Evolving Strategies to Manage Clostridium difficile Colitis

The burden of Clostridioides difficile infections in South-East Asia and the Western Pacific: A narrative review

BACKGROUND

Clostridioides difficile (formerly Clostridium difficile) is well-documented in Europe and North America to be a common cause of healthcare-associated gastrointestinal tract infections. In contrast, C difficile infection (CDI) is infrequently reported in literature from Asia, which may reflect a lack of clinician awareness. We conducted a narrative review to better understand CDI burden in Asia.

METHODS

We searched the PubMed database for English language articles related to C difficile, Asia, epidemiology, and molecular characteristics (eg, ribotype, antimicrobial resistance).

RESULTS

Fifty-eight articles that met eligibility criteria were included. C difficile prevalence ranged from 7.1% to 45.1 % of hospitalized patients with diarrhea, and toxigenic strains among all C difficile in these patients ranged from 68.2% to 91.9 % in China and from 39.0% to 60.0 % outside of China. Widespread C difficile ribotypes were RT017, RT014/020, RT012, and RT002. Recurrence in patients with CDI ranged from 3.0% to 17.2 %. Patients with CDI typically had prior antimicrobial use recently. High rates of resistance to ciprofloxacin, clindamycin, and erythromycin were frequently reported.

CONCLUSION

The regional CDI burden in Asia is still incompletely documented, seemingly due to low awareness and limited laboratory testing. Despite this apparent under recognition, the current CDI burden highlights the need for broader surveillance and for application of preventative measures against CDI in Asia.

Encapsulins

Subcellular compartmentalization is a defining feature of all cells. In prokaryotes, compartmentalization is generally achieved via protein-based strategies. The two main classes of microbial protein compartments are bacterial microcompartments and encapsulin nanocompartments. Encapsulins self-assemble into proteinaceous shells with diameters between 24 and 42 nm and are defined by the viral HK97-fold of their shell protein. Encapsulins have the ability to encapsulate dedicated cargo proteins, including ferritin-like proteins, peroxidases, and desulfurases. Encapsulation is mediated by targeting sequences present in all cargo proteins. Encapsulins are found in many bacterial and archaeal phyla and have been suggested to play roles in iron storage, stress resistance, sulfur metabolism, and natural product biosynthesis. Phylogenetic analyses indicate that they share a common ancestor with viral capsid proteins. Many pathogens encode encapsulins, and recent evidence suggests that they may contribute toward pathogenicity. The existing information on encapsulin structure, biochemistry, biological function, and biomedical relevance is reviewed here.

Acute Responses to Infectious and Inflammatory Disorders of the Gastrointestinal System

Infectious and inflammatory disorders of the gastrointestinal system are life-threatening and occur frequently in hospitalized adults. Inflammatory and inflammation-related diseases of the gastrointestinal tract seen in the acutely and critically ill have numerous causes. In acute pancreatitis and toxic infections caused by the bacterium Clostridium difficile, where severe infections can develop, inflammation plays a causative and crucial role. Severe acute pancreatitis puts a patient at risk for infected necrosis, which can result in septicemia and shock. Similarly, patients treated with antibiotics are at risk for C difficile colitis, which can progress to toxic megacolon. These conditions require volume resuscitation and interventions supported by current evidence. Percutaneous or surgical interventions are often undertaken at a critical point in these illnesses. Patients who require surgery for these diagnoses present challenges for the interprofessional team. Inflammatory and infectious disorders often can lead to complications of systemic inflammatory response syndrome, sepsis, and multiorgan failure. New strategies are on the horizon to prevent the onset of and improve care for patients with severe acute pancreatitis, fulminant C difficile infection, and megacolon.

Hyperimmune yolk extract with Immunoglobulin Y basic active principle as a possible adjuvant treatment in patients who need/benefit from neurorehabilitation, with Clostridium difficile (Clostridioides difficile) enterocolitis as intercurrent comorbidity - a systematic literature review

The study aims to add a new and beneficial perspective using Immunoinstant G food supplement as an adjuvant treatment. It is essential to study the bibliographic resources in the field to identify the current stage of knowledge on this topic. For this purpose, we have prepared a systematic literature review, focusing on the possibilities of improving the treatment of Clostridium difficile (Clostridioides difficile) enterocolitis in patients who need/benefit from neurorehabilitation. The systematic literature review was prepared using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We obtained a number of 6 articles that were considered in the elaboration of our systematic literature review. We identified that this field is insufficiently studied and needs additional clinical trials. Our study contributes to increasing this understanding based on the thorough theoretical and practical approach of this topic.

Danish national guideline for the treatment of Clostridioides difficile infection and use of faecal microbiota transplantation (FMT)

Aim: This Danish national guideline describes the treatment of adult patients with Clostridioides (formerly Clostridium) difficile (CD) infection and the use of faecal microbiota transplantation (FMT). It suggests minimum standard for implementing an FMT service.Method: Four scientific societies appointed members for a working group which conducted a systematic literature review and agreed on the text and recommendations. All clinical recommendations were evalluated for evidence level and grade of recommendation.Results: In CD infection, the use of marketed and experimental antibiotics as well as microbiota-based therapies including FMT are described. An algorithm for evaluating treatment effect is suggested. The organisation of FMT, donor recruitment and screening, laboratory preparation, clinical application and follow-up are described.Conclusion: Updated evidence for the treatment of CD infection and the use of FMT is provided.

Large-scale computational discovery and analysis of virus-derived microbial nanocompartments

Encapsulins are a class of microbial protein compartments defined by the viral HK97-fold of their capsid protein, self-assembly into icosahedral shells, and dedicated cargo loading mechanism for sequestering specific enzymes. Encapsulins are often misannotated and traditional sequence-based searches yield many false positive hits in the form of phage capsids. Here, we develop an integrated search strategy to carry out a large-scale computational analysis of prokaryotic genomes with the goal of discovering an exhaustive and curated set of all HK97-fold encapsulin-like systems. We find over 6,000 encapsulin-like systems in 31 bacterial and four archaeal phyla, including two novel encapsulin families. We formulate hypotheses about their potential biological functions and biomedical relevance, which range from natural product biosynthesis and stress resistance to carbon metabolism and anaerobic hydrogen production. An evolutionary analysis of encapsulins and related HK97-type virus families shows that they share a common ancestor, and we conclude that encapsulins likely evolved from HK97-type bacteriophages.

Clostridioides difficile Infection among Cirrhotic Patients with Variceal Bleeding

Clostridioides difficile infection (CDI) stands as the leading cause of nosocomial infection with high morbidity and mortality rates, causing a major burden on the healthcare system. Driven by antibiotics, it usually affects older patients with chronic disease or immunosuppressed or oncologic management. Variceal bleeding secondary to cirrhosis requires antibiotics to prevent bacterial translocation, and thus patients become susceptible to CDI. We aimed to investigate the risk factors for CDI in cirrhotic patients with variceal bleeding following ceftriaxone and the mortality risk in this patient’s population. We retrospectively screened 367 cirrhotic patients with variceal bleeding, from which 25 patients were confirmed with CDI, from 1 January 2017 to 31 December 2019. We found MELD to be the only multivariate predictor for mortality (odds ratio, OR = 1.281, 95% confidence interval, CI: 0.098–1.643, p = 0.042). A model of four predictors (age, days of admission, Charlson index, Child–Pugh score) was generated (area under the receiver operating characteristics curve, AUC = 0.840, 95% CI: 0.758–0.921, p < 0.0001) to assess the risk of CDI exposure. Determining the probability of getting CDI for cirrhotic patients with variceal bleeding could be a tool for doctors in taking decisions, which could be integrated in sustainable public health programs.

Meta-analysis of Postoperative Mortality and Morbidity After Total Abdominal Colectomy Versus Loop Ileostomy With Colonic Lavage for Fulminant Clostridium Difficile Colitis

BACKGROUND

Emergency surgery is often required for fulminant Clostridium difficile colitis. Total abdominal colectomy has been the treatment of choice despite high morbidity and mortality.

OBJECTIVE

The aim of this meta-analysis was to evaluate postoperative mortality and morbidity after total abdominal colectomy and loop ileostomy with colonic lavage in patients with fulminant C difficile colitis.

DATA SOURCES

Studies comparing total abdominal colectomy to loop ileostomy for fulminant C difficile colitis were identified by a systematic search of PubMed, Cochrane Library, MEDLINE, and CINAHL.

STUDY SELECTION

Relevant records were detected and screened using a cascade system (title, abstract, and/or full text article).

INTERVENTION(S)

Total abdominal colectomy (rectal-sparing resection of the entire colon with end ileostomy) was compared to loop ileostomy (exteriorization of an ileal loop not far from the ileocecal junction for colonic lavage).

MAIN OUTCOMES MEASURES

This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines. Primary outcome was postoperative mortality, defined as death occurring within 30 days after the intervention. Secondary end points were the rates of ostomy reversal, deep venous thrombosis/embolism, surgical site infection, urinary tract infection, respiratory complications, reoperations, and adverse events. Mantel-Haenszel method with random-effects model was used for meta-analysis.

RESULTS

Five observational studies (3 cohort and 2 database analysis studies) totaling 3683 patients were included. Postoperative mortality rate was 31.3% after total abdominal colectomy and 26.2% after loop ileostomy (OR = 1.36 (95% CI, 0.83-2.24); p = 0.22; number needed to treat/harm = 20; I = 55%). Ostomy reversal rate was both statistically and clinically significantly higher after loop ileostomy as compared with total abdominal colectomy (80% vs 25%; OR = 0.08 (95% CI, 0.02-0.30); p = 0.002; number needed to treat/harm = 2) with low heterogeneity (I = 0%).

LIMITATIONS

A limitation is the observational nature of the included studies introducing an overall high risk of selection bias.

CONCLUSIONS

This meta-analysis suggests that loop ileostomy with colonic lavage for fulminant C difficile colitis may be associated with similar survival and decreased surgical site infection rates as compared with total abdominal colectomy. Although loop ileostomy with colonic lavage was associated with higher ostomy reversal rates, this finding was based on the data from only 2 studies.