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Vehreschild MJGT, Schreiber S, von Müller L, Epple HJ, Weinke T, Manthey C, Oh J, Wahler S, Stallmach A. Trends in the epidemiology of Clostridioides difficile infection in Germany. Infection 2023; 51:1695-1702. [PMID: 37162717 PMCID: PMC10170422 DOI: 10.1007/s15010-023-02044-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 04/25/2023] [Indexed: 05/11/2023]
Abstract
PURPOSES Despite reports of a declining incidence over the last decade, Clostridioides difficile infection (CDI) is still considered the most important healthcare-associated causes of diarrhea worldwide. In Germany, several measures have been taken to observe, report, and influence this development. This report aims to analyze the development of hospital coding for CDI in Germany over the last decade and to use it to estimate the public health burden caused by CDI. METHODS Reports from the Institute for Hospital Remuneration Systems, German Federal Statistical Office (DESTATIS), the Robert-Koch-Institute (RKI), Saxonian authorities and hospital quality reports during 2010-2021 were examined for CDI coding and assessed in a structured expert consultation. Analysis was performed using 2019 versions of Microsoft Excel® and Microsoft Access®. RESULTS Peaks of 32,203 cases with a primary diagnosis (PD) of CDI and 78,648 cases with a secondary diagnosis (SD) of CDI were observed in 2015. The number of cases had decreased to 15,412 PD cases (- 52.1%) and 40,188 SD cases (- 48.9%) by 2021. These results were paralleled by a similar decline in notifiable severe cases. However, average duration of hospitalization of the cases remained constant during this period. CONCLUSIONS Hospital coding of CDI and notification to authorities has approximately halved from 2015 to 2021. Potential influential factors include hospital hygiene campaigns, implementation of antibiotic stewardship programs, social distancing due to the COVID-19 pandemic, and a decrease in more pathogenic subtypes of bacteria. Further research is necessary to validate the multiple possible drivers for this development.
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Affiliation(s)
| | - Stefan Schreiber
- Department Medicine I, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Rosalind-Franklin-Str. 12, 24105 Kiel, Germany
| | - Lutz von Müller
- Christophorus-Kliniken GmbH, Südring 41, 48653 Coesfeld, Germany
| | - Hans-Jörg Epple
- Charité, Universitätsmedizin Berlin, Campus Benjamin Franklin, Antibiotic Stewardship, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Thomas Weinke
- Ernst Von Bergmann Klinikum gGmbH, Charlottenstraße 72, 14467 Potsdam, Germany
| | - Carolin Manthey
- Gemeinschaftspraxis Innere Medizin (GIM), Pferdebachstr. 29, 58455 Witten, Germany
| | - Jun Oh
- Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Steffen Wahler
- St. Bernward GmbH, Friedrich-Kirsten-Str. 40, 22391 Hamburg, Germany
| | - Andreas Stallmach
- Klinik Für Innere Medizin IV, Universitätsklinikum Jena, Am Klinikum 1, 07747 Jena, Germany
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Porcari S, Severino A, Rondinella D, Bibbò S, Quaranta G, Masucci L, Maida M, Scaldaferri F, Sanguinetti M, Gasbarrini A, Cammarota G, Ianiro G. Fecal microbiota transplantation for recurrent Clostridioides difficile infection in patients with concurrent ulcerative colitis. J Autoimmun 2023; 141:103033. [PMID: 37085337 DOI: 10.1016/j.jaut.2023.103033] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/05/2023] [Accepted: 03/17/2023] [Indexed: 04/23/2023]
Abstract
AIMS Clostridioides difficile infection (CDI) is a major challenge for healthcare systems. Inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn's disease, is a risk factor for primary and recurrent CDI (rCDI). Moreover, CDI itself often worsens the clinical picture of IBD, increasing the risk of complications. Fecal microbiota transplantation (FMT) is a highly effective treatment for rCDI, but data from patients with IBD and CDI are limited and often referred to mixed cohorts. We aimed to report outcomes from a cohort of patients with UC treated with FMT for rCDI superinfection. METHODS AND RESULTS In a retrospective, single-centre cohort study we evaluated characteristics and outcomes of patients with UC who received FMT for rCDI. The primary outcome was negative C. difficile toxin 8 weeks after FMT. Thirty-five patients were included in the analysis. Sixteen patients were cured after single FMT, while 19 patients received repeat FMT. Overall, FMT cured rCDI in 32 patients (91%), and repeat FMT was significantly associated with sustained cure of CDI compared with single FMT (84% vs 50%, p = 0.018). Twenty-four patients (69%) experienced remission or an amelioration of UC activity. Serious adverse events were not observed. CONCLUSIONS In our cohort of patients with UC, FMT was highly effective in curing rCDI without severe adverse events and repeat FMT was significantly associated with CDI cure. Most patients also experienced remission or amelioration of UC activity after FMT. Our findings suggest that a sequential FMT protocol may be used routinely in patients with UC and rCDI.
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Affiliation(s)
- Serena Porcari
- Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Severino
- Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Debora Rondinella
- Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Stefano Bibbò
- Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianluca Quaranta
- Microbiology Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luca Masucci
- Microbiology Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marcello Maida
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, Caltanissetta, Italy
| | - Franco Scaldaferri
- Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maurizio Sanguinetti
- Microbiology Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Gasbarrini
- Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Cammarota
- Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianluca Ianiro
- Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy.
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Siraw BB, Reingold AL, Meyahnwi D. Association between epidemiologic case definition categories and adverse clinical outcome in patients with Clostridiodes difficile infection in San Francisco County, California: a five-year retrospective cohort study. BMC Infect Dis 2023; 23:68. [PMID: 36737685 PMCID: PMC9897617 DOI: 10.1186/s12879-023-08030-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 01/24/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Understanding the predictors of adverse clinical outcomes following incident Clostridiodes difficile infection (CDI) can help clinicians identify which patients are at risk of complications and help prioritize the provision of their care. In this study, we assessed the associations between epidemiologic case definition categories and adverse clinical outcomes in patients with CDI in San Francisco County, California. METHODS We conducted a retrospective cohort study using CDI surveillance data (n = 3274) from the California Emerging Infections Program for the time period 2016 to 2020. After independent associations were established, two multivariable logistic and log-binomial regression models were constructed for the final statistical analysis. RESULT The mean cumulative incidence of CDI cases was 78.8 cases per 100,000 population. The overall recurrence rate and the 30-day all-cause mortality rate were 11.1% and 4.5%, respectively. After adjusting for potential confounders, compared to the community associated CDI cases, healthcare facility onset (AOR = 3.1; 95% CI [1.3-7]) and community-onset-healthcare facility associated (AOR = 2.4; 95% CI [1.4-4.3]) CDI cases were found to have higher odds of all-cause 30-day mortality. Community onset-healthcare facility-associated CDI case definition category was found to be significantly associated with an increased risk of recurrence of CDI (ARR = 1.7; 95% CI [1.2-2.4]). CONCLUSION Although the incidence of community-associated CDI cases has been rising, the odds of all-cause 30-day mortality and the risk of recurrent CDI associated with these infections are lower than healthcare facility onset and community-onset healthcare facility-associated CDI cases.
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Affiliation(s)
- Bekure B. Siraw
- grid.47840.3f0000 0001 2181 7878School of Public Health, University of California, 1279 Webster St. San Francisco, Berkeley, CA 94115 USA
| | - Arthur L. Reingold
- grid.47840.3f0000 0001 2181 7878Division of Epidemiology, School of Public Health, University of California, Berkeley, CA USA
| | - Didien Meyahnwi
- grid.47840.3f0000 0001 2181 7878School of Public Health, University of California, 1279 Webster St. San Francisco, Berkeley, CA 94115 USA
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Chopra T, Hecht G, Tillotson G. Gut microbiota and microbiota-based therapies for Clostridioides difficile infection. Front Med (Lausanne) 2023; 9:1093329. [PMID: 36698844 PMCID: PMC9868170 DOI: 10.3389/fmed.2022.1093329] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/15/2022] [Indexed: 01/10/2023] Open
Abstract
Clostridioides difficile infection poses significant clinical challenges due to its recurrent nature. Current antibiotic management does not address the underlying issue, that of a disturbed gastrointestinal microbiome, called dysbiosis. This provides a supportive environment for the germination of C. difficile spores which lead to infection and toxin production as well as an array of other health conditions. The use of microbiome restoration therapies such as live biotherapeutics can reverse dysbiosis and lead to good clinical outcomes. Several such therapies are under clinical investigation.
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Affiliation(s)
- Teena Chopra
- Division of Infectious Diseases, Wayne State University, Detroit, MI, United States,*Correspondence: Teena Chopra,
| | - Gail Hecht
- Department of Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, IL, United States
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van Prehn J, Reigadas E, Vogelzang EH, Bouza E, Hristea A, Guery B, Krutova M, Norén T, Allerberger F, Coia JE, Goorhuis A, van Rossen TM, Ooijevaar RE, Burns K, Scharvik Olesen BR, Tschudin-Sutter S, Wilcox MH, Vehreschild MJGT, Fitzpatrick F, Kuijper EJ. European Society of Clinical Microbiology and Infectious Diseases: 2021 update on the treatment guidance document for Clostridioides difficile infection in adults. Clin Microbiol Infect 2021; 27 Suppl 2:S1-S21. [PMID: 34678515 DOI: 10.1016/j.cmi.2021.09.038] [Citation(s) in RCA: 248] [Impact Index Per Article: 82.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 09/23/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022]
Abstract
SCOPE In 2009, the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) published the first treatment guidance document for Clostridioides difficile infection (CDI). This document was updated in 2014. The growing literature on CDI antimicrobial treatment and novel treatment approaches, such as faecal microbiota transplantation (FMT) and toxin-binding monoclonal antibodies, prompted the ESCMID study group on C. difficile (ESGCD) to update the 2014 treatment guidance document for CDI in adults. METHODS AND QUESTIONS Key questions on CDI treatment were formulated by the guideline committee and included: What is the best treatment for initial, severe, severe-complicated, refractory, recurrent and multiple recurrent CDI? What is the best treatment when no oral therapy is possible? Can prognostic factors identify patients at risk for severe and recurrent CDI and is there a place for CDI prophylaxis? Outcome measures for treatment strategy were: clinical cure, recurrence and sustained cure. For studies on surgical interventions and severe-complicated CDI the outcome was mortality. Appraisal of available literature and drafting of recommendations was performed by the guideline drafting group. The total body of evidence for the recommendations on CDI treatment consists of the literature described in the previous guidelines, supplemented with a systematic literature search on randomized clinical trials and observational studies from 2012 and onwards. The Grades of Recommendation Assessment, Development and Evaluation (GRADE) system was used to grade the strength of our recommendations and the quality of the evidence. The guideline committee was invited to comment on the recommendations. The guideline draft was sent to external experts and a patients' representative for review. Full ESCMID endorsement was obtained after a public consultation procedure. RECOMMENDATIONS Important changes compared with previous guideline include but are not limited to: metronidazole is no longer recommended for treatment of CDI when fidaxomicin or vancomycin are available, fidaxomicin is the preferred agent for treatment of initial CDI and the first recurrence of CDI when available and feasible, FMT or bezlotoxumab in addition to standard of care antibiotics (SoC) are preferred for treatment of a second or further recurrence of CDI, bezlotoxumab in addition to SoC is recommended for the first recurrence of CDI when fidaxomicin was used to manage the initial CDI episode, and bezlotoxumab is considered as an ancillary treatment to vancomycin for a CDI episode with high risk of recurrence when fidaxomicin is not available. Contrary to the previous guideline, in the current guideline emphasis is placed on risk for recurrence as a factor that determines treatment strategy for the individual patient, rather than the disease severity.
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Affiliation(s)
- Joffrey van Prehn
- Department of Medical Microbiology, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Elena Reigadas
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Erik H Vogelzang
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Adriana Hristea
- University of Medicine and Pharmacy Carol Davila, National Institute for Infectious Diseases Prof Dr Matei Bals, Romania
| | - Benoit Guery
- Infectious Diseases Specialist, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Marcela Krutova
- Department of Medical Microbiology, Charles University in Prague and Motol University Hospital, Czech Republic
| | - Torbjorn Norén
- Faculty of Medicine and Health, Department of Laboratory Medicine, National Reference Laboratory for Clostridioides difficile, Clinical Microbiology, Örebro University Hospital, Örebro, Sweden
| | | | - John E Coia
- Department of Clinical Microbiology, Hospital South West Jutland and Department of Regional Health Research IRS, University of Southern Denmark, Esbjerg, Denmark
| | - Abraham Goorhuis
- Department of Infectious Diseases, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Tessel M van Rossen
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Rogier E Ooijevaar
- Department of Gastroenterology, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Karen Burns
- Departments of Clinical Microbiology, Beaumont Hospital & Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Sarah Tschudin-Sutter
- Department of Infectious Diseases and Infection Control, University Hospital Basel, University Basel, Universitatsspital, Basel, Switzerland
| | - Mark H Wilcox
- Department of Microbiology, Old Medical, School Leeds General Infirmary, Leeds Teaching Hospitals & University of Leeds, Leeds, United Kingdom
| | - Maria J G T Vehreschild
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany; Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Fidelma Fitzpatrick
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland; Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ed J Kuijper
- Department of Medical Microbiology, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands; National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands.
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van Rossen TM, Ooijevaar RE, Vandenbroucke-Grauls CMJE, Dekkers OM, Kuijper EJ, Keller JJ, van Prehn J. Prognostic factors for severe and recurrent Clostridioides difficile infection: a systematic review. Clin Microbiol Infect 2021; 28:321-331. [PMID: 34655745 DOI: 10.1016/j.cmi.2021.09.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/24/2021] [Accepted: 09/25/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Clostridioides difficile infection (CDI), its subsequent recurrences (rCDIs), and severe CDI (sCDI) provide a significant burden for both patients and the healthcare system. Identifying patients diagnosed with initial CDI who are at increased risk of developing sCDI/rCDI could lead to more cost-effective therapeutic choices. In this systematic review we aimed to identify clinical prognostic factors associated with an increased risk of developing sCDI or rCDI. METHODS PubMed, Embase, Emcare, Web of Science and COCHRANE Library databases were searched from database inception through March, 2021. The study eligibility criteria were cohort and case-control studies. Participants were patients ≥18 years old diagnosed with CDI, in which clinical or laboratory factors were analysed to predict sCDI/rCDI. Risk of bias was assessed by using the Quality in Prognostic Research (QUIPS) tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool modified for prognostic studies. Study selection was performed by two independent reviewers. Overview tables of prognostic factors were constructed to assess the number of studies and the respective effect direction and statistical significance of an association. RESULTS 136 studies were included for final analysis. Greater age and the presence of multiple comorbidities were prognostic factors for sCDI. Identified risk factors for rCDI were greater age, healthcare-associated CDI, prior hospitalization, proton pump inhibitors (PPIs) started during or after CDI diagnosis, and previous rCDI. CONCLUSIONS Prognostic factors for sCDI and rCDI could aid clinicians to make treatment decisions based on risk stratification. We suggest that future studies use standardized definitions for sCDI/rCDI and systematically collect and report the risk factors assessed in this review, to allow for meaningful meta-analysis of risk factors using data of high-quality trials.
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Affiliation(s)
- Tessel M van Rossen
- Amsterdam UMC, VU University Medical Center, Medical Microbiology & Infection Control, Amsterdam Infection & Immunity, Amsterdam, the Netherlands.
| | - Rogier E Ooijevaar
- Amsterdam UMC, VU University Medical Center, Gastroenterology & Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands.
| | - Christina M J E Vandenbroucke-Grauls
- Amsterdam UMC, VU University Medical Center, Medical Microbiology & Infection Control, Amsterdam Infection & Immunity, Amsterdam, the Netherlands; Aarhus University, Clinical Epidemiology, Aarhus, Denmark
| | - Olaf M Dekkers
- Leiden University Medical Center, Clinical Epidemiology, Leiden, the Netherlands
| | - Ed J Kuijper
- Leiden University Medical Center, Center for Infectious Diseases, Medical Microbiology, Leiden, the Netherlands
| | - Josbert J Keller
- Haaglanden Medical Center, Gastroenterology & Hepatology, The Hague, the Netherlands; Leiden University Medical Center, Gastroenterology & Hepatology, Leiden, the Netherlands
| | - Joffrey van Prehn
- Leiden University Medical Center, Center for Infectious Diseases, Medical Microbiology, Leiden, the Netherlands
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Jiang Y, Sarpong EM, Sears P, Obi EN. Budget Impact Analysis of Fidaxomicin Versus Vancomycin for the Treatment of Clostridioides difficile Infection in the United States. Infect Dis Ther 2021; 11:111-126. [PMID: 34292496 DOI: 10.1007/s40121-021-00480-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 06/10/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Fidaxomicin is as effective as vancomycin in treating Clostridioides difficile infection (CDI) but more effective at preventing recurrence. However, because fidaxomicin is more costly than vancomycin, its overall value in managing CDI is not well understood. This study assessed the budget impact of introducing fidaxomicin versus vancomycin for the treatment of adults with CDI from a hospital perspective in the US. METHODS A cohort-based decision analytic model was developed over a 1-year horizon. A hospital with 10,000 annual hospitalizations was simulated. The model considered two adult populations: patients with no prior CDI episode and patients with one prior CDI episode. Two scenarios were assessed per population: 15% fidaxomicin/85% vancomycin use and 100% vancomycin use. Model inputs were obtained from published sources and expert opinion. Model outcomes included cost, payment, and revenue at the hospital level, per treated CDI patient, and per admitted patient. Budget impact was calculated as the difference in revenue between scenarios. One-way sensitivity analyses tested the effects of varying model inputs on the budget impact. RESULTS In patients with no prior CDI episode, treatment with fidaxomicin resulted in potential savings over 1 year of $1105 at the hospital level, $14 per treated CDI patient, and $0.11 per admitted patient. In patients with one prior CDI episode, fidaxomicin use was associated with potential savings over 1 year of $1150 at the hospital level, $74 per treated CDI patient, and $0.12 per admitted patient. Savings were driven by a reduced rate of CDI recurrence with fidaxomicin treatment and uptake of fidaxomicin. Sensitivity analyses indicated savings when inputs were varied in most scenarios. CONCLUSION Budgetary savings can be achieved with fidaxomicin due to reduced CDI recurrence as a result of a superior sustained clinical response. Our results support considering the broader benefits of fidaxomicin, beyond its cost, when making formulary inclusion decisions.
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Affiliation(s)
- Yiling Jiang
- Merck Sharp & Dohme (UK) Ltd., 120 Moorgate, London, EC2Y 9AL, UK.
| | - Eric M Sarpong
- Merck & Co., Inc., 200 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Pamela Sears
- Merck & Co., Inc., 200 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Engels N Obi
- Merck & Co., Inc., 200 Galloping Hill Road, Kenilworth, NJ, 07033, USA
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Nelson WW, Scott TA, Boules M, Teigland C, Parente A, Unni S, Feuerstadt P. Health care resource utilization and costs of recurrent Clostridioides difficile infection in the elderly: a real-world claims analysis. J Manag Care Spec Pharm 2021; 27:828-838. [PMID: 33703939 PMCID: PMC10394752 DOI: 10.18553/jmcp.2021.20395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Clostridioides difficile infection (CDI) affected an estimated 365,000 persons in the United States in 2017. Despite a nationally decreasing trend of CDI cases, the population incidence of recurrent CDI (rCDI) has not improved. Elderly individuals (aged ≥ 65 years) are at higher risk of CDI, rCDI, and complicated CDI compared with younger individuals. OBJECTIVE: To analyze Medicare fee-for-service data for 12 months after an initial CDI episode, in order to obtain real-world data on health care resource utilization (HRU) and costs for elderly patients with CDI and rCDI. METHODS: A retrospective cohort study of patients who were aged ≥ 65 years and had a first (index) CDI diagnosis from January 1, 2010, to December 31, 2016, and continuous enrollment in Medicare Parts A, B, and D during the 12-month pre-index and 12-month post-index periods was conducted. A CDI episode was identified by either an inpatient stay with CDI diagnosis code or an outpatient medical claim with a CDI diagnosis code plus a CDI treatment. Each CDI episode was followed by a 14-day CDI claim-free period after the last CDI claim or end of CDI treatment. rCDI was a second or subsequent episode of CDI that occurred within an 8-week window after the 14-day CDI claim-free period. The number of CDI and rCDI episodes, HRU, time to recurrence, and total all-cause direct medical costs were calculated over the 12-month pre-index (baseline) and 12-month follow-up periods and stratified by number of rCDI episodes (No rCDI, 1 rCDI, 2 rCDI, 3+ rCDI). RESULTS: A total of 268,762 patients with an index CDI were included. Mean age was 78.3 years, and 69.0% were female. HRU was higher during the 6 months immediately pre-index versus 7-12 months pre-index, including a higher proportion of patients with a hospital admission (55.1% vs. 27.5%) or emergency department visit (41.3% vs. 27.4%), respectively. Moreover, 34.7% of the study population experienced rCDI. Of those who experienced 1 recurrence, 59.1% had a second recurrence, and of those who had 2 recurrences, 58.4% had a third. During the 12-month follow-up, postacute care was used by at least 70% of each rCDI cohort. The proportion of patients with ≥ 4 hospital admissions during follow-up was highest for the 3+ rCDI cohort (24.9% of patients). During the 12-month follow-up, mean total all-cause direct costs were $76,024, $99,348, $96,148, and $96,517 for the No rCDI, 1 rCDI, 2 rCDI, and 3+ rCDI cohorts, respectively, largely driven by inpatient costs. Adjusted all-cause total costs were significantly higher for all 3 rCDI cohorts compared with the No rCDI cohort. CONCLUSIONS: Elderly individuals experienced high rates of recurrence after their first CDI episode, and especially after a prior recurrence. The intensity of HRU during follow-up was higher for patients who suffered recurrences. Patients with rCDI had the burden of higher costs of care, including the patient out-of-pocket responsibility, versus patients with a single CDI episode. DISCLOSURES: Funding for this study was provided by Ferring Pharmaceuticals. Nelson is an employee of Ferring Pharmaceuticals, and Scott, Boules, and Unni were employees of Ferring Pharmaceuticals at the time of this study. Teigland and Parente are employees of Avalere Health and provided consulting services to Ferring Pharmaceuticals. Feuerstadt has served as a consultant to and on the speakers bureau for Merck and Co. and has served as a consultant for Ferring Pharmaceuticals and Roche Pharmaceuticals. Portions of the data contained in this study appeared as an abstract/ePoster for the AMCP Annual Meeting 2020, April 2020.
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Affiliation(s)
| | | | | | | | | | | | - Paul Feuerstadt
- Gastroenterology Center of Connecticut, Hamden, CT, and Division of Gastroenterology, Yale University School of Medicine, New Haven, CT
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Feuerstadt P, Boules M, Stong L, Dahdal DN, Sacks NC, Lang K, Nelson WW. Clinical complications in patients with primary and recurrent Clostridioides difficile infection: A real-world data analysis. SAGE Open Med 2021; 9:2050312120986733. [PMID: 33505698 PMCID: PMC7812403 DOI: 10.1177/2050312120986733] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 12/15/2020] [Indexed: 12/17/2022] Open
Abstract
Objective: Clostridioides difficile infection and recurrent C. difficile infection result in substantial economic burden and healthcare resource use. Sepsis and bowel surgery are known to be serious complications of C. difficile infection. This study evaluated clinical complications in patients with C. difficile infection and recurrent C. difficile infection during a 12-month period following the primary C. difficile infection. Methods: A retrospective analysis of commercial claims data from the IQVIA PharMetrics Plus™ database was conducted for patients aged 18–64 years with an index C. difficile infection episode requiring inpatient stay or an outpatient visit for C. difficile infection followed by a C. difficile infection treatment. Each C. difficile infection episode ended after a 14-day C. difficile infection-claim-free period was observed. Recurrent C. difficile infection was defined as a further C. difficile infection episode within an 8-week window following the claim-free period. Clinical complications were documented over 12 months of follow-up and stratified by the number of recurrent C. difficile infection episodes (0 rCDI, 1 rCDI, 2 rCDI, and 3+ rCDI). Results: In total, 46,571 patients with index C. difficile infection episode were included. During the 6-month pre-index, the mean (standard deviation) baseline Charlson comorbidity index score, by increasing the recurrent C. difficile infection group, was 1.2 (1.9), 1.5 (2.2), 1.8 (2.3), and 2.3 (2.5). During the 12-month follow-up, sepsis occurred in 16.5%, 27.3%, 33.1%, and 43.3% of patients, and subtotal colectomy or diverting loop ileostomy was performed in 4.6%, 7.3%, 8.9%, and 10.5% of patients, respectively, by increasing the recurrent C. difficile infection group. Conclusions: Reduction in recurrent C. difficile infection is an important step to reduce the burden of serious clinical complications, and new treatments are needed to reduce C. difficile infection recurrence.
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Affiliation(s)
- Paul Feuerstadt
- Gastroenterology Center of Connecticut, Hamden, CT, USA.,Division of Gastroenterology, Yale University School of Medicine, New Haven, CT, USA
| | - Mena Boules
- Ferring Pharmaceuticals, Inc., Parsippany, NJ, USA
| | - Laura Stong
- Ferring Pharmaceuticals, Inc., Parsippany, NJ, USA
| | | | - Naomi C Sacks
- Precision Health Economics and Outcomes Research, Boston, MA, USA.,Tufts University School of Medicine, Boston, MA, USA
| | - Kathleen Lang
- Precision Health Economics and Outcomes Research, Boston, MA, USA
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10
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Sbeit W, Kadah A, Shahin A, Abed N, Haddad H, Jabbour A, Said Ahmad H, Pellicano R, Khoury T, Mari A. Predictors of in-hospital mortality among patients with clostridium difficile infection: a multicenter study. Minerva Med 2020; 112:124-129. [PMID: 33205642 DOI: 10.23736/s0026-4806.20.07139-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI)-associated mortality is a major global health concern. Several clinical and laboratory parameters have been linked to poor prognosis in patients with CDI. In the current study, we aimed to assess the rate of in-hospital mortality among Israeli CDI patients and to look for clinical and laboratory parameters associated to death. METHODS We performed a multicenter retrospective study enrolling all patients above 18-years old who were hospitalized for CDI or with diagnosis made during hospitalization in two regional, teaching hospitals in the north of Israel (Galilee Medical Center, Nahariya and the Nazareth Hospital, Nazareth, Israel), from January 1, 2015 until January 1, 2020. All files of eligible patients were reviewed for demographic (age, gender), medical history and laboratory tests. RESULTS Overall, we included in the study 180 patients, among them 56 died in hospital due to CDI (group A) while 124 survived (group B). The average age in groups A and B was 77.02±13 vs. 71.5±19.1, respectively. On univariate analysis, several clinical and laboratory parameters were associated with in-hospital mortality, including: advanced age, renal failure, antibiotics treatment while on treatment for CDI, need for mechanical ventilation, level of hemoglobin, white blood cells (WBC) and neutrophils count, neutrophil/lymphocyte ratio, serum level of albumin, creatinine and C reactive protein. On multivariate logistic regression analysis, only 4 parameters showed statistically significant association with in-hospital mortality, including age (odds ratio [OR]: 6.97, 95%confidence interval [CI]: 4.94-8.72, P=0.003), renal failure (OR: 3.72, 95% CI: 1.22-11.24, P=0.02), WBC count (OR: 1.09, 95% CI: 1.02-1.16, P=0.008), and lower albumin level (OR: 47.62, 95% CI: 10.31-200, P<0.0001). CONCLUSIONS In this retrospective, multicenter study, age, serum albumin level, leucocytes count, and renal failure were the main predictors of in-hospital mortality in patients with CDI. Thus, antibiotic use should be weighed carefully in elderly comorbid patients, at increased risk of mortality from CDI .Prospective multicenter randomized studies investigating the effect of albumin infusion on in-hospital death of CDI patients are needed, thus enabling us to direct monitoring and treatment accordingly.
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Affiliation(s)
- Wisam Sbeit
- Department of Gastroenterology, Galilee Medical Center, Nahariya, Israel.,Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Anas Kadah
- Department of Gastroenterology, Galilee Medical Center, Nahariya, Israel.,Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Amir Shahin
- Department of Gastroenterology, Galilee Medical Center, Nahariya, Israel.,Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Nizar Abed
- Department of Gastroenterology, Galilee Medical Center, Nahariya, Israel.,Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Haya Haddad
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel.,Unit of Gastroenterology and Endoscopy, The Nazareth Hospital EMMS, Nazareth, Israel
| | - Adel Jabbour
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel.,Laboratory of Medicine, The Nazareth Hospital EMMS, Nazareth, Israel
| | - Helal Said Ahmad
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel.,Unit of Gastroenterology and Endoscopy, The Nazareth Hospital EMMS, Nazareth, Israel
| | | | - Tawfik Khoury
- Department of Gastroenterology, Galilee Medical Center, Nahariya, Israel.,Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Amir Mari
- Department of Gastroenterology, Galilee Medical Center, Nahariya, Israel - .,Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
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11
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Goltsman G, Gal G, Mizrahi EH, Mardanov S, Pinco E, Lubart E. The impact of intensive staff education on rate of Clostridium difficile-associated disease in hospitalized geriatric patients. Aging Clin Exp Res 2020; 32:2393-2398. [PMID: 31776858 DOI: 10.1007/s40520-019-01424-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 11/15/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Toxin-producing Clostridium difficile is the most common cause of nosocomial diarrhea in geriatric units. AIM The purpose of study was to check the impact of intensive staff education on rate of Clostridium difficile-associated disease in hospitalized geriatric patients. METHODS The sampling frame was all patients suffering from diarrhea checked for Clostridium difficile toxin during the years 2017-2018. Clostridium difficile-positive patients were compared to a similar number of Clostridium difficile toxin-negative patients. The data were compared to our previous study, followed by medical staff's educational program for Clostridium difficile control and prevention. RESULTS Among 217 patients with diarrhea, 60 (27.6%) were positive for Clostridium difficile toxin. The study group tended to be of older age (p = 0.06), and showed higher rate of functional impairment (p < 0.001) and mortality (p < 0.001) than Clostridium difficile toxin negative patients. The rate of Clostridium difficile toxin-positive patients did not significantly differ between the previous and current studies (20.0% and 27.6%, respectively). CONCLUSIONS AND DISCUSSION In spite of findings, that patients tended to be older, with high rate of mortality, the rate of Clostridium difficile did not change from the previous study.
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Affiliation(s)
- G Goltsman
- Internal Medicine Department, The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Internal Medicine G Department, Asaf Harofeh Medical Center, Zerifin, 70300, Israel
| | - G Gal
- School of Behavioral Sciences, Tel Aviv-Yaffo Academic College, Jaffa, Israel
| | - E H Mizrahi
- Internal Medicine Department, The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Acute Geriatric Department A, Shmuel Harofe Geriatric Medical Center, POB 2, Be'er Ya'akov, Israel
| | - S Mardanov
- Acute Geriatric Department A, Shmuel Harofe Geriatric Medical Center, POB 2, Be'er Ya'akov, Israel
| | - E Pinco
- Acute Geriatric Department A, Shmuel Harofe Geriatric Medical Center, POB 2, Be'er Ya'akov, Israel
| | - Emily Lubart
- Internal Medicine Department, The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Acute Geriatric Department A, Shmuel Harofe Geriatric Medical Center, POB 2, Be'er Ya'akov, Israel.
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12
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Enoch DA, Murray-Thomas T, Adomakoh N, Dedman D, Georgopali A, Francis NA, Karas A. Risk of complications and mortality following recurrent and non-recurrent Clostridioides difficile infection: a retrospective observational database study in England. J Hosp Infect 2020; 106:793-803. [PMID: 32987118 DOI: 10.1016/j.jhin.2020.09.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/18/2020] [Accepted: 09/20/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Clostridioides difficile infection (CDI) increases the risk of complications and mortality. We assessed the magnitude of these outcomes in a large cohort of English patients with initial and recurrent CDI. AIM To compare the risk of complications and all-cause mortality, within 12 months, among hospitalized patients ≥18 years old with hospital-associated- (HA-) CDI and recurrent CDI. METHODS Patients with HA-CDI during 2002-2013 were identified using inpatient hospital data linked to primary care and death data. Each HA-CDI case was frequency matched to two hospitalized patients without CDI on age group, sex, calendar year of admission, admission method and number of hospital care episodes. A second CDI episode starting on days 13-56 was defined as recurrence. Risks of mortality and complications at 12 months were analysed using Cox proportional hazard models. FINDINGS We included 6862 patients with HA-CDI and 13,724 without CDI. Median age was 81.0 years (IQR 71.0-87.0). Patients with HA-CDI had more comorbidities than those without CDI, and significantly higher risks of mortality (adjusted hazard ratio (95% confidence interval) 1.77 (1.67-1.87)) and complications (1.66 (1.46-1.88)) within 12 months from hospital admission. Of those with HA-CDI, 1140 (16.6%) experienced CDI recurrence. Patients with recurrent versus non-recurrent CDI also had significantly increased risk of mortality (1.32 (1.20-1.45)) and complications (1.37 (1.01-1.84)) in the 12 months from the initial CDI. CONCLUSIONS HA-CDI (versus no CDI) and recurrent CDI are both associated with significantly higher risks of complications or death within 12 months of the initial CDI episode.
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Affiliation(s)
- D A Enoch
- Public Health England, Addenbrooke's Hospital, Cambridge, UK.
| | | | - N Adomakoh
- Astellas Pharma Europe Ltd, Addlestone, UK
| | - D Dedman
- Clinical Practice Research Datalink, London, UK
| | | | - N A Francis
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - A Karas
- Astellas Pharma Europe Ltd, Addlestone, UK
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13
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Appaneal HJ, Caffrey AR, LaPlante KL. What Is the Role for Metronidazole in the Treatment of Clostridium difficile Infection? Results From a National Cohort Study of Veterans With Initial Mild Disease. Clin Infect Dis 2020; 69:1288-1295. [PMID: 30561531 DOI: 10.1093/cid/ciy1077] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 12/12/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Metronidazole may still be an appropriate therapeutic option for mild Clostridium difficile infection (CDI) in select patients, but data are limited to guide clinicians in identifying these patients. METHODS Our 2-stage study included a national cohort of Veterans with a first episode of mild CDI (2010-2014). First, among those treated with metronidazole, we identified predictors of success, defined as absence of all-cause mortality or recurrence 30 days posttreatment, using multivariable unconditional logistic regression. Second, among a subgroup of patients with characteristics predictive of success identified in the first stage, we compared clinical outcomes among those treated with metronidazole compared with vancomycin, using Cox proportional hazards models for time to 30-day all-cause mortality, CDI recurrence, and failure. RESULTS Among 3656 patients treated with metronidazole, we identified 3282 patients with success and 374 patients without success (failure). Younger age was the only independent predictor of success. Age ≤65 years was associated with an odds of success 1.63 times higher (95% confidence interval [CI], 1.29-2.06) than age >65 years. Among 115 propensity score-matched pairs ≤65 years of age, no significant differences were observed between metronidazole and vancomycin (reference) for all-cause mortality (hazard ratio [HR], 0.29 [95% CI, .06-1.38]), CDI recurrence (HR, 0.62 [95% CI, .26-1.49]), or failure (HR, 0.50 [95% CI, .23-1.07]). CONCLUSIONS Among patients ≤65 years of age with initial mild CDI, clinical outcomes were similar with metronidazole and vancomycin. These data suggest that metronidazole may be considered for the treatment of initial mild CDI among patients 65 years of age or younger.
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Affiliation(s)
- Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Kingston.,College of Pharmacy, University of Rhode Island, Kingston.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island
| | - Aisling R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Kingston.,College of Pharmacy, University of Rhode Island, Kingston.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island.,Brown University School of Public Health, Providence, Rhode Island
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Kingston.,College of Pharmacy, University of Rhode Island, Kingston.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island.,Division of Infectious Diseases, Warren Alpert Medical School, Brown University, Providence, Rhode Island
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14
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Marra AR, Perencevich EN, Nelson RE, Samore M, Khader K, Chiang HY, Chorazy ML, Herwaldt LA, Diekema DJ, Kuxhausen MF, Blevins A, Ward MA, McDanel JS, Nair R, Balkenende E, Schweizer ML. Incidence and Outcomes Associated With Clostridium difficile Infections: A Systematic Review and Meta-analysis. JAMA Netw Open 2020; 3:e1917597. [PMID: 31913488 PMCID: PMC6991241 DOI: 10.1001/jamanetworkopen.2019.17597] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE An understanding of the incidence and outcomes of Clostridium difficile infection (CDI) in the United States can inform investments in prevention and treatment interventions. OBJECTIVE To quantify the incidence of CDI and its associated hospital length of stay (LOS) in the United States using a systematic literature review and meta-analysis. DATA SOURCES MEDLINE via Ovid, Cochrane Library Databases via Wiley, Cumulative Index of Nursing and Allied Health Complete via EBSCO Information Services, Scopus, and Web of Science were searched for studies published in the United States between 2000 and 2019 that evaluated CDI and its associated LOS. STUDY SELECTION Incidence data were collected only from multicenter studies that had at least 5 sites. The LOS studies were included only if they assessed postinfection LOS or used methods accounting for time to infection using a multistate model or compared propensity score-matched patients with CDI with control patients without CDI. Long-term-care facility studies were excluded. Of the 119 full-text articles, 86 studies (72.3%) met the selection criteria. DATA EXTRACTION AND SYNTHESIS Two independent reviewers performed the data abstraction and quality assessment. Incidence data were pooled only when the denominators used the same units (eg, patient-days). These data were pooled by summing the number of hospital-onset CDI incident cases and the denominators across studies. Random-effects models were used to obtain pooled mean differences. Heterogeneity was assessed using the I2 value. Data analysis was performed in February 2019. MAIN OUTCOMES AND MEASURES Incidence of CDI and CDI-associated hospital LOS in the United States. RESULTS When the 13 studies that evaluated incidence data in patient-days due to hospital-onset CDI were pooled, the CDI incidence rate was 8.3 cases per 10 000 patient-days. Among propensity score-matched studies (16 of 20 studies), the CDI-associated mean difference in LOS (in days) between patients with and without CDI varied from 3.0 days (95% CI, 1.44-4.63 days) to 21.6 days (95% CI, 19.29-23.90 days). CONCLUSIONS AND RELEVANCE Pooled estimates from currently available literature suggest that CDI is associated with a large burden on the health care system. However, these estimates should be interpreted with caution because higher-quality studies should be completed to guide future evaluations of CDI prevention and treatment interventions.
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Affiliation(s)
- Alexandre R. Marra
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
- Division of Medical Practice, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa
| | - Eli N. Perencevich
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa
| | - Richard E. Nelson
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah, Salt Lake City
| | - Matthew Samore
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah, Salt Lake City
| | - Karim Khader
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah, Salt Lake City
| | - Hsiu-Yin Chiang
- Big Data Center, China Medical University Hospital, Taichung City, Taiwan
| | - Margaret L. Chorazy
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
| | - Loreen A. Herwaldt
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
| | - Daniel J. Diekema
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
| | | | - Amy Blevins
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis
| | - Melissa A. Ward
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
| | - Jennifer S. McDanel
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
| | - Rajeshwari Nair
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa
| | - Erin Balkenende
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
| | - Marin L. Schweizer
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa
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15
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Chu Y, Lee C, Chen H, Hung C. Predictors of mortality in patients with
Clostridium difficile
infection. ADVANCES IN DIGESTIVE MEDICINE 2019. [DOI: 10.1002/aid2.13159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Yu‐Ming Chu
- Division of Digestive Medicine, Department of Internal MedicineCathay General Hospital Taipei City Taiwan
| | - Chia‐Long Lee
- Division of Digestive Medicine, Department of Internal MedicineCathay General Hospital Taipei City Taiwan
| | - Hsin‐Yu Chen
- Division of Digestive Medicine, Department of Internal MedicineCathay General Hospital Taipei City Taiwan
| | - Chih‐Sheng Hung
- Division of Digestive Medicine, Department of Internal MedicineCathay General Hospital Taipei City Taiwan
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16
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Prabhu VS, Dubberke ER, Dorr MB, Elbasha E, Cossrow N, Jiang Y, Marcella S. Cost-effectiveness of Bezlotoxumab Compared With Placebo for the Prevention of Recurrent Clostridium difficile Infection. Clin Infect Dis 2019; 66:355-362. [PMID: 29106516 DOI: 10.1093/cid/cix809] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Indexed: 02/06/2023] Open
Abstract
Background Clostridium difficile infection (CDI) is the most commonly recognized cause of recurrent diarrhea. Bezlotoxumab, administered concurrently with antibiotics directed against C. difficile (standard of care [SoC]), has been shown to reduce the recurrence of CDI, compared with SoC alone. This study aimed to assess the cost-effectiveness of bezlotoxumab administered concurrently with SoC, compared with SoC alone, in subgroups of patients at risk of recurrence of CDI. Methods A computer-based Markov health state transition model was designed to track the natural history of patients infected with CDI. A cohort of patients entered the model with either a mild/moderate or severe CDI episode, and were treated with SoC antibiotics together with either bezlotoxumab or placebo. The cohort was followed over a lifetime horizon, and costs and utilities for the various health states were used to estimate incremental cost-effectiveness ratios (ICERs). Both deterministic and probabilistic sensitivity analyses were used to test the robustness of the results. Results The cost-effectiveness model showed that, compared with placebo, bezlotoxumab was associated with 0.12 quality-adjusted life-years (QALYs) gained and was cost-effective in preventing CDI recurrences in the entire trial population, with an ICER of $19824/QALY gained. Compared with placebo, bezlotoxumab was also cost-effective in the subgroups of patients aged ≥65 years (ICER of $15298/QALY), immunocompromised patients (ICER of $12597/QALY), and patients with severe CDI (ICER of $21430/QALY). Conclusions Model-based results demonstrated that bezlotoxumab was cost-effective in the prevention of recurrent CDI compared with placebo, among patients receiving SoC antibiotics for treatment of CDI.
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Affiliation(s)
| | | | | | | | | | - Yiling Jiang
- Merck Sharp & Dohme Ltd, Hoddesdon, Hertfordshire, United Kingdom
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17
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Hygienemaßnahmen bei Clostridioides difficile-Infektion (CDI). Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2019; 62:906-923. [DOI: 10.1007/s00103-019-02959-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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18
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Risk factors for Clostridium difficile infection in cirrhotic patients. Hepatobiliary Pancreat Dis Int 2019; 18:237-241. [PMID: 31029554 DOI: 10.1016/j.hbpd.2019.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 04/11/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Cirrhotic patients are susceptible to Clostridium difficile infection (CDI), however, the high risk factors are not clear. The present study aimed to identify the risk factors in cirrhotic patients with CDI. METHODS A total of 526 cirrhotic patients admitted to our hospital between May 2015 and October 2015 were included in this study. Stool samples were collected upon admission for the detection of CDI and toxin. CDI was monitored during the hospital stay. In total, 34 cases showed CDI. Then we analyzed the effects of age, sex, C. difficile colonization (CDC), multiple hospitalization, extended hospital stay, elevation of total bilirubin (TBIL), creatinine (Cr), Child-Pugh grade C, hepatic encephalopathy, hepatorenal syndrome, upper gastrointestinal hemorrhage, and exposure of antibiotics and proton pump inhibitor (PPI) on the CDI in cirrhotic patients. RESULTS Patients in the CDI group had more frequent CDC, multiple hospitalization, and extended hospital stay compared to those in the non-C. difficile infection (NCDI) group. Patients in the CDI group had higher TBIL and Cr, and higher frequency of Child-Pugh grade C, hepatic encephalopathy, upper gastrointestinal hemorrhage compared with those in the NCDI group. Multiple logistic regression analysis indicated that age >60 years (OR=1.689; 95% CI: 1.135-3.128), multiple hospitalization (OR=3.346; 95% CI: 1.392-8.043), length of hospital stay >20 days (OR=1.564; 95% CI: 1.113-2.563), hypoproteinemia (OR=4.962; 95% CI: 2.053-11.996), CDC (OR=18.410; 95% CI: 6.898-49.136), hepatic encephalopathy (OR=1.357; 95% CI: 1.154-2.368), and exposure of antibiotics (OR=1.865; 95% CI: 1.213-2.863) and PPI (OR=3.125; 95% CI: 1.818-7.548) were risk factors of CDI. CONCLUSIONS Age >60 years, multiple hospitalization, length of hospital stay >20 days, hypoproteinemia, CDC, hepatic encephalopathy, and exposure of antibiotics and PPI were risk factors for CDI in cirrhotic patients. These may contribute to the early diagnosis and monitoring of CDI in clinical practice.
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19
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Khanna S, Gerding DN. Current and future trends in clostridioides (clostridium) difficile infection management. Anaerobe 2019; 58:95-102. [PMID: 31054313 DOI: 10.1016/j.anaerobe.2019.04.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 04/28/2019] [Accepted: 04/29/2019] [Indexed: 01/01/2023]
Abstract
Current and future management of Clostridioides difficile infection (CDI) including antibiotic treatment is increasingly focused on preventive strategies, either prevention of recurrent CDI (rCDI) or primary prevention of CDI. In addition to newer narrow spectrum antibiotics and pulse dosing of antibiotic treatment, multiple widely differing approaches to prevention of CDI and rCDI are under clinical development or recently approved for clinical use. They include immunologics, both passive monoclonal antibodies and active vaccines targeted at C. difficile toxins, approaches to reduce antibiotic dysbiosis in the gut, microbiome restoration using fecal microbiome transplants (FMT) or biotherapeutic bacterial derivatives, and substitution of non-toxigenic C. difficile (NTCD) for toxigenic C. difficile. Newer antibiotics, monoclonal antibodies, and FMT are targeted at reducing rCDI whereas vaccines and reduction of antibiotic dysbiosis in the gut are targeted at prevention of primary CDI. Biotherapeutics may be used for prevention of either primary CDI or rCDI. Approaches such as monoclonal antibodies, FMT, and biotherapeutics provide rapid but transient preventive benefits, whereas vaccines require weeks to months to be effective, but will presumably provide long term prevention. More rapid but transient prevention strategies such as FMT and biotherapeutics could be used in combination with vaccines to provide both rapid and durable CDI prevention.
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20
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Solanky D, Pardi DS, Loftus EV, Khanna S. Colon Surgery Risk With Corticosteroids Versus Immunomodulators or Biologics in Inflammatory Bowel Disease Patients With Clostridium difficile Infection. Inflamm Bowel Dis 2019; 25:610-619. [PMID: 30260451 PMCID: PMC6783902 DOI: 10.1093/ibd/izy291] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) is an independent risk factor for Clostridium difficile infection (CDI), and CDI often precipitates IBD exacerbation. Because CDI cannot be distinguished clinically from an IBD exacerbation, management is difficult. We aimed to assess factors associated with adverse outcomes in IBD with CDI, including the role of escalating or de-escalating IBD therapy and CDI treatment. METHODS Records for patients with IBD and CDI from 2008 to 2013 were abstracted for variables including IBD severity before CDI diagnosis, CDI management, subsequent IBD exacerbation, CDI recurrence, and colon surgery. Colon surgery was defined as resection of any colonic segment within 1 year after CDI diagnosis. RESULTS We included 137 IBD patients (median age, 46 years; 55% women): 70 with ulcerative colitis (51%), 63 with Crohn's disease (46%), and 4 with indeterminate colitis (3%). Overall, 70% of CDIs were mild-moderate, 14% were severe, and 15% were severe-complicated. Clostridium difficile infection treatment choice did not vary by infection severity (P = 0.27). Corticosteroid escalation (odds ratio [OR], 5.94; 95% confidence interval [CI], 2.03-17.44) was a positive predictor of colon surgery within 1 year after CDI; older age (OR, 0.09; 95% CI, 0.01-0.44) was a negative predictor. Modifying the corticosteroid regimen did not affect CDI recurrence or risk of future IBD exacerbation. Adverse outcomes did not differ with CDI antibiotic regimens or biologic or immunomodulator regimen modification. CONCLUSIONS Corticosteroid escalation for IBD during CDI was associated with higher risk of colon surgery. Type of CDI treatment did not influence IBD outcomes. Prospective studies are needed to further elucidate optimal management in this high-risk population.
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Affiliation(s)
- Dipesh Solanky
- Mayo Clinic School of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sahil Khanna
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA,Address correspondence to: Sahil Khanna, MBBS, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA. E-mail:
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Evaluation of protective effect of Lactobacillus acidophilus La-5 on toxicity and colonization of Clostridium difficile in human epithelial cells in vitro. Anaerobe 2018; 55:142-151. [PMID: 30576791 DOI: 10.1016/j.anaerobe.2018.12.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 11/24/2018] [Accepted: 12/17/2018] [Indexed: 12/14/2022]
Abstract
Clostridium difficile infection is a range of toxin - mediated intestinal diseases that is often acquired in hospitals and small communities in developed countries. The main virulence factors of C. difficile are two exotoxins, toxin A and toxin B, which damage epithelial cells and manifest as colonic inflammation and mild to severe diarrhea. Inhibiting C. difficile adherence, colonization, and reducing its toxin production could substantially minimize its pathogenicity and lead to faster recovery from the disease. This study investigated the efficacy of probiotic secreted bioactive molecules from Lactobacillus acidophilus La-5, in decreasing C. difficile attachment and cytotoxicity in human epithelial cells in vitro. L. acidophilus La-5 cell-free supernatant (La-5 CFS) was used to treat the hypervirulent C. difficile ribotype 027 culture with subsequent monitoring of cytotoxicity and adhesion. In addition, the effect of pretreating cell lines with La-5 CFS in protecting cells from the cytotoxicity of C. difficile culture filtrate or bacterial cell attachment was examined. La-5 CFS substantially reduced the cytotoxicity and cytopathic effect of C. difficile culture filtrate on HT-29 and Caco-2 cells. Furthermore, La-5 CFS significantly reduced attachment of the C. difficile bacterial cells on both cell lines. It was also found that pretreatment of cell lines with La-5 CFS effectively protected cell lines from cytotoxicity and adherence of C. difficile. Our study suggests that La-5 CFS could potentially be used to prevent and cure C. difficile infection and relapses.
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22
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Clostridium difficile infection increases acute and chronic morbidity and mortality. Infect Control Hosp Epidemiol 2018; 40:65-71. [PMID: 30409240 DOI: 10.1017/ice.2018.280] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE In this study, we aimed to quantify short- and long-term outcomes of Clostridium difficile infection (CDI) in the elderly, including all-cause mortality, transfer to a facility, and hospitalizations. DESIGN Retrospective study using 2011 Medicare claims data, including all elderly persons coded for CDI and a sample of uninfected persons. Analysis of propensity score-matched pairs and the entire population stratified by the propensity score was used to determine the risk of all-cause mortality, new transfer to a long-term care facility (LTCF), and short-term skilled nursing facility (SNF), and subsequent hospitalizations within 30, 90, and 365 days. RESULTS The claims records of 174,903 patients coded for CDI were compared with those of 1,318,538 control patients. CDI was associated with increased risk of death (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.74-1.81; attributable mortality, 10.9%), new LTCF transfer (OR, 1.74; 95% CI, 1.67-1.82), and new SNF transfer (OR, 2.52; 95% CI, 2.46-2.58) within 30 days in matched-pairs analyses. In a stratified analysis, CDI was associated with greatest risk of 30-day all-cause mortality in persons with lowest baseline probability of CDI (hazard ratio [HR], 3.04; 95% CI, 2.83-3.26); the risk progressively decreased as the baseline probability of CDI increased. CDI was also associated with increased risk of subsequent 30-day, 90-day, and 1-year hospitalization. CONCLUSIONS CDI was associated with increased risk of short- and long-term adverse outcomes, including transfer to short- and long-term care facilities, hospitalization, and all-cause mortality. The magnitude of mortality risk varied depending on baseline probability of CDI, suggesting that even lower-risk patients may benefit from interventions to prevent CDI.
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Esteban-Vasallo MD, de Miguel-Díez J, López-de-Andrés A, Hernández-Barrera V, Jiménez-García R. Clostridium difficile-related hospitalizations and risk factors for in-hospital mortality in Spain between 2001 and 2015. J Hosp Infect 2018; 102:148-156. [PMID: 30240814 DOI: 10.1016/j.jhin.2018.09.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 09/11/2018] [Indexed: 01/05/2023]
Abstract
AIMS To examine trends in the incidence, characteristics and in-hospital outcomes of Clostridium difficile infection (CDI) hospitalizations from 2001 to 2015, to compare clinical variables among patients according to the diagnosis position (primary or secondary) of CDI, and to identify factors associated with in-hospital mortality (IHM). METHODS A retrospective study was performed using the Spanish National Hospital Discharge Database, 2001-2015. The study population included patients who had CDI as the primary or secondary diagnosis in their discharge report. Annual hospitalization rates were calculated and trends were assessed using Poisson regression models and Jointpoint analysis. Multi-variate logistic regression models were performed to identify variables associated with IHM. FINDINGS In total, 49,347 hospital discharges were identified (52.31% females, 33.69% with CDI as the primary diagnosis). The rate of hospitalization increased from 3.9 cases per 100,000 inhabitants in 2001-2003 to 12.97 cases per 100,000 inhabitants in 2013-2015. Severity of CDI and mean cost per patient increased from 6.36% and 3750.11€ to 11.19% and 4340.91€, respectively, while IHM decreased from 12.66% to 10.66%. Age, Charlson Comorbidity Index, severity, length of hospital stay and mean cost were significantly higher in patients with a primary diagnosis of CDI. Irrespective of the CDI diagnosis position, IHM was associated with male sex, older age, comorbidities, readmission and severity of CDI. Primary diagnosis of CDI was associated with lower IHM (odds ratio 0.60; 95% confidence interval 0.56-0.65). CONCLUSION CDI-related hospitalization rates are increasing, leading to a high cost burden, although IHM has decreased in recent years. Factors associated with IHM should be considered in strategies for the prevention and management of CDI.
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Affiliation(s)
| | - J de Miguel-Díez
- Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - A López-de-Andrés
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Madrid, Spain
| | - V Hernández-Barrera
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Madrid, Spain
| | - R Jiménez-García
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Madrid, Spain
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Serafino S, Consonni D, Migone De Amicis M, Sisto F, Domeniconi G, Formica S, Zarantonello M, Maraschini A, Cappellini MD, Spigaglia P, Barbanti F, Castaldi S, Fabio G. Clinical outcomes of Clostridium difficile infection according to strain type. A prospective study in medical wards. Eur J Intern Med 2018; 54:21-26. [PMID: 29650357 DOI: 10.1016/j.ejim.2018.03.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 03/16/2018] [Accepted: 03/26/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To describe clinical characteristics and outcome of Clostridium difficile infection (CDI) patients in Internal Medicine, to identify ribotypes (RTs); to evaluate the association between RT and patient clinical characteristics and report outcome. METHODS One year prospective cohort study. Clinical data, Barthel Index (BI) and outcomes were collected for all inpatients suffering from CDI (n = 148) in hospital wards in Northern Italy. 84 fecal samples were analysed for molecular typing. RESULTS 12 RTs were identified, predominantly RT018 (42.9%, n = 36/84) and RT356/607 (40.5%, n = 34/84). Patients with dementia were more frequent among those infected by RT018 [55.6% (n = 20/36) vs. 32.4% (n = 11/34), p = 0.05]. The median BI score of patients with RT018 was lower than BI score of patients with RT356/607 [10 (IQR 0-32) vs. 15 (IQR 5-50), p = 0.06]. RT018 infection was associated to higher levels of C-reactive protein [7.2 mg/dl (IQR 4.1-14.7) vs. 4.0 mg/dl (IQR 2.2-6.8), p = 0.01] and white blood cells ≥15,000/dl [33.3% (n = 12/36) vs. 14.7% (n = 5/34) of patients, p = 0.07]. Higher mortality was noted among RT018 infected patients. We found a continuous mortality increase according to the ATLAS score. CONCLUSIONS Our results confirm that RT018 and RT356/607 are the two major RTs causing CDI in older patients with a high degree of disability in Northern Italy and RT018 is associated with more serious outcomes.
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Affiliation(s)
- S Serafino
- Internal Medicine Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Italy.
| | - D Consonni
- Epidemiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - M Migone De Amicis
- Post Graduate School in Internal Medicine, University of Milan, Milan, Italy
| | - F Sisto
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - G Domeniconi
- Post graduate School in Public Health, Department Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - S Formica
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - M Zarantonello
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - A Maraschini
- Microbiology Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - M D Cappellini
- Internal Medicine Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - P Spigaglia
- Department of Infectious Diseases, Istituto Superiore di Sanità, Roma, Italy
| | - F Barbanti
- Department of Infectious Diseases, Istituto Superiore di Sanità, Roma, Italy
| | - S Castaldi
- Quality Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Biological Sciences for Health, University of Milan, Italy
| | - G Fabio
- Internal Medicine Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Appaneal HJ, Caffrey AR, Beganovic M, Avramovic S, LaPlante KL. Predictors of Mortality Among a National Cohort of Veterans With Recurrent Clostridium difficile Infection. Open Forum Infect Dis 2018; 5:ofy175. [PMID: 30327788 PMCID: PMC6101571 DOI: 10.1093/ofid/ofy175] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 07/17/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Though recurrent Clostridium difficile infection (CDI) is common and poses a major clinical concern, data are lacking regarding mortality among patients who survive their initial CDI and have subsequent recurrences. Risk factors for mortality in patients with recurrent CDI are largely unknown. METHODS Veterans Affairs patients with a first CDI (stool sample with positive C. difficile toxin(s) and ≥2 days CDI treatment) were included (2010-2014). Subsequent recurrences were defined as additional CDI episodes ≥14 days after the stool test date and within 30 days of the end of treatment. A matched (1:4) case-control analysis was conducted using multivariable conditional logistic regression to identify predictors of all-cause mortality within 30 days of the first recurrence. RESULTS Crude 30-day all-cause mortality rates were 10.6% for the initial CDI episode, 8.3% for the first recurrence, 4.2% for the second recurrence, and 5.9% for the third recurrence. Among 110 cases and 440 controls, 6 predictors of mortality were identified: use of proton pump inhibitors (PPIs; odds ratio [OR], 3.86; 95% confidence interval [CI], 2.14-6.96), any antibiotic (OR, 3.33; 95% CI, 1.79-6.17), respiratory failure (OR, 8.26; 95% CI, 1.71-39.92), congitive dysfunction (OR, 2.41; 95% CI, 1.02-5.72), nutrition deficiency (OR, 2.91; 95% CI, 1.37-6.21), and age (OR, 1.04; 95% CI, 1.01-1.07). CONCLUSIONS In our national cohort of Veterans, crude mortality decreased by 44% from the initial episode to the third recurrence. Treatment with antibiotics, use of PPIs, and underlying comorbidities were important predictors of mortality in recurrent CDI. Our study assists health care providers in identifying patients at high risk of death after CDI recurrence.
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Affiliation(s)
- Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, Rhode Island
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island
| | - Aisling R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, Rhode Island
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island
- Brown University School of Public Health, Providence, Rhode Island
| | - Maya Beganovic
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, Rhode Island
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island
| | - Sanja Avramovic
- Health Administration and Policy, George Mason University, Fairfax, Virginia
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, Rhode Island
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Examining the association between hospital-onset Clostridium difficile infection and multiple-bed room exposure: a case-control study. Infect Control Hosp Epidemiol 2018; 39:1068-1073. [PMID: 30060776 DOI: 10.1017/ice.2018.163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To determine whether assignment to a multiple-bed room increased the risk of hospital-onset C. difficile diarrhea (HO-CDI). DESIGN Case-control study. SETTING San Francisco General Hospital and Trauma Center.PopulationAdult general medical and surgical inpatients. METHODS Consecutive cases of HO-CDI were identified between January 1, 2010, and December 31, 2015. To investigate the effect of multiple-bed room exposure both at admission and at the time of symptom onset, 2 sets of controls were selected from the general medical/surgical inpatient population using incidence density sampling. Conditional logistic regression was used to estimate the relationship between room assignment (single bed vs multiple beds) and the development of HO-CDI. RESULTS In total, 187 cases were identified and matched with 512 and 515 controls for the admission and at-diagnosis analyses, respectively. The adjusted rate ratio (RR) associated with the development HO-CDI associated with multiple-bed room exposure during the 7 and 14 days immediately prior to HO-CDI diagnosis were 1.08 (95% confidence interval [CI], 0.93-1.25; P=.31) and 0.96 (95% CI, 0.93-1.18; P=.12), respectively. Furthermore, no significant association was detected in the analysis of the first 7 and 14 days after case admission or among patients with Charlson comorbidity scores ≥4 in either period. CONCLUSION Assignment of patients to multiple-bed rooms on general medical and surgical wards was not associated with an increased risk in the development of HO-CDI. Future investigation should be performed with larger cohorts in multiple sites to more definitively address the question because this issue could have implications for patient room assignment and hospital design.
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Seibert G, Ewers T, Barker AK, Slavick A, Wright MO, Stevens L, Safdar N. What do visitors know and how do they feel about contact precautions? Am J Infect Control 2018; 46:115-117. [PMID: 28732742 DOI: 10.1016/j.ajic.2017.05.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 05/09/2017] [Accepted: 05/09/2017] [Indexed: 11/17/2022]
Abstract
Patients with Clostridium difficile infection (CDI) are placed in contact precautions. We surveyed 31 visitors of CDI patients to understand their compliance, knowledge, and perceptions of contact precautions. Although most visitors knew where to find the required personal protective equipment, only 42% were fully compliant with gown and gloves. Family members accounted for 90% of visitors, and roughly half of the reasons given for not gowning were related to a lack of perceived risk for family members. Nursing staff are fundamental sources of personal protective equipment (PPE) information for visitors; however, we found variation in staff communication regarding need for visitor PPE use.
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Affiliation(s)
- Grace Seibert
- Infection Control, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Tola Ewers
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Anna K Barker
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Adam Slavick
- Infection Control, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Marc-Oliver Wright
- Infection Control, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Linda Stevens
- Nursing Quality and Safety, University of Wisconsin Hospital and Clinics Authority, Madison, WI
| | - Nasia Safdar
- Infection Control, University of Wisconsin Hospital and Clinics, Madison, WI; Division of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI; William S. Middleton Memorial Veterans Hospital, Madison, WI.
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Characteristics of Clostridium difficile infection in a high complexity hospital and report of the circulation of the NAP1/027 hypervirulent strain in Colombia. BIOMEDICA 2017; 37:466-472. [DOI: 10.7705/biomedica.v37i4.3244] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Revised: 10/27/2016] [Indexed: 11/21/2022]
Abstract
Introducción. Clostridium difficile es el principal responsable de la diarrea asociada al uso de antibióticos. En Colombia y en Latinoamérica, el conocimiento sobre el comportamiento epidemiológico de la infección por C. difficile todavía es limitado.Objetivo. Describir las características de una serie de pacientes con infección por C. difficile.Materiales y métodos. Se hizo un estudio descriptivo de una serie de casos de pacientes con infección por C. difficile atendidos en la Fundación Clínica Shaio, entre enero de 2012 y noviembre de 2015.Resultados. Se estudiaron 36 pacientes con una edad promedio de 65 años. Se determinaron los siguientes factores relacionados con la infección por C. difficile: uso previo de antimicrobianos (94,4 %), hospitalización en los últimos tres meses (66,7 %) y uso de inhibidores de la bomba de protones (50 %). Las comorbilidades más comunes fueron la enfermedad renal crónica (41,7 %) y la diabetes mellitus (30,6 %). Los síntomas más frecuentes fueron más de tres deposiciones diarreicas (97,1 %) y dolor abdominal (42,9 %). En cuanto a la gravedad de los casos, 44,4 % se clasificó como leve a moderado, 38,9 % como grave, y 11,1 % como complicado o grave. El método de diagnóstico más utilizado (63,8% de los pacientes) fue la identificación de la toxina mediante reacción en cadena de la polimerasa (PCR). La mortalidad global durante la hospitalización fue de 8 %. Se identificaron cuatro cepas del serotipo NAP1/027 y nueve muestras fueron positivas para la toxina binaria.Conclusión. La infección por C. difficile debe sospecharse en pacientes con deposiciones diarreicas y factores asociados tradicionalmente a esta enfermedad. Se reportó la circulación de cepas hipervirulentas del serotipo NAP1/027 en Colombia, lo cual debe enfrentarse con la vigilancia epidemiológica y el diagnóstico temprano
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Khanna S. Microbiota Replacement Therapies: Innovation in Gastrointestinal Care. Clin Pharmacol Ther 2017; 103:102-111. [PMID: 29071710 DOI: 10.1002/cpt.923] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 10/09/2017] [Accepted: 10/21/2017] [Indexed: 12/12/2022]
Abstract
There has been an increasing interest in the association between human disease and altered gut microbiota, and therapeutics to modulate microbiota to treat disease. Healthy human gastrointestinal microbiota is highly diverse and rich, and harbors between 500 and 2,000 species. Diseases associated with dysbiotic microbiota include antibiotic-associated diarrhea, Clostridium difficile infection, multidrug-resistant organisms, inflammatory bowel disease, obesity, metabolic syndrome, diabetes mellitus, neuropsychiatric diseases, and systemic autoimmune diseases. Microbiota replacement therapies have shown immense promise in treatment of recurrent C. difficile infection and are being studied for other indications. Microbiota replacement therapies for indications other than C. difficile infection should be performed only in research settings. There is an immense need for standardized microbiota replacement therapies for C. difficile infection. Studies are needed to elucidate long-term safety and adverse events from these therapies.
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Affiliation(s)
- Sahil Khanna
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Pakpour S, Bhanvadia A, Zhu R, Amarnani A, Gibbons SM, Gurry T, Alm EJ, Martello LA. Identifying predictive features of Clostridium difficile infection recurrence before, during, and after primary antibiotic treatment. MICROBIOME 2017; 5:148. [PMID: 29132405 PMCID: PMC5684761 DOI: 10.1186/s40168-017-0368-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 11/01/2017] [Indexed: 05/03/2023]
Abstract
BACKGROUND Colonization by the pathogen Clostridium difficile often occurs in the background of a disrupted microbial community. Identifying specific organisms conferring resistance to invasion by C. difficile is desirable because diagnostic and therapeutic strategies based on the human microbiota have the potential to provide more precision to the management and treatment of Clostridium difficile infection (CDI) and its recurrence. METHODS We conducted a longitudinal study of adult patients diagnosed with their first CDI. We investigated the dynamics of the gut microbiota during antibiotic treatment, and we used microbial or demographic features at the time of diagnosis, or after treatment, to predict CDI recurrence. To check the validity of the predictions, a meta-analysis using a previously published dataset was performed. RESULTS We observed that patients' microbiota "before" antibiotic treatment was predictive of disease relapse, but surprisingly, post-antibiotic microbial community is indistinguishable between patients that recur or not. At the individual OTU level, we identified Veillonella dispar as a candidate organism for preventing CDI recurrence; however, we did not detect a corresponding signal in the conducted meta-analysis. CONCLUSION Although in our patient population, a candidate organism was identified for negatively predicting CDI recurrence, results suggest the need for larger cohort studies that include patients with diverse demographic characteristics to generalize species that robustly confer colonization resistance against C. difficile and accurately predict disease relapse.
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Affiliation(s)
- Sepideh Pakpour
- Genome Sequencing and Analysis Program, Broad Institute, Cambridge, MA USA
- Department of Biological Engineering, Massachusetts Institute of Technology (MIT), Cambridge, MA USA
- MIT Center for Microbiome Informatics and Therapeutics, Cambridge, MA USA
| | - Amit Bhanvadia
- Division of Digestive Diseases, Lenox Hill Hospital/Northwell Health, New York, NY USA
- Medicine, SUNY Downstate Medical Center, Brooklyn, NY USA
| | - Roger Zhu
- Surgery, NewYork-Presbyterian/Queens, Flushing, NY USA
- Medicine, SUNY Downstate Medical Center, Brooklyn, NY USA
| | | | - Sean M. Gibbons
- Genome Sequencing and Analysis Program, Broad Institute, Cambridge, MA USA
- Department of Biological Engineering, Massachusetts Institute of Technology (MIT), Cambridge, MA USA
- MIT Center for Microbiome Informatics and Therapeutics, Cambridge, MA USA
| | - Thomas Gurry
- Genome Sequencing and Analysis Program, Broad Institute, Cambridge, MA USA
- Department of Biological Engineering, Massachusetts Institute of Technology (MIT), Cambridge, MA USA
- MIT Center for Microbiome Informatics and Therapeutics, Cambridge, MA USA
| | - Eric J. Alm
- Genome Sequencing and Analysis Program, Broad Institute, Cambridge, MA USA
- Department of Biological Engineering, Massachusetts Institute of Technology (MIT), Cambridge, MA USA
- MIT Center for Microbiome Informatics and Therapeutics, Cambridge, MA USA
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Epidemiology of Clostridium difficile in a County Level Hospital in China. Jundishapur J Microbiol 2017. [DOI: 10.5812/jjm.14376] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Roncarati G, Dallolio L, Leoni E, Panico M, Zanni A, Farruggia P. Surveillance of Clostridium difficile Infections: Results from a Six-Year Retrospective Study in Nine Hospitals of a North Italian Local Health Authority. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:E61. [PMID: 28075419 PMCID: PMC5295312 DOI: 10.3390/ijerph14010061] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 01/02/2017] [Accepted: 01/06/2017] [Indexed: 12/16/2022]
Abstract
Clostridium difficile is an emerging cause of healthcare associated infections. In nine hospitals of an Italian Local Health Authority the episodes of C. difficile infection (CDI) were identified using the data registered by the centralized Laboratory Information System, from 2010 to 2015. CDI incidence (positive patients for A and/or B toxins per patients-days) was analysed per year, hospital, and ward. A number of cases approximately equivalent to the mean of identified cases per year were studied retrospectively to highlight the risk factors associated to CDI and their severity. Nine hundred and forty-two patients affected by CDI were identified. The overall incidence was 3.7/10,000 patients-days, with a stable trend across the six years and the highest rates observed in smaller and outlying hospitals (up to 17.8/10,000), where the admitted patients were older and the wards with the highest incidences (long-term-care: 7.6/10,000, general medicine: 5.7/10,000) were more represented. The mean age of patients in each hospital was correlated with CDI rates. Of the 101 cases selected for the retrospective study, 86.1% were healthcare associated, 10.9% community acquired; 9.1% met the criteria for recurrent case and 23.8% for severe case of CDI. The overall mortality rate was 28.7%. Comorbidity conditions occurred in 91.1%, previous exposure to antibiotics in 76.2%, and proton pump inhibitors in 77.2%. Recurrent and severe cases were significantly associated with renal insufficiency and creatinine levels ≥2 mg/dL. The survey based on the centralized laboratory data was useful to study CDI epidemiology in the different centres in order to identify possible weaknesses and plan control strategies, in particular the reinforcement of staff training, mainly targeted at compliance with contact precautions and hand hygiene.
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Affiliation(s)
- Greta Roncarati
- Unit of Microbiology, Sant'Orsola-Malpighi Hospital, Via Massarenti 9, Bologna 40138, Italy.
| | - Laura Dallolio
- Unit of Hygiene, Public Health and Medical Statistics, Department of Biomedical and Neuromotor Sciences, University of Bologna, Via San Giacomo 12, Bologna 40126, Italy.
| | - Erica Leoni
- Unit of Hygiene, Public Health and Medical Statistics, Department of Biomedical and Neuromotor Sciences, University of Bologna, Via San Giacomo 12, Bologna 40126, Italy.
| | - Manuela Panico
- Direction of Maggiore Hospital, Local Health Authority of Bologna, Via Largo Nigrisoli 2, Bologna 40133, Italy.
| | - Angela Zanni
- Unit of Hygiene and Quality of Residential Services, Bellaria Hospital, Local Health Authority of Bologna, Via Altura 3, Bologna 40139, Italy.
| | - Patrizia Farruggia
- Unit of Hygiene and Quality of Residential Services, Bellaria Hospital, Local Health Authority of Bologna, Via Altura 3, Bologna 40139, Italy.
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Thiemann S, Smit N, Strowig T. Antibiotics and the Intestinal Microbiome : Individual Responses, Resilience of the Ecosystem, and the Susceptibility to Infections. Curr Top Microbiol Immunol 2016; 398:123-146. [PMID: 27738912 DOI: 10.1007/82_2016_504] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The intestinal microbiota is a diverse ecosystem containing thousands of microbial species, whose metabolic activity affects many aspects of human physiology. Large-scale surveys have demonstrated that an individual's microbiota composition is shaped by factors such as diet and the use of medications, including antibiotics. Loss of overall diversity and in some cases loss of single groups of bacteria as a consequence of antibiotic treatment in humans has been associated with enhanced susceptibility toward gastrointestinal infections and with enhanced weight gain and obesity in young children. Moreover, the extensive use of antibiotics has led to an increased abundance of antibiotic resistance genes (ARGs) within commensal bacteria that can be transferred to invading pathogens, which complicates the treatment of bacterial infections. In this review, we provide insight into the complex interplay between the microbiota and antibiotics focussing on (i) the effect of antibiotics on the composition of the microbiota, (ii) the impact of antibiotics on gastrointestinal infections, and (iii) finally the role of the microbiota as reservoir for ARGs. We also discuss how targeted manipulation of the microbiota may be used as an innovative therapeutic approach to reduce the incidence of bacterial infections as well as resulting complications.
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Affiliation(s)
| | - Nathiana Smit
- Helmholtz Centre for Infection Research, Brunswick, Germany
| | - Till Strowig
- Helmholtz Centre for Infection Research, Brunswick, Germany.
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