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Majumdar A, Shah MR, Park JJ, Narayanan N, Kaye KS, Bhatt PJ. Challenges and Opportunities in Antimicrobial Stewardship among Hematopoietic Stem Cell Transplant and Oncology Patients. Antibiotics (Basel) 2023; 12:antibiotics12030592. [PMID: 36978459 PMCID: PMC10044884 DOI: 10.3390/antibiotics12030592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/11/2023] [Accepted: 03/13/2023] [Indexed: 03/18/2023] Open
Abstract
Antimicrobial stewardship programs play a critical role in optimizing the use of antimicrobials against pathogens in the era of growing multi-drug resistance. However, implementation of antimicrobial stewardship programs among the hematopoietic stem cell transplant and oncology populations has posed challenges due to multiple risk factors in the host populations and the infections that affect them. The consideration of underlying immunosuppression and a higher risk for poor outcomes have shaped therapeutic decisions for these patients. In this multidisciplinary perspective piece, we provide a summary of the current landscape of antimicrobial stewardship, unique challenges, and opportunities for unmet needs in these patient populations.
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Affiliation(s)
- Anjali Majumdar
- Division of Allergy and Infectious Disease, Department of Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
- Correspondence:
| | - Mansi R. Shah
- Division of Blood Disorders, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08901, USA
| | | | - Navaneeth Narayanan
- Division of Allergy and Infectious Disease, Department of Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
- Rutgers-Ernest Mario School of Pharmacy, Piscataway, NJ 08854, USA
| | - Keith S. Kaye
- Division of Allergy and Infectious Disease, Department of Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
| | - Pinki J. Bhatt
- Division of Allergy and Infectious Disease, Department of Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
- Rutgers-Ernest Mario School of Pharmacy, Piscataway, NJ 08854, USA
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2
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Prevalence and antimicrobial resistance pattern of Clostridium difficile among hospitalized diarrheal patients: A systematic review and meta-analysis. PLoS One 2022; 17:e0262597. [PMID: 35025959 PMCID: PMC8758073 DOI: 10.1371/journal.pone.0262597] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 12/28/2021] [Indexed: 01/02/2023] Open
Abstract
Background
Clostridium difficile is the leading cause of infectious diarrhea that develops in patients after hospitalization during antibiotic administration. It has also become a big issue in community-acquired diarrhea. The emergence of hypervirulent strains of C. difficile poses a major problem in hospital-associated diarrhea outbreaks and it is difficult to treat. The antimicrobial resistance in C. difficile has worsened due to the inappropriate use of broad-spectrum antibiotics including cephalosporins, clindamycin, tetracycline, and fluoroquinolones together with the emergence of hypervirulent strains.
Objective
To estimate the pooled prevalence and antimicrobial resistance pattern of C. difficile derived from hospitalized diarrheal patients, a systematic review and meta-analysis was performed.
Methods
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed to review published studies conducted. We searched bibliographic databases from PubMed, Scopus, Google Scholar, and Cochrane Library for studies on the prevalence and antimicrobial susceptibility testing on C. difficile. The weighted pooled prevalence and resistance for each antimicrobial agent was calculated using a random-effects model. A funnel plot and Egger’s regression test were used to see publication bias.
Results
A total of 15 studies were included. Ten articles for prevalence study and 5 additional studies for antimicrobial susceptibility testing of C. difficile were included. A total of 1967/7852 (25%) C. difficile were isolated from 10 included studies for prevalence study. The overall weighted pooled proportion (WPP) of C. difficile was 30% (95% CI: 10.0–49.0; p<0.001). The analysis showed substantial heterogeneity among studies (Cochran’s test = 7038.73, I2 = 99.87%; p<0.001). The weighed pooled antimicrobial resistance (WPR) were: vancomycin 3%(95% CI: 1.0–4.0, p<0.001); metronidazole 5%(95% CI: 3.0–7.0, p<0.001); clindamycin 61%(95% CI: 52.0–69.0, p<0.001); moxifloxacin 42%(95% CI: 29–54, p<0.001); tetracycline 35%(95% CI: 22–49, p<0.001); erythromycin 61%(95% CI: 48–75, p<0.001) and ciprofloxacin 64%(95% CI: 48–80; p< 0.001) using the random effect model.
Conclusions
A higher weighted pooled prevalence of C. difficile was observed. It needs a great deal of attention to decrease the prevailing prevalence. The resistance of C. difficile to metronidazole and vancomycin was low compared to other drugs used to treat C. difficile infection. Periodic antimicrobial resistance monitoring is vital for appropriate therapy of C. difficile infection.
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Paravattil B, Zolezzi M, Nasr Z, Benkhadra M, Alasmar M, Hussein S, Maklad A. An Interventional Call-Back Service to Improve Appropriate Use of Antibiotics in Community Pharmacies. Antibiotics (Basel) 2021; 10:antibiotics10080986. [PMID: 34439036 PMCID: PMC8389014 DOI: 10.3390/antibiotics10080986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 11/16/2022] Open
Abstract
Pharmacists play a key role in tackling antibiotic misuse through counseling and education of patients and healthcare providers. The study aim is to evaluate the appropriateness of antibiotic prescriptions in community pharmacy settings while implementing an interventional call-back service to assess adherence and symptom resolution among patients prescribed an antibiotic. Patients were recruited by community pharmacists who were assigned to either the call-back, structured counseling, or standard care arms. Patients in the call-back group received intensive antibiotic counseling and a phone call from the study pharmacist 3 to 5 days after antibiotic initiation. The counseling arm patients received intensive antibiotic counseling from the study pharmacist while patients in the standard care arm received routine care. Antibiotic adherence rates among the standard care (n = 25), counseling (n = 29), and call-back (n = 26) groups were 64%, 86.2%, and 88.5%, respectively (X2 = 5.862, p = 0.053). Symptom severity scores after completion of antibiotic treatment among all groups were rated as excellent. Twenty-nine percent of the outpatient antibiotic prescriptions were deemed as inappropriate. A pharmacist call-back service is a simple and inexpensive intervention which can effectively identify opportunities for improving appropriate antibiotic use, particularly with respect to adherence.
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Abstract
Bacteria are highly interactive and possess an extraordinary repertoire of intercellular communication and social behaviors, including quorum sensing (QS). QS has been studied in detail at the molecular level, so mechanistic details are well understood in many species and are often involved in virulence. The use of different animal host models has demonstrated QS-dependent control of virulence determinants and virulence in several human pathogenic bacteria. QS also controls virulence in several plant pathogenic species. Despite the role QS plays in virulence during animal and plant laboratory-engineered infections, QS mutants are frequently isolated from natural infections, demonstrating that the function of QS during infection and its role in pathogenesis remain poorly understood and are fruitful areas for future research. We discuss the role of QS during infection in various organisms and highlight approaches to better understand QS during human infection. This is an important consideration in an era of growing antimicrobial resistance, when we are looking for new ways to target bacterial infections.
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Affiliation(s)
- Sheyda Azimi
- School of Biological Sciences, Georgia Institute of Technology, Atlanta, Georgia 30332, USA; , .,Center for Microbial Dynamics and Infection, Georgia Institute of Technology, Atlanta, Georgia 30332, USA
| | - Alexander D Klementiev
- School of Biological Sciences, Georgia Institute of Technology, Atlanta, Georgia 30332, USA; , .,Center for Microbial Dynamics and Infection, Georgia Institute of Technology, Atlanta, Georgia 30332, USA
| | - Marvin Whiteley
- School of Biological Sciences, Georgia Institute of Technology, Atlanta, Georgia 30332, USA; , .,Center for Microbial Dynamics and Infection, Georgia Institute of Technology, Atlanta, Georgia 30332, USA.,Emory-Children's Cystic Fibrosis Center, Atlanta, Georgia 30329, USA
| | - Stephen P Diggle
- School of Biological Sciences, Georgia Institute of Technology, Atlanta, Georgia 30332, USA; , .,Center for Microbial Dynamics and Infection, Georgia Institute of Technology, Atlanta, Georgia 30332, USA
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Bouza E, Aguado JM, Alcalá L, Almirante B, Alonso-Fernández P, Borges M, Cobo J, Guardiola J, Horcajada JP, Maseda E, Mensa J, Merchante N, Muñoz P, Pérez Sáenz JL, Pujol M, Reigadas E, Salavert M, Barberán J. Recommendations for the diagnosis and treatment of Clostridioides difficile infection: An official clinical practice guideline of the Spanish Society of Chemotherapy (SEQ), Spanish Society of Internal Medicine (SEMI) and the working group of Postoperative Infection of the Spanish Society of Anesthesia and Reanimation (SEDAR). REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2020; 33:151-175. [PMID: 32080996 PMCID: PMC7111242 DOI: 10.37201/req/2065.2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 01/26/2020] [Indexed: 12/12/2022]
Abstract
This document gathers the opinion of a multidisciplinary forum of experts on different aspects of the diagnosis and treatment of Clostridioides difficile infection (CDI) in Spain. It has been structured around a series of questions that the attendees considered relevant and in which a consensus opinion was reached. The main messages were as follows: CDI should be suspected in patients older than 2 years of age in the presence of diarrhea, paralytic ileus and unexplained leukocytosis, even in the absence of classical risk factors. With a few exceptions, a single stool sample is sufficient for diagnosis, which can be sent to the laboratory with or without transportation media for enteropathogenic bacteria. In the absence of diarrhoea, rectal swabs may be valid. The microbiology laboratory should include C. difficile among the pathogens routinely searched in patients with diarrhoea. Laboratory tests in different order and sequence schemes include GDH detection, presence of toxins, molecular tests and toxigenic culture. Immediate determination of sensitivity to drugs such as vancomycin, metronidazole or fidaxomycin is not required. The evolution of toxin persistence is not a suitable test for follow up. Laboratory diagnosis of CDI should be rapid and results reported and interpreted to clinicians immediately. In addition to the basic support of all diarrheic episodes, CDI treatment requires the suppression of antiperistaltic agents, proton pump inhibitors and antibiotics, where possible. Oral vancomycin and fidaxomycin are the antibacterials of choice in treatment, intravenous metronidazole being restricted for patients in whom the presence of the above drugs in the intestinal lumen cannot be assured. Fecal material transplantation is the treatment of choice for patients with multiple recurrences but uncertainties persist regarding its standardization and safety. Bezlotoxumab is a monoclonal antibody to C. difficile toxin B that should be administered to patients at high risk of recurrence. Surgery is becoming less and less necessary and prevention with vaccines is under research. Probiotics have so far not been shown to be therapeutically or preventively effective. The therapeutic strategy should be based, rather than on the number of episodes, on the severity of the episodes and on their potential to recur. Some data point to the efficacy of oral vancomycin prophylaxis in patients who reccur CDI when systemic antibiotics are required again.
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Affiliation(s)
- E Bouza
- Emilio Bouza MD, PhD, Instituto de Investigación Sanitaria Gregorio Marañón, Servicio de Microbiología Clínica y E. Infecciosas C/ Dr. Esquerdo, 46 - 28007 Madrid, Spain.
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6
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Bozzao F, Bernardi S, Dore F, Zandonà L, Fischetti F. Hypertrophic osteoarthropathy mimicking a reactive arthritis: a case report and review of the literature. BMC Musculoskelet Disord 2018; 19:145. [PMID: 29759083 PMCID: PMC5952696 DOI: 10.1186/s12891-018-2068-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 04/30/2018] [Indexed: 01/05/2023] Open
Abstract
Background Hypertrophic osteoarthropathy (HOA) is a syndrome characterized by abnormal proliferation of skin and periosteal tissues of the extremities. It can be a rare hereditary disease (pachydermoperiostosis) or can be secondary to various diseases, though mostly lung malignancies. Here, we report an unusual clinical presentation of HOA. Case presentation A 77-year-old man presented with fever, diarrhea, and an oligoarthritis involving the left knee and the ankles. Since left knee synovial fluid aspiration revealed an aseptic synovitis and Clostridium Difficile toxin was detectable in stool samples, a reactive arthritis secondary to a Clostridium Difficile induced colitis was initially suspected. However, the presence of a worsened digital clubbing and the lack of a good clinical response to steroid therapy led us to perform a radionuclide bone scanning, which revealed HOA. This turned out to be associated with a lepidic predominant lung adenocarcinoma, which was clinically and radiologically difficult to distinguish from a relapse of pneumonia. Conclusion Consistent with the literature, HOA tends to have a variable clinical presentation, mimicking that of various rheumatic diseases. This clinical case shows that HOA can present as a presumptive acute reactive arthritis, and it highlights the importance of patient’s follow-up in the differential diagnosis of inflammatory arthritis, especially when a worsened digital clubbing is present.
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Affiliation(s)
- Francesco Bozzao
- Department of Medical Sciences, University of Trieste, Cattinara Teaching Hospital, Strada di Fiume 449, 34149, Trieste, Italy.
| | - Stella Bernardi
- Department of Medical Sciences, University of Trieste, Cattinara Teaching Hospital, Strada di Fiume 449, 34149, Trieste, Italy
| | - Franca Dore
- ASUITS, Cattinara Teaching Hospital, Strada di Fiume 449, 34149, Trieste, Italy
| | - Lorenzo Zandonà
- ASUITS, Cattinara Teaching Hospital, Strada di Fiume 449, 34149, Trieste, Italy
| | - Fabio Fischetti
- Department of Medical Sciences, University of Trieste, Cattinara Teaching Hospital, Strada di Fiume 449, 34149, Trieste, Italy
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Darkoh C, Deaton M, DuPont HL. Nonantimicrobial drug targets for Clostridium difficile infections. Future Microbiol 2017; 12:975-985. [PMID: 28759258 DOI: 10.2217/fmb-2017-0024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile infection (CDI) is a major public health problem worldwide. Treatment has become complicated due to the emergence of strains with increased toxigenicity and sporulation rate, together with rampant antibiotics use that disrupts colonization resistance of the colonic microbiota. As a result, there is a critical need for nonantibiotic treatments. Therapies based on inhibiting the toxins, bacterial structures responsible for colonization, virulence and restoration of the gut microbiota are the most important nonantibiotic targets to combat CDI. This report outlines these targets and how they could become the focus of future therapeutic agents. Inhibiting colonization and virulence factors during CDI will disrupt pathogen persistence and decrease exposure to the inflammatory toxins, allowing the immune system to clear the infection.
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Affiliation(s)
- Charles Darkoh
- Department of Epidemiology, Human Genetics, & Environmental Sciences, Center For Infectious Diseases, School of Public Health, University of Texas Health Science Center, Houston, TX 77030, USA.,The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Microbiology & Infectious Diseases Program, Houston, TX 77030, USA
| | - Magdalena Deaton
- Department of Epidemiology, Human Genetics, & Environmental Sciences, Center For Infectious Diseases, School of Public Health, University of Texas Health Science Center, Houston, TX 77030, USA
| | - Herbert L DuPont
- Department of Epidemiology, Human Genetics, & Environmental Sciences, Center For Infectious Diseases, School of Public Health, University of Texas Health Science Center, Houston, TX 77030, USA.,Baylor College of Medicine, Departments of Molecular Virology & Microbiology & Medicine, Houston, TX 77030, USA
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8
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Bremer E. Clostridium difficile: A bad bug goes into defensive mode. Environ Microbiol 2017; 19:2523-2528. [PMID: 28447375 DOI: 10.1111/1462-2920.13776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 04/19/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Erhard Bremer
- Laboratory for Microbiology, Department of Biology, Philipps-University Marburg, Karl-von Frisch Str. 8, Marburg, D-35043, Germany.,LOEWE Center for Synthetic Microbiology, Philipps-University Marburg, Hans-Meerwein Str. 6, Marburg, D-35043, Germany
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9
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Darkoh C, DuPont HL. The accessory gene regulator-1 as a therapeutic target for C. difficile infections. Expert Opin Ther Targets 2017; 21:451-453. [PMID: 28338356 DOI: 10.1080/14728222.2017.1311863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Charles Darkoh
- a University of Texas Health Science Center, School of Public Health, Department of Epidemiology , Human Genetics, and Environmental Sciences, Center For Infectious Diseases , Houston , TX , USA.,b University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences , Microbiology and Infectious Diseases Program , Houston , TX , USA
| | - Herbert L DuPont
- a University of Texas Health Science Center, School of Public Health, Department of Epidemiology , Human Genetics, and Environmental Sciences, Center For Infectious Diseases , Houston , TX , USA.,b University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences , Microbiology and Infectious Diseases Program , Houston , TX , USA.,c Baylor College of Medicine , Department of Molecular Virology and Microbiology Houston , TX , USA
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10
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Modi D, Jang H, Kim S, Surapaneni M, Sankar K, Deol A, Ayash L, Bhutani D, Lum LG, Ratanatharathorn V, Manasa R, Mellert K, Chandrasekar P, Uberti JP. Fluoroquinolone prophylaxis in autologous hematopoietic stem cell transplant recipients. Support Care Cancer 2017; 25:2593-2601. [PMID: 28365897 DOI: 10.1007/s00520-017-3670-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 03/14/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE Although fluoroquinolone prophylaxis is frequently utilized in autologous hematopoietic stem cell transplant (AHSCT) patients, its impact on morbidity and mortality is uncertain. This study investigates the role of quinolone prophylaxis after AHSCT in recent years. METHODS We conducted a retrospective review of 291 consecutive adult patients who underwent AHSCT for malignant disorders, between June 2013 and January 2015. Outcomes were compared between patients who received norfloxacin prophylaxis and those who did not. The endpoints were mortality during prophylaxis and at 100 days after transplant, frequency of ICU admissions, and incidence and type of bacteremia. RESULTS Of 291 patients, 252 patients received norfloxacin prophylaxis and 39 patients did not. The mortality during prophylaxis and at 100 days as well as the median number of days of hospitalization following AHSCT did not differ between the two groups. No differences were noted in the frequency of ICU admission, incidence of septic shock, and duration of ICU stay. Patients who did not receive prophylaxis had a significantly higher rate of neutropenic fever (97%) than patients who received prophylaxis (77%) (p = 0.005). The patients with prophylaxis demonstrated a significantly higher rate of gram-positive bacteremia as compared to those without prophylaxis (p = 0.002). Frequency of Clostridium difficile infection was similar during and post-prophylaxis. More antibiotic use was noted among patients without prophylaxis [97%; median 9 (range, 5-24) days] compared to patients with prophylaxis [79%; median 7 (range, 3-36) days, p = 0.04]. CONCLUSION Although fluoroquinolone prophylaxis reduced the incidence of neutropenic fever and antibiotic use in AHSCT, it did not alter mortality or morbidity.
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Affiliation(s)
- Dipenkumar Modi
- Department of Hematology-Oncology, Karmanos Cancer Institute/Wayne State University, 4100 John R, HW04H0, Detroit, MI, 48201, USA.
| | - Hyejeong Jang
- Biostatistics Core, Karmanos Cancer Institute, Department of Oncology, Wayne State University, Detroit, MI, 48201, USA
| | - Seongho Kim
- Biostatistics Core, Karmanos Cancer Institute, Department of Oncology, Wayne State University, Detroit, MI, 48201, USA
| | - Malini Surapaneni
- Department of Internal Medicine, 3990 John R, 5904 5Hudson, Detroit, MI, 48201, USA
| | - Kamya Sankar
- Wayne State School of Medicine, 320 E Canfield Ave; Suite 315, Detroit, MI, 48201, USA
| | - Abhinav Deol
- Department of Oncology, Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute/Wayne State University, 4100 John R, 4 HW04H0, Detroit, MI, 48201, USA
| | - Lois Ayash
- Department of Oncology, Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute/Wayne State University, 4100 John R, 4 HW04H0, Detroit, MI, 48201, USA
| | - Divaya Bhutani
- Department of Oncology, Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute/Wayne State University, 4100 John R, 4 HW04H0, Detroit, MI, 48201, USA
| | - Lawrence G Lum
- Division of Hematology/Oncology, University of Virginia Cancer Center, West Complex, Rm 7191, 1300 Jefferson Park Avenue, Charlottesville, VA, USA
| | - Voravit Ratanatharathorn
- Department of Oncology, Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute/Wayne State University, 4100 John R, 4 HW04H0, Detroit, MI, 48201, USA
| | - Richard Manasa
- Clinical Trials Office Bone Marrow Transplant, Karmanos Cancer Institute, 4100 John R, WN10SC, Detroit, MI, 48201, USA
| | - Kendra Mellert
- Clinical Trials Office Bone Marrow Transplant, Karmanos Cancer Institute, 4100 John R, WN10SC, Detroit, MI, 48201, USA
| | | | - Joseph P Uberti
- Department of Oncology, Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute/Wayne State University, 4100 John R, 4 HW04H0, Detroit, MI, 48201, USA
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Pathogens of Food Animals: Sources, Characteristics, Human Risk, and Methods of Detection. ADVANCES IN FOOD AND NUTRITION RESEARCH 2017; 82:277-365. [PMID: 28427535 DOI: 10.1016/bs.afnr.2016.12.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Pathogens associated with food production (livestock) animals come in many forms causing a multitude of disease for humans. For the purpose of this review, these infectious agents can be divided into three broad categories: those that are associated with bacterial disease, those that are associated with viruses, and those that are parasitic in nature. The goal of this chapter is to provide the reader with an overview of the most common pathogens that cause disease in humans through exposure via the food chain and the consequence of this exposure as well as risk and detection methods. We have also included a collection of unusual pathogens that although rare have still caused disease, and their recognition is warranted in light of emerging and reemerging diseases. These provide the reader an understanding of where the next big outbreak could occur. The influence of the global economy, the movement of people, and food makes understanding production animal-associated disease paramount to being able to address new diseases as they arise.
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12
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Kabbani TA, Pallav K, Dowd SE, Villafuerte-Galvez J, Vanga RR, Castillo NE, Hansen J, Dennis M, Leffler DA, Kelly CP. Prospective randomized controlled study on the effects of Saccharomyces boulardii CNCM I-745 and amoxicillin-clavulanate or the combination on the gut microbiota of healthy volunteers. Gut Microbes 2016; 8:17-32. [PMID: 27973989 PMCID: PMC5341914 DOI: 10.1080/19490976.2016.1267890] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Probiotics are believed to be beneficial in maintaining a healthy gut microbiota whereas antibiotics are known to induce dysbiosis. This study aimed to examine the effects of the probiotic Saccharomyces boulardii CNCM I-745 (SB), the antibiotic Amoxicillin-Clavulanate (AC) and the combination on the microbiota and symptoms of healthy humans. Healthy subjects were randomized to one of 4 study groups: SB for 14 days, AC for 7 days, SB plus AC, Control (no treatment). Participants gave stool samples and completed gastro-intestinal symptom questionnaires. Microbiota changes in stool specimens were analyzed using 16s rRNA gene pyrosequencing (bTEFAP). Only one subject withdrew prematurely due to adverse events. Subjects treated by S boulardii + AC had fewer adverse events and tolerated the study regimen better than those receiving the AC alone. Control subjects had a stable microbiota throughout the study period. Significant microbiota changes were noted in the AC alone group during antibiotic treatment. AC associated changes included reduced prevalence of the genus Roseburia and increases in Escherichia, Parabacteroides, and Enterobacter. Microbiota alterations reverted toward baseline, but were not yet completely restored 2 weeks after antibiotherapy. No significant shifts in bacterial genera were noted in the SB alone group. Adding SB to AC led to less pronounced microbiota shifts including less overgrowth of Escherichia and to a reduction in antibiotic-associated diarrhea scores. Antibiotic treatment is associated with marked microbiota changes with both reductions and increases in different genera. S. boulardii treatment can mitigate some antibiotic-induced microbiota changes (dysbiosis) and can also reduce antibiotic-associated diarrhea.
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Affiliation(s)
- Toufic A. Kabbani
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA,Harvard School of Public Health, Harvard University, Boston, MA, USA
| | - Kumar Pallav
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Javier Villafuerte-Galvez
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Rohini R. Vanga
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Natalia E. Castillo
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Joshua Hansen
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Melinda Dennis
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Daniel A. Leffler
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ciarán P. Kelly
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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13
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Karpa KD. Probiotics for Clostridium difficile Diarrhea: Putting It into Perspective. Ann Pharmacother 2016; 41:1284-7. [PMID: 17595302 DOI: 10.1345/aph.1k228] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Clostridium difficile diarrhea is an expensive, life-threatening infection associated with serious morbidity and mortality, even among previously healthy individuals. Relapses from the infection are common following standard antibiotic treatments, with 3–5% of patients who contract C. difficile diarrhea unable to discontinue vancomycin due to continual relapses. Such patients may have a focal immunodeficiency in which they tail to mount an immune response against C. difficile. For these individuals, antimicrobial therapies are unable to eradicate the microorganism because no antibiotics are capable of killing C. difficile spores. Although they are considered alternative medicine, probiotics have provided a safe and effective means of restoring gastrointestinal flora and alleviating diarrhea, particularly for individuals experiencing multiple relapses.
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A Tetraspecific VHH-Based Neutralizing Antibody Modifies Disease Outcome in Three Animal Models of Clostridium difficile Infection. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2016; 23:774-84. [PMID: 27413067 PMCID: PMC5014919 DOI: 10.1128/cvi.00730-15] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 07/01/2016] [Indexed: 12/17/2022]
Abstract
Clostridium difficile infection (CDI), a leading cause of nosocomial infection, is a serious disease in North America, Europe, and Asia. CDI varies greatly from asymptomatic carriage to life-threatening diarrhea, toxic megacolon, and toxemia. The incidence of community-acquired infection has increased due to the emergence of hypervirulent antibiotic-resistant strains. These new strains contribute to the frequent occurrence of disease relapse, complicating treatment, increasing hospital stays, and increasing morbidity and mortality among patients. Therefore, it is critical to develop new therapeutic approaches that bypass the development of antimicrobial resistance and avoid disruption of gut microflora. Here, we describe the construction of a single heteromultimeric VHH-based neutralizing agent (VNA) that targets the two primary virulence factors of Clostridium difficile, toxins A (TcdA) and B (TcdB). Designated VNA2-Tcd, this agent has subnanomolar toxin neutralization potencies for both C. difficile toxins in cell assays. When given systemically by parenteral administration, VNA2-Tcd protected against CDI in gnotobiotic piglets and mice and to a lesser extent in hamsters. Protection from CDI was also observed in gnotobiotic piglets treated by gene therapy with an adenovirus that promoted the expression of VNA2-Tcd.
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Accessory Gene Regulator-1 Locus Is Essential for Virulence and Pathogenesis of Clostridium difficile. mBio 2016; 7:mBio.01237-16. [PMID: 27531912 PMCID: PMC4992976 DOI: 10.1128/mbio.01237-16] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
UNLABELLED Clostridium difficile infection (CDI) is responsible for most of the definable cases of antibiotic- and hospital-associated diarrhea worldwide and is a frequent cause of morbidity and mortality in older patients. C. difficile, a multidrug-resistant anaerobic pathogen, causes disease by producing toxins A and B, which are controlled by an accessory gene regulator (Agr) quorum signaling system. Some C. difficile strains encode two Agr loci in their genomes, designated agr1 and agr2 The agr1 locus is present in all of the C. difficile strains sequenced to date, whereas the agr2 locus is present in a few strains. The functional roles of agr1 and agr2 in C. difficile toxin regulation and pathogenesis were unknown until now. Using allelic exchange, we deleted components of both agr loci and examined the mutants for toxin production and virulence. The results showed that the agr1 mutant cannot produce toxins A and B; toxin production can be restored by complementation with wild-type agr1 Furthermore, the agr1 mutant is able to colonize but unable to cause disease in a murine CDI model. These findings have profound implications for CDI treatment because we have uncovered a promising therapeutic target for the development of nonantibiotic drugs to treat this life-threatening emerging pathogen by targeting the toxins directly responsible for disease. IMPORTANCE Within the last decade, the number of cases of C. difficile infections has been increasing exponentially in the United States, resulting in about 4.8 billion U.S. dollars in health care costs annually. As a multidrug-resistant, spore-forming, anaerobic pathogen, C. difficile overpopulates the colon after the gut microbiota has been altered by antibiotic therapy. With increasing resistance to antibiotic treatment of C. difficile infections, patients are experiencing higher costs of health care and a lower quality of life as treatment options decrease. During infection, C. difficile produces toxins A and B, which directly cause disease. As a result, the toxins have become promising nonantibiotic treatment targets. Here, we have identified a pathway responsible for activating the production of the toxins. This important finding opens up a unique therapeutic target for the development of a novel nonantibiotic therapy for C. difficile infections.
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Cheng JW, Xiao M, Kudinha T, Xu ZP, Hou X, Sun LY, Zhang L, Fan X, Kong F, Xu YC. The First Two Clostridium difficile Ribotype 027/ST1 Isolates Identified in Beijing, China-an Emerging Problem or a Neglected Threat? Sci Rep 2016; 6:18834. [PMID: 26740150 PMCID: PMC4703979 DOI: 10.1038/srep18834] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 11/27/2015] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile hyper-virulent ribotype 027 strain has become a significant concern globally, but has rarely been reported in Asian countries including China. Recently, a retrospective single-center study in Beijing, China, detected two ribotype 027 C. difficile isolates from two patients coming for outpatient visits in 2012 and 2013. We performed a systematic investigation of the two isolates (and patients). Both C. difficile isolates had the typical PCR ribotype 027 profile; were positive for tcdA, tcdB and binary toxin genes; belonged to multilocus sequence type 1 (ST1); had typical ribotype 027 deletions in the tcdC gene; and were highly-resistant to fluoroquinolones; but had a different MLVA profile and were not genetically related to any previously reported international ribotype 027 clones. A review of the patients' medical records showed that neither received appropriate antimicrobial treatment and were lost to follow-up after outpatient visits. We propose that C. difficile infections caused by ribotype 027 are probably a neglected problem in China, and the subsequent impact of unawareness of this problem is worrying. Appropriate testing assays and multi-center or national level surveillance for C. difficile infections and specifically for ribotype 027 should be introduced to provide essential data and guide future clinical practice.
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Affiliation(s)
- Jing-Wei Cheng
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Meng Xiao
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Timothy Kudinha
- Charles Sturt University, Leeds Parade, Orange, New South Wales 2687, Australia.,Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR - Pathology West, Westmead Hospital, University of Sydney, Darcy Road, Westmead, New South Wales 2145, Australia
| | - Zhi-Peng Xu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xin Hou
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Lin-Ying Sun
- Teaching and Research Section of Clinical Laboratory, School of Public Health, Taishan Medical School, Taian, Shandong 271000, China
| | - Li Zhang
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xin Fan
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Fanrong Kong
- Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR - Pathology West, Westmead Hospital, University of Sydney, Darcy Road, Westmead, New South Wales 2145, Australia
| | - Ying-Chun Xu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
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Johanesen PA, Mackin KE, Hutton ML, Awad MM, Larcombe S, Amy JM, Lyras D. Disruption of the Gut Microbiome: Clostridium difficile Infection and the Threat of Antibiotic Resistance. Genes (Basel) 2015; 6:1347-60. [PMID: 26703737 PMCID: PMC4690045 DOI: 10.3390/genes6041347] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 12/09/2015] [Accepted: 12/10/2015] [Indexed: 12/15/2022] Open
Abstract
Clostridium difficile is well recognized as the leading cause of antibiotic-associated diarrhea, having a significant impact in both health-care and community settings. Central to predisposition to C. difficile infection is disruption of the gut microbiome by antibiotics. Being a Gram-positive anaerobe, C. difficile is intrinsically resistant to a number of antibiotics. Mobile elements encoding antibiotic resistance determinants have also been characterized in this pathogen. While resistance to antibiotics currently used to treat C. difficile infection has not yet been detected, it may be only a matter of time before this occurs, as has been seen with other bacterial pathogens. This review will discuss C. difficile disease pathogenesis, the impact of antibiotic use on inducing disease susceptibility, and the role of antibiotic resistance and mobile elements in C. difficile epidemiology.
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Affiliation(s)
- Priscilla A Johanesen
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton 3800, Australia.
| | - Kate E Mackin
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton 3800, Australia.
| | - Melanie L Hutton
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton 3800, Australia.
| | - Milena M Awad
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton 3800, Australia.
| | - Sarah Larcombe
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton 3800, Australia.
| | - Jacob M Amy
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton 3800, Australia.
| | - Dena Lyras
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton 3800, Australia.
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Cheng JW, Xiao M, Kudinha T, Xu ZP, Sun LY, Hou X, Zhang L, Fan X, Kong F, Xu YC. The Role of Glutamate Dehydrogenase (GDH) Testing Assay in the Diagnosis of Clostridium difficile Infections: A High Sensitive Screening Test and an Essential Step in the Proposed Laboratory Diagnosis Workflow for Developing Countries like China. PLoS One 2015; 10:e0144604. [PMID: 26659011 PMCID: PMC4676637 DOI: 10.1371/journal.pone.0144604] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 11/21/2015] [Indexed: 12/18/2022] Open
Abstract
The incidence and severity of Clostridium difficile infection (CDI) in North America and Europe has increased significantly since the 2000s. However, CDI is not widely recognized in China and other developing countries due to limited laboratory diagnostic capacity and low awareness. Most published studies on laboratory workflows for CDI diagnosis are from developed countries, and thus may not be suitable for most developing countries. Therefore, an alternative strategy for developing countries is needed. In this study, we evaluated the performance of the Glutamate Dehydrogenase (GDH) test and its associated workflow on 416 fecal specimens from suspected CDI cases. The assay exhibited excellent sensitivity (100.0%) and specificity (92.8%), compared to culture based method, and thus could be a good screening marker for C. difficile but not for indication of toxin production. The VIDAS CDAB assay, which can detect toxin A/B directly from fecal specimens, showed good specificity (99.7%) and positive predictive value (97.2%), but low sensitivity (45.0%) and negative predictive value (88.3%), compared with PCR-based toxin gene detection. Therefore, we propose a practical and efficient GDH test based workflow strategy for the laboratory diagnosis of CDI in developing countries like China. By applying this new workflow, the CDI laboratory diagnosis rate was notably improved in our center, yet the increasing cost was kept at a minimum level. Furthermore, to gain some insights into the genetic population structure of C. difficile isolates from our hospital, we performed MLST and PCR toxin gene typing.
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Affiliation(s)
- Jing-Wei Cheng
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Meng Xiao
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Timothy Kudinha
- Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR–Pathology West, Westmead Hospital, University of Sydney, Darcy Road, Westmead, New South Wales, Australia
- The Charles Sturt University, Leeds Parade, Orange, New South Wales, Australia
| | - Zhi-Peng Xu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Lin-Ying Sun
- Teaching and Research Section of Clinical Laboratory, School of Public Health, Taishan Medical School, Taian, Shandong, China
| | - Xin Hou
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Li Zhang
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xin Fan
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Fanrong Kong
- Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR–Pathology West, Westmead Hospital, University of Sydney, Darcy Road, Westmead, New South Wales, Australia
| | - Ying-Chun Xu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- * E-mail:
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Identification of Recurrent Clostridium difficile Infection Using Administrative Codes: Accuracy and Implications for Surveillance. Infect Control Hosp Epidemiol 2015; 36:893-8. [DOI: 10.1017/ice.2015.102] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVETo develop an algorithm using administrative codes, laboratory data, and medication data to identify recurrent Clostridium difficile infection (CDI) and to examine the sensitivity, specificity, positive and negative predictive values, and performance of this algorithm.METHODSWe identified all patients with 2 or more International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) codes for CDI (008.45) from January 1 through December 31, 2013. Information on number of diagnosis codes, stool toxin assays (enzyme immunoassay or polymerase chain reaction), and unique prescriptions for metronidazole and vancomycin was identified. Logistic regression was used to identify independent predictors of recurrent CDI and a predictive model was developed.RESULTSA total of 591 patients with at least 2 ICD-9 codes for CDI were included (median age, 66 years). The derivation cohort consisted of 157 patients among whom 43 (27%) had recurrent CDI. Presence of 3 or more ICD-9 codes for CDI (odds ratio, 2.49), 2 or more stool tests (odds ratio, 2.88), and 2 or more prescriptions for vancomycin (odds ratio, 5.87) were independently associated with confirmed recurrent CDI. A classifier incorporating 2 or more prescriptions for vancomycin and either 2 or more stool tests or 3 or more ICD-9-CM codes had a positive predictive value of 41% and negative predictive value of 90%. The area under the receiver operating characteristic curve for this combined classifier was modest (0.69).CONCLUSIONIdentification of recurrent episodes of CDI in administrative data poses challenges. Accurate assessment of burden requires individual case review to confirm diagnosis.Infect Control Hosp Epidemiol 2015;36(8):893–898
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Abstract
Clostridium difficile is a spore-forming anaerobic gram-positive organism that is the leading cause of antibiotic-associated nosocomial infectious diarrhea in the Western world. This article describes the evolving epidemiology of C difficile infection (CDI) in the twenty-first century, evaluates the importance of vaccines against the disease, and defines the roles of both innate and adaptive host immune responses in CDI. The effects of passive immunotherapy and active vaccination against CDI in both humans and animals are also discussed.
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Affiliation(s)
- Chandrabali Ghose
- Aaron Diamond AIDS Research Center, 455 First Avenue, 7th Floor, New York, NY 10016, USA.
| | - Ciarán P Kelly
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
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21
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Abstract
UNLABELLED Clostridium difficile infection (CDI) is dramatically increasing as a cause of antibiotic- and hospital-associated diarrhea worldwide. C. difficile, a multidrug-resistant pathogen, flourishes in the colon after the gut microbiota has been altered by antibiotic therapy. Consequently, it produces toxins A and B that directly cause disease. Despite the enormous public health problem posed by this pathogen, the molecular mechanisms that regulate production of the toxins, which are directly responsible for disease, remained largely unknown until now. Here, we show that C. difficile toxin synthesis is regulated by an accessory gene regulator quorum-signaling system, which is mediated through a small (<1,000-Da) thiolactone that can be detected directly in stools of CDI patients. These findings provide direct evidence of the mechanism of regulation of C. difficile toxin synthesis and offer exciting new avenues both for rapid detection of C. difficile infection and development of quorum-signaling-based non-antibiotic therapies to combat this life-threatening emerging pathogen. IMPORTANCE Clostridium difficile infection (CDI) is the most common definable cause of hospital-acquired and antibiotic-associated diarrhea in the United States, with the total cost of treatment estimated between 1 and 4.8 billion U.S. dollars annually. C. difficile, a Gram-positive, spore-forming anaerobe, flourishes in the colon after the gut microbiota has been altered by antibiotic therapy. As a result, there is an urgent need for non-antibiotic CDI treatments that preserve the colonic microbiota. C. difficile produces toxins A and B, which are directly responsible for disease. Here, we report that C. difficile regulates its toxin synthesis by quorum signaling, in which a novel signaling peptide activates transcription of the disease-causing toxin genes. This finding provides new therapeutic targets to be harnessed for novel nonantibiotic therapy for C. difficile infections.
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22
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Lemaire A, Dombrovskiy V, Batsides G, Scholz P, Solina A, Brownstone N, Spotnitz A, Lee LY. The effect of Clostridium difficile infection on cardiac surgery outcomes. Surg Infect (Larchmt) 2014; 16:24-8. [PMID: 25402213 DOI: 10.1089/sur.2013.097] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Clostridium difficile (CD) is a common cause of healthcare-associated infectious colitis that complicates about 1% of all hospital stays in the U.S. The impact of CD on outcomes after coronary artery bypass grafting (CABG) and valvular surgery (VS) is not well known. METHODS The Nationwide Inpatient Sample (2002-2009) was queried to identify CABG and VS patients utilizing International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. Rates of CD, post-operative endocarditis and mediastinitis, hospital mortality rate, and resource utilization were evaluated. RESULTS We identified 421,294 and 90,923 patients of age 40 yrs and older who underwent CABG and VS, respectively. The CD infection was more likely to develop in patients undergoing VS than in those having CABG (odds ratio [OR] 1.8; 95% confidence interval [CI] 1.64-1.92) and was more likely after urgent or emergency admission than after elective admission (OR 1.8; 95% CI 1.68-1.94). There was a greater likelihood of mediastinitis in patients with CD after CABG than in non-complicated cases without CD, both by univariable (OR 6.0; 95% CI 3.07-11.62) and multivariable analysis with adjustment for patient age, gender, race, type of admission, and co-morbidities (OR 3.1; 95% CI 1.49-6.51). The infection thus was most likely a result of the antibiotics used to treat mediastinitis, as the patients treated for mediastinitis were most likely to develop CD. There was a significant association in patients with CD and endocarditis who underwent VS but not in patients who did not have CD. The CD infection in these patients thus was most likely a result of the antibiotics used to treat endocarditis. Endocarditis and CD developed 3.2 times (95% CI 2.65-3.97) as often as in patients without CD, a finding that was confirmed by multivariable analysis (OR 2.2; 95% CI 1.70-2.84). At the same time, in patients having VS, there was no significant association of CD and mediastinitis. Clostridium difficile infection affected the hospital mortality rate significantly after both CABG (OR 2.0; 95% CI 1.65-2.35) and VS (OR 1.9; 95% CI 1.51-2.39). Development of CD increased median hospital length of stay and cost dramatically after both CABG (from 7 d to 19 d and from $33,105 to $65,535, respectively; p<0.0001 for both) and VS (from 8 d to 24 d and from $41,876 to $95,699, respectively; p<0.0001 for both). CONCLUSIONS The development of CD worsened significantly the outcomes of adult patients undergoing cardiac surgery. There was a greater risk of CD in patients with either mediastinitis or endocarditis. The infection was associated with a higher hospital mortality rate, longer hospital stays, and greater cost after both CABG and VS.
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Affiliation(s)
- Anthony Lemaire
- Department of Surgery, UMDNJ-Robert Wood Johnson University Hospital , New Brunswick, New Jersey
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Rineh A, Kelso MJ, Vatansever F, Tegos GP, Hamblin MR. Clostridium difficile infection: molecular pathogenesis and novel therapeutics. Expert Rev Anti Infect Ther 2014; 12:131-50. [PMID: 24410618 DOI: 10.1586/14787210.2014.866515] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The Gram-positive anaerobic bacterium Clostridium difficile produces toxins A and B, which can cause a spectrum of diseases from pseudomembranous colitis to C. difficile-associated diarrhea. A limited number of C. difficile strains also produce a binary toxin that exhibits ADP ribosyltransferase activity. Here, the structure and the mechanism of action of these toxins as well as their role in disease are reviewed. Nosocomial C. difficile infection is often contracted in hospital when patients treated with antibiotics suffer a disturbance in normal gut microflora. C. difficile spores can persist on dry, inanimate surface for months. Metronidazole and oral vancomycin are clinically used for treatment of C. difficile infection but clinical failure and concern about promotion of resistance are motivating the search for novel non-antibiotic therapeutics. Methods for controlling both toxins and spores, replacing gut microflora by probiotics or fecal transplant, and killing bacteria in the anaerobic gut by photodynamic therapy are discussed.
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Affiliation(s)
- Ardeshir Rineh
- The Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA 02114, USA
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5-Aminosalicylic Acid Inhibits Acute Clostridium difficile Toxin A-Induced Colitis in Rats. Int J Inflam 2014; 2014:389621. [PMID: 25045574 PMCID: PMC4090440 DOI: 10.1155/2014/389621] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 05/21/2014] [Accepted: 06/04/2014] [Indexed: 11/22/2022] Open
Abstract
We tested the hypothesis that 5-aminosalicylic acid (5-ASA) inhibits toxin A-induced generation of colonic leukotriene B4 (LTB4) and toxin A colitis in rats. Isolated colonic segments in anesthetized rats were treated intraluminally with toxin A for 3 hours with or without 30 minutes of pretreatment with either 5-ASA or sulfapyridine and then colonic tissue levels of LTB4 were measured and inflammation was assessed. Separately, sulfasalazine was administered to rats in their drinking water for 5 days, isolated colonic segments were then prepared, toxin A was administered, and inflammation was assessed as before. Pretreatment with 5-ASA inhibited toxin A-induced increased tissue LTB4 concentration in the colon. Sulfasalazine and 5-ASA but not sulfapyridine significantly inhibited toxin A colitis. However, pretreatment with 5-ASA did not protect against direct TRPV1-mediated colitis caused by capsaicin. Toxin A stimulated the release of substance P (SP), and this effect was also inhibited by sulfasalazine and 5-ASA but not by sulfapyridine. Thus, toxin A stimulates colonic LTB4 resulting in activation of TRPV1, release of SP, and colitis. Inhibition of 5-LO by 5-ASA disrupts this pathway and supports the concept that LTB4 activation of TRPV1 plays a role in toxin A colitis.
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Finegold SM, Summanen PH, Corbett K, Downes J, Henning SM, Li Z. Pomegranate extract exhibits in vitro activity against Clostridium difficile. Nutrition 2014; 30:1210-2. [PMID: 24976424 DOI: 10.1016/j.nut.2014.02.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 11/27/2013] [Accepted: 02/27/2014] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To determine the possible utility of pomegranate extract in the management or prevention of Clostridium difficile infections or colonization. METHOD The activity of pomegranate was tested against 29 clinical C. difficile isolates using the Clinical and Laboratory Standards Institute-approved agar dilution technique. Total phenolics content of the pomegranate extract was determined by Folin-Ciocalteau colorimetric method and final concentrations of 6.25 to 400 μg/mL gallic acid equivalent were achieved in the agar. RESULTS All strains had MICs at 12.5 to 25 mg/mL gallic acid equivalent range. Our results suggest antimicrobial in vitro activity for pomegranate extract against toxigenic C. difficile. CONCLUSION Pomegranate extract may be a useful contributor to the management and prevention of C. difficile disease or colonization.
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Affiliation(s)
- Sydney M Finegold
- Infectious Diseases Section, VA Medical Center West Los Angeles, Los Angeles, California, USA; Research Service, VA Medical Center West Los Angeles, Los Angeles, California, USA; Department of Microbiology, Immunology and Molecular Genetics, UCLA School of Medicine, Los Angeles, California, USA; Department of Medicine, UCLA School of Medicine, Los Angeles, California, USA.
| | - Paula H Summanen
- Research Service, VA Medical Center West Los Angeles, Los Angeles, California, USA
| | - Karen Corbett
- Research Service, VA Medical Center West Los Angeles, Los Angeles, California, USA
| | - Julia Downes
- Research Service, VA Medical Center West Los Angeles, Los Angeles, California, USA
| | - Susanne M Henning
- UCLA Center for Human Nutrition, UCLA School of Medicine, Los Angeles, California, USA
| | - Zhaoping Li
- Research Service, VA Medical Center West Los Angeles, Los Angeles, California, USA; Department of Microbiology, Immunology and Molecular Genetics, UCLA School of Medicine, Los Angeles, California, USA; UCLA Center for Human Nutrition, UCLA School of Medicine, Los Angeles, California, USA
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Griffith M, Postelnick M, Scheetz M. Antimicrobial stewardship programs: methods of operation and suggested outcomes. Expert Rev Anti Infect Ther 2014; 10:63-73. [DOI: 10.1586/eri.11.153] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Dobreva EG, Ivanov IN, Vathcheva-Dobrevska RS, Ivanova KI, Asseva GD, Petrov PK, Kantardjiev TV. Advances in molecular surveillance of Clostridium difficile in Bulgaria. J Med Microbiol 2013; 62:1428-1434. [DOI: 10.1099/jmm.0.058149-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The increasing incidence of Clostridium difficile infection (CDI) in Bulgaria has indicated the need to implement better surveillance approaches. The aim of the present work was to improve the current surveillance of CDI in Bulgaria by introducing innovative methods for identification and typing. One hundred and twenty stool samples obtained from 108 patients were studied over 4 years from which 32 C. difficile isolates were obtained. An innovative duplex EvaGreen real-time PCR assay based on simultaneous detection of the gluD and tcdB genes was developed for rapid C. difficile identification. Four toxigenic profiles were distinguished by PCR: A+B+CDT− (53.1 %, 17/32), A−B+CDT− (28.1 %, 9/32), A+B+CDT+ (9.4 %, 3/32) and A−B−CDT− (9.4 %, 3/32). PCR ribotyping and multilocus variable number of tandem repeat analysis (MLVA7) were used for molecular characterization of the isolates. In total, nine distinct ribotypes were confirmed and the most prevalent for Bulgarian hospitals was 017 followed by 014/020, together accounting for 44 % of all isolates. Eighteen per cent of the isolates (6/32) did not match any of the 25 reference ribotypes available in this study. Twenty-four MLVA7 genotypes were detected among the clinical C. difficile isolates, distributed as follows: five for 017 ribotype, two for 014/020, 001, 002, 012 and 046 each, and one each for ribotypes 023, 070 and 078. The correlation between the typing methods was significant and allowed the identification of several clonal complexes. These results suggest that most C. difficile cases in the eight Bulgarian hospitals studied were associated with isolates belonging to the outbreak ribotypes 017 and 014/20, which are widely distributed in Europe. The real-time PCR protocol for simultaneous detection of gluD and tcdB proved to be very effective and improved C. difficile identification and confirmation of clinical C. difficile isolates.
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Affiliation(s)
- Elina G. Dobreva
- National Centre of Infectious and Parasitic Diseases (NCIPD), Microbiology Department, 26 Yanko Sakazov Boulevard, 1504 Sofia, Bulgaria
| | - Ivan N. Ivanov
- National Centre of Infectious and Parasitic Diseases (NCIPD), Microbiology Department, 26 Yanko Sakazov Boulevard, 1504 Sofia, Bulgaria
| | - Rossitza S. Vathcheva-Dobrevska
- National Centre of Infectious and Parasitic Diseases (NCIPD), Microbiology Department, 26 Yanko Sakazov Boulevard, 1504 Sofia, Bulgaria
| | - Katucha I. Ivanova
- National Centre of Infectious and Parasitic Diseases (NCIPD), Microbiology Department, 26 Yanko Sakazov Boulevard, 1504 Sofia, Bulgaria
| | - Galina D. Asseva
- National Centre of Infectious and Parasitic Diseases (NCIPD), Microbiology Department, 26 Yanko Sakazov Boulevard, 1504 Sofia, Bulgaria
| | - Petar K. Petrov
- National Centre of Infectious and Parasitic Diseases (NCIPD), Microbiology Department, 26 Yanko Sakazov Boulevard, 1504 Sofia, Bulgaria
| | - Todor V. Kantardjiev
- National Centre of Infectious and Parasitic Diseases (NCIPD), Microbiology Department, 26 Yanko Sakazov Boulevard, 1504 Sofia, Bulgaria
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Abstract
Clostridium difficile is an anaerobic, spore-forming, gram-positive bacillus that can produce severe colitis resulting in death. There has been an overall increase in the incidence of Clostridium difficile-associated disease and, particularly, an increase in the more virulent forms of the disease. Treatment of severe C difficile infection includes management of severe sepsis and shock, pathogen-directed antibiotic therapy, and, in selected cases, surgical intervention. Ultimately, prevention is the key to limiting the devastating effects of this microorganism.
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Boone JH, DiPersio JR, Tan MJ, Salstrom SJ, Wickham KN, Carman RJ, Totty HR, Albert RE, Lyerly DM. Elevated lactoferrin is associated with moderate to severe Clostridium difficile disease, stool toxin, and 027 infection. Eur J Clin Microbiol Infect Dis 2013; 32:1517-23. [PMID: 23771554 PMCID: PMC3825630 DOI: 10.1007/s10096-013-1905-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 05/27/2013] [Indexed: 12/18/2022]
Abstract
We evaluated blood and fecal biomarkers as indicators of severity in symptomatic patients with confirmed Clostridium difficile infection (CDI). Recruitment included patients with CDI based on clinical symptoms and supporting laboratory findings. Disease severity was defined by physician’s assessment and blood and fecal biomarkers were measured. Toxigenic culture done using spore enrichment and toxin B detected by tissue culture were done as confirmatory tests. Polymerase chain reaction (PCR) ribotyping was performed on each isolate. There were 98 patients recruited, with 85 (87 %) confirmed cases of toxigenic CDI (21 severe, 57 moderate, and seven mild), of which 68 (80 %) were also stool toxin-positive. Elevated lactoferrin (p = 0.01), increased white blood cell (WBC) count (p = 0.08), and low serum albumin (p = 0.03) were all associated with the more severe cases of CDI. Ribotype 027 infection accounted for 71 % of severe cases (p < 0.01) and patients with stool toxin had significantly higher lactoferrin levels and WBC counts (p < 0.05). Our findings show that elevated fecal lactoferrin, along with increased WBC count and low serum albumin, were associated with more severe CDI. In addition, patients infected with ribotype 027 and those with stool toxin had significantly higher fecal lactoferrin and WBC counts.
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Affiliation(s)
- J H Boone
- Research and Development, TechLab, Inc., 2001 Kraft Drive, Blacksburg, VA, 24060, USA,
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30
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Ochsner UA, Katilius E, Janjic N. Detection of Clostridium difficile toxins A, B and binary toxin with slow off-rate modified aptamers. Diagn Microbiol Infect Dis 2013; 76:278-85. [PMID: 23680240 DOI: 10.1016/j.diagmicrobio.2013.03.029] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Revised: 03/27/2013] [Accepted: 03/29/2013] [Indexed: 12/18/2022]
Abstract
Rapid and accurate diagnostic tests for Clostridium difficile infections (CDI) are crucial for management of patients with suspected CDI and for infection control. Enzyme immunoassays for detection of the toxins are routinely used but lack adequate sensitivity. We generated slow off-rate modified aptamers (SOMAmer™ reagents) via in vitro selection (SELEX) that bind toxins A, B and binary toxin with high affinity and specificity. Using SOMAmers alone or in conjunction with antibodies, we have developed toxin assays with a 1 pmol/L (300 pg/mL) limit of detection and a 3 log dynamic range. SOMAmers proved useful as capture or detection agents in equilibrium solution binding radioassays, pull-down capture assays, dot blots, and plate- or membrane-based sandwich assays, thus represent a promising alternative to antibodies in diagnostic applications. SOMAmers detected toxins A, B and binary toxin in culture supernatants from toxigenic C. difficile, including a BI/NAP1 strain and historic strains.
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Affiliation(s)
- Urs A Ochsner
- SomaLogic, Inc., 2945 Wilderness Place, Boulder, CO 80301, USA.
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31
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Kleger A, Schnell J, Essig A, Wagner M, Bommer M, Seufferlein T, Härter G. Fecal transplant in refractory Clostridium difficile colitis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:108-15. [PMID: 23468820 DOI: 10.3238/arztebl.2013.0108] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 11/27/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clostridium difficile infections are becoming more common, more severe, and more likely to recur. Conventional treatment with antibiotics often fails to eradicate the infection; even when it succeeds, recurrent infection is common. Complementary treatment with probiotic agents to reconstitute the physiological intestinal flora does not yield any consistent benefit. In recent years, fecal transplantation has been used in the English-speaking countries with cure rates of about 87%, but the available evidence is limited to large case series. No randomized controlled trials have been performed. We present the case of a 73-year-old woman with intractable, recurrent enterocolitis due to Clostridium difficile who was successfully treated with fecal transplantation via colonoscopy. CASE DESCRIPTION Upon the completion of antibiotic treatment for a second recurrence of enterocolitis, stool in liquid suspension was introduced into the patient's colon through a colonoscope. Prior testing had shown the stool donor to be free of acute infection or stool pathogens. The patient was given loperamide to prolong contact of the stool transplant with the colonic mucosa. She was also treated with Saccharomyces cerevisiae for four weeks. COURSE There was no clinical or microbiological evidence of a further recurrence of enterocolitis for 6 months after transplantation. Stool transplantation had no adverse effects. CONCLUSION This patient had a lasting remission of enterocolitis due to Clostridium difficile after the treatment described above. Fecal transplantation seems to be a safe and highly effective treatment for recurrent Clostridium difficile infection. It is unclear whether the administration of Saccharomyces cerevisiae confers any additional benefit.
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Affiliation(s)
- Alexander Kleger
- Ulm University Hospital Medical Center, Department of Internal Medicine I, Germany
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32
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Stewart DB, Berg A, Hegarty J. Predicting recurrence of C. difficile colitis using bacterial virulence factors: binary toxin is the key. J Gastrointest Surg 2013; 17:118-24; discussion p.124-5. [PMID: 23086451 DOI: 10.1007/s11605-012-2056-6] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Accepted: 10/11/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recurrent Clostridium difficile colitis is common, yet the ability to predict recurrence is poorly developed. METHODS Patients ≥18 years of age treated at our institution for C. difficile of any severity were consecutively enrolled. C. difficile colitis was defined as symptoms of colitis with a positive PCR stool test. Each bacterial isolate was studied for virulence factors: tcdC mutations via PCR; the presence of genes for toxins A, B, and binary toxin using restriction fragment length polymorphism; and identification of ribotype 027 by PCR. Chi-squared tests, t tests, and logistic and linear regression were used to determine which virulence factors predicted recurrence. RESULTS Sixty-nine patients (male, 57 %) were studied, with a mean age of 64 ± 13 years. Twenty-one (30 %) patients were initially diagnosed as outpatients. There was no difference (p > 0.05) between virulence factors among inpatients and outpatients. The presence of a binary toxin gene was the single virulence factor independently associated with recurrence (p = 0.02). The combination of a tcdC mutation with binary toxin gene resulted in the highest odds of recurrence (OR, 5.3; 95 % CI, 3.52-6.09). CONCLUSION Binary toxin gene is a predictor of recurrent infection. Its presence may require longer antibiotic regimens in an effort to lower already elevated recurrence rates.
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Affiliation(s)
- David B Stewart
- Department of Surgery, Penn State College of Medicine, 500 University Drive, H137, Hershey, PA 17033, USA.
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Butler MM, Shinabarger DL, Citron DM, Kelly CP, Dvoskin S, Wright GE, Feng H, Tzipori S, Bowlin TL. MBX-500, a hybrid antibiotic with in vitro and in vivo efficacy against toxigenic Clostridium difficile. Antimicrob Agents Chemother 2012; 56:4786-92. [PMID: 22733075 PMCID: PMC3421853 DOI: 10.1128/aac.00508-12] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 06/19/2012] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile infection (CDI) causes moderate to severe disease, resulting in diarrhea and pseudomembranous colitis. CDI is difficult to treat due to production of inflammation-inducing toxins, resistance development, and high probability of recurrence. Only two antibiotics are approved for the treatment of CDI, and the pipeline for therapeutic agents contains few new drugs. MBX-500 is a hybrid antibacterial, composed of an anilinouracil DNA polymerase inhibitor linked to a fluoroquinolone DNA gyrase/topoisomerase inhibitor, with potential as a new therapeutic for CDI treatment. Since MBX-500 inhibits three bacterial targets, it has been previously shown to be minimally susceptible to resistance development. In the present study, the in vitro and in vivo efficacies of MBX-500 were explored against the Gram-positive anaerobe, C. difficile. MBX-500 displayed potency across nearly 50 isolates, including those of the fluoroquinolone-resistant, toxin-overproducing NAP1/027 ribotype, performing as well as comparator antibiotics vancomycin and metronidazole. Furthermore, MBX-500 was a narrow-spectrum agent, displaying poor activity against many other gut anaerobes. MBX-500 was active in acute and recurrent infections in a toxigenic hamster model of CDI, exhibiting full protection against acute infections and prevention of recurrence in 70% of the animals. Hamsters treated with MBX-500 displayed significantly greater weight gain than did those treated with vancomycin. Finally, MBX-500 was efficacious in a murine model of CDI, again demonstrating a fully protective effect and permitting near-normal weight gain in the treated animals. These selective anti-CDI features support the further development of MBX 500 for the treatment of CDI.
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Tan CB, Rajan D, Shah M, Ahmed S, Freedman L, Rizvon K, Mustacchia P. Toxic megacolon from fulminant Clostridium difficile infection induced by topical silver sulphadiazine. BMJ Case Rep 2012; 2012:bcr-2012-006460. [PMID: 22878997 DOI: 10.1136/bcr-2012-006460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Pseudomembranous colitis and toxic megacolon (TM) are well-known complications of Clostridium difficile infections. Systemic antibiotic is considered as the major risk factor for the development of C difficile colitis. However, topical antibiotics are rarely associated with the infection. As previously thought, the use of topical antibiotic is capable of systemic absorption in damaged and denuded skin; sufficient enough to suppress the normal bowel flora. Here, we present an unusual case of TM from C difficile infection induced by topical silver sulphadiazine in a 60-year-old man with immune-bullous pemphigus vulgaris. The diagnosis is further complicated by the absence of diarrhoea as the initial presentation. Despite adequate medical and surgical intervention, the patient had an unfavourable outcome.
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Affiliation(s)
- Christopher B Tan
- Department of Internal Medicine, Nassau University Medical Center, East Meadow, New York, USA.
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35
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Case fatality associated with a hypervirulent strain in patients with culture-positive Clostridium difficile infection: a retrospective population-based study. Int J Infect Dis 2012; 16:e532-5. [DOI: 10.1016/j.ijid.2012.02.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 02/28/2012] [Indexed: 11/18/2022] Open
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36
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Erikstrup LT, Danielsen TKL, Hall V, Olsen KEP, Kristensen B, Kahlmeter G, Fuursted K, Justesen US. Antimicrobial susceptibility testing of Clostridium difficile using EUCAST epidemiological cut-off values and disk diffusion correlates. Clin Microbiol Infect 2012; 18:E266-72. [PMID: 22672504 DOI: 10.1111/j.1469-0691.2012.03907.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
With the emergence of reduced susceptibility of Clostridium difficile to metronidazole and vancomycin the value of antimicrobial susceptibility testing has increased. The aim of our study was to evaluate disk diffusion for susceptibility testing of C. difficile by comparing disk diffusion results with MICs from gradient tests and to propose zone diameter breakpoint correlates for the EUCAST epidemiological cut-off values (ECOFFs) recently published. We tested 211 clinical isolates of C. difficile, from patients with diarrhoea hospitalized at Aarhus and Odense University Hospitals, Denmark. Furthermore, ten clinical isolates of C. difficile from the Anaerobe Reference Laboratory, University Hospital of Wales, with known reduced susceptibility to either metronidazole or vancomycin, were included. Isolates were tested with Etest gradient strips and disk diffusion towards metronidazole, vancomycin and moxifloxacin on Brucella Blood Agar supplemented with hemin and vitamin K. We found an excellent agreement between inhibition zone diameter and MICs. For each MIC value, the inhibition zones varied from 0 to 8 mm, with 93% of values within 6 mm for metronidazole, 95% of values within 4 mm for vancomycin, and 98% of values within 4 mm for moxifloxacin. With proposed zone diameter breakpoints for metronidazole, vancomycin and moxifloxacin of WT ≥ 23 mm, WT ≥ 19 and WT ≥ 20 mm, respectively, we found no very major errors and only major errors below 2%. In conclusion, we suggest that disk diffusion is an option for antimicrobial susceptibility testing of C. difficile.
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Affiliation(s)
- L T Erikstrup
- Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark.
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Multi-faceted role of naturally occurring autoantibodies in fighting pathogens. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2012; 750:100-13. [PMID: 22903669 DOI: 10.1007/978-1-4614-3461-0_8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Naturally occurring antibodies (NAbs) play a vital role in the first line of defense against bacterial and viral infections. Most studies in mice and man have attributed this role to NAbs of the IgM isotype. However, there is also a significant amount of data on the anti-infectious function of NAbs of the IgG isotype. Most of these observations are derived from studies using a privileged source of NAbs, the pooled human IgG for intravenous application, IVIG. In addition to its use as a replacement in humoral immunodeficiencies, IVIG is extensively used in autoimmune and inflammatory diseases. The properties of NAbs, the principal components of IVIG, are considered crucial for their immune-regulatory properties, owing to their ability to recognize self-antigens and even autoantibodies. By virtue of these specificities for several cellular antigens, including exposed proteins that act as receptors for a variety of pathogens, certain NAbs in IVIG have a therapeutic role in preventing or modulating infections. We summarize in this chapter several examples that highlight the importance of NAbs in the control of certain bacterial and viral infections.
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Assessment of severity of Clostridium difficile infection. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2011; 25:358. [PMID: 21876855 DOI: 10.1155/2011/694787] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Slavin MA, Lingaratnam S, Mileshkin L, Booth DL, Cain MJ, Ritchie DS, Wei A, Thursky KA. Use of antibacterial prophylaxis for patients with neutropenia. Australian Consensus Guidelines 2011 Steering Committee. Intern Med J 2011; 41:102-9. [PMID: 21272174 DOI: 10.1111/j.1445-5994.2010.02341.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The use of oral prophylactic antibiotics in patients with neutropenia is controversial and not recommended by this group because of a lack of evidence showing a reduction in mortality and concerns that such practice promotes antimicrobial resistance. Recent evidence has demonstrated non-significant but consistent, improvement in all-cause mortality when fluoroquinolones (FQs) are used as primary prophylaxis. However, the consensus was that this evidence was not strong enough to recommend prophylaxis. The evidence base for FQ prophylaxis is presented alongside current consensus opinion to guide the appropriate and judicious use of these agents. Due consideration is given to patient risk, as it pertains to specific patient populations, as well as the net effect on selective pressure from antibiotics if FQ prophylaxis is routinely used in a target population. The potential costs and consequences of emerging FQ resistance, particularly among Escherichia coli, Clostridium difficile and Gram-positive organisms, are considered. As FQ prophylaxis has been advocated in some chemotherapy protocols, specific regard is given to whether FQ prophylaxis should be used to support these regimens. The group also provides recommendations for monitoring and surveillance of emerging resistance in those centres that have adopted FQ prophylaxis.
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Affiliation(s)
- M A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia.
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40
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Enoch DA, Butler MJ, Pai S, Aliyu SH, Karas JA. Clostridium difficile in children: colonisation and disease. J Infect 2011; 63:105-13. [PMID: 21664931 DOI: 10.1016/j.jinf.2011.05.016] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Revised: 05/24/2011] [Accepted: 05/26/2011] [Indexed: 12/19/2022]
Abstract
Clostridium difficile is the commonest cause of hospital acquired diarrhoea in adults and is associated with significant mortality and morbidity. The clinical significance of C. difficile in children, however, is less certain. In this article we discuss colonisation and infection and describe C. difficile in childhood in terms of risk factors, epidemiology and management.
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Affiliation(s)
- David A Enoch
- Clinical Microbiology and Public Health Laboratory, Peterborough and Stamford NHS Foundation Trust, Peterborough City Hospital, Bretton Gate, Peterborough, PE3 9GZ, UK
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Kachrimanidou M, Malisiovas N. Clostridium difficile infection: a comprehensive review. Crit Rev Microbiol 2011; 37:178-87. [PMID: 21609252 DOI: 10.3109/1040841x.2011.556598] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Clostridium difficile is one of the most important causes of healthcare acquired diarrhea. The disease spectrum caused by C. difficile infection ranges from mild, self-limited, illness to a severe, life-threatening colitis. The incidence of C. difficile associated disease has risen dramatically over the last decade, leading to increased research interest aiming at the discovery of new virulence factors and the development of new treatment and prevention regimens. This review summarizes the pathogenesis and changing epidemiology of C. difficile associated disease, the clinical spectrum and laboratory methods to diagnose C. difficile infection, and current treatment strategies.
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Affiliation(s)
- Melina Kachrimanidou
- Nuffield Department of Clinical Medicine, Oxford University, John Radcliffe Hospital Oxford, UK, OX3 9DU.
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Mathur T, Kumar M, Barman TK, Kumar GR, Kalia V, Singhal S, Raj VS, Upadhyay DJ, Das B, Bhatnagar PK. Activity of RBx 11760, a novel biaryl oxazolidinone, against Clostridium difficile. J Antimicrob Chemother 2011; 66:1087-95. [PMID: 21393140 DOI: 10.1093/jac/dkr033] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES RBx 11760, a novel oxazolidinone, was investigated for in vitro and in vivo activity against Clostridium difficile. METHODS The in vitro activity of RBx 11760 and three other agents against 50 diverse C. difficile clinical isolates and other obligate anaerobic bacteria was determined. The effect of RBx 11760 on sporulation and toxin production was determined against different C. difficile isolates. We used a hamster infection model to investigate the efficacy of RBx 11760, vancomycin and metronidazole. The mechanism of action of RBx 11760 against C. difficile ATCC 43255 was determined by macromolecular synthesis inhibition. RESULTS RBx 11760 MICs were in the range of 0.5-1 mg/L for C. difficile isolates, and it demonstrated concentration-dependent killing of C. difficile ATCC 43255 and C. difficile 6387 up to 2-4× MIC (1-2 mg/L). RBx 11760, at concentrations as low as 0.25-0.5 mg/L, resulted in a significant reduction in de novo toxin production as well as sporulation in different C. difficile isolates. In contrast, vancomycin, metronidazole and linezolid had little or no effect on toxin production and appeared to promote the formation of spores. In the hamster infection model, treatment with RBx 11760 resulted in prolonged survival of animals as compared with vancomycin or metronidazole, which correlated well with the histopathology results. Macromolecular labelling results suggest that RBx 11760 is a potent inhibitor of bacterial protein synthesis. CONCLUSIONS RBx 11760 showed excellent in vitro and in vivo activity against C. difficile, and it could be a promising novel candidate for future drug development against C. difficile infection.
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Affiliation(s)
- Tarun Mathur
- Department of Infectious Diseases, New Drug Discovery Research, Ranbaxy Research Laboratories, Gurgaon, Haryana, India.
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43
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Kelsen JR, Kim J, Latta D, Smathers S, McGowan KL, Zaoutis T, Mamula P, Baldassano RN. Recurrence rate of clostridium difficile infection in hospitalized pediatric patients with inflammatory bowel disease. Inflamm Bowel Dis 2011; 17:50-5. [PMID: 20722068 DOI: 10.1002/ibd.21421] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Accepted: 06/09/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND The incidence and associated morbidity of Clostridium difficile (CD) infection has been increasing at an alarming rate in North America. Clostridium difficile-associated diarrhea (CDAD) is the leading cause of nosocomial diarrhea in the USA. Patients with CDAD have longer average hospital admissions and additional hospital costs. Evidence has demonstrated that patients with inflammatory bowel disease (IBD) have a higher incidence of CD in comparison to the general population. The aim of this study was to compare the rate of recurrence of CD in hospitalized pediatric patients with IBD compared to hospitalized controls. The secondary aim was to evaluate whether infection with CD resulted in a more severe disease course of IBD. METHODS This was a nested case control retrospective study of hospitalized pediatric patients. Diagnosis of CD was confirmed with stool Toxin A and B analysis. The following data were obtained from the medical records: demographic information, classification of IBD including location of disease, IBD therapy, and prior surgeries. In addition, prior hospital admissions within 1 year and antibiotic exposure were recorded. The same information was recorded following CD infection. Cases were patients with IBD and CD; two control populations were also studied: patients with CD but without IBD, and patients with IBD but without CD. RESULTS For aim 1, a total of 111 eligible patients with IBD and CD infection and 77 eligible control patients with CD infection were included. The rate of recurrence of CD in the IBD population was 34% compared to 7.5% in the control population (P < 0.0001). In evaluating the effect of CD infection on IBD disease severity, we compared the 111 IBD patients with CD to a second control population of 127 IBD patients without CD. 57% of IBD-CD patients were readmitted with an exacerbation of disease within 6 months of infection with CD and 67% required escalation of therapy following CD infection, compared to 30% of IBD patients without CD (P < 0.001). Of the patients with IBD and CD, 44% of the cases were new-onset IBD, 63% were on immunosuppression therapy, and 33% were on gastric acid suppression prior to infection. In comparing the IBD-CD and control CD populations, there was no significant difference in antibiotic exposure: 33% of IBD patients and 26% of control patients were on antibiotics (P < 0.2). With regard to prior hospitalization, 10% of patients with IBD were hospitalized in the 30 days prior to infection in comparison to 27% of the control CD patients (P < 0.002). CONCLUSIONS CD infection in patients with IBD results in a higher rate of recurrence and is associated with higher morbidity than the general population. Patients with IBD often required hospitalization and escalation of therapy following infection with CD, suggesting that CD resulted in increased severity of IBD disease. In addition, IBD patients were more likely develop community-acquired CD, while the control patients developed nosocomial infections, indicating a higher susceptibility to CD infection in patients with IBD.
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Affiliation(s)
- Judith R Kelsen
- Division of Gastroenterology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.
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44
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Abstract
An understanding of the pathogenesis of infection, and the complex and fascinating 'relationship', or interaction, between the infecting organism and the host are advantageous when caring for patients with infections/infectious diseases, particularly as many of the clinical features of infection are as a consequence of the defence mechanisms mounted by the immune system. This article aims to provide a brief overview of the pathogenesis of infection, explaining how the two branches of the immune system, the innate/natural immune response, and the adaptive/acquired immune response, mount an attack against invading bacteria. Reference is made to bacteria such as Staphylococcus aureus, Clostridium difficile, Streptococcus pyogenes, Neisseria meningitidis and Mycobacterium tuberculosis, and their effect on the human host and the immune response, through the processes of attachment/entry, evasion of host defences, replication, and damage to the host.
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Affiliation(s)
- Debbie Weston
- East Kent Hospitals University NHS Foundation Trust, UK
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45
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Expression, purification and cell cytotoxicity of actin-modifying binary toxin from Clostridium difficile. Protein Expr Purif 2010; 74:42-8. [DOI: 10.1016/j.pep.2010.04.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Revised: 04/21/2010] [Accepted: 04/21/2010] [Indexed: 02/04/2023]
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Malkan AD, Pimiento JM, Maloney SP, Palesty JA, Scholand SJ. Unusual manifestations of Clostridium difficile infection. Surg Infect (Larchmt) 2010; 11:333-7. [PMID: 19795991 DOI: 10.1089/sur.2008.099] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Clostridium difficile infection (CDI) is an increasing nosocomial problem. New, more-virulent strains of C. difficile have spread across North America and Europe. Health care institutions now face a greater incidence of disease, often with greater severity. A need for surgical management for control of infection is on the increase. The clinical appearance of CDI is changed. METHODS We report four unusual and severe cases of CDI in surgical patients with a review of the relevant literature. RESULTS One patient developed CDI and required a colectomy for a perforated viscus. He developed C. difficile ileitis 12 days later that responded to medical therapy. Another patient who underwent a colectomy for infrarenal aortic occlusion, later in his hospital course, developed C. difficile ileitis and died. The third patient was hospitalized for several months for hypertension and associated morbidities. Eventually he developed severe abdominal pain and was found to have a small bowel mural abscess that grew C. difficile on culture. A fourth patient, taking long-term antibiotics for a surgical site infection of the knee, developed unexplained leukocytosis without diarrhea. Colonoscopy revealed pseudomembranous colitis that advanced to toxic megacolon. She required a colectomy and ultimately died from the disease. CONCLUSIONS Patients are at high risk from CDI in this modern era. Disease manifestations may differ from the typical presentation. A heightened awareness for diagnosing this dangerous, evolving disease is paramount.
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Affiliation(s)
- Alpin D Malkan
- Department of Surgery, Saint Mary's Health System, Waterbury, Connecticut 06705, USA.
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Diab-Elschahawi M, Fürnkranz U, Blacky A, Bachhofner N, Koller W. Re-evaluation of current A0 value recommendations for thermal disinfection of reusable human waste containers based on new experimental data. J Hosp Infect 2010; 75:62-5. [DOI: 10.1016/j.jhin.2010.01.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Accepted: 01/13/2010] [Indexed: 10/19/2022]
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Lode H. Safety and tolerability of commonly prescribed oral antibiotics for the treatment of respiratory tract infections. Am J Med 2010; 123:S26-38. [PMID: 20350633 DOI: 10.1016/j.amjmed.2010.02.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Recent data suggest that adverse events (AEs) associated with the use of antimicrobial drugs are a major safety concern, with antibiotics implicated in a significant proportion (approximately 20%) of all drug-related emergency department visits in the United States. Although most of these visits are attributable to allergic reactions (79%), certain commonly prescribed antibiotics are notable contributors to conditions that range in nature from gastrointestinal to neurologic and/or psychiatric--particularly after ED visits are adjusted per outpatient prescription visits. This article reviews medically significant AEs of agents included in the major antimicrobial classes--AEs that may be underappreciated by general practitioners. Considerable attention is devoted to the fluoroquinolone agents. Also discussed are the assessment procedures of regulatory agencies in Europe and the United States that are in place to evaluate antimicrobial safety more accurately. Offsetting potential risks and benefits associated with currently available antimicrobials in a climate in which new agents are desperately needed to combat continually evolving multiresistant pathogens remains an interesting dilemma in antimicrobial therapy.
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Affiliation(s)
- Hartmut Lode
- City Hospital Berlin-Zehlendorf, Free University of Berlin, Berlin, Germany.
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Abstract
Clostridium difficile is a critically important cause of disease in humans, particularly in hospitalized individuals. Three major factors have raised concern about the potential for this pathogen to be a cause of foodborne disease: the increasing recognition of community-associated C. difficile infection, recent studies identifying C. difficile in food animals and food, and similarities in C. difficile isolates from animals, food and humans. It is clear that C. difficile can be commonly found in food animals and food in many regions, and that strains important in human infections, such as ribotype 027/NAP1/toxinotype III and ribotype 078/toxinotype V, are often present. However, it is currently unclear whether ingestion of contaminated food can result in colonization or infection. Many questions remain unanswered regarding the role of C. difficile in community-associated diarrhoea: its source when it is a food contaminant, the infective dose, and the association between ingestion of contaminated food and disease. The significant role of this pathogen in human disease and its potential emergence as an important community-associated pathogen indicate that careful evaluation of different sources of exposure, including food, is required, but determination of the potential role of food in C. difficile infection may be difficult.
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Affiliation(s)
- J S Weese
- Department of Pathobiology, Ontartio Veterinary College, University of Guelph, Guelph, Ontario, Canada.
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Clostridium difficile testing in the clinical laboratory by use of multiple testing algorithms. J Clin Microbiol 2010; 48:889-93. [PMID: 20071552 DOI: 10.1128/jcm.01801-09] [Citation(s) in RCA: 167] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The incidence of Clostridium difficile infection (CDI) has risen almost 3-fold in the United States over the past decade, emphasizing the need for rapid and accurate tests for CDI. The Cepheid Xpert C. difficile assay is an integrated, closed, nucleic acid amplification system that automates sample preparation and real-time PCR detection of the toxin B gene (tcdB). A total of 432 stool specimens from symptomatic patients were tested by a glutamate dehydrogenase (GDH) assay, a toxin A and B enzyme immunoassay (EIA), the Xpert C. difficile assay, and a cell culture cytotoxicity neutralization assay (CCCN). The results of these methods, used individually and in combination, were compared to those of toxigenic culture. Results for the Xpert C. difficile assay alone showed a sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of 94.4, 96.3, 84.0, and 98.8%, while the EIA alone gave corresponding values of 58.3, 94.7, 68.9, and 91.9%, respectively. An algorithm using the GDH assay and the EIA (plus the CCCN if the EIA was negative) showed corresponding values of 83.1, 96.7, 83.1, and 96.1%. The Xpert C. difficile assay was statistically superior to the EIA (P, <0.001 by Fisher's exact test) and to the GDH-EIA-CCCN algorithm (P, 0.0363). Combining the GDH and Xpert C. difficile assays lowered both the sensitivity and the NPV of the Xpert assay. The GDH-EIA-CCCN procedure required, on average, 2 days to complete testing on GDH-positive results, while testing by the Xpert C. difficile assay was completed, on average, in less than 1 h. Xpert C. difficile testing yielded the highest sensitivity and NPV, in the least amount of time, of the individual- and multiple-test algorithms evaluated in this study.
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