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van Prehn J, Crobach MJT, Baktash A, Duszenko N, Kuijper EJ. Diagnostic Guidance for C. difficile Infections. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1435:33-56. [PMID: 38175470 DOI: 10.1007/978-3-031-42108-2_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Diagnosis of Clostridioides 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 or single-molecule array assays 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 been advocated by international guidelines (IDSA/SHEA and ESCMID) in order to optimize diagnostic accuracy. As a result, a survey performed in 2018-2019 in Europe revealed that most of all hospital sites reported using more than one test to diagnose CDI. 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 microbiota 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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Affiliation(s)
- Joffrey van Prehn
- Department of Medical Microbiology, Leiden University Centre for Infectious Diseases (LU-CID), Leiden University Medical Centre, Leiden, The Netherlands.
- ESCMID Study Group for C. difficile (ESGCD) and Study Group for Host and Microbiota Interaction (ESGHAMI), Basel, Switzerland.
| | - Monique J T Crobach
- Department of Medical Microbiology, Leiden University Centre for Infectious Diseases (LU-CID), Leiden University Medical Centre, Leiden, The Netherlands
| | - Amoe Baktash
- Department of Medical Microbiology, Leiden University Centre for Infectious Diseases (LU-CID), Leiden University Medical Centre, Leiden, The Netherlands
| | - Nikolas Duszenko
- Department of Medical Microbiology, Leiden University Centre for Infectious Diseases (LU-CID), Leiden University Medical Centre, Leiden, The Netherlands
| | - Ed J Kuijper
- Department of Medical Microbiology, Leiden University Centre for Infectious Diseases (LU-CID), Leiden University Medical Centre, Leiden, The Netherlands
- ESCMID Study Group for C. difficile (ESGCD) and Study Group for Host and Microbiota Interaction (ESGHAMI), Basel, Switzerland
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Couturier J, Davies K, Barbut F. Ribotypes and New Virulent Strains Across Europe. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1435:151-168. [PMID: 38175475 DOI: 10.1007/978-3-031-42108-2_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Clostridioides (formerly Clostridium) difficile is a major bacterial cause of post-antibiotic diarrhoea. The epidemiology of C. difficile infections (CDIs) has dramatically changed since the early 2000s, with an increasing incidence and severity across Europe. This trend is partly due to the emergence and rapid worldwide spread of the hypervirulent and epidemic PCR ribotype 027. Profiles of patients with CDI have also evolved, with description of community-acquired (CA) infections in patients with no traditional risk factors for CDI. However, epidemiological studies indicated that some European countries have successfully controlled the dissemination of the 027 clone whereas other countries reported the emergence of other virulent or unusual strains. The aims of this review are to summarize the current European CDI epidemiology and to describe the new virulent C. difficile strains circulating in Europe, as well as other potential emerging strains described elsewhere. Standardized typing methods and surveillance programmes are mandatory for a better understanding and monitoring of CDI in Europe.
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Affiliation(s)
- Jeanne Couturier
- National Reference Laboratory for C. difficile, Hôpital Saint-Antoine, Paris, France.
- Université Paris Cité, UMR INSERM 1139, Paris, France.
| | - Kerrie Davies
- Healthcare Associated Infections Research Group, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, UK
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID) study group for Clostridioides difficile (ESGCD), Basel, Switzerland
| | - Frédéric Barbut
- National Reference Laboratory for C. difficile, Hôpital Saint-Antoine, Paris, France
- Université Paris Cité, UMR INSERM 1139, Paris, France
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID) study group for Clostridioides difficile (ESGCD), Basel, Switzerland
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Hocking L, Wilcox M, Petrosillo N, Griffin P, Steiner T, Attara G, Doré J, Cabling M, Stockwell S, Romanelli RJ, Marjanovic S. Improving care for patients with Clostridioides difficile infection: A clinical practice and healthcare systems perspective. Front Med (Lausanne) 2023; 9:1033417. [PMID: 36714122 PMCID: PMC9877614 DOI: 10.3389/fmed.2022.1033417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/23/2022] [Indexed: 01/13/2023] Open
Abstract
Introduction Arriving at a C. difficile infection (CDI) diagnosis, treating patients and dealing with recurrences is not straightforward, but a comprehensive and well-rounded understanding of what is needed to improve patient care is lacking. This manuscript addresses the paucity of multidisciplinary perspectives that consider clinical practice related and healthcare system-related challenges to optimizing care delivery. Methods We draw on narrative review, consultations with clinical experts and patient representatives, and a survey of 95 clinical and microbiology experts from the UK, France, Italy, Australia and Canada, adding novel multi-method evidence to the knowledge base. Results and discussion We examine the patient pathway and variations in clinical practice and identify, synthesize insights on and discuss associated challenges. Examples of key challenges include the need to conduct multiple tests for a conclusive diagnosis, treatment side-effects, the cost of some antibiotics and barriers to access of fecal microbiota transplantation, difficulties in distinguishing recurrence from new infection, workforce capacity constraints to effective monitoring of patients on treatment and of recurrence, and ascertaining whether a patient has been cured. We also identify key opportunities and priorities for improving patient care that target both clinical practice and the wider healthcare system. While there is some variety across surveyed countries' healthcare systems, there is also strong agreement on some priorities. Key improvement actions seen as priorities by at least half of survey respondents in at least three of the five surveyed countries include: developing innovative products for both preventing (Canada, Australia, UK, Italy, and France) and treating (Canada, Australia, and Italy) recurrences; facilitating more multidisciplinary patient care (UK, Australia, and France); updating diagnosis and treatment guidelines (Australia, Canada, and UK); and educating and supporting professionals in primary care (Italy, UK, Canada, and Australia) and those in secondary care who are not CDI experts (Italy, Australia, and France) on identifying symptoms and managing patients. Finally, we discuss key evidence gaps for a future research agenda.
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Affiliation(s)
| | - Mark Wilcox
- School of Medicine, University of Leeds, Leeds, United Kingdom
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Nicola Petrosillo
- Policlinico Universitario, Bio-Medico Campus University Hospital, Rome, Italy
| | - Paul Griffin
- Mater Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Theodore Steiner
- Division of Infectious Diseases, The University of British Columbia, Vancouver, BC, Canada
| | - Gail Attara
- Canadian Society of Intestinal Research, Vancouver, BC, Canada
- Gastrointestinal Society, Vancouver, BC, Canada
| | - Joel Doré
- INRAE, MetaGenoPolis, AgroParisTech, Micalis Institute, Université Paris-Saclay, Jouy-en-Josas, France
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4
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Viprey VF, Granata G, Vendrik KEW, Davis GL, Petrosillo N, Kuijper EJ, Vilken T, Lammens C, Schotsman JJ, Benson AD, Cataldo MA, van der Kooi TII, Wilcox MH, Davies KA, Davies KA, Wilcox MH, Kuijper E, Rupnik M, Wingen-Heimann S, Tacconelli E, Vilken T, Petrosillo N, Bonten M, Cleuziat P, Webber C, Rupnik M, Wilcox M. European survey on the current surveillance practices, management guidelines, treatment pathways and heterogeneity of testing of Clostridioides difficile, 2018-2019: results from The Combatting Bacterial Resistance in Europe CDI (COMBACTE-CDI). J Hosp Infect 2023; 131:213-220. [PMID: 36462673 DOI: 10.1016/j.jhin.2022.11.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/22/2022] [Accepted: 11/22/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Awareness and compliance with international guidelines for diagnosis and clinical management of Clostridioides difficile infection (CDI) are unknown. AIM To compare the awareness and compliance with the recommended strategies for diagnosis and clinical management of CDI across Europe in 2018-2019. METHODS Hospital sites and their associated community practices across 12 European countries completed an online survey in 2018-2019, to report on their practices in terms of surveillance, prevention, diagnosis, and treatment of CDI. Responses were collected from 105 hospitals and 39 community general practitioners (GPs). FINDINGS Hospital sites of 11 countries reported participation in national surveillance schemes compared with six countries for international schemes. The European Society of Clinical Microbiology and Infectious Diseases (ESCMID)-recommended CDI testing methodologies were used by 82% (86/105) of hospitals, however countries reporting the highest incidence of CDI used non-recommended tests. Over 75% (80/105) of hospitals were aware of the most recent European CDI treatment guidelines at the time of this survey compared with only 26% (10/39) of surveyed GPs. However, up to 15% (16/105) of hospitals reported using the non-recommended metronidazole for recurrent CDI cases, sites in countries with lower awareness of CDI treatment guidelines. Only 37% (39/105) of hospitals adopted contact isolation precautions in case of suspected CDI. CONCLUSION Good awareness of guidelines for the management of CDI was observed across the surveyed European hospital sites. However, low compliance with diagnostic testing guidelines, infection control measures for suspected CDI, and insufficient awareness of treatment guidelines continued to be reported in some countries.
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Affiliation(s)
- V F Viprey
- Healthcare Associated Infections Research Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK.
| | - G Granata
- National Institute for Infectious Diseases "L. Spallanzani", Rome, Italy
| | - K E W Vendrik
- Leiden University Medical Center, Leiden, the Netherlands; National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - G L Davis
- Healthcare Associated Infections Research Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - N Petrosillo
- National Institute for Infectious Diseases "L. Spallanzani", Rome, Italy
| | - E J Kuijper
- Leiden University Medical Center, Leiden, the Netherlands; National Institute for Public Health and the Environment, Bilthoven, the Netherlands; European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Study Group for Clostridioides Difficile (ESGCD)
| | - T Vilken
- Laboratory of Medical Microbiology, University of Antwerp, Antwerp, Belgium
| | - C Lammens
- Laboratory of Medical Microbiology, University of Antwerp, Antwerp, Belgium
| | - J J Schotsman
- University Medical Centre Utrecht, Utrecht, the Netherlands
| | - A D Benson
- Healthcare Associated Infections Research Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - M A Cataldo
- National Institute for Infectious Diseases "L. Spallanzani", Rome, Italy
| | - T I I van der Kooi
- National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - M H Wilcox
- Healthcare Associated Infections Research Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK; European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Study Group for Clostridioides Difficile (ESGCD); Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - K A Davies
- Healthcare Associated Infections Research Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK; European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Study Group for Clostridioides Difficile (ESGCD); Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Olmedo M, Valerio M, Reigadas E, Marín M, Alcalá L, Muñoz P, Bouza E. Clinical impact of a Clostridioides ( Clostridium) difficile bedside infectious disease stewardship intervention. JAC Antimicrob Resist 2020; 2:dlaa037. [PMID: 34223003 PMCID: PMC8210181 DOI: 10.1093/jacamr/dlaa037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 01/23/2020] [Accepted: 04/06/2020] [Indexed: 11/17/2022] Open
Abstract
Objectives To evaluate the clinical impact of a bedside visit to patients with a positive Clostridioides difficile test on the antimicrobial stewardship of C. difficile infection (CDI) and non-C. difficile infections. Methods All patients ≥18 years old with positive CDI laboratory tests hospitalized between January 2017 and August 2017 received an immediate bedside intervention that consisted mainly of checking protective measures and providing recommendations on infection control and the management of CDI and other infections. Results A total of 214 patients were evaluated. The infectious disease (ID) physician was the first to establish protective measures in 25.2% of the cases. In 22/29 (75.9%) cases, physicians in charge accepted ID consultant recommendations to stop CDI treatment in asymptomatic patients. Unnecessary non-CDI antibiotics were discontinued in 19.1% of the cases. ID recommendations were not accepted by physicians in charge in only 12.6% of the cases. Conclusions A bedside rapid intervention for patients with a CDI-positive faecal sample was effective in avoiding overdiagnosis and unnecessary antibiotic treatment, optimizing anti-CDI drugs, increasing compliance with infection control measures and providing educational advice.
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Affiliation(s)
- María Olmedo
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Maricela Valerio
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - Elena Reigadas
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
| | - Mercedes Marín
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - Luis Alcalá
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Salud Carlos III, Madrid, Spain
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6
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Clostridioides difficile toxin testing and positivity in Manitoba, Canada. Infect Control Hosp Epidemiol 2020; 41:1212-1214. [PMID: 32624038 DOI: 10.1017/ice.2020.264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We assessed Clostridioides difficile toxin testing and positivity for all patients in Manitoba hospitals during June 2016-November 2018. The testing rate was 30 per 10,000 patient bed days (95% confidence interval [CI], 30-31) and the incidence rate was 3.5 per 10,000 patient bed days (95% CI, 3.3-3.7). The context of testing is essential to the interpretation of data among jurisdictions.
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7
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Clinical evaluation of a non-purified direct molecular assay for the detection of Clostridioides difficile toxin genes in stool specimens. PLoS One 2020; 15:e0234119. [PMID: 32492051 PMCID: PMC7269250 DOI: 10.1371/journal.pone.0234119] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 05/19/2020] [Indexed: 12/22/2022] Open
Abstract
Recently, a new rapid assay for the detection of tcdB gene of Clostridioides difficile was developed using the GENECUBE. The assay can directly detect the tcdB gene from stool samples without a purification in approximately 35 minutes with a few minutes of preparation process. We performed a prospective comparative study of the performance of the assay at eight institutions in Japan. Fresh residual stool samples (Bristol stool scale ≥5) were used and comparisons were performed with the BD MAX Cdiff assay and toxigenic cultures. For the evaluation of 383 stool samples compared with the BD MAX Cdiff assay, the sensitivity, and specificity of the two assays was 99.0% (379/383), 98.1% (52/53), 99.1% (327/330), respectively. In the comparison with toxigenic culture, the total, sensitivity, and specificity were 96.6% (370/383), 85.0% (51/60), and 98.8% (319/323), respectively. The current investigation indicated the GENECUBE Clostridioides difficile assay has equivalent performance with the BD MAX Cdiff assay for the detection of tcdB gene of C. difficile.
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Davies K, Davis G, Barbut F, Eckert C, Petrosillo N, Pisapia R, Gärtner B, Berger FK, Reigadas E, Bouza E, Demont C, Wilcox MH. Factors affecting reported Clostridioides difficile infection rates; the more you look the more you find, but should you believe what you see? Anaerobe 2020; 62:102178. [PMID: 32092415 DOI: 10.1016/j.anaerobe.2020.102178] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 02/15/2020] [Accepted: 02/17/2020] [Indexed: 01/05/2023]
Abstract
Reported rates of C. difficile infection (CDI) have increased in many settings; however, these can be affected by factors including testing density (test-density) and diagnostic methods. We aimed to describe the impact of multiple factors on CDI rates. Hospitals (n = 182) across five countries (France, Germany, Italy, Spain, and UK) provided data on; size and type of institution, CDI testing methodology, number of tests/month and patient-bed-days (pbds)/month over one year. Incidence rates were compared between countries, different sized institutions, types of institutions and testing method. After univariate analyses, the highest CDI rates were observed in Italy (average 11.8/10,000pbds/hospital/month), acute/primary hospitals (12.3/10,000pbds/hospital/month), small hospitals (16.7/10,000pbds/hospital/month), and hospitals using methods that do not detect toxin (NO-TOXIN) (e.g. GDH/NAAT or standalone NAAT) (10.7/10,000pbds/hospital/month). After adjusting for test-density, highest incidence rates were still in Italy, acute/primary hospitals and those using NO-TOXIN. The relative rate in long-term healthcare facilities (LTHCFs) increased, but size of institution no longer influenced the CDI rate. Test-density appears to have the largest effect on reported CDI rates. NO-TOXIN testing still influences CDI rates, even after adjusting for test-density, which is consistent with tests that 'overcall' true CDI. Low test-density can mask the true burden of CDI, e.g. in LTHCFs, highlighting the importance of good quality surveillance.
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Affiliation(s)
- Kerrie Davies
- Healthcare Associated Infections Research Group, University of Leeds, Leeds, UK.
| | - Georgina Davis
- Healthcare Associated Infections Research Group, University of Leeds, Leeds, UK
| | - Frédéric Barbut
- National Reference Laboratory for Clostridium Difficile, Saint-Antoine Hospital, Paris, France
| | - Catherine Eckert
- National Reference Laboratory for Clostridium Difficile, Saint-Antoine Hospital, Paris, France; Sorbonne Université, Centre D'immunologie et des Maladies Infectieuses-Paris, Cimi-Paris, Département de Bactériologie, AP-HP, Hôpitaux Universitaires de L'Est Parisien, F-75012, Paris, France
| | - Nicola Petrosillo
- National Institute for Infectious Diseases, L. Spallanzani, IRCCS, Rome, Italy
| | - Raffaella Pisapia
- National Institute for Infectious Diseases, L. Spallanzani, IRCCS, Rome, Italy
| | - Barbara Gärtner
- Institute of Medical Microbiology and Hygiene, National Reference Laboratory for Clostridioides (Clostridium) Difficile, Saarland University, Homburg/Saar, Germany
| | - Fabian K Berger
- Institute of Medical Microbiology and Hygiene, National Reference Laboratory for Clostridioides (Clostridium) Difficile, Saarland University, Homburg/Saar, Germany
| | - Elena Reigadas
- Hospital General Universitario Gregario Marañón, Madrid, Spain
| | - Emilio Bouza
- Hospital General Universitario Gregario Marañón, Madrid, Spain
| | | | - Mark H Wilcox
- Healthcare Associated Infections Research Group, University of Leeds, Leeds, UK
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Nana T, Moore C, Boyles T, Brink AJ, Cleghorn J, Devenish LM, du Toit B, Fredericks ES, Lekalakala-Mokaba MR, Maluleka C, Rajabally MN, Reubenson G, Shuping L, Swart K, Swe Han KS, Wadula J, Wojno J, Lowman W. South African Society of Clinical Microbiology Clostridioides difficile infection diagnosis, management and infection prevention and control guideline. S Afr J Infect Dis 2020; 35:219. [PMID: 34485483 PMCID: PMC8378053 DOI: 10.4102/sajid.v35i1.219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/24/2020] [Indexed: 12/17/2022] Open
Abstract
Clostridioides difficile infection (CDI) is a problem in both developed and developing countries and is a common hospital-acquired infection. This guideline provides evidence-based practical recommendations for South Africa and other developing countries. The scope of the guideline includes CDI diagnostic approaches; adult, paediatric and special populations treatment options; and surveillance and infection prevention and control recommendations.
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Affiliation(s)
- Trusha Nana
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Charlotte Maxeke Johannesburg Academic Hospital Microbiology Laboratory, National Health Laboratory Services, Johannesburg, South Africa
| | | | - Tom Boyles
- Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Adrian J. Brink
- Department of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Joy Cleghorn
- Life Healthcare Group, Johannesburg, South Africa
| | - Lesley M. Devenish
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Infection Control Services Laboratory, National Health Laboratory Services, Johannesburg, South Africa
| | | | - Ernst S. Fredericks
- Department of Physiology, Faculty of Science, Nelson Mandela University, Port Elizabeth, South Africa
| | - Molebogeng R. Lekalakala-Mokaba
- Department of Microbiology, Faculty of Health Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
- Dr George Mukhari Academic Hospital Microbiology Laboratory, National Health Laboratory Services, Pretoria, South Africa
| | - Caroline Maluleka
- Department of Microbiology, Faculty of Health Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
- Dr George Mukhari Academic Hospital Microbiology Laboratory, National Health Laboratory Services, Pretoria, South Africa
| | | | - Gary Reubenson
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Liliwe Shuping
- Centre for Healthcare-Associated Infections, National Institute for Communicable Diseases, a division of National Health Laboratory Service, Johannesburg, South Africa
| | - Karin Swart
- Netcare Hospitals Limited, Johannesburg, South Africa
| | - Khine Swe Swe Han
- Medical Microbiology Department, Inkosi Albert Luthuli Central Hospital Academic Complex, National Health Laboratory Services, Durban, South Africa
- Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Jeannette Wadula
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Chris Hani Baragwanath Hospital Microbiology Laboratory, National Health Laboratory Services, Johannesburg, South Africa
| | | | - Warren Lowman
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Clinical Microbiology, PathCare/Vermaak Pathologists, Johannesburg, South Africa
- Department of Clinical Microbiology and Infection Prevention and Control, WITS Donald Gordon Medical Centre, Johannesburg, South Africa
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10
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Clostridioides (Clostridium) difficile infection burden in Japan: A multicenter prospective study. Anaerobe 2019; 60:102011. [PMID: 30872073 DOI: 10.1016/j.anaerobe.2019.03.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 02/19/2019] [Accepted: 03/06/2019] [Indexed: 01/16/2023]
Abstract
Clostridioides (Clostridium) difficile is the leading cause of healthcare-associated infectious diarrhea in the developed world. Retrospective studies have shown a lower incidence of C. difficile infection (CDI) in Japan than in Europe or North America. Prospective studies are needed to determine if this is due lack of testing for C. difficile or a true difference in CDI epidemiology. A prospective cohort study of CDI was conducted from May 2014 to May 2015 at 12 medical facilities (20 wards) in Japan. Patients with at least three diarrheal bowel movements (Bristol stool grade 6-7) in the preceding 24 h were enrolled. CDI was defined by positive result on enzyme immunoassay for toxins A/B, nucleic acid amplification test for the toxin B gene or toxigenic culture. C. difficile isolates were subjected to PCR-ribotyping (RT), slpA-sequence typing (slpA-ST), and antimicrobial susceptibility testing. The overall incidence of CDI was 7.4/10,000 patient-days (PD). The incidence was highest in the five ICU wards (22.2 CDI/10,000 PD; range: 13.9-75.5/10,000 PD). The testing frequency and CDI incidence rate were highly correlated (R2 = 0.91). Of the 146 isolates, RT018/018″ was dominant (29%), followed by types 014 (23%), 002 (12%), and 369 (11%). Among the 15 non-ICU wards, two had high CDI incidence rates (13.0 and 15.9 CDI/10,000 PD), with clusters of RT018/slpA-ST smz-02 and 018"/smz-01, respectively. Three non-RT027 or 078 binary toxin-positive isolates were found. All RT018/018" isolates were resistant to moxifloxacin, gatifloxacin, clindamycin, and erythromycin. This study identified a higher CDI incidence in Japanese hospitals than previously reported by actively identifying and testing patients with clinically significant diarrhea. This suggests numerous patients with CDI are being overlooked due to inadequate diagnostic testing in Japan.
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Balsells E, Shi T, Leese C, Lyell I, Burrows J, Wiuff C, Campbell H, Kyaw MH, Nair H. Global burden of Clostridium difficile infections: a systematic review and meta-analysis. J Glob Health 2019; 9:010407. [PMID: 30603078 PMCID: PMC6304170 DOI: 10.7189/jogh.09.010407] [Citation(s) in RCA: 164] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background Clostridium difficile is a leading cause of morbidity and mortality in several countries. However, there are limited evidence characterizing its role as a global public health problem. We conducted a systematic review to provide a comprehensive overview of C. difficile infections (CDI) rates. Methods Seven databases were searched (January 2016) to identify studies and surveillance reports published between 2005 and 2015 reporting CDI incidence rates. CDI incidence rates for health care facility-associated (HCF), hospital onset-health care facility-associated, medical or general intensive care unit (ICU), internal medicine (IM), long-term care facility (LTCF), and community-associated (CA) were extracted and standardized. Meta-analysis was conducted using a random effects model. Results 229 publications, with data from 41 countries, were included. The overall rate of HCF-CDI was 2.24 (95% confidence interval CI = 1.66-3.03) per 1000 admissions/y and 3.54 (95%CI = 3.19-3.92) per 10 000 patient-days/y. Estimated rates for CDI with onset in ICU or IM wards were 11.08 (95%CI = 7.19-17.08) and 10.80 (95%CI = 3.15-37.06) per 1000 admission/y, respectively. Rates for CA-CDI were lower: 0.55 (95%CI = 0.13-2.37) per 1000 admissions/y. CDI rates were generally higher in North America and among the elderly but similar rates were identified in other regions and age groups. Conclusions Our review highlights the widespread burden of disease of C. difficile, evidence gaps, and the need for sustainable surveillance of CDI in the health care setting and the community.
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Affiliation(s)
- Evelyn Balsells
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Joint first authorship
| | - Ting Shi
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Joint first authorship
| | - Callum Leese
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Iona Lyell
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - John Burrows
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | | | - Harry Campbell
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Moe H Kyaw
- Sanofi Pasteur, Swiftwater, Pennsylvania, USA.,Joint last authorship
| | - Harish Nair
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Joint last authorship
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12
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Goret J, Blanchi J, Floch P, Peuchant O, Chrisment D, Sanchez R, Biessy H, Lemarié R, Leyssene D, Loutfi B, Mimouni S, Flao T, Bébéar C, Mégraud F. Impact of the introduction of a nucleic acid amplification test for Clostridium difficile diagnosis on stool rejection policies. Gut Pathog 2018; 10:19. [PMID: 29854009 PMCID: PMC5975266 DOI: 10.1186/s13099-018-0245-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 05/19/2018] [Indexed: 12/02/2022] Open
Abstract
Background The change from non-molecular to nucleic acid amplification tests (NAATs) is known to increase the detection of Clostridium difficile infection (CDI); however, the impact on stool rejection policies in clinical laboratories is unclear. The current guidelines have reinforced the importance of respecting strict conditions for performing tests on stool samples for CDI diagnosis. The purpose of this study was to estimate whether the implementation of molecular tests has resulted in changes in stool rejection policies between clinical laboratories that introduced NAATs and those that did not. Results A survey was conducted to evaluate the change in the number of stool samples rejected and the rejection criteria among 12 hospital laboratories in southwestern France before and after the switch from non-molecular tests to NAATs using retrospective data from June 1 till September 30, 2013 and the same period 2014. Four laboratories introduced NAATs as a second or third step in the process. A total of 1378 and 1297 stools samples were collected in 2013 and 2014, respectively. The mean number of rejected stool samples significantly increased (p < 0.001, Chi square test), with a total of 99 (7.1%) and 147 (11.3%) specimens rejected in 2013 and 2014, respectively. Notably, these laboratories had more stringent criteria and were no longer testing the stool samples of patients with CDI-positive results within 7 days. In contrast, there was a significant decrease in the rate of rejected stool samples (p < 0.001, Chi square test) in the five laboratories that did not adopt NAATs and a less stringent stool rejection policy. Conclusion Nucleic acid amplification test implementation improved compliance with recommended stool rejection policies. Laboratories should follow the recommended laboratory algorithm for the CDI diagnosis combined with the correct stool rejection policy. Electronic supplementary material The online version of this article (10.1186/s13099-018-0245-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- J Goret
- 1Laboratoire de Bactériologie, C.H.U. de Bordeaux, Groupe Hospitalier Pellegrin, Place Amélie Raba Léon, 33076 Bordeaux Cedex, France
| | - J Blanchi
- 1Laboratoire de Bactériologie, C.H.U. de Bordeaux, Groupe Hospitalier Pellegrin, Place Amélie Raba Léon, 33076 Bordeaux Cedex, France
| | - P Floch
- 2C.H.U. de Bordeaux, Hôpital Haut-Lévèque, Pessac, France
| | - O Peuchant
- 2C.H.U. de Bordeaux, Hôpital Haut-Lévèque, Pessac, France
| | | | - R Sanchez
- C.H. de Périgueux, Périgueux, France
| | - H Biessy
- G.H. de La Rochelle-Ré-Aunis, La Rochelle, France
| | - R Lemarié
- G.H. de La Rochelle-Ré-Aunis, La Rochelle, France
| | - D Leyssene
- C. H. de la Côte Basque, Bayonne, France
| | - B Loutfi
- C.H. Mont de Marsan, Mont de Marsan, France
| | | | - T Flao
- C.H.I.C Marmande-Tonneins, Marmande, France
| | - C Bébéar
- 1Laboratoire de Bactériologie, C.H.U. de Bordeaux, Groupe Hospitalier Pellegrin, Place Amélie Raba Léon, 33076 Bordeaux Cedex, France
| | - F Mégraud
- 1Laboratoire de Bactériologie, C.H.U. de Bordeaux, Groupe Hospitalier Pellegrin, Place Amélie Raba Léon, 33076 Bordeaux Cedex, France
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13
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Abstract
PURPOSE OF REVIEW Molecular-based diagnostic methods for the detection of gastrointestinal pathogens are becoming increasingly commonplace in microbiology laboratories. This review aims to summarize recent developments in this field and discuss the clinical application and limitations of implementing these techniques. RECENT FINDINGS Recent evaluations of multiplex PCR assays show increased sensitivity whenever compared with standard microbiological culture-based methods. In addition to shorter turnaround times, assays can detect an increased repertoire of pathogens from a single specimen and provide useful information for infection prevention and control practices. There are many limitations, however, associated with their use, including clinical interpretation of results and lack of concordance between different test panels. Newer technologies, such as metagenomic analysis, can provide comprehensive information useful to both patient management and public health surveillance. SUMMARY Molecular techniques are capable of replacing culture in the diagnosis of gastrointestinal infections. Whether all positive results, however, represent true infection is still debateable, as is the clinical significance of identifying more than one pathogen. As it currently stands, microbiological culture remains vital for public health surveillance, monitoring antibiotic resistance and managing outbreaks.
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14
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Barbut F, Bouée S, Longepierre L, Goldberg M, Bensoussan C, Levy-Bachelot L. Excess mortality between 2007 and 2014 among patients with Clostridium difficile infection: a French health insurance database analysis. J Hosp Infect 2018; 98:21-28. [DOI: 10.1016/j.jhin.2017.07.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 07/07/2017] [Indexed: 12/18/2022]
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15
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Couturier J, Davies K, Gateau C, Barbut F. Ribotypes and New Virulent Strains Across Europe. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1050:45-58. [PMID: 29383663 DOI: 10.1007/978-3-319-72799-8_4] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Clostridium difficile is a major bacterial cause of post-antibiotic diarrhoea. The epidemiology of C. difficile infections (CDI) has dramatically changed since the early 2000s, with an increasing incidence and severity across Europe. This trend is partly due to the emergence and rapid worldwide spread of the hypervirulent and epidemic PCR ribotype 027. Profiles of patients with CDI have also evolved, with description of community-acquired (CA) infections in patients with no traditional risk factors for CDI. However, recent epidemiological studies indicated that some European countries have successfully controlled the dissemination of the 027 clone whereas other countries recently reported the emergence of other virulent or unusual strains. The aims of this review are to summarize the current European CDI epidemiology and to describe the new virulent C. difficile strains circulating in Europe, as well as other potential emerging strains described elsewhere. Standardized typing methods and surveillance programmes are mandatory for a better understanding and monitoring of CDI in Europe.
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Affiliation(s)
- Jeanne Couturier
- National Reference Laboratory for C. difficile, Hôpital Saint-Antoine, Paris, France. .,Université Paris Descartes, Faculté de Pharmacie, Paris, France.
| | - Kerrie Davies
- Healthcare Associated Infections Research Group, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, UK
| | - Cécile Gateau
- National Reference Laboratory for C. difficile, Hôpital Saint-Antoine, Paris, France
| | - Frédéric Barbut
- National Reference Laboratory for C. difficile, Hôpital Saint-Antoine, Paris, France.,Université Paris Descartes, Faculté de Pharmacie, Paris, France
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16
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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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17
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Krutova M, Kinross P, Barbut F, Hajdu A, Wilcox MH, Kuijper EJ. How to: Surveillance of Clostridium difficile infections. Clin Microbiol Infect 2017; 24:469-475. [PMID: 29274463 DOI: 10.1016/j.cmi.2017.12.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 12/09/2017] [Accepted: 12/13/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND The increasing incidence of Clostridium difficile infections (CDI) in healthcare settings in Europe since 2003 has affected both patients and healthcare systems. The implementation of effective CDI surveillance is key to enable monitoring of the occurrence and spread of C. difficile in healthcare and the timely detection of outbreaks. AIMS The aim of this review is to provide a summary of key components of effective CDI surveillance and to provide some practical recommendations. We also summarize the recent and current national CDI surveillance activities, to illustrate strengths and weaknesses of CDI surveillance in Europe. SOURCES For the definition of key components of CDI surveillance, we consulted the current European Society of Clinical Microbiology and Infectious Diseases (ESCMID) CDI-related guidance documents and the European Centre for Disease Prevention and Control (ECDC) protocol for CDI surveillance in acute care hospitals. To summarize the recent and current national CDI surveillance activities, we discussed international multicentre CDI surveillance studies performed in 2005-13. In 2017, we also performed a new survey of existing CDI surveillance systems in 33 European countries. CONTENT Key components for CDI surveillance are appropriate case definitions of CDI, standardized CDI diagnostics, agreement on CDI case origin definition, and the presentation of CDI rates with well-defined numerators and denominators. Incorporation of microbiological data is required to provide information on prevailing PCR ribotypes and antimicrobial susceptibility to first-line CDI treatment drugs. In 2017, 20 European countries had a national CDI surveillance system and 21 countries participated in ECDC-coordinated CDI surveillance. Since 2014, the number of centres with capacity for C. difficile typing has increased to 35 reference or central laboratories in 26 European countries. IMPLICATIONS Incidence rates of CDI, obtained from a standardized CDI surveillance system, can be used as an important quality indicator of healthcare at hospital as well as country level.
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Affiliation(s)
- M Krutova
- Department of Medical Microbiology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic; European Society of Clinical Microbiology and Infectious Diseases (ESCMID) study group for Clostridium difficile (ESGCD).
| | - P Kinross
- Surveillance and Response Support Unit, European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - F Barbut
- National Reference Laboratory for C. difficile, Hôpital Saint-Antoine, Paris, France; European Society of Clinical Microbiology and Infectious Diseases (ESCMID) study group for Clostridium difficile (ESGCD)
| | - A Hajdu
- Department of Hospital Hygiene and Communicable Disease Control, Ministry of Human Capacities, Budapest, Hungary
| | - M H Wilcox
- Leeds Teaching Hospitals NHS Trust & University of Leeds, Leeds, United Kingdom; European Society of Clinical Microbiology and Infectious Diseases (ESCMID) study group for Clostridium difficile (ESGCD)
| | - E J Kuijper
- Department of Medical Microbiology, Leiden University Medical Centre, Leiden, The Netherlands; European Society of Clinical Microbiology and Infectious Diseases (ESCMID) study group for Clostridium difficile (ESGCD)
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18
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Nosocomial-acquired and community-onset Clostridium difficile infection at an academic hospital in Italy: Epidemiology, recurrences and toxin genes distribution. J Infect Chemother 2017; 23:763-768. [PMID: 28899610 DOI: 10.1016/j.jiac.2017.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 07/03/2017] [Accepted: 08/04/2017] [Indexed: 01/27/2023]
Abstract
Toxinogenic Clostridium difficile infection (CDI) is a leading cause of infectious diarrhea. In this retrospective cohort study the molecular epidemiology of hospital-acquired and community-associated CDI was investigated in patients admitted to a tertiary care hospital. CD in stools samples was revealed by a two steps diagnostic algorithm, firstly screening for positivity to GDH antigen and thereafter RT-PCR analysis. Increased CDI incidence was observed ranging from 1.70episodes/10000patient-days in the 1st year, to 2.62 in the 2nd year, mostly hospitalized in the medicine wards, followed by outpatients (5.74 and 5.12episodes/10.000patient-days respectively). CDI positive were older than CDI negative patients and presented increased trend of diarrhea episodes as the patients' age increased. RT-PCR positive patients (n° = 314) were classified according to the CD toxin producing genes in three groups (1-3, carrying tcdB, both tcdB and cdt, and the two genes plus the deletion Δ117 of tcdC, respectively). The incidence of the group 2 and 3 increased statistically with the age of the patients showing correlation with the gender. Higher frequency of patients belonging to group 1 and group 3 was observed in the medical wards. Of note was the high incidence of group 3 in outpatients. Interestingly, patients with previous health care contacts had higher risk (RR = 1.88) of being infected by CD strains with higher toxicity than community patients. Recurrence rate was 15.9%. In conclusion the knowledge of the toxigenic profiles and of their relationships to gender, age and wards distribution may help the clinicians in the clinical management of the disease.
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