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Di Bella S, Sanson G, Monticelli J, Zerbato V, Principe L, Giuffrè M, Pipitone G, Luzzati R. Clostridioides difficile infection: history, epidemiology, risk factors, prevention, clinical manifestations, treatment, and future options. Clin Microbiol Rev 2024; 37:e0013523. [PMID: 38421181 DOI: 10.1128/cmr.00135-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
SUMMARYClostridioides difficile infection (CDI) is one of the major issues in nosocomial infections. This bacterium is constantly evolving and poses complex challenges for clinicians, often encountered in real-life scenarios. In the face of CDI, we are increasingly equipped with new therapeutic strategies, such as monoclonal antibodies and live biotherapeutic products, which need to be thoroughly understood to fully harness their benefits. Moreover, interesting options are currently under study for the future, including bacteriophages, vaccines, and antibiotic inhibitors. Surveillance and prevention strategies continue to play a pivotal role in limiting the spread of the infection. In this review, we aim to provide the reader with a comprehensive overview of epidemiological aspects, predisposing factors, clinical manifestations, diagnostic tools, and current and future prophylactic and therapeutic options for C. difficile infection.
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Affiliation(s)
- Stefano Di Bella
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Trieste, Italy
| | - Gianfranco Sanson
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Trieste, Italy
| | - Jacopo Monticelli
- Infectious Diseases Unit, Trieste University Hospital (ASUGI), Trieste, Italy
| | - Verena Zerbato
- Infectious Diseases Unit, Trieste University Hospital (ASUGI), Trieste, Italy
| | - Luigi Principe
- Microbiology and Virology Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Mauro Giuffrè
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Trieste, Italy
- Department of Internal Medicine (Digestive Diseases), Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Giuseppe Pipitone
- Infectious Diseases Unit, ARNAS Civico-Di Cristina Hospital, Palermo, Italy
| | - Roberto Luzzati
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Trieste, Italy
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Safdar N, Parmasad V, Brown R, Carayon P, Lepak A, O'Horo JC, Schulz L. Decreasing ICU-associated Clostridioides difficile infection through fluoroquinolone restriction, the FIRST trial: a study protocol. BMJ Open 2021; 11:e046480. [PMID: 34187821 PMCID: PMC8245435 DOI: 10.1136/bmjopen-2020-046480] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 06/16/2021] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Clostridioides difficile infection (CDI) is one of the most common healthcare-associated infections in the USA, having high incidence in intensive care units (ICU). Antibiotic use increases risk of CDI, with fluoroquinolones (FQs) particularly implicated. In healthcare settings, antibiotic stewardship (AS) and infection control interventions are effective in CDI control, but there is little evidence regarding the most effective AS interventions. Preprescription authorisation (PPA) restricting FQs is a potentially promising AS intervention to reduce CDI. The FQ Restriction for the Prevention of CDI (FIRST) trial will evaluate the effectiveness of an FQ PPA intervention in reducing CDI rates in adult ICUs compared with preintervention care, and evaluate implementation effectiveness using a human-factors and systems engineering model. METHODS AND ANALYSIS This is a multisite, stepped-wedge, cluster, effectiveness-implementation clinical trial. The trial will take place in 12 adult medical-surgical ICUs with ≥10 beds, using Epic as electronic health record (EHR) and pre-existing AS programmes. Sites will receive facilitated implementation support over the 15-month trial period, succeeded by 9 months of follow-up. The intervention comprises a clinical decision support system for FQ PPA, integrated into the site EHRs. Each ICU will be considered a single site and all ICU admissions included in the analysis. Clinical data will be extracted from EHRs throughout the trial and compared with the corresponding pretrial period, which will constitute the baseline for statistical analysis. Outcomes will include ICU-onset CDI rates, FQ days of therapy (DOT), alternative antibiotic DOT, average length of stay and hospital mortality. The study team will also collect implementation data to assess implementation effectiveness using the Systems Engineering Initiative for Patient Safety model. ETHICS AND DISSEMINATION The trial was approved by the Institutional Review Board at the University of Wisconsin-Madison (2018-0852-CP015). Results will be made available to participating sites, funders, infectious disease societies, critical care societies and other researchers. TRIAL REGISTRATION NUMBER NCT03848689.
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Affiliation(s)
- Nasia Safdar
- Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Vishala Parmasad
- Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Roger Brown
- School of Nursing, University of Wisconsin-Madison Graduate School, Madison, Wisconsin, USA
| | - Pascale Carayon
- Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Alexander Lepak
- Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | | | - Lucas Schulz
- Pharmacy, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
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Stephenson B, Lanzas C, Lenhart S, Ponce E, Bintz J, Dubberke ER, Day J. Comparing intervention strategies for reducing Clostridioides difficile transmission in acute healthcare settings: an agent-based modeling study. BMC Infect Dis 2020; 20:799. [PMID: 33115427 PMCID: PMC7594474 DOI: 10.1186/s12879-020-05501-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 10/12/2020] [Indexed: 12/15/2022] Open
Abstract
Background Clostridioides difficile infection (CDI) is one of the most common healthcare infections. Common strategies aiming at controlling CDI include antibiotic stewardship, environmental decontamination, and improved hand hygiene and contact precautions. Mathematical models provide a framework to evaluate control strategies. Our objective is to evaluate the effectiveness of control strategies in decreasing C. difficile colonization and infection using an agent-based model in an acute healthcare setting. Methods We developed an agent-based model that simulates the transmission of C. difficile in medical wards. This model explicitly incorporates healthcare workers (HCWs) as vectors of transmission, tracks individual patient antibiotic histories, incorporates varying risk levels of antibiotics with respect to CDI susceptibility, and tracks contamination levels of ward rooms by C. difficile. Interventions include two forms of antimicrobial stewardship, increased environmental decontamination through room cleaning, improved HCW compliance, and a preliminary assessment of vaccination. Results Increased HCW compliance with CDI patients was ranked as the most effective intervention in decreasing colonizations, with reductions up to 56%. Antibiotic stewardship practices were highly ranked after contact precaution compliance. Vaccination and reduction of high-risk antibiotics were the most effective intervention in decreasing CDI. Vaccination reduced CDI cases to up to 90%, and the reduction of high-risk antibiotics decreased CDI cases up to 23%. Conclusions Overall, interventions that decrease patient susceptibility to colonization by C. difficile, such as antibiotic stewardship, were the most effective interventions in reducing both colonizations and CDI cases.
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Affiliation(s)
- Brittany Stephenson
- Department of Engineering, Computing, and Mathematical Sciences, Lewis University, 1 University Parkway, Romeoville, 60446, IL, USA.
| | - Cristina Lanzas
- Department of Population Health and Pathobiology, North Carolina State University, 1052 William Moore Drive, Raleigh, 27606, NC, USA
| | - Suzanne Lenhart
- Department of Mathematics, University of Tennessee, 1403 Circle Drive, Knoxville, 37996, TN, USA
| | - Eduardo Ponce
- Department of Electrical Engineering and Computer Science, University of Tennessee, 1520 Middle Drive, Knoxville, 37996, TN, USA
| | - Jason Bintz
- School of Arts and Sciences, Johnson University, Knoxville, 37998, TN, USA
| | - Erik R Dubberke
- Division of Infectious Disease, Washington University School of Medicine, 660 S Euclid Ave, St. Louis, 63110, MO, USA
| | - Judy Day
- Department of Mathematics, University of Tennessee, 1403 Circle Drive, Knoxville, 37996, TN, USA.,Department of Electrical Engineering and Computer Science, University of Tennessee, 1520 Middle Drive, Knoxville, 37996, TN, USA
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A Single-Center Experience and Literature Review of Management Strategies for Clostridium difficile Infection in Hematopoietic Stem Cell Transplant Patients. ACTA ACUST UNITED AC 2019; 28:10-15. [PMID: 33424210 DOI: 10.1097/ipc.0000000000000798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Introduction The aim of our study is to evaluate risk factors associated with the development of C. difficile infection (CDI) in hematopoietic stem cell transplant (HSCT) patients, determine its incidence and report outcomes of CDI in our patient population. Methods We performed a retrospective review of medical records of adult HSCT recipients diagnosed between 2013 and 2016 at our center. Logistic regression models were used to determine the relationship between risk factors and the odds of CDI. Results The overall incidence of CDI in HSCT patients was 9.4%. The incidence of CDI was higher in allogeneic HSCT (20%) versus autologous HSCT (4.8%). No statistically significant differences in age, gender, cancer type, transplant type were found between those who developed CDI and those who did not. However, patients with CDI had a longer length of stay (25 days) and used more antibiotics (30 days prior to and during admission for HSCT) than non-CDI patients (19 days). Only two of 17 patients (11.8%) with CDI experienced recurrence among 180 patients after HSCT. No patient suffered from toxic megacolon or ileus and no patient underwent colectomy. There was no mortality associated with CDI at our center. Conclusion CDI has an incidence rate of 9.4% in HSCT recipients. Established risk factors including age, gender, cancer type, and transplant type were not identified as risk factors in our population. However, longer LOS and use of greater than four lines of antibiotics were observed among those with CDI compared to those without CDI.
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Abstract
Clostridium difficile is a gram-positive bacterium notorious for causing epidemic diarrhea globally with a significant health burden. The pathogen is clinically challenging with increasing antibiotic resistance and recurrence rate. We provide here an in-depth review of one particular strain/ribotype 027, commonly known as NAP1/B1/027 or North American pulsed-field gel electrophoresis type 1, restriction endonuclease analysis type B1, polymerase chain reaction ribotype 027, which has shown a much higher recurrence rate than other strains.
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Affiliation(s)
- Rawish Fatima
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Muhammad Aziz
- Internal Medicine, University of Kansas Medical Center, Kansas City, USA
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Gupta SB, Dubberke ER. Reprint of: Overview and changing epidemiology of Clostridium difficile infection. SEMINARS IN COLON AND RECTAL SURGERY 2018. [DOI: 10.1053/j.scrs.2018.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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ASID/ACIPC position statement - Infection control for patients with Clostridium difficile infection in healthcare facilities. Infect Dis Health 2018; 24:32-43. [PMID: 30691583 DOI: 10.1016/j.idh.2018.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 10/08/2018] [Accepted: 10/08/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND In 2011, the Australasian Society for Infectious Diseases (ASID) and the Australian Infection Control Association (AICA), now known as the Australasian College of Infection Prevention and Control (ACIPC), produced a position statement on infection control requirements for preventing and controlling Clostridium difficile infection (CDI) in healthcare settings. METHODS The statement updated in 2017 to reflect new literature available .The authors reviewed the 2011 position statement and critically appraised new literature published between 2011 and 2017 and relevant current infection control guidelines to identify where new evidence had become available or best practice had changed. RESULTS The position statement was updated incorporating the new findings. A draft version of the updated position statement was circulated for consultation to members of ASID and ACIPC. The authors responded to all comments received and updated the position statement. CONCLUSIONS This updated position statement emphasizes the importance of health service organizations having evidence-based infection prevention and control programs and comprehensive antimicrobial stewardship programs, to ensure the risk of C. difficile acquisition, transmission and infection is minimised.
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Aljefri DM, Christensen AB, Gibson AK, Postelnick M. Role of Antimicrobial Stewardship Programs in Decreasing Hospital-Associated Clostridium difficile Infections. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018. [DOI: 10.1007/s40506-018-0151-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Bommiasamy AK, Connelly C, Moren A, Dodgion C, Bestall K, Cline A, Martindale RG, Schreiber MA, Kiraly LN. Institutional review of the implementation and use of a Clostridium difficile infection bundle and probiotics in adult trauma patients. Am J Surg 2018; 215:825-830. [PMID: 29490870 DOI: 10.1016/j.amjsurg.2018.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 12/30/2017] [Accepted: 01/02/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a common cause of healthcare associated infections contributing to morbidity and mortality. Our objective was to evaluate the impact of the implementation of a CDI bundle along with probiotic utilization. METHODS A retrospective review of trauma admissions from 2008 to 2014 was performed. The CDI bundle was implemented in stages from 2009 through 2014 with probiotics initiated in 2010. The bundle included changes in cleaning practices, education, screening, and contact precautions. RESULTS 4632 (49%) patients received antibiotics with 21% receiving probiotics. Probiotic use was associated with increased age, male sex, more severely injured, and antibiotic use. CDI incidence decreased from 11.2 to 4.8 per 1000 admissions, p = .03. Among patients who received antibiotics CDI incidence decreased from 2.2% to 0.7%, p = .01. CONCLUSIONS We report the largest series of a CDI bundle implementation including probiotics. During the period of adoption of these interventions, the incidence of CDI decreased significantly.
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Affiliation(s)
- Aravind K Bommiasamy
- Department of Surgery, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd, Mail Code: L223, Portland, OR 97239, USA.
| | - Christopher Connelly
- Department of Surgery, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd, Mail Code: L223, Portland, OR 97239, USA
| | - Alexi Moren
- Department of Surgery, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd, Mail Code: L223, Portland, OR 97239, USA
| | - Chris Dodgion
- Department of Surgery, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd, Mail Code: L223, Portland, OR 97239, USA
| | - Kelsey Bestall
- Department of Surgery, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd, Mail Code: L223, Portland, OR 97239, USA
| | - Anthony Cline
- Department of Surgery, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd, Mail Code: L223, Portland, OR 97239, USA
| | - Robert G Martindale
- Department of Surgery, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd, Mail Code: L223, Portland, OR 97239, USA
| | - Martin A Schreiber
- Department of Surgery, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd, Mail Code: L223, Portland, OR 97239, USA
| | - Laszlo N Kiraly
- Department of Surgery, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd, Mail Code: L223, Portland, OR 97239, USA
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Clostridium Difficile Infection in Acute Care Hospitals: Systematic Review and Best Practices for Prevention. Infect Control Hosp Epidemiol 2018; 38:476-482. [PMID: 28300019 DOI: 10.1017/ice.2016.324] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Prevention of Clostridium difficile infection (CDI) in acute-care hospitals is a priority for hospitals and clinicians. We performed a qualitative systematic review to update the evidence on interventions to prevent CDI published since 2009. DESIGN We searched Ovid, MEDLINE, EMBASE, The Cochrane Library, CINAHL, the ISI Web of Knowledge, and grey literature databases from January 1, 2009 to August 1, 2015. SETTING We included studies performed in acute-care hospitals. PATIENTS OR PARTICIPANTS We included studies conducted on hospitalized patients that investigated the impact of specific interventions on CDI rates. INTERVENTIONS We used the QI-Minimum Quality Criteria Set (QI-MQCS) to assess the quality of included studies. Interventions were grouped thematically: environmental disinfection, antimicrobial stewardship, hand hygiene, chlorhexidine bathing, probiotics, bundled approaches, and others. A meta-analysis was performed when possible. RESULTS Of 3,236 articles screened, 261 met the criteria for full-text review and 46 studies were ultimately included. The average quality rating was 82% according to the QI-MQCS. The most effective interventions, resulting in a 45% to 85% reduction in CDI, included daily to twice daily disinfection of high-touch surfaces (including bed rails) and terminal cleaning of patient rooms with chlorine-based products. Bundled interventions and antimicrobial stewardship showed promise for reducing CDI rates. Chlorhexidine bathing and intensified hand-hygiene practices were not effective for reducing CDI rates. CONCLUSIONS Daily and terminal cleaning of patient rooms using chlorine-based products were most effective in reducing CDI rates in hospitals. Further studies are needed to identify the components of bundled interventions that reduce CDI rates. Infect Control Hosp Epidemiol 2017;38:476-482.
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Wei SC, Chang TA, Chao TH, Chen JS, Chou JW, Chou YH, Chuang CH, Hsu WH, Huang TY, Hsu TC, Lin CC, Lin HH, Lin JK, Lin WC, Ni YH, Shieh MJ, Shih IL, Shun CT, Tsang YM, Wang CY, Wang HY, Weng MT, Wu DC, Wu WC, Yen HH, Wong JM. Management of ulcerative colitis in Taiwan: consensus guideline of the Taiwan Society of Inflammatory Bowel Disease. Intest Res 2017; 15:266-284. [PMID: 28670225 PMCID: PMC5478753 DOI: 10.5217/ir.2017.15.3.266] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 05/03/2017] [Accepted: 05/04/2017] [Indexed: 12/17/2022] Open
Abstract
Ulcerative colitis (UC) is an inflammatory bowel disease characterized by chronic mucosal inflammation of the colon, and the prevalence and incidence of UC have been steadily increasing in Taiwan. A steering committee was established by the Taiwan Society of Inflammatory Bowel Disease to formulate statements on the diagnosis and management of UC taking into account currently available evidence and the expert opinion of the committee. Accurate diagnosis of UC requires thorough clinical, endoscopic, and histological assessment and careful exclusion of differential diagnoses, particularly infectious colitis. The goals of UC therapy are to induce and maintain remission, reduce the risk of complications, and improve quality of life. As outlined in the recommended treatment algorithm, choice of treatment is dictated by severity, extent, and course of disease. Patients should be evaluated for hepatitis B virus and tuberculosis infection prior to immunosuppressive treatment, especially with steroids and biologic agents, and should be regularly monitored for reactivation of latent infection. These consensus statements are also based on current local evidence with consideration of factors, and could be serve as concise and practical guidelines for supporting clinicians in the management of UC in Taiwan.
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Affiliation(s)
- Shu-Chen Wei
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ting-An Chang
- Department of Pathology, Taipei City Hospital Renai Branch, Taipei, Taiwan
| | - Te-Hsin Chao
- Division of Colorectal Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jinn-Shiun Chen
- Division of Colorectal Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Jen-Wei Chou
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Yenn-Hwei Chou
- Division of General Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Chiao-Hsiung Chuang
- Department of Internal Medicine, National Cheng Kung University Hospital, National Cheng Kung University College of Medicine, Tainan, Taiwan
| | - Wen-Hung Hsu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Municipal Hsiaokang Hospital, Kaohsiung, Taiwan
| | - Tien-Yu Huang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tzu-Chi Hsu
- Division of Colon and Rectal Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chun-Chi Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hung-Hsin Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Surgery, National Yang-Ming University, Taipei, Taiwan
| | - Jen-Kou Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wei-Chen Lin
- Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Yen-Hsuan Ni
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Jium Shieh
- Department of Oncology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - I-Lun Shih
- Department of Medical Imaging, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chia-Tung Shun
- Department of Pathology and Forensic Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yuk-Ming Tsang
- Division of Medical Imaging, Department of Radiology, Far Eastern Memorial Hospital, New Taipei City, Taipei, Taiwan
| | - Cheng-Yi Wang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Horng-Yuan Wang
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan.,MacKay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan.,MacKay Medical College, New Taipei City, Taipei, Taiwan
| | - Meng-Tzu Weng
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taipei, Taiwan
| | - Deng-Chyang Wu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taipei, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taipei, Taiwan
| | - Wen-Chieh Wu
- Division of Gastroenterology, Department of Medicine, Taipei City Hospital Renai Branch, Taipei, Taiwan
| | - Hsu-Heng Yen
- Division of Gastroenterology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Jau-Min Wong
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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de With K, Allerberger F, Amann S, Apfalter P, Brodt HR, Eckmanns T, Fellhauer M, Geiss HK, Janata O, Krause R, Lemmen S, Meyer E, Mittermayer H, Porsche U, Presterl E, Reuter S, Sinha B, Strauß R, Wechsler-Fördös A, Wenisch C, Kern WV. Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases. Infection 2017; 44:395-439. [PMID: 27066980 PMCID: PMC4889644 DOI: 10.1007/s15010-016-0885-z] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Introduction In the time of increasing resistance and paucity of new drug development there is a growing need for strategies to enhance rational use of antibiotics in German and Austrian hospitals. An evidence-based guideline on recommendations for implementation of antibiotic stewardship (ABS) programmes was developed by the German Society for Infectious Diseases in association with the following societies, associations and institutions: German Society of Hospital Pharmacists, German Society for Hygiene and Microbiology, Paul Ehrlich Society for Chemotherapy, The Austrian Association of Hospital Pharmacists, Austrian Society for Infectious Diseases and Tropical Medicine, Austrian Society for Antimicrobial Chemotherapy, Robert Koch Institute. Materials and methods A structured literature research was performed in the databases EMBASE, BIOSIS, MEDLINE and The Cochrane Library from January 2006 to November 2010 with an update to April 2012 (MEDLINE and The Cochrane Library). The grading of recommendations in relation to their evidence is according to the AWMF Guidance Manual and Rules for Guideline Development. Conclusion The guideline provides the grounds for rational use of antibiotics in hospital to counteract antimicrobial resistance and to improve the quality of care of patients with infections by maximising clinical outcomes while minimising toxicity. Requirements for a successful implementation of ABS programmes as well as core and supplemental ABS strategies are outlined. The German version of the guideline was published by the German Association of the Scientific Medical Societies (AWMF) in December 2013.
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Affiliation(s)
- K de With
- Division of Infectious Diseases, University Hospital Carl Gustav Carus at the TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| | - F Allerberger
- Division Public Health, Austrian Agency for Health and Food Safety (AGES), Vienna, Austria
| | - S Amann
- Hospital Pharmacy, Munich Municipal Hospital, Munich, Germany
| | - P Apfalter
- Institute for Hygiene, Microbiology and Tropical Medicine (IHMT), National Reference Centre for Nosocomial Infections and Antimicrobial Resistance, Elisabethinen Hospital Linz, Linz, Austria
| | - H-R Brodt
- Department of Infectious Disease Medical Clinic II, Goethe-University Frankfurt, Frankfurt, Germany
| | - T Eckmanns
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - M Fellhauer
- Hospital Pharmacy, Schwarzwald-Baar Hospital, Villingen-Schwenningen, Germany
| | - H K Geiss
- Department of Hospital Epidemiology and Infectiology, Sana Kliniken AG, Ismaning, Germany
| | - O Janata
- Department for Hygiene and Infection Control, Danube Hospital, Vienna, Austria
| | - R Krause
- Section of Infectious Diseases and Tropical Medicine, Medical University of Graz, Graz, Austria
| | - S Lemmen
- Division of Infection Control and Infectious Diseases, University Hospital RWTH Aachen, Aachen, Germany
| | - E Meyer
- Institute of Hygiene and Environmental Medicine, Charité, University Medicine Berlin, Berlin, Germany
| | - H Mittermayer
- Institute for Hygiene, Microbiology and Tropical Medicine (IHMT), National Reference Centre for Nosocomial Infections and Antimicrobial Resistance, Elisabethinen Hospital Linz, Linz, Austria
| | - U Porsche
- Department for Clinical Pharmacy and Drug Information, Landesapotheke, Landeskliniken Salzburg (SALK), Salzburg, Austria
| | - E Presterl
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Vienna, Austria
| | - S Reuter
- Clinic for General Internal Medicine, Infectious Diseases, Pneumology and Osteology, Klinikum Leverkusen, Leverkusen, Germany
| | - B Sinha
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - R Strauß
- Department of Medicine 1, Gastroenterology, Pneumology and Endocrinology, University Hospital Erlangen, Erlangen, Germany
| | - A Wechsler-Fördös
- Department of Antibiotics and Infection Control, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | - C Wenisch
- Medical Department of Infection and Tropical Medicine, Kaiser Franz Josef Hospital, Vienna, Austria
| | - W V Kern
- Division of Infectious Diseases, Department of Medicine, Freiburg University Medical Center, Freiburg, Germany
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Balsells E, Filipescu T, Kyaw MH, Wiuff C, Campbell H, Nair H. Infection prevention and control of Clostridium difficile: a global review of guidelines, strategies, and recommendations. J Glob Health 2016; 6:020410. [PMID: 28028434 PMCID: PMC5140074 DOI: 10.7189/jogh.06.020410] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Clostridium difficile is the leading cause of health care-associated infections. Given the high incidence of C. difficile infection (CDI) and the lack of primary prevention through immunization, health care professionals should be aware of the most current guidance, as well as strengths and limitations of the evidence base underpinning this guidance. METHODS We identified publicly available national or organizational guidelines related to CDI infection and prevention control (IPC) published between 2000 and 2015 and for any health care setting through an internet search using the Google search engine. We reviewed CDI-targeted IPC recommendations and describe the assessment of evidence in available guidelines. RESULTS We identified documents from 28 countries/territories, mainly from acute care hospitals in North America, the Western Pacific, and Europe (18 countries). We identified only a few specific recommendations for long-term care facilities (LTCFs) and from countries in South America (Uruguay and Chile), South East Asia (Thailand), and none for Africa or Eastern Mediterranean. Of 10 IPC areas, antimicrobial stewardship was universally recognized as essential and supported by high quality evidence. Five other widely reported "strong" recommendations were: effective environment cleaning (including medical equipment), case isolation, use of personal protective equipment, surveillance, and education. Several unresolved and emerging issues were documented and currently available evidence was classified mainly as of mixed quality. CONCLUSION Our review underlines the need for targeted CDI IPC guidelines in several countries and for LTCFs. International harmonisation on the assessment of the evidence for best practices is needed as well as more robust evidence to support targeted recommendations.
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Affiliation(s)
- Evelyn Balsells
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland (UK)
| | - Teodora Filipescu
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland (UK)
| | | | | | - Harry Campbell
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland (UK); Joint last authorship
| | - Harish Nair
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland (UK); Public Health Foundation of India, New Delhi, India; Joint last authorship
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Antimicrobial Stewardship and Environmental Decontamination for the Control of Clostridium difficile Transmission in Healthcare Settings. Bull Math Biol 2016; 79:36-62. [PMID: 27826877 DOI: 10.1007/s11538-016-0224-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 10/11/2016] [Indexed: 01/05/2023]
Abstract
We implement an agent-based model for Clostridium difficile transmission in hospitals that accounts for several processes and individual factors including environmental and antibiotic heterogeneity in order to evaluate the efficacy of various control measures aimed at reducing environmental contamination and mitigating the effects of antibiotic use on transmission. In particular, we account for local contamination levels that contribute to the probability of colonization and we account for both the number and type of antibiotic treatments given to patients. Simulations illustrate the relative efficacy of several strategies for the reduction of nosocomial colonizations and nosocomial diseases.
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Prevention of Clostridium difficile Infection: A Systematic Survey of Clinical Practice Guidelines. Infect Control Hosp Epidemiol 2016; 37:901-908. [PMID: 27267201 DOI: 10.1017/ice.2016.104] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is the most common cause of hospital-acquired infectious diarrhea. OBJECTIVE To analyze the methodological quality, content, and supporting evidence among clinical practice guidelines (CPGs) on CDI prevention. DESIGN AND SETTING We searched medical databases and gray literature for CPGs on CDI prevention published January 2004-January 2015. Three reviewers independently screened articles and rated CPG quality using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument, composed of 23 items, rated 1-7, within 6 domains. We reported each domain score as a percentage of its maximum possible score and standardized range. We summarized recommendations, extracted their supporting articles, and rated individually the level of evidence using the Oxford Centre for Evidence-Based Medicine Levels of Evidence. RESULTS Of 2,578 articles screened, 5 guidelines met inclusion criteria. Median AGREE II scores and interquartile ranges were: clarity of presentation, 75.9% (75.9%-79.6%); scope and purpose, 74.1% (68.5%-85.2%); editorial independence, 63.9% (47.2%-66.7%); applicability, 43.1% (19.4%-55.6%); stakeholder involvement, 40.7% (38.9%-44.4%); and rigor of development, 18.1% (17.4%-35.4%). CPGs addressed several common strategies for CDI prevention, including antibiotic stewardship, hypochlorite solutions, probiotic prophylaxis, and bundle strategies. Recommendations were often not consistent with evidence, and most were based on low-level studies. CONCLUSION CPGs did not adhere well to AGREE II reporting standards. Furthermore, there was limited transparency in moving from evidence to recommendations. CDI prevention CPGs need to better adhere to AGREE-II and be transparent in moving from evidence to recommendations, and recommendations need to be consistent with available evidence. Infect Control Hosp Epidemiol 2016;37:901-908.
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An Economic Analysis of Strategies to Control Clostridium Difficile Transmission and Infection Using an Agent-Based Simulation Model. PLoS One 2016; 11:e0152248. [PMID: 27031464 PMCID: PMC4816545 DOI: 10.1371/journal.pone.0152248] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 03/11/2016] [Indexed: 12/18/2022] Open
Abstract
Background A number of strategies exist to reduce Clostridium difficile (C. difficile) transmission. We conducted an economic evaluation of “bundling” these strategies together. Methods We constructed an agent-based computer simulation of nosocomial C. difficile transmission and infection in a hospital setting. This model included the following components: interactions between patients and health care workers; room contamination via C. difficile shedding; C. difficile hand carriage and removal via hand hygiene; patient acquisition of C. difficile via contact with contaminated rooms or health care workers; and patient antimicrobial use. Six interventions were introduced alone and "bundled" together: (a) aggressive C. difficile testing; (b) empiric isolation and treatment of symptomatic patients; (c) improved adherence to hand hygiene and (d) contact precautions; (e) improved use of soap and water for hand hygiene; and (f) improved environmental cleaning. Our analysis compared these interventions using values representing 3 different scenarios: (1) base-case (BASE) values that reflect typical hospital practice, (2) intervention (INT) values that represent implementation of hospital-wide efforts to reduce C. diff transmission, and (3) optimal (OPT) values representing the highest expected results from strong adherence to the interventions. Cost parameters for each intervention were obtained from published literature. We performed our analyses assuming low, normal, and high C. difficile importation prevalence and transmissibility of C. difficile. Results INT levels of the “bundled” intervention were cost-effective at a willingness-to-pay threshold of $100,000/quality-adjusted life-year in all importation prevalence and transmissibility scenarios. OPT levels of intervention were cost-effective for normal and high importation prevalence and transmissibility scenarios. When analyzed separately, hand hygiene compliance, environmental decontamination, and empiric isolation and treatment were the interventions that had the greatest impact on both cost and effectiveness. Conclusions A combination of available interventions to prevent CDI is likely to be cost-effective but the cost-effectiveness varies for different levels of intensity of the interventions depending on epidemiological conditions such as C. difficile importation prevalence and transmissibility.
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Goldstein EJC, Johnson S, Maziade PJ, McFarland LV, Trick W, Dresser L, Millette M, Mazloum H, Low DE. Pathway to Prevention of Nosocomial Clostridium difficile Infection. Clin Infect Dis 2016; 60 Suppl 2:S148-58. [PMID: 25922401 DOI: 10.1093/cid/civ142] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND To address the significant morbidity and mortality rates associated with nosocomial Clostridium difficile-associated diarrhea (CDAD), a series of recommendations and a pathway to prevention were developed. METHODS An expert panel of infectious disease (ID) specialists participated in a modified Delphi process with specific objectives: (1) conduct a review for CDAD and prevention; (2) develop statements based upon panel members' opinions; (3) hold a panel meeting during the 2012 IDWeek; and (4) review the final recommendations and prevention pathway prior to submission for publication. RESULTS The panel voted on (1) antibiotic stewardship (7 of 8 panelists); (2) reduction of other potentially modifiable risk factors (variable); (3) utilization of specific probiotics to prevent C. difficile overgrowth (8/8); (4) staff education regarding CDAD preventive measures (8/8); (5) appropriate hand hygiene for everyone (7/8); (6) environmental cleaning (8/8); (7) medical equipment disinfection (7/8); (8) early detection of CDAD in symptomatic patients (7/8); (9) usage of protective clothing/gloves (8/8); (10) proper measures during outbreak (8/8); and (11) surveillance to monitor efficacy data of preventive measures (8/8). CONCLUSIONS The panel members agreed with 11 of 17 recommendations presented. The additional recommendations by the panel were proton pump inhibitor use as a risk factor and the use of adjunctive therapy with specific probiotic, as it was approved by Health Canada for the risk reduction of CDAD in hospitalized patients.
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Affiliation(s)
- Ellie J C Goldstein
- RM Alden Research Laboratory and the David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Stuart Johnson
- Hines VA Hospital and Loyola University Medical Center, Chicago, Illinois
| | | | - Lynne V McFarland
- Department of Medicinal Chemistry, University of Washington, Seattle
| | | | - Linda Dresser
- Leslie Dan Faculty of Pharmacy, University of Toronto, Ontario
| | | | | | - Donald E Low
- Mount Sinai Hospital, University of Toronto, Ontario, Canada
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Abstract
Clostridium difficile infection (CDI) is the leading cause of antibiotic-associated and nosocomial infectious diarrhea. Presenting as clostridium difficile colitis, it is a significant cause of morbidity and mortality. Metronidazole is regarded as the agent of choice for CDl therapy and also for the first recurrence in most patients with mild to moderate CDI. Vancomycin is recommended as an initial therapy for patients with severe CDI. With recent Food and Drug Administration-approval fidaxomicin is available for clinical use and is as effective as vancomycin with lower relapse rates. Rifaximin and fecal bacteriotherapy are alternative approaches in patients with severe or refractory CDI, before surgical intervention. Antibiotic research is ongoing to add potential new drugs such as teicoplanin, ramoplanin, fusidic acid, nitazoxanide, rifampin, bacitracin to our armamentarium. Role of toxin-binding agents is still questionable. Monoclonal antibody and intravenous immunoglobulin are still investigational therapies that could be promising options. The ongoing challenges in the treatment of CDI include management of recurrence and presence of resistance strains such as NAP1/BI/027, but early recognition of surgical candidates can potentially decrease mortality in CDI.
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Wenzler E, Mulugeta SG, Danziger LH. The Antimicrobial Stewardship Approach to Combating Clostridium Difficile. Antibiotics (Basel) 2015; 4:198-215. [PMID: 27025621 PMCID: PMC4790327 DOI: 10.3390/antibiotics4020198] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 06/10/2015] [Accepted: 06/15/2015] [Indexed: 12/14/2022] Open
Abstract
Clostridium difficile remains a major public health threat and continues to contribute to excess morbidity, mortality and healthcare costs. Antimicrobial stewardship programs have demonstrated success in combating C. difficile, primarily through antibiotic restrictive strategies. As the incidence and prevalence of C. difficile associate disease continues to increase both in the hospital and community setting, additional stewardship approaches are needed. This manuscript reviews stewardship interventions that have been successful against C. difficile associated disease and proposes future tactics that antimicrobial stewardship programs may employ to develop a more global approach to combat this difficult pathogen.
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Affiliation(s)
- Eric Wenzler
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL 60612, USA.
| | - Surafel G Mulugeta
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL 60612, USA.
| | - Larry H Danziger
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL 60612, USA.
- College of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA.
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Esposito S, Umbrello G, Castellazzi L, Principi N. Treatment of Clostridium difficile infection in pediatric patients. Expert Rev Gastroenterol Hepatol 2015; 9:747-55. [PMID: 25912469 DOI: 10.1586/17474124.2015.1039988] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Clostridium difficile causes infections that can either remain asymptomatic or manifest as clinical disease. In this report, problems, possible solutions, and future perspectives on the treatment of C. difficile infections (CDIs) in pediatric patients are discussed. CDI, despite increasing as a consequence of the overuse and misuse of antibiotics, remains relatively uncommon in pediatrics mainly because younger children are poorly susceptible to the action of C. difficile toxins. In most such cases, C. difficile disease is mild to moderate and discontinuation of the administered antibiotics in patients receiving these drugs when CDI develops, or administration of metronidazole, is sufficient to solve this problem. In severe or frequently relapsing cases, vancomycin is the drug of choice. Probiotics do not seem to add significant advantages. Other treatment options must be reserved for severe cases and be considered as a salvage treatment, although potential advantages in pediatric patients remain unclear.
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Affiliation(s)
- Susanna Esposito
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Reveles KR, Lee GC, Boyd NK, Frei CR. The rise in Clostridium difficile infection incidence among hospitalized adults in the United States: 2001-2010. Am J Infect Control 2014; 42:1028-32. [PMID: 25278388 DOI: 10.1016/j.ajic.2014.06.011] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 06/11/2014] [Accepted: 06/16/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) incidence is a growing concern. This study provides national estimates of CDI over 10 years and identifies trends in mortality and hospital length of stay (LOS) among hospitalized adults with CDI. METHODS We conducted a retrospective analysis of the US National Hospital Discharge Surveys from 2001-2010. Eligible cases included adults aged ≥ 18 years discharged from a hospital with an ICD-9-CM diagnosis code for CDI (008.45). Data weights were used to derive national estimates. CDI incidence rates were depicted as CDI discharges per 1,000 total adult discharges. RESULTS These data represent 2.2 million adult hospital discharges for CDI over the study period. CDI incidence increased from 4.5 CDI discharges per 1,000 total adult discharges in 2001 to 8.2 CDI discharges per 1,000 total adult discharges in 2010. The overall in-hospital mortality rate was 7.1% for the study period. Mortality increased slightly over the study period, from 6.6% in 2001 to 7.2% in 2010. Median hospital LOS was 8 days (interquartile range, 4-14 days), and remained stable over the study period. CONCLUSIONS The incidence of CDI among hospitalized adults in the United States nearly doubled from 2001-2010. Furthermore, there is little evidence of improvement in patient mortality or hospital LOS.
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Affiliation(s)
- Kelly R Reveles
- College of Pharmacy, The University of Texas at Austin, Austin, TX; Pharmacotherapy Education and Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX.
| | - Grace C Lee
- College of Pharmacy, The University of Texas at Austin, Austin, TX; Pharmacotherapy Education and Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Natalie K Boyd
- College of Pharmacy, The University of Texas at Austin, Austin, TX; Pharmacotherapy Education and Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Christopher R Frei
- College of Pharmacy, The University of Texas at Austin, Austin, TX; Pharmacotherapy Education and Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX
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Gupta SB, Dubberke ER. Overview and changing epidemiology of Clostridium difficile infection. SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2014.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Lanzas C, Dubberke ER. Effectiveness of screening hospital admissions to detect asymptomatic carriers of Clostridium difficile: a modeling evaluation. Infect Control Hosp Epidemiol 2014; 35:1043-50. [PMID: 25026622 DOI: 10.1086/677162] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Both asymptomatic and symptomatic Clostridium difficile carriers contribute to new colonizations and infections within a hospital, but current control strategies focus only on preventing transmission from symptomatic carriers. Our objective was to evaluate the potential effectiveness of methods targeting asymptomatic carriers to control C. difficile colonization and infection (CDI) rates in a hospital ward: screening patients at admission to detect asymptomatic C. difficile carriers and placing positive patients into contact precautions. METHODS We developed an agent-based transmission model for C. difficile that incorporates screening and contact precautions for asymptomatic carriers in a hospital ward. We simulated scenarios that vary according to screening test characteristics, colonization prevalence, and type of strain present at admission. RESULTS In our baseline scenario, on average, 42% of CDI cases were community-onset cases. Within the hospital-onset (HO) cases, approximately half were patients admitted as asymptomatic carriers who became symptomatic in the ward. On average, testing for asymptomatic carriers reduced the number of new colonizations and HO-CDI cases by 40%-50% and 10%-25%, respectively, compared with the baseline scenario. Test sensitivity, turnaround time, colonization prevalence at admission, and strain type had significant effects on testing efficacy. CONCLUSIONS Testing for asymptomatic carriers at admission may reduce both the number of new colonizations and HO-CDI cases. Additional reductions could be achieved by preventing disease in patients who are admitted as asymptomatic carriers and developed CDI during the hospital stay.
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Affiliation(s)
- Cristina Lanzas
- Department of Biomedical and Diagnostic Sciences, University of Tennessee, Knoxville, Tennessee
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van Kleef E, Gasparrini A, Guy R, Cookson B, Hope R, Jit M, Robotham JV, Deeny SR, Edmunds WJ. Nosocomial transmission of C. difficile in English hospitals from patients with symptomatic infection. PLoS One 2014; 9:e99860. [PMID: 24932484 PMCID: PMC4059673 DOI: 10.1371/journal.pone.0099860] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 05/16/2014] [Indexed: 11/30/2022] Open
Abstract
Background Recent evidence suggests that less than one-quarter of patients with symptomatic nosocomial Clostridium difficile infections (CDI) are linked to other in-patients. However, this evidence was limited to one geographic area. We aimed to investigate the level of symptomatic CDI transmission in hospitals located across England from 2008 to 2012. Methods A generalized additive mixed-effects Poisson model was fitted to English hospital-surveillance data. After adjusting for seasonal fluctuations and between-hospital variation in reported CDI over time, possible clustering (transmission between symptomatic in-patients) of CDI cases was identified. We hypothesised that a temporal proximity would be reflected in the degree of correlation between in-hospital CDI cases per week. This correlation was modelled through a latent autoregressive structure of order 1 (AR(1)). Findings Forty-six hospitals (33 general, seven specialist, and six teaching hospitals) located in all English regions met our criteria. In total, 12,717 CDI cases were identified; seventy-five per cent of these occurred >48 hours after admission. There were slight increases in reports during winter months. We found a low, but statistically significant, correlation between successive weekly CDI case incidences (phi = 0.029, 95%CI: 0.009–0.049). This correlation was five times stronger in a subgroup analysis restricted to teaching hospitals (phi = 0.104, 95%CI: 0.048–0.159). Conclusions The results suggest that symptomatic patient-to-patient transmission has been a source of CDI-acquisition in English hospitals in recent years, and that this might be a more important transmission route in teaching hospitals. Nonetheless, the weak correlation indicates that, in line with recent evidence, symptomatic cases might not be the primary source of nosocomial CDI in England.
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Affiliation(s)
- Esther van Kleef
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- Public Health England, Colindale, London, United Kingdom
- * E-mail:
| | | | - Rebecca Guy
- Public Health England, Colindale, London, United Kingdom
| | | | - Russell Hope
- Public Health England, Colindale, London, United Kingdom
| | - Mark Jit
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- Public Health England, Colindale, London, United Kingdom
| | | | - Sarah R. Deeny
- Public Health England, Colindale, London, United Kingdom
| | - W. John Edmunds
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Killeen S, Martin ST, Hyland J, O' Connell PR, Winter DC. Clostridium difficile enteritis: a new role for an old foe. Surgeon 2014; 12:256-62. [PMID: 24618362 DOI: 10.1016/j.surge.2014.01.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 01/16/2014] [Accepted: 01/16/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Small bowel involvement of Clostridium difficile is increasingly encountered. Data on many management aspects are lacking. AIM To synthesis existing reports and assess the frequency, pathophysiology, outcomes, risk factors, diagnosis and management of C. difficle enteritis. METHODS A systematic review of the literature was conducted to evaluate evidence regarding frequency, pathophysiology, risk factors, optimal diagnosis, management and outcomes for C. difficle enteritis. Three major databases (PubMed, MEDLINE and the Cochrane Library) were searched. The review included original articles reporting C. difficle enteritis from January 1950 to December 2012. RESULTS C. difficle enteritis is rare but increasingly encountered. Presentation is variable and distinct predisposing factors include emergency surgery, white race and increased age. Diagnosis generally involves a sensitive but often non specific screening test for C. difficile antigens. Oral metronidazole represents first line therapy and surgery may be required for complications. Outcomes are inconsistent but may be improving. CONCLUSIONS A high index of clinical suspicion, early diagnosis and treatment are vital. Further prospective studies are needed to determine the significance of asymptomatic small bowel C. difficile infections.
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Affiliation(s)
- S Killeen
- St. Vincent's University Hospital, Department of Colorectal Surgery, Dublin 4, Ireland.
| | - S T Martin
- St. Vincent's University Hospital, Department of Colorectal Surgery, Dublin 4, Ireland
| | - J Hyland
- St. Vincent's University Hospital, Department of Colorectal Surgery, Dublin 4, Ireland
| | - P R O' Connell
- St. Vincent's University Hospital, Department of Colorectal Surgery, Dublin 4, Ireland
| | - D C Winter
- St. Vincent's University Hospital, Department of Colorectal Surgery, Dublin 4, Ireland
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Burrowes B, Harper DR, Anderson J, McConville M, Enright MC. Bacteriophage therapy: potential uses in the control of antibiotic-resistant pathogens. Expert Rev Anti Infect Ther 2014; 9:775-85. [DOI: 10.1586/eri.11.90] [Citation(s) in RCA: 126] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Rubin MA, Jones M, Leecaster M, Khader K, Ray W, Huttner A, Huttner B, Toth D, Sablay T, Borotkanics RJ, Gerding DN, Samore MH. A simulation-based assessment of strategies to control Clostridium difficile transmission and infection. PLoS One 2013; 8:e80671. [PMID: 24278304 PMCID: PMC3836736 DOI: 10.1371/journal.pone.0080671] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 10/09/2013] [Indexed: 12/16/2022] Open
Abstract
Background Clostridium difficile is one of the most common and important nosocomial pathogens, causing severe gastrointestinal disease in hospitalized patients. Although "bundled" interventions have been proposed and promoted, optimal control strategies remain unknown. Methods We designed an agent-based computer simulation of nosocomial C. difficile transmission and infection, which included components such as: patients and health care workers, and their interactions; room contamination via C. difficile shedding; C. difficile hand carriage and removal via hand hygiene; patient acquisition of C. difficile via contact with contaminated rooms or health care workers; and patient antimicrobial use. We then introduced six interventions, alone and "bundled" together: aggressive C. difficile testing; empiric isolation and treatment of symptomatic patients; improved adherence to hand hygiene and contact precautions; improved use of soap and water for hand hygiene; and improved environmental cleaning. All interventions were tested using values representing base-case, typical intervention, and optimal intervention scenarios. Findings In the base-case scenario, C. difficile infection rates ranged from 8–21 cases/10,000 patient-days, with a case detection fraction between 32%–50%. Implementing the "bundle" at typical intervention levels had a large impact on C. difficile acquisition and infection rates, although intensifying the intervention to optimal levels had much less additional impact. Most of the impact came from improved hand hygiene and empiric isolation and treatment of suspected C. difficile cases. Conclusion A "bundled" intervention is likely to reduce nosocomial C. difficile infection rates, even under typical implementation conditions. Real-world implementation of the "bundle" should focus on those components of the intervention that are likely to produce the greatest impact on C. difficile infection rates, such as hand hygiene and empiric isolation and treatment of suspected cases.
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Affiliation(s)
- Michael A. Rubin
- Department of Internal Medicine, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States of America
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
- * E-mail:
| | - Makoto Jones
- Department of Internal Medicine, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States of America
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - Molly Leecaster
- Department of Internal Medicine, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States of America
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - Karim Khader
- Department of Internal Medicine, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States of America
| | - Willy Ray
- Department of Internal Medicine, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States of America
| | - Angela Huttner
- Infection Control Program, Geneva University Hospitals, Geneva, Switzerland
| | - Benedikt Huttner
- Infection Control Program, Geneva University Hospitals, Geneva, Switzerland
| | - Damon Toth
- Department of Internal Medicine, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States of America
| | - Theodore Sablay
- Department of Internal Medicine, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States of America
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - Robert J. Borotkanics
- Department of Environmental Health Sciences, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Dale N. Gerding
- Department of Internal Medicine, Edward Hines Jr. Department of Veterans Affairs Hospital, Hines, Illinois, United States of America
| | - Matthew H. Samore
- Department of Internal Medicine, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States of America
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
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Dawson KL, Mooney ML. Clostridium difficile infection after lung transplantation: Are we really doing everything possible? J Heart Lung Transplant 2013; 32:1002-4. [DOI: 10.1016/j.healun.2013.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 07/16/2013] [Indexed: 11/16/2022] Open
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Abstract
The prevalence of Clostridium difficile infection (CDI) in inflammatory bowel disease (IBD) has become a focus of increased attention, as the C. difficile epidemic continues to grow. Although first documented more than 20 years ago, only in recent years has the relationship between these 2 entities been better clarified, and recent epidemiologic studies have shown that IBD patients are at increased susceptibility for CDI compared with the general population. Despite this increased attention, much still remains unknown, and the overlapping clinical presentations of CDI and IBD pose barriers to diagnosis and standardized treatment. Moreover, given the relationship between mortality and severity of CDI in IBD patients, early recognition of those who are at increased risk for infection is of paramount importance to improve patient outcome.
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Montoya M, Detorres O. Antimicrobial selection and its impact on the incidence of Clostridium difficile-associated diarrhea. J Pharm Pract 2013; 26:483-7. [PMID: 23940122 DOI: 10.1177/0897190013499524] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The study objective was to determine which antimicrobials place patients at a higher risk for Clostridium difficile-associated diarrhea (CDAD) and which interventions can reduce their risk. All patients with diarrhea and a positive toxin assay for Clostridium difficile for 3 months were included in the study. Patients were broken down into either community-acquired infection or health care-associated infection based on symptom onset, antibiotic usage prior to admission, and where the patient was admitted from. Physicians were educated on antimicrobials that place patients at higher risk for CDAD and alternative agents to use. Physician education consisted of in-service presentations, posters, Medical Grand Rounds, and an article in the physician newsletter highlighting the initial results of this study and alternative antimicrobial regimens. After implementation of educational programs, a repeat sample of patients was reviewed to determine effectiveness of the physician education. Cases of CDAD increased secondary to testing changes at our facility. Implicated antimicrobial usage did decrease after educational program implementation.
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Role of the environment in the transmission of Clostridium difficile in health care facilities. Am J Infect Control 2013; 41:S105-10. [PMID: 23622740 DOI: 10.1016/j.ajic.2012.12.009] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 12/15/2012] [Accepted: 12/18/2012] [Indexed: 12/30/2022]
Abstract
Recent data demonstrate that the contaminated hospital surface environment plays a key role in the transmission of Clostridium difficile. Enhanced environmental cleaning of rooms housing Clostridium difficile-infected patients is warranted, and, if additional studies demonstrate a benefit of "no-touch" methods (eg, ultraviolet irradiation, hydrogen peroxide systems), their routine use should be considered.
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Rutala WA, Weber DJ. Role of the hospital environment in disease transmission, with a focus on Clostridium difficile. ACTA ACUST UNITED AC 2013. [DOI: 10.1071/hi12057] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Borkow G, Monk A. Fighting nosocomial infections with biocidal non-intrusive hard and soft surfaces. World J Clin Infect Dis 2012; 2:77-90. [DOI: 10.5495/wjcid.v2.i4.77] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Approximately 7 million people worldwide acquire a healthcare associated infection each year. Despite aggressive monitoring, hand washing campaigns and other infection control measures, nosocomial infections (NI) rates, especially those caused by antibiotic resistant pathogens, are unacceptably high worldwide. Additional ways to fight these infections need to be developed. A potential overlooked and neglected source of nosocomial pathogens are those found in non-intrusive soft and hard surfaces located in clinical settings. Soft surfaces, such as patient pyjamas and beddings, can be an excellent substrate for bacterial and fungal growth under appropriate temperature and humidity conditions as those present between patients and the bed. Bed making in hospitals releases large quantities of microorganisms into the air, which contaminate the immediate and non-immediate surroundings. Microbes can survive on hard surfaces, such as metal trays, bed rails and door knobs, for very prolonged periods of time. Thus soft and hard surfaces that are in direct or indirect contact with the patients can serve as a source of nosocomial pathogens. Recently it has been demonstrated that copper surfaces and copper oxide containing textiles have potent intrinsic biocidal properties. This manuscript reviews the recent laboratory and clinical studies, which demonstrate that biocidal surfaces made of copper or containing copper can reduce the microbiological burden and the NI rates.
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Brady RRW, Rodrigues MA, Harrison R, Rae C, Graham C, Poxton IR, Gibb AP. Knowledge of Clostridium difficile infection among UK health-care workers: development of a knowledge assessment tool. Scott Med J 2012; 57:124-30. [DOI: 10.1258/smj.2012.012015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Doctors’ knowledge provides the basis to support good practice in infection prevention and control. However, there exists a paucity of validated knowledge assessment tools that can be reliably employed to identify poor knowledge levels of Clostridium difficile infection (CDI) within populations of doctors, preventing the effective identification of knowledge deficiencies and focused targeting of educational interventions. Here, we describe a development process to validate a novel CDI knowledge assessment tool for doctors. Two previously published CDI knowledge questionnaires were amalgamated to produce a combined questionnaire. Content was further evaluated by a panel of CDI experts, producing the ‘Lothian’ questionnaire. These questionnaires were tested in control populations comprising either infection control nurse (ICN) specialists or non-clinically trained individuals, and a cohort of medical staff. We compared the efficacy of the ‘Lothian’ questionnaire against that of previous questionnaire reports. We found that all of the questionnaires studied significantly discriminated between non-clinical and clinical populations (ICNs and medical staff) ( P < 0.001) and had similar levels of sensitivity and specificity in discrimination between these targeted populations. This study describes the development of a robust CDI knowledge assessment tool that can be used to evaluate knowledge levels among doctors, compare populations and assist the targeting of educational interventions and plot trends following such interventions.
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Affiliation(s)
- R R W Brady
- Department of Colorectal Surgery, Western General Hospital, Edinburgh, Scotland, UK
| | - M A Rodrigues
- Department of Colorectal Surgery, Western General Hospital, Edinburgh, Scotland, UK
| | - R Harrison
- Department of Acute Medicine, Western General Hospital, Edinburgh, Scotland, UK
| | - C Rae
- Infection Control Services, Western General Hospital, Edinburgh, Scotland, UK
| | - C Graham
- Epidemiology and Statistics Core, University of Edinburgh, WTCRF, Edinburgh, Scotland, UK
| | - I R Poxton
- Centre for Infectious Diseases, University of Edinburgh, Edinburgh, Scotland, UK
| | - A P Gibb
- Department of Laboratory Medicine, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
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Saccharomyces boulardii for the prevention of antibiotic-associated diarrhea in adult hospitalized patients: a single-center, randomized, double-blind, placebo-controlled trial. Am J Gastroenterol 2012; 107:922-31. [PMID: 22472744 DOI: 10.1038/ajg.2012.56] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Antibiotic-associated diarrhea (AAD) and Clostridium difficile-associated diarrhea (CDAD) are common complications of antibiotic use. Probiotics were effective in preventing AAD and CDAD in several randomized controlled trials. This study was aimed at testing the effect of Saccharomyces boulardii on the occurrence of AAD and CDAD in hospitalized patients. METHODS A single-center, randomized, double-blind, placebo-controlled, parallel-group trial was performed. Patients being prescribed antibiotics or on antibiotic therapy for <48 h were eligible. Exclusion criteria were ongoing diarrhea, recent assumption of probiotics, lack of informed consent, inability to ingest capsules, and severe pancreatitis. Patients received a capsule containing S. boulardii or an indistinguishable placebo twice daily within 48 h of beginning antibiotic therapy, continued treatment for 7 days after antibiotic withdrawal, and were followed for 12 weeks after ending antibiotic treatment. RESULTS Of 562 consecutive eligible patients, 275 patients aged 79.2 ± 9.8 years (134 on placebo) were randomized and 204 aged 78.4 ± 10.0 years (98 on placebo) completed the follow-up. AAD developed in 13.3% (13/98) of the patients receiving placebo and in 15.1% (16/106) of those receiving S. boulardii (odds ratio for S. boulardii vs. placebo, 1.16; 95% confidence interval (CI), 0.53-2.56). Five cases of CDAD occurred, 2 in the placebo group (2.0%) and 3 in the probiotic group (2.8%; odds ratio for S. boulardii vs. placebo, 1.40; 95% CI, 0.23-8.55). There was no difference in mortality rates (12.7% vs. 15.6%, P=0.60). CONCLUSIONS In elderly hospitalized patients, S. boulardii was not effective in preventing the development of AAD.
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VerLee KE, Finks JL, Wilkins MJ, Wells EV. Michigan Clostridium difficile hospital discharges: frequency, mortality, and charges, 2002-2008. Public Health Rep 2012; 127:62-71. [PMID: 22298923 DOI: 10.1177/003335491212700107] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Clostridium difficile (C. difficile) causes an intestinal bacterial infection of increasing importance in Michigan residents and health-care facilities. The specific burden and health-care costs of C. difficile infection (CDI) were previously unknown. We evaluated the frequency, mortality, and health-care charges of CDI from Michigan hospital discharge data. METHODS The Michigan Department of Community Health purchased discharge data from all Michigan acute care hospitals from the Michigan Health and Hospital Association. We extracted all hospital discharges from 2002 through 2008 containing the International Classification of Diseases, Ninth Revision code for intestinal infection due to C. difficile. Discharges were stratified by principle diagnosis and comorbidity level. Total hospitalization charges were standardized to the 2008 U.S. dollar. RESULTS From 2002 through 2008, 68,686 hospital discharges with CDI occurred. The annual rate increased from 463.1 to 1096.5 CDI discharges per 100,000 discharges. CDI discharge rates were substantially higher among the elderly, females, and black people. Of all CDI discharges, 5,924 (8.6%) patients died. The mean total health-care charge for the time period was $67,149, and the annual mean increased 35% from 2002 to 2008. Hospital charges varied significantly by race/ethnicity and age. People with Medicaid insurance accrued the highest charges. CONCLUSION Across Michigan, the CDI burden is growing substantially and affecting vulnerable populations. Surveillance utilizing hospital discharge data can illuminate trends and inform intervention targets. To reduce disease and health-care charges, increased prevention and infection-control efforts should be directed toward high-risk populations, such as the elderly.
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Affiliation(s)
- Kerrie E VerLee
- Council of State and Territorial Epidemiologists, Atlanta, GA, USA.
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Abstract
PPIs have become one of the most commonly used medications worldwide, as they are the treatment of choice for several acid-related gastrointestinal disorders. However, concerns have been raised about PPI therapy, including the risk of pneumonia, bone fractures and enteric infections, and a possible interaction with clopidogrel that could increase the risk of cardiovascular events. Observational studies have shown very modest associations between PPI therapy and these risks, although the association between PPI treatment and the risk of enteric infections seems to be stronger than the association with other risk factors. However, given the inherent limitations of observational studies, these associations could be attributable to bias and/or confounding factors. In addition, evidence from randomized, controlled trials does not support a clinically significant effect of PPI therapy on the risk of cardiovascular events in patients taking clopidogrel or the risk of pneumonia. Nevertheless, it is impossible to exclude the possibility that some of these associations might be causal or indeed that PPI therapy has an as yet unknown long-term adverse effect. As with any therapy, therefore, it is advisable to prescribe PPIs only to patients for whom these drugs have been proven beneficial.
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Abstract
Despite the availability of newer antifungal drugs, outcomes for patients with invasive fungal infections (IFIs) continue to be poor, in large part due to delayed diagnosis and initiation of appropriate antifungal therapy. Standard histopathologic diagnostic techniques are often untenable in at-risk patients, and culture-based diagnostics typically are too insensitive or nonspecific, or provide results after too long a delay for optimal IFI management. Newer surrogate markers of IFIs with improved sensitivity and specificity are needed to enable earlier diagnosis and, ideally, to provide prognostic information and/or permit therapeutic monitoring. Surrogate assays should also be accessible and easy to implement in the hospital. Several nonculture-based assays of newer surrogates are making their way into the medical setting or are currently under investigation. These new or up-and-coming surrogates include antigens/antibodies (mannan and antimannan antibodies) or fungal metabolites (d-arabinitol) for detection of invasive candidiasis, the Aspergillus cell wall component galactomannan used to detect invasive aspergillosis, or the fungal cell wall component and panfungal marker β-glucan. In addition, progress continues with use of polymerase chain reaction- or other nucleic acid- or molecular-based assays for diagnosis of either specific or generic IFIs, although the various methods must be better standardized before any of these approaches can be more fully implemented into the medical setting. Investigators are also beginning to explore the possibility of combining newer surrogate markers with each other or with more standard diagnostic approaches to improve sensitivity, specificity, and capacity for earlier diagnosis, at a time when fungal burden is still relatively low and more responsive to antifungal therapy.
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Rosenberg DJ. Infections, bacterial resistance, and antimicrobial stewardship: the emerging role of hospitalists. J Hosp Med 2012; 7 Suppl 1:S34-43. [PMID: 23677633 DOI: 10.1002/jhm.978] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Revised: 08/09/2011] [Accepted: 08/28/2011] [Indexed: 11/10/2022]
Abstract
The care of patients with serious infections both within and outside healthcare settings is increasingly complicated by the high prevalence of resistant or multidrug-resistant (MDR) pathogens. Moreover, infections caused by MDR versus susceptible bacteria or other pathogens are associated with significantly higher mortality, length of hospital stay, and healthcare costs. Antimicrobial misuse or overuse is the primary driver for development of antimicrobial resistance, suggesting that better use of antimicrobials will translate into improved patient outcomes, more efficient use of hospital resources, and lowered healthcare costs. Antimicrobial stewardship refers to the various practices and procedures utilized to optimize antimicrobial use. The primary goal of antimicrobial stewardship is to improve patient outcomes and lower antimicrobial resistance and other unintended consequences of antimicrobial therapy. Secondary goals are to reduce length of hospital stays and healthcare-related costs. Hospitalists are increasingly involved in the care of hospitalized patients throughout the United States. Expertise in managing conditions requiring hospitalization, and experience in quality improvement across a wide range of clinical conditions, make hospitalists well positioned to participate in the development and implementation of hospital-based antimicrobial stewardship programs designed to improve patient outcomes, reduce antimicrobial resistance, and provide more efficient and lower-cost hospital care.
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Affiliation(s)
- David J Rosenberg
- Department of Medicine, Division of General Internal Medicine, North Shore University Hospital, Manhasset, NY 11030, USA. .
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Cheng AC, Ferguson JK, Richards MJ, Robson JM, Gilbert GL, McGregor A, Roberts S, Korman TM, Riley TV. Australasian Society for Infectious Diseases guidelines for the diagnosis and treatment of Clostridium difficile infection. Med J Aust 2011; 194:353-8. [DOI: 10.5694/j.1326-5377.2011.tb03006.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Accepted: 10/07/2010] [Indexed: 01/05/2023]
Affiliation(s)
- Allen C Cheng
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC
- Infectious Diseases Unit, Alfred Hospital, Melbourne, VIC
| | - John K Ferguson
- John Hunter Hospital, Newcastle, NSW
- University of Newcastle, Newcastle, NSW
| | - Michael J Richards
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, VIC
- University of Melbourne, Melbourne, VIC
| | | | - Gwendolyn L Gilbert
- Centre for Infectious Diseases and Microbiology, Institute of Clinical Pathology and Medical Research, Sydney, NSW
| | | | - Sally Roberts
- Clinical Microbiology Laboratory, LabPlus, Auckland District Health Board, Auckland, NZ
| | - Tony M Korman
- Infectious Diseases, Monash Medical Centre, Melbourne, VIC
| | - Thomas V Riley
- Microbiology and Immunology, University of Western Australia, Perth, WA
- Division of Microbiology and Infectious Diseases, PathWest Laboratory Medicine WA, Perth, WA
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Prevention of Clostridium difficile infections: efficacious and high-quality probiotics can produce the expected effect when used appropriately. Am J Gastroenterol 2011; 106:804. [PMID: 21468077 DOI: 10.1038/ajg.2010.494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Stuart RL, Marshall C, McLaws ML, Boardman C, Russo PL, Harrington G, Ferguson JK. ASID/AICA position statement – Infection control guidelines for patients with Clostridium difficile infection in healthcare settings. ACTA ACUST UNITED AC 2011. [DOI: 10.1071/hi11011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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