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Sinha P, Guerrant RL. The Costly Vicious Cycle of Infections and Malnutrition. J Infect Dis 2024; 229:1611-1613. [PMID: 37972258 PMCID: PMC11175688 DOI: 10.1093/infdis/jiad513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 11/19/2023] Open
Abstract
Malnutrition, which continues to affect hundreds of millions of people worldwide, is both a cause and consequence of a range of infectious diseases. In this perspective piece, we provide an overview of the bidirectional relationship between malnutrition and infectious diseases. In addition to enteric infections, we use tuberculosis as a case study of this relationship between malnutrition and infectious diseases, and to demonstrate the potential of nutritional interventions to mitigate mortality and morbidity from infectious diseases. We conclude with suggestions on advancing our understanding of the vicious cycle of microbes and malnutrition and finding ways to break it.
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Affiliation(s)
- Pranay Sinha
- Section of Infectious Diseases, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Richard L Guerrant
- Division of Infectious Diseases and International Medicine, University of Virginia, Charlottesville, Virginia, USA
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Remelli F, Mattioli I, Govoni B, Zurlo A, De Giorgio R, Volpato S, Cultrera R. Recurrence of Clostridioides difficile infection and mortality in older inpatients. Eur Geriatr Med 2024; 15:743-751. [PMID: 38448711 DOI: 10.1007/s41999-024-00942-x] [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: 10/20/2023] [Accepted: 01/10/2024] [Indexed: 03/08/2024]
Abstract
PURPOSE The prevalence of Clostridioides difficile infection in older and frail population is extremely high and adverse outcomes, including future recurrences and premature mortality, are common. Nonetheless, the clinical risk profile for Clostridioides difficile recurrence in older people is still controversial. We aimed to investigate: 1) the association between Clostridioides difficile recurrence and 6-month mortality; 2) the risk factors for Clostridioides difficile recurrence after hospital discharge. METHODS This is a retrospective study on adults with a first episode of Clostridioides difficile infection admitted to all Internal Medicine and Geriatrics Units of the University Hospital of Ferrara (Italy) between January 2018 and December 2020. For each patient, sociodemographic, clinical and laboratory data were collected through hospital database system. The primary and secondary outcomes were mortality and recurrence within 6 months from the first infectious episode, respectively. RESULTS The mean age of the 386 enrolled patients was 77.8 years; 61.7% were females. Twelve percent patients had Clostridioides difficile recurrence and 32.1% patients died during the 6-month follow-up. At Cox analysis, after adjustment for the potential confounders, participants with recurrence reported a twofold risk of death compared to those without recurrence (HR, 95% CI 2.45, 1.59-3.78). Compared to patients treated with metronidazole, those treated with vancomycin showed a lower risk of recurrence (log-rank p < 0.001). CONCLUSION Clostridioides difficile recurrence is associated with a higher risk of mortality and it may itself be a marker of frailty and vulnerability. Vancomycin treatment during the infectious episode was associated with lower recurrence rate, as compared to metronidazole.
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Affiliation(s)
- Francesca Remelli
- Department of Medical Science, University of Ferrara, Via Aldo Moro, 8, 44124, Ferrara, Italy
| | - Irene Mattioli
- Department of Medicine, Azienda AUSL of Ferrara, Ferrara, Italy
| | - Benedetta Govoni
- Geriatrics Unit, Azienda Ospedaliero-Universitaria of Ferrara, Ferrara, Italy
| | - Amedeo Zurlo
- Department of Medical Science, University of Ferrara, Via Aldo Moro, 8, 44124, Ferrara, Italy
- Geriatrics Unit, Azienda Ospedaliero-Universitaria of Ferrara, Ferrara, Italy
| | - Roberto De Giorgio
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Stefano Volpato
- Department of Medical Science, University of Ferrara, Via Aldo Moro, 8, 44124, Ferrara, Italy.
- Geriatrics Unit, Azienda Ospedaliero-Universitaria of Ferrara, Ferrara, Italy.
| | - Rosario Cultrera
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Infectious Diseases, Azienda Unità Sanitaria Locale of Ferrara, Ferrara, Italy
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Angulo FJ, Oliva SP, Carrico R, Furmanek S, Zamparo J, Gonzalez E, Gray S, Ford KD, Swerdlow D, Moïsi JC, Ramirez J. Frequency of stool specimen collection and testing for Clostridioides difficile of hospitalized adults and long-term care facility residents with new-onset diarrhea in Louisville, Kentucky. Int J Infect Dis 2022; 120:196-200. [PMID: 35477052 DOI: 10.1016/j.ijid.2022.04.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 04/11/2022] [Accepted: 04/20/2022] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES This study aimed to determine the stool specimen collection and Clostridioides difficile (C. difficile) testing frequency from inpatients and long-term care facility (LTCF) residents with new-onset diarrhea. METHODS A cross-sectional study was conducted in all wards of 9 adult hospitals (3532 beds) and 14 LTCFs (1205 beds) in Louisville, Kentucky to identify new-onset diarrhea (≥3 loose stools in the past 24 h and not present in the preceding 24 h) among Louisville adults via electronic medical record review, nurse interviews, and patient interviews during a 1-2 week observation period in 2018-2019. RESULTS Among Louisville-resident inpatients, 167 patients with 9731 inpatient-days had new-onset diarrhea (1.7/100 inpatient-days). Stool specimens were collected from 32% (53/167); 12 (23%) specimens were laboratory-confirmed for C. difficile infection (CDI) (12.3 cases/10,000 inpatient-days). Among LTCF residents, 63 with 10,402 LTCF resident-days had new-onset diarrhea (0.6/100 LTCF resident-days). Stool specimens were collected from 32% (20/63); 9 (45%) specimens were laboratory-confirmed for CDI (8.6 cases/10,000 LTCF resident-days). CONCLUSIONS New-onset diarrhea was common among inpatients and LTCF residents. Only one-third of patients with new-onset diarrhea had a stool specimen collected and tested for C. difficile-indicative of a potential CDI underdiagnosis-although, further studies are needed to confirm the extent of CDI underdiagnosis.
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Affiliation(s)
- Frederick J Angulo
- Medical Development and Scientific/Clinical Affairs, Pfizer Vaccines, 500 Arcola Road 4024 NE Alameda Street, Collegeville, PA 19426, USA.
| | - Senén Peña Oliva
- Center of Excellence for Research in Infectious Diseases (CERID), Division of Infectious Diseases, School of Medicine, University of Louisville, 501 East Broadway, Suite 100, Louisville, KY 40202, USA
| | - Ruth Carrico
- Center of Excellence for Research in Infectious Diseases (CERID), Division of Infectious Diseases, School of Medicine, University of Louisville, 501 East Broadway, Suite 100, Louisville, KY 40202, USA
| | - Stephen Furmanek
- Center of Excellence for Research in Infectious Diseases (CERID), Division of Infectious Diseases, School of Medicine, University of Louisville, 501 East Broadway, Suite 100, Louisville, KY 40202, USA; Norton Healthcare, Norton Infectious Diseases Institute, Louisville, KY 40202, USA
| | - Joann Zamparo
- Medical Development and Scientific/Clinical Affairs, Pfizer Vaccines, 500 Arcola Road 4024 NE Alameda Street, Collegeville, PA 19426, USA
| | - Elisa Gonzalez
- Medical Development and Scientific/Clinical Affairs, Pfizer Vaccines, 500 Arcola Road 4024 NE Alameda Street, Collegeville, PA 19426, USA
| | - Sharon Gray
- Medical Development and Scientific/Clinical Affairs, Pfizer Vaccines, 500 Arcola Road 4024 NE Alameda Street, Collegeville, PA 19426, USA
| | - Kimbal D Ford
- Medical Development and Scientific/Clinical Affairs, Pfizer Vaccines, 500 Arcola Road 4024 NE Alameda Street, Collegeville, PA 19426, USA
| | - David Swerdlow
- Medical Development and Scientific/Clinical Affairs, Pfizer Vaccines, 500 Arcola Road 4024 NE Alameda Street, Collegeville, PA 19426, USA; Beacon Epidemiology Associates, LLC, Phoenixville, PA 19460, USA
| | - Jennifer C Moïsi
- Medical Development and Scientific/Clinical Affairs, Pfizer Vaccines, 500 Arcola Road 4024 NE Alameda Street, Collegeville, PA 19426, USA
| | - Julio Ramirez
- Center of Excellence for Research in Infectious Diseases (CERID), Division of Infectious Diseases, School of Medicine, University of Louisville, 501 East Broadway, Suite 100, Louisville, KY 40202, USA; Norton Healthcare, Norton Infectious Diseases Institute, Louisville, KY 40202, USA
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Abstract
Environmental enteropathy is a chronic condition of the small intestine associated with increased intestinal permeability, mucosal inflammation, malabsorption, and systemic inflammation. It is commonly accompanied by enteric infections and is misleadingly considered a subclinical disease. Potential effects of enteric infections and enteropathy on vaccine responses, child growth, cognitive development, and even later life obesity, diabetes, and metabolic syndrome are increasingly being recognized. Herein, we review the evolving challenges to defining environmental enteropathy and enteric infections, current evidence for the magnitude and determinants of its burden, new assessment tools, and relevant interventions.
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Affiliation(s)
- Elizabeth T Rogawski
- Department of Public Health Sciences, University of Virginia, PO Box 801379, Carter Harrison Research Building MR-6, 345 Crispell Drive, Room 2520, Charlottesville, VA 22908-1379, USA; Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, PO Box 801379, Carter Harrison Research Building MR-6, 345 Crispell Drive, Room 2520, Charlottesville, VA 22908-1379, USA.
| | - Richard L Guerrant
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, PO Box 801379, Carter Harrison Research Building MR-6, 345 Crispell Drive, Room 2520, Charlottesville, VA 22908-1379, USA
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Jose S, Madan R. Neutrophil-mediated inflammation in the pathogenesis of Clostridium difficile infections. Anaerobe 2016; 41:85-90. [PMID: 27063896 DOI: 10.1016/j.anaerobe.2016.04.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 04/04/2016] [Indexed: 12/19/2022]
Abstract
Clostridium difficile is the most important cause of nosocomial infectious diarrhea in the western world. C. difficile infections are a major healthcare burden with approximately 500,000 new cases every year and an estimated annual cost of nearly $1 billion in the U.S. Furthermore, the infections are no longer restricted to health care facilities, and recent studies indicate spread of C. difficile infection to the community as well. The clinical spectrum of C. difficile infection ranges from asymptomatic colonization to severe diarrhea, fulminant colitis and death. This spectrum results from a complex interplay between bacterial virulence factors, the colonic microbiome and the host inflammatory response. The overall vigor of host inflammatory response is believed to be an important determinant of C. difficile disease severity, and a more robust immune response is associated with worse outcomes. Neutrophils are the primary cells that respond to C. difficile invasion and neutrophilic inflammation is the hallmark of C. difficile-associated disease. In this review, we will focus on the role of neutrophils (infiltration to infected tissue, pathogen clearance and resolution of inflammation) in the immuno-pathogenesis of C. difficile-associated disease (CDAD).
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Affiliation(s)
- Shinsmon Jose
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati, OH 45267, USA
| | - Rajat Madan
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati, OH 45267, USA.
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Prata MDMG, Havt A, Bolick DT, Pinkerton R, Lima A, Guerrant RL. Comparisons between myeloperoxidase, lactoferrin, calprotectin and lipocalin-2, as fecal biomarkers of intestinal inflammation in malnourished children. ACTA ACUST UNITED AC 2016; 2:134-139. [PMID: 27746954 PMCID: PMC5061054 DOI: 10.15761/jts.1000130] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Fecal biomarkers have emerged as important tools to assess intestinal inflammation and enteropathy. The aim of this study was to investigate the correlations between the fecal markers, myeloperoxidase (MPO), lactoferrin (FL), calprotectin (FC) and lipocalin-2 (Lcn-2), and to compare differences by breastfeeding status as well as normalization by fecal protein or by fecal weight. Simultaneous, quantitative MPO, FL, FC and Lcn-2, levels were determined in frozen fecal specimens collected from 78 children (mean age 15.2 ± 5.3 months) in a case-control study of childhood malnutrition in Brazil. The biomarker concentrations were measured by enzymelinked immunosorbent assay. The correlations among all biomarkers were significant (P<0.01). There were stronger correlations of fecal MPO with fecal lactoferrin and calprotectin, with lower, but still highly significant correlations of all 3 inflammatory biomarkers with Lcn-2 likely because the latter may also reflect enterocyte damage as well as neutrophil presence. Furthermore, the biomarker results with protein normalized compared to simple fecal weight normalized values showed only a slightly better correlation suggesting that the added cost and time for protein normalization added little to carefully measured fecal weights as denominators. In conclusion, fecal MPO correlates tightly with fecal lactoferrin and calprotectin irrespective of breastfeeding status and provides a common, available biomarker for comparison of human and animal model studies.
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Affiliation(s)
- Mara de Moura Gondim Prata
- Department of Physiology and Pharmacology and INCT-Biomedicine, Faculty of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - A Havt
- Department of Physiology and Pharmacology and INCT-Biomedicine, Faculty of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - D T Bolick
- Center for Global Health, Division of Infectious Diseases and International Medicine, University of Virginia School of Medicine, Charlottesville, VA 22908, USA
| | - R Pinkerton
- Department of Physiology and Pharmacology and INCT-Biomedicine, Faculty of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - Aam Lima
- Department of Physiology and Pharmacology and INCT-Biomedicine, Faculty of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - R L Guerrant
- Center for Global Health, Division of Infectious Diseases and International Medicine, University of Virginia School of Medicine, Charlottesville, VA 22908, USA; Department of Physiology and Pharmacology and INCT-Biomedicine, Faculty of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
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Pannone AF, Wang XQ, Archbald-Pannone LR. Peripheral Inflammation and Functional Decline in the National Health and Nutrition Examination Survey Elderly Population. J Am Geriatr Soc 2016; 64:654-6. [PMID: 27000345 DOI: 10.1111/jgs.14009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Aaron F Pannone
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Xin-Qun Wang
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Laurie R Archbald-Pannone
- Division of General Medicine, Geriatrics, and Palliative Care, Division of Infectious Diseases and International Health, Department of Internal Medicine, University of Virginia, Charlottesville, Virginia
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Archbald-Pannone LR, McMurry TL, Guerrant RL, Warren CA. Delirium and other clinical factors with Clostridium difficile infection that predict mortality in hospitalized patients. Am J Infect Control 2015; 43:690-3. [PMID: 25920706 DOI: 10.1016/j.ajic.2015.03.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 03/18/2015] [Accepted: 03/19/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) severity has increased, especially among hospitalized older adults. We evaluated clinical factors to predict mortality after CDI. METHODS We collected data from inpatients diagnosed with CDI at a U.S. academic medical center (HSR-IRB#13630). We evaluated age, Charlson comorbidity index (CCI), whether patients were admitted from a long-term care facility, whether patients were in an intensive care unit (ICU) at the time of diagnosis, white blood cell count (WBC), blood urea nitrogen (BUN), low body mass index, and delirium as possible predictors. A parsimonious predictive model was chosen using the Akaike information criterion (AIC) and a best subsets model selection algorithm. The area under the receiver operating characteristic curve was used to assess the model's comparative, with the AIC as the selection criterion for all subsets to measure fit and control for overfitting. RESULTS From the 362 subjects, the selected model included CCI, WBC, BUN, ICU, and delirium. The logistic regression coefficients were converted to a points scale and calibrated so that each unit on the CCI contributed 2 points, ICU admission contributed 5 points, each unit of WBC (natural log scale) contributed 3 points, each unit of BUN contributed 5 points, and delirium contributed 11 points.Our model shows substantial ability to predict short-term mortality in patients hospitalized with CDI. CONCLUSION Patients who were diagnosed in the ICU and developed delirium are at the highest risk for dying within 30 days of CDI diagnosis.
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Affiliation(s)
- Laurie R Archbald-Pannone
- Division of General, Geriatric, Palliative, and Hospital Medicine, Department of Internal Medicine, University of Virginia, Charlottesville, VA; Division of Infectious Diseases and International Health, Department of Internal Medicine, University of Virginia, Charlottesville, VA.
| | - Timothy L McMurry
- Division of Biostatistics, Department of Public Health Sciences, University of Virginia, Charlottesville, VA
| | - Richard L Guerrant
- Division of Infectious Diseases and International Health, Department of Internal Medicine, University of Virginia, Charlottesville, VA
| | - Cirle A Warren
- Division of Infectious Diseases and International Health, Department of Internal Medicine, University of Virginia, Charlottesville, VA
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Swale A, Miyajima F, Roberts P, Hall A, Little M, Beadsworth MBJ, Beeching NJ, Kolamunnage-Dona R, Parry CM, Pirmohamed M. Calprotectin and lactoferrin faecal levels in patients with Clostridium difficile infection (CDI): a prospective cohort study. PLoS One 2014; 9:e106118. [PMID: 25170963 PMCID: PMC4149523 DOI: 10.1371/journal.pone.0106118] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 07/28/2014] [Indexed: 12/31/2022] Open
Abstract
Measurement of both calprotectin and lactoferrin in faeces has successfully been used to discriminate between functional and inflammatory bowel conditions, but evidence is limited for Clostridium difficile infection (CDI). We prospectively recruited a cohort of 164 CDI cases and 52 controls with antibiotic-associated diarrhoea (AAD). Information on disease severity, duration of symptoms, 30-day mortality and 90-day recurrence as markers of complicated CDI were recorded. Specimens were subject to microbiological culture and PCR-ribotyping. Levels of faecal calprotectin (FC) and lactoferrin (FL) were measured by ELISA. Statistical analysis was conducted using percentile categorisation. ROC curve analysis was employed to determine optimal cut-off values. Both markers were highly correlated with each other (r2 = 0.74) and elevated in cases compared to controls (p<0.0001; ROC>0.85), although we observed a large amount of variability across both groups. The optimal case-control cut-off point was 148 mg/kg for FC and 8.1 ng/µl for FL. Median values for FL in CDI cases were significantly greater in patients suffering from severe disease compared to non-severe disease (104.6 vs. 40.1 ng/µl, p = 0.02), but were not significant for FC (969.3 vs. 512.7 mg/kg, p = 0.09). Neither marker was associated with 90-day recurrence, prolonged CDI symptoms, positive culture results and colonisation by ribotype 027. Both FC and FL distinguished between CDI cases and AAD controls. Although FL was associated with disease severity in CDI patients, this showed high inter-individual variability and was an isolated finding. Thus, FC and FL are unlikely to be useful as biomarkers of complicated CDI disease.
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Affiliation(s)
- Andrew Swale
- The Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, United Kingdom
- The Royal Liverpool and Broadgreen University Hospital Trust, Liverpool, United Kingdom
| | - Fabio Miyajima
- The Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, United Kingdom
- The Royal Liverpool and Broadgreen University Hospital Trust, Liverpool, United Kingdom
| | - Paul Roberts
- The Royal Liverpool and Broadgreen University Hospital Trust, Liverpool, United Kingdom
| | - Amanda Hall
- Institute of Infection and Global Heath, University of Liverpool, Liverpool, United Kingdom
| | - Margaret Little
- The Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, United Kingdom
- The Royal Liverpool and Broadgreen University Hospital Trust, Liverpool, United Kingdom
| | - Mike B. J. Beadsworth
- The Royal Liverpool and Broadgreen University Hospital Trust, Liverpool, United Kingdom
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Nick J. Beeching
- The Royal Liverpool and Broadgreen University Hospital Trust, Liverpool, United Kingdom
- NIHR Health Protection Unit in Gastrointestinal Infections, Liverpool, United Kingdom
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | - Chris M. Parry
- Institute of Infection and Global Heath, University of Liverpool, Liverpool, United Kingdom
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Munir Pirmohamed
- The Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, United Kingdom
- The Royal Liverpool and Broadgreen University Hospital Trust, Liverpool, United Kingdom
- * E-mail:
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Clostridium difficile ribotype 027 is most prevalent among inpatients admitted from long-term care facilities. J Hosp Infect 2014; 88:218-21. [PMID: 25228227 DOI: 10.1016/j.jhin.2014.06.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Accepted: 06/27/2014] [Indexed: 01/05/2023]
Abstract
Intestinal inflammation was evaluated using faecal lactoferrin and ribotype in 196 hospitalized adults with Clostridium difficile infection to determine the impact of ribotype 027 in long-term care facilities (LTCFs). LTCF residents (n=28) had greater antibiotic use (P=0.049) and more ribotype 027 infection [odds ratio (OR): 4.87; 95% confidence interval (CI): 2.02-11.74; P<0.01], compared to those admitted from home. Patients infected with ribotype 027 strains had worse six-month mortality (OR: 1.90; 95% CI: 1.08-3.34; P=0.03) and more inflammation (95.26 vs 36.08 μg/mL; P=0.006), compared to those infected with non-027 strains. This study was not designed to determine acquisition site, but, in this population, suggests that the location from which the patient has been admitted is strongly associated with ribotype 027 and more severe C. difficile disease.
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Archbald-Pannone L. Survey of C. difficile-Specific Infection Control Policies in Local Long-Term Care Facilities. INTERNATIONAL JOURNAL OF CLINICAL MEDICINE 2014; 5:414-419. [PMID: 24932422 PMCID: PMC4052894 DOI: 10.4236/ijcm.2014.57056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The incidence and severity of Clostridium difficile infection (CDI) has been increasing and long-term care facility (LTCF) residents are at high risk given their age, co-morbidities, and high antibiotic exposure. Infection control policies are crucial for controlling CDI, but there are currently no regulatory guidelines in the United States. Therefore, we evaluated infection control policies in local LTCFs to define the CDI-specific policies and the administrative and staff understanding of CDI, so as to identify perceived barriers for compliance. METHODS IRB approval was sought and exemption granted, all 8 local LTCFs were asked to participate. Each facility was visited by study personnel who interviewed the administrative Infection Control Practitioner (ICP) and 3 - 4 Licensed Practical Nurses (LPNs) with distinct survey format. Infection control policies were then compared to the SHEA recommendations for CDI in LTCFs. RESULTS Of the eligible facilities, 75% (n = 6) participated. ICP (n = 6) and LPNs (n = 21) were interviewed. All facilities accept residents with active CDI and 2 had written CDI-specific infection control policies. All facilities had hand hygiene or glove use policies and 2 had policies for the use of sporicidal environmental cleaning. No facility restricted antibiotic use. Each facility has a policy to instruct their staff through in-services, either annually or upon new hire, but 33% (n = 7) LPNs reported no facility-based CDI training. While 80% (n = 17) of LPNs felt comfortable with the facility CDI policies, only 11 accurately restated it. ICPs felt the most relevant barrier to staff compliance was time constraints (n = 4, 67%), however, LPNs felt it was limited knowledge (n = 10, 48%) and poor communication (n = 2, 10%). DISCUSSION AND CONCLUSIONS With the increasing incidence and severity of CDI in LCTF, few of the facilities surveyed had CDI-specific policies. Despite CDI-specific training, there is a perceived knowledge and communication gap for staff caring for residents with CDI.
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Affiliation(s)
- Laurie Archbald-Pannone
- Department of Internal Medicine, Division of General Medicine, Geriatrics, and Palliative Care, Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, USA
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12
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Boone JH, DiPersio JR, Tan MJ, Salstrom SJ, Wickham KN, Carman RJ, Totty HR, Albert RE, Lyerly DM. Elevated lactoferrin is associated with moderate to severe Clostridium difficile disease, stool toxin, and 027 infection. Eur J Clin Microbiol Infect Dis 2013; 32:1517-23. [PMID: 23771554 PMCID: PMC3825630 DOI: 10.1007/s10096-013-1905-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 05/27/2013] [Indexed: 12/18/2022]
Abstract
We evaluated blood and fecal biomarkers as indicators of severity in symptomatic patients with confirmed Clostridium difficile infection (CDI). Recruitment included patients with CDI based on clinical symptoms and supporting laboratory findings. Disease severity was defined by physician’s assessment and blood and fecal biomarkers were measured. Toxigenic culture done using spore enrichment and toxin B detected by tissue culture were done as confirmatory tests. Polymerase chain reaction (PCR) ribotyping was performed on each isolate. There were 98 patients recruited, with 85 (87 %) confirmed cases of toxigenic CDI (21 severe, 57 moderate, and seven mild), of which 68 (80 %) were also stool toxin-positive. Elevated lactoferrin (p = 0.01), increased white blood cell (WBC) count (p = 0.08), and low serum albumin (p = 0.03) were all associated with the more severe cases of CDI. Ribotype 027 infection accounted for 71 % of severe cases (p < 0.01) and patients with stool toxin had significantly higher lactoferrin levels and WBC counts (p < 0.05). Our findings show that elevated fecal lactoferrin, along with increased WBC count and low serum albumin, were associated with more severe CDI. In addition, patients infected with ribotype 027 and those with stool toxin had significantly higher fecal lactoferrin and WBC counts.
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Affiliation(s)
- J H Boone
- Research and Development, TechLab, Inc., 2001 Kraft Drive, Blacksburg, VA, 24060, USA,
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Alfa MJ, Olson N, Buelow-Smith L, Murray BL. Alkaline detergent combined with a routine ward bedpan washer disinfector cycle eradicates Clostridium difficile spores from the surface of plastic bedpans. Am J Infect Control 2013; 41:381-3. [PMID: 23040603 DOI: 10.1016/j.ajic.2012.04.326] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 04/17/2012] [Accepted: 04/17/2012] [Indexed: 12/17/2022]
Abstract
The cleaning efficiency of a ward bedpan washer disinfector was evaluated using various cycle parameters and detergent to determine which conditions could effectively eliminate Clostridium difficile spores from the surface of bedpans. Results revealed that the regular intensive cycle with thermal conditions of 85°C for 60 seconds plus the addition of an alkaline detergent was sufficient to eradicate C difficile spores. However, these thermal conditions alone, without detergent, were not adequate.
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Affiliation(s)
- Michelle J Alfa
- Department of Medical Microbiology, University of Manitoba, Winnipeg, Manitoba, Canada.
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MAPK-activated protein kinase 2 contributes to Clostridium difficile-associated inflammation. Infect Immun 2012; 81:713-22. [PMID: 23264053 DOI: 10.1128/iai.00186-12] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Clostridium difficile infection (CDI) results in toxin-induced epithelial injury and marked intestinal inflammation. Fecal markers of intestinal inflammation correlate with CDI disease severity, but regulation of the inflammatory response is poorly understood. Previous studies demonstrated that C. difficile toxin TcdA activates p38 kinase in tissue culture cells and mouse ilium, resulting in interleukin-8 (IL-8) release. Here, we investigated the role of phosphorylated mitogen-activated protein kinase (MAPK)-activated protein kinase (MK2 kinase, pMK2), a key mediator of p38-dependent inflammation, in CDI. Exposure of cultured intestinal epithelial cells to the C. difficile toxins TcdA and TcdB resulted in p38-dependent MK2 activation. Toxin-induced IL-8 and GROα release required MK2 activity. We found that p38 and MK2 are activated in response to other actin-disrupting agents, suggesting that toxin-induced cytoskeleton disruption is the trigger for kinase-dependent cytokine response. Phosphorylated MK2 was detected in the intestines of C. difficile-infected hamsters and mice, demonstrating for the first time that the pathway is activated in infected animals. Furthermore, we found that elevated pMK2 correlated with the presence of toxigenic C. difficile among 100 patient stool samples submitted for C. difficile testing. In conclusion, we find that MK2 kinase is activated by TcdA and TcdB and regulates the expression of proinflammatory cytokines. Activation of p38-MK2 in infected animals and humans suggests that this pathway is a key driver of intestinal inflammation in patients with CDI.
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Affiliation(s)
- J E Morley
- Division of Geriatric Medicine, Saint Louis University School of Medicine, St. Louis, MO 63104, USA.
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