Risk factors for Clostridium difficile toxin-positive nosocomial diarrhoea

Ways to Improve Insights into Clindamycin Pharmacology and Pharmacokinetics Tailored to Practice

Given the increase in bacterial resistance and the decrease in the development of new antibiotics, the appropriate use of old antimicrobials has become even more compulsory. Clindamycin is a lincosamide antibiotic approved for adults and children as a drug of choice for systemic treatment of staphylococcal, streptococcal, and gram-positive anaerobic bacterial infections. Because of its profile and high bioavailability, it is commonly used as part of an oral multimodal alternative for prolonged parenteral antibiotic regimens, e.g., to treat bone and joint or prosthesis-related infections. Clindamycin is also frequently used for (surgical) prophylaxis in the event of beta-lactam allergy. Special populations (pediatrics, pregnant women) have altered cytochrome P450 (CYP)3A4 activity. As clindamycin is metabolized by the CYP3A4/5 enzymes to bioactive N-demethyl and sulfoxide metabolites, knowledge of the potential relevance of the drug’s metabolites and disposition in special populations is of interest. Furthermore, drug–drug interactions derived from CYP3A4 inducers and inhibitors, and the data on the impact of the disease state on the CYP system, are still limited. This narrative review provides a detailed survey of the currently available literature on pharmacology and pharmacokinetics and identifies knowledge gaps (special patient population, drug–drug, and drug–disease interactions) to describe a research strategy for precision medicine.

Clostridioides difficile epidemiology in the Middle and the Far East

OBJECTIVES

Clostridioides difficile is an important pathogen of healthcare-associated gastrointestinal infections. Recently, an increased number of C. difficile infection (CDI) surveillance data has been reported from Asia. The aim of this review is to summarize the data on the prevalence, distribution and molecular epidemiology of CDI in the Middle and the Far East.

METHODS

Literature was drawn from a search of PubMed up to September 30, 2021.

RESULTS

The meta-analysis of data from 111 studies revealed the pooled CDI prevalence rate in the Middle and the Far East of 12.4% (95% CI 11.4-13.3); 48 studies used PCR for CDI laboratory diagnoses. The predominant types (RT)/sequence type (ST) differ between individual countries (24 studies, 14 countries). Frequently found RTs were 001, 002, 012, 017, 018 and 126; RT017 was predominant in the Far East. The epidemic RT027 was detected in 8 countries (22 studies), but its predominance was reported only in three studies (Israel and Iran). The contamination of vegetable and meat or meat products and/or intestinal carriage of C. difficile in food and companion animals have been reported; the C. difficile RTs/STs identified overlapped with those identified in humans.

CONCLUSIONS

A large number of studies on CDI prevalence in humans from the Middle and the Far East have been published; countries with no available data were identified. The number of studies on C. difficile from non-human sources is limited. Comparative genomic studies of isolates from different sources are needed.

Risk Factors of Patients With Diarrhea for Having Clostridioides (Clostridium) difficile Infection

Nosocomial infections with Clostridioides (Clostridium) difficile have become an emergent health threat. We sought to define risk factors for a C. difficile infection (CDI) beyond the widely known ones, such as antibiotic use and prior hospital stay. We therefore focused on a group of patients with diarrhea in order to identify risk factors for C. difficile infection among this symptomatic cohort. A total of 121 hospitalized patients from Seesen/Germany with diarrhea were included who submitted a stool sample and were interviewed about their socio-demographic background, lifestyle and state of health using a standardized questionnaire. Antibiotic potential of diuretics was examined by agar diffusion test. C. difficile was identified in 29 patients resulting in a prevalence of 24.0%. The infection was hospital-acquired in most cases (p < 0.001, 82.1%; n = 23/28, versus 29/91, 31.9%). The generally accepted risk factor previous antibiotic use was confirmed in this study (p = 0.002, n = 23/28 CDI patients, 82.1%, versus n = 44/91 non-CDI patients, 48.4%). The following additional risk factors were identified: regular consumption of proton pump inhibitors; PPI (p = 0.011, n = 24/29, 82.8% vs. n = 52/92, 56.5%), CDI patients ate less vegetables (p = 0.001, n = 12/29, 41.4% vs. 69/92, 75.0%). The intake of the diuretic agent torasemid in patients with CDI (p = 0.005, n = 18/29, 62.1%) was higher than in patients without (n = 30/92, 32.6%). More patients with CDI had to undergo a surgery in the previous year (p = 0.022, n = 13/29, 44.8% vs. n = 21/92, 22.8%) and held more birds (p = 0.056, n = 4/29, 13.8%) than individuals of the negative group (n = 3/92, 3.3%). In conclusion, although no antibiotic potential was detected in diuretics, especially torasemid seems to have significant influence for the occurrence of a CDI as well as a nutrition poor in vegetables. A diet rich in vegetables represented a fourfold lower risk for a CDI (OR 0.240, CI (0.0720 - 0.796]).

Effects of fermented ginseng on the gut microbiota and immunity of rats with antibiotic-associated diarrhea

ETHNOPHARMACOLOGICAL RELEVANCE

Ginseng (Panax ginseng Meyer) is a well-known herb in traditional Chinese medicine and has been used to treat many diseases for thousands of years. Recent studies have shown that ginseng is a promising agent for improving the gut microbiota and treating ulcerative colitis. Fermentation is a common process in traditional Chinese medicine making that can be used to enhance efficacy and reduce toxicity.

AIM OF THE STUDY

The purpose of the present study was to research the efficacy of ginseng fermented with probiotics (Lactobacillus fermentum) on the gut microbiota and immunity of rats with antibiotic-associated diarrhea (AAD).

MATERIALS AND METHODS

SPF Sprague-Dawley rats were randomly divided into eight groups: control group, antibiotic group, natural recovery group, and five groups treated with different doses of fermented ginseng (FG1 to FG5). A model of AAD was established by treating the rats with triple antibiotics, and obvious symptoms of AAD were observed. A histopathological analysis of the colon was performed. The total bacteria in the intestinal microbiota and five types of gut microbes in the feces were detected by quantitative PCR. The expression levels of related immune factors TLR4 and NF-κB in the colon were assayed.

RESULTS

An appropriate dose of fermented ginseng (0.5 g/kg/d) relieved some of the symptoms of AAD and colon inflammation and reduced the expression of the immune factors TLR4 and NF-κB in the colon. The alteration of the gut microbiota observed in the rats treated with antibiotics also returned to normal after treatment with fermented ginseng. Moreover, different doses of fermented ginseng exerted different influences on the gut microbiota, and excessively high or low doses of fermented ginseng were disadvantageous for resolving the symptoms of AAD and promoting recovery.

CONCLUSIONS

These results demonstrate that fermented ginseng can treat AAD symptoms and colon inflammation and restore the gut microbiota to its original state.

Risk Factors and Costs Associated With Clostridium difficile Colitis in Patients With Prosthetic Joint Infection Undergoing Revision Total Hip Arthroplasty

BACKGROUND

With the increased demand for primary total hip arthroplasty (THA) and corresponding rise in revision procedures, it is imperative to understand the factors contributing to the development of Clostridium difficile colitis. We aimed to provide a detailed analysis of: (1) the incidence of; (2) the demographics, lengths of stay, and total costs for; and (3) the risk factors and mortality associated with the development of C. difficile colitis after revision THA.

METHODS

The National Inpatient Sample database was queried for all individuals diagnosed with a periprosthetic joint infection and who underwent all-component revision THA between 2009 and 2013 (n = 40,876). Patients who developed C. difficile colitis during their inpatient hospital stay were identified. Multilevel logistic regression analysis was conducted to assess the association between hospital- and patient-specific characteristics and the development of C. difficile colitis.

RESULTS

The overall incidence of C. difficile colitis after revision THA was 1.7%. These patients were significantly older (74 vs 65 years), had greater lengths of hospital stay (19 vs 9 days), accumulated greater costs ($51,641 vs $28,282), and were more often treated in an urban hospital compared to their counterparts who did not develop C. difficile colitis (P < .001 for all). Patients with colitis also had a significantly higher in-hospital mortality compared to those without (5.6% vs 1.4%; P < .001).

CONCLUSION

While C. difficile colitis infection is an uncommon event following revision THA, it can have potentially devastating consequences. Our analysis demonstrates that this infection is associated with a longer hospital stay, higher costs, and greater in-hospital mortality.

Current and future treatment options for community-associated MRSA infection

INTRODUCTION

Community-associated MRSA (CA-MRSA) represents a global epidemic which beautifully encapsulates the fascinating ability of bacterial organisms to adapt quickly on an evolutionary basis to the extreme selective pressure of antibiotic exposure. In stark contrast to Healthcare-associated MRSA (HA-MRSA), it has become apparent that CA-MRSA is less straight forward of a challenge in terms of controlling its transmission, and has forced clinicians to adjust empiric management of clinical syndromes such as skin and soft tissue infection (SSTI) as well as pneumonia.

AREAS COVERED

This review details the history and epidemiology of CA-MRSA, while covering both current and future treatment options that are and may be available to clinicians. The authors reviewed both historic and more recent literature on this ever-evolving topic.

EXPERT OPINION

While development of new anti-MRSA agents should be encouraged, the importance of antimicrobial stewardship in the battle to stay ahead of the curve with regards to the ongoing control of the MRSA epidemic should be emphasised.

Analysis of risk factors and clinical manifestations associated with Clostridium difficile disease in Serbian hospitalized patients

Clostridium difficile is the leading cause of infectious diarrhoea in hospitalized patients. The aim of this study was to determine the risk factors important for the development of hospital-acquired Clostridium difficile-associated disease and clinical manifestations of Clostridium difficile-associated disease. The clinical trial group included 37 hospitalized patients who were selected according to the inclusion criteria. A control group of 74 hospitalized patients was individually matched with cases based on hospital, age (within 4 years), sex and month of admission. Clostridium difficile-associated disease most commonly manifested as diarrhoea (56.76%) and colitis (32%), while in 8.11% of patients, it was diagnosed as pseudomembranous colitis, and in one patient, it was diagnosed as fulminant colitis. Statistically significant associations (p<0.05) were found with the presence of chronic renal failure, chronic obstructive pulmonary disease, cerebrovascular accident (stroke) and haemodialysis. In this study, it was confirmed that all the groups of antibiotics, except for tetracycline and trimethoprim-sulfamethoxazole, were statistically significant risk factors for Clostridium difficile-associated disease (p<0.05). However, it was difficult to determine the individual role of antibiotics in the development of Clostridium difficile-associated disease. Univariate logistic regression also found that applying antibiotic therapy, the duration of antibiotic therapy, administration of two or more antibiotics to treat infections, administering laxatives and the total number of days spent in the hospital significantly affected the onset of Clostridium difficile-associated disease (p<0.05), and associations were confirmed using the multivariate model for the application of antibiotic therapy (p=0.001), duration of antibiotic treatment (p=0.01), use of laxatives (p=0.01) and total number of days spent in the hospital (p=0.001). In this study of patients with hospital-acquired diarrhoea, several risk factors for the development of Clostridium difficile-associated disease were identified.

Can we improve the therapy of Clostridium difficile infection in elderly patients?

BACKGROUND

Clostridium difficile infection (CDI) is becoming a serious problem predominantly in geriatric patients, who are a significant risk group. The goal of this study was to evaluate the risk factors for mortality in CDI patients and to construct a binary logistic regression model that describes the probability of mortality in geriatric patients suffering from CDI.

METHODS

In this retrospective study, we evaluated a group of 235 patients over 65 years of age with confirmed diagnoses of CDI, hospitalized at the Department of Internal Medicine, Geriatrics and General Practice, Brno, from January 2008 to December 2013. The examined group comprised 148 women (63 %) and 87 men (37 %). For the diagnosis of CDI, confirmation of A and B toxins in the patients' stool or an autopsy confirmation was crucial.

RESULTS

The impact of antibiotic therapy on the increased incidence of CDI was clearly confirmed in our study group when examining patients' histories. Other risk factors included cerebrovascular disease, dementia, the presence of pressure ulcers, and immobility. Our new model consisted of a combination of the following parameters: the number of antibiotics used (from patients' history), nutritional status (Mini Nutritional Assessment short-form test), presence of pressure ulcers, and occurrence of fever.

CONCLUSION

Our logistic regression model may predict mortality in geriatric patients suffering from CDI. This could help improve the therapeutic process.

Role of FODMAP content in enteral nutrition-associated diarrhea

Gastrointestinal symptoms including diarrhea are common complications of enteral nutrition (EN); however, the cause is unclear. Mode of EN delivery that alters digestion and possibly absorption is suggested to contribute to the high incidence of diarrhea; however, enteral formula is frequently blamed. Most research has focused on fiber-supplemented EN, with a meta-analysis showing that fiber reduces the incidence of diarrhea in non-intensive care unit studies. Other hypotheses include formula osmolality and FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) content. FODMAPs are poorly absorbed short-chain carbohydrates that exert an osmotic effect. Dietary FODMAPs have been shown to reduce gastrointestinal symptoms, including diarrhea, in those with irritable bowel syndrome and, given a high-enough dose, will induce a laxative effect in most people. As FODMAPs are commonly added to enteral formula and EN is frequently used as the main source of nutrition, it is reasonable to hypothesize that EN provides more FODMAPs than usual dietary intake and increases risk for developing diarrhea. This hypothesis was assessed through a retrospective study showing that the standard-use enteral formula Isosource 1.5 had a protective effect of developing diarrhea. The only characteristic unique to Isosource 1.5 was the lower FODMAP content as determined through methodologies previously validated for food analysis. Methodologies for application to enteral formulas are currently undergoing formal validation. Once confirmed for application in enteral formula, future directions include FODMAP analysis of specific ingredients to increase understanding of potential problems associated with enteral formula and a randomized, controlled trial investigating the role of formula FODMAP content.

Risk factors, preemptive therapy, and antiperistaltic agents for Clostridium difficile infection in cancer patients

BACKGROUND

Clostridium difficile infection (CDI) is a serious complication of chemotherapy including high-dose regimens with autologous stem cell transplantation (ASCT). Antiperistaltic agents are contraindicated in CDI and preemptive CDI therapy is not recommended. We assessed the incidence, risk factors, and outcomes of CDI in patients with newly diagnosed multiple myeloma (MM) receiving similar antineoplastic therapy and supportive care including antiperistaltic agents and preemptive CDI antibiotics for significant diarrhea.

METHODS

A total of 303 consecutive MM patients (2004-2007) were enrolled in a protocol consisting of induction chemotherapy, tandem melphalan (MEL)-ASCT, and consolidation. Patients with grade 2-4 diarrhea were simultaneously tested for CDI, and initiated on antiperistaltic agents (loperamide) and preemptive anti-CDI therapy. Risk factors, including prior CDI and MM immunoglobulin (Ig) isotype, were evaluated. Multinomial logistic regression was used to compute the relative risk ratio (RRR) and 95% confidence intervals (CIs).

RESULTS

There were 43 cases of CDI (14.2%) during 1529 chemotherapy courses (536 ASCT). IgA MM protected against CDI (RRR 0.35; 95% CI 0.13-0.93, P = 0.04) whereas CDI during first induction markedly increased the risk of recurrence during second induction (RRR = 10.94; 95% CI 1.90, 62.92, P = 0.01) and following MEL-ASCT (RRR = 6.63; 95% CI 1.51, 29.12, P = 0.01). No CDI-related surgical intervention or death ensued despite use of antiperistaltic agents.

CONCLUSIONS

CDI was not uncommon in cancer patients receiving chemotherapy. IgA myeloma appears to be protective. Concurrent antiperistaltic (loperamide) and preemptive CDI therapies were associated with excellent outcomes. Prior CDI history increased the risk for recurrence during successive chemotherapy courses.

Antibiotic overuse and resistance in dermatology

Antibiotics have a significant role in dermatology, treating a wide range of diseases, including acne, rosacea, inflammatory skin conditions and skin structure infections, such as cellulitis, folliculitis, carbuncles, and furuncles. Because of their consistent use, utility, and availability, antibiotics are susceptible to overuse within the medical practice, and, specific to this discussion, in the dermatologic setting. The issue of continuously increasing risk of antibiotic resistance remains an important concern to the dermatologist. The scope of this review will be to provide an overview of the common antibiotics used in the dermatologic setting with an emphasis on identifying areas of overuse, reported bacterial resistance, and discussion of clinical management aimed at decreasing antibiotic resistance.

Evaluating contemporary antibiotics as a risk factor for Clostridium difficile infection in surgical trauma patients

BACKGROUND

With most Clostridium difficile infections (CDI) occurring after exposure to antimicrobial treatment, specific antibiotics and duration of exposure were evaluated independently for increased risk of CDI in surgical patients.

METHODS

A retrospective, case-control design was used to study surgical inpatients. The case group had a positive Clostridium difficile toxin assay, whereas the control group did not.

RESULTS

Four antibiotics had a risk that was statistically significant for causing CDI in surgical patients: cefepime (odds ratio [OR], 5.7; 95% confidence interval [CI], 1.7-19.1; p = 0.0044), imipenem/cilastatin (OR, 3.2; 95% CI, 1.2-8.9; p = 0.0388), piperacillin/tazobactam (OR, 2.4; 95% CI, 1.3-4.5; p = 0.0067), and vancomycin (OR, 1.9; 95% CI, 1.0-3.5; p = 0.0439). Exposure longer than 7 days to cefepime (p = 0.0006), piperacillin/tazobactam (p = 0.0021), and imipenem/cilastatin (p = 0.0171) also increased risk for development of CDI.

CONCLUSION

The use of cefepime, imipenem/cilastatin, piperacillin/tazobactam, and vancomycin and the use of multiple classes of antibiotics for at least 7 days significantly increased the risk of CDI in surgical inpatients.

Clostridium difficile–Associated Diarrhea at a Community Hospital: Ten-Year Analysis of Infection Rates and the Relationship with Proton Pump Inhibitor Use

Purpose

To investigate the relationship between proton pump inhibitor (PPI) use and the incidence of Clostridium difficile–associated diarrhea (CDAD) at a community hospital.

Methods

The number of inpatient admissions, inpatient cases of CDAD, and PPI and antimicrobial doses were collected for each year from 2000 to 2009. Correlations between incidence of CDAD and doses of PPI and antimicrobials were calculated using Spearman's rank correlation coefficient analysis.

Results

The incidence of CDAD correlated with the number of doses of PPI per admission (ρ = 0.891, P < .001) and with the number of doses of antimicrobials per admission (ρ = 0.806, .005 > P > .001). The correlation of CDAD incidence with high-risk and low-risk antimicrobials was significant for both groups (ρ = 0.624, .05 > P > .025, and ρ = 0.881, P < .001, respectively). The correlation of oral and intravenous PPI dosing and CDAD incidence was significant for both (ρ=0.903, P < .001, and ρ=0.806, .005 > P > .001, respectively). Multiple regression analysis with both antimicrobials and PPIs as predictors of CDAD was statistically significant ( R2 = 0.75, P = .0082).

Conclusion

The incidence of CDAD is correlated with PPI use. Antimicrobials are a well-established risk factor for CDAD, and our study reinforces this. Prescribers should consider limiting risk of CDAD by the judicious use of PPIs.

Risk factors for Clostridium difficile toxin-positive diarrhea: a population-based prospective case-control study

Increased incidence and severity of Clostridium difficile infections (CDIs) is of major concern. However, by minimizing known risk factors, the incidence can be decreased. The aim of this investigation was to calculate the incidence and assess risk factors for CDI in our population. A 1-year prospective population-based nationwide study in Iceland of CDIs was carried out. For risk factor evaluation, each case was matched with two age- and sex-matched controls that tested negative for C. difficile toxin. A total of 128 CDIs were identified. The crude incidence was 54 cases annually per 100,000 population >18 years of age. Incidence increased exponentially with older age (319 per 100,000 population >86 years of age). Community-acquired origin was 27 %. Independent risk factors included: dicloxacillin (odds ratio [OR]: 7.55, 95 % confidence interval [CI]: 1.89-30.1), clindamycin (OR: 6.09, 95 % CI: 2.23-16.61), ceftriaxone (OR: 4.28, 95 % CI: 1.59-11.49), living in a retirement home (OR: 3.9, 95 % CI: 1.69-9.16), recent hospital stay (OR: 2.3, 95 % CI: 1.37-3.87). Proton pump inhibitors (PPIs) were used by 60/111 (54 %) versus 91/222 (41 %) (p = 0.026) and ciprofloxacin 19/111 (17 %) versus 19/222 (9 %) (p = 0.027) for cases and controls, respectively. In all, 75 % of primary CDIs treated with metronidazole recovered from one course of treatment. CDI was mostly found among elderly patients. The most commonly identified risk factors were broad-spectrum antibiotics and recent contact with health care institutions. PPI use was significantly more prevalent among CDI patients.

Treatment of Clostridium difficile-associated diarrhea

Clostridium difficile-associated diarrhea (CDAD) is a serious subtype of antibiotic-associated diarrhea. In recent years, the incidence and severity of CDAD have significantly increased worldwide. Clostridium difficile is a Gram-positive enteric pathogen and can produce toxin A and toxin B, which induce cytopathic changes and lead to a series of clinical manifestations of infection. Although the use of broad spectrum antibiotics is the most common cause for the development of CDAD, age, chronic disease, long-term hospitalization and other factors are also possible risk factors. Patients with confirmed or highly suspected CDAD should immediately discontinue antibiotics and switch to other drugs which do not tend to cause CDAD. Treatment with metronidazole or vancomycin is recommended. Recent studies show that teicoplanin, probiotics, monoclonal antibody and Chinese medicine are also effective for this disease. In this paper, we discuss the prevention and treatment of CDAD.

Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children

Evidence-based guidelines for the management of patients with methicillin-resistant Staphylococcus aureus (MRSA) infections were prepared by an Expert Panel of the Infectious Diseases Society of America (IDSA). The guidelines are intended for use by health care providers who care for adult and pediatric patients with MRSA infections. The guidelines discuss the management of a variety of clinical syndromes associated with MRSA disease, including skin and soft tissue infections (SSTI), bacteremia and endocarditis, pneumonia, bone and joint infections, and central nervous system (CNS) infections. Recommendations are provided regarding vancomycin dosing and monitoring, management of infections due to MRSA strains with reduced susceptibility to vancomycin, and vancomycin treatment failures.

Clostridium difficile-associated disease among patients in Dhahran, Saudi Arabia

Clostridium difficile-associated diarrhea (CDAD) is an important healthcare-associated infection. However, there are no data from Saudi Arabia on this disease. A two-year prospective, observational study on the incidence of CDAD in a hospital in Saudi Arabia was carried out. Stool analysis for C. difficile toxins A and B was carried out by an enzyme-linked immunosorbent assay. Medical and laboratory records were reviewed. Of the total number of patients, there were 53.3% male and the mean age was 44.6 ± 27.2 years. Of the 913 specimens, only 42 (4.6%) were positive for C. difficile toxins. The annual incidence rates of C. difficile were 1.2 and 0.9 per 1000 discharges, and 2.4 and 1.7 per 10,000 patient days in 2007 and 2008, respectively. Of the total number of cases, 52.4% were with onset in the hospital, 38.1% were with onset in the community and 9.5% were community-onset but healthcare facility-associated CDAD. Of the cases, 16 (39%) patients did not have exposure to antimicrobial drugs in the 3 months prior to the test date. The remaining patients received antimicrobial drug therapy. Cephalosporin and fluoroquinolone were the most common antimicrobial drugs used. Overall, the prevalence of C. difficile-associated diarrhea was low; further studies are required in Saudi Arabia to elucidate the true prevalence of the disease.

Diarrhoea during enteral nutrition is predicted by the poorly absorbed short-chain carbohydrate (FODMAP) content of the formula

BACKGROUND

Although it is recognized that diarrhoea commonly complicates enteral nutrition, the causes remain unknown.

AIM

To identify factors associated with diarrhoea in patients receiving enteral nutrition with specific attention to formula composition.

METHODS

Medical histories of in-patients receiving enteral nutrition were identified by ICD-10-AM coding and randomly selected from the year 2003 to 2008. Clinical and demographic data were extracted. Formulas were classified according to osmolality, fibre and FODMAP (fermentable oligo-, di- and mono-saccharides and polyols) content.

RESULTS

Formula FODMAP levels ranged from 10.6 to 36.5 g/day. Of 160 patients receiving enteral nutrition, 61% had diarrhoea. Univariate analysis showed diarrhoea was associated with length of stay >21 days (OR 4.2), enteral nutrition duration >11 days (OR 4.0) and antibiotic use (OR 2.1). After adjusting for influencing variables through a logistic regression model, a greater than five-fold reduction in risk of developing diarrhoea was seen in patients initiated on Isosource 1.5 (P = 0.029; estimated OR 0.18). The only characteristic unique to this formula was its FODMAP content, being 47-71% lower than any other formula.

CONCLUSIONS

Length of stay and enteral nutrition duration independently predicted diarrhoea development, while being initiated on a lower FODMAP formula reduced the likelihood of diarrhoea. As retrospective evaluation does not support a cause-effect relationship, an interventional study investigating FODMAPs in enteral formula is indicated.

Risk factors for and estimated incidence of community-associated Clostridium difficile infection, North Carolina, USA

We determined estimated incidence of and risk factors for community-associated Clostridium difficile infection (CA-CDI) among patients treated at 6 North Carolina hospitals. CA-CDI case-patients were defined as adults (>18 years of age) with a positive stool test result for C. difficile toxin and no hospitalization within the prior 8 weeks. CA-CDI incidence was 21 and 46 per 100,000 person-years in Veterans Affairs (VA) outpatients and Durham County populations, respectively. VA case-patients were more likely than controls to have received antimicrobial drugs (adjusted odds ratio [aOR] 17.8, 95% confidence interval [CI] 6.6-48] and to have had a recent outpatient visit (aOR 5.1, 95% CI 1.5-17.9). County case-patients were more likely than controls to have received antimicrobial drugs (aOR 9.1, 95% CI 2.9-28.9), to have gastroesophageal reflux disease (aOR 11.2, 95% CI 1.9-64.2), and to have cardiac failure (aOR 3.8, 95% CI 1.1-13.7). Risk factors for CA-CDI overlap with those for healthcare-associated infection.

What have we learned about antimicrobial use and the risks for Clostridium difficile-associated diarrhoea?

Clostridium difficile is recognized as a major cause of antibiotic-associated diarrhoea and colitis. Antimicrobial agents have been repeatedly recognized as a causative risk for C. difficile-associated diarrhoea (CDAD) and more recently fluoroquinolones have been particularly implicated. Unfortunately, not all reports of antimicrobial associations with CDAD have excluded variables other than antimicrobial use. Prevention of CDAD usually involves infection control interventions and antimicrobial restriction policies may not be fully substantiated by currently available data; however, antimicrobial drug restriction seems prudent in outbreak situations.

Oxytetracycline treatment reduces bacterial diversity of intestinal microbiota of Atlantic salmon

The effect of oxytetracycline (OTC) treatment on intestinal bacterial populations in juvenile Atlantic salmon Salmo salar was evaluated. Oxytetracycline was administered by way of medicated feed to fish held in experimental tanks. Restriction fragment length polymorphism and sequencing of 16S rDNA from isolates were used to analyze the intestinal microbiota before, during, and after OTC administration. The microbiota from untreated fish was more diverse, consisting mainly of Pseudomonas, Acinetobacter, Bacillus, Flavobacterium, Psycrobacter, and Brevundimonas spp. In contrast, the microbiota of the OTC-treated group was characterized by lower diversity and consisted only of Aeromonas, clustering with A. sobria and A. salmonicida. Antibiotic-resistant isolates were identified as Aeromonas spp.; sequencing the resistance determinant showed it to be the tetE gene. Overall, OTC treatment changed the composition of the intestinal microbiota of Atlantic salmon, as evidenced by a reduction in bacterial diversity. These results support the current concern that antibiotic treatment can facilitate the proliferation of opportunistic bacteria by eradicating competing microorganisms.

Clostridium difficile infection after total joint arthroplasty: who is at risk?

Clostridium difficile-associated diarrhea is a recognized postoperative complication. However, the exact risk factors for this condition after total joint arthroplasty (TJA) remain unknown. This case-controlled study intended to identify the predisposing factors for this condition. There were 16 cases of C difficile infections after 9880 TJA (0.16% incidence) between January 2001 and May 2006 at our institution. The cases were matched with 32 controls for month/year of surgery and surgeon. This study suggests that patients with deteriorated physical status or those who receive greater than one antibiotic after surgery are at a higher risk for developing C difficile-associated diarrhea after TJA.

Infection control measures to limit the spread of Clostridium difficile

Clostridium difficile-associated diarrhoea (CDAD) presents mainly as a nosocomial infection, usually after antimicrobial therapy. Many outbreaks have been attributed to C. difficile, some due to a new hyper-virulent strain that may cause more severe disease and a worse patient outcome. As a result of CDAD, large numbers of C. difficile spores may be excreted by affected patients. Spores then survive for months in the environment; they cannot be destroyed by standard alcohol-based hand disinfection, and persist despite usual environmental cleaning agents. All these factors increase the risk of C. difficile transmission. Once CDAD is diagnosed in a patient, immediate implementation of appropriate infection control measures is mandatory in order to prevent further spread within the hospital. The quality and quantity of antibiotic prescribing should be reviewed to minimise the selective pressure for CDAD. This article provides a review of the literature that can be used for evidence-based guidelines to limit the spread of C. difficile. These include early diagnosis of CDAD, surveillance of CDAD cases, education of staff, appropriate use of isolation precautions, hand hygiene, protective clothing, environmental cleaning and cleaning of medical equipment, good antibiotic stewardship, and specific measures during outbreaks. Existing local protocols and practices for the control of C. difficile should be carefully reviewed and modified if necessary.

Increasing seroprevalence of Clostridium difficile in an adult Danish general population

The incidence of Clostridium difficile-associated infections is increasing, but it remains to be defined whether any change in the seroprevalence of C. difficile has also occurred. In a population-based study of the general adult population, 734 subjects, aged 15-69 years, were examined on two occasions 8 years apart (1990 and 1998) for the presence of antibodies against C. difficile in serum. The overall seroprevalence of C. difficile increased significantly from 19% in 1990 to 27% in 1998 (P<0.0001). The seroprevalence increased with increasing age in both 1990 and 1998, but the increase was about four times higher in 1998 than in 1990. In conclusion, the observed increase in seroprevalence suggests a higher exposure to C. difficile in the general Danish adult population.

Case-control study of antibiotic use and subsequent Clostridium difficile-associated diarrhea in hospitalized patients

OBJECTIVE

To determine which antibiotics increase or decrease the risk of Clostridium difficile-associated diarrhea (CDAD).

DESIGN

Retrospective case-control study.

SETTING

Nonprofit, integrated healthcare delivery system in Northern California.

PATIENTS

Study participants included patients with cases of hospital-acquired CDAD that occurred during the period from 1999 through 2005 (n=1,142) and control patients (n= 3,351) matched for facility, calendar quarter during which hospitalization occurred, diagnosis related group for the index hospitalization, and length of hospital stay. All case and control patients had received antibiotics in the 60 days before the index date. For each antibiotic, the risk of CDAD was examined in relation to whether the patient received the antibiotic, after adjustment for use of other antibiotics, demographic characteristics, selected health conditions, and use of healthcare services.

RESULTS

The following antibiotics were associated with a significantly increased risk of acquiring CDAD: imipenem-cilastin (odds ratio [OR], 2.77), clindamycin (OR, 2.31), cefuroxime (OR, 2.16), moxifloxacin (OR, 1.88), ceftazidime (OR, 1.82), cefpodoxime (OR, 1.58), ceftizoxime (OR, 1.57), and ceftriaxone (OR, 1.49). Metronidazole and doxycycline were associated with a significantly reduced risk of CDAD (OR for metronidazole, 0.67; OR for doxycycline, 0.41). Other factors associated with an increased risk of CDAD were older age, longer hospital stays, use of proton pump inhibitors, prior gastrointestinal disease, and prior infection (not including C. difficile infection.)

CONCLUSIONS

Some antibiotics appear to increase the risk of acquiring CDAD, notably clindamycin, third-generation cephalosporins, and carbapenems, whereas metronidazole and doxycycline appear to be protective, compared with other antibiotics.

Diarrheal diseases in the elderly

Diarrhea in the elderly population is one disease that needs special attention in treatment and management, especially in acute- and long-term care residents, because of their multiple comorbidities, immunosenescence, frailty, and poor nutritional status. Close follow-up to ensure adequate hydration and electrolyte replacement and infection control measures to contain outbreaks should be emphasized to caregivers and nursing staff in acute- and long-term care facilities. Although C difficile colitis causes significant morbidity and mortality in this population, judicious use of antibiotics is important to decrease the incidence and recurrence of the disease. When the diarrhea is chronic and all stool testings and serologies have been performed, the patient may benefit from endoscopy and colonoscopy for biopsy. Attentive and vigilant nursing staff is crucial in the timely diagnosis and treatment of diarrheal diseases to improve quality of life and reduce mortality.

Fluoroquinolone use and risk factors for Clostridium difficile-associated disease within a Veterans Administration health care system

BACKGROUND

Prompted by the changing profile of Clostridium difficile infection and the impact of formulary policies in hospitals, we performed this study when an increase in the incidence of C. difficile-associated disease was noted at our health care center (Veterans Administration Puget Sound Health Care System, Seattle, Washington).

METHODS

A retrospective, matched case-control study of patients presenting to the Veterans Administration Puget Sound Health Care System, Seattle, Washington during 2004 was performed. Conditional logistic analysis determined risk factors for case patients, defined as individuals with diarrhea and test results (i.e., culture or toxin assay results) positive for C. difficile, and control subjects, defined as individuals with diarrhea and test results negative for C. difficile.

RESULTS

C. difficile-associated disease incidence was 29.2 cases per 10,000 inpatient-days. The increase in the incidence of C. difficile-associated diarrhea that paralleled increased gatifloxacin use was not attributable to use of the antimicrobial but was a reflection of seasonal variation in the rate of C. difficile-associated disease. Multivariate analysis controlling for the time at which the assay was performed, the age of the patient, ward, and source of acquisition (community-acquired vs. nosocomial disease) found 6 significant risk factors for C. difficile-associated diarrhea: receipt of clindamycin (adjusted odds ratio [aOR], 29.9; 95% confidence interval [CI], 3.58-249.4), receipt of penicillin (aOR, 4.1; 95% CI, 1.2-13.9), having a lower intestinal condition (aOR, 2.8; 95% CI, 1.3-6.1), total number of antibiotics received (aOR, 1.4; 95% CI, 1.1-1.7), number of prior hospital admissions (aOR, 1.3; 95% CI, 1.1-1.6), and number of comorbid conditions (aOR, 1.3; 95% CI, 1.1-1.5).

CONCLUSIONS

The increase in the number of cases of C. difficile-associated disease was not attributable to a formulary change of fluoroquinolones; instead, the incidence was within expected seasonal variations for C. difficile-associated disease. Recognition of community-acquired cases and the use of culture may help to identify additional cases of C. difficile-associated disease. Early diagnosis and treatment of C. difficile cases may shorten the duration of hospital stays and reduce the number of outbreaks and readmissions, mortality, and other consequences of C. difficile infection.

Clostridium difficile: dealing with a silent menace

Clostridium difficile infection is a growing problem and infection is not confined to acute hospitals. People with C. difficile may be cared for in community hospitals or at home. Some people with C. difficile suffer recurrent bouts of infection, others are left with ongoing bowel problems as a result of the infection. Prevention, wherever possible, through prudent antibiotic prescribing and scrupulous infection control procedures can reduce infection risks. Prompt diagnosis and treatment can reduce the risks of life threatening colitis or chronic bowel problems.