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Suárez-Carantoña C, Corbacho-Loarte MD, Del Campo Albendea L, Kamel-Rey S, Halperin AV, Escudero-Sánchez R, Ponce-Alonso M, Moreno S, Cobo J. Is advanced age still a risk factor for recurrence of C. difficile infection in the era of new treatments? Age Ageing 2024; 53:afae182. [PMID: 39141079 DOI: 10.1093/ageing/afae182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND Advanced age has been widely identified as a risk factor for recurrent Clostridioides difficile infection (CDI), but most related studies were performed before the introduction of novel therapies. The aim of this study was to compare CDI characteristics and outcomes in patients over and under 80 years old with CDI and their outcomes in the era of new treatments. METHODS This was a retrospective cohort study of patients diagnosed with CDI from January 2021 to December 2022 in an academic hospital. We compared recurrence and mortality at 12 weeks after the end of treatment. An extension of the Fine and Grey model adjusted for competing events was used to assess the effect of age on recurrence. RESULTS Four hundred seventy-six patients were considered to have CDI (320 in patients <80 years and 156 in ≥80 years). CDI in older patients was more frequently healthcare-associated and was more severe. Although the Charlson index was almost identical between populations, comorbidities clearly differed. New treatments (bezlotoxumab, fidaxomicin and faecal microbiota transplantation) were more frequently used in older patients without statistical significance (41.3% vs. 33.4%, P = .053). There were 69 (14.5%) recurrences, with no differences by age group after adjusting for competing events. Mortality was greater in the oldest (35.3%) than in the youngest (13.1%); P < .001. CONCLUSIONS No differences in CDI recurrence rates were found between age groups. However, there was a high mortality rate in patients ≥80 years old, which emphasises the urgent need to improve the prevention and treatment of CDI in this group.
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Affiliation(s)
- Cecilia Suárez-Carantoña
- Internal Medicine Department, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
- Faculty of Medicine and Health Sciences, Alcalá University, Madrid, Spain
| | - María Dolores Corbacho-Loarte
- Infectious Diseases Department, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Laura Del Campo Albendea
- Biostatistics Department, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
- CIBER de Epidemiologia y Salud Pública, Instituto de Salud Carlos III, Madrid, Spain
| | - Sara Kamel-Rey
- Internal Medicine Department, Hospital Universitario Severo Ochoa, Madrid, Spain
| | | | - Rosa Escudero-Sánchez
- Infectious Diseases Department, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Manuel Ponce-Alonso
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
- Microbiology Department, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Santiago Moreno
- Faculty of Medicine and Health Sciences, Alcalá University, Madrid, Spain
- Infectious Diseases Department, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Javier Cobo
- Infectious Diseases Department, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
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2
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Madden GR, Boone RH, Lee E, Sifri CD, Petri WA. Predicting Clostridioides difficile infection outcomes with explainable machine learning. EBioMedicine 2024; 106:105244. [PMID: 39018757 PMCID: PMC11286990 DOI: 10.1016/j.ebiom.2024.105244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 06/28/2024] [Accepted: 07/01/2024] [Indexed: 07/19/2024] Open
Abstract
BACKGROUND Clostridioides difficile infection results in life-threatening short-term outcomes and the potential for subsequent recurrent infection. Predicting these outcomes at diagnosis, when important clinical decisions need to be made, has proven to be a difficult task. METHODS 52 clinical features from existing models or the literature were collected retrospectively within ±48 h of diagnosis among 1660 inpatient infections. A modified desirability of outcome ranking (DOOR) was designed to encompass clinically-important severe events attributable to the acute infection (intensive care transfer due to sepsis, shock, colectomy/ileostomy, mortality) and/or 60-day recurrence. A deep neural network was constructed and interpreted using SHapley Additive exPlanations (SHAP). High-importance features were used to train a reduced, shallow network and performance was compared to existing conventional models (7 severity, 7 recurrence; after summing DOOR probabilities to align with conventional binary outputs) using area under the ROC curve (AUROC) and DeLong tests. FINDINGS The full (52-feature) model achieved an out-of-sample AUROC 0.823 for severity and 0.678 for recurrence. SHAP identified 13 unique, highly-important features (age, hypotension, initial treatment, onset, PCR cycle threshold, number of prior episodes, antibiotic exposure, fever, hypotension, pressors, leukocytosis, creatinine, lactate) that were used to train a reduced model, which performed similarly to the full model (severity AUROC difference P = 0.130; recurrence P = 0.426) and significantly better than the top severity model (reduced model predicting severity 0.837, ATLAS 0.749; P = 0.001). The reduced model also outperformed the top recurrence model, but this was not statistically-significant (reduced model recurrence AUROC 0.653, IDSA Recurrence Risk Criteria 0.595; P = 0.196). The final, reduced model was deployed as a web application with real-time SHAP explanations. INTERPRETATION Our final model outperformed existing severity and recurrence models; however, it requires external validation. A DOOR output allows specific clinical questions to be asked with explainable predictions that can be feasibly implemented with limited computing resources. FUNDING National Institutes of Health-Institute of Allergy and Infectious Diseases.
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Affiliation(s)
- Gregory R Madden
- Division of Infectious Diseases & International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA; Office of Hospital Epidemiology/Infection Prevention & Control, University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Rachel H Boone
- Department of Microbiology, Immunology, and Cancer Biology, University of Virginia, Charlottesville, VA, USA
| | - Emmanuel Lee
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Costi D Sifri
- Division of Infectious Diseases & International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA; Office of Hospital Epidemiology/Infection Prevention & Control, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - William A Petri
- Department of Microbiology, Immunology, and Cancer Biology, University of Virginia, Charlottesville, VA, USA
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3
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van Rossen TM, van Beurden YH, Bogaards JA, Budding AE, Mulder CJJ, Vandenbroucke-Grauls CMJE. Fecal microbiota composition is a better predictor of recurrent Clostridioides difficile infection than clinical factors in a prospective, multicentre cohort study. BMC Infect Dis 2024; 24:687. [PMID: 38987677 PMCID: PMC11238444 DOI: 10.1186/s12879-024-09506-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 06/13/2024] [Indexed: 07/12/2024] Open
Abstract
INTRODUCTION Clostridioides difficile infection (CDI) is the most common cause of antibiotic-associated diarrhoea. Fidaxomicin and fecal microbiota transplantation (FMT) are effective, but expensive therapies to treat recurrent CDI (reCDI). Our objective was to develop a prediction model for reCDI based on the gut microbiota composition and clinical characteristics, to identify patients who could benefit from early treatment with fidaxomicin or FMT. METHODS Multicentre, prospective, observational study in adult patients diagnosed with a primary episode of CDI. Fecal samples and clinical data were collected prior to, and after 5 days of CDI treatment. Follow-up duration was 8 weeks. Microbiota composition was analysed by IS-pro, a bacterial profiling technique based on phylum- and species-specific differences in the 16-23 S interspace regions of ribosomal DNA. Bayesian additive regression trees (BART) and adaptive group-regularized logistic ridge regression (AGRR) were used to construct prediction models for reCDI. RESULTS 209 patients were included, of which 25% developed reCDI. Variables related to microbiota composition provided better prediction of reCDI and were preferentially selected over clinical factors in joint prediction models. Bacteroidetes abundance and diversity after start of CDI treatment, and the increase in Proteobacteria diversity relative to baseline, were the most robust predictors of reCDI. The sensitivity and specificity of a BART model including these factors were 95% and 78%, but these dropped to 67% and 62% in out-of-sample prediction. CONCLUSION Early microbiota response to CDI treatment is a better predictor of reCDI than clinical prognostic factors, but not yet sufficient enough to predict reCDI in daily practice.
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Affiliation(s)
- Tessel M van Rossen
- Department of Medical Microbiology & Infection Control, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
- Amsterdam Institute for Infection and Immunity, Amsterdam, The Netherlands.
- Department of Gastroenterology & Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
- Amsterdam Gastroenterology Endocrinology Metabolism Institute, Amsterdam, The Netherlands.
| | - Yvette H van Beurden
- Department of Gastroenterology & Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Johannes A Bogaards
- Amsterdam Institute for Infection and Immunity, Amsterdam, The Netherlands
- Department of Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam, The Netherlands
| | | | - Chris J J Mulder
- Department of Gastroenterology & Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism Institute, Amsterdam, The Netherlands
| | - Christina M J E Vandenbroucke-Grauls
- Department of Medical Microbiology & Infection Control, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Institute for Infection and Immunity, Amsterdam, The Netherlands
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
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4
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Escudero-Sanchez R, Ramos-Martínez A, Caballero-Bermejo AF, Díaz-Pollán B, Ruiz-Carrascoso G, Samperio MO, García PM, Amador PM, Romo FG, Segarra OM, Jiménez GN, Del Campo Albendea L, García AM, Cobo J. Bezlotoxumab during the first episode of Clostridioides difficile infection in patients at high risk of recurrence. Eur J Clin Microbiol Infect Dis 2024; 43:533-540. [PMID: 38236366 DOI: 10.1007/s10096-024-04762-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 01/12/2024] [Indexed: 01/19/2024]
Abstract
PURPOSE To describe a cohort with a high risk of recurrence who received bezlotoxumab during the first episode of Clostridioides difficile infection (CDI) and to compare this cohort with patients with similar characteristics who did not receive the monoclonal antibody. METHODS A prospective and multicentre study of patients with a high risk of recurrence (expected recurrence rate>35%) who were treated with bezlotoxumab during their first episode of CDI was conducted. A propensity score-matched model 1:2 was used to compare both cohorts that were weighed according to basal characteristics (hospital-acquisition, creatinine value, and fidaxomicin as a CDI treatment). RESULTS Sixty patients (mean age:72 years) were prospectively treated with bezlotoxumab plus anti-Clostridioides antibiotic therapy. Vancomycin (48 patients) and fidaxomicin (12 patients) were prescribed for CDI treatment, and bezlotoxumab was administered at a mean of 4.2 (SD:2.1) days from the beginning of therapy. Recurrence occurred in nine out of 54 (16.7%) evaluable patients at 8 weeks. Forty bezlotoxumab-treated patients were matched with 69 non-bezlotoxumab-treated patients. Recurrence rates at 12 weeks were 15.0% (6/40) in bezlotoxumab-treated patients vs. 23.2% (16/69) in non-bezlotoxumab-treated patients (OR:0.58 [0.20-1.65]). No adverse effects were observed related to bezlotoxumab infusion. Only one of 9 patients with previous heart failure developed heart failure. CONCLUSION We observed that patients treated with bezlotoxumab in a real-world setting during a first episode of CDI having high risk of recurrence, presented low rate of recurrence. However, a significant difference in recurrence could not be proved in comparison to the controls. We did not detect any other safety concerns.
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Affiliation(s)
- Rosa Escudero-Sanchez
- Infectious Disease Department, Ramon y Cajal University Hospital, Madrid, Spain.
- Instituto de Salud Carlos III (IRYCIS), Ctra. Colmenar viejo, km 9,1. Zip code, 28034, Madrid, Spain.
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain.
| | - Antonio Ramos-Martínez
- Internal Medicine Department, University Hospital Puerta de Hierro-Majadahonda, Madrid, Spain
| | | | - Beatriz Díaz-Pollán
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Infectious Diseases Unit, Internal Medicine Department, La Paz University Hospital, Madrid, Spain
- La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Guillermo Ruiz-Carrascoso
- La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
- Microbiology Department, La Paz University Hospital, Madrid, Spain
| | - María Olmedo Samperio
- Microbiology and Infectious Disease Department, Gregorio Marañón University Hospital, Madrid, Spain
| | - Patricia Muñoz García
- Microbiology and Infectious Disease Department, Gregorio Marañón University Hospital, Madrid, Spain
| | | | | | - Oriol Martín Segarra
- Infectious Disease Department, Fundación Alcorcon University Hospital, Madrid, Spain
| | - Gema Navarro Jiménez
- Infectious Disease Department, Fundación Alcorcon University Hospital, Madrid, Spain
| | - Laura Del Campo Albendea
- Biostatistics Unit, University Hospital Ramon y Cajal, Madrid, Spain
- Biomedical Research Networking Center for Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Alfonso Muriel García
- Biostatistics Unit, University Hospital Ramon y Cajal, Madrid, Spain
- Biomedical Research Networking Center for Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Universidad de Alcalá, Madrid, Spain
| | - Javier Cobo
- Infectious Disease Department, Ramon y Cajal University Hospital, Madrid, Spain
- Instituto de Salud Carlos III (IRYCIS), Ctra. Colmenar viejo, km 9,1. Zip code, 28034, Madrid, Spain
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
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5
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Li J, Chaudhary D, Sharma V, Sharma V, Avula V, Ssentongo P, Wolk DM, Zand R, Abedi V. An integrated pipeline for prediction of Clostridioides difficile infection. Sci Rep 2023; 13:16532. [PMID: 37783691 PMCID: PMC10545794 DOI: 10.1038/s41598-023-41753-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 08/31/2023] [Indexed: 10/04/2023] Open
Abstract
With the expansion of electronic health records(EHR)-linked genomic data comes the development of machine learning-enable models. There is a pressing need to develop robust pipelines to evaluate the performance of integrated models and minimize systemic bias. We developed a prediction model of symptomatic Clostridioides difficile infection(CDI) by integrating common EHR-based and genetic risk factors(rs2227306/IL8). Our pipeline includes (1) leveraging phenotyping algorithm to minimize temporal bias, (2) performing simulation studies to determine the predictive power in samples without genetic information, (3) propensity score matching to control for the confoundings, (4) selecting machine learning algorithms to capture complex feature interactions, (5) performing oversampling to address data imbalance, and (6) optimizing models and ensuring proper bias-variance trade-off. We evaluate the performance of prediction models of CDI when including common clinical risk factors and the benefit of incorporating genetic feature(s) into the models. We emphasize the importance of building a robust integrated pipeline to avoid systemic bias and thoroughly evaluating genetic features when integrated into the prediction models in the general population and subgroups.
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Affiliation(s)
- Jiang Li
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, PA, USA
| | - Durgesh Chaudhary
- Neuroscience Institute, Geisinger Health System, Danville, PA, USA
- Department of Neurology, College of Medicine, The Pennsylvania State University, Hershey, PA, 17033, USA
| | - Vaibhav Sharma
- Geisinger Commonwealth School of Medicine, Danville, PA, USA
| | - Vishakha Sharma
- College of Osteopathic Medicine, Kansas City University, Kansas City, MO, USA
| | - Venkatesh Avula
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, PA, USA
| | - Paddy Ssentongo
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Donna M Wolk
- Molecular and Microbial Diagnostics and Development, Geisinger Medical Center, Danville, PA, USA
| | - Ramin Zand
- Neuroscience Institute, Geisinger Health System, Danville, PA, USA
- Department of Neurology, College of Medicine, The Pennsylvania State University, Hershey, PA, 17033, USA
| | - Vida Abedi
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, PA, USA.
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, PA, USA.
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6
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Vázquez-Cuesta S, Lozano García N, Fernández AI, Olmedo M, Kestler M, Alcalá L, Marín M, Bermejo J, Díaz FFA, Muñoz P, Bouza E, Reigadas E. Microbiome profile and calprotectin levels as markers of risk of recurrent Clostridioides difficile infection. Front Cell Infect Microbiol 2023; 13:1237500. [PMID: 37780848 PMCID: PMC10534046 DOI: 10.3389/fcimb.2023.1237500] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/23/2023] [Indexed: 10/03/2023] Open
Abstract
Introduction Clostridioides difficile infection (CDI) is the main cause of nosocomial diarrhoea in developed countries. Recurrent CDI (R-CDI), which affects 20%-30% of patients and significantly increases hospital stay and associated costs, is a key challenge. The main objective of this study was to explore the role of the microbiome and calprotectin levels as predictive biomarkers of R-CDI. Methods We prospectively (2019-2021) included patients with a primary episode of CDI. Clinical data and faecal samples were collected. The microbiome was analysed by sequencing the hypervariable V4 region of the 16S rRNA gene on an Illumina Miseq platform. Results We enrolled 200 patients with primary CDI, of whom 54 developed R-CDI and 146 did not. We analysed 200 primary samples and found that Fusobacterium increased in abundance, while Collinsella, Senegalimassilia, Prevotella and Ruminococcus decreased in patients with recurrent versus non-recurrent disease. Elevated calprotectin levels correlated significantly with R-CDI (p=0.01). We built a risk index for R-CDI, including as prognostic factors age, sex, immunosuppression, toxin B amplification cycle, creatinine levels and faecal calprotectin levels (overall accuracy of 79%). Discussion Calprotectin levels and abundance of microbial genera such as Fusobacterium and Prevotella in primary episodes could be useful as early markers of R-CDI. We propose a readily available model for prediction of R-CDI that can be applied at the initial CDI episode. The use of this tool could help to better tailor treatments according to the risk of R-CDI.
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Affiliation(s)
- Silvia Vázquez-Cuesta
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Biochemistry and Molecular Biology Department, Faculty of Biology, Universidad Complutense de Madrid (UCM), Madrid, Spain
| | - Nuria Lozano García
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Ana I. Fernández
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - María Olmedo
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Martha Kestler
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
| | - Luis Alcalá
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en red de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - Mercedes Marín
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
- Centro de Investigación Biomédica en red de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - Javier Bermejo
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
- Centro de Investigación Biomédica en red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Francisco Fernández-Avilés Díaz
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
- Centro de Investigación Biomédica en red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
- Centro de Investigación Biomédica en red de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
- Centro de Investigación Biomédica en red de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - Elena Reigadas
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
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7
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Mullish BH, Martinez-Gili L, Chekmeneva E, Correia GDS, Lewis MR, Horneffer-Van Der Sluis V, Roberts LA, McDonald JAK, Pechlivanis A, Walters JRF, McClure EL, Marchesi JR, Allegretti JR. Assessing the clinical value of faecal bile acid profiling to predict recurrence in primary Clostridioides difficile infection. Aliment Pharmacol Ther 2022; 56:1556-1569. [PMID: 36250604 DOI: 10.1111/apt.17247] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 08/30/2022] [Accepted: 09/26/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Factors influencing recurrence risk in primary Clostridioides difficile infection (CDI) are poorly understood, and tools predicting recurrence are lacking. Perturbations in bile acids (BAs) contribute to CDI pathogenesis and may be relevant to primary disease prognosis. AIMS To define stool BA dynamics in patients with primary CDI and to explore signatures predicting recurrence METHODS: Weekly stool samples were collected from patients with primary CDI from the last day of anti-CDI therapy until recurrence or, otherwise, through 8 weeks post-completion. Ultra-high performance liquid chromatography-mass spectrometry was used to profile BAs. Stool bile salt hydrolase (BSH) activity was measured to determine primary BA bacterial deconjugation capacity. Multivariate and univariate models were used to define differential BA trajectories in patients with recurrence versus those without, and to assess faecal BAs as predictive markers for recurrence. RESULTS Twenty (36%) of 56 patients (median age: 57, 64% male) had recurrence; 80% of recurrences occurred within the first 9 days post-antibiotic treatment. Principal component analysis of stool BA profiles demonstrated clustering by recurrence status and post-treatment timepoint. Longitudinal faecal BA trajectories showed recovery of secondary BAs and their derivatives only in patients without recurrence. BSH activity increased over time only among non-relapsing patients (β = 0.056; likelihood ratio test p = 0.018). A joint longitudinal-survival model identified five stool BAs with area under the receiver operating characteristic curve >0.73 for predicting recurrence within 9 days post-CDI treatment. CONCLUSIONS Gut BA metabolism dynamics differ in primary CDI patients between those developing recurrence and those who do not. Individual BAs show promise as potential novel biomarkers to predict CDI recurrence.
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Affiliation(s)
- Benjamin H Mullish
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, St Mary's Hospital Campus, Imperial College London, London, UK.,Departments of Gastroenterology and Hepatology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Laura Martinez-Gili
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, St Mary's Hospital Campus, Imperial College London, London, UK.,Section of Bioinformatics, Division of Systems Medicine, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - Elena Chekmeneva
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, National Phenome Centre, IRDB Building, Hammersmith House Campus, Imperial College London, London, UK.,Section of Bioanalytical Chemistry, Division of Systems Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Gonçalo D S Correia
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, National Phenome Centre, IRDB Building, Hammersmith House Campus, Imperial College London, London, UK.,Section of Bioanalytical Chemistry, Division of Systems Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Matthew R Lewis
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, National Phenome Centre, IRDB Building, Hammersmith House Campus, Imperial College London, London, UK.,Section of Bioanalytical Chemistry, Division of Systems Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Verena Horneffer-Van Der Sluis
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, National Phenome Centre, IRDB Building, Hammersmith House Campus, Imperial College London, London, UK.,Section of Bioanalytical Chemistry, Division of Systems Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK.,Department for Diagnostics, Institute for Clinical Chemistry and Laboratory Medicine, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Lauren A Roberts
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, St Mary's Hospital Campus, Imperial College London, London, UK
| | - Julie A K McDonald
- MRC Centre for Molecular Bacteriology and Infection, Imperial College London, London, UK
| | - Alexandros Pechlivanis
- Section of Bioanalytical Chemistry, Division of Systems Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK.,Laboratory of Analytical Chemistry, Department of Chemistry, Aristotle University of Thessaloniki, Thessaloniki, Greece.,Biomic_Auth, Bioanalysis and Omics Laboratory, Center for Interdisciplinary Research and Innovation (CIRI-AUTH), Thessaloniki, Greece
| | - Julian R F Walters
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, St Mary's Hospital Campus, Imperial College London, London, UK.,Departments of Gastroenterology and Hepatology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Emma L McClure
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Julian R Marchesi
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, St Mary's Hospital Campus, Imperial College London, London, UK
| | - Jessica R Allegretti
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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8
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Ruzicka D, Kondo T, Fujimoto G, Craig AP, Kim SW, Mikamo H. Development of a clinical prediction model for recurrence and mortality outcomes after Clostridioides difficile infection using a machine learning approach. Anaerobe 2022; 77:102628. [PMID: 35985607 DOI: 10.1016/j.anaerobe.2022.102628] [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: 12/24/2021] [Revised: 06/29/2022] [Accepted: 08/10/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Clostridioides difficile infection (CDI) is associated with a large burden of morbidity and mortality worldwide. Previous studies have developed models for predicting recurrence and mortality following CDI, but no machine learning predictive models have been developed specifically using data from Japanese patients. METHODS Using a database of records from acute care hospitals in Japan, we extracted records from January 2012 to September 2016 (plus a 60-day lookback window). A total of 19,159 patients were included. We used a machine learning approach, XGBoost, and compared it to a traditional unregularized logistic regression model. The first 80% of the dataset (by patient index date) was used to optimize model hyperparameters and train the final models, and evaluation was performed on the remaining 20%. We measured model performance by the area under the receiver operator curve and assessed feature importance using Shapley additive explanations. RESULTS Performance was similar between the machine learning approach and the classical logistic regression model. Logistic regression performed slightly better than XGBoost for predicting mortality. CONCLUSION XGBoost performed slightly better than logistic regression for predicting recurrence, but it was not competitive with existing published models. Despite this, a future machine learning-based application provided in a bedside setting at low cost might be a clinically useful tool.
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Affiliation(s)
- Daniel Ruzicka
- Medical Affairs, MSD K.K., Tokyo, Japan, Kitanomaru Square, 1-13-12 Kudan-kita, Chiyoda-ku, Tokyo, 102-8667, Japan
| | - Takayuki Kondo
- Medical Affairs, MSD K.K., Tokyo, Japan, Kitanomaru Square, 1-13-12 Kudan-kita, Chiyoda-ku, Tokyo, 102-8667, Japan.
| | - Go Fujimoto
- Medical Affairs, MSD K.K., Tokyo, Japan, Kitanomaru Square, 1-13-12 Kudan-kita, Chiyoda-ku, Tokyo, 102-8667, Japan
| | - Andrew P Craig
- Real World Evidence Solutions, IQVIA Solutions Japan K.K., Takanawa 4-10-18, Minato-ku, Tokyo, 108-0074, Japan
| | - Seok-Won Kim
- Real World Evidence Solutions, IQVIA Solutions Japan K.K., Takanawa 4-10-18, Minato-ku, Tokyo, 108-0074, Japan
| | - Hiroshige Mikamo
- Department of Clinical Infectious Diseases, Aichi Medical University Graduate School of Medicine, 1-1, Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
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9
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Dawkins JJ, Allegretti JR, Gibson TE, McClure E, Delaney M, Bry L, Gerber GK. Gut metabolites predict Clostridioides difficile recurrence. MICROBIOME 2022; 10:87. [PMID: 35681218 PMCID: PMC9178838 DOI: 10.1186/s40168-022-01284-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/02/2022] [Indexed: 05/10/2023]
Abstract
BACKGROUND Clostridioides difficile infection (CDI) is the most common hospital acquired infection in the USA, with recurrence rates > 15%. Although primary CDI has been extensively linked to gut microbial dysbiosis, less is known about the factors that promote or mitigate recurrence. Moreover, previous studies have not shown that microbial abundances in the gut measured by 16S rRNA amplicon sequencing alone can accurately predict CDI recurrence. RESULTS We conducted a prospective, longitudinal study of 53 non-immunocompromised participants with primary CDI. Stool sample collection began pre-CDI antibiotic treatment at the time of diagnosis, and continued up to 8 weeks post-antibiotic treatment, with weekly or twice weekly collections. Samples were analyzed using (1) 16S rRNA amplicon sequencing, (2) liquid chromatography/mass-spectrometry metabolomics measuring 1387 annotated metabolites, and (3) short-chain fatty acid profiling. The amplicon sequencing data showed significantly delayed recovery of microbial diversity in recurrent participants, and depletion of key anaerobic taxa at multiple time-points, including Clostridium cluster XIVa and IV taxa. The metabolomic data also showed delayed recovery in recurrent participants, and moreover mapped to pathways suggesting distinct functional abnormalities in the microbiome or host, such as decreased microbial deconjugation activity, lowered levels of endocannabinoids, and elevated markers of host cell damage. Further, using predictive statistical/machine learning models, we demonstrated that the metabolomic data, but not the other data sources, can accurately predict future recurrence at 1 week (AUC 0.77 [0.71, 0.86; 95% interval]) and 2 weeks (AUC 0.77 [0.69, 0.85; 95% interval]) post-treatment for primary CDI. CONCLUSIONS The prospective, longitudinal, and multi-omic nature of our CDI recurrence study allowed us to uncover previously unrecognized dynamics in the microbiome and host presaging recurrence, and, in particular, to elucidate changes in the understudied gut metabolome. Moreover, we demonstrated that a small set of metabolites can accurately predict future recurrence. Our findings have implications for development of diagnostic tests and treatments that could ultimately short-circuit the cycle of CDI recurrence, by providing candidate metabolic biomarkers for diagnostics development, as well as offering insights into the complex microbial and metabolic alterations that are protective or permissive for recurrence. Video Abstract.
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Affiliation(s)
- Jennifer J. Dawkins
- Department of Pathology, Brigham & Woman’s Hospital, Harvard Medical School, Boston, MA USA
- Harvard-MIT Health Sciences & Technology, Harvard Medical School, MIT, Cambridge, MA USA
| | - Jessica R. Allegretti
- Massachusetts Host-Microbiome Center, Boston, MA USA
- Division of Gastroenterology, Brigham & Woman’s Hospital, Harvard Medical School, Boston, MA USA
| | - Travis E. Gibson
- Department of Pathology, Brigham & Woman’s Hospital, Harvard Medical School, Boston, MA USA
| | - Emma McClure
- Division of Gastroenterology, Brigham & Woman’s Hospital, Harvard Medical School, Boston, MA USA
| | - Mary Delaney
- Massachusetts Host-Microbiome Center, Boston, MA USA
| | - Lynn Bry
- Department of Pathology, Brigham & Woman’s Hospital, Harvard Medical School, Boston, MA USA
- Massachusetts Host-Microbiome Center, Boston, MA USA
| | - Georg K. Gerber
- Department of Pathology, Brigham & Woman’s Hospital, Harvard Medical School, Boston, MA USA
- Harvard-MIT Health Sciences & Technology, Harvard Medical School, MIT, Cambridge, MA USA
- Massachusetts Host-Microbiome Center, Boston, MA USA
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10
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OUP accepted manuscript. J Antimicrob Chemother 2022; 77:1996-2002. [DOI: 10.1093/jac/dkac106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 03/07/2022] [Indexed: 11/12/2022] Open
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11
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Rao K, Dubberke ER. Can prediction scores be used to identify patients at risk of Clostridioides difficile infection? Curr Opin Gastroenterol 2022; 38:7-14. [PMID: 34628418 DOI: 10.1097/mog.0000000000000793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW To describe the current state of literature on modeling risk of incident and recurrent Clostridioides difficile infection (iCDI and rCDI), to underscore limitations, and to propose a path forward for future research. RECENT FINDINGS There are many published risk factors and models for both iCDI and rCDI. The approaches include scores with a limited list of variables designed to be used at the bedside, but more recently have also included automated tools that take advantage of the entire electronic health record. Recent attempts to externally validate scores have met with mixed success. SUMMARY For iCDI, the performance largely hinges on the incidence, which even for hospitalized patients can be low (often <1%). Most scores fail to achieve high accuracy and/or are not externally validated. A challenge in predicting rCDI is the significant overlap with risk factors for iCDI, reducing the discriminatory ability of models. Automated electronic health record-based tools show promise but portability to other centers is challenging. Future studies should include external validation and consider biomarkers to augment performance.
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Affiliation(s)
- Krishna Rao
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Erik R Dubberke
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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12
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van Prehn J, Reigadas E, Vogelzang EH, Bouza E, Hristea A, Guery B, Krutova M, Norén T, Allerberger F, Coia JE, Goorhuis A, van Rossen TM, Ooijevaar RE, Burns K, Scharvik Olesen BR, Tschudin-Sutter S, Wilcox MH, Vehreschild MJGT, Fitzpatrick F, Kuijper EJ. European Society of Clinical Microbiology and Infectious Diseases: 2021 update on the treatment guidance document for Clostridioides difficile infection in adults. Clin Microbiol Infect 2021; 27 Suppl 2:S1-S21. [PMID: 34678515 DOI: 10.1016/j.cmi.2021.09.038] [Citation(s) in RCA: 248] [Impact Index Per Article: 82.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 09/23/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022]
Abstract
SCOPE In 2009, the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) published the first treatment guidance document for Clostridioides difficile infection (CDI). This document was updated in 2014. The growing literature on CDI antimicrobial treatment and novel treatment approaches, such as faecal microbiota transplantation (FMT) and toxin-binding monoclonal antibodies, prompted the ESCMID study group on C. difficile (ESGCD) to update the 2014 treatment guidance document for CDI in adults. METHODS AND QUESTIONS Key questions on CDI treatment were formulated by the guideline committee and included: What is the best treatment for initial, severe, severe-complicated, refractory, recurrent and multiple recurrent CDI? What is the best treatment when no oral therapy is possible? Can prognostic factors identify patients at risk for severe and recurrent CDI and is there a place for CDI prophylaxis? Outcome measures for treatment strategy were: clinical cure, recurrence and sustained cure. For studies on surgical interventions and severe-complicated CDI the outcome was mortality. Appraisal of available literature and drafting of recommendations was performed by the guideline drafting group. The total body of evidence for the recommendations on CDI treatment consists of the literature described in the previous guidelines, supplemented with a systematic literature search on randomized clinical trials and observational studies from 2012 and onwards. The Grades of Recommendation Assessment, Development and Evaluation (GRADE) system was used to grade the strength of our recommendations and the quality of the evidence. The guideline committee was invited to comment on the recommendations. The guideline draft was sent to external experts and a patients' representative for review. Full ESCMID endorsement was obtained after a public consultation procedure. RECOMMENDATIONS Important changes compared with previous guideline include but are not limited to: metronidazole is no longer recommended for treatment of CDI when fidaxomicin or vancomycin are available, fidaxomicin is the preferred agent for treatment of initial CDI and the first recurrence of CDI when available and feasible, FMT or bezlotoxumab in addition to standard of care antibiotics (SoC) are preferred for treatment of a second or further recurrence of CDI, bezlotoxumab in addition to SoC is recommended for the first recurrence of CDI when fidaxomicin was used to manage the initial CDI episode, and bezlotoxumab is considered as an ancillary treatment to vancomycin for a CDI episode with high risk of recurrence when fidaxomicin is not available. Contrary to the previous guideline, in the current guideline emphasis is placed on risk for recurrence as a factor that determines treatment strategy for the individual patient, rather than the disease severity.
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Affiliation(s)
- Joffrey van Prehn
- Department of Medical Microbiology, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Elena Reigadas
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Erik H Vogelzang
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Adriana Hristea
- University of Medicine and Pharmacy Carol Davila, National Institute for Infectious Diseases Prof Dr Matei Bals, Romania
| | - Benoit Guery
- Infectious Diseases Specialist, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Marcela Krutova
- Department of Medical Microbiology, Charles University in Prague and Motol University Hospital, Czech Republic
| | - Torbjorn Norén
- Faculty of Medicine and Health, Department of Laboratory Medicine, National Reference Laboratory for Clostridioides difficile, Clinical Microbiology, Örebro University Hospital, Örebro, Sweden
| | | | - John E Coia
- Department of Clinical Microbiology, Hospital South West Jutland and Department of Regional Health Research IRS, University of Southern Denmark, Esbjerg, Denmark
| | - Abraham Goorhuis
- Department of Infectious Diseases, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Tessel M van Rossen
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Rogier E Ooijevaar
- Department of Gastroenterology, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Karen Burns
- Departments of Clinical Microbiology, Beaumont Hospital & Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Sarah Tschudin-Sutter
- Department of Infectious Diseases and Infection Control, University Hospital Basel, University Basel, Universitatsspital, Basel, Switzerland
| | - Mark H Wilcox
- Department of Microbiology, Old Medical, School Leeds General Infirmary, Leeds Teaching Hospitals & University of Leeds, Leeds, United Kingdom
| | - Maria J G T Vehreschild
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany; Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Fidelma Fitzpatrick
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland; Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ed J Kuijper
- Department of Medical Microbiology, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands; National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands.
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van Rossen TM, Ooijevaar RE, Vandenbroucke-Grauls CMJE, Dekkers OM, Kuijper EJ, Keller JJ, van Prehn J. Prognostic factors for severe and recurrent Clostridioides difficile infection: a systematic review. Clin Microbiol Infect 2021; 28:321-331. [PMID: 34655745 DOI: 10.1016/j.cmi.2021.09.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/24/2021] [Accepted: 09/25/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Clostridioides difficile infection (CDI), its subsequent recurrences (rCDIs), and severe CDI (sCDI) provide a significant burden for both patients and the healthcare system. Identifying patients diagnosed with initial CDI who are at increased risk of developing sCDI/rCDI could lead to more cost-effective therapeutic choices. In this systematic review we aimed to identify clinical prognostic factors associated with an increased risk of developing sCDI or rCDI. METHODS PubMed, Embase, Emcare, Web of Science and COCHRANE Library databases were searched from database inception through March, 2021. The study eligibility criteria were cohort and case-control studies. Participants were patients ≥18 years old diagnosed with CDI, in which clinical or laboratory factors were analysed to predict sCDI/rCDI. Risk of bias was assessed by using the Quality in Prognostic Research (QUIPS) tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool modified for prognostic studies. Study selection was performed by two independent reviewers. Overview tables of prognostic factors were constructed to assess the number of studies and the respective effect direction and statistical significance of an association. RESULTS 136 studies were included for final analysis. Greater age and the presence of multiple comorbidities were prognostic factors for sCDI. Identified risk factors for rCDI were greater age, healthcare-associated CDI, prior hospitalization, proton pump inhibitors (PPIs) started during or after CDI diagnosis, and previous rCDI. CONCLUSIONS Prognostic factors for sCDI and rCDI could aid clinicians to make treatment decisions based on risk stratification. We suggest that future studies use standardized definitions for sCDI/rCDI and systematically collect and report the risk factors assessed in this review, to allow for meaningful meta-analysis of risk factors using data of high-quality trials.
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Affiliation(s)
- Tessel M van Rossen
- Amsterdam UMC, VU University Medical Center, Medical Microbiology & Infection Control, Amsterdam Infection & Immunity, Amsterdam, the Netherlands.
| | - Rogier E Ooijevaar
- Amsterdam UMC, VU University Medical Center, Gastroenterology & Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands.
| | - Christina M J E Vandenbroucke-Grauls
- Amsterdam UMC, VU University Medical Center, Medical Microbiology & Infection Control, Amsterdam Infection & Immunity, Amsterdam, the Netherlands; Aarhus University, Clinical Epidemiology, Aarhus, Denmark
| | - Olaf M Dekkers
- Leiden University Medical Center, Clinical Epidemiology, Leiden, the Netherlands
| | - Ed J Kuijper
- Leiden University Medical Center, Center for Infectious Diseases, Medical Microbiology, Leiden, the Netherlands
| | - Josbert J Keller
- Haaglanden Medical Center, Gastroenterology & Hepatology, The Hague, the Netherlands; Leiden University Medical Center, Gastroenterology & Hepatology, Leiden, the Netherlands
| | - Joffrey van Prehn
- Leiden University Medical Center, Center for Infectious Diseases, Medical Microbiology, Leiden, the Netherlands
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14
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Kelly CP, Poxton IR, Shen J, Wilcox MH, Gerding DN, Zhao X, Laterza OF, Railkar R, Guris D, Dorr MB. Effect of Endogenous Clostridioides difficile Toxin Antibodies on Recurrence of C. difficile Infection. Clin Infect Dis 2021; 71:81-86. [PMID: 31628838 DOI: 10.1093/cid/ciz809] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 09/30/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Endogenous antibodies (eAbs) against Clostridioides (Clostridium) difficile toxins may protect against recurrence of C. difficile infection (rCDI). This hypothesis was tested using placebo group data from MODIFY (Monoclonal Antibodies for C. difficile Therapy) I and II (NCT01241552 and NCT01513239, respectively), global, randomized phase 3 trials that assessed the efficacy and safety of the antitoxin monoclonal antibodies bezlotoxumab and actoxumab in participants receiving antibiotic therapy for CDI. METHODS A placebo infusion (normal saline) was administered on study day 1. Serum samples were collected on day 1, week 4, and week 12, and eAb-A and eAb-B titers were measured by 2 validated electrochemiluminescence immunoassays. Rates of initial clinical cure and rCDI were summarized by eAb titer category (low, medium, high) at each time point. RESULTS Serum eAb titers were available from a total of 773 participants. The proportion of participants with high eAb-A and eAb-B titers increased over time. Rates of initial clinical cure were similar across eAb titer categories. There was no correlation between eAb-A titers and rCDI rate at any time point. However, there was a negative correlation between rCDI and eAb-B titer on day 1 and week 4. rCDI occurred in 22% of participants with high eAb-B titers at baseline compared with 35% with low or medium titers (P = .015). CONCLUSIONS Higher eAb titers against toxin B, but not toxin A, were associated with protection against rCDI. These data are consistent with the observed efficacy of bezlotoxumab, and lack of efficacy of actoxumab, in the MODIFY trials. CLINICAL TRIALS REGISTRATION NCT01241552 and NCT01513239.
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Affiliation(s)
- Ciarán P Kelly
- Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ian R Poxton
- University of Edinburgh, Edinburgh, United Kingdom
| | | | - Mark H Wilcox
- Leeds Teaching Hospitals and University of Leeds, United Kingdom
| | - Dale N Gerding
- Loyola University Chicago Stritch School of Medicine, Maywood.,Edward Hines Jr Veterans Affairs Hospital, Hines, Illinois
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15
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van Rossen TM, van Dijk LJ, Heymans MW, Dekkers OM, Vandenbroucke-Grauls CMJE, van Beurden YH. External validation of two prediction tools for patients at risk for recurrent Clostridioides difficile infection. Therap Adv Gastroenterol 2021; 14:1756284820977385. [PMID: 33456500 PMCID: PMC7797589 DOI: 10.1177/1756284820977385] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/03/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND One in four patients with primary Clostridioides difficile infection (CDI) develops recurrent CDI (rCDI). With every recurrence, the chance of a subsequent CDI episode increases. Early identification of patients at risk for rCDI might help doctors to guide treatment. The aim of this study was to externally validate published clinical prediction tools for rCDI. METHODS The validation cohort consisted of 129 patients, diagnosed with CDI between 2018 and 2020. rCDI risk scores were calculated for each individual patient in the validation cohort using the scoring tools described in the derivation studies. Per score value, we compared the average predicted risk of rCDI with the observed number of rCDI cases. Discrimination was assessed by calculating the area under the receiver operating characteristic curve (AUC). RESULTS Two prediction tools were selected for validation (Cobo 2018 and Larrainzar-Coghen 2016). The two derivation studies used different definitions for rCDI. Using Cobo's definition, rCDI occurred in 34 patients (26%) of the validation cohort: using the definition of Larrainzar-Coghen, we observed 19 recurrences (15%). The performance of both prediction tools was poor when applied to our validation cohort. The estimated AUC was 0.43 [95% confidence interval (CI); 0.32-0.54] for Cobo's tool and 0.42 (95% CI; 0.28-0.56) for Larrainzar-Coghen's tool. CONCLUSION Performance of both prediction tools was disappointing in the external validation cohort. Currently identified clinical risk factors may not be sufficient for accurate prediction of rCDI.
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Affiliation(s)
- Tessel M. van Rossen
- Amsterdam UMC, Vrije Universiteit Amsterdam, Medical Microbiology and Infection Control, Amsterdam Infection and Immunity Institute, Amsterdam UMC location VUmc, PK 2X132, De Boelelaan 1117, Amsterdam, 1081 HV, The Netherlands
| | - Laura J. van Dijk
- Amsterdam UMC, Vrije Universiteit Amsterdam, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Institute, Amsterdam, The Netherlands
| | - Martijn W. Heymans
- Amsterdam UMC, Vrije Universiteit Amsterdam, Epidemiology and Data Science, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Olaf M. Dekkers
- Leiden University Medical Center, Clinical Epidemiology, Leiden, The Netherlands
| | - Christina M. J. E. Vandenbroucke-Grauls
- Amsterdam UMC, Vrije Universiteit Amsterdam, Medical Microbiology and Infection Control, Amsterdam Infection and Immunity Institute, Amsterdam, The Netherlands
| | - Yvette H. van Beurden
- Amsterdam UMC, Vrije Universiteit Amsterdam, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Institute, Amsterdam, The Netherlands
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16
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Escudero-Sánchez R, Valencia-Alijo A, Cuéllar Tovar S, Merino-de Lucas E, García Fernández S, Gutiérrez-Rojas Á, Ramos-Martínez A, Salavert Lletí M, Castro Hernández I, Giner L, Cobo J. Real-life experience with fidaxomicin in Clostridioides difficile infection: a multicentre cohort study on 244 episodes. Infection 2021; 49:475-482. [PMID: 33417171 DOI: 10.1007/s15010-020-01567-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 12/14/2020] [Indexed: 02/08/2023]
Abstract
The high cost of fidaxomicin has restricted its use despite the benefit of a lower Clostridioides difficile infection (CDI) recurrence rate at 4 weeks of follow-up. This short follow-up represents the main limitation of pivotal clinical trials of fidaxomicin, and some recent studies question its benefits over vancomycin. Moreover, the main risk factors of recurrence after treatment with fidaxomicin remain unknown. We designed a multicentre retrospective cohort study among four Spanish hospitals to assess the efficacy of fidaxomicin in real life and to investigate risk factors of fidaxomicin failure at weeks 8 and 12. Two-hundred forty-four patients were included. Fidaxomicin was used in 96 patients (39.3%) for a first episode of CDI, in 95 patients (38.9%) for a second episode, and in 53 patients (21.7%) for a third or subsequent episode. Patients treated with fidaxomicin in a first episode were younger (59.9 years vs 73.5 years), but they had more severe episodes (52.1% vs. 32.4%). The recurrence rates for patients treated in the first episode were 6.5% and 9.7% at weeks 8 and 12, respectively. Recurrence rates increased for patients treated at second or ulterior episodes (16.3% and 26.4% at week 8, respectively). Age greater than or equal to 85 years and having had a previous episode of CDI were identified as recurrence risk factors at weeks 8 and 12. We conclude that the outcomes with fidaxomicin in real life are at least as good as those observed in clinical trials despite a more demanding evaluation. Be it 85 years of age or older, and the use after a first episode appears to be independent factors of CDI recurrence after treatment with fidaxomicin.
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Affiliation(s)
- Rosa Escudero-Sánchez
- Infectious Disease Department, University Hospital Ramon Y Cajal, Ctra. Colmenar Viejo, Km 9,1. Zip code 28034, Madrid, Spain. .,Spanish Network for Research in Infectious Disease (REIPI), Madrid, Spain.
| | - Angela Valencia-Alijo
- Internal Medicine Department, University Hospital Puerta de Hierro-Majadahonda, Madrid, Spain
| | | | | | - Sergio García Fernández
- Spanish Network for Research in Infectious Disease (REIPI), Madrid, Spain.,Microbiology Department, University Hospital Ramón Y Cajal, Madrid, Spain
| | - Ángela Gutiérrez-Rojas
- Internal Medicine Department, University Hospital Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Antonio Ramos-Martínez
- Internal Medicine Department, University Hospital Puerta de Hierro-Majadahonda, Madrid, Spain
| | | | | | - Livia Giner
- Internal Medicine Department, University Hospital General de Alicante, Alicante, Spain
| | - Javier Cobo
- Infectious Disease Department, University Hospital Ramon Y Cajal, Ctra. Colmenar Viejo, Km 9,1. Zip code 28034, Madrid, Spain.,Spanish Network for Research in Infectious Disease (REIPI), Madrid, Spain
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Bermejo Boixareu C, Tutor-Ureta P, Ramos Martínez A. [Updated review of Clostridium difficile infection in elderly]. Rev Esp Geriatr Gerontol 2020; 55:225-235. [PMID: 32423602 DOI: 10.1016/j.regg.2019.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 12/10/2019] [Accepted: 12/19/2019] [Indexed: 06/11/2023]
Abstract
Clostridium difficile infection is the most common cause of health care-associated diarrhoea, and its incidence increases with age. Clinical challenges, risk of resistance to treatment, risk of recurrence, and treatment responses are different in elderly. The aim of this review is to discuss the updated epidemiology, pathophysiology, diagnosis, and therapeutic management of C. difficile infection in elderly with the available data.
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Affiliation(s)
| | - Pablo Tutor-Ureta
- Servicio de Medicina Interna, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | - Antonio Ramos Martínez
- Servicio de Medicina Interna, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
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Clinical Predictors of Recurrence After Primary Clostridioides difficile Infection: A Prospective Cohort Study. Dig Dis Sci 2020; 65:1761-1766. [PMID: 31667694 PMCID: PMC8630805 DOI: 10.1007/s10620-019-05900-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 10/10/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Recurrent Clostridioides difficile infection (CDI) is a major public health threat. While clinical prediction tools exist, they do not incorporate the newest Infectious Diseases Society of America guidelines. METHODS This was a prospective longitudinal study of patients experiencing their first episode of uncomplicated CDI. Patients were followed from diagnosis through 8 weeks post-completion of their anti-CDI therapy to assess recurrence. Stool was collected at diagnosis and weekly for 8 weeks following treatment. Recurrence was defined as diarrhea as well as a positive stool test by toxin EIA (EIA) for C. difficile. Fisher's exact test for binary variables and Student's t test for continuous variables were performed. Cox regression was performed to assess for predictors of CDI recurrence. RESULTS Seventy-five patients were enrolled between August 1, 2015, and September 1, 2018. Mean age 58.1 years ± 15.5, 69.3% female, 74.7% were white, 11.3% had baseline irritable bowel syndrome, and 54.7% were actively using PPIs. Over the 8-week follow-up period, 22 patients developed a confirmed CDI recurrence. Univariate predictors of recurrence included treatment with metronidazole (40.9% vs 15.1%, p = 0.03), initially diagnosis by EIA (77.3% vs 43.4%, p = 0.007) and platelet count (206 ± 72.1 vs 270.9 ± 114.8, p = 0.03). A Cox regression model revealed primary diagnosis by EIA (HR 3.39, 95% CI 1.23, 9.31, p = 0.018) and treatment with metronidazole (HR 3.27 95% CI 1.31-8.19, p = 0.01) remain predictors for CDI recurrence. CONCLUSION In a large prospective longitudinal cohort of uncomplicated CDI patients, treatment with metronidazole and diagnosis via EIA were the most robust predictors of CDI recurrence.
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Bouza E, Aguado JM, Alcalá L, Almirante B, Alonso-Fernández P, Borges M, Cobo J, Guardiola J, Horcajada JP, Maseda E, Mensa J, Merchante N, Muñoz P, Pérez Sáenz JL, Pujol M, Reigadas E, Salavert M, Barberán J. Recommendations for the diagnosis and treatment of Clostridioides difficile infection: An official clinical practice guideline of the Spanish Society of Chemotherapy (SEQ), Spanish Society of Internal Medicine (SEMI) and the working group of Postoperative Infection of the Spanish Society of Anesthesia and Reanimation (SEDAR). REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2020; 33:151-175. [PMID: 32080996 PMCID: PMC7111242 DOI: 10.37201/req/2065.2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 01/26/2020] [Indexed: 12/12/2022]
Abstract
This document gathers the opinion of a multidisciplinary forum of experts on different aspects of the diagnosis and treatment of Clostridioides difficile infection (CDI) in Spain. It has been structured around a series of questions that the attendees considered relevant and in which a consensus opinion was reached. The main messages were as follows: CDI should be suspected in patients older than 2 years of age in the presence of diarrhea, paralytic ileus and unexplained leukocytosis, even in the absence of classical risk factors. With a few exceptions, a single stool sample is sufficient for diagnosis, which can be sent to the laboratory with or without transportation media for enteropathogenic bacteria. In the absence of diarrhoea, rectal swabs may be valid. The microbiology laboratory should include C. difficile among the pathogens routinely searched in patients with diarrhoea. Laboratory tests in different order and sequence schemes include GDH detection, presence of toxins, molecular tests and toxigenic culture. Immediate determination of sensitivity to drugs such as vancomycin, metronidazole or fidaxomycin is not required. The evolution of toxin persistence is not a suitable test for follow up. Laboratory diagnosis of CDI should be rapid and results reported and interpreted to clinicians immediately. In addition to the basic support of all diarrheic episodes, CDI treatment requires the suppression of antiperistaltic agents, proton pump inhibitors and antibiotics, where possible. Oral vancomycin and fidaxomycin are the antibacterials of choice in treatment, intravenous metronidazole being restricted for patients in whom the presence of the above drugs in the intestinal lumen cannot be assured. Fecal material transplantation is the treatment of choice for patients with multiple recurrences but uncertainties persist regarding its standardization and safety. Bezlotoxumab is a monoclonal antibody to C. difficile toxin B that should be administered to patients at high risk of recurrence. Surgery is becoming less and less necessary and prevention with vaccines is under research. Probiotics have so far not been shown to be therapeutically or preventively effective. The therapeutic strategy should be based, rather than on the number of episodes, on the severity of the episodes and on their potential to recur. Some data point to the efficacy of oral vancomycin prophylaxis in patients who reccur CDI when systemic antibiotics are required again.
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Affiliation(s)
- E Bouza
- Emilio Bouza MD, PhD, Instituto de Investigación Sanitaria Gregorio Marañón, Servicio de Microbiología Clínica y E. Infecciosas C/ Dr. Esquerdo, 46 - 28007 Madrid, Spain.
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Clostridium difficile infection in oncohematologic patients. Med Clin (Barc) 2019; 153:e54. [PMID: 30981437 DOI: 10.1016/j.medcli.2019.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 01/17/2019] [Indexed: 11/24/2022]
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Recurrent community-acquired Clostridium(Clostridioides)difficile infection in Serbianchildren. Eur J Clin Microbiol Infect Dis 2019; 39:509-516. [PMID: 31713000 DOI: 10.1007/s10096-019-03751-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 10/24/2019] [Indexed: 12/18/2022]
Abstract
Information on recurrent Clostridium difficile infections (rCDI) in children is rare and limited, especially community acquired (CA-CDI).This study was designed to identify risk factors for rCA-CDI in Serbian pediatric population. The study group included 71 children (aged from 1 to 14 years) with a first episode of CDI. Data were collected from 56 (78.87%) children with only one episode of CA-CDI and from 15 (21.13%) children with rCA-CDI were mutually compared. The following parameters were found to be statistically significantly more frequent in the children with rCA-CDI group (p < 0.05); leukemia as underlying disease, treatment with immunosuppressive and-or cytostatic drugs, and treatment with antibiotics. Similarly, previously visits to outpatient facilities, daycare hospitals and hospitals were also associated with rCDI. Analysis of clinical symptoms and laboratory parameters, revealed a statistically significant association of the severity of the first episode of CDI (determined by an increase in body temperature, higher maximum WBC and higher CRP) with development of a rCDI. Ribotype (RT) 027 was more common in children with rCA-CDI (66.7%, p = 0.006). During the seven-year research period, we found a rate of rCA-CDI rate in children of 21.13%. Our study identified several parameters statistically significantly more frequently in children with rCA-CDI. The obtained results will serve as a basis for future larger studies, but new prospective, studies are necessary to build a prediction model of rCDI in children that can be used to guide the treatment to prevent rCDI.
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Major G, Bradshaw L, Boota N, Sprange K, Diggle M, Montgomery A, Jawhari A, Spiller RC. Follow-on RifAximin for the Prevention of recurrence following standard treatment of Infection with Clostridium Difficile (RAPID): a randomised placebo controlled trial. Gut 2019; 68:1224-1231. [PMID: 30254135 PMCID: PMC6582824 DOI: 10.1136/gutjnl-2018-316794] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) recurs after initial treatment in approximately one in four patients. A single-centre pilot study suggested that this could be reduced using 'follow-on' rifaximin treatment. We aimed to assess the efficacy of rifaximin treatment in preventing recurrence. METHODS A multisite, parallel group, randomised, placebo controlled trial recruiting patients aged ≥18 years immediately after resolution of CDI through treatment with metronidazole or vancomycin. Participants received either rifaximin 400 mg three times a day for 2 weeks, reduced to 200 mg three times a day for a further 2 weeks or identical placebo. The primary endpoint was recurrence of CDI within 12 weeks of trial entry. RESULTS Between December 2012 and March 2016, 151 participants were randomised to either rifaximin or placebo. Primary outcome data were available on 130. Mean age was 71.9 years (SD 15.3). Recurrence within 12 weeks was 29.5% (18/61) among participants allocated to placebo compared with 15.9% (11/69) among those allocated to rifaximin, a difference between groups of 13.7% (95% CI -28.1% to 0.7%, p=0.06). The risk ratio was 0.54 (95% CI 0.28 to 1.05, p=0.07). During 6-month safety follow-up, nine participants died in each group (12%). Adverse event rates were similar between groups. CONCLUSION While 'follow-on' rifaximin after CDI appeared to halve recurrence rate, we failed to reach our recruitment target in this group of frail elderly patients, so the estimated effect of rifaximin lacks precision. A meta-analysis including a previous trial suggests that rifaximin may be effective; however, further, larger confirmatory studies are needed.
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Affiliation(s)
- Giles Major
- Nottingham Digestive Diseases Centre and NIHR Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust, the University of Nottingham, Nottingham, Notts, UK
| | - Lucy Bradshaw
- Nottingham Clinical Trials Unit (NCTU), University of Nottingham, Nottingham, UK
| | - Nafisa Boota
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Kirsty Sprange
- Nottingham Clinical Trials Unit (NCTU), University of Nottingham, Nottingham, UK
| | - Mathew Diggle
- Clinical Microbiology Department, Nottingham University Hospitals NHS Trust, Nottingham, Nottinghamshire, UK
| | - Alan Montgomery
- Nottingham Clinical Trials Unit (NCTU), University of Nottingham, Nottingham, UK
| | - Aida Jawhari
- Clinical Microbiology Department, Nottingham University Hospitals NHS Trust, Nottingham, Nottinghamshire, UK
| | - Robin C Spiller
- Nottingham Digestive Diseases Centre and NIHR Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust, the University of Nottingham, Nottingham, Notts, UK
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Li BY, Oh J, Young VB, Rao K, Wiens J. Using Machine Learning and the Electronic Health Record to Predict Complicated Clostridium difficile Infection. Open Forum Infect Dis 2019; 6:ofz186. [PMID: 31139672 PMCID: PMC6527086 DOI: 10.1093/ofid/ofz186] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 04/13/2019] [Indexed: 02/06/2023] Open
Abstract
Background Clostridium (Clostridioides) difficile infection (CDI) is a health care–associated infection that can lead to serious complications. Potential complications include intensive care unit (ICU) admission, development of toxic megacolon, need for colectomy, and death. However, identifying the patients most likely to develop complicated CDI is challenging. To this end, we explored the utility of a machine learning (ML) approach for patient risk stratification for complications using electronic health record (EHR) data. Methods We considered adult patients diagnosed with CDI between October 2010 and January 2013 at the University of Michigan hospitals. Cases were labeled complicated if the infection resulted in ICU admission, colectomy, or 30-day mortality. Leveraging EHR data, we trained a model to predict subsequent complications on each of the 3 days after diagnosis. We compared our EHR-based model to one based on a small set of manually curated features. We evaluated model performance using a held-out data set in terms of the area under the receiver operating characteristic curve (AUROC). Results Of 1118 cases of CDI, 8% became complicated. On the day of diagnosis, the model achieved an AUROC of 0.69 (95% confidence interval [CI], 0.55–0.83). Using data extracted 2 days after CDI diagnosis, performance increased (AUROC, 0.90; 95% CI, 0.83–0.95), outperforming a model based on a curated set of features (AUROC, 0.84; 95% CI, 0.75–0.91). Conclusions Using EHR data, we can accurately stratify CDI cases according to their risk of developing complications. Such an approach could be used to guide future clinical studies investigating interventions that could prevent or mitigate complicated CDI.
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Affiliation(s)
- Benjamin Y Li
- Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, Michigan
| | - Jeeheh Oh
- Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, Michigan
| | - Vincent B Young
- Department of Internal Medicine/Division of Infectious Diseases, University of Michigan, Ann Arbor, Michigan.,Department of Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan
| | - Krishna Rao
- Department of Internal Medicine/Division of Infectious Diseases, University of Michigan, Ann Arbor, Michigan
| | - Jenna Wiens
- Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, Michigan
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Cózar A, Ramos-Martínez A, Merino E, Martínez-García C, Shaw E, Marrodán T, Calbo E, Bereciartúa E, Sánchez-Muñoz LA, Salavert M, Pérez-Rodríguez MT, García D, Bravo-Ferrer JM, Gálvez-Acebal J, Henríquez C, Cuquet J, Gil-Campesino H, Torres L, Sánchez-Porto A, Royuela A, Cobo J. High delayed mortality after the first episode of Clostridium difficile infection. Anaerobe 2019; 57:93-98. [PMID: 30959165 DOI: 10.1016/j.anaerobe.2019.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 04/03/2019] [Accepted: 04/04/2019] [Indexed: 12/19/2022]
Abstract
Clostridium difficile infection (CDI) is characterized by a high delayed and unrelated mortality. Predicting delayed mortality in CDI patients could allow the implementation of interventions that could reduce these events. A prospective multicentric study was carried out to investigate prognostic factors associated with mortality. It was based on a cohort (July 2015 to February 2016) of 295 patients presenting with CDI. Logistic regression was used and the model was calibrated using the Hosmer-Lemeshow test. The mortality rate at 75 days in our series was 18%. Age (>65 years), comorbidity (defined by heart failure, diabetes mellitus with any organ lesion, renal failure, active neoplasia or immunosuppression) and fecal incontinence at clinical presentation were associated with delayed (75-day) mortality. When present, each of the aforementioned variables added one point to the score. Mortalities with 0, 1, 2 and 3 points were 0%, 9.4%, 18.5% and 38.2%, respectively. The area under the ROC curve was 0.743, and the Hosmer-Lemeshow goodness-of-fit test p value was 0.875. Therefore, the prediction of high delayed mortality in CDI patients by our scoring system could promote measures for increasing survival in suitable cases.
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Affiliation(s)
- Alberto Cózar
- Servicio de Medicina Interna, Hospital Universitario Puerta de Hierro-Majadahonda, Spain.
| | - Antonio Ramos-Martínez
- Unidad de Enfermedades Infecciosas, Hospital Universitario Puerta de Hierro-Majadahonda, Spain.
| | - Esperanza Merino
- Unidad de Enfermedades Infecciosas, Hospital Universitario de Alicante, Spain.
| | | | - Evelyn Shaw
- Servicio de Enfermedades Infecciosas, Hospital Universitario de Bellvitge, Epidemiologia de Les Infeccions Bacterianes, Patologia Infecciosa I Transplantament, Institut D'Investigació Biomèdica de Bellvitge, IDIBELL, Spain.
| | | | - Esther Calbo
- Servicio de Medicina Interna, Unidad de Control de La Infección, Hospital Universitario Mútua Terrasssa, Spain.
| | - Elena Bereciartúa
- Unidad de Enfermedades Infecciosas, Hospital Universitario Cruces, Spain.
| | - Luis A Sánchez-Muñoz
- Servicio de Medicina Interna, Hospital Clínico Universitario de Valladolid, Spain.
| | - Miguel Salavert
- Unidad de Enfermedades Infecciosas, Hospital Universitario y Politécnico La Fe (Valencia), Spain.
| | - M Teresa Pérez-Rodríguez
- Unidad de Patología Infecciosa (Servicio de Medicina Interna), Complejo Universitario de Vigo, Spain.
| | - Dácil García
- Sección de Infecciones, Servicio de Medicina Interna Hospital Universitario de Canarias, La Laguna (Tenerife), Spain.
| | | | - Juan Gálvez-Acebal
- Servicio de Enfermedades Infecciosas, Hospital Virgen Macarena, Sevilla, Spain.
| | - César Henríquez
- Servicio de Medicina Interna, Hospital Fundación Alcorcón, Spain.
| | - Jordi Cuquet
- Proceso de Infecciones, Servicio de Medicina Interna, Hospital General de Granollers, Spain.
| | - Helena Gil-Campesino
- Servicio de Microbiología, Hospital Nuestra Señora de Candelaria. Sta. Cruz de Tenerife, Spain.
| | - Luis Torres
- Servicio de Microbiología, Hospital San Jorge de Huesca, Spain.
| | - Antonio Sánchez-Porto
- Servicio de Microbiología, Hospital SAS, La Línea (La Línea de La Concepción), Spain.
| | - Ana Royuela
- Servicio de Bioestadística Clínica, Hospital Universitario Puerta de Hierro-Majadahonda, Spain.
| | - Javier Cobo
- Servicio de Enfermedades Infecciosas, Hospital Universitario Ramón y Cajal, IRYCIS, Spain.
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Figueroa Castro CE, Munoz-Price LS. Advances in Infection Control for Clostridioides (Formerly Clostridium) difficile Infection. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2019. [DOI: 10.1007/s40506-019-0179-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Toxin B PCR Amplification Cycle Threshold Adds Little to Clinical Variables for Predicting Outcomes in Clostridium difficile Infection: a Retrospective Cohort Study. J Clin Microbiol 2019; 57:JCM.01125-18. [PMID: 30463889 DOI: 10.1128/jcm.01125-18] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 11/07/2018] [Indexed: 12/18/2022] Open
Abstract
The objective of the present study was to evaluate the value of the PCR cycle threshold (CT ) for predicting the recurrence/severity of infection compared to that of toxin detection plus clinical variables. First episodes of Clostridium difficile infection (CDI) diagnosed during 2015 at our institution were included. Samples were tested for glutamate dehydrogenase (GDH) and toxin A/B by use of a single enzyme immunoassay (EIA). The Xpert C. difficile PCR assay was performed on GDH-positive samples. Medical data were reviewed by investigators blinded to diagnostic results for comparison of patients with and without recurrence or a poor outcome (severe/severe-complicated CDI episodes and all-cause death). We generated two sets of predictive models by incorporating the presence of a positive toxin EIA ("EIA-including model") or the optimal PCR CT cutoff value ("PCR-including model") into the clinical variables. Among 227 episodes of CDI included in the study, the rates of recurrence and poor outcome were 15.8% and 30.8%, respectively. The mean PCR CT was lower for episodes with recurrence (24.00 ± 3.28 versus 26.02 ± 4.54; P = 0.002) or a poor outcome (24.9 ± 4.24 versus 26.05 ± 4.47; P = 0.07). The optimal cutoff value for recurrence was 25.65 (sensitivity, 77.8% [95% confidence interval {CI}, 60.9 to 89.9]; and specificity, 46.6% [95% CI, 39.4 to 53.9]). The area under the receiver operator characteristics curve (auROC) for the "PCR-including model" was similar to that for the "EIA-including model" (0.785 versus 0.775, respectively). The optimal PCR CT value for poor outcome was 27.55 (sensitivity, 78.6% [95% CI, 67.1 to 87.5]; and specificity, 35.7% [95% CI, 28.2 to 43.7]). The auROC of the "PCR-including model" was again similar to that of the "EIA-including model" (0.804 versus 0.801). Despite the inverse correlation between PCR CT and the risk of CDI recurrence/severity, this determination does not meaningfully increase the predictive value of clinical variables plus toxin EIA.
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Daniels LM, Kufel WD. Clinical review of Clostridium difficile infection: an update on treatment and prevention. Expert Opin Pharmacother 2018; 19:1759-1769. [PMID: 30220230 DOI: 10.1080/14656566.2018.1524872] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Clostridium difficile infection (CDI) has become a significant healthcare-associated infection and is strongly associated with antibiotic use. Practice guidelines have recently been revised incorporating updated recommendations for diagnosis, treatment, and prevention. AREAS COVERED This review discusses updated aspects of CDI management. New and emerging pharmacologic options for treatment and prevention are reviewed. EXPERT OPINION Metronidazole is associated with lower rates of treatment success compared to vancomycin and should no longer be used as primary therapy for the first episode of CDI or recurrent disease. Vancomycin or fidaxomicin are now recommended for first-line therapy for most cases of CDI. Fecal microbiota transplant is effective and safe for the treatment of recurrent CDI. Evidence supports the use of fidaxomicin and bezlotoxumab for prevention of recurrent CDI; however, the costs associated with these therapies may limit their use. Validated risk prediction tools are needed to identify patients most likely to benefit from these treatments. Future advancements in microbiota targeting treatments will emerge as promising alternatives to standard CDI treatments. Antibiotic stewardship and infection control measures will remain essential components for CDI management.
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Affiliation(s)
- Lindsay M Daniels
- a Department of Pharmacy , University of North Carolina Medical Center , Chapel Hill , NC , USA.,b Division of Practice Advancement and Clinical Education, Eshelman School of Pharmacy , University of North Carolina , Chapel Hill , NC , USA
| | - Wesley D Kufel
- c Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences , Binghamton University , Binghamton , NY , USA.,d Department of Medicine , Upstate Medical University.,e Department of Pharmacy , Upstate University Hospital , Syracuse , NY , USA
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Cobo J. A comprehensive approach for the patient with Clostridium difficile infection. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2018; 31 Suppl 1:27-31. [PMID: 30209919 PMCID: PMC6459568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
During the last decade there have been many changes and advances in the research on Clostridium difficile infection (CDI). We have improved diagnostic and therapeutic tools and, at the same time, we have learned that the CDI implies, especially in the most vulnerable patients, an important morbidity. CDI has traditionally been undervalued and it is widely dispersed in hospitals. Surely, there is inertness in its management and there are also broad areas of improvement. If we add to this the high cost of the new drugs and the practical difficulties to implement the faecal microbiota transplant, we realize that we may not be taking full advantage of all the opportunities to improve patient's outcomes. The implementation of policies that favour the supervision of all CDI cases by an expert in infectious diseases will contribute to a better global management of this important disease.
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Farowski F, Els G, Tsakmaklis A, Higgins PG, Kahlert CR, Stein-Thoeringer CK, Bobardt JS, Dettmer-Wilde K, Oefner PJ, Vehreschild JJ, Vehreschild MJ. Assessment of urinary 3-indoxyl sulfate as a marker for gut microbiota diversity and abundance of Clostridiales. Gut Microbes 2018; 10:133-141. [PMID: 30118620 PMCID: PMC6546351 DOI: 10.1080/19490976.2018.1502536] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 06/04/2018] [Accepted: 07/09/2018] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES After allogeneic hematopoietic stem cell transplantation (allo-HCT), urinary levels of 3-indoxyl sulfate (3-IS) correlate with the relative abundance of bacteria from the class Clostridia (RAC), and antibiotic treatment is considered the major determinant of this outcome. A high RAC has been associated with favorable outcome after allo-HCT and protection from Clostridium difficile infection (CDI). We assessed correlations between alpha diversity, RAC and urinary 3-IS levels in a non-allo-HCT clinical cohort of antibiotic treated patients to further explore 3-IS as a biomarker of reduced diversity and predisposition to CDI. METHODS Fecal and urinary specimens were analyzed from 40 non-allo-HCT hospitalized patients before and 9 ± 2 days after initiation of intravenous antibiotic treatment. Fecal microbiota were analyzed by 16s RNA sequencing and urinary 3-IS was analyzed by liquid chromatography-tandem mass spectrometry. Receiver operating characteristic (ROC) analysis was performed to assess the predictive value of 3-IS. RESULTS At a RAC cutoff of <30%, the binary logarithm of 3-IS (medium 3-IS: ≤2.5; high 3-IS: >2.5) was predictive with an accuracy of 82% (negative predictive value: 87%, positive predictive value 67%). Accuracy was improved by combing antibiotic history with 3-IS levels (accuracy 89%, npv 88%, ppv 92%). CONCLUSION In conjunction with patient antibiotic history, 3-IS is a candidate marker to predict RAC.
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Affiliation(s)
- Fedja Farowski
- Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- German Centre for Infection Research (DZIF), partner site Bonn-Cologne, Cologne, Germany
| | - Gregor Els
- Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Anastasia Tsakmaklis
- Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Paul G. Higgins
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Cologne, Germany
| | - Christian R. Kahlert
- Clinic of Infectious Diseases and Hospital Epidemiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
- Infectious Diseases and Hospital Epidemiology, Children’s Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - Christoph K. Stein-Thoeringer
- Clinic und Polyclinic for Internal Medicine II, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
- Immunology program, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Johanna S. Bobardt
- Clinic und Polyclinic for Internal Medicine II, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Katja Dettmer-Wilde
- Institute of Functional Genomics, University of Regensburg, Regensburg, Germany
| | - Peter J. Oefner
- Institute of Functional Genomics, University of Regensburg, Regensburg, Germany
| | - Jörg Janne Vehreschild
- Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- German Centre for Infection Research (DZIF), partner site Bonn-Cologne, Cologne, Germany
| | - Maria J.G.T. Vehreschild
- Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- German Centre for Infection Research (DZIF), partner site Bonn-Cologne, Cologne, Germany
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An Observational Cohort Study of Clostridium difficile Ribotype 027 and Recurrent Infection. mSphere 2018; 3:3/3/e00033-18. [PMID: 29794054 PMCID: PMC5967198 DOI: 10.1128/msphere.00033-18] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 05/02/2018] [Indexed: 12/18/2022] Open
Abstract
CDI is a major public health issue, with over 400,000 cases per year in the United States alone. Recurrent CDI is common, occurring in approximately one in five individuals after a primary episode. Although interventions exist that could reduce the risk of recurrence, deployment in all patients is limited by cost, invasiveness, and/or an undetermined long-term safety profile. Thus, clinicians need risk stratification tools to properly allocate treatments. Because prior research on clinical predictors has failed to yield a reliable, reproducible, and effective predictive model to assist treatment decisions, accurate biomarkers of recurrence would be of great value. This study tested whether PCR ribotype independently predicted rCDI, and the data build upon prior research in showing that ribotype 027 is associated with rCDI. Recurrent Clostridium difficile infection (rCDI) frequently complicates recovery from CDI. Accurately predicting rCDI would allow judicious allocation of limited resources, but published models have met with limited success. Thus, biomarkers predictive of recurrence have been sought. This study tested whether PCR ribotype independently predicted rCDI. Stool samples from nonpregnant inpatients ≥18 years of age with diarrhea were included from October 2010 to January 2013 after the patients tested positive for C. difficile in the clinical microbiology laboratory. Per guidelines, the rCDI was defined as a positive test for C. difficile at >2 weeks but ≤8 weeks from the index episode. For each sample, a single colony of C. difficile was isolated by anaerobic culture, confirmed to be toxigenic by PCR, and ribotyped. Simple logistic regression and multiple logistic regression were used to model the primary outcome of rCDI, incorporating a wide range of clinical parameters. In total, 927 patients with 968 index episodes of CDI were included, with 110 (11.4%) developing rCDI. Age and use of proton pump inhibitors or concurrent antibiotics did not increase the risk of rCDI. Low serum bilirubin levels and ribotype 027 were associated with increased risk of rCDI on unadjusted analysis, with health care-associated CDI being inversely associated. In the final multivariable model, ribotype 027 was the strongest independent predictor of rCDI (odds ratio, 2.17; 95% confidence interval, 1.33 to 3.56; P = 0.002). Ribotype 027 is an independent predictor of rCDI. IMPORTANCE CDI is a major public health issue, with over 400,000 cases per year in the United States alone. Recurrent CDI is common, occurring in approximately one in five individuals after a primary episode. Although interventions exist that could reduce the risk of recurrence, deployment in all patients is limited by cost, invasiveness, and/or an undetermined long-term safety profile. Thus, clinicians need risk stratification tools to properly allocate treatments. Because prior research on clinical predictors has failed to yield a reliable, reproducible, and effective predictive model to assist treatment decisions, accurate biomarkers of recurrence would be of great value. This study tested whether PCR ribotype independently predicted rCDI, and the data build upon prior research in showing that ribotype 027 is associated with rCDI.
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