1
|
Patel AH, Pathak GN, Chen A, Greenberg P, Mazzaferro N, Patel A, Mallangada N, Minacapelli CD, Catalano K, Suthar H, Rustgi VK. Outcomes and risk factors for mortality in clostridioides difficile infection in patients with NAFLD and NASH. Ann Hepatol 2024; 29:101510. [PMID: 38714224 DOI: 10.1016/j.aohep.2024.101510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 03/16/2024] [Accepted: 03/27/2024] [Indexed: 05/09/2024]
Abstract
INTRODUCTION AND OBJECTIVES Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease worldwide and can progress to non-alcoholic steatohepatitis (NASH) and, ultimately, cirrhosis. Clostridioides difficile is the most common nosocomial cause of diarrhea and is associated with worse clinical outcomes in other liver diseases, including cirrhosis, but has not been extensively evaluated in concomitant NAFLD/NASH. MATERIALS AND METHODS We conducted a retrospective cohort study using the National Inpatient Sample database from 2015 to 2017. Patients with a diagnosis of CDI, NAFLD, and NASH were identified using International Classification of Diseases (Tenth Revision) codes. The outcomes of our study include length of stay, hospitalization cost, mortality, and predictors of mortality. RESULTS The CDI and NASH cohort had a higher degree of comorbidity burden and prevalence of peptic ulcer disease, congestive heart failure, diabetes mellitus, and cirrhosis. Patients with NASH and CDI had a significantly higher mortality rate compared to the CDI only cohort (mortality, 7.11 % vs. 6.36 %; P = 0.042). Patients with CDI and NASH were at increased risk for liver-related complications, acute kidney injury, and septic shock (P < 0.001) compared to patients with CDI only. Older age, intestinal complications, pneumonia, sepsis and septic shock, and liver failure conferred an increased risk of mortality among the CDI and NASH cohort. CONCLUSIONS Patients with NASH had a higher rate of liver-related complications, progression to septic shock, and mortality rate following CDI infection compared to the CDI only cohort.
Collapse
Affiliation(s)
- Ankoor H Patel
- Internal Medicine, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ, the United States
| | - Gaurav N Pathak
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, the United States
| | - Alexander Chen
- Internal Medicine, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ, the United States
| | - Patricia Greenberg
- Department of Biostatistics & Epidemiology, Rutgers School of Public Health, Piscataway, NJ, the United States
| | - Natale Mazzaferro
- Department of Biostatistics & Epidemiology, Rutgers School of Public Health, Piscataway, NJ, the United States
| | - Anish Patel
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, the United States
| | - Naveen Mallangada
- Internal Medicine, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ, the United States
| | - Carlos D Minacapelli
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, the United States; Center for Liver Diseases and Masses, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, the United States
| | - Kaitlyn Catalano
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, the United States; Center for Liver Diseases and Masses, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, the United States
| | - Hansel Suthar
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, the United States; Center for Liver Diseases and Masses, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, the United States
| | - Vinod K Rustgi
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, the United States; Center for Liver Diseases and Masses, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, the United States.
| |
Collapse
|
2
|
Effect of Doxycycline in Decreasing the Severity of Clostridioides difficile Infection in Mice. Antibiotics (Basel) 2022; 11:antibiotics11010116. [PMID: 35052993 PMCID: PMC8772929 DOI: 10.3390/antibiotics11010116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/05/2022] [Accepted: 01/11/2022] [Indexed: 11/28/2022] Open
Abstract
Background: Doxycycline possesses antibacterial activity against Clostridioides difficile and anti-inflammatory effects. Materials and Methods: The influence of doxycycline on the development of CDI was studied in an established animal model of CDI using C57BL/6 mice. Results: Mice intraperitoneally administered doxycycline had higher cecum weight (1.3 ± 0.1 vs. 0.5 ± 0.1 g; p < 0.001) and less body weight reduction (0.7 ± 0.5 g vs. −17.4 ± 0.2 g; p < 0.001) than untreated mice infected with C. difficile. Oral doxycycline, metronidazole, or vancomycin therapy resulted in less body weight reduction in mice with CDI than in untreated mice (1.1 ± 0.1 g, 1.3 ± 0.2 g, 1.2 ± 0.1 g, vs. 2.9 ± 0.3 g; p < 0.001). Doxycycline therapy led to lower expression levels of inflammatory cytokines, such as macrophage inflammatory protein-2 (0.4 ± 0.1 vs. 2.9 ± 1.3, p = 0.02), and higher levels of zonula occludens-1 (1.2 ± 0.1 vs. 0.8 ± 0.1, p = 0.02) in colonic tissues than in untreated mice. Conclusions: Concurrent intraperitoneal administration of doxycycline and oral C. difficile challenge does not aggravate the disease severity of CDI, and oral doxycycline may be a potential therapeutic option for CDI.
Collapse
|
3
|
Lee PC, Chang TE, Wang YP, Lee KC, Lin YT, Chiou JJ, Huang CW, Yang UC, Li FY, Huang HC, Wu CY, Huang YH, Hou MC. Alteration of gut microbial composition associated with the therapeutic efficacy of fecal microbiota transplantation in Clostridium difficile infection. J Formos Med Assoc 2021; 121:1636-1646. [PMID: 34836663 DOI: 10.1016/j.jfma.2021.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 09/27/2021] [Accepted: 11/01/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND/PURPOSE Clostridium difficile infection (CDI) leads to a significant cause of hospital-acquired morbidity and mortality. Fecal microbiota transplantation (FMT) is effective to treat recurrent or refractory CDI (rCDI). However, the change of microbial composition contributed by FMT and its association with treatment outcomes is not well determined in Taiwan. We aimed to investigate the efficacy of FMT and the association with microbial alteration endemically. METHODS Twelve patients who received FMT for rCDI in Taipei Veterans General Hospital were prospectively enrolled from April 2019 to July 2020. The clinical assessments and fecal microbial analyses in comparison with fecal materials of unrelated donors were conducted before and after FMT. RESULTS The overall success rate of FMT for rCDI was 91.7%. A prominence of Proteobacteria, Gammaproteobacteria and Enterobacteriales were observed in the feces of patients with rCDI. Increased fecal phylogenetic diversities and a significant microbial dissimilarity were provided by successful FMT compared to patients before treatment. However, the distinctness was not obvious between patients' feces at baseline and after unsuccessful FMT. Moreover, dynamic change of fecal microbial composition after FMT was observed during follow-up but did not interrupt the treatment effects of FMT. CONCLUSION Gut dysbiosis commonly co-exists in patients with rCDI. Restoration of gut microbial communities by FMT provides a promising strategy to treat antibiotic-failed CDI, and the extent of microbial change would be related to the treatment outcomes of FMT. Besides, the effectiveness of FMT for CDI could be maintained even the gut microbiota has diverged over time.
Collapse
Affiliation(s)
- Pei-Chang Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Pharmacology, National Yang Ming Chiao Tung University, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tien-En Chang
- Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yen-Po Wang
- Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Kuei-Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Tsung Lin
- Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jen-Jie Chiou
- Institute of Biomedical Informatics, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chi-Wei Huang
- Institute of Biomedical Informatics, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ueng-Cheng Yang
- Institute of Biomedical Informatics, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Fen-Yau Li
- Department of Pathology, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hui-Chun Huang
- Division of General Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chun-Ying Wu
- Division of Basic Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Biomedical Informatics, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ming-Chih Hou
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| |
Collapse
|
4
|
Risk factors of Clostridium difficile-associated diarrhea in hospitalized adults: Vary by hospitalized duration. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2021; 54:276-283. [DOI: 10.1016/j.jmii.2019.07.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/17/2019] [Accepted: 07/29/2019] [Indexed: 02/06/2023]
|
5
|
Wu KS, Syue LS, Cheng A, Yen TY, Chen HM, Chiu YH, Hsu YL, Chiu CH, Su TY, Tsai WL, Chen WY, Huang CH, Hung HM, Huang LJ, Kuo HJ, Lin PC, Yang CH, Hong PL, Lee SSJ, Chen YS, Liu YC, Huang LM. Recommendations and guidelines for the treatment of Clostridioides difficile infection in Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2020; 53:191-208. [PMID: 32169531 DOI: 10.1016/j.jmii.2020.02.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 01/19/2020] [Accepted: 02/01/2020] [Indexed: 12/13/2022]
Abstract
Clostridioides difficile infection (CDI) is a major enteric disease associated with antibiotic use and a leading cause of hospital-acquired infections worldwide. This is the first guideline for treatment of CDI in Taiwan, aiming to optimize medical care for patients with CDI. The target audience of this document includes all healthcare personnel who are involved in the medical care of patients with CDI. The 2018 Guidelines Recommendations for Evidence-based Antimicrobial agents use in Taiwan (GREAT) working group was formed, comprising of infectious disease specialists from 13 medical centers in Taiwan, to review the evidence and draft recommendations using the grading of recommendations assessment, development, and evaluation (GRADE) methodology. A nationwide expert panel reviewed the recommendations during a consensus meeting in March 2019. The recommendation is endorsed by the Infectious Diseases Society of Taiwan (IDST). This guideline describes the epidemiology and risk factors of CDI, and provides recommendations for treatment of CDI in both adults and children. Recommendations for treatment of the first episode of CDI, first recurrence, second and subsequent recurrences of CDI, severe CDI, fulminant CDI, and pediatric CDI are provided.
Collapse
Affiliation(s)
- Kuan-Sheng Wu
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ling-Shan Syue
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Aristine Cheng
- Division of Infectious Diseases, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ting-Yu Yen
- Departments of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hsien-Meng Chen
- Division of Infectious Disease, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Yu-Hsin Chiu
- Division of Infectious Diseases, Chi-Mei Medical Center, Tainan, Taiwan
| | - Yu-Lung Hsu
- Division of Pediatric Infectious Diseases, China Medical University Children's Hospital, China Medical University, Taichung, Taiwan
| | - Chun-Hsiang Chiu
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ting-Yi Su
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Wan-Lin Tsai
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Wei-Yu Chen
- Division of General Medicine, Infectious Disease, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Chung-Hao Huang
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Huei-Min Hung
- Department of Pediatrics, Chang Gung Children's Hospital, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ling-Ju Huang
- Division of General Medicine, Infectious Diseases, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hong-Jie Kuo
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Pei-Chin Lin
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Department of Pharmacy, School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Hsiang Yang
- Department of Pharmacy, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Pi-Lien Hong
- Department of Pharmacy, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Susan Shin-Jung Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Yao-Shen Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yung-Ching Liu
- Division of Infectious Diseases, Taipei Medical University Shuang Ho Hospital, Taipei, Taiwan
| | - Li-Ming Huang
- Departments of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| |
Collapse
|
6
|
Ho J, Wong SH, Doddangoudar VC, Boost MV, Tse G, Ip M. Regional differences in temporal incidence of Clostridium difficile infection: a systematic review and meta-analysis. Am J Infect Control 2020; 48:89-94. [PMID: 31387772 DOI: 10.1016/j.ajic.2019.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/07/2019] [Accepted: 07/08/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Previous decades have witnessed a change in the epidemiology of Clostridium difficile infections. This study aimed to determine temporal trends in the incidence of C difficile infection across geographic regions. METHODS An initial search of the relevant literature was conducted from date inception to October 2018 without language restriction. We estimated the pooled incidences using logit transformation, weighted by inverse variance. The Joinpoint Regression Analysis Program was used to explore its temporal trend. RESULTS Globally, the estimated incidence of C difficile infection increased from 6.60 per 10,000 patient-days in 1997 to 13.8 per 10,000 patient-days in 2004. Thereafter, a significant downward trend was observed, at -8.75% annually until 2015. From 2005 to 2015, the incidences in most European countries decreased at a rate between 1.97% and 4.11% per annum, except in France, where an increasing incidence was observed (β = 0.16; P < .001). The incidences have stabilized in North America over the same period; however, in Asia, the incidence increased significantly from 2006 to 2014 (annualized percentage change = 14.4%; P < .001). The increase was greatest in Western Asian countries, including Turkey and Israel (β > 0.10; P < .004). CONCLUSIONS This study revealed rapid changes in the incidence of C difficile infection. This meta-analysis should inform the allocation of resources for controlling C difficile infection and future surveillance efforts in countries where epidemiologic information on C difficile infection remains sparse.
Collapse
Affiliation(s)
- Jeffery Ho
- Department of Microbiology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong.
| | - Sunny H Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Vijaya C Doddangoudar
- Nitte Gulabi Shetty Memorial Institute of Pharmaceutical Sciences, Nitte University, India
| | - Maureen V Boost
- School of Optometry, The Hong Kong Polytechnic University, Hong Kong
| | - Gary Tse
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Margaret Ip
- Department of Microbiology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| |
Collapse
|
7
|
Chu Y, Lee C, Chen H, Hung C. Predictors of mortality in patients with
Clostridium difficile
infection. ADVANCES IN DIGESTIVE MEDICINE 2019. [DOI: 10.1002/aid2.13159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Yu‐Ming Chu
- Division of Digestive Medicine, Department of Internal MedicineCathay General Hospital Taipei City Taiwan
| | - Chia‐Long Lee
- Division of Digestive Medicine, Department of Internal MedicineCathay General Hospital Taipei City Taiwan
| | - Hsin‐Yu Chen
- Division of Digestive Medicine, Department of Internal MedicineCathay General Hospital Taipei City Taiwan
| | - Chih‐Sheng Hung
- Division of Digestive Medicine, Department of Internal MedicineCathay General Hospital Taipei City Taiwan
| |
Collapse
|
8
|
Lin TC, Hung YP, Ko WC, Ruan JW. Fecal microbiota transplantation for Clostridium difficile infection in Taiwan: Establishment and implementation. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2019; 52:841-850. [PMID: 31607571 DOI: 10.1016/j.jmii.2019.08.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 08/22/2019] [Accepted: 08/25/2019] [Indexed: 12/17/2022]
Abstract
Clostridium difficile infection (CDI) remains a major public health issue, and fecal microbiota transplantation (FMT) has become one of the standard therapies for recurrent or refractory CDI. When compared to medical therapies, such as metronidazole or vancomycin, FMT has a high rate of treatment response with acceptable safety and efficiency. Following promulgation of the amendments in September 2018 in Taiwan, FMT has been indicated for recurrent or refractory CDI. The Taiwan Microbiota Consortium contributed to the Taiwan FMT Expert Consensus, which established basic norms and stipulated essential principles, including the indications for transplantation, eligible locations and personnel, donor screening policies, fecal sample handling, and post-FMT follow-up. However, establishing an eligible FMT team in a qualified hospital remains a clinical challenge, and the requirement for facilities and well-screened donors impedes the implementation of FMT. In this review, we aim to provide domestic FMT teams with explicit instructions to facilitate realization and increase the practice of FMT. Based on the Taiwan FMT Expert Consensus and current regulations, we performed a literature review and integrated the experiences of Taiwanese multidisciplinary experts into this article. The content intends to offer clinicians up-to-date evidence and highlight the essential points of FMT.
Collapse
Affiliation(s)
- Tien-Ching Lin
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yuan-Pin Hung
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Executive Yuan, Tainan, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Jhen-Wei Ruan
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Tainan, Taiwan.
| |
Collapse
|
9
|
Detecting Clostridium difficile outbreaks with ward-specific cut-off levels based on the Poisson distribution. Infect Control Hosp Epidemiol 2019; 40:265-266. [DOI: 10.1017/ice.2018.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
10
|
Balsells E, Shi T, Leese C, Lyell I, Burrows J, Wiuff C, Campbell H, Kyaw MH, Nair H. Global burden of Clostridium difficile infections: a systematic review and meta-analysis. J Glob Health 2019; 9:010407. [PMID: 30603078 PMCID: PMC6304170 DOI: 10.7189/jogh.09.010407] [Citation(s) in RCA: 150] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background Clostridium difficile is a leading cause of morbidity and mortality in several countries. However, there are limited evidence characterizing its role as a global public health problem. We conducted a systematic review to provide a comprehensive overview of C. difficile infections (CDI) rates. Methods Seven databases were searched (January 2016) to identify studies and surveillance reports published between 2005 and 2015 reporting CDI incidence rates. CDI incidence rates for health care facility-associated (HCF), hospital onset-health care facility-associated, medical or general intensive care unit (ICU), internal medicine (IM), long-term care facility (LTCF), and community-associated (CA) were extracted and standardized. Meta-analysis was conducted using a random effects model. Results 229 publications, with data from 41 countries, were included. The overall rate of HCF-CDI was 2.24 (95% confidence interval CI = 1.66-3.03) per 1000 admissions/y and 3.54 (95%CI = 3.19-3.92) per 10 000 patient-days/y. Estimated rates for CDI with onset in ICU or IM wards were 11.08 (95%CI = 7.19-17.08) and 10.80 (95%CI = 3.15-37.06) per 1000 admission/y, respectively. Rates for CA-CDI were lower: 0.55 (95%CI = 0.13-2.37) per 1000 admissions/y. CDI rates were generally higher in North America and among the elderly but similar rates were identified in other regions and age groups. Conclusions Our review highlights the widespread burden of disease of C. difficile, evidence gaps, and the need for sustainable surveillance of CDI in the health care setting and the community.
Collapse
Affiliation(s)
- Evelyn Balsells
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Joint first authorship
| | - Ting Shi
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Joint first authorship
| | - Callum Leese
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Iona Lyell
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - John Burrows
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | | | - Harry Campbell
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Moe H Kyaw
- Sanofi Pasteur, Swiftwater, Pennsylvania, USA.,Joint last authorship
| | - Harish Nair
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Joint last authorship
| |
Collapse
|
11
|
Clostridium difficile-associated Diarrhea in Developing Countries: A Systematic Review and Meta-Analysis. Infect Dis Ther 2019; 8:87-103. [PMID: 30659481 PMCID: PMC6374231 DOI: 10.1007/s40121-019-0231-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Indexed: 02/08/2023] Open
Abstract
Introduction The prevalence of Clostridium difficile infection is rapidly increasing worldwide, but prevalence is difficult to estimate in developing countries where awareness, diagnostic resources, and surveillance protocols are limited. As diarrhea is the hallmark symptom, we conducted a systematic review and meta-analysis to determine the prevalence and incidence of C. difficile infection in patients in these regions who presented with diarrhea. Methods We conducted a systematic literature search of MEDLINE/PubMed, Scopus, and Latin-American and Caribbean Health Sciences Literature databases to identify and analyze data from recent studies providing prevalence or incidence rates of C. difficile-associated diarrhea in developing countries within four regions: Africa–Middle East, developing Asia, Latin America, and China. Our objectives were to determine the current prevalence and incidence density rates of first episodes of C. difficile-associated diarrhea in developing countries. Results Within the regions included in our analysis, prevalence of C. difficile infection in patients with diarrhea was 15% (95% CI 13–17%) (including community and hospitalized patients), with no significant difference across regions. The incidence of C. difficile infection in 17 studies including this information was 8.5 per 10,000 patient-days (95% CI 5.83–12.46). Prevalence was significantly higher in hospitalized patients versus community patients (p = 0.0227). Conclusion Our prevalence estimate of 15% is concerning; however, low awareness and inconsistent diagnostic and surveillance protocols suggest this is markedly underestimated. Enhanced awareness and management of C. difficile infection in patients with diarrhea, along with improvements in infection control and surveillance practices, should be implemented to reduce prevalence of C. difficile-associated diarrhea in developing countries. Funding Pfizer Inc. Electronic supplementary material The online version of this article (10.1007/s40121-019-0231-8) contains supplementary material, which is available to authorized users.
Collapse
|
12
|
Clostridium difficile co-infection in inflammatory bowel disease is associated with significantly increased in-hospital mortality. Eur J Gastroenterol Hepatol 2018; 30:1041-1046. [PMID: 29894325 DOI: 10.1097/meg.0000000000001185] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Inflammatory bowel disease (IBD) patients with Clostridium difficile co-infection (CDCI) have an increased risk of morbidity and mortality. We aim to evaluate the impact of CDCI on in-hospital outcomes among adults with IBD hospitalized in the USA. PATIENTS AND METHODS Using the 2007-2013 Nationwide Inpatient Sample, hospitalizations among US adults with Crohn's disease (CD), ulcerative colitis (UC) and CDCI were identified using ICD-9 coding. Hospital charges, hospital length of stay (LOS), and in-hospital mortality was stratified by CD and UC and compared using χ-testing and Student's t-test. Predictors of hospital charges, LOS, and in-hospital mortality were evaluated with multivariate regression models and were adjusted for age, sex, race/ethnicity, year, insurance status, hospital characteristics, and CDCI. RESULTS Among 224 500 IBD hospitalizations (174 629 CD and 49 871 UC), overall prevalence of CDCI was 1.22% in CD and 3.41% in UC. On multivariate linear regression, CDCI was associated with longer LOS among CD [coefficient: 5.30, 95% confidence interval (CI): 4.61-5.99, P<0.001] and UC (coefficient 4.08, 95% CI: 3.54-4.62, P<0.001). Higher hospital charges associated with CDCI were seen among CD (coefficient: $35 720, 95% CI: $30 041-$41 399, P<0.001) and UC (coefficient: $26 009, 95% CI: $20 970-$31 046, P<0.001). On multivariate logistic regression, CDCI was associated with greater risk of in-hospital mortality (CD: odds ratio: 2.74, 95% CI: 1.94-3.87, P<0.001; UC: OR: 5.50, 95% CI: 3.83-7.89, P<0.001). CONCLUSION Among US adults with CD and UC related hospitalizations, CDCI is associated with significantly greater in-hospital mortality and greater healthcare utilization.
Collapse
|
13
|
Hung YP, Tsai PJ, Lee YT, Tang HJ, Lin HJ, Liu HC, Lee JC, Tsai BY, Hsueh PR, Ko WC. Nationwide surveillance of ribotypes and antimicrobial susceptibilities of toxigenic Clostridium difficile isolates with an emphasis on reduced doxycycline and tigecycline susceptibilities among ribotype 078 lineage isolates in Taiwan. Infect Drug Resist 2018; 11:1197-1203. [PMID: 30147348 PMCID: PMC6101014 DOI: 10.2147/idr.s162874] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objectives The information of antimicrobial susceptibility, toxin gene, and ribotype distribution of toxigenic Clostridium difficile isolates in Taiwan remain limited. Patients and methods The study was conducted from January 2015 to December 2016 in 5 hospitals in Taiwan. Adults aged ≥20 years with a hospital stay for >5 days were included, and those with colectomy or intestinal infection due to other enteropathogens were excluded. Multiplex PCR was used to detect tcdA, tcdB, cdtA, cdtB, and tcdC deletions, and antimicrobial susceptibility for metronidazole, vancomycin, doxycycline, and tigecycline was investigated. Ribotypes of those isolates with tcdC deletion and tcdA+/tcdB+ were determined. Results Of 1112 C. difficile isolates collected from adults at 5 hospitals, 842 were toxigenic, including 749 (89.0%) tcdA+/tcdB+ isolates and 93 (11.0%) tcdA−/tcdB+. Of the toxigenic isolates, 76 (9.0%) had a tcdC deletion and were cdtA+/cdtB+, indicative of hypervirulence, and RT078 lineage, including RT126, RT127, and RT078, predominated (n=53, 76.3%). Similar to the susceptibility data in Asia countries, metronidazole or vancomycin resistance was rare, noted in 1.2% or 2.1%, respectively. Reduced doxycycline susceptibility (minimum inhibitory concentration [MIC] of ≥8 mg/L) was more common among RT078 lineage than non-RT078 lineage (75.9%, 44/58 vs 6.0%, 47/784; P<0.001). Also reduced tigecycline susceptibility (MIC ≥0.125 mg/L) was more common among RT078 lineage (20.7%, 12/58 vs 6.5%, 51/784; P<0.001). Conclusion In Taiwan, toxigenic C. difficile isolates remain susceptible to metronidazole and vancomycin. RT078 lineage predominated among toxigenic isolates with cdtA, cdtB, and tcdC deletion, and more often had reduced doxycycline and tigecycline susceptibility than the isolates other than RT078 lineage.
Collapse
Affiliation(s)
- Yuan-Pin Hung
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, .,Graduate Institute of Clinical Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Pei-Jane Tsai
- Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yuan-Ti Lee
- Institute of Medicine and School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Division of Infectious Diseases, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Hung-Jen Tang
- Department of Internal Medicine, Chi-Mei Hospital, Tainan, Taiwan
| | - Hsiao-Ju Lin
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, .,Graduate Institute of Clinical Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hsiu-Chuan Liu
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan
| | - Jen-Chieh Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan,
| | - Bo-Yang Tsai
- Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po-Ren Hsueh
- Departments of Laboratory Medicine and Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan,
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, .,Center of Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan, .,Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan,
| |
Collapse
|
14
|
Abstract
Clostridium difficile is an anaerobic, Gram-positive, spore-forming, toxin-secreting bacillus that has long been recognized to be the most common etiologic pathogen of antibiotic-associated diarrhea. C. difficile infection (CDI) is now the most common cause of health care-associated infections in the United States and accounts for 12% of these infections (Magill SS et al., N Engl J Med370:1198-1208, 2014). Among emerging pathogens of public health importance in the United States, CDI has the highest population-based incidence, estimated at 147 per 100,000 (Lessa FC et al., N Engl J Med372:825-834, 2015). In a report on antimicrobial resistance, C. difficile has been categorized by the Centers for Disease Control and Prevention as one of three "urgent" threats (http://www.cdc.gov/drugresistance/threat-report-2013/). Although C. difficile was first described in the late 1970s, the past decade has seen the emergence of hypertoxigenic strains that have caused increased morbidity and mortality worldwide. Pathogenic strains, host susceptibility, and other regional factors vary and may influence the clinical manifestation and approach to intervention. In this article, we describe the global epidemiology of CDI featuring the different strains in circulation outside of North America and Europe where strain NAP1/027/BI/III had originally gained prominence. The elderly population in health care settings has been disproportionately affected, but emergence of CDI in children and healthy young adults in community settings has, likewise, been reported. New approaches in management, including fecal microbiota transplantation, are discussed.
Collapse
|
15
|
Borren NZ, Ghadermarzi S, Hutfless S, Ananthakrishnan AN. The emergence of Clostridium difficile infection in Asia: A systematic review and meta-analysis of incidence and impact. PLoS One 2017; 12:e0176797. [PMID: 28463987 PMCID: PMC5413003 DOI: 10.1371/journal.pone.0176797] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 04/17/2017] [Indexed: 12/18/2022] Open
Abstract
Background Clostridium difficile infection (CDI) is the most common healthcare associated infection and is highly prevalent in Europe and North America. Limited data is available on the prevalence of CDI in Asia. However, secular increases in prevalence of risk factors for CDI suggest that it may be emerging as a major cause of morbidity, highlighting the urgent need for a systematic study of the prevalence of CDI in Asia. Methods We systematically searched PubMed/Medline and Embase for publications from Asia between 2000–16 examining prevalence of CDI. A random-effects meta-analysis was performed to calculate the pooled prevalence of CDI in Asia and to identify subgroups and regions at high risk. Results Our meta-analysis included 51 studies from throughout Asia including 37,663 patients at risk among whom confirmed CDI was found in 4,343 patients. The pooled proportion of confirmed CDI among all patients with diarrhea was 14.8% with a higher prevalence in East Asia (19.5%), compared with South Asia (10.5%) or the Middle East (11.1%). There were an estimated 5.3 episodes of CDI per 10,000 patient days, similar to rates reported from Europe and North America. Infections due to hypervirulent strains were rare. CDI-related mortality was 8.9%. Conclusions In a meta-analysis of 51 studies, we observed similar rates of CDI in Asia in comparison to Europe and North America. Increased awareness and improved surveillance of Clostridium difficile is essential to reduce incidence and morbidity.
Collapse
Affiliation(s)
- Nienke Z. Borren
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- University of Groningen, Groningen, The Netherlands
| | - Shadi Ghadermarzi
- Division of Gastroenterology & Hepatology, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Susan Hutfless
- Division of Gastroenterology & Hepatology, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Ashwin N. Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| |
Collapse
|
16
|
Tsai CS, Hung YP, Lee JC, Lee NY, Chen PL, Syue LS, Li MC, Li CW, Ko WC. Community-onset Clostridium difficile infection at a tertiary medical center in southern Taiwan, 2007-2015. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2016; 51:243-250. [PMID: 28089100 DOI: 10.1016/j.jmii.2016.08.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 08/22/2016] [Accepted: 08/23/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is well-known as the major cause of infectious diarrhea in hospitalized patients. Community-onset CDI (CO-CDI) is an emerging threat. However, clinical information of CO-CDI in Taiwan remains scarce. METHODS A retrospective study was conducted at a medical center in southern Taiwan. Symptomatic patients between 2007 and 2015 with C. difficile toxin or tcdB detected in stool were identified as CDI, and were classified as CO-CDI [including community-associated CDI (CA-CDI) and community-onset health care facility-associated CDI (CO-HCFA-CDI)] and health care facility-onset CDI (HCFO-CDI). RESULTS Of 427 patients, 15 (3.5%) were CA-CDI, 49 (11.5%) CO-HCFA-CDI, and 363 (85.0%) HCFO-CDI. Despite major involvement of the elderly (mean age: 66.1 years vs. 69.9 years, p = 0.46), no significant differences were noted between CA-CDI and CO-HCFA-CDI groups, except that solid organ cancer was more common in the CO-HCFA-CDI group. The CO-CDI group more often presented with abdominal pain but had shorter hospital stays and less exposure of proton-pump inhibitors or broad-spectrum antibiotics than the HCFO-CDI group did. The mortality rate related to CDI was 4.7% (3 patients) in the CO-CDI group. Despite a lower in-hospital mortality rate in the CO-CDI group (10.9% vs. 22.0%; p = 0.04), the recurrence rate was similar (10.9% vs. 7.2%; p = 0.3). CONCLUSIONS CO-CDI is not common but associated with substantial morbidity and mortality. Physicians should put CDI into consideration among patients who present community-onset fever, diarrhea, or abdominal pain alone or in combination.
Collapse
Affiliation(s)
- Chin-Shiang Tsai
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yuan-Pin Hung
- Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan; Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Executive Yuan, Tainan, Taiwan
| | - Jen-Chieh Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Nan-Yao Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan
| | - Po-Lin Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan
| | - Ling-Shan Syue
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ming-Chi Li
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chia-Wen Li
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan.
| |
Collapse
|
17
|
Clostridium difficile Infections in Medical Intensive Care Units of a Medical Center in Southern Taiwan: Variable Seasonality and Disease Severity. PLoS One 2016; 11:e0160760. [PMID: 27509051 PMCID: PMC4979958 DOI: 10.1371/journal.pone.0160760] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 07/25/2016] [Indexed: 01/24/2023] Open
Abstract
Critical patients are susceptible to Clostridium difficile infections (CDIs), which cause significant morbidity and mortality in the hospital. In Taiwan, the epidemiology of CDI in intensive care units (ICUs) is not well understood. This study was aimed to describe the incidence and the characteristics of CDI in the ICUs of a medical center in southern Taiwan. Adult patients with diarrhea but without colostomy/colectomy or laxative use were enrolled. Stool samples were collected with or without 5 ml alcohol and were plated on cycloserine-cefoxitin-fructose agar. C. difficile identification was confirmed by polymerase chain reaction. There were 1,551 patients admitted to ICUs, 1,488 screened, and 145 with diarrhea. A total of 75 patients were excluded due either to laxative use, a lack of stool samples, or refusal. Overall, 70 patients were included, and 14 (20%) were diagnosed with CDI, with an incidence of 8.8 cases per 10,000 patient-days. The incidence of CDI was found to be highest in March 2013 and lowest in the last quarter of 2013. The cases were categorized as the following: 5 severe, complicated, 5 severe, and 4 mild or moderate diseases. Among the 14 cases of CDI, the median patient age was 74 (range: 47-94) years, and the median time from admission to diarrhea onset was 16.5 (4-53) days. Eight cases received antimicrobial treatment (primarily metronidazole), and the time to diarrheal resolution was 11.5 days. Though 6 cases were left untreated, no patients died of CDI. The in-hospital mortality of CDI cases was 50%, similar to that of patients without CDI (46.4%; P = 1.0). We concluded that the overall incidence of CDI in our medical ICUs was low and there were variable seasonal incidences and disease severities of CDI.
Collapse
|
18
|
Wu YC, Lee JJ, Tsai BY, Liu YF, Chen CM, Tien N, Tsai PJ, Chen TH. Potentially hypervirulent Clostridium difficile PCR ribotype 078 lineage isolates in pigs and possible implications for humans in Taiwan. Int J Med Microbiol 2016; 306:115-22. [PMID: 26915500 DOI: 10.1016/j.ijmm.2016.02.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 02/02/2016] [Accepted: 02/07/2016] [Indexed: 12/30/2022] Open
Abstract
Clostridium difficile is a human and animal pathogen. Recently, the incidence of community-acquired C. difficile infection has increased, and many studies have indicated that C. difficile might be food-borne. The correlation between C. difficile infection in humans and in animals has been a topic of debate. The objective of this study was to determine the genetic relatedness of C. difficile from human and pigs in Taiwan. We investigated the molecular epidemiology of C. difficile in healthy humans and pigs from 2011 to 2015. The isolation rate of C. difficile from pigs in 13 commercial farms was 49% (100/204), and a high proportion of hypervirulent (C. difficile carrying tcdA, tcdB, and cdtA/B genes and a 39-bp deletion in the tcdC gene) ribotype 078 lineage isolates (90%, 90/100; including 078, 126, 127, and 066-like isolates) were identified. In addition, the C. difficile ribotype 127 isolates from pigs typically exhibited moxifloxacin resistance (37/43; 86%). In healthy humans, the isolation rate was 4.3% (3/69), and all healthy human isolates were non-toxigenic. In particular, we compared the porcine isolates with two patient strains (ribotype 127) obtained from two hospitals in central Taiwan. The multilocus variable number tandem repeat analysis revealed a high genetic relatedness between ribotype 127 from patients and pigs. This study indicated that isolates of the ribotype 078 lineage, and especially ribotype 127, were widely distributed in pig farms and showed a high frequency of moxifloxacin resistance. The closely related ribotype 127 from patients and pigs may have had a common origin or low diversity. In conclusion, C. difficile ribotype 127 is a noteworthy pathogen in pigs and poses a potential public health threat.
Collapse
Affiliation(s)
- Ying-Chen Wu
- Graduate Institute of Veterinary Pathobiology, College of Veterinary Medicine, National Chung Hsing University, No.250, Guoguang Rd., South Dist., Taichung 402, Taiwan.
| | - Jen-Jie Lee
- Graduate Institute of Veterinary Pathobiology, College of Veterinary Medicine, National Chung Hsing University, No.250, Guoguang Rd., South Dist., Taichung 402, Taiwan.
| | - Bo-Yang Tsai
- Department of Microbiology and Immunology, National Cheng Kung University, Medical College, No. 1, University Rd., Tainan 70101, Taiwan.
| | - Yi-Fen Liu
- Graduate Institute of Microbiology and Public Health, College of Veterinary Medicine, National Chung Hsing University, No.250, Guoguang Rd., South Dist., Taichung 402, Taiwan.
| | - Chih-Ming Chen
- Department of Internal Medicine, Tungs' Taichung MetroHarbor Hospital, No.699, Sec. 8, Taiwan Blvd., Taichung 435, Taiwan.
| | - Ni Tien
- Department of Laboratory Medicine, China Medical University Hospital, No.91 Hsuehshih Rd., Taichung 404, Taiwan.
| | - Pei-Jane Tsai
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Medical College, No. 1, University Rd., Tainan 70101, Taiwan.
| | - Ter-Hsin Chen
- Graduate Institute of Veterinary Pathobiology, College of Veterinary Medicine, National Chung Hsing University, No.250, Guoguang Rd., South Dist., Taichung 402, Taiwan.
| |
Collapse
|
19
|
Hung YP, Lee JC, Lin HJ, Liu HC, Wu YH, Tsai PJ, Ko WC. Doxycycline and Tigecycline: Two Friendly Drugs with a Low Association with Clostridium Difficile Infection. Antibiotics (Basel) 2015; 4:216-29. [PMID: 27025622 PMCID: PMC4790331 DOI: 10.3390/antibiotics4020216] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Revised: 04/25/2015] [Accepted: 06/15/2015] [Indexed: 12/29/2022] Open
Abstract
Clostridium difficile infection (CDI) is known to be associated with prior exposure to many classes of antibiotics. Standard therapy for CDI (i.e., metronidazole and vancomycin) is associated with high recurrence rates. Although tetracycline derivatives such as tetracycline, doxycycline or tigecycline are not the standard therapeutic choices for CDI, they may serve as an alternative or a component of combination therapy. Previous tetracycline or doxycycline usage had been shown to have less association with CDI development. Tigecycline, a broad-spectrum glycylcycline with potency against many gram-positive or gram-negative pathogens, had been successfully used to treat severe or refractory CDI. The in vitro susceptibility of C. difficile clinical isolates to tigecycline in many studies showed low minimal inhibitory concentrations. Tigecycline can suppress in vitro toxin production in both historical and hypervirulent C. difficile strains and reduce spore production in a dose-dependent manner. Tetracycline compounds such as doxycycline, minocycline, and tigecycline possess anti-inflammatory properties that are independent of their antibiotic activity and may contribute to their therapeutic effect for CDI. Although clinical data are limited, doxycycline is less likely to induce CDI, and tigecycline can be considered one of the therapeutic choices for severe or refractory CDI.
Collapse
Affiliation(s)
- Yuan-Pin Hung
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan 70043, Taiwan.
- Department of Internal Medicine, National Cheng Kung University Hospital, No. 138, Sheng Li Road, Tainan 70403, Taiwan.
- Graduate Institute of Clinical Medicine, National Health Research Institutes, Tainan 70403, Taiwan.
| | - Jen-Chieh Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, No. 138, Sheng Li Road, Tainan 70403, Taiwan.
| | - Hsiao-Ju Lin
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan 70043, Taiwan.
- Department of Internal Medicine, National Cheng Kung University Hospital, No. 138, Sheng Li Road, Tainan 70403, Taiwan.
- Graduate Institute of Clinical Medicine, National Health Research Institutes, Tainan 70403, Taiwan.
| | - Hsiao-Chieh Liu
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan 70043, Taiwan.
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Medical College, Tainan 70102, Taiwan.
| | - Yi-Hui Wu
- Department of Internal Medicine, E-da Hospital, Kaohsiung 82445, Taiwan.
| | - Pei-Jane Tsai
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Medical College, Tainan 70102, Taiwan.
- Center of Infectious Disease and Signaling Research, National Cheng Kung University, Tainan 70102, Taiwan.
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, No. 138, Sheng Li Road, Tainan 70403, Taiwan.
- Department of Medicine, National Cheng Kung University, Medical College, Tainan 70102, Taiwan.
| |
Collapse
|
20
|
Hung YP, Lee JC, Lin HJ, Liu HC, Wu YH, Tsai PJ, Ko WC. Clinical impact of Clostridium difficile colonization. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2015; 48:241-8. [DOI: 10.1016/j.jmii.2014.04.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 04/12/2014] [Accepted: 04/21/2014] [Indexed: 01/05/2023]
|
21
|
Hung YP, Ko WC, Chou PH, Chen YH, Lin HJ, Liu YH, Tsai HW, Lee JC, Tsai PJ. Proton-Pump Inhibitor Exposure Aggravates Clostridium difficile-Associated Colitis: Evidence From a Mouse Model. J Infect Dis 2015; 212:654-63. [PMID: 25805751 DOI: 10.1093/infdis/jiv184] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Accepted: 03/11/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Clostridium difficile is currently the leading cause of infectious diarrhea in hospitalized patients. In addition to the infection due to toxigenic C. difficile in the gastrointestinal tract of susceptible hosts, other predisposing factors for C. difficile infection (CDI) are identified, including advanced age, a prolonged hospital stay, and use of acid-suppressive drugs. Of note, exposure to gastric acid-reducing agents, such as H2 blockers and proton pump inhibitors (PPIs), remains a controversial risk factor, and has been associated with CDI in some studies but not in others. A mouse model of antibiotic-associated clostridial colitis was established to examine the role of PPIs for CDI. MATERIALS AND METHODS A mouse model of antibiotic-associated clostridial colitis was set up. NF-κB reporter mice were used to address the in vivo spatial and temporal inflammatory patterns of C. difficile-associated colitis. Serum levels of lipopolysaccharide and dextran-FITC were measured to reflect the barrier permeability of affected intestines. RESULTS Mice with CDI that were exposed to PPI exhibited greater losses of stool consistency and body and cecal weights than those that were not exposed to PPI. Further, more neutrophilic infiltrations, epithelial damage, and inflammatory cytokine expression were noted in colon specimens of the mice with PPI exposure. More-evident inflammatory responses were detected by in vivo imaging of NF-κB reporter mice with CDI that were exposed to PPI. Gut barrier permeability was increased to a greater extent, as reflected by higher serum levels of lipopolysaccharide and dextran-FITC in mice with CDI that were exposed to PPI. CONCLUSIONS Our mouse model demonstrates that PPI exposure increases the severity of intestinal inflammation in mice with C. difficile-associated colitis.
Collapse
Affiliation(s)
- Yuan-Pin Hung
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare Department of Internal Medicine Graduate Institute of Clinical Medicine, National Health Research Institutes, Tainan, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine Center for Infection Control, National Cheng Kung University Hospital Department of Medicine, National Cheng Kung University Medical College
| | - Po-Han Chou
- Department of Medical Laboratory Science and Biotechnology
| | - Yi-Hsuan Chen
- Department of Medical Laboratory Science and Biotechnology
| | - Hsiao-Ju Lin
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare Department of Internal Medicine Graduate Institute of Clinical Medicine, National Health Research Institutes, Tainan, Taiwan
| | - Ya-Hui Liu
- Department of Medical Laboratory Science and Biotechnology
| | | | | | - Pei-Jane Tsai
- Department of Medical Laboratory Science and Biotechnology Center of Infectious Disease and Signaling Research, National Cheng Kung University
| |
Collapse
|
22
|
Seek and you shall find: prevalence of Clostridium difficile in Wuhan, China. Am J Infect Control 2015; 43:301-2. [PMID: 25557771 DOI: 10.1016/j.ajic.2014.11.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 10/28/2014] [Accepted: 11/13/2014] [Indexed: 12/26/2022]
Abstract
Clostridium difficile infection (CDI) is one of the leading health care acquired-infections in the United States, but much of the epidemiology and burden of disease is unknown in China. The aim of this study was to determine the prevalence and possible risk factors of CDI among hospitalized patients with diarrhea in Wuhan, China. The overall prevalence of CDI was 28% (31/111). The findings of this study suggest the prevalence of CDI in hospitalized patients with diarrhea is higher then what has been previously reported in the current literature.
Collapse
|
23
|
Ji DD, Huang IH, Lai CC, Wu FT, Jiang DDS, Hsu BM, Lin WC. Prevalence and characterization of enterotoxigenic Bacteroides fragilis and toxigenic Clostridium difficile in a Taipei emergency department. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2014; 50:83-89. [PMID: 25648668 DOI: 10.1016/j.jmii.2014.12.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 12/11/2014] [Accepted: 12/17/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND/PURPOSE Enterotoxigenic Bacteroides fragilis (ETBF) and toxin-encoding Clostridium difficile (TXCD) are associated with gastroenteritis. Routine anaerobic blood culture for recovery of these anaerobic pathogens is not used for the detection of their toxins, especially for toxin-variant TXCD. The aim of this study was to investigate the prevalence and risk factors of the genotypes of these anaerobes in patients with acute diarrheal illnesses. METHODS The data and samples of 513 patients with gastroenteritis were collected in a Taipei emergency department from March 1, 2006 to December 31, 2009. Nonenterotoxigenic B. fragilis (NTBF) and ETBF and the toxin genotypes of TXCD were detected by molecular methods. RESULTS The prevalence rates of NTBF, ETBF, and TXCD infections were 33.14%, 1.56%, and 2.34%, respectively. ETBF infections often occurred in the elderly (average age = 67.13 years) and during the cold, dry winters. TXCD infections were widely distributed in age and often occurred in the warm, wet springs and summers. The symptoms of ETBF-infected patients were significantly more severe than those of NTBF-infected patients. CONCLUSION This study identified and analyzed the prevalence, risk factors, and clinical presentations of these anaerobic infections. Future epidemiologic and clinical studies are needed to understand the role of ETBF and TXCD in human gastroenteritis.
Collapse
Affiliation(s)
- Dar-Der Ji
- Department of Tropical Medicine, National Yang-Ming University, Taipei, Taiwan, ROC; Research and Diagnostics, Centers for Disease Control, Department of Health, Taiwan, ROC
| | - I-Hsiu Huang
- Department of Microbiology and Immunology, National Cheng Kung University, Tainan, Taiwan, ROC
| | - Chao-Chih Lai
- Emergency Department, Taipei City Hospital, Ren-Ai Branch, Taiwan, ROC
| | - Fang-Tzy Wu
- Research and Diagnostics, Centers for Disease Control, Department of Health, Taiwan, ROC
| | | | - Bing-Mu Hsu
- Department of Earth and Environmental Sciences, National Chung Cheng University, Chiayi, Taiwan, ROC
| | - Wei-Chen Lin
- Department of Parasitology, National Cheng Kung University, Tainan, Taiwan, ROC.
| |
Collapse
|
24
|
Clostridium difficile ribotype 126 in southern Taiwan: A cluster of three symptomatic cases. Anaerobe 2014; 30:188-92. [DOI: 10.1016/j.anaerobe.2014.06.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Accepted: 06/05/2014] [Indexed: 11/18/2022]
|
25
|
Hung YP, Lin HJ, Wu CJ, Chen PL, Lee JC, Liu HC, Wu YH, Yeh FH, Tsai PJ, Ko WC. Vancomycin-resistant Clostridium innocuum bacteremia following oral vancomycin for Clostridium difficile infection. Anaerobe 2014; 30:24-6. [PMID: 25102472 DOI: 10.1016/j.anaerobe.2014.07.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 07/08/2014] [Accepted: 07/21/2014] [Indexed: 01/29/2023]
Abstract
An 85 year-old male initially admitted for septic shock due to urinary tract infection experienced Clostridium difficile-associated diarrhea during hospitalization and was treated by oral vancomycin. His clinical course was complicated by cytomegalovirus colitis and then vancomycin-resistant Clostridium innocuum bacteremia, which was cured by uneventfully parenteral piperacillin-tazobactam therapy.
Collapse
Affiliation(s)
- Yuan-Pin Hung
- Departments of Internal Medicine, Tainan Hospital, Ministry of Health & Welfare, Tainan, Taiwan; Department of Internal Medicine, National Cheng Kung University Hospital and Medical College, Tainan, Taiwan; Graduate Institute of Clinical Medicine, National Health Research Institutes, Tainan, Taiwan
| | - Hsiao-Ju Lin
- Departments of Internal Medicine, Tainan Hospital, Ministry of Health & Welfare, Tainan, Taiwan; Department of Internal Medicine, National Cheng Kung University Hospital and Medical College, Tainan, Taiwan; Graduate Institute of Clinical Medicine, National Health Research Institutes, Tainan, Taiwan
| | - Chi-Jung Wu
- Graduate Institute of Clinical Medicine, National Health Research Institutes, Tainan, Taiwan; National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Tainan, Taiwan
| | - Po-Lin Chen
- Department of Internal Medicine, National Cheng Kung University Hospital and Medical College, Tainan, Taiwan
| | - Jen-Chieh Lee
- Department of Internal Medicine, National Cheng Kung University Hospital and Medical College, Tainan, Taiwan
| | - Hsiao-Chieh Liu
- Departments of Internal Medicine, Tainan Hospital, Ministry of Health & Welfare, Tainan, Taiwan; Experiment and Diagnosis, Tainan Hospital, Ministry of Health & Welfare, Tainan, Taiwan
| | - Yi-Hui Wu
- Department of Internal Medicine, E-Da Hospital, Kaohsiung, Taiwan
| | - Fang Hao Yeh
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Medical College, Tainan, Taiwan
| | - Pei-Jane Tsai
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Medical College, Tainan, Taiwan; Center of Infectious Disease and Signaling Research, National Cheng Kung University, Tainan City, Taiwan.
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital and Medical College, Tainan, Taiwan.
| |
Collapse
|
26
|
Yoshizawa N, Matsui T, Yano Y, Nakabayashi S, Seki T, Aritomi T. Prevalence of Clostridium difficile Infection in a Regional Core Hospital and Related Factors. ACTA ACUST UNITED AC 2014. [DOI: 10.3862/jcoloproctology.67.74] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|
27
|
Otete EH, Ahankari AS, Jones H, Bolton KJ, Jordan CW, Boswell TC, Wilcox MH, Ferguson NM, Beck CR, Puleston RL. Parameters for the mathematical modelling of Clostridium difficile acquisition and transmission: a systematic review. PLoS One 2013; 8:e84224. [PMID: 24376797 PMCID: PMC3869946 DOI: 10.1371/journal.pone.0084224] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 11/12/2013] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Mathematical modelling of Clostridium difficile infection dynamics could contribute to the optimisation of strategies for its prevention and control. The objective of this systematic review was to summarise the available literature specifically identifying the quantitative parameters required for a compartmental mathematical model of Clostridium difficile transmission. METHODS Six electronic healthcare databases were searched and all screening, data extraction and study quality assessments were undertaken in duplicate. Results were synthesised using a narrative approach. RESULTS Fifty-four studies met the inclusion criteria. Reproduction numbers for hospital based epidemics were described in two studies with a range from 0.55 to 7. Two studies provided consistent data on incubation periods. For 62% of cases, symptoms occurred in less than 4 weeks (3-28 days) after infection. Evidence on contact patterns was identified in four studies but with limited data reported for populating a mathematical model. Two studies, including one without clinically apparent donor-recipient pairs, provided information on serial intervals for household or ward contacts, showing transmission intervals of <1 week in ward based contacts compared to up to 2 months for household contacts. Eight studies reported recovery rates of between 75%-100% for patients who had been treated with either metronidazole or vancomycin. Forty-nine studies gave recurrence rates of between 3% and 49% but were limited by varying definitions of recurrence. No study was found which specifically reported force of infection or net reproduction numbers. CONCLUSIONS There is currently scant literature overtly citing estimates of the parameters required to inform the quantitative modelling of Clostridium difficile transmission. Further high quality studies to investigate transmission parameters are required, including through review of published epidemiological studies where these quantitative estimates may not have been explicitly estimated, but that nonetheless contain the relevant data to allow their calculation.
Collapse
Affiliation(s)
- Eroboghene H. Otete
- School of Community Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Anand S. Ahankari
- School of Community Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Helen Jones
- School of Community Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Kirsty J. Bolton
- Melbourne School of Population and Global Health , University of Melbourne, Melbourne, Australia
- School of Mathematical Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Caroline W. Jordan
- NHS England Area Team Derbyshire, Nottingham and Nottinghamshire, United Kingdom
| | - Tim C. Boswell
- Department of Clinical Microbiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Mark H. Wilcox
- Department of Microbiology, University of Leeds, Leeds, United Kingdom
| | - Neil M. Ferguson
- School of Public Health, Imperial College London, London, United Kingdom
| | - Charles R. Beck
- School of Community Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Richard L. Puleston
- School of Community Health Sciences, University of Nottingham, Nottingham, United Kingdom
| |
Collapse
|
28
|
Chen YB, Gu SL, Wei ZQ, Shen P, Kong HS, Yang Q, Li LJ. Molecular epidemiology of Clostridium difficile in a tertiary hospital of China. J Med Microbiol 2013; 63:562-569. [PMID: 24344206 DOI: 10.1099/jmm.0.068668-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Clostridium difficile infection (CDI) is caused by toxin-producing strains. It accounts for 20-30 % of antibiotic-associated diarrhoea and particularly accounts for 90 % of pseudomembranous colitis. The epidemiological study of C. difficile is thus important. In this study, we report the molecular epidemiology and ward distribution of C. difficile in a tertiary hospital of China. A total of 161 toxigenic strains were isolated from 1845 patients originating from different wards and the strains were characterized based on toxin profile and multilocus sequence typing. Variable isolation rates were observed in different wards and the occurrence was higher in intensive care unit and geriatric wards. Toxin gene profiling revealed that, out of the 161 isolates, 134 (83.2)% were positive for both toxin A (tcdA) and toxin B (tcdB) (A+B+) followed by toxin A-negative and B-positive (A-B+) (16.8 %) isolates. However, only three of the toxigenic strains (1.9 %) were positive for both the cdtA and cdtB genes. Based on the molecular epidemiology study, a total of 30 different sequence types (STs), including one new ST (ST-220), were distinguishable. ST-54 was the most prevalent (23.0 %), followed by ST-35 (19.3 %) and ST-37 (10.0 %). None of the isolates belonged to ST-1 (ribotype 027) or ST-11 (ribotype 078). Taken together, the toxin profile and the molecular epidemiological data showed that all the ST-37 clades were of toxin type A-B+, which accounted for 59.3 % of all type A-B+ isolates. Meanwhile the clade 1 genotype, ST-54, was widely distributed among the geriatric, infection and haematology wards. There was no outbreak of C. difficile infection during our study; however the possibility of prolonged outbreaks cannot be completely ignored.
Collapse
Affiliation(s)
- Yun-Bo Chen
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, PR China.,State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, PR China
| | - Si-Lan Gu
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, PR China.,State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, PR China
| | - Ze-Qing Wei
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, PR China.,State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, PR China
| | - Ping Shen
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, PR China.,State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, PR China
| | - Hai-Sheng Kong
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, PR China.,State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, PR China
| | - Qing Yang
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, PR China.,State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, PR China
| | - Lan-Juan Li
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, PR China.,State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, PR China
| |
Collapse
|
29
|
Lin HJ, Hung YP, Liu HC, Lee JC, Lee CI, Wu YH, Tsai PJ, Ko WC. Risk factors for Clostridium difficile-associated diarrhea among hospitalized adults with fecal toxigenic C. difficile colonization. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2013; 48:183-9. [PMID: 24064285 DOI: 10.1016/j.jmii.2013.08.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 07/31/2013] [Accepted: 08/09/2013] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients with toxigenic Clostridium difficile colonization (tCDC) are at risk of developing C. difficile-associated diarrhea (CDAD). However, the risk factors of hospitalized patients with tCDC developing CDAD are not clear. METHODS We conducted an 18-month prospective study at a medical ward in a district hospital in southern Taiwan. Within 48 hours of admission, weekly stool samples from asymptomatic hospitalized patients were obtained to detect fecal CDC. A polymerase chain reaction for tcdB was performed to determine toxigenic isolates. CDAD was diagnosed if the patient had diarrhea and toxigenic C. difficile present in a stool sample. RESULTS A total 483 patients with stool samples were eligible for the study. Eighty-six (17.8%) patients had tCDC after screening, of whom 14 (16.3%) developed CDAD during follow-up. Among those with tCDC, patients with subsequent CDAD were more likely to have diabetes mellitus (p = 0.01) and to have received piperacillin-tazobactam (p = 0.04), or proton-pump inhibitors (PPIs; p = 0.04) than those without developing CDAD. The variables were statistically significant as determined by multivariate analysis. However, the 60-day crude mortality rates among tCDC patients with and without subsequent development of CDAD were similar. CONCLUSION Diabetes mellitus and recent receipt of piperacillin-tazobactam or PPIs are independent risk factors for the development of CDAD among hospitalized patients with tCDC.
Collapse
Affiliation(s)
- Hsiao-Ju Lin
- Department of Internal Medicine, Tainan Hospital, Department of Health, Executive Yuan, Tainan, Taiwan
| | - Yuan-Pin Hung
- Department of Internal Medicine, Tainan Hospital, Department of Health, Executive Yuan, Tainan, Taiwan; Graduate Institute of Clinical Medicine, National Health Research Institutes, Tainan, Taiwan
| | - Hsiu-Chuan Liu
- Department of Experiment and Diagnosis, Tainan Hospital, Department of Health, Executive Yuan, Tainan, Taiwan
| | - Jen-Chieh Lee
- Department of Internal Medicine, National Cheng Kung University Medical College and Hospital, Tainan, Taiwan
| | - Chih-I Lee
- Department of Internal Medicine, Tainan Hospital, Department of Health, Executive Yuan, Tainan, Taiwan
| | - Yi-Hui Wu
- Department of Internal Medicine, E-Da Hospital, Kaohsiung, Taiwan
| | - Pei-Jane Tsai
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University Medical College, Tainan, Taiwan.
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Medical College and Hospital, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Medical College and Hospital, Tainan, Taiwan; Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan.
| |
Collapse
|
30
|
Clinical manifestations of Clostridium difficile infection in a medical center in Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2013; 47:491-6. [PMID: 23978490 DOI: 10.1016/j.jmii.2013.06.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 06/10/2013] [Accepted: 06/24/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND/PURPOSE To investigate the clinical characteristics of Clostridium difficile infection (CDI) at a medical center in Taiwan. METHODS Patients with CDI were identified from medical records at the National Taiwan University Hospital (Taipei, Taiwan). The following information was gathered and analyzed to better understand the clinical manifestations of CDI: age; sex; underlying immunocompromised conditions; laboratory data; in-hospital mortality; and previous use of drugs such as antimicrobial agents, steroids, and antipeptic ulcer agents. RESULTS During the years 2000-2010, 122 patients were identified as having CDI. This included 92 patients with nontoxigenic CDI (i.e., positive stool culture for C. difficile but negative results for toxins A and B) and 30 patients with toxigenic CDI (i.e., positive stool culture cultures for C. difficile and positive results for toxins A and B). Of the 122 patients, 48 (39%) patients were older than 65 years and most patients acquired the CDI while in the hospital. Active cancer was the most common reason for hospitalization, followed by diabetes mellitus, and end-stage renal disease. More than 90% of the patients had received antibiotics before acquiring CDI. The results of fecal leukocyte examinations were positive in 33 (27%) patients. The overall in-hospital mortality rate was 26.2%. There were no significant differences between patients with nontoxigenic CDI and patients with toxigenic CDI. CONCLUSION Clostridium difficile infection can develop in healthcare facilities and in community settings, especially in immunocompromised patients.
Collapse
|
31
|
Hung YP, Lin HJ, Wu TC, Liu HC, Lee JC, Lee CI, Wu YH, Wan L, Tsai PJ, Ko WC. Risk factors of fecal toxigenic or non-toxigenic Clostridium difficile colonization: impact of Toll-like receptor polymorphisms and prior antibiotic exposure. PLoS One 2013; 8:e69577. [PMID: 23936050 PMCID: PMC3723847 DOI: 10.1371/journal.pone.0069577] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 06/10/2013] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND This study is to investigate the significance and risk factors of fecal toxigenic (tCdC) or non-toxigenic Clostridium difficile colonization (ntCdC) among hospitalized patients. METHODS Adults admitted to medical wards in a district hospital between January 2011 and June 2012 were enrolled, and those with a history of colectomy, C. difficile fecal colonization or infection or receipt of either metronidazole or oral vancomycin within 3 months, were excluded. Stools collected within 48 hours after admission and every week during hospitalization were cultured for C. difficile. FINDINGS Among the 441 enrolled patients, 84 (20.0%) had CdC at initial screening, including 58 (13.2%) with tCdC and 26 (6.8%) with ntCdC. Among patients with initial negative fecal screening for CdC, it took an average of 70.6 days or 66.5 days to develop tCdC or ntCdC during the study period. Finally 78 (17.7%) had tCdC and 34 (7.7%) had ntCdC. During the follow-up period, the patients with tCdC had a higher risk of CDAD (11/79, 14.1%) than those without CdC (3/328, 0.9%) and those with ntCdC (0/34, 0%) (P<0.001). In multivariate analysis, the TLR4 rs1927914 polymorphism (GG genotype) (odds ratio [OR] 4.4, 95% confidence interval [CI] 1.6-11.8, P = 0.003) and recent cefepime therapy (OR 5.3, 95% CI 2.1-13.2, P<0.001) were independently associated with tCdC, whereas recent cefuroxime (OR 11.7, 95% CI 2.3-60.2, P = 0.003) and glycopeptide therapy (OR 10.9, CI: 2.1-57.2, P = 0.005) associated with ntCdC. CONCLUSION The incidence of CDAD is highest in patients with tCdC and lowest in patients with ntCdC, and the TLR4 rs1927914 polymorphism GG genotype and recent cefepime therapy were independently associated with tCdC.
Collapse
Affiliation(s)
- Yuan-Pin Hung
- Department of Internal Medicine, Tainan Hospital, Department of Health, Executive Yuan, Tainan, Taiwan
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
- Graduate Institute of Clinical Medicine, National Health Research Institutes, Tainan, Taiwan
| | - Hsiao-Ju Lin
- Department of Internal Medicine, Tainan Hospital, Department of Health, Executive Yuan, Tainan, Taiwan
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
- Graduate Institute of Clinical Medicine, National Health Research Institutes, Tainan, Taiwan
| | - Tai-Chieh Wu
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Medical College, Tainan, Taiwan
| | - Hsiu-Chuan Liu
- Department of Experiment and Diagnosis, Tainan Hospital, Department of Health, Executive Yuan, Tainan, Taiwan
| | - Jen-Chieh Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chih-I Lee
- Department of Internal Medicine, Tainan Hospital, Department of Health, Executive Yuan, Tainan, Taiwan
| | - Yi-Hui Wu
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
- Department of Internal Medicine, PingTung Christian Hospita, PingTung, Taiwan
| | - Lei Wan
- School of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Pei-Jane Tsai
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Medical College, Tainan, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
- Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan
- Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan
| |
Collapse
|
32
|
Wei HL, Wei SH, Huang CW, Shih CH, Huang YW, Lu MC, Hsu JC, Liou YS, Chiou CS. Molecular typing and epidemiology of Clostridium difficile in respiratory care wards of central Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2013; 48:65-71. [PMID: 23726464 DOI: 10.1016/j.jmii.2013.03.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2012] [Revised: 02/27/2013] [Accepted: 03/28/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND/PURPOSE In industrialized countries, Clostridium difficile is the major cause of nosocomial diarrhea. This study involved a broad overview of baseline epidemiology for C. difficile in Taiwan. MATERIALS AND METHODS Point prevalence was estimated from a prospective survey conducted in the respiratory care wards of six hospitals in central Taiwan. Polymerase chain reaction (PCR) ribotyping and multiple-locus variable-number tandem-repeat analysis (MLVA) were performed on all toxigenic C. difficile isolates, including asymptomatic and symptomatic strains. RESULTS A total of 149 patients were screened for C. difficile; the point prevalence for C. difficile infection (CDI) and C. difficile colonization was 4% and 19%, respectively. CDI cases were significantly related to end-stage renal disease, and C. difficile colonization cases were significantly associated with previous admission to an acute-care facility. No hypervirulent PCR ribotype 027 strain was found. MLVA detected two clusters of CDI-related and three clusters of asymptomatic C. difficile strains circulating in wards. CONCLUSION Our results demonstrate a high prevalence of toxigenic C. difficile colonization in hospitals. Infection control personnel should pay attention to the increasing numbers of CDI cases, and molecular typing for C. difficile should be performed when necessary.
Collapse
Affiliation(s)
- Hsiao-Lun Wei
- The Central Region Laboratory, Centers for Disease Control, Taichung, Taiwan
| | - Sung-Hsi Wei
- The Third Branch Office, Centers for Disease Control, Taichung, Taiwan
| | | | | | | | - Min-Chi Lu
- Chung Shan Medical University Hospital, Taichung, Taiwan
| | | | | | - Chien-Shun Chiou
- The Central Region Laboratory, Centers for Disease Control, Taichung, Taiwan.
| |
Collapse
|
33
|
Analysis of anti-Clostridium difficile activity of thuricin CD, vancomycin, metronidazole, ramoplanin, and actagardine, both singly and in paired combinations. Antimicrob Agents Chemother 2013; 57:2882-6. [PMID: 23571539 DOI: 10.1128/aac.00261-13] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Due to the ongoing problem of recurrence of Clostridium difficile-associated diarrhea following antibiotic treatment, there is an urgent need for alternative treatment options. We assessed the MICs of five antimicrobials singly and in combinations against a range of C. difficile clinical isolates. Ramoplanin-actagardine combinations were particularly effective, with partial synergistic/additive effects observed against 61.5% of C. difficile strains tested.
Collapse
|
34
|
Abstract
The medical records of 84 patients with stool cultures positive for Clostridium difficile during the period August 2007 to June 2009 were retrospectively reviewed. A case of confirmed (toxigenic)C. difficile infection (CDI) was defined by the presence of symptoms (fever, diarrhoea, abdominal discomfort or distension, ileus) and the presence of toxigenic C. difficile. Patients with compatible clinical symptoms and stool cultures positive for non-toxigenic C. difficile isolates were defined as probable (non-toxigenic) CDI cases. Of these 84 patients, 50 (59.5%) were diagnosed as confirmed CDI and 34 (40.5%) as probable CDI. Thirteen (15.5%) of the 84 patients died during their hospital stay. Usage of proton pump inhibitors was a significant independent risk factor for CDI (OR 3.21, P=0.014). Of the 50 isolates associated with confirmed CDI, seven (8.3%) carried binary toxin genes (cdtAB), and six (7.1%) had a deletion in the tcdC gene. The mortality rate in confirmed CDI patients with isolates exhibiting deletion in the tcdC gene (2/6, 33.3%), those with isolates harbouring binary toxin genes (2/7, 28.6%), and those with isolates containing mutations in gyrA (2/7, 28.6%) and gyrB (1/2, 50%) was higher than the overall mortality rate (10/50, 20%) in patients with confirmed CDI.
Collapse
|
35
|
Hung YP, Tsai PJ, Hung KH, Liu HC, Lee CI, Lin HJ, Wu YH, Wu JJ, Ko WC. Impact of toxigenic Clostridium difficile colonization and infection among hospitalized adults at a district hospital in southern Taiwan. PLoS One 2012; 7:e42415. [PMID: 22876321 PMCID: PMC3411658 DOI: 10.1371/journal.pone.0042415] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 07/05/2012] [Indexed: 01/05/2023] Open
Abstract
Background The impact of toxigenic Clostridium difficile colonization (tCDC) in hospitalized patients is not clear. Aim To study the significance of tCDC in hospitalized patients. Methods A prospective study in the medical wards of a regional hospital was performed from January to June 2011. Fecal samples collected from patients at the time of admission were tested for tcdB by real-time polymerase chain reaction (PCR) and cultured for C. difficile. The patients were followed up weekly or when they developed diarrhea during hospitalization. If C. difficile was isolated, tcdA and tcdB would be tested by multiplex PCR. The primary outcome was the development of C. difficile-associated diarrhea (CDAD). Findings Of 168 patients enrolled, females predominated (87, 51.8%), and the mean patient age was 75.4 years old. Approximately 70% of the patients were nursing home residents, and one third had a recent hospitalization within the prior three months. Twenty-eight (16.7%) patients had tCDC, including 16 (9.5%) patients with tCDC at the time of admission and 12 (7.2%) with tCDC during the follow-up period. With regard to the medications taken during hospitalization, the patients were more likely to have tCDC if they had received more than one class of antibiotics than if they had received monotherapy (odds ratio [OR] 6.67, 95% confidence interval [CI] 1.41–31.56, P = 0.01), particularly if they received a glycopeptide in combination with a cephalosporin or penicillin or a cephalosporin and a carbapenem. More patients with tCDC developed CDAD than those without tCDC (17.9%, 5/28 vs. 1.4%, 2/140, P = 0.002). Overall 7 (4.2%) of the 168 patients developed CDAD, and crude mortality rate of those with and without tCDC was similar (21.4%, 6/28 vs. 19.4%, 27/140, P = 0.79). Conclusion Recent use of glycopeptides and β-lactam antibiotics is associated with toxigenic C. difficile colonization, which is a risk factor for developing C. difficile-associated diarrhea.
Collapse
Affiliation(s)
- Yuan-Pin Hung
- Department of Internal Medicine, Tainan Hospital, Department of Health, Executive Yuan, Tainan, Taiwan
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
- Graduate Institute of Clinical Medicine, National Health Research Institutes, Tainan, Taiwan
| | - Pei-Jane Tsai
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Medical College, Tainan, Taiwan
| | - Kuei-Hsiang Hung
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Medical College, Tainan, Taiwan
| | - Hsiu-Chuan Liu
- Department of Experiment and Diagnosis, Tainan Hospital, Department of Health, Executive Yuan, Tainan, Taiwan
| | - Chih-I Lee
- Department of Internal Medicine, Tainan Hospital, Department of Health, Executive Yuan, Tainan, Taiwan
| | - Hsiao-Ju Lin
- Department of Internal Medicine, Tainan Hospital, Department of Health, Executive Yuan, Tainan, Taiwan
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yi-Hui Wu
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Jiunn-Jong Wu
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Medical College, Tainan, Taiwan
- * E-mail: (J-JW); (W-CK)
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
- Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan
- Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan
- * E-mail: (J-JW); (W-CK)
| |
Collapse
|
36
|
Kim J, Kang JO, Kim H, Seo MR, Choi TY, Pai H, Kuijper EJ, Sanders I, Fawley W. Epidemiology of Clostridium difficile infections in a tertiary-care hospital in Korea. Clin Microbiol Infect 2012; 19:521-7. [PMID: 22712697 DOI: 10.1111/j.1469-0691.2012.03910.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
To survey healthcare-associated Clostridium difficile infection (HA-CDI) in a 900-bed tertiary-care hospital, we prospectively investigated the epidemiology of CDI and distribution of PCR-ribotypes. From February 2009 through January 2010, all patients with HA-CDI were enrolled. Epidemiological information and prescription records for antibiotics were collected. The C. difficile isolates were characterized using reference strains and were tested for antibiotic susceptibility. During the survey, incidence of HA-CDI was 71.6 per 100 000 patient-days. In total, 140 C. difficile isolates were obtained from 166 patients with HA-CDI. The PCR-ribotyping yielded 38 distinct ribotypes. The three most frequently found ribotypes made up 56.4% of all isolates; they comprised 37 isolates (26.4%) of PCR-ribotype 018, 22 (15.7%) of toxin A-negative PCR-ribotype 017, and 20 (14.3%) of PCR-ribotype 001. Clostridium difficile PCR-ribotype 018 was present in all departments throughout the hospital during the 11 months, whereas ribotype 017 and ribotype 001 appeared mostly in the pulmonary department. Hypervirulent C. difficile PCR-ribotype 027 was detected in 1 month on two wards. The incidence of CDI in each department showed a seven-fold difference, which correlated significantly with the amount of prescribed clindamycin (R = 0.783, p 0.013) or moxifloxacin (R = 0.733, p 0.025) in the departments. The rates of resistance of the three commonest ribotypes to clindamycin and moxifloxacin were significantly higher than those of other strains (92.1% versus 38.2% and 89.5% versus 27.3%, respectively). CDI is an important nosocomially acquired infection and this study emphasizes the importance of implementing country-wide surveillance to detect and control CDI in Korea.
Collapse
Affiliation(s)
- J Kim
- Department of Internal Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Mitchell BG, Gardner A. Mortality and Clostridium difficile infection: a review. Antimicrob Resist Infect Control 2012; 1:20. [PMID: 22958425 PMCID: PMC3533881 DOI: 10.1186/2047-2994-1-20] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 05/12/2012] [Indexed: 12/18/2022] Open
Abstract
Background Clostridium difficile infection (CDI) is a common cause of diarrhoea in hospitalised patients. Around the world, the incidence and severity of CDI appears to be increasing, particularly in the northern hemisphere. The purpose of this integrative review was to investigate and describe mortality in hospitalised patients with CDI. Methods A search of the literature between 1 January 2005 and 30 April 2011 focusing on mortality and CDI in hospitalised patients was conducted using electronic databases. Papers were reviewed and analysed individually and themes were combined using integrative methods. Results All cause mortality at 30 days varied from 9% to 38%. Three studies report attributable mortality at 30 days, varying from 5.7% to 6.9%. In hospital mortality ranged from 8% to 37.2% Conclusion All cause 30 day mortality appeared to be high, with 15 studies indicating a mortality of 15% or greater. Findings support the notion that CDI is a serious infection and measures to prevent and control CDI are needed. Future studies investigating the mortality of CDI in settings outside of Europe and North America are needed. Similarly, future studies should include data on patient co-morbidities.
Collapse
Affiliation(s)
- Brett G Mitchell
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Dickson, PO BOX 256, ACT, Australia.
| | | |
Collapse
|
38
|
Characterizations of clinical isolates of clostridium difficile by toxin genotypes and by susceptibility to 12 antimicrobial agents, including fidaxomicin (OPT-80) and rifaximin: a multicenter study in Taiwan. Antimicrob Agents Chemother 2012; 56:3943-9. [PMID: 22508299 DOI: 10.1128/aac.00191-12] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
A total of 403 nonduplicate isolates of Clostridium difficile were collected at three major teaching hospitals representing northern, central, and southern Taiwan from January 2005 to December 2010. Of these 403 isolates, 170 (42.2%) were presumed to be nontoxigenic due to the absence of genes for toxins A or B or binary toxin. The remaining 233 (57.8%) isolates carried toxin A and B genes, and 39 (16.7%) of these also had binary toxin genes. The MIC(90) of all isolates for fidaxomicin and rifaximin was 0.5 μg/ml (range, ≤ 0.015 to 0.5 μg/ml) and >128 μg/ml (range, ≤ 0.015 to >128 μg/ml), respectively. All isolates were susceptible to metronidazole (MIC(90) of 0.5 μg/ml; range, ≤ 0.03 to 4 μg/ml). Two isolates had reduced susceptibility to vancomycin (MICs, 4 μg/ml). Only 13.6% of isolates were susceptible to clindamycin (MIC of ≤ 2 μg/ml). Nonsusceptibility to moxifloxacin (n = 81, 20.1%) was accompanied by single or multiple mutations in gyrA and gyrB genes in all but eight moxifloxacin-nonsusceptible isolates. Two previously unreported gyrB mutations might independently confer resistance (MIC, 16 μg/ml), Ser416 to Ala and Glu466 to Lys. Moxifloxacin-resistant isolates were cross-resistant to ciprofloxacin and levofloxacin, but some moxifloxacin-nonsusceptible isolates remained susceptible to gemifloxacin or nemonoxacin at 0.5 μg/ml. This study found the diversity of toxigenic and nontoxigenic strains of C. difficile in the health care setting in Taiwan. All isolates tested were susceptible to metronidazole and vancomycin. Fidaxomicin exhibited potent in vitro activity against all isolates tested, while the more than 10% of Taiwanese isolates with rifaximin MICs of ≥ 128 μg/ml raises concerns.
Collapse
|
39
|
Vardakas KZ, Polyzos KA, Patouni K, Rafailidis PI, Samonis G, Falagas ME. Treatment failure and recurrence of Clostridium difficile infection following treatment with vancomycin or metronidazole: a systematic review of the evidence. Int J Antimicrob Agents 2012; 40:1-8. [PMID: 22398198 DOI: 10.1016/j.ijantimicag.2012.01.004] [Citation(s) in RCA: 193] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Revised: 01/04/2012] [Accepted: 01/05/2012] [Indexed: 12/30/2022]
Abstract
The objective of this review was to evaluate the frequency of treatment failure and recurrence of Clostridium difficile infection (CDI) following treatment with vancomycin or metronidazole in recently performed studies (last 10 years). Searches in PubMed and Scopus were performed by two reviewers independently. Data regarding treatment failure and recurrence following metronidazole and vancomycin treatment were extracted and analysed. In total, 39 articles (7005 patients) were selected for inclusion in the systematic review. The reported treatment failure was 22.4% with metronidazole (16 studies) and 14.2% with vancomycin (8 studies). Recurrence of CDI occurred in 27.1% of patients following metronidazole treatment (18 studies) and 24.0% of patients following vancomycin treatment (8 studies). Mean treatment failure and recurrence in the selected studies was 22.3% (24 studies) and 22.1% (37 studies). The reported outcomes depended on the study design (higher in prospective and retrospective cohort studies than in randomised controlled trials), geographic location of the study (higher in North America than in Europe and Asia), funding (higher in studies funded by non-profit organisations than pharmaceutical companies), mean age of the studied population (higher in older patients) and duration of follow-up (higher in studies with follow-up >1 month). In conclusion, infection with C. difficile is associated with 22.4% and 14.2% treatment failure and 27.1% and 24.0% recurrence after treatment with metronidazole and vancomycin, respectively. The variation in the reported outcomes amongst studies depends on the study design, location, funding, age and follow-up period.
Collapse
|
40
|
|
41
|
Lee YC, Wang JT, Chen AC, Sheng WH, Chang SC, Chen YC. Changing incidence and clinical manifestations of Clostridium difficile-associated diarrhea detected by combination of glutamate dehydrogenase and toxin assay in Northern Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2011; 45:287-95. [PMID: 22209696 DOI: 10.1016/j.jmii.2011.12.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2011] [Revised: 07/13/2011] [Accepted: 08/19/2011] [Indexed: 01/25/2023]
Abstract
BACKGROUND/PURPOSE The incidence of Clostridium difficile-associated diarrhea (CDAD) is increasing worldwide. Spread of an epidemic hypervirulent strain in southern Taiwan was associated with poor outcome. This prospective study evaluates the incidence and clinical manifestation of CDAD following a hospital-wide hand hygiene promotion program in a 2,200-bed teaching hospital in northern Taiwan. PATIENTS AND METHODS From June 1, 2010 to October 31, 2010, a predefined protocol was used to actively survey CDAD at 11 high-risk units. Stool samples of patients with antibiotic-associated diarrhea (AAD) were submitted for stool culture and toxin A/B assay using a combined enzyme immunoassay. CDAD was diagnosed by a positive toxin assay. RESULTS The incidence of CDAD was 0.45/1000 patient-days and was highest in medical intensive care units (7.9/1000 patient-days), followed by hemato-oncology wards, and infectious disease wards. Occurrence of CDAD was associated with ≥3 stool pus cells per high power field (p = 0.018), prior use of metronidazole (p = 0.029), high usage of beta-lactamase stable penicillins (p = 0.046), and anaerobe-active antibiotics (p = 0.029). No attributable mortality was found. The incidence of CDAD was lower than that previously observed (1.0/1000 patient-days in 2003, p < 0.001). CONCLUSION This study showed a lower incidence of CDAD and absence of attributable mortality. The impact of hand hygiene promotion and other infection control measures on decreasing incidence of CDAD warrants further elucidation.
Collapse
Affiliation(s)
- Yi-Chieh Lee
- Division of Infectious Disease, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | | | | | | | | | | |
Collapse
|
42
|
Antimicrobial susceptibilities and molecular epidemiology of clinical isolates of Clostridium difficile in taiwan. Antimicrob Agents Chemother 2011; 55:1701-5. [PMID: 21263053 DOI: 10.1128/aac.01440-10] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The antimicrobial susceptibility and virulence factors of Clostridium difficile clinical isolates in Taiwan have not previously been reported. One hundred and thirteen isolates were collected from two major teaching hospitals in Taiwan from 2001 to 2009. Molecular typing was performed by an automated repetitive extragenic palindromic sequence-based PCR (rep-PCR) method (DiversiLab; Bacterial Barcodes, Inc., Athens, GA) and PCR ribotyping. Detection of tcdA, tcdB, cdtA, and cdtB genes was performed using a multiplex PCR assay, and gyrA and gyrB genes of moxifloxacin-nonsusceptible isolates were sequenced. All isolates were susceptible to vancomycin and metronidazole. Ninety-five (84%) isolates were susceptible to moxifloxacin, and the MIC(90) for nemonoxacin was 4 μg/ml. Tigecycline showed favorable antibacterial activity (MIC(90) of 0.06 μg/ml). Thirteen rep-PCR types were identified as a predominant rep-PCR type (type A; non-North American pulsed-field gel electrophoresis type 1 [NAP1], -NAP7, or -NAP8) accounting for 52.2% (59 isolates). Nine of 18 moxifloxacin-nonsusceptible isolates belonged to the rep-PCR type A. The rep-PCR type A and C isolates were distinct from NAP1 (ribotype 027) and NAP8 (ribotype 078) as determined by PCR ribotyping. Seventy-four (65%) isolates harbored tcdA and tcdB, and 15 (13%) harbored cdtAB encoding binary toxin. Eleven isolates had a gene deletion in tcdC, including a 39-bp deletion (9 isolates) and an 18-bp deletion (2). In conclusion, dissemination of a predominant C. difficile clone in southern and northern Taiwan was noted. However, no NAP1 (ribotype 027) isolate could be discovered in this study.
Collapse
|