencias, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Milena Camargo
- Molecular Biology and Immunology Department, Fundación Instituto de Inmunología de Colombia (FIDIC), Bogotá, Colombia
| | - Dora Inés Ríos-Chaparro
- Universidad del Rosario, Facultad de Ciencias Naturales y Matemáticas, Programa de Biología, Grupo de Investigaciones Microbiológicas-UR (GIMUR), Bogotá, Colombia
| | - Paula Gómez
- Universidad del Rosario, School of Medicine and Health Sciences, Bogotá, Colombia
| | - Manuel Alfonso Patarroyo
- Molecular Biology and Immunology Department, Fundación Instituto de Inmunología de Colombia (FIDIC), Bogotá, Colombia.,Universidad del Rosario, School of Medicine and Health Sciences, Bogotá, Colombia
| | - Juan David Ramírez
- Universidad del Rosario, Facultad de Ciencias Naturales y Matemáticas, Programa de Biología, Grupo de Investigaciones Microbiológicas-UR (GIMUR), Bogotá, Colombia
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177
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Grześkowiak Ł, Martínez-Vallespín B, Dadi TH, Radloff J, Amasheh S, Heinsen FA, Franke A, Reinert K, Vahjen W, Zentek J, Pieper R. Formula Feeding Predisposes Neonatal Piglets to Clostridium difficile Gut Infection. J Infect Dis 2017; 217:1442-1452. [DOI: 10.1093/infdis/jix567] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 10/24/2017] [Indexed: 12/20/2022] Open
Affiliation(s)
| | | | - Temesgen H Dadi
- Department of Mathematics and Computer Science, Institute of Computer Science, Kiel, Germany
- Max Planck Institute for Molecular Genetics, Berlin, Kiel, Germany
| | - Judith Radloff
- Institute of Veterinary Physiology, Freie Universität Berlin, Kiel, Germany
| | - Salah Amasheh
- Institute of Veterinary Physiology, Freie Universität Berlin, Kiel, Germany
| | - Femke-Anouska Heinsen
- Institute of Clinical Molecular Biology, Christian-Albrechts-University of Kiel, University Hospital Schleswig Holstein, Kiel, Germany
| | - Andre Franke
- Institute of Clinical Molecular Biology, Christian-Albrechts-University of Kiel, University Hospital Schleswig Holstein, Kiel, Germany
| | - Knut Reinert
- Department of Mathematics and Computer Science, Institute of Computer Science, Kiel, Germany
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178
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Bai Y, Sun X, Jin Y, Wang Y, Li J. Accuracy of Xpert Clostridium difficile assay for the diagnosis of Clostridium difficile infection: A meta analysis. PLoS One 2017; 12:e0185891. [PMID: 29016644 PMCID: PMC5633177 DOI: 10.1371/journal.pone.0185891] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 09/21/2017] [Indexed: 12/18/2022] Open
Abstract
Background There is an urgent need for rapid and accurate microbiological diagnostic assay for detection of Clostridium difficile infection (CDI). We assessed the diagnostic accuracy of the Xpert Clostridium difficile assay (Xpert CD) for the diagnosis of CDI. Methods We searched PubMed, EMBASE, and Cochrane Library databases to identify studies according to predetermined criteria. STATA 13.0 software was used to analyze the tests for sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and area under the summary receiver operating characteristic curves (AUC). QUADAS-2 was used to assess the quality of included studies with RevMan 5.2. Heterogeneity in accuracy measures was tested with Spearman correlation coefficient and Chi-square. Results A total of 22 studies were included in the meta-analysis. The pooled sensitivity (95% confidence intervals [CI]) was 0.97 (0.95–0.99) and specificity was 0.95 (0.94–0.96). The AUC was 0.99 (0.97–0.99). Significant heterogeneity was observed when we pooled most of the accuracy measures of selected studies. Conclusions The Xpert CD assay is a useful diagnostic tool with high sensitivity and specificity in diagnosing toxigenic CDI, and this method has excellent usability due to its rapidity and simplicity.
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Affiliation(s)
- Yuanyuan Bai
- Department of Clinical Laboratory, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, PR China
| | - Xiaorong Sun
- Department of Pathology, Jinan Women and Children’s Health Hospital, Jinan, PR China
| | - Yan Jin
- Department of Clinical Laboratory, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, PR China
| | - Yueling Wang
- Department of Clinical Laboratory, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, PR China
| | - Juan Li
- Department of Pathology, Jinan Women and Children’s Health Hospital, Jinan, PR China
- * E-mail:
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Legaria MC, Rollet R, Di Martino A, Castello L, Barberis C, Rossetti MA, Guardati MC, Fernández Canigia L, Carloni G, Litterio M, Rocchi M, Anchart EG, Trejo FM, Minnaard J, Klajn D, Predari SC. Detection of toxigenic Clostridioides [Clostridium] difficile: Usefulness of two commercially available enzyme immunoassays and a PCR assay on stool samples and stool isolates. Rev Argent Microbiol 2017; 50:36-44. [PMID: 28988901 DOI: 10.1016/j.ram.2017.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 12/19/2016] [Accepted: 01/13/2017] [Indexed: 02/07/2023] Open
Abstract
The best laboratory diagnostic approach to detect Clostridioides [Clostridium] difficile infection (CDI) is a subject of ongoing debate. With the aim of evaluating four laboratory diagnostic methods, 250 unformed stools from patients with suspected CDI submitted to nine medical center laboratories from November 2010 to December 2011, were studied using: (1) an immunochromatographic rapid assay test that combines the qualitative determination of glutamate dehydrogenase (GDH) plus toxins A and B (QAB), the CDIFF QUIK CHEK COMPLETE assay; (2) an enzyme immunoassay for qualitative determination of toxins A and B, the RIDASCREEN™ C. difficile Toxin A/B assay (RAB); (3) a PCR for the toxin B gene assay (PCR); and (4) the toxigenic culture (TC). C. difficile isolates from direct toxin negative stools by QAB, RAB and PCR were evaluated for toxigenicity by the same direct tests, in order to assess the contribution of the TC (QAB-TC, RAB-TC, PCR-TC). A combination of the cell culture cytotoxicity neutralization assay (CCCNA) in stools, and the same assay on isolates from direct negative samples (CCCNA-TC) was considered the reference method (CCCNA/CCCNA-TC). Of the 250 stools tested, 107 (42.8%) were positive by CCCNA/CCCNA-TC. The GDH and PCR/PCR-TC assays were the most sensitive, 91.59% and 87.62%, respectively. The QAB, RAB, QAB/QAB-TC and RAB/RAB-TC had the highest specificities, ca. 95%. A negative GDH result would rule out CDI, however, its low positive likelihood ratio (PLR) of 3.97 indicates that a positive result should always be complemented with the detection of toxins. If the RAB, QAB, and PCR assays do not detect toxins from direct feces, the toxigenic culture should be performed. In view of our results, the most accurate and reliable methods to be applied in a clinical microbiology laboratory were the QAB/QAB-TC, and RAB/RAB-TC, with PLRs >10 and negative likelihood ratios <0.30.
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Affiliation(s)
- María C Legaria
- Subcomisión de Bacterias Anaerobias de la Sociedad Argentina de Bacteriología, Micología y Parasitología Clínicas - Asociación Argentina de Microbiología, Ciudad Autónoma de Buenos Aires (CABA), Argentina; Hospital General de Agudos Dr. Enrique Tornú, CABA, Argentina.
| | - Raquel Rollet
- Subcomisión de Bacterias Anaerobias de la Sociedad Argentina de Bacteriología, Micología y Parasitología Clínicas - Asociación Argentina de Microbiología, Ciudad Autónoma de Buenos Aires (CABA), Argentina; Hospital de Infecciosas Dr. Francisco Javier Muñiz, CABA, Argentina
| | - Ana Di Martino
- Subcomisión de Bacterias Anaerobias de la Sociedad Argentina de Bacteriología, Micología y Parasitología Clínicas - Asociación Argentina de Microbiología, Ciudad Autónoma de Buenos Aires (CABA), Argentina; Sanatorio de la Trinidad Mitre, CABA, Argentina
| | - Liliana Castello
- Subcomisión de Bacterias Anaerobias de la Sociedad Argentina de Bacteriología, Micología y Parasitología Clínicas - Asociación Argentina de Microbiología, Ciudad Autónoma de Buenos Aires (CABA), Argentina; Instituto de Investigaciones Médicas Alfredo Lanari, Universidad de Buenos Aires, CABA, Argentina
| | - Claudia Barberis
- Subcomisión de Bacterias Anaerobias de la Sociedad Argentina de Bacteriología, Micología y Parasitología Clínicas - Asociación Argentina de Microbiología, Ciudad Autónoma de Buenos Aires (CABA), Argentina; Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, CABA, Argentina
| | - María A Rossetti
- Subcomisión de Bacterias Anaerobias de la Sociedad Argentina de Bacteriología, Micología y Parasitología Clínicas - Asociación Argentina de Microbiología, Ciudad Autónoma de Buenos Aires (CABA), Argentina; Hospital Interzonal General de Agudos Presidente Perón, Avellaneda, Provincia de Buenos Aires, Argentina
| | - María C Guardati
- Subcomisión de Bacterias Anaerobias de la Sociedad Argentina de Bacteriología, Micología y Parasitología Clínicas - Asociación Argentina de Microbiología, Ciudad Autónoma de Buenos Aires (CABA), Argentina; Hospital de Emergencias Dr. Clemente Álvarez, Rosario, Provincia de Santa Fe, Argentina
| | - Liliana Fernández Canigia
- Subcomisión de Bacterias Anaerobias de la Sociedad Argentina de Bacteriología, Micología y Parasitología Clínicas - Asociación Argentina de Microbiología, Ciudad Autónoma de Buenos Aires (CABA), Argentina; Hospital Alemán, CABA, Argentina
| | - Graciela Carloni
- Subcomisión de Bacterias Anaerobias de la Sociedad Argentina de Bacteriología, Micología y Parasitología Clínicas - Asociación Argentina de Microbiología, Ciudad Autónoma de Buenos Aires (CABA), Argentina; Facultad de Ciencias Veterinarias, Universidad de Buenos Aires, CABA, Argentina
| | - Mirta Litterio
- Subcomisión de Bacterias Anaerobias de la Sociedad Argentina de Bacteriología, Micología y Parasitología Clínicas - Asociación Argentina de Microbiología, Ciudad Autónoma de Buenos Aires (CABA), Argentina; Hospital Nacional de Pediatría Dr. Prof. Juan P. Garrahan, CABA, Argentina
| | - Marta Rocchi
- Hospital Nacional de Clínicas de Córdoba, Córdoba, Argentina
| | - Eduardo G Anchart
- Centro de Especialidades Médicas Ambulatorias de Rosario MH Zuasnábar (Cemar), Secretaría de Salud Pública de Rosario, Provincia de Santa Fe, Argentina
| | - Fernando M Trejo
- Centro de Investigación y Desarrollo en Criotecnología de Alimentos (CIDCA) - Cátedra de Microbiología Facultad de Ciencias Exactas, Universidad Nacional de La Plata, La Plata, Provincia de Buenos Aires, Argentina
| | - Jessica Minnaard
- Centro de Investigación y Desarrollo en Criotecnología de Alimentos (CIDCA) - Cátedra de Microbiología Facultad de Ciencias Exactas, Universidad Nacional de La Plata, La Plata, Provincia de Buenos Aires, Argentina
| | - Diana Klajn
- Hospital General de Agudos Dr. Enrique Tornú, CABA, Argentina
| | - Silvia C Predari
- Subcomisión de Bacterias Anaerobias de la Sociedad Argentina de Bacteriología, Micología y Parasitología Clínicas - Asociación Argentina de Microbiología, Ciudad Autónoma de Buenos Aires (CABA), Argentina; Instituto de Investigaciones Médicas Alfredo Lanari, Universidad de Buenos Aires, CABA, Argentina
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180
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Identification of Clostridium difficile Asymptomatic Carriers in a Tertiary Care Hospital. BIOMED RESEARCH INTERNATIONAL 2017; 2017:5450829. [PMID: 29098156 PMCID: PMC5643058 DOI: 10.1155/2017/5450829] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 08/11/2017] [Accepted: 08/27/2017] [Indexed: 12/18/2022]
Abstract
Background The diagnosis of Clostridium difficile infection (CDI) increases concern that asymptomatic carriers of toxigenic C. difficile may be diagnosed with CDI. Methods A matched case control study was conducted in inpatients in a tertiary care center. The first 50 patients with diarrhea and a positive polymerase chain reaction (PCR) test beginning February 1, 2015, were identified as cases. Control patients were hospitalized patients receiving antibiotics, but with no diarrhea, housed in a room as close as possible to each case during the same admission time. A convenience sample of healthcare workers who cared for C. difficile infected patients was also tested. Results We found two positive PCR results for C. difficile in controls (4.1%). None of these healthcare workers were positive for C. difficile by PCR. There was no difference between groups with respect to overall antibiotic use before the requested PCR for Clostridium difficile (p = 0.359). The majority of cases had a high proportion of gastrointestinal disorders (71.4%) compared with control (8.2%), p < 0.001. Patients with neoplasia had a higher chance of being identified as cases (p = 0.041). Conclusions PCR should not be the only diagnostic tool but should be complementary to other methods and to the medical history.
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Implementation of a Clinical Decision Support Tool for Stool Cultures and Parasitological Studies in Hospitalized Patients. J Clin Microbiol 2017; 55:3350-3354. [PMID: 28954902 DOI: 10.1128/jcm.01052-17] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 09/21/2017] [Indexed: 01/05/2023] Open
Abstract
There is substantial evidence that stool culture and parasitological examinations are of minimal to no value after 3 days of hospitalization. We implemented and studied the impact of a clinical decision support tool (CDST) to decrease the number of unnecessary stool cultures (STCUL), ova/parasite (O&P) examinations, and Giardia/Cryptosporidium enzyme immunoassay screens (GC-EIA) performed for patients hospitalized >3 days. We studied the frequency of stool studies ordered before or on day 3 and after day 3 of hospitalization (i.e., categorical orders/total number of orders) before and after this intervention and denoted the numbers and types of microorganisms detected within those time frames. This intervention, which corresponded to a custom-programmed hard-stop alert tool in the Epic hospital information system, allowed providers to override the intervention by calling the laboratory, if testing was deemed medically necessary. Comparative statistics were employed to determine significance, and cost savings were estimated based on our internal costs. Before the intervention, 129/670 (19.25%) O&P examinations, 47/204 (23.04%) GC-EIA, and 249/1,229 (20.26%) STCUL were ordered after 3 days of hospitalization. After the intervention, 46/521 (8.83%) O&P examinations, 27/157 (17.20%) GC-EIA, and 106/1,028 (10.31%) STCUL were ordered after 3 days of hospitalization. The proportions of reductions in the number of tests performed after 3 days and the associated P values were 54.1% for O&P examinations (P < 0.0001), 22.58% for GC-EIA (P = 0.2807), and 49.1% for STCUL (P < 0.0001). This was estimated to have resulted in $8,108.84 of cost savings. The electronic CDST resulted in a substantial reduction in the number of evaluations of stool cultures and the number of parasitological examinations for patients hospitalized for more than 3 days and in a cost savings while retaining the ability of the clinician to obtain these tests if clinically indicated.
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182
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Chaudhry R, Sharma N, Gupta N, Kant K, Bahadur T, Shende TM, Kumar L, Kabra SK. Nagging Presence of Clostridium difficile Associated Diarrhoea in North India. J Clin Diagn Res 2017; 11:DC06-DC09. [PMID: 29207702 DOI: 10.7860/jcdr/2017/29096.10592] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 06/20/2017] [Indexed: 01/05/2023]
Abstract
Introduction Clostridium Difficile Associated Diarrhoea (CDAD) is a significant cause of morbidity in hospitalised patients worldwide. The data on clinical epidemiology of this disease in Indian subcontinent is scarce. Aim To evaluate the risk factors and clinical course of patients with CDAD. Materials and Methods A cross-sectional study was planned at our tertiary care centre, All India Institute of Medical Sciences, whereby, all patients who had nosocomial diarrhea between 2010 and 2014 were included in the study. Their clinical and laboratory profile were recorded using structured questionnaire and their stool samples were subjected to ELISA for detection of toxins A and B (Premier toxins A and B). Those patients who had toxins A and B in their stool samples were diagnosed as CDAD. The clinical and laboratory profile of CDAD patients were further analysed. Results A total of 791 patients with nosocomial diarrhea were included in this study. CDAD was diagnosed in a total of 48(6%) patients. The year wise breakdown of the positive patients is as follows: 7/135 (5.2%), 4/156 (2.6%), 5/141 (3.5%), 9/193 (4.7%) and 23/166 (13.8%), respectively. A total of 16/48 (33.3%) of CDAD cases belonged to the age group of 51-60 years. Malignancy (n=15, 31.25%) was the most common underlying pathological condition. All the patients had a history of antibiotic intake. Most common antibiotic used in the patients of CDAD was third generation cephalosporins (n=27, 56.25%). The use of clindamycin, carbapenems and colistin increased in the year 2014. Mean duration of hospital stay was 9.8 days. Diarrhoea was associated with fever in 50% of the patients while abdominal pain was seen in 39.6% of the patients. Conclusion The control of Clostridium difficile infection suffers from the rampant use of higher antibiotics. There is a need for proper implementation of antimicrobial stewardship programmes and better hospital infection control to stop the transmission of this nagging bug.
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Affiliation(s)
- Rama Chaudhry
- Professor, Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Nidhi Sharma
- Scientist, Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Nitin Gupta
- Senior Resident, Department of Infectious Disease, Medicine and Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Kamla Kant
- Senior Resident, Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Tej Bahadur
- PhD Scholar, Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Trupti M Shende
- Senior Resident, Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Lalit Kumar
- Professor, Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Sushil K Kabra
- Professor, Department of Paediatrics, All India Institute of Medical Sciences, New Delhi, India
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183
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Origüen J, Corbella L, Orellana MÁ, Fernández-Ruiz M, López-Medrano F, San Juan R, Lizasoain M, Ruiz-Merlo T, Morales-Cartagena A, Maestro G, Parra P, Villa J, Delgado R, Aguado JM. Comparison of the clinical course of Clostridium difficile infection in glutamate dehydrogenase-positive toxin-negative patients diagnosed by PCR to those with a positive toxin test. Clin Microbiol Infect 2017; 24:414-421. [PMID: 28811244 DOI: 10.1016/j.cmi.2017.07.033] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 07/27/2017] [Accepted: 07/28/2017] [Indexed: 01/05/2023]
Abstract
OBJECTIVES To evaluate the potential role of PCR-based assays in the over-diagnosis of Clostridium difficile infection (CDI) by using a validated diagnostic algorithm in daily clinical practice. METHODS We performed a retrospective cohort study evaluating all C. difficile-positive stool samples identified at our institution during a 12-month period, to compare outcomes and recurrence rates between patients with a positive enzyme immunoassay (EIA) for both glutamate dehydrogenase (GDH) and toxin A/B ('toxin-positive group'), with those with GDH-positive, toxin-negative samples in whom the diagnosis was made by a positive PCR-based assay ('toxin-/PCR+ group'). Medical records were reviewed by two independent investigators blinded to the mode of diagnosis. RESULTS We analysed 231 first CDI episodes (106 (45.8 %) in the 'toxin-positive group' and 125 (54.1%) in the 'toxin-/PCR+ group'). Both groups had similar baseline characteristics. Patients in the 'toxin-positive group' presented more frequently with a severe/severe complicated form than those in the 'toxin-/PCR+ group' (36 (33.9%) versus 24 (19.2%); p 0.011) and had more recurrences (27 (25.5%) versus 9 (7.2%); p 0.001). Diagnosis of CDI based on a GDH/toxin-positive EIA independently predicted severe/severe-complicated course (adjusted OR 2.11; 95% CI 1.06-4.22; p 0.033) and recurrence (adjusted OR 3.79; 95% CI 1.65-8.69; p 0.002). There were no differences in all-cause mortality (12.3% versus 12.0%; p 0.95) or CDI-attributable mortality (4.7% versus 4.8%; p 0.93). CONCLUSIONS Toxin-positive patients were more likely to have severe-complicated forms of CDI and recurrences. Nevertheless, CDI-related complications may still occasionally occur among toxin-negative patients diagnosed by PCR, which stresses the need for individualized clinical evaluation.
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Affiliation(s)
- J Origüen
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (i+12), School of Medicine, Universidad Complutense, Madrid, Spain.
| | - L Corbella
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - M Á Orellana
- Department of Microbiology, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - M Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - F López-Medrano
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - R San Juan
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - M Lizasoain
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - T Ruiz-Merlo
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - A Morales-Cartagena
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - G Maestro
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - P Parra
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - J Villa
- Department of Microbiology, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - R Delgado
- Department of Microbiology, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - J M Aguado
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
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Comparative performance study of six commercial molecular assays for rapid detection of toxigenic Clostridium difficile. Clin Microbiol Infect 2017; 23:567-572. [DOI: 10.1016/j.cmi.2017.02.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 02/13/2017] [Accepted: 02/14/2017] [Indexed: 12/19/2022]
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Abstract
PURPOSE OF THE REVIEW Review tests available for detection of Clostridium difficile (C. Diff) induced disease, including when such tests should be done in children and how they should be interpreted. RECENT FINDINGS Multiple tests are available for detecting disease due to C. diff. These include colonoscopy and stool analysis. Colonoscopy with biopsy is the most sensitive test for detecting the presence of colitis. The toxins produced by the C. diff. (toxin A, toxin B, and binary toxin) are the agents that cause injury and disease. Only toxin producing C. diff. Strains will cause disease. Binary toxin by itself is not thought to produce disease. Binary toxin causes disease in humans when present with toxin A and B producing bacteria, and has been implicated with fulminant life threatening disease. Stool analyses vary in sensitivity and specificity depending on the assay used. The presence of toxin producing strains of C diff. in the stool does not equate with disease. The presence of a toxin-producing bacteria or toxins (A or B) only equates with disease if diarrhea or a diseased colon (toxic megacolon, ileus, and sepsis) is present. Nucleic acid amplification testing (NAAT), when used in the stool from patients with diarrhea, appears to be the most efficient study to detect the gene that encodes for toxin A and B and thus to diagnose C. diff.-induced disease. Infants have a high carriage rate of C. diff. and are believed not to develop disease from it or its toxins. Infants should not be tested for C. difficile. The NAAT is most specific when done on patients with diarrhea with liquid stools. Testing for C. difficile should only be done on patients with diarrhea. One can assume that a patient who has no diarrhea and is not ill does not have C. diff.-induced disease. Treatment should be limited to patients with diarrhea who test positive for C. diff. toxin (A or B) or toxin-producing bacteria. Direct testing for binary toxin is not commercially available. Binary toxin is only thought to cause disease in humans when C. diff. toxin (A and B)-producing bacteria are present.
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Affiliation(s)
- Randolph McConnie
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Rush University Children's Hospital, Chicago, IL, USA.
- Departments of Pediatrics and Internal Medicine, Rush Medical College, 1725 W Harrison St #710, Chicago, IL, 60612, USA.
| | - Arthur Kastl
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Abstract
Hospital-associated infection (HAI) in immunocompromised patients can result in high rates of morbidity and mortality. Infections caused by multidrug-resistant organisms (MDROs) are especially worrisome because of the limited choice of remaining antibiotics available when a patient becomes colonized or infected with an MDRO. It is therefore important that immunocompromised patients be cared for in an environment that limits the risk for acquiring infections. However, with healthcare being increasingly delivered in settings other than the traditional inpatient hospital wards, a bigger effort will need to be set forth to prevent or rapidly diagnose HAI. The last few years have seen a significant increase in the number of singleplex and multiplex molecular assays for the detection of many of the organisms responsible for HAI, but more is needed as infections caused by organisms like Legionella pneumophila and Aspergillus species are still diagnosed with methods that have relatively low yield and are slow to provide actionable results. Finally, the use of novel techniques for outbreak investigations will provide new information on transmission of infectious agents in healthcare settings and allow stronger, evidence-based recommendations to be developed for prevention of HAIs in the immunocompromised host.
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187
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Clostridium difficile PCR Cycle Threshold Predicts Free Toxin. J Clin Microbiol 2017; 55:2651-2660. [PMID: 28615471 DOI: 10.1128/jcm.00563-17] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 06/09/2017] [Indexed: 12/18/2022] Open
Abstract
There is no stand-alone Clostridium difficile diagnostic that can sensitively and rapidly detect fecal free toxins. We investigated the performance of the C. difficile PCR cycle threshold (CT ) for predicting free toxin status. Consecutive stool samples (n = 312) positive for toxigenic C. difficile by the GeneXpert C. difficile/Epi tcdB PCR assay were tested with the rapid membrane C. Diff Quik Chek Complete immunoassay (RMEIA). RMEIA toxin-negative samples were tested with the cell cytotoxicity neutralization assay (CCNA) and tgcBIOMICS enzyme-linked immunosorbent assay (ELISA). Using RMEIA alone or in combination with CCNA and/or ELISA as the reference method, the accuracy of CT was measured at different CT cutoffs. Using RMEIA as the reference method, a CT cutoff of 26.35 detected toxin-positive samples with a sensitivity, specificity, positive predictive value, and negative predictive value of 96.0% (95% confidence interval [CI], 90.2% to 98.9%), 65.9% (95% CI, 59.0% to 72.2%), 57.4% (95% CI, 52.7% to 62%), and 97.1% (95% CI, 92.8% to 98.9), respectively. Inclusion of CCNA in the reference method improved CT specificity to 78.0% (95% CI, 70.7% to 84.2%). Intercartridge lot CT variability measured as the average coefficient of variation was 2.8% (95% CI, 1.2% to 3.2%). Standardizing the input stool volume did not improve CT toxin specificity. The median CT values were not significantly different between stool samples with Bristol scores of 5, 6, and 7, between pediatric and adult samples, or between presumptive 027 and non-027 strains. In addition to sensitively detecting toxigenic C. difficile in stool, on-demand PCR may also be used to accurately predict toxin-negative stool samples, thus providing additional results in PCR-positive stool samples to guide therapy.
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Kociolek LK, Bovee M, Carter D, Ciolino JD, Patel R, O'Donnell A, Rupp AH, Zheng X, Shulman ST, Patel SJ. Impact of a Healthcare Provider Educational Intervention on Frequency of Clostridium difficile Polymerase Chain Reaction Testing in Children: A Segmented Regression Analysis. J Pediatric Infect Dis Soc 2017; 6:142-148. [PMID: 27190172 PMCID: PMC5907876 DOI: 10.1093/jpids/piw027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 04/03/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND. Although Clostridium difficile infections (CDIs) are increasingly diagnosed in children, many children diagnosed with CDI lack classic risk factors. Frequent use of highly sensitive tcdB polymerase chain reaction (PCR) testing in low-risk patients leads to CDI misdiagnosis and unnecessary CDI antibiotic use in children with C difficile carriage. METHODS. For this quasi-experimental study, we developed and implemented an educational intervention (EI) to inform healthcare providers (HCPs) about tcdB PCR test limitations. We provided HCP didactic education and built an electronic notification into the tcdB PCR test order that describes scenarios in which carriage is more likely than CDI. Segmented regression analysis assessed changes in level (ie, overall rates) and trend of C difficile testing rate ([TR] number of tests performed per 1000 patient encounters) and test positivity rate ([PR] number of positive tests per 1000 patient encounters) between the pre- (August 2009-August 2013) and postintervention (February 2014-July 2015) periods. RESULTS. Hospital-wide, absolute TR reduction was 0.71 (P[level] = .0067; P[trend] = .0042) and absolute PR reduction was 0.14 (P[level] = .22; P[trend] = .018). In the outpatient setting, absolute TR reduction was 0.30 (P[level] = .0015; P[trend] < .001) and absolute PR reduction was 0.09 (P[level] = .0069; P[trend] = .046). The incidence density of healthcare facility-associated CDI did not significantly change after the EI. The EI was associated with avoidance of 574 tests and 113 positive tests (and subsequent antibiotic courses) during the postintervention period, which saved approximately $250 000 in patient charges related to CDI testing and treatment. CONCLUSIONS. Healthcare provider education can cost-effectively reduce the frequency of C difficile testing and CDI misdiagnosis by improving test utilization among low-risk children.
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Affiliation(s)
| | | | | | | | - Rupal Patel
- Department of Pharmacy, Ann & Robert H. Lurie Children's Hospital of Chicago
| | | | | | - Xiaotian Zheng
- Pathology and Laboratory Medicine
- Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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189
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Arnold BJ, Balm MND, Burton MA, Blackmore TK. Culture enhanced toxin detection improves diagnosis of Clostridium difficile infection. Infect Dis Health 2017. [DOI: 10.1016/j.idh.2017.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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190
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Steen Redeker E, Eersels K, Akkermans O, Royakkers J, Dyson S, Nurekeyeva K, Ferrando B, Cornelis P, Peeters M, Wagner P, Diliën H, van Grinsven B, Cleij TJ. Biomimetic Bacterial Identification Platform Based on Thermal Wave Transport Analysis (TWTA) through Surface-Imprinted Polymers. ACS Infect Dis 2017; 3:388-397. [PMID: 28388095 PMCID: PMC5432958 DOI: 10.1021/acsinfecdis.7b00037] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
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This
paper introduces a novel bacterial identification assay based on thermal
wave analysis through surface-imprinted polymers (SIPs). Aluminum
chips are coated with SIPs, serving as synthetic cell receptors that
have been combined previously with the heat-transfer method (HTM)
for the selective detection of bacteria. In this work, the concept
of bacterial identification is extended toward the detection of nine
different bacterial species. In addition, a novel sensing approach,
thermal wave transport analysis (TWTA), is introduced, which analyzes
the propagation of a thermal wave through a functional interface.
The results presented here demonstrate that bacterial rebinding to
the SIP layer resulted in a measurable phase shift in the propagated
wave, which is most pronounced at a frequency of 0.03 Hz. In this
way, the sensor is able to selectively distinguish between the different
bacterial species used in this study. Furthermore, a dose–response
curve was constructed to determine a limit of detection of 1 ×
104 CFU mL–1, indicating that TWTA is
advantageous over HTM in terms of sensitivity and response time. Additionally,
the limit of selectivity of the sensor was tested in a mixed bacterial
solution, containing the target species in the presence of a 99-fold
excess of competitor species. Finally, a first application for the
sensor in terms of infection diagnosis is presented, revealing that
the platform is able to detect bacteria in clinically relevant concentrations
as low as 3 × 104 CFU mL–1 in spiked
urine samples.
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Affiliation(s)
- Erik Steen Redeker
- Maastricht Science
Programme, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Kasper Eersels
- Maastricht Science
Programme, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
- Soft-Matter
Physics and Biophysics Section, Department of Physics and Astronomy, KU Leuven, Celestijnenlaan 200 D, B-3001 Leuven, Belgium
| | - Onno Akkermans
- Maastricht Science
Programme, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Jeroen Royakkers
- Maastricht Science
Programme, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Simba Dyson
- Maastricht Science
Programme, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Kunya Nurekeyeva
- Maastricht Science
Programme, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Beniamino Ferrando
- Maastricht Science
Programme, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Peter Cornelis
- Soft-Matter
Physics and Biophysics Section, Department of Physics and Astronomy, KU Leuven, Celestijnenlaan 200 D, B-3001 Leuven, Belgium
| | - Marloes Peeters
- Faculty of Science and
Engineering, School of Science and the Environment, Division of Chemistry
and Environmental Science, Manchester Metropolitan University, Chester Street, Manchester M1 5GD, United Kingdom
| | - Patrick Wagner
- Soft-Matter
Physics and Biophysics Section, Department of Physics and Astronomy, KU Leuven, Celestijnenlaan 200 D, B-3001 Leuven, Belgium
| | - Hanne Diliën
- Maastricht Science
Programme, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Bart van Grinsven
- Maastricht Science
Programme, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Thomas Jan Cleij
- Maastricht Science
Programme, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
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191
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Truong C, Schroeder LF, Gaur R, Anikst VE, Komo I, Watters C, McCalley E, Kulik C, Pickham D, Lee NJ, Banaei N. Clostridium difficile rates in asymptomatic and symptomatic hospitalized patients using nucleic acid testing. Diagn Microbiol Infect Dis 2017; 87:365-370. [DOI: 10.1016/j.diagmicrobio.2016.12.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/16/2016] [Accepted: 12/30/2016] [Indexed: 12/19/2022]
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192
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Strategies for Optimizing the Diagnostic Predictive Value of Clostridium difficile Molecular Diagnostics. J Clin Microbiol 2017; 55:1244-1248. [PMID: 28275072 DOI: 10.1128/jcm.00147-17] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Because nucleic acid amplification tests (NAATs) do not distinguish Clostridium difficile infection (CDI) and asymptomatic C. difficile carriage, the diagnostic predictive value of NAATs is limited when used in patients with a low probability of CDI. In this issue of the Journal of Clinical Microbiology, Truong et al. (J. Clin. Microbiol., 55:1276-1284, 2017, https://doi.org/10.1128/JCM.02319-16) report significant reductions in hospital-onset CDI and oral vancomycin utilization at their institution following implementation of a novel intervention that leveraged their clinical bioinformatics resources to prevent C. difficile testing of stools from patients without clinically significant diarrhea and in patients with recent laxative use.
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193
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Martínez-Meléndez A, Camacho-Ortiz A, Morfin-Otero R, Maldonado-Garza HJ, Villarreal-Treviño L, Garza-González E. Current knowledge on the laboratory diagnosis of Clostridium difficile infection. World J Gastroenterol 2017; 23:1552-1567. [PMID: 28321156 PMCID: PMC5340807 DOI: 10.3748/wjg.v23.i9.1552] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 01/21/2017] [Accepted: 02/17/2017] [Indexed: 02/06/2023] Open
Abstract
Clostridium difficile (C. difficile) is a spore-forming, toxin-producing, gram-positive anaerobic bacterium that is the principal etiologic agent of antibiotic-associated diarrhea. Infection with C. difficile (CDI) is characterized by diarrhea in clinical syndromes that vary from self-limited to mild or severe. Since its initial recognition as the causative agent of pseudomembranous colitis, C. difficile has spread around the world. CDI is one of the most common healthcare-associated infections and a significant cause of morbidity and mortality among older adult hospitalized patients. Due to extensive antibiotic usage, the number of CDIs has increased. Diagnosis of CDI is often difficult and has a substantial impact on the management of patients with the disease, mainly with regards to antibiotic management. The diagnosis of CDI is primarily based on the clinical signs and symptoms and is only confirmed by laboratory testing. Despite the high burden of CDI and the increasing interest in the disease, episodes of CDI are often misdiagnosed. The reasons for misdiagnosis are the lack of clinical suspicion or the use of inappropriate tests. The proper diagnosis of CDI reduces transmission, prevents inadequate or unnecessary treatments, and assures best antibiotic treatment. We review the options for the laboratory diagnosis of CDI within the settings of the most accepted guidelines for CDI diagnosis, treatment, and prevention of CDI.
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194
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Williams MR, Stedtfeld RD, Waseem H, Stedtfeld T, Upham B, Khalife W, Etchebarne B, Hughes M, Tiedje JM, Hashsham SA. Implications of direct amplification for measuring antimicrobial resistance using point-of-care devices. ANALYTICAL METHODS : ADVANCING METHODS AND APPLICATIONS 2017; 9:1229-1241. [PMID: 29657581 PMCID: PMC5898395 DOI: 10.1039/c6ay03405e] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Antimicrobial resistance (AMR) is recognized as a global threat to human health. Rapid detection and characterization of AMR is a critical component of most antibiotic stewardship programs. Methods based on amplification of nucleic acids for detection of AMR are generally faster than culture-based approaches but they still require several hours to more than a day due to the need for transporting the sample to a centralized laboratory, processing of sample, and sometimes DNA purification and concentration. Nucleic acids-based point-of-care (POC) devices are capable of rapidly diagnosing antibiotic-resistant infections which may help in making timely and correct treatment decisions. However, for most POC platforms, sample processing for nucleic acids extraction and purification is also generally required prior to amplification. Direct amplification, an emerging possibility for a number of polymerases, has the potential to eliminate these steps without significantly impacting diagnostic performance. This review summarizes direct amplification methods and their implication for rapid measurement of AMR. Future research directions that may further strengthen the possibility of integrating direct amplification methods with POC devices are also summarized.
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Affiliation(s)
- M R Williams
- Department of Civil and Environmental Engineering, Michigan State University, East Lansing, MI 48824, USA
| | - R D Stedtfeld
- Department of Civil and Environmental Engineering, Michigan State University, East Lansing, MI 48824, USA
| | - H Waseem
- Department of Civil and Environmental Engineering, Michigan State University, East Lansing, MI 48824, USA
| | - T Stedtfeld
- Department of Civil and Environmental Engineering, Michigan State University, East Lansing, MI 48824, USA
| | - B Upham
- Pediatrics and Human Development, Michigan State University, East Lansing, MI 48824, USA
| | - W Khalife
- Department of Microbiology, Sparrow Laboratories, Sparrow Health System, Lansing, MI 48912, USA
| | - B Etchebarne
- Osteopathic Medical Specialties, Section of Emergency Medicine, Michigan State University, East Lansing, MI 4882, USA
| | - M Hughes
- Osteopathic Medical Specialties, Section of Emergency Medicine, Michigan State University, East Lansing, MI 4882, USA
| | - J M Tiedje
- Center for Microbial Ecology, Michigan State University, East Lansing, MI 48824, USA
- Department of Plant, Soil and Microbial Sciences, Michigan State University, East Lansing, MI 48824, USA
| | - S A Hashsham
- Department of Civil and Environmental Engineering, Michigan State University, East Lansing, MI 48824, USA
- Center for Microbial Ecology, Michigan State University, East Lansing, MI 48824, USA
- Department of Plant, Soil and Microbial Sciences, Michigan State University, East Lansing, MI 48824, USA
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195
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Das S, Shibib DR, Vernon MO. The new frontier of diagnostics: Molecular assays and their role in infection prevention and control. Am J Infect Control 2017; 45:158-169. [PMID: 28159066 PMCID: PMC7115290 DOI: 10.1016/j.ajic.2016.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 08/19/2016] [Accepted: 08/19/2016] [Indexed: 01/05/2023]
Abstract
Recent advances in technology over the last decade have propelled the microbiology laboratory into a pivotal role in infection prevention and control. The rapid adaptation of molecular technologies to the field of clinical microbiology now greatly influences infectious disease management and significantly impacts infection control practices. This review discusses recent developments in molecular techniques in the diagnosis of infectious diseases. It describes the basic concepts of molecular assays, discusses their advantages and limitations, and characterizes currently available commercial assays with respect to cost, interpretive requirements, and clinical utility.
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196
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Kumar S, Pollok R, Muscat I, Planche T. Diagnosis and outcome of Clostridium difficile infection by toxin enzyme immunoassay and polymerase chain reaction in an island population. J Gastroenterol Hepatol 2017; 32:415-419. [PMID: 27505006 DOI: 10.1111/jgh.13504] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM Clostridium difficile infection (CDI) is a potentially life-threatening cause of diarrhea. Correct laboratory diagnosis is essential to differentiate CDI from other causes of diarrhea. A positive fecal C. difficile toxin (CDT) is the best indicator of CDI, but the significance of a positive fecal nucleic acid amplification test (NAAT) remains unclear. Our aim was to elucidate the significance of CDI diagnostics in patients in Jersey. METHODS A retrospective, 5-year study was conducted at an island district general hospital of patients who developed CDI. Patients were grouped according to CDT and NAAT status and their association with outcome (indicators of severity and 30-day case-fatality rate) compared. RESULTS A total of 207 specimens were toxin positive, 92 NAAT positive and toxin negative, and 39 had a stool sample negative by both toxin and NAAT testing. A positive toxin stool sample was associated with both significantly higher white cell count (14.5 × 109 /L vs 11.3 × 109 /L, P = 0.003) and C-reactive protein (114.7 mg/dL vs 82.9 mg/dL, P = 0.001), but NAAT positivity was not (P = 0.269, 0.728). A positive CDT assay was a significant independent predictor of death (odds ratio [OR]: 1.89 [95% CI: 1.04-3.43], P = 0.046), but a positive NAAT in CDT negative samples was not (OR: 1.02 [95% CI: 0.34-3.12], P = 1.0). CONCLUSIONS The findings of this study, derived from evolving clinical practice, provide greater clarity in the interpretation of CDI diagnostics. In CDT-negative disease, a positive NAAT neither predicts disease severity nor mortality. NAAT-positive and toxin-negative patients require instigation of infection control measures, but the need for specific treatment remains unclear.
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Affiliation(s)
- Shankar Kumar
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Richard Pollok
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Ivan Muscat
- Microbiology Department, Jersey General Hospital, Jersey, UK
| | - Timothy Planche
- Department of Medical Microbiology, St George's University Hospitals NHS Foundation Trust, London, UK
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197
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Lteif L. The Daniel K. Inouye College of Pharmacy Scripts: Updates on Clostridium difficile Infection: Advances in Laboratory Testing to Aid Diagnosis and Treatment. HAWAI'I JOURNAL OF MEDICINE & PUBLIC HEALTH : A JOURNAL OF ASIA PACIFIC MEDICINE & PUBLIC HEALTH 2017; 76:59-64. [PMID: 28210531 PMCID: PMC5304430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Clostridium difficile remains a major source of nosocomial infections and associated diarrhea. More recently, community-acquired cases are on the rise creating a concern for a serious public health threat. Appropriate infection control precautions as well as prevention and optimal management may help to avoid detrimental outbreaks. A key step is utilizing laboratory testing for quick and accurate diagnosis of potential cases. This overview article describes Clostridium difficile infection control and prevention methods and updates the most recent management strategies including a focus on the utilization and interpretation of laboratory diagnostic testing and appropriate treatment.
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Affiliation(s)
- Louis Lteif
- Assistant Professor, Department of Pharmacy Practice, The Daniel K. Inouye College of Pharmacy, University of Hawai'i at Hilo, Hilo, HI
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198
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Point-Counterpoint: What Is the Optimal Approach for Detection of Clostridium difficile Infection? J Clin Microbiol 2017; 55:670-680. [PMID: 28077697 DOI: 10.1128/jcm.02463-16] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTIONIn 2010, we published an initial Point-Counterpoint on the laboratory diagnosis of Clostridium difficile infection (CDI). At that time, nucleic acid amplification tests (NAATs) were just becoming commercially available, and the idea of algorithmic approaches to CDI was being explored. Now, there are numerous NAATs in the marketplace, and based on recent proficiency test surveys, they have become the predominant method used for CDI diagnosis in the United States. At the same time, there is a body of literature that suggests that NAATs lack clinical specificity and thus inflate CDI rates. Hospital administrators are taking note of institutional CDI rates because they are publicly reported. They have become an important metric impacting hospital safety ratings and value-based purchasing; hospitals may have millions of dollars of reimbursement at risk. In this Point-Counterpoint using a frequently asked question approach, Ferric Fang of the University of Washington, who has been a consistent advocate for a NAAT-only approach for CDI diagnosis, will discuss the value of a NAAT-only approach, while Christopher Polage of the University of California Davis and Mark Wilcox of Leeds University, Leeds, United Kingdom, each of whom has recently written important articles on the value of toxin detection in the diagnosis, will discuss the impact of toxin detection in CDI diagnosis.
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199
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Brook I. Anaerobic Bacteria. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00184-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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200
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Morris KA, Macfarlane-Smith LR, Wilcox MH. Evaluation of the novel artus C. difficile QS-RGQ, VanR QS-RGQ and MRSA/SA QS-RGQ assays for the laboratory diagnosis of Clostridium difficile infection (CDI), and for vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) screening. Eur J Clin Microbiol Infect Dis 2016; 36:823-829. [PMID: 27987047 DOI: 10.1007/s10096-016-2867-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 12/06/2016] [Indexed: 12/16/2022]
Abstract
Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) are worldwide prevalent healthcare-associated pathogens. We have evaluated three Qiagen artus QS-RGQ assays for the detection of these pathogens. We examined 200 stool samples previously tested for C. difficile infection (CDI), 94 rectal swabs previously screened for VRE and 200 MRSA screening nasal swabs. With the routine diagnostic laboratory results being adopted as the gold standard, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the artus C. difficile assay were 100%, for the artus VanR QS-RGQ assay, 95, 68, 44 and 98%, and for the artus MRSA/SA assay, 80, 94, 93 and 83%, respectively. The artus VanR assay detected the vanA and/or vanB genes in 32% of culture-negative VRE screens; in 71% of these cases, only vanB was detected. An over-estimation of the rate of faecal VRE colonisation could be due to a patient population with high rates of faecal carriage of non-enterococcal species carrying vanB. Based on our findings, we conclude that all three artus QS-RGQ assays could be a useful addition to a diagnostic laboratory, and that the optimal choice of assay should be determined according to user needs.
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Affiliation(s)
- K A Morris
- Microbiology Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | | | - M H Wilcox
- Microbiology Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute for Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
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