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Wieczorkiewicz JT, Skinner AM, Cheknis A, Petrella LA, Stevens VW, Wright LM, Gerding DN, Johnson S. Epidemiology of Clostridioides difficile infection at one hospital 10 years after an outbreak of the epidemic C. difficile strain BI/027: changing strain prevalence, antimicrobial susceptibilities, and patient antibiotic exposures. Antimicrob Agents Chemother 2024; 68:e0069824. [PMID: 38953622 PMCID: PMC11304679 DOI: 10.1128/aac.00698-24] [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: 05/15/2024] [Accepted: 06/11/2024] [Indexed: 07/04/2024] Open
Abstract
In contrast to the epidemiology 10 years earlier at our hospital when the epidemic restriction endonuclease analysis (REA) group strain BI accounted for 72% of Clostridioides difficile isolates recovered from first-episode C. difficile infection (CDI) cases, BI represented 19% of first-episode CDI isolates in 2013-2015. Two additional REA group strains accounted for 31% of isolates (Y, 16%; DH, 12%). High-level resistance to fluoroquinolones and azithromycin was more common among BI isolates than among DH, Y, and non-BI/DH/Y isolates. Multivariable analysis revealed that BI cases were 2.47 times more likely to be associated with fluoroquinolone exposure compared to non-BI cases (95% confidence interval [CI]: 1.12-5.46). In addition, the odds of developing a CDI after third- or fourth-generation cephalosporin exposure was 2.83 times for DH cases than for non-DH cases (95% CI: 1.06-7.54). Fluoroquinolone use in the hospital decreased from 2005 to 2015 from a peak of 113 to a low of 56 antimicrobial days/1,000 patient days. In contrast, cephalosporin use increased from 42 to 81 antimicrobial days/1,000 patient days. These changes correlated with a decrease in geometric mean MIC for ciprofloxacin (61.03 to 42.65 mg/L, P = 0.02) and an increase in geometric mean MIC for ceftriaxone (40.87 to 86.14 mg/L, P < 0.01) among BI isolates. The BI strain remained resistant to fluoroquinolones, but an overall decrease in fluoroquinolone use and increase in cephalosporin use were associated with a decrease in the prevalence of BI, an increased diversity of C. difficile strain types, and the emergence of strains DH and Y.
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Affiliation(s)
- Jeffrey T. Wieczorkiewicz
- Clinical Pharmacy, Edward Hines Jr., VA Hospital, Hines, Illinois, USA
- Department of Pharmacy Practice, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois, USA
| | - Andrew M. Skinner
- Research and Infectious Diseases Section, George E Wahlen VA Medical Center, Salt Lake City, Utah, USA
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Adam Cheknis
- Research Section, Edward Hines Jr., VA Hospital, Hines, Illinois, USA
| | | | - Vanessa W. Stevens
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, George E Wahlen VA Medical Center, Salt Lake City, Utah, USA
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Lorinda M. Wright
- Research Section, Edward Hines Jr., VA Hospital, Hines, Illinois, USA
| | - Dale N. Gerding
- Research Section, Edward Hines Jr., VA Hospital, Hines, Illinois, USA
| | - Stuart Johnson
- Research Section, Edward Hines Jr., VA Hospital, Hines, Illinois, USA
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Crone AS, Wright LM, Cheknis A, Johnson S, Pacheco SM, Skinner AM. Characteristics and outcomes of Clostridioides difficile infection after a change in the diagnostic testing algorithm. Infect Control Hosp Epidemiol 2024; 45:57-62. [PMID: 37462099 DOI: 10.1017/ice.2023.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
BACKGROUND Polymerase chain reaction (PCR) testing for the detection of C. difficile is a highly sensitive test. Some clinical laboratories have included a 2-step testing algorithm utilizing PCR plus toxin enzyme immunoassays (EIAs) to increase specificity. OBJECTIVE To determine the risk factors and outcomes of C. difficile PCR-positive/toxin-positive encounters compared to PCR-positive/toxin-negative encounters. DESIGN Retrospective study. SETTING A Veterans' Affairs hospital. METHODS A retrospective case-control study of patient encounters with a positive C. difficile test by PCR and either a toxin EIA-positive assay (ie, cases) or toxin EIA-negative assay (ie, controls). Clinically relevant exposures and risk factors were determined to assess CDI recurrence at 30 days. Available encounter stool specimens were cultured for C. difficile and were subjected to restriction endonuclease analysis (REA) strain typing. RESULTS Among 130 C. difficile PCR-positive patient encounters, 80 (61.5%) were toxin EIA negative and 50 (38.5%) were toxin EIA positive. Encounters that were toxin positive were more frequently treated (96.0%) compared to toxin-negative encounters (71.3%; P < .01). A multivariable logistic regression model revealed that toxin-negative encounters were less likely to suffer a recurrent CDI episode within 30 days (odds ratio [OR], 0.20, 95% confidence interval [CI], 0.05-0.83). Additionally, a higher C. difficile PCR cycle threshold predicted a lower risk of CDI recurrence at 30 days. (OR, 0.82; 95% CI, 0.68-0.98). During the study period, the REA group Y strain accounted for most toxin-negative encounters (32.5%; P = .05), whereas REA group BI strain accounted for most toxin-positive encounters (24.3%; P = .02). CONCLUSIONS A testing strategy of PCR plus toxin EIA helped predict recurrent CDI.
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Affiliation(s)
- Andrew S Crone
- Research Service and Infectious Diseases Section, Edward Hines, Jr. VA Hospital, Hines, Illinois
- Department of Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Lorinda M Wright
- Research Service and Infectious Diseases Section, Edward Hines, Jr. VA Hospital, Hines, Illinois
| | - Adam Cheknis
- Research Service and Infectious Diseases Section, Edward Hines, Jr. VA Hospital, Hines, Illinois
| | - Stuart Johnson
- Research Service and Infectious Diseases Section, Edward Hines, Jr. VA Hospital, Hines, Illinois
- Department of Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Susan M Pacheco
- Research Service and Infectious Diseases Section, Edward Hines, Jr. VA Hospital, Hines, Illinois
- Department of Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Andrew M Skinner
- Research Service and Infectious Diseases Section, Edward Hines, Jr. VA Hospital, Hines, Illinois
- Department of Medicine, Loyola University Medical Center, Maywood, Illinois
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Wright LM, Skinner AM, Cheknis A, McBurney C, Ge L, Pacheco SM, Leehey D, Gerding DN, Johnson S. Effect of the COVID-19 Pandemic on Rates and Epidemiology of Clostridioides difficile Infection in One VA Hospital. Antibiotics (Basel) 2023; 12:1159. [PMID: 37508255 PMCID: PMC10376799 DOI: 10.3390/antibiotics12071159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 06/30/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023] Open
Abstract
The COVID-19 pandemic was associated with increases in some healthcare-associated infections. We investigated the impact of the pandemic on the rates and molecular epidemiology of Clostridioides difficile infection (CDI) within one VA hospital. We anticipated that the potential widespread use of antibiotics for pneumonia during the pandemic might increase CDI rates given that antibiotics are a major risk for CDI. Hospital data on patients with CDI and recurrent CDI (rCDI) were reviewed both prior to the COVID-19 pandemic (2015 to 2019) and during the pandemic (2020-2021). Restriction endonuclease analysis (REA) strain typing was performed on CD isolates recovered from stool samples collected from October 2019 to March 2022. CDI case numbers declined by 43.2% in 2020 to 2021 compared to the annual mean over the previous 5 years. The stool test positivity rate was also lower during the COVID-19 pandemic (14.3% vs. 17.2%; p = 0.013). Inpatient hospitalization rates declined, and rates of CDI among inpatients were reduced by 34.2% from 2020 to 2021. The mean monthly cases of rCDI also declined significantly after 2020 [3.38 (95% CI: 2.89-3.87) vs. 1.92 (95% CI: 1.27-2.56); p = <0.01]. Prior to the pandemic, REA group Y was the most prevalent CD strain among the major REA groups (27.3%). During the first wave of the pandemic, from 8 March 2020, to 30 June 2020, there was an increase in the relative incidence of REA group BI (26.7% vs. 9.1%); After adjusting for CDI risk factors, a multivariable logistic regression model revealed that the odds of developing an REA group BI CDI increased during the first pandemic wave (OR 6.41, 95% CI: 1.03-39.91) compared to the pre-pandemic period. In conclusion, the incidence of CDI and rCDI decreased significantly during the COVID-19 pandemic. In contrast, REA BI (Ribotype 027), a virulent, previously epidemic CD strain frequently associated with hospital transmission and outbreaks, reappeared as a prevalent strain during the first wave of the pandemic, but subsequently disappeared, and overall CDI rates declined.
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Affiliation(s)
- Lorinda M. Wright
- Edward Hines Jr. VA Hospital, 5000 S. 5th Ave., Hines, IL 60141, USA; (A.M.S.); (A.C.); (C.M.); (L.G.); (S.M.P.); (D.L.); (D.N.G.); (S.J.)
| | - Andrew M. Skinner
- Edward Hines Jr. VA Hospital, 5000 S. 5th Ave., Hines, IL 60141, USA; (A.M.S.); (A.C.); (C.M.); (L.G.); (S.M.P.); (D.L.); (D.N.G.); (S.J.)
- Chicago Stritch School of Medicine, Loyola University, 2160 S. First Ave., Maywood, IL 60153, USA
| | - Adam Cheknis
- Edward Hines Jr. VA Hospital, 5000 S. 5th Ave., Hines, IL 60141, USA; (A.M.S.); (A.C.); (C.M.); (L.G.); (S.M.P.); (D.L.); (D.N.G.); (S.J.)
| | - Conor McBurney
- Edward Hines Jr. VA Hospital, 5000 S. 5th Ave., Hines, IL 60141, USA; (A.M.S.); (A.C.); (C.M.); (L.G.); (S.M.P.); (D.L.); (D.N.G.); (S.J.)
| | - Ling Ge
- Edward Hines Jr. VA Hospital, 5000 S. 5th Ave., Hines, IL 60141, USA; (A.M.S.); (A.C.); (C.M.); (L.G.); (S.M.P.); (D.L.); (D.N.G.); (S.J.)
| | - Susan M. Pacheco
- Edward Hines Jr. VA Hospital, 5000 S. 5th Ave., Hines, IL 60141, USA; (A.M.S.); (A.C.); (C.M.); (L.G.); (S.M.P.); (D.L.); (D.N.G.); (S.J.)
- Chicago Stritch School of Medicine, Loyola University, 2160 S. First Ave., Maywood, IL 60153, USA
| | - David Leehey
- Edward Hines Jr. VA Hospital, 5000 S. 5th Ave., Hines, IL 60141, USA; (A.M.S.); (A.C.); (C.M.); (L.G.); (S.M.P.); (D.L.); (D.N.G.); (S.J.)
- Chicago Stritch School of Medicine, Loyola University, 2160 S. First Ave., Maywood, IL 60153, USA
| | - Dale N. Gerding
- Edward Hines Jr. VA Hospital, 5000 S. 5th Ave., Hines, IL 60141, USA; (A.M.S.); (A.C.); (C.M.); (L.G.); (S.M.P.); (D.L.); (D.N.G.); (S.J.)
| | - Stuart Johnson
- Edward Hines Jr. VA Hospital, 5000 S. 5th Ave., Hines, IL 60141, USA; (A.M.S.); (A.C.); (C.M.); (L.G.); (S.M.P.); (D.L.); (D.N.G.); (S.J.)
- Chicago Stritch School of Medicine, Loyola University, 2160 S. First Ave., Maywood, IL 60153, USA
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Skinner AM, Petrella LA, Cheknis A, Johnson S. Antimicrobial susceptibility of Clostridioides difficile to omadacycline and comparator antimicrobials. J Antimicrob Chemother 2023; 78:1779-1784. [PMID: 37279600 DOI: 10.1093/jac/dkad170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 05/11/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Omadacycline is a novel aminomethylcycline tetracycline antimicrobial that was approved for the treatment of community-associated bacterial pneumonia (CABP) and acute bacterial skin and skin structure infections (ABSSSI) in 2018. Omadacycline has demonstrated a high degree of in vitro activity towards Clostridioides difficile and previous data have hypothesized that use of omadacycline for CABP or ABSSSI may decrease the risk of C. difficile infections. OBJECTIVES To compare the in vitro antimicrobial activity of omadacycline versus commonly used antimicrobials for the approved indications of use. METHODS We compared the antimicrobial activity of eight antimicrobials approved for CABP and ABSSSI against omadacycline by agar dilution on 200 clinically relevant contemporary C. difficile isolates representing local and national prevalent strain types. RESULTS The in vitro omadacycline geometric mean MIC was 0.07 mg/L. Ceftriaxone resistance was noted in >50% of all isolates tested. The epidemic strain group, identified as restriction endonuclease analysis (REA) group BI, was commonly resistant to azithromycin (92%), moxifloxacin (86%) and clindamycin (78%). REA group DH strains had an elevated trimethoprim/sulfamethoxazole geometric mean MIC of 17.30 mg/L compared with the geometric mean MIC of 8.14 mg/L noted in all other isolates. In the REA group BK isolates that had a doxycycline MIC of ≥2 mg/L, the omadacycline MIC was <0.5 mg/L. CONCLUSIONS Among 200 contemporary C. difficile isolates, there were no notable elevations in the in vitro omadacycline MIC, indicating a high level of activity towards C. difficile in comparison with commonly used antimicrobials for CABP and ABSSSI.
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Affiliation(s)
- Andrew M Skinner
- Department of Medicine, Loyola University Medical Center, Maywood, IL, USA
- Research Section, Infection Diseases Section, Edward Hines Jr. VA Hospital, Hines, IL, USA
| | - Laurica A Petrella
- Research Section, Infection Diseases Section, Edward Hines Jr. VA Hospital, Hines, IL, USA
| | - Adam Cheknis
- Research Section, Infection Diseases Section, Edward Hines Jr. VA Hospital, Hines, IL, USA
| | - Stuart Johnson
- Department of Medicine, Loyola University Medical Center, Maywood, IL, USA
- Research Section, Infection Diseases Section, Edward Hines Jr. VA Hospital, Hines, IL, USA
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Skinner AM, Phillips ST, Merrigan MM, O’Leary KJ, Sambol SP, Siddiqui F, Peterson LR, Gerding DN, Johnson S. The Relative Role of Toxins A and B in the Virulence of Clotridioides difficile. J Clin Med 2020; 10:jcm10010096. [PMID: 33396595 PMCID: PMC7796042 DOI: 10.3390/jcm10010096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 12/24/2020] [Accepted: 12/26/2020] [Indexed: 01/03/2023] Open
Abstract
Most pathogenic strains of C. difficile possess two large molecular weight single unit toxins with four similar functional domains. The toxins disrupt the actin cytoskeleton of intestinal epithelial cells leading to loss of tight junctions, which ultimately manifests as diarrhea in the host. While initial studies of purified toxins in animal models pointed to toxin A (TcdA) as the main virulence factor, animal studies using isogenic mutants demonstrated that toxin B (TcdB) alone was sufficient to cause disease. In addition, the natural occurrence of TcdA−/TcdB+ (TcdA−/B+)mutant strains was shown to be responsible for cases of C. difficile infection (CDI) with symptoms identical to CDI caused by fully toxigenic (A+/B+) strains. Identification of these cases was delayed during the period when clinical laboratories were using immunoassays that only detected TcdA (toxA EIA). Our hospital laboratory at the time performed culture as well as toxA EIA on patient stool samples. A total of 1.6% (23/1436) of all clinical isolates recovered over a 2.5-year period were TcdA−/B+ variants, the majority of which belonged to the restriction endonuclease analysis (REA) group CF and toxinotype VIII. Despite reports of serious disease due to TcdA−/B+ CF strains, these infections were typically mild, often not requiring specific treatment. While TcdB alone may be sufficient to cause disease, clinical evidence suggests that both toxins have a role in disease.
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Affiliation(s)
- Andrew M. Skinner
- Research Service, Edward Hines Jr., Veterans Affairs Hospital, Infectious Disease Section, Hines, IL 60141, USA; (A.M.S.); (S.T.P.); (M.M.M.); (S.P.S.); (F.S.); (D.N.G.)
- Department of Medicine, Loyola University Medical Center, Chicago, IL 60153, USA
| | - S. Tyler Phillips
- Research Service, Edward Hines Jr., Veterans Affairs Hospital, Infectious Disease Section, Hines, IL 60141, USA; (A.M.S.); (S.T.P.); (M.M.M.); (S.P.S.); (F.S.); (D.N.G.)
- Department of Medicine, Loyola University Medical Center, Chicago, IL 60153, USA
| | - Michelle M. Merrigan
- Research Service, Edward Hines Jr., Veterans Affairs Hospital, Infectious Disease Section, Hines, IL 60141, USA; (A.M.S.); (S.T.P.); (M.M.M.); (S.P.S.); (F.S.); (D.N.G.)
| | - Kevin J. O’Leary
- Department of Medicine, Northwestern University Medical School, Chicago, IL 60611, USA;
| | - Susan P. Sambol
- Research Service, Edward Hines Jr., Veterans Affairs Hospital, Infectious Disease Section, Hines, IL 60141, USA; (A.M.S.); (S.T.P.); (M.M.M.); (S.P.S.); (F.S.); (D.N.G.)
| | - Farida Siddiqui
- Research Service, Edward Hines Jr., Veterans Affairs Hospital, Infectious Disease Section, Hines, IL 60141, USA; (A.M.S.); (S.T.P.); (M.M.M.); (S.P.S.); (F.S.); (D.N.G.)
| | - Lance R. Peterson
- Pritzker School of Medicine, University of Chicago, Chicago, IL 60637, USA;
| | - Dale N. Gerding
- Research Service, Edward Hines Jr., Veterans Affairs Hospital, Infectious Disease Section, Hines, IL 60141, USA; (A.M.S.); (S.T.P.); (M.M.M.); (S.P.S.); (F.S.); (D.N.G.)
| | - Stuart Johnson
- Research Service, Edward Hines Jr., Veterans Affairs Hospital, Infectious Disease Section, Hines, IL 60141, USA; (A.M.S.); (S.T.P.); (M.M.M.); (S.P.S.); (F.S.); (D.N.G.)
- Department of Medicine, Loyola University Medical Center, Chicago, IL 60153, USA
- Correspondence:
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Kodori M, Ghalavand Z, Yadegar A, Eslami G, Azimirad M, Krutova M, Abadi A, Zali MR. Molecular characterization of pathogenicity locus (PaLoc) and tcdC genetic diversity among tcdA +B +Clostridioides difficile clinical isolates in Tehran, Iran. Anaerobe 2020; 66:102294. [PMID: 33181348 DOI: 10.1016/j.anaerobe.2020.102294] [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: 08/16/2020] [Revised: 10/28/2020] [Accepted: 11/01/2020] [Indexed: 12/11/2022]
Abstract
Clostridioides difficile is the main cause of healthcare-associated diarrhea worldwide. It is proposed that certain C. difficile toxinotypes with distinct pathogenicity locus (PaLoc) variants are associated with disease severity and outcomes. Additionally, few studies have described the common C. difficile toxinotypes, and also little is known about the tcdC variants in Iranian isolates. We characterized the toxinotypes and the tcdC genotypes from a collection of Iranian clinical C. difficile tcdA+B+ isolates with known ribotypes (RTs). Fifty C. difficile isolates with known RTs and carrying the tcdA and tcdB toxin genes were analyzed. Toxinotyping was carried out based on a PCR-RFLP analysis of a 19.6 kb region encompassing the PaLoc. Genetic diversity of the tcdC gene was determined by the sequencing of the gene. Of the 50 C. difficile isolates investigated, five distinct toxinotypes were recognized. Toxinotypes 0 (33/50, 66%) and V (11/50, 22%) were the most frequently found. C. difficile isolates of the toxinotype 0 mostly belonged to RT 001 (12/33, 36.4%), whereas toxinotype V consisted of RT 126 (9/11, 81.8%). The tcdC sequencing showed six variants (35/50, 70%); tcdC-sc3 (24%), tcdC-A (22%), tcdC-sc9 (18%), tcdC-B (2%), tcdC-sc14 (2%), and tcdC-sc15 (2%). The remaining isolates were wild-types (15/50, 30%) in the tcdC gene. The present study demonstrates that the majority of clinical tcdA+B+ isolates of C. difficile frequently harbor tcdC genetic variants. We also found that the RT 001/toxinotype 0 and the RT 126/toxinotype V are the most common types among Iranian isolates. Further studies are needed to investigate the putative association of various tcdC genotypes with CDI severity and its recurrence.
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Affiliation(s)
- Mansoor Kodori
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zohreh Ghalavand
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Abbas Yadegar
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Gita Eslami
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Masoumeh Azimirad
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Marcela Krutova
- Department of Medical Microbiology, Charles University, 2nd Faculty of Medicine, Motol University Hospital, Prague, Czech Republic; European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Clostridioides Difficile (ESGCD), Basel, Switzerland
| | - Alireza Abadi
- Department of Health & Community Medicine, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Zali
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Cheknis A, Devaris D, Chesnel L, Dale SE, Nary J, Sambol SP, Citron DM, Goering RV, Johnson S. Characterization of Clostridioides difficile isolates recovered from two Phase 3 surotomycin treatment trials by restriction endonuclease analysis, PCR ribotyping and antimicrobial susceptibilities. J Antimicrob Chemother 2020; 75:3120-3125. [PMID: 32747931 DOI: 10.1093/jac/dkaa297] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 06/05/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES To investigate the molecular epidemiology and antimicrobial susceptibility of Clostridioides difficile isolates from patients with C. difficile infection (CDI) from two Phase 3 clinical trials of surotomycin. METHODS In both trials [Protocol MK-4261-005 (NCT01597505) conducted across Europe, North America and Israel; and Protocol MK-4261-006 (NCT01598311) conducted across North America, Asia-Pacific and South America], patients with CDI were randomized (1:1) to receive oral surotomycin (250 mg twice daily) or oral vancomycin (125 mg four times per day) for 10 days. Stool samples were collected at baseline and C. difficile isolates were characterized by restriction endonuclease analysis (REA) and PCR ribotyping. Susceptibility testing was performed by agar dilution, according to CLSI recommendations. RESULTS In total, 1147 patients were included in the microbiological modified ITT population. Of 992 recovered isolates, 922 (92.9%) were typed. There was a high association between REA groups and their corresponding predominant PCR ribotype (RT) for BI, DH, G and CF strains. REA group A showed more diverse PCR RTs. Overall, the most common strain was BI/RT027 (20.3%) followed by Y/RT014/020 (15.0%) and DH/RT106 (7.2%). The BI/RT027 strain was particularly prevalent in Europe (29.9%) and Canada (23.6%), with lower prevalence in the USA (16.8%) and Australia/New Zealand (3.4%). Resistance was most prevalent in the BI/RT027 strain, particularly to metronidazole, vancomycin and moxifloxacin. CONCLUSIONS A wide variation in C. difficile strains, both within and across different geographical regions, was documented by both REA and ribotyping, which showed overall good correlation.
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Affiliation(s)
| | | | | | | | - Julia Nary
- ACM Global Laboratories, Rochester, NY, USA
| | | | | | | | - Stuart Johnson
- Edward Hines, Jr. VA Hospital, Hines, IL, USA.,Loyola University Medical Center, Maywood, IL, USA
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Johnson S, Citron DM, Gerding DN, Wilcox MH, Goldstein EJC, Sambol SP, Best EL, Eves K, Jansen E, Dorr MB. Efficacy of bezlotoxumab in trial participants infected with Clostridioides difficile strain BI associated with poor outcomes. Clin Infect Dis 2020; 73:e2616-e2624. [PMID: 32735653 DOI: 10.1093/cid/ciaa1035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 07/30/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Bezlotoxumab reduced rates of recurrent Clostridioides difficile infection (rCDI) versus placebo in MODIFY I/II trial participants receiving antibacterial drug treatment for CDI. A secondary objective of MODIFY I/II was to assess bezlotoxumab's efficacy against C. difficile strains associated with increased rates of morbidity and mortality. METHODS In this post-hoc analysis of pooled MODIFY I/II data, efficacy endpoints were assessed in participants infected with restriction endonuclease analysis (REA) BI and non-BI strains of C. difficile at study entry. Treatment outcomes were compared between participants receiving bezlotoxumab (alone or with actoxumab: B, B+A) and those receiving no bezlotoxumab (placebo or actoxumab: P, A). RESULTS From 2559 randomized participants, C. difficile was isolated from 1588 (67.2%) baseline stool samples. Participants with BI strains (n=328) were older and had more risk factors for rCDI than non-BI strain participants (n=1260). There were no differences in initial clinical cure rate between BI and non-BI strains in either group. The rCDI rates for BI strains treated with bezlotoxumab was lower than for the no bezlotoxumab group (B, B+A vs P, A: 23.6% vs 43.9%) and was also lower for the non-BI strains (B, B+A vs P, A: 21.4% vs 36.1%). Rates of 30-day CDI-associated re-hospitalization were greater with BI versus non-BI strains in both groups. CONCLUSIONS Infection with BI strains of C. difficile predicted poor outcomes in the MODIFY I/II trials. Bezlotoxumab (B, B+A) treatment was effective both in BI and non-BI subpopulations.
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Affiliation(s)
- Stuart Johnson
- Edward Hines, Jr. VA Hospital, Hines, IL, USA.,Loyola University, Maywood, IL, USA
| | | | | | - Mark H Wilcox
- Leeds Teaching Hospital, Leeds, UK.,University of Leeds, Leeds, UK
| | | | - Susan P Sambol
- Edward Hines, Jr. VA Hospital, Hines, IL, USA.,Loyola University, Maywood, IL, USA
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Snydman DR, McDermott LA, Jenkins SG, Goldstein EJC, Patel R, Forbes BA, Johnson S, Gerding DN, Thorpe CM, Walk ST. Epidemiologic trends in Clostridioides difficile isolate ribotypes in United States from 2011 to 2016. Anaerobe 2020; 63:102185. [PMID: 32387171 DOI: 10.1016/j.anaerobe.2020.102185] [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: 01/22/2020] [Revised: 03/04/2020] [Accepted: 03/05/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Geographic and temporal trends in the distribution of PCR ribotypes for Clostridioides difficile associated diarrheal isolates obtained in the United States (US) are changing. As part of a US national surveillance program of C. difficile susceptibility to fidaxomicin, we quantified the distribution of PCR ribotypes of stool isolates collected from 2011 to 2016. METHODS C. difficile isolates or C. difficile toxin + stools from patients with C. difficile infection (CDI) were submitted for testing to Tufts Medical Center from 6 geographically distinct medical centers. Following isolation and confirmation as C. difficile, approximately 35% of the isolates were randomly sampled, stratified by center, for PCR ribotyping by capillary gel electrophoresis. Toxin gene profiling was performed on all isolates. RESULTS 939 isolates from a total of 2814 (33.4%) isolated over the 6 years were analyzed. Seventy unique ribotypes were observed, including 19 ribotypes observed 10 or more times. Sixteen ribotypes were not previously observed in our data base. Ribotype 027 declined by more than 60% over the 6 years of the survey from 35.3% to 13.1% (p < 0.001). Ribotype 106 was the most common in 2016, followed by 027 and 014-020. There were strong correlations between 027 and binary toxin with the 18 base pair deletion of tcdC and ribotype 078-126 had 100% concordance with the previously described tcdC 39 base pair deletion. CONCLUSIONS The frequency of ribotypes in the US has changed with a marked decline in 027. Each of the geographical areas had variations which differed from each other, but collectively, these results suggest that the changing epidemiology of C. difficile in the US is consistent with what is being seen in Europe. Continued surveillance and monitoring of changes in ribotype distributions of C. difficile are warranted.
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Affiliation(s)
| | | | | | | | - R Patel
- Mayo Clinic, Rochester, MN, USA
| | - B A Forbes
- Virginia Commonwealth, Richmond, VA, USA
| | - S Johnson
- Loyola University Medical Center, Maywood, IL, USA; Edward Hines Jr. VA Hospital, Hines, IL, USA
| | - D N Gerding
- Loyola University Medical Center, Maywood, IL, USA; Edward Hines Jr. VA Hospital, Hines, IL, USA
| | | | - S T Walk
- Montana State University, Bozeman, MT, USA
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Ochfeld E, Balmert LC, Patel SJ, Muller WJ, Kociolek LK. Risk factors for Clostridioides (Clostridium) difficile infection following solid organ transplantation in children. Transpl Infect Dis 2019; 21:e13149. [PMID: 31332916 DOI: 10.1111/tid.13149] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 06/30/2019] [Accepted: 07/07/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Clostridioides (Clostridium) difficile infection (CDI) in pediatric solid organ transplant (SOT) recipients is a growing problem, though CDI risk factors in this population are poorly understood. Our objective was to characterize CDI risk factors in pediatric SOT recipients. METHODS This retrospective case-control study, performed at a single freestanding academic children's hospital, included all SOT recipients age 1-22 years who were tested for C. difficile by toxin B gene PCR between August 2009 and August 2017. CDI risk factors were assessed by comparing PCR-positive and PCR-negative cases by generalized linear mixed models. RESULTS Between August 2009 and August 2017, 409 SOTs were performed of which 138 (33.7%), 134 (32.8%), 131 (32.0%), and 6 (1.5%) were kidney, liver, heart, and small intestine transplants, respectively. Of 205 SOT recipients were tested for CDI, with 723 C. difficile PCR tests performed among these patients. 68/205 (33%) patients developed CDI at least once during the study period. Median (interquartile range) time to diagnosis of first CDI following SOT was 8.9 (1.2, 19.6) months. CDI was independently associated with calcineurin inhibitor use at time of C. difficile testing (odds ratio [OR] 2.38, 95% confidence interval [CI] 1.08, 5.24, P = 0.03) and systemic antibiotic exposure within 30 days of C. difficile testing (OR 1.74, 95% CI 1.08, 2.79, P = 0.02). CONCLUSIONS CDI is a common, relatively late post-transplant complication and independently associated with calcineurin inhibitor and systemic antibiotic exposure. The potential impact of specific immunosuppressive drug and antibiotic selection on CDI risk reduction requires further investigation.
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Affiliation(s)
- Elisa Ochfeld
- Pediatric Allergy-Immunology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Division of Allergy-Immunology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lauren C Balmert
- Department of Preventive Medicine-Biostatistics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sameer J Patel
- Pediatric Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - William J Muller
- Pediatric Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Larry K Kociolek
- Pediatric Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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