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Doyle H, Valek AL, Murillo T, Ayres AM, Slaughter J, Berg ML, Snyder GM. A novel approach to correcting attribution of Clostridioides difficile in a healthcare setting. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e246. [PMID: 38156213 PMCID: PMC10753511 DOI: 10.1017/ash.2023.516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/09/2023] [Accepted: 11/13/2023] [Indexed: 12/30/2023]
Abstract
Objective To describe a novel attribution metric estimating the causal source location of healthcare-associated Clostridioides difficile and compare it with the current US National Healthcare Safety Network (NHSN) surveillance reporting standard. Design Quality improvement study. Setting Two acute care facilities. Methods A novel attribution metric assigned days of attribution to locations where patients were located for 14 days before and the day of their C. difficile diagnosis. We correlated the NHSN-assigned unit attribution with the novel attribution measure and compared the proportion of attribution assigned to inpatient units. Results During a 30-month period, there were 727 NHSN C. difficile healthcare-associated infections (HAIs) and 409 non-HAIs; the novel metric attributed 17,034 days. The correlation coefficients for NHSN and novel attributions among non-ICU units were 0.79 (95% CI, 0.76-0.82) and 0.74 (95% CI, 0.70-0.78) and among ICU units were 0.70 (95% CI, 0.63-0.76) and 0.69 (95% CI, 0.60-0.77) at facilities A and B, respectively. The distribution of difference in percent attribution showed higher inpatient unit attribution using NHSN measure than the novel attribution metric: 38% of ICU units and 15% of non-ICU units in facility A, and 20% of ICU units and 25% of non-ICU units in facility B had a median difference >0; no inpatient units showed a greater attribution using the novel attribution metric. Conclusion The novel attribution metric shifts attribution from inpatient units to other settings and correlates modestly with NHSN methodology of attribution. If validated, the attribution metric may more accurately target C. difficile reduction efforts.
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Affiliation(s)
- Hunter Doyle
- Department of Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Abby L. Valek
- Department of Infection Prevention and Control, UPMC Presbyterian/Shadyside, Pittsburgh, PA, USA
| | - Theresa Murillo
- Department of Infection Prevention and Control, UPMC Senior Communities, Pittsburgh, PA, USA
| | - Ashley M. Ayres
- Department of Infection Prevention and Control, UPMC Presbyterian/Shadyside, Pittsburgh, PA, USA
| | - Julie Slaughter
- Department of Infection Prevention and Control, UPMC Presbyterian/Shadyside, Pittsburgh, PA, USA
| | - Madeline L. Berg
- Department of Infection Prevention and Control, UPMC Presbyterian/Shadyside, Pittsburgh, PA, USA
| | - Graham M. Snyder
- Department of Infection Prevention and Control, UPMC Presbyterian/Shadyside, Pittsburgh, PA, USA
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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2
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MacKenzie EL, Murillo C, Bartlett AH, Marrs R, Landon EM, Ridgway JP. Clostridioides difficile colonization and the frequency of subsequent treatment for C. difficile infection in critically ill patients. Infect Control Hosp Epidemiol 2023; 44:1782-1787. [PMID: 36658099 DOI: 10.1017/ice.2022.240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To determine risk factors for Clostridioides difficile colonization and C. difficile infection (CDI) among patients admitted to the intensive care unit (ICU). DESIGN Retrospective observational cohort study. SETTING Tertiary-care facility. PATIENTS All adult patients admitted to an ICU from July 1, 2015, to November 6, 2019, who were tested for C. difficile colonization. Patients with CDI were excluded. METHODS Information was collected on patient demographics, comorbidities, laboratory results, and prescriptions. We defined C. difficile colonization as a positive nucleic acid amplification test for C. difficile up to 48 hours before or 24 hours after intensive care unit (ICU) admission without evidence of active infection. We defined active infection as the receipt of an antibiotic whose only indication is the treatment of CDI. The primary outcome measure was the development of CDI up to 30 days after ICU admission. Logistic regression was used to model associations between clinical variables and the development of CDI. RESULTS The overall C. difficile colonization rate was 4% and the overall CDI rate was 2%. Risk factors for the development of CDI included C. difficile colonization (aOR, 13.3; 95% CI, 8.3-21.3; P < .0001), increased ICU length of stay (aOR, 1.04; 95% CI, 1.03-1.05; P < .0001), and a history of inflammatory bowel disease (aOR, 3.8; 95% CI, 1.3-11.1; P = .02). Receipt of any antibiotic during the ICU stay was associated with a borderline increased odds of CDI (aOR, 1.9; 95% CI, 1.0-3.4; P = .05). CONCLUSION C. difficile colonization is associated with the development of CDI among ICU patients.
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Affiliation(s)
- Erica L MacKenzie
- Department of Medicine, Section of Infectious Diseases & Global Health, The University of Chicago Medicine, Chicago, Illinois
| | - Cynthia Murillo
- Department of Infection Control and Prevention, The University of Chicago Medicine, Chicago, Illinois
| | - Allison H Bartlett
- Department of Pediatrics, Section of Infectious Diseases, The University of Chicago Medicine, Chicago, Illinois
| | - Rachel Marrs
- Department of Infection Control and Prevention, The University of Chicago Medicine, Chicago, Illinois
| | - Emily M Landon
- Department of Medicine, Section of Infectious Diseases & Global Health, The University of Chicago Medicine, Chicago, Illinois
- Department of Infection Control and Prevention, The University of Chicago Medicine, Chicago, Illinois
| | - Jessica P Ridgway
- Department of Medicine, Section of Infectious Diseases & Global Health, The University of Chicago Medicine, Chicago, Illinois
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Gilboa M, Baharav N, Melzer E, Regev-Yochay G, Yahav D. Screening for Asymptomatic Clostridioides difficile Carriage Among Hospitalized Patients: A Narrative Review. Infect Dis Ther 2023; 12:2223-2240. [PMID: 37704801 PMCID: PMC10581986 DOI: 10.1007/s40121-023-00856-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/04/2023] [Indexed: 09/15/2023] Open
Abstract
Clostridioides difficile infection (CDI) has become the most common healthcare-associated infection in the United States, with considerable morbidity, mortality, and healthcare costs. Assessing new preventive strategies is vital. We present a literature review of studies evaluating a strategy of screening and isolation of asymptomatic carriers in hospital settings. Asymptomatic detection of C. difficile is reported in ~ 10-20% of admitted patients. Risk factors for carriage include recent hospitalization, previous antibiotics, older age, lower functional capacity, immunosuppression, and others. Asymptomatic C. difficile carriers of toxigenic strains are at higher risk for progression to CDI. They are also shedders of C. difficile spores and may contribute to the persistence and transmission of this bacterium. Screening for asymptomatic carriers at hospital admission can theoretically reduce CDI by isolating carriers to reduce transmission, and implementing antibiotic stewardship measures targeting carriers to prevent progression to clinical illness. Several observational studies, summarized in this review, have reported implementing screening and isolation strategies, and found a reduction in CDI rates. Nevertheless, the data are still limited to a few observational studies, and this strategy is not commonly practiced. Studies supporting screening were performed in North America, coinciding with the period of dominance of the 027/BI/NAP1 strain. Additional studies evaluating screening, followed by infection control and antibiotic stewardship measures, are needed.
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Affiliation(s)
- Mayan Gilboa
- Infection Prevention Unit, Sheba Medical Center, Ramat-Gan, Israel.
- Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel-Aviv, Israel.
| | - Nadav Baharav
- Infectious Diseases Unit, Sheba Medical Center, Ramat-Gan, Israel
| | - Eyal Melzer
- Infection Prevention Unit, Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel-Aviv, Israel
| | - Gili Regev-Yochay
- Infection Prevention Unit, Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel-Aviv, Israel
| | - Dafna Yahav
- Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel-Aviv, Israel
- Infectious Diseases Unit, Sheba Medical Center, Ramat-Gan, Israel
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Stojanowski J, Konieczny A, Lis Ł, Frosztęga W, Brzozowska P, Ciszewska A, Rydzyńska K, Sroka M, Krakowska K, Gołębiowski T, Hruby Z, Kusztal M, Krajewska M. The Artificial Neural Network as a Diagnostic Tool of the Risk of Clostridioides difficile Infection among Patients with Chronic Kidney Disease. J Clin Med 2023; 12:4751. [PMID: 37510869 PMCID: PMC10380971 DOI: 10.3390/jcm12144751] [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: 05/07/2023] [Revised: 07/09/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
The majority of recently published studies indicate a greater incidence and mortality due to Clostridioides difficile infection (CDI) in patients with chronic kidney disease (CKD). Hospitalization, older age, the use of antibiotics, immunosuppression, proton pump inhibitors (PPI), and chronic diseases such as CKD are responsible for the increased prevalence of infections. The aim of the study is to identify clinical indicators allowing, in combination with artificial intelligence (AI) techniques, the most accurate assessment of the patients being at elevated risk of CDI.
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Affiliation(s)
- Jakub Stojanowski
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Andrzej Konieczny
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Łukasz Lis
- Department of Nephrology with Transplantation and Internal Medicine Subunits, Regional Specialistic Hospital, Kamienskiego 73a, 51-124 Wroclaw, Poland
| | - Weronika Frosztęga
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Patrycja Brzozowska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Anna Ciszewska
- Department of Nephrology with Transplantation and Internal Medicine Subunits, Regional Specialistic Hospital, Kamienskiego 73a, 51-124 Wroclaw, Poland
| | - Klaudia Rydzyńska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Michał Sroka
- Department of Nephrology with Transplantation and Internal Medicine Subunits, Regional Specialistic Hospital, Kamienskiego 73a, 51-124 Wroclaw, Poland
| | - Kornelia Krakowska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Tomasz Gołębiowski
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Zbigniew Hruby
- Department of Nephrology with Transplantation and Internal Medicine Subunits, Regional Specialistic Hospital, Kamienskiego 73a, 51-124 Wroclaw, Poland
| | - Mariusz Kusztal
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Magdalena Krajewska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
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Lee KB, Lee M, Suh JW, Yang KS, Chung Y, Kim JY, Kim SB, Sohn JW, Yoon YK. Clinical prediction rule for identifying older patients with toxigenic clostridioides difficile at the time of hospital admission. BMC Geriatr 2023; 23:127. [PMID: 36879198 PMCID: PMC9990199 DOI: 10.1186/s12877-023-03808-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 02/08/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND This study aimed to develop and validate a clinical prediction rule to screen older patients at risk of being toxigenic Clostridioides difficile carriers at the time of hospital admission. METHODS This retrospective case-control study was performed at a university-affiliated hospital. Active surveillance using a real-time polymerase chain reaction (PCR) assay for the toxin genes of C. difficile was conducted among older patients (≥ 65 years) upon admission to the Division of Infectious Diseases of our institution. This rule was drawn from a derivative cohort between October 2019 and April 2021 using a multivariable logistic regression model. Clinical predictability was evaluated in the validation cohort between May 2021 and October 2021. RESULTS Of 628 PCR screenings for toxigenic C. difficile carriage, 101 (16.1%) yielded positive findings. To establish clinical prediction rules in the derivation cohort, the formula was derived using significant predictors for toxigenic C. difficile carriage at admission, such as septic shock, connective tissue diseases, anemia, recent use of antibiotics, and recent use of proton-pump inhibitors. In the validation cohort, the sensitivity, specificity, and positive and negative predictive values of the prediction rule, based on a cut-off value of ≥ 0.45, were 78.3%, 70.8%, 29.5%, and 95.4%, respectively. CONCLUSION This clinical prediction rule for identifying toxigenic C. difficile carriage at admission may facilitate the selective screening of high-risk groups. To implement it in a clinical setting, more patients from other medical institutions need to be prospectively examined.
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Affiliation(s)
- Ki-Byung Lee
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, 02841, Seoul, Republic of Korea
| | - Mina Lee
- Infection Control Unit, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Jin Woong Suh
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, 02841, Seoul, Republic of Korea
| | - Kyung-Sook Yang
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Youseung Chung
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, 02841, Seoul, Republic of Korea
| | - Jeong Yeon Kim
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, 02841, Seoul, Republic of Korea
| | - Sun Bean Kim
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, 02841, Seoul, Republic of Korea
| | - Jang Wook Sohn
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, 02841, Seoul, Republic of Korea
| | - Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, 02841, Seoul, Republic of Korea.
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6
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Morgan DJ, Dubberke ER, Hink T, Paszkiewicz G, Burnham CAD, Pineles L, Magder L, Johnson JK, Leekha S, Harris AD. The Impact of Universal Glove and Gown Use on Clostridioides Difficile Acquisition: A Cluster-Randomized Trial. Clin Infect Dis 2023; 76:e1202-e1207. [PMID: 35776131 DOI: 10.1093/cid/ciac519] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/15/2022] [Accepted: 06/22/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Clostridioides difficile is the most common cause of healthcare-associated infections in the United States. It is unknown whether universal gown and glove use in intensive care units (ICUs) decreases acquisition of C. difficile. METHODS This was a secondary analysis of a cluster-randomized trial in 20 medical and surgical ICUs in 20 US hospitals from 4 January 2012 to 4 October 2012. After a baseline period, ICUs were randomized to standard practice for glove and gown use versus the intervention of all healthcare workers being required to wear gloves and gowns for all patient contact and when entering any patient room (contact precautions). The primary outcome was acquisition of toxigenic C. difficile determined by surveillance cultures collected on admission and discharge from the ICU. RESULTS A total of 21 845 patients had both admission and discharge perianal swabs cultured for toxigenic C. difficile. On admission, 9.43% (2060/21 845) of patients were colonized with toxigenic C. difficile. No significant difference was observed in the rate of toxigenic C. difficile acquisition with universal gown and glove use. Differences in acquisition rates in the study period compared with the baseline period in control ICUs were 1.49 per 100 patient-days versus 1.68 per 100 patient-days in universal gown and glove ICUs (rate difference, -0.28; generalized linear mixed model, P = .091). CONCLUSIONS Glove and gown use for all patient contact in medical and surgical ICUs did not result in a reduction in the acquisition of C. difficile compared with usual care. CLINICAL TRIALS REGISTRATION NCT01318213.
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Affiliation(s)
- Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine and VA Maryland Healthcare System, Baltimore, Maryland, USA
| | - Erik R Dubberke
- Department of Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Tiffany Hink
- Department of Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Gwen Paszkiewicz
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Carey-Ann D Burnham
- Departments of Pathology and Immunology, Medicine, Molecular Microbiology, and Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Lisa Pineles
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Larry Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - J Kristie Johnson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Surbhi Leekha
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Anthony D Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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7
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Wen BJ, Te LG, Liu XX, Zhao JH. The value of fecal calprotectin in Clostridioides difficile infection: A systematic review. Front Physiol 2022; 13:881816. [PMID: 35991191 PMCID: PMC9382106 DOI: 10.3389/fphys.2022.881816] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
As a marker of inflammation, calprotectin has potential application value in a variety of inflammatory diseases, such as arthritis and bacterial infections. Clostridioides difficile infection (CDI) is an infectious disease that causes intestinal damage and inflammation. This systematic review aims to determine whether fecal calprotectin has application value in CDI. Nine databases were searched from inception to 6 June 2022, and 17 studies were included. These studies were divided into four groups according to their content. Generally speaking, fecal calprotectin is not an ideal indicator for the diagnosis and prognosis prediction of CDI but may serve as a potential indicator for assessing disease severity and as a readily detectable marker for CDI screening. In addition, patients in need of treatment or with detectable toxins in stool may tend to have higher levels of fecal calprotectin. In summary, fecal calprotectin has some potential application value in CDI. However, further studies are needed to verify these findings and determine the reliability of calprotectin as a biomarker for CDI.
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Affiliation(s)
- Bao-Jiang Wen
- The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
- Hebei Provincial Center for Clinical Laboratories, Shijiazhuang, Hebei, China
- Graduate School of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Li-Ger Te
- Graduate School of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Xiao-Xuan Liu
- The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
- Hebei Provincial Center for Clinical Laboratories, Shijiazhuang, Hebei, China
- Graduate School of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jian-Hong Zhao
- The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
- Hebei Provincial Center for Clinical Laboratories, Shijiazhuang, Hebei, China
- *Correspondence: Jian-Hong Zhao,
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8
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Clostridioides difficile Infection in Liver Cirrhosis: A Concise Review. Can J Gastroenterol Hepatol 2022; 2022:4209442. [PMID: 35711246 PMCID: PMC9197604 DOI: 10.1155/2022/4209442] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/04/2022] [Accepted: 05/24/2022] [Indexed: 12/16/2022] Open
Abstract
Clostridium difficile is a Gram-positive bacillus with fecal-oral transmission and is currently one of the most common nosocomial infections worldwide, which was renamed Clostridioides difficile in 2016. Clostridioides difficile infection (CDI) is a prevalent infection in cirrhosis and negatively affects prognosis. This study aimed to provide a concise review with clinical practice implications. The prevalence of CDI in cirrhotic patients increases, while the associated mortality decreases. Multiple groups of risk factors increase the likelihood of CDI in patients with cirrhosis, such as antibiotic use, the severity of cirrhosis, some comorbidities, and demographic aspects. Treatment in the general population is currently described in the latest guidelines. In patients with cirrhosis, rifaximin and lactulose have been shown to reduce CDI risk due to their modulatory effects on the intestinal flora, although conflicting results exist. Fecal microbiota transplantation (FMT) as a treatment for the second or subsequent CDI recurrences has demonstrated a good safety and efficacy in cirrhosis and CDI. Future validation in more prospective studies is needed. Screening of asymptomatic patients appears to be discouraged for the prevention currently, with strict hand hygiene and cleaning of the ward and medical equipment surfaces being the cornerstone of minimizing transmission.
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Martak D, Gbaguidi-Haore H, Meunier A, Valot B, Conzelmann N, Eib M, Autenrieth IB, Slekovec C, Tacconelli E, Bertrand X, Peter S, Hocquet D, Guther J. High prevalence of Pseudomonas aeruginosa carriage in residents of French and German long-term care facilities. Clin Microbiol Infect 2022; 28:1353-1358. [PMID: 35597505 DOI: 10.1016/j.cmi.2022.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 04/22/2022] [Accepted: 05/03/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To determine prevalence, incidence, and factors associated with Pseudomonas aeruginosa (PA) intestinal carriage in residents of long-term care facilities (LTCFs) and to understand the population structure of this pathogen in LTCFs from two European countries. METHODS We assessed the prevalence of PA intestinal carriage and the incidence of acquisition by collecting fecal samples from 403 residents of 20 LTCFs. We collected 289 environmental samples from sinks and drinking water. Factors associated with carriage and acquisition of intestinal PA were identified. All PA isolates had their antibiotic phenotypic resistance profile determined and their genome sequenced, from which we assessed the population structure of the collection and identified resistance determinants. RESULTS We found a high proportion of residents with PA intestinal carriage (51.6%) over the entire study period. Over the follow-up period, 28.6% of the residents acquired intestinal PA. Older age (Odds ratio [OR] = 1.29, 95% confidence interval [CI]: 1.09-1.52; p = 0.002), urinary incontinence (OR = 2.56, 95% CI: 1.37-4.88; p = 0.003), and male gender (OR = 2.55), 95% CI: 1.05-6.18; p = 0.039) were associated with higher probability of carriage. Wheelchair usage (OR = 4.56, 95% CI: 1.38-15.05; p = 0.013) and a body mass index >25 (OR = 3.71, 95% CI: 1.17-11.82; p = 0.026) were associated with higher risk of PA acquisition. Population structure of our isolates was mainly non-clonal with 112 different STs among the 241 isolates. Most represented STs were high risk clones ST253 (n=26), ST17 (n=11), ST244 (n=11), ST309 (n=10), and ST395 (n=10). Most PA isolates (86.3%) were susceptible to antibiotics, with no acquired genes conferring resistance to antipseudomonal agents. CONCLUSIONS We found an unexpected high prevalence of PA intestinal carriage in LTCF residents mainly associated with individual-level factors. Our study revealed a polyclonal PA population structure suggesting that individual acquisition is more frequent than resident-to-resident transmission.
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Affiliation(s)
- Daniel Martak
- Service d'Hygiène Hospitalière, Centre Hospitalier Universitaire, Besançon, France; UMR 6249 Chrono-environnement, CNRS, Université de Bourgogne Franche-Comté, Besançon, France.
| | - Houssein Gbaguidi-Haore
- Service d'Hygiène Hospitalière, Centre Hospitalier Universitaire, Besançon, France; UMR 6249 Chrono-environnement, CNRS, Université de Bourgogne Franche-Comté, Besançon, France
| | - Alexandre Meunier
- Service d'Hygiène Hospitalière, Centre Hospitalier Universitaire, Besançon, France; UMR 6249 Chrono-environnement, CNRS, Université de Bourgogne Franche-Comté, Besançon, France
| | - Benoit Valot
- UMR 6249 Chrono-environnement, CNRS, Université de Bourgogne Franche-Comté, Besançon, France
| | - Nadine Conzelmann
- Infectious Diseases, Dept. of Internal Medicine I, University Hospital Tübingen, Tübingen, Germany
| | - Michael Eib
- Institute of Medical Microbiology and Hygiene, University Hospital Tübingen, Tübingen, Germany
| | - Ingo B Autenrieth
- University Hospital Heidelberg, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany
| | - Céline Slekovec
- Service d'Hygiène Hospitalière, Centre Hospitalier Universitaire, Besançon, France; UMR 6249 Chrono-environnement, CNRS, Université de Bourgogne Franche-Comté, Besançon, France
| | - Evelina Tacconelli
- Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Italy
| | - Xavier Bertrand
- Service d'Hygiène Hospitalière, Centre Hospitalier Universitaire, Besançon, France; UMR 6249 Chrono-environnement, CNRS, Université de Bourgogne Franche-Comté, Besançon, France
| | - Silke Peter
- Institute of Medical Microbiology and Hygiene, University Hospital Tübingen, Tübingen, Germany
| | - Didier Hocquet
- Service d'Hygiène Hospitalière, Centre Hospitalier Universitaire, Besançon, France; UMR 6249 Chrono-environnement, CNRS, Université de Bourgogne Franche-Comté, Besançon, France; Centre de Ressources Biologiques - Filière Microbiologique de Besançon, Centre Hospitalier Universitaire, Besançon, France
| | - Julia Guther
- Institute of Medical Microbiology and Hygiene, University Hospital Tübingen, Tübingen, Germany
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Chen Y, Lv T, Yan D, Zheng L, Zheng B, Wang J, Gu S, Li L. Disordered Intestinal Microbial Communities During Clostridioides difficile Colonization and Subsequent Infection of Hepatic Cirrhosis Patients in a Tertiary Care Hospital in China. Front Cell Infect Microbiol 2022; 12:825189. [PMID: 35433508 PMCID: PMC9010725 DOI: 10.3389/fcimb.2022.825189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/09/2022] [Indexed: 12/13/2022] Open
Abstract
Patients with hepatic cirrhosis are more susceptible to Clostridioides difficile infection (CDI) and colonization with Clostridioides difficile (C. difficile). Asymptomatic C. difficile colonization is thought to predispose to subsequent CDI. However, the dynamic gut microbiota changes remain unclear. In this study, we used 16S rRNA gene sequencing to longitudinally monitor alterations in the intestinal microbiota of 22 hepatic cirrhosis patients with toxigenic C. difficile colonization at admission (pre-CDI) and developed CDI during hospitalization, subdivided into pre-CDI and CDI. 21 hospitalized cirrhotic patients without C. difficile colonization served as controls (HC). Compared with HC, pre-CDI and CDI samples had significantly decreased microbial richness and diversity, a significantly higher relative abundance of opportunistic pathogen Enterococcus, and a lower relative abundance of beneficial symbionts, such as Faecalibacterium, Dorea, and Roseburia. Three biomarkers showed high accuracy for distinguishing pre-CDI samples from HC with an area under the curve (AUC) up to 0.81. In conclusion, our study explored the changes of the gut microbiome before and after CDI. The gut microbial richness as well as diversity in CDI patients were notably reduced, relative to controls. Imbalance of the intestinal flora may be related to the risk for development of CDI. Identifying key members of the gut microbiota and illustrating their roles and mechanisms of action in CDI development are important avenues for future research.
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Affiliation(s)
- Yunbo Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Tao Lv
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Dong Yan
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Lisi Zheng
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Beiwen Zheng
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jingxia Wang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Silan Gu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- *Correspondence: Silan Gu,
| | - Lanjuan Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Bacterial Research Platform, Jinan Microecological Biomedicine Shandong Laboratory, Jinan, China
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11
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Spagnól MF, Signori D, Comerlato PH, Tonietto TA, Caierão J, Pasqualotto AC, Martins AF, Falci DR. High rate of Clostridioides difficile colonization in patients admitted to intensive care: A prospective cohort study. Anaerobe 2022; 74:102538. [PMID: 35202793 DOI: 10.1016/j.anaerobe.2022.102538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/01/2022] [Accepted: 02/17/2022] [Indexed: 02/08/2023]
Abstract
Here, we evaluated the frequency of C. difficile colonization and its impact on clinical outcomes in patients admitted to intensive care units in Brazil. From ninety-two patients screened 16 (17.3%) were colonized by C. difficile. Colonized patients had higher Simplified Acute Physiology Score III (SAPS III), however there was no association between C. difficile colonization with diarrhea or mortality. The C. difficile strains sequenced belonged to clade 1 and presented high vancomycin-resistant rates.
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Affiliation(s)
- Marcio Fernando Spagnól
- Hospital Nossa Senhora da Conceição, Internal Medicine Service, Álvares Cabral, 565, Porto Alegre, RS, 91350250, Brazil; Universidade Federal do Rio Grande do Sul, Medical Science Post-Graduation Program, Ramiro Barcelos, 2400, Porto Alegre, RS, 90035003, Brazil.
| | - Daniela Signori
- Universidade Federal do Rio Grande do Sul, Agriculture and Environment Microbiology Post-Graduation Program, Sarmento Leite, 500, Porto Alegre, RS, 90050170, Brazil.
| | - Pedro Henrique Comerlato
- Hospital de Clínicas de Porto Alegre, Intensive Care Unit, Ramiro Barcelos, 2350, Porto Alegre, RS, 90035903, Brazil.
| | - Tiago Antônio Tonietto
- Hospital de Clínicas de Porto Alegre, Intensive Care Unit, Ramiro Barcelos, 2350, Porto Alegre, RS, 90035903, Brazil; Hospital Nossa Senhora da Conceição, Intensive Care Unit, Álvares Cabral, 565, Porto Alegre, RS, 91350250, Brazil.
| | - Juliana Caierão
- Universidade Federal do Rio Grande do Sul, Pharmaceutical Science Post-Graduation Program, Ipiranga, 2752, Porto Alegre, RS, 90610000, Brazil.
| | - Alessandro C Pasqualotto
- Universidade Federal de Ciências da Saúde de Porto Alegre, Department of Internal Medicine, Sarmento Leite, 245, Porto Alegre, RS, 90050170, Brazil; Santa Casa de Misericordia de Porto Alegre, Molecular Biology Laboratory, Professor Annes Dias, 295, Porto Alegre, RS, 90020090, Brazil.
| | - Andreza Francisco Martins
- Universidade Federal do Rio Grande do Sul, Medical Science Post-Graduation Program, Ramiro Barcelos, 2400, Porto Alegre, RS, 90035003, Brazil; Hospital Nossa Senhora da Conceição, Intensive Care Unit, Álvares Cabral, 565, Porto Alegre, RS, 91350250, Brazil; Hospital de Clínicas de Porto Alegre, Bioinformatic Core, Ramiro Barcelos, 2350, Porto Alegre, RS, 90035903, Brazil.
| | - Diego R Falci
- Universidade Federal do Rio Grande do Sul, Medical Science Post-Graduation Program, Ramiro Barcelos, 2400, Porto Alegre, RS, 90035003, Brazil; Hospital de Clínicas de Porto Alegre, Infectious Diseases Service, Ramiro Barcelos, 2350, Porto Alegre, RS, 90035903, Brazil.
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12
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Leibovici L, Rodríguez-Baño J, Chemaly RF, Cutler S, Huttner A, Kalil AC, Leeflang M, Lina G, Paul M, Scudeller L, Tassios PT, Yusuf E. Prediction models in CMI. Clin Microbiol Infect 2021; 28:311-312. [PMID: 34902543 DOI: 10.1016/j.cmi.2021.12.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 12/05/2021] [Indexed: 11/24/2022]
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13
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Worley J, Delaney ML, Cummins CK, DuBois A, Klompas M, Bry L. Genomic Determination of Relative Risks for Clostridioides difficile Infection From Asymptomatic Carriage in Intensive Care Unit Patients. Clin Infect Dis 2021; 73:e1727-e1736. [PMID: 32676661 PMCID: PMC8678446 DOI: 10.1093/cid/ciaa894] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 06/24/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Clostridioides difficile infections (CDIs) are among the most prevalent hospital-associated infections (HAIs), particularly for intensive care unit (ICU) patients. The risks for developing active CDI from asymptomatic carriage of C. difficile are not well understood. METHODS We identified asymptomatic C. difficile carriage among 1897 ICU patients using rectal swabs from an existing ICU vancomycin-resistant enterococci (VRE) surveillance program. C. difficile isolates from VRE swabs, and from C. difficile-positive stool samples, were genome sequenced. Spatial-temporal data from hospital records assessed genomically identified clusters for potential transmission events. RESULTS Genomic analyses identified a diverse set of strains in infected patients and asymptomatic carriers. A total of 7.4% of ICU patients asymptomatically carried C. difficile; 69% of isolates carried an intact toxin locus. In contrast, 96% of C. difficile stool isolates were toxin encoding. CDI rates in asymptomatic carriers of toxin-encoding strains were 5.3% versus 0.57% in noncarriers. The relative risk for CDI with asymptomatic carriage of a toxin-encoding strain was 9.32 (95% confidence interval, 3.25-26.7). Genomic identification of clonal clusters supported analyses for asymptomatic transmission events, with spatial-temporal overlaps identified in 13 of 28 cases. CONCLUSIONS Our studies provide the first genomically confirmed assessments of CDI relative risk from asymptomatic carriage of toxin-encoding strains and highlight the complex dynamics of asymptomatic transmission in ICUs. Asymptomatic carriers are an active reservoir of C. difficile in the nosocomial environment. C. difficile screening can be implemented within existing HAI surveillance programs and has the potential to support infection-control efforts against this pathogen.
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Affiliation(s)
- Jay Worley
- Massachusetts Host-Microbiome Center, Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- National Center for Biotechnology Information, National Library of Medicine, National Institutes of Health, Bethesda, Maryland, USA
| | - Mary L Delaney
- Massachusetts Host-Microbiome Center, Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Clinical Microbiology Laboratory, Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher K Cummins
- Massachusetts Host-Microbiome Center, Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrea DuBois
- Massachusetts Host-Microbiome Center, Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Clinical Microbiology Laboratory, Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lynn Bry
- Massachusetts Host-Microbiome Center, Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Clinical Microbiology Laboratory, Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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14
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Sahra S, Abureesh M, Amarnath S, Alkhayyat M, Badran R, Jahangir A, Gumaste V. Clostridioides difficile infection in liver cirrhosis patients: A population-based study in United States. World J Hepatol 2021; 13:926-938. [PMID: 34552699 PMCID: PMC8422922 DOI: 10.4254/wjh.v13.i8.926] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/11/2021] [Accepted: 07/22/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Clostridioides (formerly Clostridium) difficile infection (CDI) is an increasingly frequent cause of morbidity and mortality in hospitalized patients. Multiple risk factors are documented in the literature that includes, but are not limited to, antibiotics use, advanced age, and gastric acid suppression. Several epidemiological studies have reported an increased incidence of CDI in advanced liver disease patients. Some have also demonstrated a higher prevalence of nosocomial infections in cirrhotic patients.
AIM To use a large nationwide database, we sought to determine CDI’s risk among liver cirrhosis patients in the United States.
METHODS We queried a commercial database (Explorys IncTM, Cleveland, OH, United States), and obtained an aggregate of electronic health record data from 26 major integrated United States healthcare systems comprising 360 hospitals in the United States from 2018 to 2021. Diagnoses were organized into the Systematized Nomenclature of Medicine Clinical Terms (SNOMED–CT) hierarchy. Statistical analysis for the multivariable model was performed using Statistical Package for Social Sciences (SPSS version 25, IBM CorpTM). For all analyses, a two-sided P value of < 0.05 was considered statistically significant.
RESULTS There were a total of 19387760 patients in the database who were above 20 years of age between the years 2018-2021. Of those, 133400 were diagnosed with liver cirrhosis. The prevalence of CDI amongst the liver cirrhosis population was 134.93 per 100.000 vs 19.06 per 100.000 in non-cirrhotic patients (P < 0.0001). The multivariate analysis model uncovered that cirrhotic patients were more likely to develop CDI (OR: 1.857; 95%CI: 1.665-2.113, P < 0.0001) compared to those without any prior history of liver cirrhosis.
CONCLUSION In this large database study, we uncovered that cirrhotic patients have a significantly higher CDI prevalence than those without cirrhosis. Liver cirrhosis may be an independent risk factor for CDI. Further prospective studies are needed to clarify this possible risk association that may lead to the implementation of screening methods in this high-risk population.
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Affiliation(s)
- Syeda Sahra
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Mohammad Abureesh
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Shivantha Amarnath
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Motasem Alkhayyat
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Rawan Badran
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Abdullah Jahangir
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Vivek Gumaste
- Department of Gastroenterology, Staten Island University Hospital, Staten Island, NY 10305, United States
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15
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van Werkhoven CH, Ducher A, Berkell M, Mysara M, Lammens C, Torre-Cisneros J, Rodríguez-Baño J, Herghea D, Cornely OA, Biehl LM, Bernard L, Dominguez-Luzon MA, Maraki S, Barraud O, Nica M, Jazmati N, Sablier-Gallis F, de Gunzburg J, Mentré F, Malhotra-Kumar S, Bonten MJM, Vehreschild MJGT. Incidence and predictive biomarkers of Clostridioides difficile infection in hospitalized patients receiving broad-spectrum antibiotics. Nat Commun 2021; 12:2240. [PMID: 33854064 PMCID: PMC8046770 DOI: 10.1038/s41467-021-22269-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 03/03/2021] [Indexed: 02/06/2023] Open
Abstract
Trial enrichment using gut microbiota derived biomarkers by high-risk individuals can improve the feasibility of randomized controlled trials for prevention of Clostridioides difficile infection (CDI). Here, we report in a prospective observational cohort study the incidence of CDI and assess potential clinical characteristics and biomarkers to predict CDI in 1,007 patients ≥ 50 years receiving newly initiated antibiotic treatment with penicillins plus a beta-lactamase inhibitor, 3rd/4th generation cephalosporins, carbapenems, fluoroquinolones or clindamycin from 34 European hospitals. The estimated 90-day cumulative incidences of a first CDI episode is 1.9% (95% CI 1.1-3.0). Carbapenem treatment (Hazard Ratio (95% CI): 5.3 (1.7-16.6)), toxigenic C. difficile rectal carriage (10.3 (3.2-33.1)), high intestinal abundance of Enterococcus spp. relative to Ruminococcus spp. (5.4 (2.1-18.7)), and low Shannon alpha diversity index as determined by 16 S rRNA gene profiling (9.7 (3.2-29.7)), but not normalized urinary 3-indoxyl sulfate levels, predicts an increased CDI risk.
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Affiliation(s)
- Cornelis H van Werkhoven
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | | | - Matilda Berkell
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Mohamed Mysara
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
- Microbiology Unit, Environment Health and Safety, Belgian Nuclear Research Centre, SCK.CEN, Mol, Belgium
| | - Christine Lammens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Julian Torre-Cisneros
- Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba (UCO), Cordoba, Spain
| | - Jesús Rodríguez-Baño
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Departamento de Medicina, Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBiS), Sevilla, Spain
| | - Delia Herghea
- Oncology Institute Prof. Dr. I Chiricuta, Cluj Napoca, Romania
| | - Oliver A Cornely
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Chair Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Lena M Biehl
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Louis Bernard
- Centre hospitalo-universitaire de Tours, Tours, France
| | | | - Sofia Maraki
- University Hospital of Heraklion, Heraklion, Greece
| | - Olivier Barraud
- Université Limoges, INSERM U1092, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - Maria Nica
- Infectious and Tropical Diseases Hospital "Dr. Victor Babes", Bucharest, Romania
| | - Nathalie Jazmati
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Cologne, Germany
- Labor Dr. Wisplinghoff, Cologne, Germany
| | | | | | | | - Surbhi Malhotra-Kumar
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Maria J G T Vehreschild
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany.
- 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.
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16
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Clostridium difficile: Diagnosis and the Consequence of Over Diagnosis. Infect Dis Ther 2021; 10:687-697. [PMID: 33770398 PMCID: PMC8116462 DOI: 10.1007/s40121-021-00417-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 02/16/2021] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile infection (CDI) is a leading cause of healthcare-associated infections, accounting for significant disease burden and mortality. The clinical spectrum of C. difficile ranges from asymptomatic colonization to toxic megacolon and fulminant colitis. CDI is characterized by new onset of ≥ 3 unformed stools in 24 h and is confirmed by laboratory test for the presence of toxigenic C. difficile. Currently, laboratory tests to diagnose CDI include toxigenic culture, glutamate dehydrogenase (GDH), nucleic acid amplification test (NAAT), and toxins A/B enzyme immunoassay (EIA). The sensitivities of these tests are variable with toxin EIA ranging from 53 to 60% and with NAAT at about 95%. Overall, the specificity is > 90% for these methods. However, the positive predictive value (PPV) depends on the disease prevalence with lower CDI rates associated with lower PPVs. Notably, the widespread use of the highly sensitive NAAT and its relatively lower clinical specificity have led to overdiagnosis of C. difficile by identifying carriers when NAAT is used as the sole diagnostic method. Overdiagnosis of C. difficile has resulted in unwarranted treatment, possibly attributing to resistance to metronidazole and vancomycin, increased risk for overgrowth of vancomycin-resistant enterococci strains in stool specimens, and increased hospitalization thereby impacting patient safety and healthcare costs. Strategies to optimize the clinical sensitivity and specificity of current laboratory tests are critical to differentiate the clinical CDI from colonization. To achieve high diagnostic yield, if preagreed institutional criteria for stool submission are not used, a multistep approach to CDI diagnosis is recommended, such as either GDH or NAAT followed by toxins A/B EIA in conjunction with laboratory stewardship by evaluating C. difficile test orders for appropriateness and providing feedback. Furthermore, antimicrobial stewardship, along with provider education on appropriate testing for C. difficile, is vital to differentiate CDI from colonization.
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17
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Risk factors for Clostridioides difficile colonization among hospitalized adults: A meta-analysis and systematic review. Infect Control Hosp Epidemiol 2020; 42:565-572. [PMID: 33118886 DOI: 10.1017/ice.2020.1236] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To identify risk factors for asymptomatic Clostridioides difficile colonization among hospitalized adults utilizing a meta-analysis, which may enable early identification of colonized patients at risk of spreading C. difficile. DESIGN Meta-analysis and systematic review. METHODS We systematically searched MEDLINE, Scopus, Web of Science, and EMBASE from January 1, 1975, to February 15, 2020, for articles related to C. difficile colonization among hospitalized adults. Studies with multivariable analyses evaluating risk factors for asymptomatic colonization were eligible. RESULTS Among 5,506 studies identified in the search, 19 studies met the inclusion criteria. Included studies reported 20,334 adult patients of whom 1,588 were asymptomatically colonized with C. difficile. Factors associated with an increased risk of colonization were hospitalization in the previous 6 months (OR, 2.18; 95% CI, 1.86-2.56; P < .001), use of gastric acid suppression therapy within the previous 8 weeks (OR, 1.42; 95% CI, 1.17-1.73; P < .001), tube feeding (OR, 2.02; 95% CI, 1.06-3.85; P = .03), and corticosteroid use in the previous 8 weeks (OR, 1.58; 95% CI, 1.14-2.17; P = .006). Receipt of antibiotics in the previous 3 months (OR, 1.37; 95% CI, 0.94-2.01; P = .10) was not associated with statistically significant effects on risk of colonization. CONCLUSIONS C. difficile colonization was significantly associated with previous hospitalization, gastric acid suppression, tube feeding, and corticosteroid use. Recognition of these risk factors may assist in identifying asymptomatic carriers of C. difficile and taking appropriate measures to reduce transmission.
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18
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Davies K, Lawrence J, Berry C, Davis G, Yu H, Cai B, Gonzalez E, Prantner I, Kurcz A, Macovei I, Pituch H, Nováková E, Nyč O, Gärtner B, Berger FK, Oleastro M, Cornely OA, Vehreschild MJGT, Pedneault L, Wilcox M. Risk Factors for Primary Clostridium difficile Infection; Results From the Observational Study of Risk Factors for Clostridium difficile Infection in Hospitalized Patients With Infective Diarrhea (ORCHID). Front Public Health 2020; 8:293. [PMID: 32766196 PMCID: PMC7379483 DOI: 10.3389/fpubh.2020.00293] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/03/2020] [Indexed: 01/05/2023] Open
Abstract
Background: There are inconsistent data on the risk factors for Clostridium difficile infection (CDI) in the literature. Aims: To use two C. difficile infection (CDI) case-control study groups to compare risk factors in hospitalized patients with diarrhea across different countries. Methods: A multi-center group of CDI cases/controls were identified by standardized testing from seven countries from the prior EUropean, multi-center, prospective bi-annual point prevalence study of CLostridium difficile Infection in hospitalized patients with Diarrhea (EUCLID). A second group of CDI cases/controls was identified from a single center in Germany [parallel study site (PSS)]. Data were extracted from the medical notes to assess CDI risk factors. Univariate analyses and multivariate logistic regression models were used to identify and compare risk factors between the two groups. Results: There were 253 and 158 cases and 921 and 584 controls in the PSS and EUCLID groups, respectively. Significant variables from univariate analyses in both groups were age ≥65, number of antibiotics (OR 1.2 for each additional antibiotic) and prior hospital admission (all p < 0.001). Congestive heart failure, diabetes, admission from assisted living or Emergency Department, proton pump inhibitors, and chronic renal disease were significant in PSS (all p < 0.05) but not EUCLID. Dementia and admitted with other bacterial diseases were significant in EUCLID (p < 0.05) but not PSS. Following multivariate analyses, age ≥ 65, number of antibiotics and prior hospital admission were consistently identified as CDI risk factors in each individual group and combined datasets. Conclusion: Our results show that the same CDI risk factors were identified across datasets. These were age ≥ 65 years, antibiotic use and prior hospital admission. Importantly, the odds of developing CDI increases with each extra antibiotic prescribed.
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Affiliation(s)
- Kerrie Davies
- Healthcare Associated Infections Research Group, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, United Kingdom
| | - Jody Lawrence
- Vaccine Research and Development, Pfizer Inc., Pearl River, NY, United States
| | - Claire Berry
- Healthcare Associated Infections Research Group, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, United Kingdom
| | - Georgina Davis
- Healthcare Associated Infections Research Group, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, United Kingdom
| | - Holly Yu
- Vaccine Research and Development, Pfizer Inc., Pearl River, NY, United States
| | - Bing Cai
- Vaccine Research and Development, Pfizer Inc., Pearl River, NY, United States
| | - Elisa Gonzalez
- Vaccine Research and Development, Pfizer Inc., Pearl River, NY, United States
| | - Ida Prantner
- Department of Hospital Epidemiology and Hygiene, National Center for Epidemiology, Budapest, Hungary
| | - Andrea Kurcz
- Department of Hospital Epidemiology and Hygiene, National Center for Epidemiology, Budapest, Hungary
| | - Ioana Macovei
- Cantacuzino National Medico-Military Institute for Research and Development, Bucharest, Romania
| | - Hanna Pituch
- Department of Medical Microbiology, Medical University of Warsaw, Warsaw, Poland
| | - Elena Nováková
- Department of Microbiology and Immunology in Jessenius Faculty of Medicine Martin, Comenius University Bratislava, Martin, Slovakia
| | - Otakar Nyč
- Department of Medical Microbiology, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Barbara Gärtner
- Germany National Reference Centre for Clostridiodies Clostridium difficile, Institute of Medical Microbiology and Hygiene, Saarland University of Medical Center, Homburg, Germany
| | - Fabian K Berger
- German National Reference Center for Clostridioides (Clostridium) Difficile, Institute of Medical Microbiology and Hygiene, Saarland University, Saarbrücken, Germany
| | - Monica Oleastro
- Department of Infectious Diseases, National Institute of Health Dr. Ricardo Jorge, Lisbon, Portugal
| | - Oliver A Cornely
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Department I of Internal Medicine, Clinical Trials Center Cologne (ZKS Köln), University of Cologne, Cologne, Germany
| | - Maria J G T Vehreschild
- Department I of Internal Medicine, Germany and German Centre for Infection Research (DZIF), University Hospital of Cologne, Partner Site Bonn-Cologne, Cologne, Germany
| | - Louise Pedneault
- Vaccine Research and Development, Pfizer Inc., Pearl River, NY, United States
| | - Mark Wilcox
- Healthcare Associated Infections Research Group, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, United Kingdom
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Bassotti G, Marchegiani A, Marconi P, Fettucciari K. The cytotoxic synergy between Clostridioides difficile toxin B and proinflammatory cytokines: an unholy alliance favoring the onset of Clostridioides difficile infection and relapses. Microbiologyopen 2020; 9:e1061. [PMID: 32657021 PMCID: PMC7424247 DOI: 10.1002/mbo3.1061] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/31/2020] [Accepted: 04/30/2020] [Indexed: 02/06/2023] Open
Abstract
Clostridioides difficile infection (CDI) represents an important health problem worldwide, with significant morbidity and mortality. This infection has also high recurrence rates, whose pathophysiological grounds are still poorly understood. Based on our experiments in vitro with Clostridioides difficile toxin B and existing experimental and clinical evidence, we propose that primary CDI and relapses might be favored by a mechanism that involves the enhancement of the toxicity of toxin B by proinflammatory cytokines, tumor necrosis factor alpha, and interferon gamma on the enteric glial cells and their network in an environment characterized by a strong dysmicrobism.
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Affiliation(s)
- Gabrio Bassotti
- Gastroenterology & Hepatology Section, Department of Medicine, University of Perugia Medical School, Perugia, Italy.,Gastroenterology & Hepatology Unit, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Andrea Marchegiani
- School of Biosciences and Veterinary Medicine, University of Camerino, Macerata, Italy
| | - Pierfrancesco Marconi
- Department of Experimental Medicine, University of Perugia Medical School, Perugia, Italy
| | - Katia Fettucciari
- Department of Experimental Medicine, University of Perugia Medical School, Perugia, Italy
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Han SH, Yi J, Kim JH, Moon HW. Investigation of Intestinal Microbiota and Fecal Calprotectin in Non-Toxigenic and Toxigenic Clostridioides difficile Colonization and Infection. Microorganisms 2020; 8:microorganisms8060882. [PMID: 32545219 PMCID: PMC7356005 DOI: 10.3390/microorganisms8060882] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/09/2020] [Accepted: 06/09/2020] [Indexed: 12/25/2022] Open
Abstract
In this study, we aimed to evaluate the composition of the intestinal microbiota and level of fecal calprotectin in Clostridioides difficile-colonized patients. We included 102 C. difficile non-colonized (group I), 93 C. difficile colonized subjects (group II), and 89 diarrhea patients with C. difficile (group III). Chao1 index for alpha diversity and principal coordinate analysis was performed for beta diversity using QIIME. The mean relative abundance in each group was compared at the phylum and genus levels. Fecal calprotectin was measured using EliA calprotectin (Thermo Fisher Scientific). Group II showed significantly lower levels of Sutterella, Blautia, Ruminococcus, Faecalibacterium, Bilophila, and Ruminococcaceae and higher levels of Enterobacteriaceae compared to group I (p = 0.012, 0.003, 0.002, 0.001, 0.027, 0.022, and 0.036, respectively). Toxigenic C. difficile colonized subjects showed significantly lower levels of Prevotella, Phascolarctobacterium, Succinivibrio, Blautia, and higher levels of Bacteroides. The level of fecal calprotectin in group III was significantly higher than those in group I and group II (p < 0.001 for both). These data could be valuable in understanding C. difficile colonization process and the microbiota and inflammatory markers could be further studied to differentiate colonization from CDI.
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Affiliation(s)
- Sung-Hee Han
- BioCore Co. Ltd., Biotechnology, Yongin 64844, Korea;
| | - Joowon Yi
- Samkwang Medical Laboratories, Seoul 06742, Korea;
| | - Ji-Hoon Kim
- Advanced BioVision Inc., Incheon 21999, Korea;
| | - Hee-Won Moon
- Department of Laboratory Medicine, Konkuk University School of Medicine, Seoul 05030, Korea
- Correspondence: ; Tel.: +82-2-2030-5583; Fax: +82-2-2030-5587
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21
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Reduced Clostridioides difficile infection in a pragmatic stepped-wedge initiative using admission surveillance to detect colonization. PLoS One 2020; 15:e0230475. [PMID: 32191763 PMCID: PMC7082001 DOI: 10.1371/journal.pone.0230475] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 02/29/2020] [Indexed: 12/12/2022] Open
Abstract
Background Clostridioides difficile Infection (CDI) is a persistent healthcare issue. In the US, CDI is the most common infectious cause of hospital-onset (HO) diarrhea. Objective Assess the impact of admission testing for toxigenic C. difficile colonization on the incidence of HO-CDI. Design Pragmatic stepped-wedge Infection Control initiative. Setting NorthShore University HealthSystem is a four-hospital system near Chicago, IL. Patients All patients admitted to the four hospitals during the initiative. Interventions From September 2017 through August 2018 we conducted a quality improvement program where admitted patients had a peri-rectal swab tested for toxigenic C. difficile. All colonized patients were placed into contact precautions. Measurements We tested admissions who: i) had been hospitalized within two months, ii) had a past C. difficile positive test, and/or iii) were in a long-term care facility within six months. We measured compliance with all other practices to reduce the incidence of HO-CDI. Results 30% of admissions were tested and 8.3% were positive. In the year prior to the initiative (Period 1) there were 63,057 admitted patients when HO-CDI incidence was 5.96 cases/10,000 patient days. During the 12-month initiative (Period 2) there were 62,760 admissions and the HO-CDI incidence was 4.23 cases/10,000 patient days (p = 0.02). There were no other practice or antibiotic use changes. Continuing admission surveillance provided a HO-CDI incidence of 2.9 cases/10,000 patient days during the final 9 months of 2018 (p<0.0001 compared to Period 1), equaling <1 case/1,000 admissions. Limitations This was not a randomized controlled trial, and multiple prevention practices were in place at the time of the admission surveillance initiative. Conclusion Admission C. difficile surveillance testing is an important tool for preventing hospital-onset C. difficile infection. Registration This quality improvement initiative is registered at ClinicalTrials.gov. The unique registration identifier number is NCT04014608.
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Gilboa M, Houri-Levi E, Cohen C, Tal I, Rubin C, Feld-Simon O, Brom A, Eden-Friedman Y, Segal S, Rahav G, Regev-Yochay G. Environmental shedding of toxigenic Clostridioides difficile by asymptomatic carriers: A prospective observational study. Clin Microbiol Infect 2020; 26:1052-1057. [PMID: 31904567 DOI: 10.1016/j.cmi.2019.12.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 12/17/2019] [Accepted: 12/19/2019] [Indexed: 01/23/2023]
Abstract
OBJECTIVES The aim was to compare the burden of environmental shedding of toxigenic Clostridioides difficile among asymptomatic carriers, C. difficile-infected (CDI) patients and non-carriers in an inpatient non-epidemic setting. METHODS C. difficile carriage was determined by positive toxin-B PCR from rectal swabs of asymptomatic patients. Active CDI was defined as a positive two-step enzyme immunoassay/polymerase chain reaction (EIA/PCR) test in patients with more than three unformed stools/24 hr. C. difficile environmental contamination was assessed by obtaining specimens from ten sites in the patients' rooms. Toxigenic strains were identified by PCR. We created a contamination scale to define the overall level of room contamination that ranged from clean to heavy contamination. RESULTS One hundred and seventeen rooms were screened: 70 rooms inhabited by C. difficile carriers, 30 rooms by active CDI patients and 17 rooms by non C. difficile -carriers (control). In the carrier rooms 29 (41%) had more than residual contamination, from which 17 (24%) were heavily contaminated. In the CDI rooms 12 (40%) had more than residual contamination from which three (10%) were heavily contaminated, while in the control rooms, one room (6%) had more than residual contamination and none were heavily contaminated. In a multivariate analysis, the contamination score of rooms inhabited by carriers did not differ from rooms of CDI patients, yet both were significantly more contaminated than those of non-carriers odd ratio 12.23 and 11.16 (95% confidence interval 1.5-99.96 p 0.0195, and 1.19-104.49 p 0.035), respectively. DISCUSSION Here we show that the rooms of C. difficile carriers are as contaminated as those of patients with active CDI and significantly more than those of non-carriers.
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Affiliation(s)
- M Gilboa
- Internal Medicine D, Sheba Medical Centre, Ramat Gan, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Infectious Disease Unit, Sheba Medical Centre, Ramat Gan, Israel.
| | - E Houri-Levi
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Internal Medicine B, Sheba Medical Centre, Ramat Gan, Israel
| | - C Cohen
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Infection Control & Prevention Unit, Sheba Medical Centre, Ramat Gan, Israel
| | - I Tal
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Infection Control & Prevention Unit, Sheba Medical Centre, Ramat Gan, Israel
| | - C Rubin
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Biostatistics Unit, Gertner Institute, Ramat Gan, Israel
| | - O Feld-Simon
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Infectious Disease Unit, Sheba Medical Centre, Ramat Gan, Israel; Internal Medicine F, Sheba Medical Centre, Ramat Gan, Israel
| | - A Brom
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Infection Control & Prevention Unit, Sheba Medical Centre, Ramat Gan, Israel; Internal Medicine T, Sheba Medical Centre, Ramat Gan, Israel
| | - Y Eden-Friedman
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Internal Medicine E, Sheba Medical Centre, Ramat Gan, Israel
| | - S Segal
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Infection Control & Prevention Unit, Sheba Medical Centre, Ramat Gan, Israel
| | - G Rahav
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Infectious Disease Unit, Sheba Medical Centre, Ramat Gan, Israel
| | - G Regev-Yochay
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Infectious Disease Unit, Sheba Medical Centre, Ramat Gan, Israel; Infection Control & Prevention Unit, Sheba Medical Centre, Ramat Gan, Israel
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