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Kunishima H, Ichiki K, Ohge H, Sakamoto F, Sato Y, Suzuki H, Nakamura A, Fujimura S, Matsumoto K, Mikamo H, Mizutani T, Morinaga Y, Mori M, Yamagishi Y, Yoshizawa S. Japanese Society for infection prevention and control guide to Clostridioides difficile infection prevention and control. J Infect Chemother 2024; 30:673-715. [PMID: 38714273 DOI: 10.1016/j.jiac.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 05/09/2024]
Affiliation(s)
- Hiroyuki Kunishima
- Department of Infectious Diseases. St. Marianna University School of Medicine, Japan.
| | - Kaoru Ichiki
- Department of Infection Control and Prevention, Hyogo Medical University Hospital, Japan
| | - Hiroki Ohge
- Department of Infectious Diseases, Hiroshima University Hospital, Japan
| | - Fumie Sakamoto
- Quality Improvement and Safety Center, Itabashi Chuo Medical Center, Japan
| | - Yuka Sato
- Department of Infection Control and Nursing, Graduate School of Nursing, Aichi Medical University, Japan
| | - Hiromichi Suzuki
- Department of Infectious Diseases, University of Tsukuba School of Medicine and Health Sciences, Japan
| | - Atsushi Nakamura
- Department of Infection Prevention and Control, Graduate School of Medical Sciences, Nagoya City University, Japan
| | - Shigeru Fujimura
- Division of Clinical Infectious Diseases and Chemotherapy, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Japan
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, Japan
| | - Hiroshige Mikamo
- Department of Clinical Infectious Diseases, Aichi Medical University, Japan
| | | | - Yoshitomo Morinaga
- Department of Microbiology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
| | - Minako Mori
- Department of Infection Control, Hiroshima University Hospital, Japan
| | - Yuka Yamagishi
- Department of Clinical Infectious Diseases, Kochi Medical School, Kochi University, Japan
| | - Sadako Yoshizawa
- Department of Laboratory Medicine/Department of Microbiology and Infectious Diseases, Faculty of Medicine, Toho University, Japan
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Pumiglia L, Wilson L, Rashidi L. Clostridioides difficile Colitis. Surg Clin North Am 2024; 104:545-556. [PMID: 38677819 DOI: 10.1016/j.suc.2023.11.005] [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: 04/29/2024]
Abstract
Clostridioides difficile colitis is an important source of hospital-acquired diarrhea associated with antibiotic use. Symptoms are profuse watery diarrhea, typically following a course of antibiotics; however, some cases of fulminant disease may manifest with shock, ileus, or megacolon. Nonfulminant colitis is treated with oral fidaxomicin. C difficile colitis has a high potential for recurrence, and recurrent episodes are also treated with fidaxomicin. Bezlotoxumab is another medication that may be used in populations at high risk for further recurrence. Fulminant disease is treated with maximal medical therapy and early surgical consultation. Antibiotic stewardship is critical to preventing C difficile colitis.
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Affiliation(s)
- Luke Pumiglia
- Department of General Surgery, Madigan Army Medical Center, 9040 Jackson Avenue, Joint Base Lewis-McChord, WA 98431, USA
| | - Lexi Wilson
- Department of Colorectal Surgery, Swedish Medical Center, 747 Broadway, Seattle, WA 98122, USA
| | - Laila Rashidi
- Department of Surgery, MultiCare Health Care System, Washington State University, 3124 19th Street Suite 220, Tacoma, WA 98405, USA.
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Watkin S, Yongblah F, Burton J, Hartley JC, Cloutman-Green E. Clostridioides difficile detection and infection in children: are they just small adults? J Med Microbiol 2024; 73. [PMID: 38526913 DOI: 10.1099/jmm.0.001816] [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: 03/27/2024] Open
Abstract
Clostridioides difficile is a well-recognized healthcare-associated pathogen, with its significance widely recognized in adult populations. Despite this, there is limited data on the significance of detection within paediatric populations, both for individual patient management and wider transmission risk-based considerations. High rates of colonization are understood to occur in infants, with increasing levels up to 11 months, and colonization rates similar to adults by 8 years old. Sources of C. difficile are ubiquitous, with detection in companion animals and food sources, as well as within the clinical and wider environment. Due to the close interactions that occur between children and the environment, it is understandable that increasing recognition is afforded to the community acquisition of C. difficile in children. Other risk factors for the detection of C. difficile in children are similar to those observed in adults, including prior hospitalization and underlying conditions affecting gut health and motility. Recent studies have shown rising awareness of the role of asymptomatic carriage of C. difficile in healthcare transmission. Prior to this, paediatric patient populations were less likely to be screened due to uncertainty regarding the significance of detection; however, this increased awareness has led to a review of possible carriage testing pathways. Despite this increased attention, C. difficile infection remains poorly defined in paediatric populations, with limited dedicated paediatric data sets making comparison challenging. This is further complicated by the fact that infection in children frequently self resolves without additional therapies. Due to this, C. difficile remains a management challenge in paediatric settings.
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Affiliation(s)
- Sam Watkin
- Department of Civil Environmental and Geomatic Engineering, Healthy Infrastructure Research Group, University College London, Chadwick Building, London, UK
| | - Francis Yongblah
- Great Ormond Street Hospital NHS Foundation Trust, Camelia Botnar Laboratories, Department of Microbiology, London, UK
| | - James Burton
- Great Ormond Street Hospital NHS Foundation Trust, Camelia Botnar Laboratories, Department of Microbiology, London, UK
| | - John C Hartley
- Great Ormond Street Hospital NHS Foundation Trust, Camelia Botnar Laboratories, Department of Microbiology, London, UK
| | - Elaine Cloutman-Green
- Department of Civil Environmental and Geomatic Engineering, Healthy Infrastructure Research Group, University College London, Chadwick Building, London, UK
- Great Ormond Street Hospital NHS Foundation Trust, Camelia Botnar Laboratories, Department of Microbiology, London, UK
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Henderickx JG, Crobach MJ, Terveer EM, Smits WK, Kuijper EJ, Zwittink RD. Fungal and bacterial gut microbiota differ between Clostridioides difficile colonization and infection. MICROBIOME RESEARCH REPORTS 2023; 3:8. [PMID: 38455084 PMCID: PMC10917615 DOI: 10.20517/mrr.2023.52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/21/2023] [Accepted: 11/30/2023] [Indexed: 03/09/2024]
Abstract
Aim: The bacterial microbiota is well-recognized for its role in Clostridioides difficile colonization and infection, while fungi and yeasts remain understudied. The aim of this study was to analyze the predictive value of the mycobiota and its interactions with the bacterial microbiota in light of C. difficile colonization and infection. Methods: The mycobiota was profiled by ITS2 sequencing of fecal DNA from C. difficile infection (CDI) patients (n = 29), asymptomatically C. difficile colonization (CDC) patients (n = 38), and hospitalized controls with C. difficile negative stool culture (controls; n = 38). Previously published 16S rRNA gene sequencing data of the same cohort were used additionally for machine learning and fungal-bacterial network analysis. Results: CDI patients were characterized by a significantly higher abundance of Candida spp. (MD 0.270 ± 0.089, P = 0.002) and Candida albicans (MD 0.165 ± 0.082, P = 0.023) compared to controls. Additionally, they were deprived of Aspergillus spp. (MD -0.067 ± 0.026, P = 0.000) and Penicillium spp. (MD -0.118 ± 0.043, P = 0.000) compared to CDC patients. Network analysis revealed a positive association between several fungi and bacteria in CDI and CDC, although the analysis did not reveal a direct association between Clostridioides spp. and fungi. Furthermore, the microbiota machine learning model outperformed the models based on the mycobiota and the joint microbiota-mycobiota model. The microbiota classifier successfully distinguished CDI from CDC [Area Under the Receiver Operating Characteristic (AUROC) = 0.884] and CDI from controls (AUROC = 0.905). Blautia and Bifidobacterium were marker genera associated with CDC patients and controls. Conclusion: The gut mycobiota differs between CDI, CDC, and controls and may affect Clostridioides spp. through indirect interactions. The mycobiota data alone could not successfully discriminate CDC from controls or CDI patients and did not have additional predictive value to the bacterial microbiota data. The identification of bacterial marker genera associated with CDC and controls warrants further investigation.
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Affiliation(s)
- Jannie G.E. Henderickx
- Center for Microbiome Analyses and Therapeutics, Department of Medical Microbiology, Leiden University Medical Center, Leiden 2333 ZA, the Netherlands
- Department of Medical Microbiology and Leiden University Center of Infectious Diseases (LU-CID), Leiden University Medical Center, Leiden 2333 ZA, the Netherlands
| | - Monique J.T. Crobach
- Department of Medical Microbiology and Leiden University Center of Infectious Diseases (LU-CID), Leiden University Medical Center, Leiden 2333 ZA, the Netherlands
| | - Elisabeth M. Terveer
- Department of Medical Microbiology and Leiden University Center of Infectious Diseases (LU-CID), Leiden University Medical Center, Leiden 2333 ZA, the Netherlands
- Netherlands Donor Feces Bank, Department of Medical Microbiology, Leiden University Medical Center, Leiden 2333 ZA, the Netherlands
| | - Wiep Klaas Smits
- Center for Microbiome Analyses and Therapeutics, Department of Medical Microbiology, Leiden University Medical Center, Leiden 2333 ZA, the Netherlands
- Department of Medical Microbiology and Leiden University Center of Infectious Diseases (LU-CID), Leiden University Medical Center, Leiden 2333 ZA, the Netherlands
| | - Ed J. Kuijper
- Center for Microbiome Analyses and Therapeutics, Department of Medical Microbiology, Leiden University Medical Center, Leiden 2333 ZA, the Netherlands
- Department of Medical Microbiology and Leiden University Center of Infectious Diseases (LU-CID), Leiden University Medical Center, Leiden 2333 ZA, the Netherlands
- Netherlands Donor Feces Bank, Department of Medical Microbiology, Leiden University Medical Center, Leiden 2333 ZA, the Netherlands
| | - Romy D. Zwittink
- Center for Microbiome Analyses and Therapeutics, Department of Medical Microbiology, Leiden University Medical Center, Leiden 2333 ZA, the Netherlands
- Department of Medical Microbiology and Leiden University Center of Infectious Diseases (LU-CID), Leiden University Medical Center, Leiden 2333 ZA, the Netherlands
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Filippidis P, Senn L, Poncet F, Grandbastien B, Prod'hom G, Greub G, Guery B, Blanc DS. Core genome multilocus sequence typing of Clostridioides difficile to investigate transmission in the hospital setting. Eur J Clin Microbiol Infect Dis 2023; 42:1469-1476. [PMID: 37870711 PMCID: PMC10651541 DOI: 10.1007/s10096-023-04676-9] [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: 07/26/2023] [Accepted: 10/02/2023] [Indexed: 10/24/2023]
Abstract
PURPOSE Traditional epidemiological investigations of healthcare-associated Clostridioides difficile infection (HA-CDI) are often insufficient. This study aimed to evaluate a procedure that includes secondary isolation and genomic typing of single toxigenic colonies using core genome multilocus sequence typing (cgMLST) for the investigation of C. difficile transmission. METHODS We analyzed retrospectively all toxigenic C. difficile-positive stool samples stored at the Lausanne University Hospital over 6 consecutive months. All isolates were initially typed and classified using a modified double-locus sequence typing (DLST) method. Genome comparison of isolates with the same DLST and clustering were subsequently performed using cgMLST. The electronic administrative records of patients with CDI were investigated for spatiotemporal epidemiological links supporting hospital transmission. A comparative descriptive analysis between genomic and epidemiological data was then performed. RESULTS From January to June 2021, 86 C. difficile isolates were recovered from thawed samples of 71 patients. Thirteen different DLST types were shared by > 1 patient, and 13 were observed in single patients. A genomic cluster was defined as a set of isolates from different patients with ≤ 3 locus differences, determined by cgMLST. Seven genomic clusters were identified, among which plausible epidemiological links were identified in only 4/7 clusters. CONCLUSION Among clusters determined by cgMLST analysis, roughly 40% included unexplained HA-CDI acquisitions, which may be explained by unidentified epidemiological links, asymptomatic colonization, and/or shared common community reservoirs. The use of DLST, followed by whole genome sequencing analysis, is a promising and cost-effective stepwise approach for the investigation of CDI transmission in the hospital setting.
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Affiliation(s)
- Paraskevas Filippidis
- Infection Prevention and Control Unit, Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Laurence Senn
- Infection Prevention and Control Unit, Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fabrice Poncet
- Infection Prevention and Control Unit, Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Swiss National Reference Center for Emerging Antibiotic Resistance (NARA), University of Fribourg, Fribourg, Switzerland
| | - Bruno Grandbastien
- Infection Prevention and Control Unit, Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Guy Prod'hom
- Institute of Microbiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Gilbert Greub
- Institute of Microbiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Benoit Guery
- Infection Prevention and Control Unit, Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Dominique S Blanc
- Infection Prevention and Control Unit, Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
- Swiss National Reference Center for Emerging Antibiotic Resistance (NARA), University of Fribourg, Fribourg, Switzerland.
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Ötleş E, Balczewski EA, Keidan M, Oh J, Patel A, Young VB, Rao K, Wiens J. Clostridioides difficile infection surveillance in intensive care units and oncology wards using machine learning. Infect Control Hosp Epidemiol 2023; 44:1776-1781. [PMID: 37088695 PMCID: PMC10665879 DOI: 10.1017/ice.2023.54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE Screening individuals admitted to the hospital for Clostridioides difficile presents opportunities to limit transmission and hospital-onset C. difficile infection (HO-CDI). However, detection from rectal swabs is resource intensive. In contrast, machine learning (ML) models may accurately assess patient risk without significant resource usage. In this study, we compared the effectiveness of swab surveillance to daily risk estimates produced by an ML model to identify patients who will likely develop HO-CDI in the intensive care unit (ICU) setting. DESIGN A prospective cohort study was conducted with patient carriage of toxigenic C. difficile identified by rectal swabs analyzed by anaerobic culture and polymerase chain reaction (PCR). A previously validated ML model using electronic health record data generated daily risk of HO-CDI for every patient. Swab results and risk predictions were compared to the eventual HO-CDI status. PATIENTS Adult inpatient admissions taking place in University of Michigan Hospitals' medical and surgical intensive care units and oncology wards between June 6th and October 8th, 2020. RESULTS In total, 2,979 admissions, representing 2,044 patients, were observed over the course of the study period, with 39 admissions developing HO-CDIs. Swab surveillance identified 9 true-positive and 87 false-positive HO-CDIs. The ML model identified 9 true-positive and 226 false-positive HO-CDIs; 8 of the true-positives identified by the model differed from those identified by the swab surveillance. CONCLUSION With limited resources, an ML model identified the same number of HO-CDI admissions as swab-based surveillance, though it generated more false-positives. The patients identified by the ML model were not yet colonized with C. difficile. Additionally, the ML model identifies at-risk admissions before disease onset, providing opportunities for prevention.
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Affiliation(s)
- Erkin Ötleş
- Medical Scientist Training Program, University of Michigan Medical School, Ann Arbor, Michigan
- Department of Industrial & Operations Engineering, College of Engineering, University of Michigan, Ann Arbor, Michigan
| | - Emily A. Balczewski
- Medical Scientist Training Program, University of Michigan Medical School, Ann Arbor, Michigan
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan
| | - Micah Keidan
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Jeeheh Oh
- Department of Electrical Engineering and Computer Science, College of Engineering, University of Michigan, Ann Arbor, Michigan
| | - Alieysa Patel
- Department of Pathology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Vincent B. Young
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Krishna Rao
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Jenna Wiens
- Department of Electrical Engineering and Computer Science, College of Engineering, University of Michigan, Ann Arbor, Michigan
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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: 6] [Impact Index Per Article: 6.0] [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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Carling PC, Parry MF, Olmstead R. Environmental approaches to controlling Clostridioides difficile infection in healthcare settings. Antimicrob Resist Infect Control 2023; 12:94. [PMID: 37679758 PMCID: PMC10483842 DOI: 10.1186/s13756-023-01295-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 08/25/2023] [Indexed: 09/09/2023] Open
Abstract
As today's most prevalent and costly healthcare-associated infection, hospital-onset Clostridioides difficile infection (HO-CDI) represents a major threat to patient safety world-wide. This review will discuss how new insights into the epidemiology of CDI have quantified the prevalence of C. difficile (CD) spore contamination of the patient-zone as well as the role of asymptomatically colonized patients who unavoidable contaminate their near and distant environments with resilient spores. Clarification of the epidemiology of CD in parallel with the development of a new generation of sporicidal agents which can be used on a daily basis without damaging surfaces, equipment, or the environment, led to the research discussed in this review. These advances underscore the potential for significantly mitigating HO-CDI when combined with ongoing programs for optimizing the thoroughness of cleaning as well as disinfection. The consequence of this paradigm-shift in environmental hygiene practice, particularly when combined with advances in hand hygiene practice, has the potential for significantly improving patient safety in hospitals globally by mitigating the acquisition of CD spores and, quite plausibly, other environmentally transmitted healthcare-associated pathogens.
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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: 0] [Impact Index Per Article: 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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de-la-Rosa-Martinez D, Bobadilla Del Valle M, Esteban-Kenel V, Zinser Peniche P, Ponce De León Garduño A, Cornejo Juárez P, Sánchez Cruz MN, Camacho-Ortiz A, Vilar-Compte D. Molecular characterization and genotyping of isolates from cancer patients with Clostridioides difficile infection or asymptomatic colonization. J Med Microbiol 2023; 72. [PMID: 37624363 DOI: 10.1099/jmm.0.001748] [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: 08/26/2023] Open
Abstract
Introduction. Cancer patients with Clostridioides difficile infection (CDI) are at a higher risk for adverse outcomes. In addition, a high prevalence of Clostridioides difficile asymptomatic colonization (CDAC) has been reported in this vulnerable population.Gap Statement. The molecular characteristics and potential role of CDAC in healthcare-related transmission in the cancer population have been poorly explored.Aim. We aimed to compare the molecular and genotypic characteristics of C. difficile isolates from cancer patients with CDAC and CDI.Method. We conducted a prospective cohort study of cancer patients with CDAC or CDI from a referral centre. Molecular characterization, typification and tcdC gene expression of isolates were performed.Results. The hospital-onset and community-onset healthcare facility-associated CDI rates were 4.5 cases/10 000 patient-days and 1.4 cases/1 000 admissions during the study period. Fifty-one C. difficile strains were isolated: 37 (72 %) and 14 (28 %) from patients with CDI or CDAC, respectively. All isolates from symptomatic patients were tcdA+/tcdB+, and four (10 %) were ctdA+/ctdB+. In the CDAC group, 10 (71 %) isolates were toxigenic, and none were ctdA+/ctdB+. The Δ18 in-frame tcdC deletion and two transition mutations were found in five isolates. After bacterial typing, 60 % of toxigenic isolates from asymptomatic carriers were clonal to those from patients with C. difficile-associated diarrhoea. No NAP1/027/BI strains were detected.Conclusions. We found a clonal association between C. difficile isolates from patients with CDAC and CDI. Studies are needed to evaluate the potential role of asymptomatic carriers in the dynamics of nosocomial transmission to support infection control measures and reduce the burden of CDI in high-risk groups.
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Affiliation(s)
- Daniel de-la-Rosa-Martinez
- Plan de Estudios Combinados en Medicina (PECEM), Faculty of Medicine, Universidad Nacional Autonoma de Mexico, México City, Mexico
- Departament of Infectious Diseases, Instituto Nacional de Cancerología, Mexico City, Mexico
| | - Miriam Bobadilla Del Valle
- Laboratory of Clinical Microbiology, Departament of Infectious Diseases, Instituto Nacional de Ciencias Medicas y Nutrición, Mexico City, Mexico
| | - Veronica Esteban-Kenel
- Laboratory of Clinical Microbiology, Departament of Infectious Diseases, Instituto Nacional de Ciencias Medicas y Nutrición, Mexico City, Mexico
| | - Paola Zinser Peniche
- Departament of Infectious Diseases, Instituto Nacional de Cancerología, Mexico City, Mexico
| | - Alfredo Ponce De León Garduño
- Laboratory of Clinical Microbiology, Departament of Infectious Diseases, Instituto Nacional de Ciencias Medicas y Nutrición, Mexico City, Mexico
| | | | - María Nancy Sánchez Cruz
- Laboratory of Clinical Microbiology, Departament of Infectious Diseases, Instituto Nacional de Ciencias Medicas y Nutrición, Mexico City, Mexico
| | - Adrian Camacho-Ortiz
- Department of Infectious Diseases, Department of Internal Medicine, Hospital Universitario Dr. Jose Eleuterio Gonzalez, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Diana Vilar-Compte
- Departament of Infectious Diseases, Instituto Nacional de Cancerología, Mexico City, Mexico
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11
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Skjøt-Arkil H, Rune Nanthan K, Chen M, Rosenvinge FS. Carrier prevalence of Clostridioides difficile in emergency departments and the association of prior antibiotic consumption: a combined cross-sectional and nested case-control study. J Antimicrob Chemother 2023:dkad213. [PMID: 37409612 DOI: 10.1093/jac/dkad213] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/25/2023] [Indexed: 07/07/2023] Open
Abstract
INTRODUCTION Clostridioides difficile infection is an urgent public health threat, and the incidence has been increasing over the last decades. Knowledge of the prevalence of C. difficile in acutely admitted patients and risk factors for colonization with C. difficile assists emergency departments (EDs) in prioritizing preventive initiatives. This national study aimed to describe prevalence and risk factors for C. difficile carriers acutely admitted to EDs, focusing on the impact of earlier antibiotic prescription. METHODS We conducted a nationwide analytic cross-sectional study with prospective data collection combined with a nested case-control study with retrospective data collection. All adults visiting one of eight Danish EDs were interviewed and examined for C. difficile. Using a national register, we collected the antibiotic history within the 2 years prior to enrolment. The primary outcome was the prevalence of C. difficile colonization, and secondary outcomes were related to risk factors and prior antibiotic prescription. Multivariate analyses examined the association between earlier antibiotic prescription and C. difficile colonization. RESULTS Of 5019 participants, 89 were colonized with C. difficile (prevalence of 1.8%). A significant and exposure-dependent association was found for penicillins [DDD/person-year(PY) > 20; OR 4.93 (95% CI 2.22-10.97)] and fluoroquinolones [DDD/PY > 20; OR 8.81 (95% CI 2.54-30.55)], but not macrolides. Timing of the prescription did not affect the association. CONCLUSIONS One out of 55 patients visiting a Danish ED were colonized with C. difficile. Risk factors for colonization included high age, comorbidity and prior prescription of fluoroquinolones and penicillins.
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Affiliation(s)
- Helene Skjøt-Arkil
- Department of Regional Health Research at University of Southern Denmark, Aabenraa, Denmark
- Emergency Department at University Hospital of Southern Denmark, Aabenraa, Denmark
| | - Kumanan Rune Nanthan
- Emergency Department at University Hospital of Southern Denmark, Aabenraa, Denmark
| | - Ming Chen
- Department of Microbiology at University Hospital of Southern Denmark, Aabenraa, Denmark
| | - Flemming S Rosenvinge
- Department of Clinical Microbiology at Odense University Hospital, and Research Unit of Clinical Microbiology at University of Southern Denmark, Odense, Denmark
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12
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Abstract
Clostridioides difficile is a common cause of community-associated and health care-associated infections. Older adults are disproportionately affected, and long-term care facilities (LTCFs) have borne a substantial proportion of the burden of C difficile infection (CDI). Recurrences of CDI are common in older adults and have substantial adverse effects on quality of life. Appropriate diagnostic testing and management is essential for older adults in the community and in LTCFs. This review focuses on current concepts related to the epidemiology, diagnosis, and management of CDI in older adults.
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Affiliation(s)
- Curtis J Donskey
- Geriatric Research Education and Clinical Center, Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA; Case Western Reserve University School of Medicine, Cleveland, OH, USA.
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13
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Agnew E, Davies KA, Viprey VF, Evans S, Davis GL, Hope R, Wilcox MH, Wingen-Heimann SM, Robotham JV. Impact of testing on Clostridioides difficile infection in hospitals across Europe: a mathematical model. Clin Microbiol Infect 2023:S1198-743X(23)00057-5. [PMID: 36773769 DOI: 10.1016/j.cmi.2023.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 01/18/2023] [Accepted: 02/05/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVES The prevalence of Clostridioides difficile infection (CDI) has been shown to vary markedly between European countries, both in hospitals and in the community. Determining the true prevalence has proven challenging. Without systematic testing in hospitals, the unchecked transmission of CDI can lead to large outbreaks in more susceptible cohorts. We investigate the success of CDI surveillance and control measures across Europe, by examining the dynamics of disease spread from the community into a hospital setting. We focus on national differences, such as variability in testing and sampling, disease prevalence in communities and hospitals, and antimicrobial usage. METHODS We developed a stochastic, compartmental, dynamic mathematical model parameterized using sampling and testing rate data from COMBACTE-CDI, a multicountry study in which all diarrhoeal stool samples (N = 3163) from European laboratories were tested for CDI, and data for antimicrobial usage and incidence of hospital cases sourced from the European Centre for Disease Prevention and Control. RESULTS The framework estimates the prevalence of CDI among hospital patients across European countries and explores how national differences impact the dynamics, transmission, and relative incidence of CDI within the hospital setting. The model illustrates the mechanisms influencing these national differences, namely, antimicrobial usage rates, national sampling and testing rates, and community prevalence of CDI. DISCUSSION Differential costs for testing and practicalities of scaling up testing mean every country needs to consider balancing CDI testing costs against the costs of treatment and care of patients with CDI.
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Affiliation(s)
- Emily Agnew
- Healthcare Associated Infection and Antimicrobial Resistance Division, National Infection Service, Public Health England, London, UK.
| | - Kerrie A Davies
- COMBACTE-CDI European Coordinator Laboratory, Healthcare Associated Infections Research Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK; European Society of Clinical Microbiology and Infectious Diseases Study Group for Clostridioides difficile, UK
| | - Virginie F Viprey
- COMBACTE-CDI European Coordinator Laboratory, Healthcare Associated Infections Research Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Stephanie Evans
- Healthcare Associated Infection and Antimicrobial Resistance Division, National Infection Service, Public Health England, London, UK
| | - Georgina L Davis
- COMBACTE-CDI European Coordinator Laboratory, Healthcare Associated Infections Research Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Russell Hope
- Healthcare Associated Infection and Antimicrobial Resistance Division, National Infection Service, Public Health England, London, UK
| | - Mark H Wilcox
- COMBACTE-CDI European Coordinator Laboratory, Healthcare Associated Infections Research Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK; European Society of Clinical Microbiology and Infectious Diseases Study Group for Clostridioides difficile, UK
| | - Sebastian M Wingen-Heimann
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; FOM University of Applied Sciences, Cologne, Germany
| | - Julie V Robotham
- Healthcare Associated Infection and Antimicrobial Resistance Division, National Infection Service, Public Health England, London, UK
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14
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Chen Y, Lv T, Yan D, Zheng L, Zheng B, Wang J, Gu S, Li L. Disordered Intestinal Microbial Communities During Clostridioides difficile Colonization and Subsequent Infection of Hepatic Cirrhosis Patients in a Tertiary Care Hospital in China. Front Cell Infect Microbiol 2022; 12:825189. [PMID: 35433508 PMCID: PMC9010725 DOI: 10.3389/fcimb.2022.825189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/09/2022] [Indexed: 12/13/2022] Open
Abstract
Patients with hepatic cirrhosis are more susceptible to Clostridioides difficile infection (CDI) and colonization with Clostridioides difficile (C. difficile). Asymptomatic C. difficile colonization is thought to predispose to subsequent CDI. However, the dynamic gut microbiota changes remain unclear. In this study, we used 16S rRNA gene sequencing to longitudinally monitor alterations in the intestinal microbiota of 22 hepatic cirrhosis patients with toxigenic C. difficile colonization at admission (pre-CDI) and developed CDI during hospitalization, subdivided into pre-CDI and CDI. 21 hospitalized cirrhotic patients without C. difficile colonization served as controls (HC). Compared with HC, pre-CDI and CDI samples had significantly decreased microbial richness and diversity, a significantly higher relative abundance of opportunistic pathogen Enterococcus, and a lower relative abundance of beneficial symbionts, such as Faecalibacterium, Dorea, and Roseburia. Three biomarkers showed high accuracy for distinguishing pre-CDI samples from HC with an area under the curve (AUC) up to 0.81. In conclusion, our study explored the changes of the gut microbiome before and after CDI. The gut microbial richness as well as diversity in CDI patients were notably reduced, relative to controls. Imbalance of the intestinal flora may be related to the risk for development of CDI. Identifying key members of the gut microbiota and illustrating their roles and mechanisms of action in CDI development are important avenues for future research.
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Affiliation(s)
- 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, College of Medicine, Zhejiang University, Hangzhou, China
| | - 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, College of Medicine, Zhejiang University, Hangzhou, China
| | - Dong Yan
- 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, College of Medicine, Zhejiang University, Hangzhou, China
| | - Lisi Zheng
- 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, College of Medicine, Zhejiang University, Hangzhou, China
| | - Beiwen Zheng
- 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, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jingxia 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, College of Medicine, Zhejiang University, Hangzhou, China
| | - Silan Gu
- 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, College of Medicine, Zhejiang University, Hangzhou, China
- *Correspondence: Silan Gu,
| | - Lanjuan Li
- 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, College of Medicine, Zhejiang University, Hangzhou, China
- Bacterial Research Platform, Jinan Microecological Biomedicine Shandong Laboratory, Jinan, China
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15
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Gowler CD, Slayton RB, Reddy SC, O’Hagan JJ. Improving mathematical modeling of interventions to prevent healthcare-associated infections by interrupting transmission or pathogens: How common modeling assumptions about colonized individuals impact intervention effectiveness estimates. PLoS One 2022; 17:e0264344. [PMID: 35226689 PMCID: PMC8884501 DOI: 10.1371/journal.pone.0264344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 02/08/2022] [Indexed: 12/03/2022] Open
Abstract
Mathematical models are used to gauge the impact of interventions for healthcare-associated infections. As with any analytic method, such models require many assumptions. Two common assumptions are that asymptomatically colonized individuals are more likely to be hospitalized and that they spend longer in the hospital per admission because of their colonization status. These assumptions have no biological basis and could impact the estimated effects of interventions in unintended ways. Therefore, we developed a model of methicillin-resistant Staphylococcus aureus transmission to explicitly evaluate the impact of these assumptions. We found that assuming that asymptomatically colonized individuals were more likely to be admitted to the hospital or spend longer in the hospital than uncolonized individuals biased results compared to a more realistic model that did not make either assumption. Results were heavily biased when estimating the impact of an intervention that directly reduced transmission in a hospital. In contrast, results were moderately biased when estimating the impact of an intervention that decolonized hospital patients. Our findings can inform choices modelers face when constructing models of healthcare-associated infection interventions and thereby improve their validity.
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Affiliation(s)
- Camden D. Gowler
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Department of Ecology and Evolutionary Biology, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Rachel B. Slayton
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Sujan C. Reddy
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Justin J. O’Hagan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- * E-mail:
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16
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Whole-Genome Sequencing Reveals the High Nosocomial Transmission and Antimicrobial Resistance of Clostridioides difficile in a Single Center in China, a Four-Year Retrospective Study. Microbiol Spectr 2022; 10:e0132221. [PMID: 35019676 PMCID: PMC8754133 DOI: 10.1128/spectrum.01322-21] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Clostridioides difficile, which causes life-threatening diarrheal disease, presents an urgent threat to health care systems. In this study, we present a retrospective genomic and epidemiological analysis of C. difficile in a large teaching hospital. First, we collected 894 nonduplicate fecal samples from patients during a whole year to elucidate the C. difficile molecular epidemiology. We then presented a detailed description of the population structure of C. difficile based on 270 isolates separated between 2015 and 2020 and clarified the genetic and phenotypic features by MIC and whole-genome sequencing. We observed a high carriage rate (19.4%, 173/894) of C. difficile among patients in this hospital. The population structure of C. difficile was diverse with a total of 36 distinct STs assigned. In total, 64.8% (175/270) of the isolates were toxigenic, including four CDT-positive (C. difficile transferase) isolates, and 50.4% (135/268) of the isolates were multidrug-resistant. Statistically, the rates of resistance to erythromycin, moxifloxacin, and rifaximin were higher for nontoxigenic isolates. Although no vancomycin-resistant isolates were detected, the MIC for vancomycin was higher for toxigenic isolates (P < 0.01). The in-hospital transmission was observed, with 43.8% (110/251) of isolates being genetically linked to a prior case. However, no strong correlation was detected between the genetic linkage and epidemiological linkage. Asymptomatic colonized patients play the same role in nosocomial transmission as infected patients, raising the issue of routine screening of C. difficile on admission. This work provides an in-depth description of C. difficile in a hospital setting and paves the way for better surveillance and effective prevention of related diseases in China. IMPORTANCEClostridioides difficile infections (CDI) are the leading cause of healthcare-associated diarrhea and are known to be resistant to multiple antibiotics. In the past decade, C. difficile has emerged rapidly and has spread globally, causing great concern among American and European countries. However, research on CDI remains limited in China. Here, we characterized the comprehensive spectrum of C. difficile by whole-genome sequencing (WGS) in a Chinese hospital, showing a high detection rate among patients, diverse genome characteristics, a high level of antibiotic resistance, and an unknown nosocomial transmission risk of C. difficile. During the study period, two C. difficile transferase (CDT)-positive isolates belonging to a new multilocus sequence type (ST820) were detected, which have caused serious clinical symptoms. This work describes C. difficile integrally and provides new insight into C. difficile surveillance based on WGS in China.
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17
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Alharbi AK, Ahmed MA, Tashkandi A, Alkhathaami FA, Alshehri AI. Persistent Clostridium Difficile Diarrhea, Thinking Beyond Pseudomembranous Colitis: A Case Report. Cureus 2021; 13:e20704. [PMID: 35106241 PMCID: PMC8788889 DOI: 10.7759/cureus.20704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2021] [Indexed: 11/05/2022] Open
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18
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Health Care Environmental Hygiene: New Insights and Centers for Disease Control and Prevention Guidance. Infect Dis Clin North Am 2021; 35:609-629. [PMID: 34362536 DOI: 10.1016/j.idc.2021.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Recent research has significantly clarified the impact of optimizing patient-zone environmental hygiene. New insights into the environmental microbial epidemiology of many hospital-associated pathogens, especially Clostridioides difficile, have clarified and quantified the role of ongoing occult pathogen transmission from the near-patient environment. The recent development of safe, broadly effective surface chemical disinfectants has led to new opportunities to broadly enhance environmental hygiene in all health care settings. The Centers for Disease Control and Prevention has recently developed a detailed guidance to assist all health care settings in implementing optimized programs to mitigate health care-associated pathogen transmission from the near-patient surfaces.
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19
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Frentrup M, Thiel N, Junker V, Behrens W, Münch S, Siller P, Kabelitz T, Faust M, Indra A, Baumgartner S, Schepanski K, Amon T, Roesler U, Funk R, Nübel U. Agricultural fertilization with poultry manure results in persistent environmental contamination with the pathogen Clostridioides difficile. Environ Microbiol 2021; 23:7591-7602. [PMID: 33998128 DOI: 10.1111/1462-2920.15601] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 05/13/2021] [Indexed: 11/30/2022]
Abstract
During a field experiment applying broiler manure for fertilization of agricultural land, we detected viable Clostridioides (also known as Clostridium) difficile in broiler faeces, manure, dust and fertilized soil. A large diversity of toxigenic C. difficile isolates was recovered, including PCR ribotypes common from human disease. Genomic relatedness of C. difficile isolates from dust and from soil, recovered more than 2 years after fertilization, traced their origins to the specific chicken farm that had delivered the manure. We present evidence of long-term contamination of agricultural soil with manure-derived C. difficile and demonstrate the potential for airborne dispersal of C. difficile through dust emissions during manure application. Clostridioides genome sequences virtually identical to those from manure had been recovered from chicken meat and from human infections in previous studies, suggesting broiler-associated C. difficile are capable of zoonotic transmission.
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Affiliation(s)
- Martinique Frentrup
- Leibniz-Institute DSMZ-German Collection of Microorganisms and Cell Cultures, Braunschweig, Germany
| | - Nadine Thiel
- Leibniz-Institute DSMZ-German Collection of Microorganisms and Cell Cultures, Braunschweig, Germany
| | - Vera Junker
- Leibniz-Institute DSMZ-German Collection of Microorganisms and Cell Cultures, Braunschweig, Germany
| | - Wiebke Behrens
- Leibniz-Institute DSMZ-German Collection of Microorganisms and Cell Cultures, Braunschweig, Germany
| | - Steffen Münch
- Leibniz Centre for Agricultural Landscape Research (ZALF), Müncheberg, Germany
| | - Paul Siller
- Institute for Animal Hygiene and Environmental Health (ITU), Free University Berlin, Berlin, Germany
| | - Tina Kabelitz
- Leibniz Institute for Agricultural Engineering and Bioeconomy (ATB), Potsdam, Germany
| | - Matthias Faust
- Leibniz-Institute for Tropospheric Research (TROPOS), Leipzig, Germany
| | - Alexander Indra
- AGES-Austrian Agency for Health and Food Safety, Vienna, Austria.,Paracelsus Medical University of Salzburg, Salzburg, Austria
| | | | | | - Thomas Amon
- Institute for Animal Hygiene and Environmental Health (ITU), Free University Berlin, Berlin, Germany.,Leibniz Institute for Agricultural Engineering and Bioeconomy (ATB), Potsdam, Germany
| | - Uwe Roesler
- Institute for Animal Hygiene and Environmental Health (ITU), Free University Berlin, Berlin, Germany
| | - Roger Funk
- Leibniz Centre for Agricultural Landscape Research (ZALF), Müncheberg, Germany
| | - Ulrich Nübel
- Leibniz-Institute DSMZ-German Collection of Microorganisms and Cell Cultures, Braunschweig, Germany.,German Center for Infection Research (DZIF), Partner Site Braunschweig-Hannover, Braunschweig, Germany.,Braunschweig Integrated Center of Systems Biology (BRICS), Technical University, Braunschweig, Germany
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20
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Clostridioides difficile Infection: A Room for Multifaceted Interventions. J Clin Med 2020; 9:jcm9124114. [PMID: 33419243 PMCID: PMC7767249 DOI: 10.3390/jcm9124114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 12/17/2020] [Indexed: 12/17/2022] Open
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21
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Risk factors for Clostridioides difficile colonization among hospitalized adults: A meta-analysis and systematic review. Infect Control Hosp Epidemiol 2020; 42:565-572. [PMID: 33118886 DOI: 10.1017/ice.2020.1236] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To identify risk factors for asymptomatic Clostridioides difficile colonization among hospitalized adults utilizing a meta-analysis, which may enable early identification of colonized patients at risk of spreading C. difficile. DESIGN Meta-analysis and systematic review. METHODS We systematically searched MEDLINE, Scopus, Web of Science, and EMBASE from January 1, 1975, to February 15, 2020, for articles related to C. difficile colonization among hospitalized adults. Studies with multivariable analyses evaluating risk factors for asymptomatic colonization were eligible. RESULTS Among 5,506 studies identified in the search, 19 studies met the inclusion criteria. Included studies reported 20,334 adult patients of whom 1,588 were asymptomatically colonized with C. difficile. Factors associated with an increased risk of colonization were hospitalization in the previous 6 months (OR, 2.18; 95% CI, 1.86-2.56; P < .001), use of gastric acid suppression therapy within the previous 8 weeks (OR, 1.42; 95% CI, 1.17-1.73; P < .001), tube feeding (OR, 2.02; 95% CI, 1.06-3.85; P = .03), and corticosteroid use in the previous 8 weeks (OR, 1.58; 95% CI, 1.14-2.17; P = .006). Receipt of antibiotics in the previous 3 months (OR, 1.37; 95% CI, 0.94-2.01; P = .10) was not associated with statistically significant effects on risk of colonization. CONCLUSIONS C. difficile colonization was significantly associated with previous hospitalization, gastric acid suppression, tube feeding, and corticosteroid use. Recognition of these risk factors may assist in identifying asymptomatic carriers of C. difficile and taking appropriate measures to reduce transmission.
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Frentrup M, Zhou Z, Steglich M, Meier-Kolthoff JP, Göker M, Riedel T, Bunk B, Spröer C, Overmann J, Blaschitz M, Indra A, von Müller L, Kohl TA, Niemann S, Seyboldt C, Klawonn F, Kumar N, Lawley TD, García-Fernández S, Cantón R, del Campo R, Zimmermann O, Groß U, Achtman M, Nübel U. A publicly accessible database for Clostridioides difficile genome sequences supports tracing of transmission chains and epidemics. Microb Genom 2020; 6:mgen000410. [PMID: 32726198 PMCID: PMC7641423 DOI: 10.1099/mgen.0.000410] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/30/2020] [Indexed: 01/02/2023] Open
Abstract
Clostridioides difficile is the primary infectious cause of antibiotic-associated diarrhea. Local transmissions and international outbreaks of this pathogen have been previously elucidated by bacterial whole-genome sequencing, but comparative genomic analyses at the global scale were hampered by the lack of specific bioinformatic tools. Here we introduce a publicly accessible database within EnteroBase (http://enterobase.warwick.ac.uk) that automatically retrieves and assembles C. difficile short-reads from the public domain, and calls alleles for core-genome multilocus sequence typing (cgMLST). We demonstrate that comparable levels of resolution and precision are attained by EnteroBase cgMLST and single-nucleotide polymorphism analysis. EnteroBase currently contains 18 254 quality-controlled C. difficile genomes, which have been assigned to hierarchical sets of single-linkage clusters by cgMLST distances. This hierarchical clustering is used to identify and name populations of C. difficile at all epidemiological levels, from recent transmission chains through to epidemic and endemic strains. Moreover, it puts newly collected isolates into phylogenetic and epidemiological context by identifying related strains among all previously published genome data. For example, HC2 clusters (i.e. chains of genomes with pairwise distances of up to two cgMLST alleles) were statistically associated with specific hospitals (P<10-4) or single wards (P=0.01) within hospitals, indicating they represented local transmission clusters. We also detected several HC2 clusters spanning more than one hospital that by retrospective epidemiological analysis were confirmed to be associated with inter-hospital patient transfers. In contrast, clustering at level HC150 correlated with k-mer-based classification and was largely compatible with PCR ribotyping, thus enabling comparisons to earlier surveillance data. EnteroBase enables contextual interpretation of a growing collection of assembled, quality-controlled C. difficile genome sequences and their associated metadata. Hierarchical clustering rapidly identifies database entries that are related at multiple levels of genetic distance, facilitating communication among researchers, clinicians and public-health officials who are combatting disease caused by C. difficile.
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Affiliation(s)
| | - Zhemin Zhou
- Warwick Medical School, University of Warwick, UK
| | - Matthias Steglich
- Leibniz Institute DSMZ, Braunschweig, Germany
- German Center for Infection Research (DZIF), Partner site Hannover-Braunschweig, Germany
| | | | | | - Thomas Riedel
- Leibniz Institute DSMZ, Braunschweig, Germany
- German Center for Infection Research (DZIF), Partner site Hannover-Braunschweig, Germany
| | - Boyke Bunk
- Leibniz Institute DSMZ, Braunschweig, Germany
| | | | - Jörg Overmann
- Leibniz Institute DSMZ, Braunschweig, Germany
- German Center for Infection Research (DZIF), Partner site Hannover-Braunschweig, Germany
- Braunschweig Integrated Center of Systems Biology (BRICS), Technical University, Braunschweig, Germany
| | - Marion Blaschitz
- AGES-Austrian Agency for Health and Food Safety, Vienna, Austria
| | - Alexander Indra
- AGES-Austrian Agency for Health and Food Safety, Vienna, Austria
| | | | - Thomas A. Kohl
- Research Center Borstel, Germany
- German Center for Infection Research (DZIF), Partner site Hamburg-Lübeck-Borstel, Germany
| | - Stefan Niemann
- Research Center Borstel, Germany
- German Center for Infection Research (DZIF), Partner site Hamburg-Lübeck-Borstel, Germany
| | | | - Frank Klawonn
- Biostatistics, Helmholtz Centre for Infection Research, Braunschweig, Germany
- Institute for Information Engineering, Ostfalia University, Wolfenbüttel, Germany
| | | | | | - Sergio García-Fernández
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal, and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain
| | - Rafael Cantón
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal, and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain
| | - Rosa del Campo
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal, and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain
| | | | - Uwe Groß
- University Medical Center Göttingen, Germany
| | - Mark Achtman
- Warwick Medical School, University of Warwick, UK
| | - Ulrich Nübel
- Leibniz Institute DSMZ, Braunschweig, Germany
- German Center for Infection Research (DZIF), Partner site Hannover-Braunschweig, Germany
- Braunschweig Integrated Center of Systems Biology (BRICS), Technical University, Braunschweig, Germany
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Clostridioides difficile in transplant patients: early diagnosis, treatment, and prevention. Curr Opin Infect Dis 2020; 32:307-313. [PMID: 31116134 DOI: 10.1097/qco.0000000000000560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE OF REVIEW Clostridioides difficile infection is common in solid organ transplant and hematopoietic stem-cell transplant recipients and is associated with significant morbidity and mortality. These populations are also underrepresented in clinical trials, making optimal management difficult. Because of this, management of these populations follows national guideline recommendations. This review aims to summarize the recent relevant literature pertaining to the clinical management of C. difficile infection in transplant patients, with a particular focus on diagnosis, treatment, and prevention. RECENT FINDINGS Early diagnosis of C. difficile colonization may mitigate both horizontal and vertical transmission (progression from colonization to colitis) of infection. Once diagnosed, recent literature suggests antibiotic treatment should align with that recommended by national guidelines. Fecal microbiota transplant is an emerging therapy for recurrent C. difficile infection, and recent data have demonstrated safety and efficacy. Prevention strategies including antimicrobial stewardship, probiotic administration, antibiotic administration, and bezlotoxumab may be beneficial in transplant populations, but more data are needed to confirm recent findings. SUMMARY Studies evaluating C. difficile infection in transplant patients are only recently starting to emerge. Further research is needed to identify optimal treatment and prevention strategies, and to examine novel strategies such as microbiome manipulation.
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Hooker EA, Ulrich D, Brooks D. Successful Removal of Clostridioides Difficile Spores and Pathogenic Bacteria From a Launderable Barrier Using a Commercial Laundry Process. Infect Dis (Lond) 2020; 13:1178633720923657. [PMID: 32528224 PMCID: PMC7263102 DOI: 10.1177/1178633720923657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 04/11/2020] [Indexed: 02/01/2023] Open
Abstract
Background: To properly clean and disinfect hospital mattresses, bed manufacturers recommend a 3- to 6-step process to remove all pathogenic bacteria. An alternative is to use a removable barrier on the mattress, which is laundered after each use. The current study was to determine efficacy of a commercial laundry process in eliminating Clostridioides difficile (C diff) spores, Mycobacterium terrae (M terrae), methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa (P aeruginosa), Klebsiella pneumoniae (K pneumoniae), and Escherichia coli (E coli) from a barrier. Methods: A test barrier received 3 unique microbial suspensions in separate locations, each suspension having a known quantity of specific microorganisms: C diff spores, M terrae, and a mixed suspension of MRSA, S aureus, P aeruginosa, K pneumoniae, and E coli. A wash load contained the test barrier and 11 additional ballast barriers. Various soils were spread onto the barriers to simulate heavy soiling that may occur in a wash load: Each barrier received a small amount of mixed soil, 50% received urine, 25% received blood, and 25% received a large amount of additional mixed soil. The load was laundered using 71°C (160°F) water, detergent, and chlorine bleach, with final drying at 71°C (160°F). After laundering, remaining colony-forming units (CFUs) of each microorganism were counted at the applied locations. Each test was replicated 3 times. Industry-accepted methods were used to produce suspensions, apply inoculum, and recover organisms after laundering. Results: Before laundering, test barriers contained at least 7.0 log10 cfu/mL of each microorganism distributed over 103 cm2. After laundering, in all cases, no residual CFUs were detected over the test area, resulting in greater than 6.0 log10 reductions for every organism. (P < .05). Conclusions: Under extreme test conditions including the presence of soil, the laundry process removed all detectable pathogenic bacteria and spores from the barrier.
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Affiliation(s)
| | | | - Dane Brooks
- Research and Development Department, Q Laboratories, Cincinnati, OH, USA
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Saad-Roy CM, Wingreen NS, Levin SA, Grenfell BT. Dynamics in a simple evolutionary-epidemiological model for the evolution of an initial asymptomatic infection stage. Proc Natl Acad Sci U S A 2020; 117:11541-11550. [PMID: 32385153 PMCID: PMC7261016 DOI: 10.1073/pnas.1920761117] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Pathogens exhibit a rich variety of life history strategies, shaped by natural selection. An important pathogen life history characteristic is the propensity to induce an asymptomatic yet productive (transmissive) stage at the beginning of an infection. This characteristic is subject to complex trade-offs, ranging from immunological considerations to population-level social processes. We aim to classify the evolutionary dynamics of such asymptomatic behavior of pathogens (hereafter "latency") in order to unify epidemiology and evolution for this life history strategy. We focus on a simple epidemiological model with two infectious stages, where hosts in the first stage can be partially or fully asymptomatic. Immunologically, there is a trade-off between transmission and progression in this first stage. For arbitrary trade-offs, we derive different conditions that guarantee either at least one evolutionarily stable strategy (ESS) at zero, some, or maximal latency of the first stage or, perhaps surprisingly, at least one unstable evolutionarily singular strategy. In this latter case, there is bistability between zero and nonzero (possibly maximal) latency. We then prove the uniqueness of interior evolutionarily singular strategies for power-law and exponential trade-offs: Thus, bistability is always between zero and maximal latency. Overall, previous multistage infection models can be summarized with a single model that includes evolutionary processes acting on latency. Since small changes in parameter values can lead to abrupt transitions in evolutionary dynamics, appropriate disease control strategies could have a substantial impact on the evolution of first-stage latency.
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Affiliation(s)
- Chadi M Saad-Roy
- Lewis-Sigler Institute for Integrative Genomics, Princeton University, Princeton, NJ 08544;
| | - Ned S Wingreen
- Lewis-Sigler Institute for Integrative Genomics, Princeton University, Princeton, NJ 08544
- Department of Molecular Biology, Princeton University, Princeton, NJ 08544
| | - Simon A Levin
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ 08544;
| | - Bryan T Grenfell
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ 08544;
- Woodrow Wilson School of Public and International Affairs, Princeton University, Princeton, NJ 08544
- Division of International Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, MD 20892
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Emberger J, Hitchcock MM, Markley JD. Diagnostic Stewardship Approaches to Clostridioides difficile Infection in the Era of Two-Step Testing: a Shifting Landscape. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2020. [DOI: 10.1007/s40506-020-00223-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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27
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Crobach MJT, Ducarmon QR, Terveer EM, Harmanus C, Sanders IMJG, Verduin KM, Kuijper EJ, Zwittink RD. The Bacterial Gut Microbiota of Adult Patients Infected, Colonized or Noncolonized by Clostridioides difficile. Microorganisms 2020; 8:microorganisms8050677. [PMID: 32384826 PMCID: PMC7284656 DOI: 10.3390/microorganisms8050677] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/01/2020] [Accepted: 05/04/2020] [Indexed: 12/15/2022] Open
Abstract
: Gut microbiota composition in patients with Clostridioides difficile colonization is not well investigated. We aimed to identify bacterial signatures associated with resistance and susceptibility to C. difficile colonization (CDC) and infection (CDI). Therefore, gut microbiota composition from patients with CDC (n = 41), with CDI (n = 41), and without CDC (controls, n = 43) was determined through 16S rRNA gene amplicon sequencing. Bacterial diversity was decreased in CDC and CDI patients (p<0.01). Overall microbiota composition was significantly different between control, CDC, and CDI patients (p = 0.001). Relative abundance of Clostridioides (most likely C. difficile) increased stepwise from controls to CDC and CDI patients. In addition, differential abundance analysis revealed that CDI patients' gut microbiota was characterized by significantly higher relative abundance of Bacteroides and Veillonella than CDC patients and controls. Control patients had significantly higher Eubacterium hallii and Fusicatenibacter abundance than colonized patients. Network analysis indicated that Fusicatenibacter was negatively associated with Clostridioides in CDI patients, while Veillonella was positively associated with Clostridioides in CDC patients. Bacterial microbiota diversity decreased in both CDC and CDI patients, but harbored a distinct microbiota. Eubacterium hallii and Fusicatenibacter may indicate resistance against C. difficile colonization and subsequent infection, while Veillonella may indicate susceptibility to colonization and infection by C. difficile.
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Affiliation(s)
- Monique J. T. Crobach
- Experimental Bacteriology, Department of Medical Microbiology, Center for Infectious Diseases, Leiden University Medical Center, 2333ZA Leiden, The Netherlands; (M.J.T.C.); (Q.R.D.); (E.M.T.); (C.H.); (I.M.J.G.S.); (E.J.K.)
| | - Quinten R. Ducarmon
- Experimental Bacteriology, Department of Medical Microbiology, Center for Infectious Diseases, Leiden University Medical Center, 2333ZA Leiden, The Netherlands; (M.J.T.C.); (Q.R.D.); (E.M.T.); (C.H.); (I.M.J.G.S.); (E.J.K.)
- Center for Microbiome Analyses and Therapeutics, Department of Medical Microbiology, Center for Infectious Diseases, Leiden University Medical Center, 2333ZA Leiden, The Netherlands
| | - Elisabeth M. Terveer
- Experimental Bacteriology, Department of Medical Microbiology, Center for Infectious Diseases, Leiden University Medical Center, 2333ZA Leiden, The Netherlands; (M.J.T.C.); (Q.R.D.); (E.M.T.); (C.H.); (I.M.J.G.S.); (E.J.K.)
- Center for Microbiome Analyses and Therapeutics, Department of Medical Microbiology, Center for Infectious Diseases, Leiden University Medical Center, 2333ZA Leiden, The Netherlands
- Netherlands Donor Feces Bank, 2333ZA Leiden, The Netherlands
| | - Celine Harmanus
- Experimental Bacteriology, Department of Medical Microbiology, Center for Infectious Diseases, Leiden University Medical Center, 2333ZA Leiden, The Netherlands; (M.J.T.C.); (Q.R.D.); (E.M.T.); (C.H.); (I.M.J.G.S.); (E.J.K.)
| | - Ingrid M. J. G. Sanders
- Experimental Bacteriology, Department of Medical Microbiology, Center for Infectious Diseases, Leiden University Medical Center, 2333ZA Leiden, The Netherlands; (M.J.T.C.); (Q.R.D.); (E.M.T.); (C.H.); (I.M.J.G.S.); (E.J.K.)
| | - Kees M. Verduin
- Department of Microbiology and Infection Prevention, Amphia Hospital, 4818CK Breda, The Netherlands;
| | - Ed J. Kuijper
- Experimental Bacteriology, Department of Medical Microbiology, Center for Infectious Diseases, Leiden University Medical Center, 2333ZA Leiden, The Netherlands; (M.J.T.C.); (Q.R.D.); (E.M.T.); (C.H.); (I.M.J.G.S.); (E.J.K.)
- Center for Microbiome Analyses and Therapeutics, Department of Medical Microbiology, Center for Infectious Diseases, Leiden University Medical Center, 2333ZA Leiden, The Netherlands
- Netherlands Donor Feces Bank, 2333ZA Leiden, The Netherlands
| | - Romy D. Zwittink
- Experimental Bacteriology, Department of Medical Microbiology, Center for Infectious Diseases, Leiden University Medical Center, 2333ZA Leiden, The Netherlands; (M.J.T.C.); (Q.R.D.); (E.M.T.); (C.H.); (I.M.J.G.S.); (E.J.K.)
- Center for Microbiome Analyses and Therapeutics, Department of Medical Microbiology, Center for Infectious Diseases, Leiden University Medical Center, 2333ZA Leiden, The Netherlands
- Correspondence: ; Tel.: +31-(0)71-526-4830
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Shen A. Clostridioides difficile Spores: Bile Acid Sensors and Trojan Horses of Transmission. Clin Colon Rectal Surg 2020; 33:58-66. [PMID: 32104157 DOI: 10.1055/s-0040-1701230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The Gram-positive, spore-forming bacterium, Clostridioides difficile is the leading cause of healthcare-associated infections in the United States, although it also causes a significant number of community-acquired infections. C. difficile infections, which range in severity from mild diarrhea to toxic megacolon, cost more to treat than matched infections, with an annual treatment cost of approximately $6 billion for almost half-a-million infections. These high-treatment costs are due to the high rates of C. difficile disease recurrence (>20%) and necessity for special disinfection measures. These complications arise in part because C. difficile makes metabolically dormant spores, which are the major infectious particle of this obligate anaerobe. These seemingly inanimate life forms are inert to antibiotics, resistant to commonly used disinfectants, readily disseminated, and capable of surviving in the environment for a long period of time. However, upon sensing specific bile salts in the vertebrate gut, C. difficile spores transform back into the vegetative cells that are responsible for causing disease. This review discusses how spores are ideal vectors for disease transmission and how antibiotics modulate this process. We also describe the resistance properties of spores and how they create challenges eradicating spores, as well as promote their spread. Lastly, environmental reservoirs of C. difficile spores and strategies for destroying them particularly in health care environments will be discussed.
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Affiliation(s)
- Aimee Shen
- Department of Molecular Biology and Microbiology, Tufts University School of Medicine, Boston, Massachusetts
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Baron SW, Ostrowsky BE, Nori P, Drory DY, Levi MH, Szymczak WA, Rinke ML, Southern WN. Screening of Clostridioides difficile carriers in an urban academic medical center: Understanding implications of disease. Infect Control Hosp Epidemiol 2020; 41:149-153. [PMID: 31822302 PMCID: PMC7702293 DOI: 10.1017/ice.2019.309] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Efforts to reduce Clostridioides difficile infection (CDI) have targeted transmission from patients with symptomatic C. difficile. However, many patients with the C. difficile organism are carriers without symptoms who may serve as reservoirs for spread of infection and may be at risk for progression to symptomatic C. difficile. To estimate the prevalence of C. difficile carriage and determine the risk and speed of progression to symptomatic C. difficile among carriers, we established a pilot screening program in a large urban hospital. DESIGN Prospective cohort study. SETTING An 800-bed, tertiary-care, academic medical center in the Bronx, New York. PARTICIPANTS A sample of admitted adults without diarrhea, with oversampling of nursing facility patients. METHODS Perirectal swabs were tested by polymerase chain reaction for C. difficile within 24 hours of admission, and patients were followed for progression to symptomatic C. difficile. Development of symptomatic C. difficile was compared among C. difficile carriers and noncarriers using a Cox proportional hazards model. RESULTS Of the 220 subjects, 21 (9.6%) were C. difficile carriers, including 10.2% of the nursing facility residents and 7.7% of the community residents (P = .60). Among the 21 C. difficile carriers, 8 (38.1%) progressed to symptomatic C. difficile, but only 4 (2.0%) of the 199 noncarriers progressed to symptomatic C. difficile (hazard ratio, 23.9; 95% CI, 7.2-79.6; P < .0001). CONCLUSIONS Asymptomatic carriage of C. difficile is prevalent among admitted patients and confers a significant risk of progression to symptomatic CDI. Screening for asymptomatic carriers may represent an opportunity to reduce CDI.
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Affiliation(s)
- Sarah W Baron
- Division of Hospital Medicine, Department of Medicine, Montefiore Medical Center, Bronx, New York
- Montefiore Medical Center, Bronx, New York
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Belinda E Ostrowsky
- Division of Infectious Disease, Department of Medicine, Montefiore Medical Center, Bronx, New York
- Montefiore Medical Center, Bronx, New York
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Priya Nori
- Division of Infectious Disease, Department of Medicine, Montefiore Medical Center, Bronx, New York
- Montefiore Medical Center, Bronx, New York
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - David Y Drory
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Michael H Levi
- Department of Pathology, Montefiore Medical Center, Bronx, New York
- Montefiore Medical Center, Bronx, New York
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Wendy A Szymczak
- Department of Pathology, Montefiore Medical Center, Bronx, New York
- Montefiore Medical Center, Bronx, New York
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Michael L Rinke
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Children's Hospital at Montefiore, Bronx, New York
- Montefiore Medical Center, Bronx, New York
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - William N Southern
- Division of Hospital Medicine, Department of Medicine, Montefiore Medical Center, Bronx, New York
- Montefiore Medical Center, Bronx, New York
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
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Muñoz-Price LS, Hanson R, Singh S, Nattinger AB, Penlesky A, Buchan BW, Ledeboer NA, Beyer K, Namin S, Zhou Y, Pezzin LE. Association Between Environmental Factors and Toxigenic Clostridioides difficile Carriage at Hospital Admission. JAMA Netw Open 2020; 3:e1919132. [PMID: 31922563 PMCID: PMC6991319 DOI: 10.1001/jamanetworkopen.2019.19132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
IMPORTANCE Clostridioides difficile infection is the most frequent health care-associated infection in the United States. However, exposure to this organism might occur outside the health care setting. OBJECTIVE To examine whether exposure to environmental factors, such as livestock farms, is associated with a higher probability of being colonized with C difficile at hospital admission. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted from May 1, 2017, to June 30, 2018, at a teaching-affiliated hospital in Milwaukee, Wisconsin. All consecutive patients underwent C difficile screening using a nucleic acid amplification test at hospital admission. Data analyses were performed from July 2018 to October 2019. EXPOSURES The distances from patient residence to the nearest livestock farms, meat processing plants, raw materials services, and sewage facilities were measured in addition to risk factors previously evaluated in other studies. MAIN OUTCOMES AND MEASURES The main outcome was a positive result on C difficile screening tests performed within 72 hours of hospital admission. RESULTS A total of 3043 patients admitted to the hospital were included in the final analysis. Of those, 1564 (51.4%) were women and 2074 (68.9%) were white, with a mean (SD) age of 62.0 (15.9) years; 978 patients (32.1%) were admitted to hematology-oncology units. At first admission, 318 patients (10.4%) were detected through testing as C difficile carriers. Multivariable logistic regression analyses were performed on a stratified sample of patients based on hematology-oncology admission status. These analyses indicated that although patients admitted to hematology-oncology units were 35% more likely to be colonized with C difficile, no significant association existed between their sociodemographic and economic characteristics or health care and environmental exposures and the likelihood of a positive C difficile test result. In contrast, among patients admitted to non-hematology-oncology units, comorbidities increased the likelihood for colonization by more than 4 times; women had 60% greater colonization than men, and a history of recent hospitalization (ie, within the preceding 6 months) increased the likelihood of colonization by 70%. Residential proximity to livestock farms were all significantly associated with a higher likelihood of a positive C difficile test result. Residential proximity to livestock farms more than doubled the probability of C difficile colonization in patients admitted to non-hematology-oncology units. CONCLUSIONS AND RELEVANCE A shorter distance between residence and livestock farms was associated with C difficile colonization. Knowledge of the epidemiology of C difficile in the community surrounding the hospital is important, as it has potential implications for the incidence of hospital-onset C difficile infection.
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Affiliation(s)
- L. Silvia Muñoz-Price
- Division of Infectious Diseases, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Ryan Hanson
- Collaborative for Healthcare Delivery Science, Medical College of Wisconsin, Milwaukee
| | - Siddhartha Singh
- Collaborative for Healthcare Delivery Science, Medical College of Wisconsin, Milwaukee
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Ann B. Nattinger
- Collaborative for Healthcare Delivery Science, Medical College of Wisconsin, Milwaukee
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Annie Penlesky
- Collaborative for Healthcare Delivery Science, Medical College of Wisconsin, Milwaukee
| | - Blake W. Buchan
- Department of Pathology, Medical College of Wisconsin, Milwaukee
| | | | - Kirsten Beyer
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee
| | - Sima Namin
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee
| | - Yuhong Zhou
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee
| | - Liliana E. Pezzin
- Collaborative for Healthcare Delivery Science, Medical College of Wisconsin, Milwaukee
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee
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Hooker EA, Mallow PJ, McKinney C, Gnoni ML, Fernandez Gonzales F. Use of a Launderable Bed Barrier and Antibiotic Stewardship to Decrease Hospital Onset Clostridioides difficile Infections in an Acute Care Hospital: A Retrospective Pre-Post Case Study. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2019; 6:196-202. [PMID: 32685591 PMCID: PMC7299494 DOI: 10.36469/001c.11149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 12/02/2019] [Accepted: 11/22/2019] [Indexed: 06/11/2023]
Abstract
BACKGROUND Hospital-onset Clostridioides difficile infection (HO-CDI) is a major source of morbidity and mortality. The objective of this research was to evaluate the reduction in HO-CDI through the use of a launderable bed barrier (BB) and an antibiotic stewardship program (ASP). METHODS A retrospective pre-post study was conducted at an acute care hospital in Kentucky. The preintervention period was September 2014 through March 2016. The BB and the ASP were introduced in April 2016, and the post-intervention period for this study ended September 2018. The rate of HO-CDI was calculated from the actual number of HO-CDI divided by the number of patient days each month. The number of defined daily doses of antibiotic therapy was measured each quarter. Hand disinfection compliance, length-of-stay (LOS), case mix index (CMI), and average age of patients were collected to control for confounding in the regression models. RESULTS There were 34 HO-CDIs and 42 672 patient days in the pre-intervention period and 31 HO-CDIs and 65 882 patient days in the post-intervention period. The average monthly count of HO-CDI was 1.79 (SD 1.51) and 1.03 (SD 0.96) during the pre- and post-periods, respectively. The average monthly rate (per 10 000 patient-days) was 7.94 (SD 6.30) in the pre-intervention period and 4.71 (SD 4.42) during the post-intervention period. The use of antibiotics decreased by 37% (p <0.0001) over the study period. The combination of the BB and the ASP were associated with a 59% (95% CI 36-96%, p 0.034) reduction in HO-CDI. CONCLUSIONS The use of a launderable BB and the ASP were associated with a statistically and clinically significant reduction in HO-CDI in the acute care hospital setting.
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Affiliation(s)
- Edmond A. Hooker
- Xavier University,
United States of America
- University of Cincinnati,
United States of America
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Paquet-Bolduc B, Gervais P, Roussy JF, Trottier S, Oughton M, Brukner I, Longtin J, Loo VG, Dascal A, Longtin Y. Detection and Isolation of Clostridium difficile Asymptomatic Carriers During Clostridium difficile Infection Outbreaks: An Exploratory Study. Clin Infect Dis 2019; 67:1781-1783. [PMID: 29771298 DOI: 10.1093/cid/ciy425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 05/11/2018] [Indexed: 12/27/2022] Open
Abstract
During 4 Clostridium difficile infection outbreaks, unit-wide screening of 114 patients led to detection and isolation of 15 (13%) C. difficile asymptomatic carriers. Carriage prevalence varied between outbreaks, from 0% to 29% (P = .004). Isolating carriers was not associated with significantly shorter outbreak durations, compared with historical controls.
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Affiliation(s)
| | - Philippe Gervais
- Quebec Heart and Lung Institute, Quebec City, Quebec.,Laval University Faculty of Medicine, Quebec City, Quebec
| | - Jean-Francois Roussy
- Quebec Heart and Lung Institute, Quebec City, Quebec.,Laval University Faculty of Medicine, Quebec City, Quebec
| | - Sylvie Trottier
- Quebec Heart and Lung Institute, Quebec City, Quebec.,Laval University Faculty of Medicine, Quebec City, Quebec
| | - Matthew Oughton
- Jewish General Hospital, Quebec, Canada.,McGill University Faculty of Medicine, Quebec, Canada
| | | | - Jean Longtin
- Laval University Faculty of Medicine, Quebec City, Quebec
| | - Vivian G Loo
- McGill University Faculty of Medicine, Quebec, Canada.,McGill University Health Center, Montreal, Quebec, Canada
| | - Andre Dascal
- Jewish General Hospital, Quebec, Canada.,McGill University Faculty of Medicine, Quebec, Canada
| | - Yves Longtin
- Jewish General Hospital, Quebec, Canada.,McGill University Faculty of Medicine, Quebec, Canada
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O'Hagan JJ, McDonald LC. The Challenges of Tracking Clostridium difficile to Its Source in Hospitalized Patients. Clin Infect Dis 2019; 68:210-212. [PMID: 29846537 DOI: 10.1093/cid/ciy461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 05/24/2018] [Indexed: 12/18/2022] Open
Affiliation(s)
- Justin J O'Hagan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - L Clifford McDonald
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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34
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Mahida YR. New concepts in C. difficile management. Br Med Bull 2019; 131:109-118. [PMID: 31583398 DOI: 10.1093/bmb/ldz029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 08/05/2019] [Accepted: 08/09/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Clostridium difficile infection is transmitted via spores, and the disease is mediated via secreted toxins. It represents a significant healthcare problem, and clinical presentation can range from asymptomatic carriage to life-threatening pseudomembranous colitis. SOURCES OF DATA publications in the field, with a focus on recent developments and concepts. AREAS OF AGREEMENT infection control measures, antibiotic stewardship and current management of the initial episode of C. difficile infection. AREAS OF CONTROVERSY selection and sequence of interventions for the management of recurrent C. difficile infection; management of persistent carriers of toxigenic C. difficile in patients at high risk of subsequent C. difficile infection. GROWING POINTS use of faecal microbiota transplantation for recurrent C. difficile infection. AREAS TIMELY FOR DEVELOPING RESEARCH role of specific microbiota-mediated interventions and vaccination in the treatment and prevention of C. difficile infection.
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Affiliation(s)
- Y R Mahida
- Nottingham Digestive Diseases Centre, Queen's Medical Centre, Nottingham, UK
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35
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Universal screening for Clostridioides difficile in a tertiary hospital: risk factors for carriage and clinical disease. Clin Microbiol Infect 2019; 25:1127-1132. [DOI: 10.1016/j.cmi.2019.02.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 01/27/2019] [Accepted: 02/02/2019] [Indexed: 01/12/2023]
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Abstract
Clostridioides difficile (formerly Clostridium) is a major cause of healthcare associated diarrhea, and is increasingly present in the community. Historically, C difficile infection was considered easy to diagnose and treat. Over the past two decades, however, diagnostic techniques have changed in line with a greater understanding of the physiopathology of C difficile infection and the use of new therapeutic molecules. The evolution of diagnosis showed there was an important under- and misdiagnosis of C difficile infection, emphasizing the importance of algorithms recommended by European and North American infectious diseases societies to obtain a reliable diagnosis. Previously, metronidazole was considered the reference drug to treat C difficile infection, but more recently vancomycin and other newer drugs are shown to have higher cure rates. Recurrence of infection represents a key parameter in the evaluation of new drugs, and the challenge is to target the right population with the adapted therapeutic molecule. In multiple recurrences, fecal microbiota transplantation is recommended. New approaches, including antibodies, vaccines, and new molecules are already available or in the pipeline, but more data are needed to support the inclusion of these in practice guidelines. This review aims to provide a baseline for clinicians to understand and stratify their choice in the diagnosis and treatment of C difficile infection based on the most recent data available.
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Affiliation(s)
- Benoit Guery
- Infectious Diseases Service, Department of Medicine, University Hospital and University of Lausanne, Lausanne, Switzerland
- French Group of Faecal Microbiota Transplantation
- European Study Group on Host and Microbiota Interactions
- European Study Group on Clostridium difficile
| | - Tatiana Galperine
- Infectious Diseases Service, Department of Medicine, University Hospital and University of Lausanne, Lausanne, Switzerland
- French Group of Faecal Microbiota Transplantation
| | - Frédéric Barbut
- National Reference Laboratory for Clostridium difficile, Paris, France
- INSERM, Faculté de Pharmacie de Paris, Université Paris Descartes, Paris, France
- European Study Group on Clostridium difficile
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Halstead F, Ravi A, Thomson N, Nuur M, Hughes K, Brailey M, Oppenheim B. Whole genome sequencing of toxigenic Clostridium difficile in asymptomatic carriers: insights into possible role in transmission. J Hosp Infect 2019; 102:125-134. [DOI: 10.1016/j.jhin.2018.10.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 10/15/2018] [Indexed: 01/05/2023]
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García-Fernández S, Frentrup M, Steglich M, Gonzaga A, Cobo M, López-Fresneña N, Cobo J, Morosini MI, Cantón R, Del Campo R, Nübel U. Whole-genome sequencing reveals nosocomial Clostridioides difficile transmission and a previously unsuspected epidemic scenario. Sci Rep 2019; 9:6959. [PMID: 31061423 PMCID: PMC6502822 DOI: 10.1038/s41598-019-43464-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/25/2019] [Indexed: 12/19/2022] Open
Abstract
To trace the routes and frequencies of transmission of Clostridioides difficile in a tertiary-care hospital in Madrid (Spain), we sequenced the genomes from all C. difficile isolates collected over 36 months (2014-2016) that were indistinguishable from any other isolate by PCR ribotyping. From a total of 589 C. difficile infection cases, we cultivated and PCR-ribotyped 367 C. difficile isolates (62%), of which 265 were genome-sequenced. Based on close relatedness of successively collected isolates (≤2 SNPs difference in their genomes), whole-genome sequencing revealed a total of 17 independent, putative transmission clusters, caused by various C. difficile strains and each containing 2 to 18 cases, none of which had been detected previously by standard epidemiological surveillance. Proportions of linked isolates varied widely among PCR ribotypes, from 3% (1/36) for ribotype 014/020 to 60% (12/20) for ribotype 027, suggesting differential aptitudes for nosocomial spread. Remarkably, only a minority (17%) of transmission recipients had direct ward contact to their presumed donors and specific C. difficile genome types frequently went undetectable for several months before re-emerging later, suggesting reservoirs for the pathogen outside of symptomatic patients. Taken together, our analysis based on genome sequencing suggested considerable within-hospital epidemic spread of C. difficile, even though epidemiological data initially had been inconspicuous.
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Affiliation(s)
- Sergio García-Fernández
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal, and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain.,Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain
| | | | - Matthias Steglich
- Leibniz Institute DSMZ, Braunschweig, Germany.,German Center of Infection Research (DZIF), Braunschweig, Germany
| | | | - Marta Cobo
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal, and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Nieves López-Fresneña
- Servicio de Medicina Preventiva, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Javier Cobo
- Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain.,Servicio de Enfermedades Infecciosas, and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - María-Isabel Morosini
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal, and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain.,Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain
| | - Rafael Cantón
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal, and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain.,Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain
| | - Rosa Del Campo
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal, and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain.,Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain
| | - Ulrich Nübel
- Leibniz Institute DSMZ, Braunschweig, Germany. .,German Center of Infection Research (DZIF), Braunschweig, Germany. .,Braunschweig Integrated Center of Systems Biology (BRICS), Technical University, Braunschweig, Germany.
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Gonzalez-Orta M, Saldana C, Ng-Wong Y, Cadnum J, Jencson A, Jinadatha C, Donskey CJ. Are Many Patients Diagnosed With Healthcare-associated Clostridioides difficile Infections Colonized With the Infecting Strain on Admission? Clin Infect Dis 2019; 69:1801-1804. [DOI: 10.1093/cid/ciz189] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 02/28/2019] [Indexed: 02/04/2023] Open
Abstract
Abstract
In a cohort of 480 patients admitted to an acute care hospital, 68 (14%) had positive perirectal cultures for toxigenic Clostridioides difficile on admission. Of the 11 patients (2%) diagnosed with healthcare-associated C. difficile infections, 3 (27%) had genetically related admission and infection isolates, based on whole-genome sequencing.
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Affiliation(s)
- Melany Gonzalez-Orta
- Research Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland Clinic Foundation, Ohio
- Department of Medicine, Cleveland Clinic Foundation, Ohio
| | - Carlos Saldana
- Research Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland Clinic Foundation, Ohio
- Department of Medicine, Cleveland Clinic Foundation, Ohio
| | - Yilen Ng-Wong
- Research Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland Clinic Foundation, Ohio
| | - Jennifer Cadnum
- Research Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland Clinic Foundation, Ohio
| | - Annette Jencson
- Research Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland Clinic Foundation, Ohio
| | - Chetan Jinadatha
- Department of Medicine, Central Texas Veterans Health Care System, Temple, Texas A&M University, Bryan
- College of Medicine, Texas A&M University, Bryan
| | - Curtis J Donskey
- Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
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Zhou Y, Mao L, Yu J, Lin Q, Luo Y, Zhu X, Sun Z. Epidemiology of Clostridium difficile infection in hospitalized adults and the first isolation of C. difficile PCR ribotype 027 in central China. BMC Infect Dis 2019; 19:232. [PMID: 30845918 PMCID: PMC6407249 DOI: 10.1186/s12879-019-3841-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 02/21/2019] [Indexed: 02/08/2023] Open
Abstract
Background Clostridium difficile infection (CDI) is an emerging healthcare problem in the world. The purpose of this study was to perform a systematic epidemiological research of CDI in Tongji hospital, the central of China. Methods Stool samples from hospitalized adults suspected of CDI were enrolled. The diagnosis of CDI were based on the combination of clinical symptoms and laboratory results. Clinical features of CDI and non-CDI patients were compared by appropriate statistical tests to determine the risk factors of CDI. Multilocus sequence typing (MLST) was employed for molecular epidemiological analysis. Susceptibility testing and relevant antimicrobial agent resistance genes were performed as well. Results From June 2016 to September 2017, 839 hospitalized adults were enrolled. Among them, 107 (12.8%, 107/839) patients were C. difficile culture positive, and 73 (8.7%, 73/839) were infected with toxigenic C. difficile (TCD), with tcdA + tcdB+ strains accounting for 90.4% (66/73) and tcdA-tcdB+ for 9.6% (7/73). Meanwhile, two TCD strains were binary toxin positive and one of them was finally identified as CD027. Severe symptoms were observed in these two cases. Multivariate analysis indicated antibiotic exposure (p = 0.001, OR = 5.035) and kidney disease (p = 0.015, OR = 8.329) significantly increased the risk of CDI. Phylogenetic tree analysis demonstrated 21 different STs, including one new ST (ST467); and the most dominant type was ST54 (35.6%, 26/73). Multidrug-resistant (MDR) TCD were 53.4% (39/73); resistance to ciprofloxacin, erythromycin, and clindamycin were > 50%. Other antibiotics showed relative efficiency and all strains were susceptible to metronidazole and vancomycin. All moxifloxacin-resistant isolates carried a mutation in GyrA (Thr82 → Ile), with one both having mutation in GyrB (Ser366 → Ala). Conclusions Knowledge of epidemiological information for CDI is limited in China. Our finding indicated tcdA + tcdB+ C. difficile strains were the dominant for CDI in our hospital. Significant risk factors for CDI in our setting appeared to be antibiotic exposure and kidney disease. Metronidazole and vancomycin were still effective for CDI. Although no outbreak was observed, the first isolation of CD027 in center China implied the potential spread of this hypervirulent clone. Further studies are needed to enhance our understanding of the epidemiology of CDI in China. Electronic supplementary material The online version of this article (10.1186/s12879-019-3841-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yu Zhou
- Department of Laboratory Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Zhejiang, 310014, Hangzhou, China
| | - Liyan Mao
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Road, Wuhan, 430030, China
| | - Jing Yu
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Road, Wuhan, 430030, China
| | - Qun Lin
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Road, Wuhan, 430030, China
| | - Ying Luo
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Road, Wuhan, 430030, China
| | - Xuhui Zhu
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Road, Wuhan, 430030, China.
| | - Ziyong Sun
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Road, Wuhan, 430030, China.
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Wu YL, Yang XY, Ding XX, Li RJ, Pan MS, Zhao X, Hu XQ, Zhang JJ, Yang LQ. Exposure to infected/colonized roommates and prior room occupants increases the risks of healthcare-associated infections with the same organism. J Hosp Infect 2019; 101:231-239. [DOI: 10.1016/j.jhin.2018.10.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 10/15/2018] [Indexed: 11/24/2022]
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Vedantam G, Kochanowsky J, Lindsey J, Mallozzi M, Roxas JL, Adamson C, Anwar F, Clark A, Claus-Walker R, Mansoor A, McQuade R, Monasky RC, Ramamurthy S, Roxas B, Viswanathan VK. An Engineered Synthetic Biologic Protects Against Clostridium difficile Infection. Front Microbiol 2018; 9:2080. [PMID: 30233548 PMCID: PMC6134020 DOI: 10.3389/fmicb.2018.02080] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 08/14/2018] [Indexed: 12/18/2022] Open
Abstract
Morbidity and mortality attributed to Clostridium difficile infection (CDI) have increased over the past 20 years. Currently, antibiotics are the only US FDA-approved treatment for primary C. difficile infection, and these are, ironically, associated with disease relapse and the threat of burgeoning drug resistance. We previously showed that non-toxin virulence factors play key roles in CDI, and that colonization factors are critical for disease. Specifically, a C. difficile adhesin, Surface Layer Protein A (SlpA) is a major contributor to host cell attachment. In this work, we engineered Syn-LAB 2.0 and Syn-LAB 2.1, two synthetic biologic agents derived from lactic acid bacteria, to stably and constitutively express a host-cell binding fragment of the C. difficile adhesin SlpA on their cell-surface. Both agents harbor conditional suicide plasmids expressing a codon-optimized chimera of the lactic acid bacterium's cell-wall anchoring surface-protein domain, fused to the conserved, highly adherent, host-cell-binding domain of C. difficile SlpA. Both agents also incorporate engineered biocontrol, obviating the need for any antibiotic selection. Syn-LAB 2.0 and Syn-LAB 2.1 possess positive biophysical and in vivo properties compared with their parental antecedents in that they robustly and constitutively display the SlpA chimera on their cell surface, potentiate human intestinal epithelial barrier function in vitro, are safe, tolerable and palatable to Golden Syrian hamsters and neonatal piglets at high daily doses, and are detectable in animal feces within 24 h of dosing, confirming robust colonization. In combination, the engineered strains also delay (in fixed doses) or prevent (when continuously administered) death of infected hamsters upon challenge with high doses of virulent C. difficile. Finally, fixed-dose Syn-LAB ameliorates diarrhea in a non-lethal model of neonatal piglet enteritis. Taken together, our findings suggest that the two synthetic biologics may be effectively employed as non-antibiotic interventions for CDI.
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Affiliation(s)
- Gayatri Vedantam
- School of Animal and Comparative Biomedical Sciences, The University of Arizona, Tucson, AZ, United States
- Department of Immunobiology, The University of Arizona, Tucson, AZ, United States
- Bio5 Institute for Collaborative Research, The University of Arizona, Tucson, AZ, United States
- Southern Arizona VA Health Care System, Tucson, AZ, United States
| | - Joshua Kochanowsky
- Department of Immunobiology, The University of Arizona, Tucson, AZ, United States
| | - Jason Lindsey
- School of Animal and Comparative Biomedical Sciences, The University of Arizona, Tucson, AZ, United States
| | - Michael Mallozzi
- School of Animal and Comparative Biomedical Sciences, The University of Arizona, Tucson, AZ, United States
| | - Jennifer Lising Roxas
- School of Animal and Comparative Biomedical Sciences, The University of Arizona, Tucson, AZ, United States
| | - Chelsea Adamson
- School of Animal and Comparative Biomedical Sciences, The University of Arizona, Tucson, AZ, United States
| | - Farhan Anwar
- School of Animal and Comparative Biomedical Sciences, The University of Arizona, Tucson, AZ, United States
| | - Andrew Clark
- School of Animal and Comparative Biomedical Sciences, The University of Arizona, Tucson, AZ, United States
| | - Rachel Claus-Walker
- School of Animal and Comparative Biomedical Sciences, The University of Arizona, Tucson, AZ, United States
| | - Asad Mansoor
- School of Animal and Comparative Biomedical Sciences, The University of Arizona, Tucson, AZ, United States
| | - Rebecca McQuade
- School of Animal and Comparative Biomedical Sciences, The University of Arizona, Tucson, AZ, United States
| | - Ross Calvin Monasky
- School of Animal and Comparative Biomedical Sciences, The University of Arizona, Tucson, AZ, United States
| | - Shylaja Ramamurthy
- School of Animal and Comparative Biomedical Sciences, The University of Arizona, Tucson, AZ, United States
| | - Bryan Roxas
- School of Animal and Comparative Biomedical Sciences, The University of Arizona, Tucson, AZ, United States
| | - V. K. Viswanathan
- School of Animal and Comparative Biomedical Sciences, The University of Arizona, Tucson, AZ, United States
- Department of Immunobiology, The University of Arizona, Tucson, AZ, United States
- Bio5 Institute for Collaborative Research, The University of Arizona, Tucson, AZ, United States
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Transmission of Clostridium difficile from asymptomatically colonized or infected long-term care facility residents. Infect Control Hosp Epidemiol 2018; 39:909-916. [PMID: 29848392 DOI: 10.1017/ice.2018.106] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To test the hypothesis that long-term care facility (LTCF) residents with Clostridium difficile infection (CDI) or asymptomatic carriage of toxigenic strains are an important source of transmission in the LTCF and in the hospital during acute-care admissions. DESIGN A 6-month cohort study with identification of transmission events was conducted based on tracking of patient movement combined with restriction endonuclease analysis (REA) and whole-genome sequencing (WGS). SETTING Veterans Affairs hospital and affiliated LTCF.ParticipantsThe study included 29 LTCF residents identified as asymptomatic carriers of toxigenic C. difficile based on every other week perirectal screening and 37 healthcare facility-associated CDI cases (ie, diagnosis >3 days after admission or within 4 weeks of discharge to the community), including 26 hospital-associated and 11 LTCF-associated cases. RESULTS Of the 37 CDI cases, 7 (18·9%) were linked to LTCF residents with LTCF-associated CDI or asymptomatic carriage, including 3 of 26 hospital-associated CDI cases (11·5%) and 4 of 11 LTCF-associated cases (36·4%). Of the 7 transmissions linked to LTCF residents, 5 (71·4%) were linked to asymptomatic carriers versus 2 (28·6%) to CDI cases, and all involved transmission of epidemic BI/NAP1/027 strains. No incident hospital-associated CDI cases were linked to other hospital-associated CDI cases. CONCLUSIONS Our findings suggest that LTCF residents with asymptomatic carriage of C. difficile or CDI contribute to transmission both in the LTCF and in the affiliated hospital during acute-care admissions. Greater emphasis on infection control measures and antimicrobial stewardship in LTCFs is needed, and these efforts should focus on LTCF residents during hospital admissions.
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Abstract
Recent increases in the incidence of Clostridium difficile infection (CDI) have been observed in all age groups, but the elderly have been disproportionately affected and long-term care facilities (LTCFs) have borne a significant proportion of the increasing burden. Recurrences are common in older adults and may have significant adverse effects on quality of life. Ensuring appropriate diagnostic testing and management is challenging for older adults in the community and in LTCFs. This review focuses on current concepts related to the epidemiology, diagnosis, and management of CDI in older adults.
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Affiliation(s)
- Curtis J Donskey
- Geriatric Research Education and Clinical Center, Cleveland Veterans Affairs Medical Center, 10701 East Boulevard, Cleveland, OH 44106, USA; Case Western Reserve University School of Medicine, 10,000 Euclid Avenue, Cleveland, OH 44106, USA.
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Hines AG, Freifeld A, Zhao X, Berry AA, Willett L, Iwen PC, Simonsen KA. Clostridium difficile stool shedding in infants hospitalized in two neonatal intensive care units is lower than previous point prevalence estimates using molecular diagnostic methods. BMC Pediatr 2018; 18:137. [PMID: 29653526 PMCID: PMC5898000 DOI: 10.1186/s12887-018-1113-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 04/08/2018] [Indexed: 02/04/2023] Open
Abstract
Background The point prevalence of Clostridium difficile stool shedding in hospitalized infants from two neonatal intensive care units (NICUs) was examined utilizing standard clinical testing compared with duplex PCR to identify toxigenic and non-toxigenic C. difficile strains. Methods All infants from the two NICUs affiliated with a single academic medical center were eligible for inclusion. Stool collection was blinded to patient characteristics and occurred during a one week period at each NICU and repeated with a second weeklong collection 6 months later to increase sample size. Stools were tested for C. difficile using EIA (GDH/toxin A/B) with samples testing +/+ or +/− subsequently evaluated by Loop-Mediated Isothermal Amplification (LAMP) and by duplex PCR amplification of tcdB and tpi (housekeeping) genes. Cytotoxicity assays were performed on all samples positive for C. difficile by any modality. Results Eighty-four stools were collected from unique infants for evaluation. EIA results showed 6+/+ [7.1%], 7 +/− [8.3%], and 71 −/− [84.5%] samples. All 6 EIA +/+ were confirmed as toxigenic C. difficile by LAMP; 6/7 EIA +/− were negative by LAMP with one identified as invalid. Duplex PCR concurred with LAMP in all 6 stools positive for toxigenic C. difficile. PCR identified 2 EIA −/− stools positive for tpi, indicating shedding of non-toxigenic C. difficile. Cytotoxicity assay was positive in 4/6 duplex PCR positive samples and negative for all stools that were EIA +/− but negative by molecular testing. Conclusions C. difficile blinded point prevalence in infants from two NICUs was 7.1% by molecular methods; and lower than expected based on historical incidence estimates. In house duplex PCR had excellent concordance with clinically available LAMP and EIA tests, and added detection of non-toxigenic C. difficile strain shedding. Evolving NICU care practices may be influencing the composition of infant gut microbiota and reducing the point prevalence of C. difficile shedding in NICU patient stools.
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Affiliation(s)
- Andrea Green Hines
- Adult Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA.,Pediatric Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Alison Freifeld
- Adult Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Xing Zhao
- Pediatric Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Lynne Willett
- Neonatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Peter C Iwen
- Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Kari A Simonsen
- Pediatric Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA.
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Clostridium difficile Exposures, Colonization, and the Microbiome: Implications for Prevention. Infect Control Hosp Epidemiol 2018; 39:596-602. [PMID: 29553000 DOI: 10.1017/ice.2018.36] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
New studies have been published regarding the epidemiology of Clostridium difficile in topics such as asymptomatic C. difficile colonization, community-associated C. difficile infection, environmental contamination outside healthcare settings, animal colonization, and the interactions between C. difficile and the gut microbiome. In addition to summarizing these findings, this review offers a perspective on the potential impact of high-throughput sequencing and other potential techniques on the prevention of C. difficile.Infect Control Hosp Epidemiol 2018;39:596-602.
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Abstract
Clostridium difficile is the main causative agent of antibiotic-associated and health care-associated infective diarrhea. Recently, there has been growing interest in alternative sources of C. difficile other than patients with Clostridium difficile infection (CDI) and the hospital environment. Notably, the role of C. difficile-colonized patients as a possible source of transmission has received attention. In this review, we present a comprehensive overview of the current understanding of C. difficile colonization. Findings from gut microbiota studies yield more insights into determinants that are important for acquiring or resisting colonization and progression to CDI. In discussions on the prevalence of C. difficile colonization among populations and its associated risk factors, colonized patients at hospital admission merit more attention, as findings from the literature have pointed to their role in both health care-associated transmission of C. difficile and a higher risk of progression to CDI once admitted. C. difficile colonization among patients at admission may have clinical implications, although further research is needed to identify if interventions are beneficial for preventing transmission or overcoming progression to CDI.
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Durovic A, Widmer AF, Tschudin-Sutter S. New insights into transmission of Clostridium difficile infection-narrative review. Clin Microbiol Infect 2018; 24:483-492. [PMID: 29427800 DOI: 10.1016/j.cmi.2018.01.027] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 01/22/2018] [Accepted: 01/27/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Traditionally, Clostridium difficile has been considered a typical healthcare-associated pathogen-that is, one transmitted within healthcare facilities and thus prevented by implementation of standard infection control measures. Recently this concept has been challenged by studies suggesting a relevant role for community acquisition of C. difficile. AIMS To discusses the current literature, compiled during the last decade, reporting on sources of acquisition of C. difficile and subsequent transmission. SOURCES The databases PubMed, Medline, Embase and the Cochrane Database were searched for articles published from 1 January 2007 to 30 June 2017 reporting on possible transmission pathways of C. difficile and/or suggesting a source of acquisition of C. difficile. All study types reporting on adult populations were considered; case reports and series were excluded. The PRISMA guidelines for the reporting of systematic reviews were followed. CONTENT Among 24 original articles included, 63% report on transmission of C. difficile in healthcare settings and 37% investigate sources and transmission of C. difficile in the community. Contact with symptomatic carriers (53.3%), the hospital environment (40.0%) and asymptomatic carriers (20%) were the most commonly reported transmission pathways within healthcare settings. The leading sources for acquisition of C. difficile in the community include direct contact with symptomatic and asymptomatic carriers in the community, including infants (30%) and residents of long-term non-acute care facilities (30%), followed by contact with contaminated environments in outpatient care settings (20%) and exposure to livestock or livestock farms (20%). IMPLICATIONS In healthcare settings, future control efforts may need to focus on extending cleaning and disinfection procedures beyond the immediate surroundings of symptomatic carriers. Potential targets to prevent acquisition of C. difficile in the community include household settings, long-term care facilities and outpatient settings, while the role of livestock in entertaining transmission requires further investigation.
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Affiliation(s)
- A Durovic
- Medical University Department, Division of Oncology and Hematology, Kantonsspital Aarau, Aarau, Switzerland
| | - A F Widmer
- Department of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - S Tschudin-Sutter
- Department of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, University Basel, Basel, Switzerland.
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Abstract
PURPOSE OF REVIEW Gastrointestinal outbreaks in the healthcare setting cause increased morbidity and mortality in an already vulnerable population. Optimization of infection prevention measures can be a challenge in healthcare settings. This review describes new literature that may change the traditional infection prevention approach to such outbreaks. RECENT FINDINGS Asymptomatic carriers of both norovirus and Clostridium difficile can pose risk of transmission to others and the environment. Rapid recognition and diagnosis can decrease the extent of an outbreak. No-touch technologies for environmental disinfection are new and effective tools. Infection prevention consultant services and systems redesign can augment efforts to control baseline infection rates and outbreaks. Antimicrobial stewardship continues to be essential to prevent C. difficile infection. SUMMARY New approaches are needed to stem the tide of norovirus and C. difficile clusters and outbreaks in healthcare settings. Accurate recognition, testing, and implementation of infection prevention measures can be supported with rapid testing modalities, access to updated guidelines and no-touch disinfection systems. The work-environment culture should be carefully assessed and restructured using human engineering models to promote effective infection prevention practices. Antimicrobial stewardship initiatives are needed at the bedside and at national levels.
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Squellati R. Evidence-Based Practice in the Treatment for Antibiotic-Associated Diarrhea in the Intensive Care Unit. Crit Care Nurs Clin North Am 2017; 30:87-99. [PMID: 29413218 DOI: 10.1016/j.cnc.2017.10.008] [Citation(s) in RCA: 3] [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
Unit nurses provide care to patients with serious health conditions. Often antibiotics are recommended to fight infections. Sometimes patients are on proton pump inhibitors (PPI). Antibiotics and PPIs may lead to diarrhea, causing the patient more discomfort, and possibly leading to a more serious infection. One serious infection is caused by Clostridium difficile, which causes death in some cases. About 75% of patients on antibiotics may not need antibiotics. Several studies showed less diarrhea in patients on probiotics. However, probiotics cause harm to some patients, which needs to be considered. Nurses need to ensure that antibiotic stewardship is followed.
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