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Waitzberg D, Guarner F, Hojsak I, Ianiro G, Polk DB, Sokol H. Can the Evidence-Based Use of Probiotics (Notably Saccharomyces boulardii CNCM I-745 and Lactobacillus rhamnosus GG) Mitigate the Clinical Effects of Antibiotic-Associated Dysbiosis? Adv Ther 2024; 41:901-914. [PMID: 38286962 PMCID: PMC10879266 DOI: 10.1007/s12325-024-02783-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 01/05/2024] [Indexed: 01/31/2024]
Abstract
Dysbiosis corresponds to the disruption of a formerly stable, functionally complete microbiota. In the gut, this imbalance can lead to adverse health outcomes in both the short and long terms, with a potential increase in the lifetime risks of various noncommunicable diseases and disorders such as atopy (like asthma), inflammatory bowel disease, neurological disorders, and even behavioural and psychological disorders. Although antibiotics are highly effective in reducing morbidity and mortality in infectious diseases, antibiotic-associated diarrhoea is a common, non-negligible clinical sign of gut dysbiosis (and the only visible one). Re-establishment of a normal (functional) gut microbiota is promoted by completion of the clinically indicated course of antibiotics, the removal of any other perturbing external factors, the passage of time (i.e. recovery through the microbiota's natural resilience), appropriate nutritional support, and-in selected cases-the addition of probiotics. Systematic reviews and meta-analyses of clinical trials have confirmed the strain-specific efficacy of some probiotics (notably the yeast Saccharomyces boulardii CNCM I-745 and the bacterium Lactobacillus rhamnosus GG) in the treatment and/or prevention of antibiotic-associated diarrhoea in children and in adults. Unusually for a probiotic, S. boulardii is a eukaryote and is not therefore directly affected by antibiotics-making it suitable for administration in cases of antibiotic-associated diarrhoea. A robust body of evidence from clinical trials and meta-analyses shows that the timely administration of an adequately dosed probiotic (upon initiation of antibiotic treatment or within 48 h) can help to prevent or resolve the consequences of antibiotic-associated dysbiosis (such as diarrhoea) and promote the resilience of the gut microbiota and a return to the pre-antibiotic state. A focus on the prescription of evidence-based, adequately dosed probiotics should help to limit unjustified and potentially ineffective self-medication.
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Affiliation(s)
- Dan Waitzberg
- Department of Gastroenterology, LIM-35, School of Medicine, University of São Paulo, São Paulo, Brazil
| | | | - Iva Hojsak
- Referral Centre for Pediatric Gastroenterology and Nutrition, School of Medicine, University of Zagreb, Zagreb, Croatia
- University of Zagreb Medical School, Zagreb, Croatia
| | - Gianluca Ianiro
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Medical and Surgical Sciences, UOC Gastroenterologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Department of Medical and Surgical Sciences, UOC CEMAD Centro Malattie Dell'Apparato Digerente, Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, Rome, Italy
| | - D Brent Polk
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, San Diego, and Rady Children's Hospital, University of California, San Diego, CA, USA
| | - Harry Sokol
- Gastroenterology Department, Saint-Antoine Hospital, Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine, CRSA, AP-HP, 184 Rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.
- Université Paris-Saclay, INRAe, AgroParisTech, Micalis Institute, Jouy-en-Josas, France.
- Paris Center for Microbiome Medicine (PaCeMM) FHU, Paris, France.
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Miles-Jay A, Snitkin ES, Lin MY, Shimasaki T, Schoeny M, Fukuda C, Dangana T, Moore N, Sansom SE, Yelin RD, Bell P, Rao K, Keidan M, Standke A, Bassis C, Hayden MK, Young VB. Longitudinal genomic surveillance of carriage and transmission of Clostridioides difficile in an intensive care unit. Nat Med 2023; 29:2526-2534. [PMID: 37723252 PMCID: PMC10579090 DOI: 10.1038/s41591-023-02549-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/17/2023] [Indexed: 09/20/2023]
Abstract
Despite enhanced infection prevention efforts, Clostridioides difficile remains the leading cause of healthcare-associated infections in the United States. Current prevention strategies are limited by their failure to account for patients who carry C. difficile asymptomatically, who may act as hidden reservoirs transmitting infections to other patients. To improve the understanding of asymptomatic carriers' contribution to C. difficile spread, we conducted admission and daily longitudinal culture-based screening for C. difficile in a US-based intensive care unit over nine months and performed whole-genome sequencing on all recovered isolates. Despite a high burden of carriage, with 9.3% of admissions having toxigenic C. difficile detected in at least one sample, only 1% of patients culturing negative on admission to the unit acquired C. difficile via cross-transmission. While patients who carried toxigenic C. difficile on admission posed minimal risk to others, they themselves had a 24-times greater risk for developing a healthcare-onset C. difficile infection than noncarriers. Together, these findings suggest that current infection prevention practices can be effective in preventing nosocomial cross-transmission of C. difficile, and that decreasing C. difficile infections in hospitals further will require interventions targeting the transition from asymptomatic carriage to infection.
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Affiliation(s)
- Arianna Miles-Jay
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Evan S Snitkin
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, USA.
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Michael Y Lin
- Division of Infectious Diseases, Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Teppei Shimasaki
- Division of Infectious Diseases, Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Michael Schoeny
- Division of Infectious Diseases, Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Christine Fukuda
- Division of Infectious Diseases, Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Thelma Dangana
- Division of Infectious Diseases, Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Nicholas Moore
- Division of Infectious Diseases, Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Sarah E Sansom
- Division of Infectious Diseases, Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Rachel D Yelin
- Division of Infectious Diseases, Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Pamela Bell
- Division of Infectious Diseases, Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Krishna Rao
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Micah Keidan
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Alexandra Standke
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Christine Bassis
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Mary K Hayden
- Division of Infectious Diseases, Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Vincent B Young
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, USA
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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3
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Gilboa M, Baharav N, Melzer E, Regev-Yochay G, Yahav D. Screening for Asymptomatic Clostridioides difficile Carriage Among Hospitalized Patients: A Narrative Review. Infect Dis Ther 2023; 12:2223-2240. [PMID: 37704801 PMCID: PMC10581986 DOI: 10.1007/s40121-023-00856-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/04/2023] [Indexed: 09/15/2023] Open
Abstract
Clostridioides difficile infection (CDI) has become the most common healthcare-associated infection in the United States, with considerable morbidity, mortality, and healthcare costs. Assessing new preventive strategies is vital. We present a literature review of studies evaluating a strategy of screening and isolation of asymptomatic carriers in hospital settings. Asymptomatic detection of C. difficile is reported in ~ 10-20% of admitted patients. Risk factors for carriage include recent hospitalization, previous antibiotics, older age, lower functional capacity, immunosuppression, and others. Asymptomatic C. difficile carriers of toxigenic strains are at higher risk for progression to CDI. They are also shedders of C. difficile spores and may contribute to the persistence and transmission of this bacterium. Screening for asymptomatic carriers at hospital admission can theoretically reduce CDI by isolating carriers to reduce transmission, and implementing antibiotic stewardship measures targeting carriers to prevent progression to clinical illness. Several observational studies, summarized in this review, have reported implementing screening and isolation strategies, and found a reduction in CDI rates. Nevertheless, the data are still limited to a few observational studies, and this strategy is not commonly practiced. Studies supporting screening were performed in North America, coinciding with the period of dominance of the 027/BI/NAP1 strain. Additional studies evaluating screening, followed by infection control and antibiotic stewardship measures, are needed.
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Affiliation(s)
- Mayan Gilboa
- Infection Prevention Unit, Sheba Medical Center, Ramat-Gan, Israel.
- Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel-Aviv, Israel.
| | - Nadav Baharav
- Infectious Diseases Unit, Sheba Medical Center, Ramat-Gan, Israel
| | - Eyal Melzer
- Infection Prevention Unit, Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel-Aviv, Israel
| | - Gili Regev-Yochay
- Infection Prevention Unit, Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel-Aviv, Israel
| | - Dafna Yahav
- Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel-Aviv, Israel
- Infectious Diseases Unit, Sheba Medical Center, Ramat-Gan, Israel
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4
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Lee KB, Lee M, Suh JW, Yang KS, Chung Y, Kim JY, Kim SB, Sohn JW, Yoon YK. Clinical prediction rule for identifying older patients with toxigenic clostridioides difficile at the time of hospital admission. BMC Geriatr 2023; 23:127. [PMID: 36879198 PMCID: PMC9990199 DOI: 10.1186/s12877-023-03808-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 02/08/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND This study aimed to develop and validate a clinical prediction rule to screen older patients at risk of being toxigenic Clostridioides difficile carriers at the time of hospital admission. METHODS This retrospective case-control study was performed at a university-affiliated hospital. Active surveillance using a real-time polymerase chain reaction (PCR) assay for the toxin genes of C. difficile was conducted among older patients (≥ 65 years) upon admission to the Division of Infectious Diseases of our institution. This rule was drawn from a derivative cohort between October 2019 and April 2021 using a multivariable logistic regression model. Clinical predictability was evaluated in the validation cohort between May 2021 and October 2021. RESULTS Of 628 PCR screenings for toxigenic C. difficile carriage, 101 (16.1%) yielded positive findings. To establish clinical prediction rules in the derivation cohort, the formula was derived using significant predictors for toxigenic C. difficile carriage at admission, such as septic shock, connective tissue diseases, anemia, recent use of antibiotics, and recent use of proton-pump inhibitors. In the validation cohort, the sensitivity, specificity, and positive and negative predictive values of the prediction rule, based on a cut-off value of ≥ 0.45, were 78.3%, 70.8%, 29.5%, and 95.4%, respectively. CONCLUSION This clinical prediction rule for identifying toxigenic C. difficile carriage at admission may facilitate the selective screening of high-risk groups. To implement it in a clinical setting, more patients from other medical institutions need to be prospectively examined.
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Affiliation(s)
- Ki-Byung Lee
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, 02841, Seoul, Republic of Korea
| | - Mina Lee
- Infection Control Unit, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Jin Woong Suh
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, 02841, Seoul, Republic of Korea
| | - Kyung-Sook Yang
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Youseung Chung
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, 02841, Seoul, Republic of Korea
| | - Jeong Yeon Kim
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, 02841, Seoul, Republic of Korea
| | - Sun Bean Kim
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, 02841, Seoul, Republic of Korea
| | - Jang Wook Sohn
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, 02841, Seoul, Republic of Korea
| | - Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, 02841, Seoul, Republic of Korea.
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Calatayud M, Duysburgh C, Van den Abbeele P, Franckenstein D, Kuchina-Koch A, Marzorati M. Long-Term Lactulose Administration Improves Dysbiosis Induced by Antibiotic and C. difficile in the PathoGut TM SHIME Model. Antibiotics (Basel) 2022; 11:1464. [PMID: 36358119 PMCID: PMC9686563 DOI: 10.3390/antibiotics11111464] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 09/28/2023] Open
Abstract
Clostridioides difficile infection (CDI) is the leading cause of antibiotic-associated diarrhea and an important nosocomial infection with different severity degrees. Disruption of the gut microbiota by broad-spectrum antibiotics creates a proper environment for C. difficile colonization, proliferation, and clinical disease onset. Restoration of the gut microbial ecosystem through prebiotic interventions can constitute an effective complementary treatment of CDI. Using an adapted simulator of the human gut microbial ecosystem, the PathoGutTM SHIME, the effect of different long-term and repeated dose lactulose treatments was tested on C. difficile germination and growth in antibiotic-induced dysbiotic gut microbiota environments. The results showed that lactulose reduced the growth of viable C. difficile cells following clindamycin treatment, shifted the antibiotic-induced dysbiotic microbial community, and stimulated the production of health-promoting metabolites (especially butyrate). Recovery of the gut microenvironment by long-term lactulose administration following CDI was also linked to lactate production, decrease in pH and modulation of bile salt metabolism. At a structural level, lactulose showed a significant bifidogenic potential and restored key commensal members of the gut ecosystem such as Lactobacillaceae, Veillonellaceae and Lachnospiraceae. These results support further human intervention studies aiming to validate the in vitro beneficial effects of lactulose on gut microbiome recovery during antibiotic exposure and CDI.
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Affiliation(s)
- Marta Calatayud
- ProDigest BV, Technologiepark 82, 9052 Ghent, Belgium
- Center of Microbial Ecology and Technology (CMET), Ghent University, Coupure Links 653, 9000 Ghent, Belgium
| | | | | | | | | | - Massimo Marzorati
- ProDigest BV, Technologiepark 82, 9052 Ghent, Belgium
- Center of Microbial Ecology and Technology (CMET), Ghent University, Coupure Links 653, 9000 Ghent, Belgium
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6
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Clostridioides difficile Infection in Liver Cirrhosis: A Concise Review. Can J Gastroenterol Hepatol 2022; 2022:4209442. [PMID: 35711246 PMCID: PMC9197604 DOI: 10.1155/2022/4209442] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/04/2022] [Accepted: 05/24/2022] [Indexed: 12/16/2022] Open
Abstract
Clostridium difficile is a Gram-positive bacillus with fecal-oral transmission and is currently one of the most common nosocomial infections worldwide, which was renamed Clostridioides difficile in 2016. Clostridioides difficile infection (CDI) is a prevalent infection in cirrhosis and negatively affects prognosis. This study aimed to provide a concise review with clinical practice implications. The prevalence of CDI in cirrhotic patients increases, while the associated mortality decreases. Multiple groups of risk factors increase the likelihood of CDI in patients with cirrhosis, such as antibiotic use, the severity of cirrhosis, some comorbidities, and demographic aspects. Treatment in the general population is currently described in the latest guidelines. In patients with cirrhosis, rifaximin and lactulose have been shown to reduce CDI risk due to their modulatory effects on the intestinal flora, although conflicting results exist. Fecal microbiota transplantation (FMT) as a treatment for the second or subsequent CDI recurrences has demonstrated a good safety and efficacy in cirrhosis and CDI. Future validation in more prospective studies is needed. Screening of asymptomatic patients appears to be discouraged for the prevention currently, with strict hand hygiene and cleaning of the ward and medical equipment surfaces being the cornerstone of minimizing transmission.
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7
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Zhou Y, Zhou W, Xiao T, Chen Y, Lv T, Wang Y, Zhang S, Cai H, Chi X, Kong X, Zhou K, Shen P, Shan T, Xiao Y. Comparative genomic and transmission analysis of Clostridioides difficile between environmental, animal, and clinical sources in China. Emerg Microbes Infect 2021; 10:2244-2255. [PMID: 34756150 PMCID: PMC8648027 DOI: 10.1080/22221751.2021.2005453] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Clostridioides difficile is the most common pathogen causing antibiotic-associated diarrhea. Previous studies showed that diverse sources, aside from C. difficile infection (CDI) patients, played a major role in C. difficile hospital transmission. This study aimed to investigate relationships and transmission potential of C. difficile strains from different sources. A prospective study was conducted both in the intensive care unit (ICU) and six livestock farms in China in 2018–2019. Ninety-eight strains from CDI patients (10 isolates), asymptomatic hospitalized carriers (55), the ICU environment (12), animals (14), soil (4), and farmers (3) were collected. Sequence type (ST) 3/ribotype (RT) 001, ST35/RT046, and ST48/RT596 were dominant types, distributed widely in multiple sources. Core-genome single-nucleotide polymorphism (cgSNP) analysis showed that hospital and farm strains shared several common clonal groups (CGs, strains separated by ≤ 2 cgSNPs) (CG4/ST3/RT001, CG7/ST35/RT046, CG11/ST48/RT596). CDI patients, asymptomatic carriers, and the ICU environment strains also shared several common CGs. The number of virulence genes was not statistically different between strains from different sources. Multi-source strains in the same CG carried identical virulence gene sequences, including pathogenicity genes at the pathogenicity locus and adhesion-related genes at S-layer cassette. Resistance genes (ermB, tetM, etc.) were widespread in multiple sources, and multi-source strains in the same CG had similar resistance phenotypes and carried consistent transposons and plasmid types. The study indicated that interspecies and cross-regional transmission of C. difficile occurs between animals, the environment, and humans. Community-associated strains from both farms and asymptomatic hospitalized carriers were important reservoirs of CDI in hospitals.
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Affiliation(s)
- Yanzi Zhou
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China, 310003
| | - Wangxiao Zhou
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China, 310003
| | - Tingting Xiao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China, 310003
| | - Yunbo Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China, 310003
| | - Tao Lv
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China, 310003
| | - Yuan Wang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China, 310003
| | - Shuntian Zhang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China, 310003
| | - Hongliu Cai
- Department of Intensive Care Unit, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China, 310003
| | - Xiaohui Chi
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China, 310003
| | - Xiaoyang Kong
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China, 310003
| | - Kai Zhou
- Shenzhen Institute of Respiratory Diseases, the First Affiliated Hospital (Shenzhen People's Hospital), Southern University of Science and Technology, and Second Clinical Medical College, Jinan University, Shenzhen, China, 518000
| | - Ping Shen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China, 310003
| | - Tongling Shan
- Department of Swine Infectious Diseases, Shanghai Veterinary Research Institute, Chinese Academy of Agricultural Sciences, Shanghai, PR China
| | - Yonghong Xiao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China, 310003
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Khanafer N, Vanhems P, Bennia S, Martin-Gaujard G, Juillard L, Rimmelé T, Argaud L, Martin O, Huriaux L, Marcotte G, Hernu R, Floccard B, Cassier P, Group S. Factors Associated with Clostridioides (Clostridium) Difficile Infection and Colonization: Ongoing Prospective Cohort Study in a French University Hospital. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18147528. [PMID: 34299978 PMCID: PMC8307155 DOI: 10.3390/ijerph18147528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/13/2021] [Indexed: 01/03/2023]
Abstract
Introduction: Clostridioides (Clostridium) difficile can be isolated from stool in 3% of healthy adults and in at least 10% of asymptomatic hospitalized patients. C. difficile, the most common cause of hospital-acquired infectious diarrhea in the developed world, has re-emerged in recent years with increasing incidence and severity. In an effort to reduce the spread of the pathogen, published recommendations suggest isolation and contact precautions for patients suffering from C. difficile infection (CDI). However, asymptomatic colonized patients are not targeted by infection control policies, and active surveillance for colonization is not routinely performed. Moreover, given the current changes in the epidemiology of CDI, particularly the emergence of new virulent strains either in the hospital or community settings, there is a need for identification of factors associated with colonization by C. difficile and CDI. Methods and analysis: We are carrying out a prospective, observational, cohort study in Edouard Herriot Hospital, Hospices Civils de Lyon, a 900-bed university hospital in Lyon, France. All consecutive adult patients admitted on selected units are eligible to participate in the study. Stool samples or rectal swabs for C. difficile testing are obtained on admission, every 3–5 days during hospitalization, at the onset of diarrhea (if applicable), and at discharge. Descriptive and logistic regression analyses will be completed to mainly estimate the proportion of asymptomatic colonization at admission, and to evaluate differences between factors associated with colonization and those related to CDI. Ethics: The study is conducted in accordance with the ethical principles of the Declaration of Helsinki, French law, and the Good Clinical Practice guidelines. The study protocol design was approved by the participating units, the ethics committee and the hospital institutional review board (Comité de protection des personnes et Comission Nationale de l’Informatique et des Libertés; N°: 00009118). Dissemination: The results of this study will be disseminated by presenting the findings locally at each participating ward, as well as national and international scientific meetings. Findings will be shared with interested national societies crafting guidelines in CDI.
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Affiliation(s)
- Nagham Khanafer
- International Center for Infectiology Research (CIRI), Inserm U1111, CNRS UMR5308, ENS de Lyon, Lyon 1 University, 69342 Lyon, France;
- Department of Hygiene, Epidemiology, and Prevention, Edouard Herriot Hospital, Hospices Civils de Lyon, 69437 Lyon, France;
- European Study Group for Clostridioides Difficile (ESGCD), 4001 Basel, Switzerland
- Correspondence:
| | - Philippe Vanhems
- International Center for Infectiology Research (CIRI), Inserm U1111, CNRS UMR5308, ENS de Lyon, Lyon 1 University, 69342 Lyon, France;
- Department of Hygiene, Epidemiology, and Prevention, Edouard Herriot Hospital, Hospices Civils de Lyon, 69437 Lyon, France;
- INSERM, F-CRIN, Réseau Innovative Clinical Research in Vaccinology (I-REIVAC), 75679 Paris, France
| | - Sabrina Bennia
- Department of Hygiene, Epidemiology, and Prevention, Edouard Herriot Hospital, Hospices Civils de Lyon, 69437 Lyon, France;
| | | | - Laurent Juillard
- Nephrology Department, Edouard Herriot Hospital, Hospices Civils de Lyon, 69002 Lyon, France;
| | - Thomas Rimmelé
- Anesthesia and Intensive Care Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, 69437 Lyon, France; (T.R.); (O.M.); (L.H.); (G.M.); (B.F.)
- EA 7426 PI3 (Pathophysiology of Injury-Induced Immunosuppression), Lyon 1 University, Hospices Civils de Lyon, Biomérieux, 69437 Lyon, France
| | - Laurent Argaud
- Medical Intensive Care Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, 69437 Lyon, France; (L.A.); (R.H.)
| | - Olivier Martin
- Anesthesia and Intensive Care Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, 69437 Lyon, France; (T.R.); (O.M.); (L.H.); (G.M.); (B.F.)
| | - Laetitia Huriaux
- Anesthesia and Intensive Care Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, 69437 Lyon, France; (T.R.); (O.M.); (L.H.); (G.M.); (B.F.)
| | - Guillaume Marcotte
- Anesthesia and Intensive Care Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, 69437 Lyon, France; (T.R.); (O.M.); (L.H.); (G.M.); (B.F.)
| | - Romain Hernu
- Medical Intensive Care Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, 69437 Lyon, France; (L.A.); (R.H.)
| | - Bernard Floccard
- Anesthesia and Intensive Care Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, 69437 Lyon, France; (T.R.); (O.M.); (L.H.); (G.M.); (B.F.)
| | - Pierre Cassier
- Environnemental Laboratory, Institut des Agents Infectieux, Hospices Civils de Lyon, 69317 Lyon, France;
| | - Study Group
- Edouard Herriot Hospital, Hospices Civils de Lyon, 69437 Lyon, France;
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Budi N, Safdar N, Rose WE. Treatment issues in recurrent Clostridioides difficile infections and the possible role of germinants. FEMS MICROBES 2020; 1:xtaa001. [PMID: 37333958 PMCID: PMC10117431 DOI: 10.1093/femsmc/xtaa001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 09/14/2020] [Indexed: 07/30/2023] Open
Abstract
Clostridioides difficile is the number one cause of hospital-acquired infections in the United States and one of the CDC's urgent-level pathogen threats. The inflammation caused by pathogenic C. difficile results in diarrhea and pseudomembranous colitis. Patients who undergo clinically successful treatment for this disease commonly experience recurrent infections. Current treatment options can eradicate the vegetative cell form of the bacteria but do not impact the spore form, which is impervious to antibiotics and resists conventional environmental cleaning procedures. Antibiotics used in treating C. difficile infections (CDI) often do not eradicate the pathogen and can prevent regeneration of the microbiome, leaving them vulnerable to recurrent CDI and future infections upon subsequent non-CDI-directed antibiotic therapy. Addressing the management of C. difficile spores in the gastrointestinal (GI) tract is important to make further progress in CDI treatment. Currently, no treatment options focus on reducing GI spores throughout CDI antibiotic therapy. This review focuses on colonization of the GI tract, current treatment options and potential treatment directions emphasizing germinant with antibiotic combinations to prevent recurrent disease.
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Affiliation(s)
- Noah Budi
- Corresponding author: School of Pharmacy, University of Wisconsin-Madison, Room 4123, 777 Highland Avenue, Madison, WI 53705, USA. Tel: +1-920-419-7704; E-mail:
| | - Nasia Safdar
- Division of Infectious Diseases, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA, 53726
| | - Warren E Rose
- School of Pharmacy, University of Wisconsin-Madison, Madison, WI, USA, 53705
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Antibiotic Exposure and Risk for Hospital-Associated Clostridioides difficile Infection. Antimicrob Agents Chemother 2020; 64:AAC.02169-19. [PMID: 31964789 DOI: 10.1128/aac.02169-19] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 01/11/2020] [Indexed: 01/08/2023] Open
Abstract
Clostridioides difficile infection (CDI) is a health care-associated infection associated with significant morbidity and cost, with highly varied risk across populations. More effective, risk-based prevention strategies are needed. Here, we investigate risk factors for hospital-associated CDI in a large integrated health system. In a retrospective cohort of all adult admissions to 21 Intermountain Healthcare hospitals from 2006 to 2012, we identified all symptomatic (i) hospital-onset and (ii) health care-facility-associated, community-onset CDI. We then evaluated the risk associated with antibiotic exposure, including that of specific agents, using multivariable logistic regression. A total of 2,356 cases of CDI among 506,068 admissions were identified (incidence, 46.6 per 10,000). Prior antibiotic use was the dominant risk factor, where for every antibiotic day of therapy prior to the index admission, the odds of subsequent CDI increased by 12.8% (95% confidence interval [CI], 12.2 to 13.4%; P < 0.0001). This was a much stronger association than was inpatient antibiotic exposure (odds ratio [OR], 1.007 [95% CI, 1.005 to 1.009]; P < 0.0001). The highest-risk antibiotics included second-generation and later cephalosporins (especially oral), carbapenems, fluoroquinolones, and clindamycin, while doxycycline and daptomycin were associated with a lower CDI risk. We concluded that cumulative antibiotic exposure prior to admission is the greatest contributor to the risk of subsequent CDI. Most classes of antibiotics carry some risk, which varies by drug and route. This information may be useful for antimicrobial stewardship efforts.
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Reduced Clostridioides difficile infection in a pragmatic stepped-wedge initiative using admission surveillance to detect colonization. PLoS One 2020; 15:e0230475. [PMID: 32191763 PMCID: PMC7082001 DOI: 10.1371/journal.pone.0230475] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 02/29/2020] [Indexed: 12/12/2022] Open
Abstract
Background Clostridioides difficile Infection (CDI) is a persistent healthcare issue. In the US, CDI is the most common infectious cause of hospital-onset (HO) diarrhea. Objective Assess the impact of admission testing for toxigenic C. difficile colonization on the incidence of HO-CDI. Design Pragmatic stepped-wedge Infection Control initiative. Setting NorthShore University HealthSystem is a four-hospital system near Chicago, IL. Patients All patients admitted to the four hospitals during the initiative. Interventions From September 2017 through August 2018 we conducted a quality improvement program where admitted patients had a peri-rectal swab tested for toxigenic C. difficile. All colonized patients were placed into contact precautions. Measurements We tested admissions who: i) had been hospitalized within two months, ii) had a past C. difficile positive test, and/or iii) were in a long-term care facility within six months. We measured compliance with all other practices to reduce the incidence of HO-CDI. Results 30% of admissions were tested and 8.3% were positive. In the year prior to the initiative (Period 1) there were 63,057 admitted patients when HO-CDI incidence was 5.96 cases/10,000 patient days. During the 12-month initiative (Period 2) there were 62,760 admissions and the HO-CDI incidence was 4.23 cases/10,000 patient days (p = 0.02). There were no other practice or antibiotic use changes. Continuing admission surveillance provided a HO-CDI incidence of 2.9 cases/10,000 patient days during the final 9 months of 2018 (p<0.0001 compared to Period 1), equaling <1 case/1,000 admissions. Limitations This was not a randomized controlled trial, and multiple prevention practices were in place at the time of the admission surveillance initiative. Conclusion Admission C. difficile surveillance testing is an important tool for preventing hospital-onset C. difficile infection. Registration This quality improvement initiative is registered at ClinicalTrials.gov. The unique registration identifier number is NCT04014608.
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