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Lee MJ, Heywood N, Sagar PM, Brown SR, Fearnhead NS. Association of Coloproctology of Great Britain and Ireland consensus exercise on surgical management of fistulating perianal Crohn's disease. Colorectal Dis 2017; 19:418-429. [PMID: 28387062 DOI: 10.1111/codi.13672] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 01/04/2017] [Indexed: 02/08/2023]
Abstract
AIM Management of fistulating perianal Crohn's disease (fpCD) is a significant challenge for a colorectal surgeon. A recent survey of surgical practice in this condition showed variation in management approaches. As a result we set out to devise recommendations for practice for UK colorectal surgeons. METHOD Results from a national survey were used to devise a set of potential consensus statements. Consultant colorectal surgeons were invited to participate in the exercise via the previous survey and the mailing list of the professional society. Iterative voting was performed on each statement using a five-point Likert scale and electronic voting, with opportunity for discussion and refinement between each vote. Consensus was defined as > 80% agreement. RESULTS Seventeen surgeons and two patient representatives voted upon 51 statements. Consensus was achieved on 39 items. Participants advocated a patient-centred approach by a colorectal specialist, within strong multidisciplinary teamworking. The use of anti-TNFα therapy is advocated. Where definitive surgical techniques are considered they should be carefully selected to avoid adverse impact on function. Ano/rectovaginal fistulas should be managed by specialists in fistulating disease. Stoma or proctectomy could be discussed earlier in a patient's treatment pathway to improve choice, as they may improve quality of life. CONCLUSION This consensus provides principles and guidance for best practice in managing patients with fpCD.
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Affiliation(s)
- M J Lee
- Department of Oncology and Metabolism, Medical School, University of Sheffield, Sheffield, UK.,Department of General Surgery, Sheffield Teaching Hospitals, Sheffield, UK
| | - N Heywood
- University Hospital South Manchester, Manchester, UK
| | - P M Sagar
- St James University Hospital, Leeds, UK
| | - S R Brown
- Department of General Surgery, Sheffield Teaching Hospitals, Sheffield, UK
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2
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Pilcante J, Rojas P, Ernst D, Sarmiento M, Ocqueteau M, Bertin P, García M, Rodriguez M, Jara V, Ajenjo M, Ramirez P. Clostridium difficile infection in Chilean patients submitted to hematopoietic stem cell transplantation. Rev Bras Hematol Hemoter 2015; 37:388-94. [PMID: 26670401 PMCID: PMC4678790 DOI: 10.1016/j.bjhh.2015.07.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 07/22/2015] [Accepted: 07/27/2015] [Indexed: 12/21/2022] Open
Abstract
Introduction Patients submitted to hematopoietic stem cell transplantation have an increased risk of Clostridium difficile infection and multiple risk factors have been identified. Published reports have indicated an incidence from 9% to 30% of transplant patients however to date there is no information about infection in these patients in Chile. Methods A retrospective analysis was performed of patients who developed C. difficile infection after hematopoietic stem cell transplantations from 2000 to 2013. Statistical analysis used the Statistical Package for the Social Sciences software. Results Two hundred and fifty patients were studied (mean age: 39 years; range: 17–69), with 147 (59%) receiving allogeneic transplants and 103 (41%) receiving autologous transplants. One hundred and ninety-two (77%) patients had diarrhea, with 25 (10%) cases of C. difficile infection being confirmed. Twenty infected patients had undergone allogeneic transplants, of which ten had acute lymphoblastic leukemia, three had acute myeloid leukemia and seven had other diseases (myelodysplastic syndrome, chronic myeloid leukemia, severe aplastic anemia). In the autologous transplant group, five patients had C. difficile infection; two had multiple myeloma, one had amyloidosis, one had acute myeloid leukemia and one had germinal carcinoma. The overall incidence of C. difficile infection was 4% within the first week, 6.4% in the first month and 10% in one year, with no difference in overall survival between infected and non-infected groups (72.0% vs. 67.6%, respectively; p-value = 0.56). Patients infected after allogeneic transplants had a slower time to neutrophil engraftment compared to non-infected patients (17.5 vs. 14.9 days, respectively; p-value = 0.008). In the autologous transplant group there was no significant difference in the neutrophil engraftment time between infected and non-infected patients (12.5 days vs. 11.8 days, respectively; p-value = 0.71). In the allogeneic transplant group, the median time to acute graft-versus-host disease was similar between the two groups (p-value = 0.08), as was the incidence of grades 1–4 acute graft-versus-host disease (40% vs. 48%; p-value >0.05). Conclusion The incidence of C. difficile infection after hematopoietic stem cell transplantation was low, with a significant number of cases occurring shortly after transplantation. Allogeneic transplants had a three-time higher risk of infection compared to autologous transplants, but this was not associated with increased mortality, decreased overall survival or higher risk of acute graft-versus-host disease.
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Affiliation(s)
| | | | - Daniel Ernst
- Pontificia Universidad Católica, Santiago, Chile
| | | | | | - Pablo Bertin
- Pontificia Universidad Católica, Santiago, Chile
| | - Maria García
- Pontificia Universidad Católica, Santiago, Chile
| | | | | | - Maria Ajenjo
- Pontificia Universidad Católica, Santiago, Chile
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3
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Jawa RS, Mercer DW. Clostridium difficile-associated infection: a disease of varying severity. Am J Surg 2012; 204:836-42. [PMID: 23036604 DOI: 10.1016/j.amjsurg.2012.05.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Revised: 05/24/2012] [Accepted: 05/24/2012] [Indexed: 01/05/2023]
Abstract
Clostridium difficile-associated infection (CDI) can have varying severity from asymptomatic carriage to fulminant colitis. Its incidence and virulence in North America are increasing. The increase in virulence is associated with emergence of the highly toxigenic North American pulsed field gel electrophoresis-1 strain. The major risk factor for CDI is exposure to antibiotics. Another major risk factor is hospitalization. The spectrum of CDI ranges from asymptomatic carriers to fulminant disease. Although asymptomatic carriers require no treatment, fulminant disease carries a substantial mortality regardless of management strategy.
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Affiliation(s)
- Randeep S Jawa
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE 68198-3280, USA
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4
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Willems L, Porcher R, Lafaurie M, Casin I, Robin M, Xhaard A, Andreoli AL, Rodriguez-Otero P, Dhedin N, Socié G, Ribaud P, Peffault de Latour R. Clostridium difficile infection after allogeneic hematopoietic stem cell transplantation: incidence, risk factors, and outcome. Biol Blood Marrow Transplant 2012; 18:1295-301. [PMID: 22387347 DOI: 10.1016/j.bbmt.2012.02.010] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 02/22/2012] [Indexed: 12/21/2022]
Abstract
Clostridium difficile (C. difficile) infection was observed in 13% of recipients after hematopoietic stem cell transplantation (HSCT), mainly in the first month posttransplantation. Risk factors were cord blood as the source of stem cells, acute graft-versus-host disease (GVHD), and total body irradiation (TBI). No association was found with an increased risk of mortality. The purpose of this study was to evaluate the incidence, risk factors, and outcome of C. difficile infection (CDI) after HSCT. We conducted a single-center, retrospective, cohort study on all patients who received an allogeneic HSCT from January 2004 to December 2007. All patients with diarrhea in the first year after HSCT were tested for the presence of C. difficile in stools. Among the 407 assessable patients, 53 presented at least 1 CDI in the first year post-HSCT. The total incidence rate was 5.6 cases of CDI per 10,000 patient-days. Fifty percent of cases were diagnosed in the first month after HSCT, and 95% occurred during the first 6 months. Fewer than 5% of patients with CDI had severe diarrhea and severe complications were never observed. TBI in the conditioning regimen, cord blood as the source of stem cells, and acute graft-versus-host disease (aGVHD) were independently associated with CDI. Six patients (11%) had a recurrence of CDI. Four patients required second-line treatment with vancomycin. With a median follow-up of 22 months, the 2-year overall survival rates were similar between patients who presented a CDI and those who did not. CDI was observed in approximately 13% of recipients after HSCT, mainly in the first month posttransplantation and was associated with CB, aGVHD, and TBI. CDI was not associated either with severe complications or with an increased risk of mortality in this large cohort of patients.
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Affiliation(s)
- Lise Willems
- Service Hématologie Greffe, AP-HP, Hôpital Saint-Louis, 1 avenue Claude Vellefaux, Paris, France.
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5
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Obritsch MD, Stroup JS, Carnahan RM, Scheck DN. Clostridium difficile-associated diarrhea in a tertiary care medical center. Proc AMIA Symp 2011; 23:363-7. [PMID: 20944758 DOI: 10.1080/08998280.2010.11928654] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
This retrospective, case-control study aimed to identify variables associated with the incidence of Clostridium difficile-associated diarrhea (CDAD) in acute care facilities and to specifically identify the relationship of fluoroquinolones and acid suppressive agents in the development of CDAD. Seventy-one symptomatic patients positive for C. difficile toxin A or B hospitalized for at least 72 hours were compared with 142 control patients hospitalized for at least 72 hours who were not positive for C. difficile toxin A or B. Two controls were matched to one case patient for age within 5 years, unit of admission, and date of admission. The mean ages for cases and controls were 63.5 and 62.7 years, respectively. After adjusting for two confounding variables-hospital stay within 3 months and Charlson Comorbidity Index-conditional multiple logistic regression identified six risk factors for development of CDAD: gastrointestinal procedures within 60 days (odds ratio [OR] 9.1, P < 0.013), levofloxacin exposure (OR 8.2, P < 0.033), moxifloxacin exposure (OR 4.1, P < 0.026), imipenem exposure (OR 14.9, P < 0.014), laxative use (OR 20.2, P < 0.0001), and immunosuppressive use (OR 20.7, P < 0.034). The risk of CDAD after exposure to levofloxacin or moxifloxacin was not significantly different. Acid suppressive therapy was not a risk factor for CDAD development.
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Affiliation(s)
- Marilee D Obritsch
- Intensive Care Unit (Obritsch) and Department of Infectious Diseases (Scheck), Hillcrest Medical Center, Tulsa, Oklahoma; the Department of Internal Medicine, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma (Stroup); and the Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa (Carnahan)
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Kachrimanidou M, Malisiovas N. Clostridium difficile infection: a comprehensive review. Crit Rev Microbiol 2011; 37:178-87. [PMID: 21609252 DOI: 10.3109/1040841x.2011.556598] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Clostridium difficile is one of the most important causes of healthcare acquired diarrhea. The disease spectrum caused by C. difficile infection ranges from mild, self-limited, illness to a severe, life-threatening colitis. The incidence of C. difficile associated disease has risen dramatically over the last decade, leading to increased research interest aiming at the discovery of new virulence factors and the development of new treatment and prevention regimens. This review summarizes the pathogenesis and changing epidemiology of C. difficile associated disease, the clinical spectrum and laboratory methods to diagnose C. difficile infection, and current treatment strategies.
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Affiliation(s)
- Melina Kachrimanidou
- Nuffield Department of Clinical Medicine, Oxford University, John Radcliffe Hospital Oxford, UK, OX3 9DU.
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7
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Freeman J, Bauer MP, Baines SD, Corver J, Fawley WN, Goorhuis B, Kuijper EJ, Wilcox MH. The changing epidemiology of Clostridium difficile infections. Clin Microbiol Rev 2010; 33 Suppl 1:S42-5. [PMID: 20610822 DOI: 10.1016/s0924-8579(09)70016-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The epidemiology of Clostridium difficile infection (CDI) has changed dramatically during this millennium. Infection rates have increased markedly in most countries with detailed surveillance data. There have been clear changes in the clinical presentation, response to treatment, and outcome of CDI. These changes have been driven to a major degree by the emergence and epidemic spread of a novel strain, known as PCR ribotype 027 (sometimes referred to as BI/NAP1/027). We review the evidence for the changing epidemiology, clinical virulence and outcome of treatment of CDI, and the similarities and differences between data from various countries and continents. Community-acquired CDI has also emerged, although the evidence for this as a distinct new entity is less clear. There are new data on the etiology of and potential risk factors for CDI; controversial issues include specific antimicrobial agents, gastric acid suppressants, potential animal and food sources of C. difficile, and the effect of the use of alcohol-based hand hygiene agents.
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Affiliation(s)
- J Freeman
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom
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8
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Weese JS, Kaese HJ, Baird JD, Kenney DG, Staempfli HR. Suspected ciprofloxacin-induced colitis in four horses. EQUINE VET EDUC 2010. [DOI: 10.1111/j.2042-3292.2002.tb00167.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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9
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Elmer GW. Variable time of onset ofClostridium difficiledisease initiated by antimicrobial treatment in hamsters. MICROBIAL ECOLOGY IN HEALTH AND DISEASE 2009. [DOI: 10.1080/089106099435745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Gary W. Elmer
- Department of Medicinal Chemistry, Box 357610, University of Washington, Seattle
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10
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Debast SB, Vaessen N, Choudry A, Wiegers-Ligtvoet EAJ, van den Berg RJ, Kuijper EJ. Successful combat of an outbreak due to Clostridium difficile PCR ribotype 027 and recognition of specific risk factors. Clin Microbiol Infect 2009; 15:427-34. [PMID: 19416295 DOI: 10.1111/j.1469-0691.2009.02713.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In the period April-September 2005, an outbreak of Clostridium difficile infection (CDI) due to PCR ribotype 027 occurred among 50 patients in a 341-bed community hospital in Harderwijk, The Netherlands. A retrospective case-control study was performed to identify risk factors specific for CDI, using a group of patients with CDI (n = 45), a group of randomly selected control patients without diarrhoea (n = 90), and a group of patients with non-infectious diarrhoea (n = 109). Risk factors for CDI and for non-CDI diarrhoea were identified using multiple logistic regression analysis. Independent risk factors for CDI were: age above 65 years (OR 2.6; 95% CI 1.0-5.7), duration of hospitalization (OR 1.04 per additional day; 95% CI 1.0-1.1), and antibiotic use (OR 12.5; 95% CI 3.2-48.1). Of the antibiotics used, cephalosporins and fluoroquinolones were identified as the major risk factors for development of CDI. The risk of developing CDI was particularly high in people receiving a combination of a cephalosporin and a fluoroquinolone (OR 57.5; 95% CI 6.8-483.6). The main factors affecting the risk of non-CDI diarrhoea were proton-pump inhibitors, immunosuppressive drugs, underlying digestive system disease, previous surgery, and gastric tube feeding. The outbreak ended only after implementation of restricted use of cephalosporins and a complete ban on fluoroquinolones, in addition to general hygienic measures, cohorting of patients in a separate ward, education of staff, and intensified environmental cleaning. The results of this study support the importance of appropriate antimicrobial stewardship in the control of hospital outbreaks with C. difficile PCR ribotype 027.
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Affiliation(s)
- S B Debast
- Department of Medical Microbiology, St Jansdal Hospital, Harderwijk and Meander Medical Centre, Amersfoort, The Netherlands.
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11
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Gallagher JC, Du JK, Rose C. Severe Pseudomembranous Colitis After Moxifloxacin Use: A Case Series. Ann Pharmacother 2009; 43:123-8. [DOI: 10.1345/aph.1l335] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To describe the illnesses of 4 patients who developed severe pseudomembranous colitis after receiving moxifloxacin. CASE SUMMARY Four patients received moxifloxacin for pulmonary infections prior to developing positive Clostridium difficile toxin assays; all 4 later died from complications associated with C. difficile–associated disease (CDAD). Three patients developed CDAD while outpatients, although all of them had recent hospitalizations and their disease was presumed to be hospital related. All patients presented with diffuse abdominal pain, fever, and diarrhea. The patients were all treated surgically with total abdominal colectomies and medically with metronidazole. DISCUSSION Recent reports have highlighted the connection between fluoroquinolones and CDAD, in contrast to historical studies and assumptions. Evidence in the literature about differences in the propensity of various fluoroquinolones to cause CDAD is conflicting. The Naranjo probability scale revealed a probable relationship between moxifloxacin and CDAD for 3 patients, and a possible relationship for 1 patient. CONCLUSIONS Our cases highlight the need for vigilance in monitoring patients for signs of CDAD when using any antibiotic, including moxifloxacin. Patients with suspected severe CDAD need to be managed aggressively to avoid poor outcomes.
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Affiliation(s)
- Jason C Gallagher
- Jason C Gallagher PharmD BCPS, Clinical Assistant Professor, Clinical Specialist, Infectious Diseases, School of Pharmacy, Temple University, Philadelphia, PA
| | - Jennifer K Du
- Jennifer K Du PharmD, Clinical Pharmacist, Sutter Infusion & Pharmacy Services, Emeryville, CA
| | - Christina Rose
- Christina Rose PharmD BCPS, Clinical Assistant Professor, Clinical Specialist, Critical Care, School of Pharmacy, Temple University
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12
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Jaber MR, Olafsson S, Fung WL, Reeves ME. Clinical review of the management of fulminant clostridium difficile infection. Am J Gastroenterol 2008; 103:3195-203; quiz 3204. [PMID: 18853982 DOI: 10.1111/j.1572-0241.2008.02198.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a frequent cause of morbidity and mortality among elderly hospitalized patients. A small but increasing number of patients have developed fulminant CDI, and a significant number of these patients require emergency colectomy. In this review, we discuss the risk factors, pathophysiology, diagnosis, and management of fulminant CDI. DATA SOURCES A literature search (Medline, Embase, Cochrane Library, Biosis, Science Citation Index, Ovid Journals) was performed from the period between January 1980 and June 2008 using the key words "Clostridium difficile,""pseudomembranous enterocolitis,""colectomy,""acute abdomen,""antibiotic-associated diarrhea," or "fulminant Clostridium difficile colitis." Articles not in English or not related to human subjects were excluded. For this review, we analyzed the articles identified in our original search and those articles cited in the original review articles. No randomized trials were found on the surgical management of fulminant CDI and only retrospective studies with a minimum of five patients were used in the review. With respect to medical treatment, we based our review on guideline articles, systematic reviews, and available randomized trials. CONCLUSION Both the incidence and severity of CDI are increasing. Fulminant CDI is underappreciated as a life-threatening disease because of a lack of awareness of its severity and its nonspecific clinical syndrome. Early diagnosis and treatment are essential for a good outcome, and early surgical intervention should be used in patients who are unresponsive to medical therapy. The surgical procedure of choice is a total abdominal colectomy with end ileostomy, although the mortality rate remains high.
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Affiliation(s)
- M Raffat Jaber
- Department of Surgery, Loma Linda University Medical Center, Loma, Linda, California 92354, USA
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13
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Deshpande A, Pant C, Jain A, Fraser TG, Rolston DDK. Do fluoroquinolones predispose patients to Clostridium difficile associated disease? A review of the evidence. Curr Med Res Opin 2008; 24:329-33. [PMID: 18067688 DOI: 10.1185/030079908x253735] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Clostridium difficile associated diarrhea (CDAD) is an important cause of hospital-acquired diarrhea, and increasingly of community-acquired diarrhea. The occurrence of CDAD in the hospitalized patient is associated with increased length of stay, morbidity, mortality, and healthcare costs. Exposure to antimicrobials is the single most important predisposing factor for acquiring CDAD. The data suggesting that fluoroquinolones are an important risk factor for CDAD is becoming stronger. Also, different fluoroquinolones may pose different risks for CDAD development. OBJECTIVES The aim of this commentary is to summarize the literature as it relates to the role that fluoroquinolones may have in CDAD. METHODS PubMed and Ovid MEDLINE were searched using the terms fluoroquinolones, ciprofloxacin, levofloxacin, gatifloxacin, and moxifloxacin in combination with C. difficile, CDAD, pseudomembranous colitis and antibiotic associated diarrhea. RESULTS The evidence for an association between fluoroquinolone use and CDAD, especially CDAD due to the hypervirulent NAP1 strain or the polymerase chain reaction ribotype 027, is becoming stronger. CONCLUSIONS Fluoroquinolones appear to predispose patients to CDAD. The data are suggestive but not conclusive. More studies are needed to define the role that fluoroquinolones play in the development of CDAD. Meticulous and enhanced infection control practices at all times and the judicious use of antimicrobials will help contain the epidemic of CDAD.
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McFarland LV, Beneda HW, Clarridge JE, Raugi GJ. Implications of the changing face of Clostridium difficile disease for health care practitioners. Am J Infect Control 2007; 35:237-53. [PMID: 17482995 DOI: 10.1016/j.ajic.2006.06.004] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2006] [Revised: 06/19/2006] [Accepted: 06/20/2006] [Indexed: 01/19/2023]
Abstract
Recent reported outbreaks of Clostridium difficile-associated disease in Canada have changed the profile of C difficile infections. Historically, C difficile disease was thought of mainly as a nosocomial disease associated with broad-spectrum antibiotics, and the disease was usually not life threatening. The emergence of an epidemic strain, BI/NAP1/027, which produces a binary toxin in addition to the 2 classic C difficile toxins A and B and is resistant to some fluoroquinolones, was associated with large numbers of cases with high rates of mortality. Recently, C difficile has been reported more frequently in nonhospital-based settings, such as community-acquired cases. The C difficile disease is also being reported in populations once considered of low risk (children and young healthy women). In addition, poor response to metronidazole treatment is increasing. Faced with an increasing incidence of C difficile infections and the changing profile of patients who become infected, this paper will reexamine the current concepts on the epidemiology and treatment of C difficile-associated disease, present new hypotheses for risk factors, examine the role of spores in the transmission of C difficile, and provide recommendations that may enhance infection control practices.
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Affiliation(s)
- Lynne V McFarland
- From the Department of Health Services Research and Development, Veterans Administration Puget Sound Health Care System, Seattle, WA 98101, USA.
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15
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Bhalla A. Quinolones: A Nosocomial Risk Factor for Clostridium Difficile—Associated Diarrhea. Can Pharm J (Ott) 2006. [DOI: 10.1177/171516350613900204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Alka Bhalla
- Alka Bhalla is a clinical editor at the Canadian Pharmacists Association
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16
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Jimeno Sáinz A, Guerrero L, Artal A, Remacha B, Cebrián C, Bejarano E, Molina E. [A 74-year-old woman with severe abdominal pain]. GASTROENTEROLOGIA Y HEPATOLOGIA 2005; 28:433-4. [PMID: 16137479 DOI: 10.1157/13077766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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17
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Changela U, Cannon JP, Aneziokoro C, Shah PS, Thottapurathu L, Lentino J. Risk factors and mortality associated with Clostridium difficile-associated diarrhoea at a VA hospital. Int J Antimicrob Agents 2005; 24:562-6. [PMID: 15555878 DOI: 10.1016/j.ijantimicag.2004.07.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2004] [Accepted: 07/06/2004] [Indexed: 01/09/2023]
Abstract
The objective of this study was to evaluate the risk of certain patient co-morbidities and antibiotics in the development of Clostridium difficile-associated diarrhoea (CDAD). Hospitalized patients developing CDAD during a specified period were compared with a cohort of patients, matched by age, without a diagnosis of CDAD, who were hospitalized during the same time period. Data collection included demographics, hospital ward, co-morbid conditions, antibiotics received, and mortality. Gender and age were similar in both groups. Co-morbid conditions significantly associated with the case group included cancer and COPD. The most commonly prescribed antibiotics in the case versus control group included levofloxacin, intravenous vancomycin, clindamycin, and piperacillin/tazobactam. The case group was associated with a higher mortality rate.
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Affiliation(s)
- Ursula Changela
- Pharmacy Services, Edward Hines Jr. VA Hospital, Fifth Avenue and Roosevelt Road, Building 200, Room 1243, Hines, IL 60141, USA
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Gaynes R, Rimland D, Killum E, Lowery HK, Johnson TM, Killgore G, Tenover FC. Outbreak of Clostridium difficile infection in a long-term care facility: association with gatifloxacin use. Clin Infect Dis 2004; 38:640-5. [PMID: 14986246 DOI: 10.1086/381551] [Citation(s) in RCA: 214] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2003] [Accepted: 10/22/2003] [Indexed: 11/03/2022] Open
Abstract
To determine the cause of an increase in the rate of Clostridium difficile-associated diarrhea (CDAD) in a long-term care facility (LTCF), we analyzed CDAD cases among LTCF patients from October 2001 through June 2002. CDAD cases were identified from review of all enzyme immunoassays positive for C. difficile toxin A. The increase coincided with a formulary change from levofloxacin to gatifloxacin. We performed a case-control study in which we randomly selected control subjects from 612 LTCF admissions during this period. Although we examined a variety of risk factors, logistic regression analysis only demonstrated associations between CDAD and use of clindamycin (P=.005) and gatifloxacin, the latter being associated with an increasing risk of CDAD with increasing duration of gatifloxacin therapy (P<.0001). We concluded that an outbreak of CDAD in an LTCF was associated with a formulary change from levofloxacin to gatifloxacin. The rate of CDAD in the LTCF decreased after a change back to levofloxacin.
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Affiliation(s)
- Robert Gaynes
- Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
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Abstract
A 22-year-old woman was admitted to the hospital with pneumonia, urinary tract infection, anemia, thrombocytopenia, and leukocytosis. After receiving moxifloxacin for 5 days, she experienced diarrhea with cramping and abdominal pain. She was diagnosed with Clostridium difficile-associated diarrhea (CDAD) after C. difficile toxin was identified in a stool specimen. Metronidazole was begun, and the CDAD resolved with continued moxifloxacin administration. Virtually any antibiotic can lead to development of CDAD through disruption of the normal colonic flora, allowing for overgrowth of C. difficile. Although moxifloxacin is generally well tolerated, clinicians should be aware of its potential for inducing CDAD.
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Affiliation(s)
- Douglas N Carroll
- Department of Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Tulsa, Oklahoma 74135-2512, USA.
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McCusker ME, Harris AD, Perencevich E, Roghmann MC. Fluoroquinolone use and Clostridium difficile-associated diarrhea. Emerg Infect Dis 2003; 9:730-3. [PMID: 12781017 PMCID: PMC3000134 DOI: 10.3201/eid0906.020385] [Citation(s) in RCA: 148] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
We performed a case-control study to evaluate the association between antibiotic use and Clostridium difficile-associated diarrhea (CDAD), matching for admission unit and time at risk for CDAD. A multivariable regression model showed that treatment with fluoroquinolones (odds ratio 12.7; 95% confidence interval 2.6 to 61.6) was the strongest risk factor for CDAD.
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Affiliation(s)
| | - Anthony D. Harris
- Veterans Affairs Maryland Health Care System, Baltimore, Maryland, USA
| | - Eli Perencevich
- Veterans Affairs Maryland Health Care System, Baltimore, Maryland, USA
| | - Mary-Claire Roghmann
- University of Maryland, Baltimore, Maryland, USA
- Veterans Affairs Maryland Health Care System, Baltimore, Maryland, USA
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Thomas C, Golledge CL, Riley TV. Ciprofloxacin and Clostridium difficile--associated diarrhea. Infect Control Hosp Epidemiol 2002; 23:637-8; author reply 638. [PMID: 12452287 DOI: 10.1086/503451] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
Biotherapeutic agents offer unique advantages over traditional treatments for infectious diarrhea, and several have been shown to be effective (Table 4). These therapeutic microbial agents are most effective in types of infectious diseases that are associated with a disruption of the normal intestinal microecology (e.g., AAD, C. difficile disease). The impact of biotherapeutic agents on rotaviral diarrhea is of special clinical importance because this is the most common cause of pediatric diarrhea, and there is no defined treatment. Strong efforts need to be made to limit antibiotic exposure in children. Biotherapeutic agents offer a safe and effective nonantibiotic method of treating this important pathogen, especially after the withdrawal of a rotaviral vaccine from the market by the FDA. However, for many biotherapeutic agents, well-done, placebo-controlled trials still are lacking, and not all types of infectious diarrhea respond to these agents. Continued research in this innovative therapeutic area is warranted.
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Affiliation(s)
- G W Elmer
- Department of Medicinal Chemistry, School of Pharmacy, University of Washington, Seattle, Washington, USA.
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Yip C, Loeb M, Salama S, Moss L, Olde J. Quinolone use as a risk factor for nosocomial Clostridium difficile-associated diarrhea. Infect Control Hosp Epidemiol 2001; 22:572-5. [PMID: 11732787 DOI: 10.1086/501954] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine modifiable risk factors for nosocomial Clostridium difficile-associated diarrhea (CDAD). DESIGN Case-control study. SETTING 300-bed tertiary-care hospital. PARTICIPANTS Hospital inpatients present during the 3-month study period. METHODS Case-patients identified with nosocomial CDAD over the study period were compared to two sets of control patients: inpatients matched by age, gender, and date of admission; and inpatients matched by duration of hospital stay. Variables including demographic data, comorbid illnesses, antibiotic exposure, and use of gastrointestinal medications were assessed for case- and control-patients. Conditional logistic regression was performed to identify risk factors for nosocomial CDAD. RESULTS 27 case-patients were identified and were compared to the two sets of controls (1:1 match for each comparison set). For the first set of controls, use of ciprofloxacin (odds ratio [OR], 5.5; 95% confidence interval [CI 95], 1.2-24.8; P=.03) was the only variable that remained significant in the multivariable model. For the second set of controls, prior exposure to cephalosporins (OR, 6.7; CI 95, 1.3-33.7; P=.02) and to ciprofloxacin (OR, 9.5; CI 95, 1.01-88.4; P=.05) were kept in the final model. CONCLUSIONS Along with cephalosporins, prior quinolone use predisposed hospitalized patients to nosocomial CDAD. Quinolones should be used judiciously in acute-care hospitals, particularly in those where CDAD is endemic.
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Affiliation(s)
- C Yip
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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McFarland LV. Microecologic approaches for traveler's diarrhea, antibiotic-associated diarrhea, and acute pediatric diarrhea. Curr Gastroenterol Rep 1999; 1:301-7. [PMID: 10980964 DOI: 10.1007/s11894-999-0113-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Bacterial and viral diarrhea remain important causes of morbidity and mortality throughout the world. Current concerns with medical costs, increasing frequency of antibiotic resistance, and overuse of antibiotics in general have redirected therapeutic approaches for diarrhea from traditional drugs to the use of living therapeutic organisms. Awareness of the important role of normal flora in the microecology of the intestines in fighting infection, along with the recent availability of well-controlled clinical trials for these agents, has brought microecologic therapies to the forefront of clinical practice.
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Affiliation(s)
- L V McFarland
- Department of Medicinal Chemistry, University of Washington. Correspondence to author at Biocodex, Inc., 1910 Fairview Avenue East, #208, Seattle, WA 98102, USA
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McFarland LV, Surawicz CM, Rubin M, Fekety R, Elmer GW, Greenberg RN. Recurrent Clostridium difficile disease: epidemiology and clinical characteristics. Infect Control Hosp Epidemiol 1999; 20:43-50. [PMID: 9927265 DOI: 10.1086/501553] [Citation(s) in RCA: 281] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To describe the epidemiology, diagnosis, risk factors, patient impact, and treatment strategies for recurrent Clostridium difficile-associated disease (CDAD). DESIGN Data were collected as part of a blinded, placebo-controlled clinical trial testing a new combination treatment for recurrent CDAD. Retrospective data regarding prior CDAD episodes were collected from interviews and medical-chart review. Prospective data on the current CDAD episode, risk factors, and recurrence rates were collected during a 2-month follow-up. SETTINGS National referral study. PARTICIPANTS Patients with recurrent CDAD. INTERVENTIONS Treatment with a 10-day course of low-dose (500 mg/d) or high-dose (2 g/d) vancomycin or metronidazole (1 g/d). RESULTS Recurrent CDAD was found to have a lengthy course involving multiple episodes of diarrhea, abdominal cramping, nausea, and fever. CDAD may recur over several years despite frequent treatment with antibiotics. Recurrence rates were similar regardless of the choice or dose of antibiotic. Recurrent CDAD is not a trivial disease: patients may have multiple episodes (as many as 14), may require hospitalization, and the mean lifetime cost of direct medical care was $10,970 per patient. Fortunately, the disease does not become progressively more severe as the number of episodes increase. Two risk factors predictive for recurrent CDAD were found: increasing age and a decreased quality-of-life score at enrollment. CONCLUSIONS Recurrent CDAD is a persistent disease that may result in prolonged hospital stays, additional medical costs, and rare serious complications.
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Affiliation(s)
- L V McFarland
- Department of Medicinal Chemistry, University of Washington, Seattle, USA
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