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Bishop EJ, Tiruvoipati R. Management of Clostridioides difficile infection in adults and challenges in clinical practice: review and comparison of current IDSA/SHEA, ESCMID and ASID guidelines. J Antimicrob Chemother 2022; 78:21-30. [PMID: 36441203 PMCID: PMC9780550 DOI: 10.1093/jac/dkac404] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Clostridioides difficile infection (CDI) remains a significant clinical challenge both in the management of severe and severe-complicated disease and the prevention of recurrence. Guidelines released by the Infectious Diseases Society of America and Society for Healthcare Epidemiology of America (IDSA/SHEA) and ESCMID had some consensus as well as some discrepancies in disease severity classification and treatment recommendations. We review and compare the key clinical strategies from updated IDSA/SHEA, ESCMID and current Australasian guidelines for CDI management in adults and discuss relevant issues for clinicians, particularly in the management of severe-complicated infection. Updated IDSA/SHEA and ESCMID guidelines now reflect the increased efficacy of fidaxomicin in preventing recurrence and have both promoted fidaxomicin to first-line therapy with an initial CDI episode in both non-severe and severe disease and endorsed the role of bezlotoxumab in the prevention of recurrent infection. Vancomycin remains acceptable therapy and metronidazole is not preferred. For severe-complicated infection the IDSA/SHEA recommends high-dose oral ± rectal vancomycin and IV metronidazole, whilst in an important development, ESCMID has endorsed fidaxomicin and tigecycline as part of combination anti-CDI therapy, for the first time. The role of faecal microbiota transplantation (FMT) in second CDI recurrence is now clearer, but timing and mode of FMT in severe-complicated refractory disease still requires further study.
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Affiliation(s)
| | - Ravindranath Tiruvoipati
- Peninsula Clinical School, Monash University, Melbourne, Victoria, Australia,Department of Intensive Care Medicine, Peninsula Health, Melbourne, Victoria, Australia,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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2
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Carlson TJ, Gonzales-Luna AJ, Garey KW. Fulminant Clostridioides difficile Infection: A Review of Treatment Options for a Life-Threatening Infection. Semin Respir Crit Care Med 2022; 43:28-38. [PMID: 35172356 DOI: 10.1055/s-0041-1740973] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Fulminant Clostridioides difficile infection (FCDI) encompasses 3 to 5% of all CDI cases with associated mortality rates between 30 and 40%. Major treatment modalities include surgery and medical management with antibiotic and nonantibiotic therapies. However, identification of patients with CDI that will progress to FCDI is difficult and makes it challenging to direct medical management and identify those who may benefit from surgery. Furthermore, since it is difficult to study such a critically ill population, data investigating treatment options are limited. Surgical management with diverting loop ileostomy (LI) instead of a total abdominal colectomy (TAC) with end ileostomy has several appealing advantages, and studies have not consistently demonstrated a clinical benefit with this less-invasive strategy, so both LI and TAC remain acceptable surgical options. Successful medical management of FCDI is complicated by pharmacokinetic changes that occur in critically ill patients, and there is an absence of high-quality studies that included patients with FCDI. Recommendations accordingly include a combination of antibiotics administered via multiple routes to ensure adequate drug concentrations in the colon: intravenous metronidazole, high-dose oral vancomycin, and rectal vancomycin. Although fidaxomicin is now recommended as first-line therapy for non-FCDI, there are limited clinical data to support its use in FCDI. Several nonantibiotic therapies, including fecal microbiota transplantation and intravenous immunoglobulin, have shown success as adjunctive therapies, but they are unlikely to be effective alone. In this review, we aim to summarize diagnosis and treatment options for FCDI.
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Affiliation(s)
- Travis J Carlson
- Department of Clinical Sciences, High Point University Fred Wilson School of Pharmacy, High Point, North Carolina
| | - Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas
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3
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Kampouri E, Croxatto A, Prod’hom G, Guery B. Clostridioides difficile Infection, Still a Long Way to Go. J Clin Med 2021; 10:jcm10030389. [PMID: 33498428 PMCID: PMC7864166 DOI: 10.3390/jcm10030389] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 12/11/2022] Open
Abstract
Clostridioides difficile is an increasingly common pathogen both within and outside the hospital and is responsible for a large clinical spectrum from asymptomatic carriage to complicated infection associated with a high mortality. While diagnostic methods have considerably progressed over the years, the optimal diagnostic algorithm is still debated and there is no single diagnostic test that can be used as a standalone test. More importantly, the heterogeneity in diagnostic practices between centers along with the lack of robust surveillance systems in all countries and an important degree of underdiagnosis due to lack of clinical suspicion in the community, hinder a more accurate evaluation of the burden of disease. Our improved understanding of the physiopathology of CDI has allowed some significant progress in the treatment of CDI, including a broader use of fidaxomicine, the use of fecal microbiota transplantation for multiples recurrences and newer approaches including antibodies, vaccines and new molecules, already developed or in the pipeline. However, the management of CDI recurrences and severe infections remain challenging and the main question remains: how to best target these often expensive treatments to the right population. In this review we discuss current diagnostic approaches, treatment and potential prevention strategies, with a special focus on recent advances in the field as well as areas of uncertainty and unmet needs and how to address them.
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Affiliation(s)
- Eleftheria Kampouri
- Infectious Diseases Service, Department of Medicine, University Hospital and University of Lausanne, 1011 Lausanne, Switzerland;
| | - Antony Croxatto
- Institute of Microbiology, Department of Medical Laboratory and Pathology, University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; (A.C.); (G.P.)
| | - Guy Prod’hom
- Institute of Microbiology, Department of Medical Laboratory and Pathology, University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; (A.C.); (G.P.)
| | - Benoit Guery
- Infectious Diseases Service, Department of Medicine, University Hospital and University of Lausanne, 1011 Lausanne, Switzerland;
- Correspondence: ; Tel.: +41-21-314-1643
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4
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Adelman MW, Woodworth MH, Shaffer VO, Martin GS, Kraft CS. Critical Care Management of the Patient with Clostridioides difficile. Crit Care Med 2021; 49:127-139. [PMID: 33156122 PMCID: PMC7967892 DOI: 10.1097/ccm.0000000000004739] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To review published clinical evidence on management of Clostridioides difficile infection in critically ill patients. DATA SOURCES We obtained relevant studies from a PubMed literature review and bibliographies of reviewed articles. STUDY SELECTION We selected English-language studies addressing aspects of C. difficile infection relevant to critical care clinicians including epidemiology, risk factors, diagnosis, treatment, and prevention, with a focus on high-quality clinical evidence. DATA EXTRACTION We reviewed potentially relevant studies and abstracted information on study design, methods, patient selection, and results of relevant studies. This is a synthetic (i.e., not systematic) review. DATA SYNTHESIS C. difficile infection is the most common healthcare-associated infection in the United States. Antibiotics are the most significant C. difficile infection risk factor, and among antibiotics, cephalosporins, clindamycin, carbapenems, fluoroquinolones, and piperacillin-tazobactam confer the highest risk. Age, diabetes mellitus, inflammatory bowel disease, and end-stage renal disease are risk factors for C. difficile infection development and mortality. C. difficile infection diagnosis is based on testing appropriately selected patients with diarrhea or on clinical suspicion for patients with ileus. Patients with fulminant disease (C. difficile infection with hypotension, shock, ileus, or megacolon) should be treated with oral vancomycin and IV metronidazole, as well as rectal vancomycin in case of ileus. Patients who do not respond to initial therapy should be considered for fecal microbiota transplant or surgery. Proper infection prevention practices decrease C. difficile infection risk. CONCLUSIONS Strong clinical evidence supports limiting antibiotics when possible to decrease C. difficile infection risk. For patients with fulminant C. difficile infection, oral vancomycin reduces mortality, and adjunctive therapies (including IV metronidazole) and interventions (including fecal microbiota transplant) may benefit select patients. Several important questions remain regarding fulminant C. difficile infection management, including which patients benefit from fecal microbiota transplant or surgery.
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Affiliation(s)
- Max W. Adelman
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael H. Woodworth
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Virginia O. Shaffer
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Greg S. Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Emory Critical Care Center, Atlanta, GA, USA
| | - Colleen S. Kraft
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
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5
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Teixeira A, Tripathi K, Greeff Y, Sorour O, Mccallion P, Davis G, Sorour K. Intracolonic Administration of Vancomycin in Intensive Care Unit Patients with Severe Clostridium Difficile Colitis. Cureus 2020; 12:e11573. [PMID: 33364098 PMCID: PMC7749802 DOI: 10.7759/cureus.11573] [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] [Accepted: 11/19/2020] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a major cause of antibiotic-associated diarrhea worldwide. The incidence of sepsis has been shown to be increasing due to severe or fulminant colitis. Oral vancomycin is the treatment of choice for CDI, but it is often ineffective in patients in the intensive care unit (ICU) due to poor intestinal motility. We present a review of eight cases with severe to fulminant CDI treated with adjunctive intracolonic vancomycin (ICV) administration. METHODS A retrospective chart review identified patients in sepsis with severe colitis and positive Clostridium difficile toxin A or B. Patients who had failed standard therapy for CDI were given adjunctive ICV through an enteric tube, which was inserted via colonoscopy. To indicate the severity of patients, the patients selected had required vasopressor support. RESULTS Eight patients (37.5% females) received this adjunctive treatment; the mean age was 73.25. The average Acute Physiology and Chronic Health Evaluation (APACHE) 2 score at the time of the procedure was 39. The median length of stay was 5.5 days, with in-hospital mortality of 37.5% and an average time to death of 1.33 days from the day of colonoscopy. Conclusion: Colonoscopic decompression and administration of vancomycin for fulminant CDI using an enteric tube can have favorable outcomes in severely ill patients whose surgical options carry a high risk of mortality. Further larger randomized controlled trials are needed to evaluate its efficacy.
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Affiliation(s)
- Alex Teixeira
- Gastroenterology and Hepatology, Signature Healthcare Brockton Hospital, Brockton, USA
| | - Kartikeya Tripathi
- Gastroenterology, University of Massachusetts Medical School Baystate, Springfield, USA
| | - Yesenia Greeff
- Gastroenterology and Hepatology, University of Massachusetts Medical School Baystate, Springfield, USA
| | - Omar Sorour
- Internal Medicine, University of Massachusetts, Worcester, USA
| | - Paul Mccallion
- Anesthesiology, Signature Healthcare Brockton Hospital, Brockton, USA
| | - Garrison Davis
- Internal Medicine, Signature Healthcare Brockton Hospital, Brockton, USA
| | - Khaled Sorour
- Critical Care Medicine, Signature Healthcare Brockton Hospital, Brockton, USA
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6
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Bader MS, Hawboldt J, Main C, Mertz D, Loeb M, Farrell A, Joyce J. Review of high dose vancomycin in the treatment of Clostridioides difficile infection. Infect Dis (Lond) 2020; 52:847-857. [PMID: 32744879 DOI: 10.1080/23744235.2020.1800080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Guidelines recommend oral vancomycin as first-line therapy for Clostridioides difficile infection. Guideline recommendations vary regarding dosing of vancomycin. Our aim was to summarize the current evidence on the efficacy and adverse effects of high dose oral and vancomycin retention enema (>500 mg/day) for the treatment of C. difficile infection. METHODS We searched clinical studies and major guidelines in the English language using MEDLINE, the Cochrane Library and Embase from 1985 until 15 April 2020. RESULTS No evidence supports the use of high dose oral vancomycin in the treatment of severe C. difficile infection. Weak evidence from observational studies supports the use of high dose oral vancomycin in addition to intravenous metronidazole and high dose vancomycin retention enema in fulminant C. difficile infection. Vancomycin retention enema can be used in severe C. difficile infection when oral administration is not possible, or in conditions when the oral formulation cannot reach the colon such as Hartman's pouch, ileostomies, or colon diversions. CONCLUSIONS The dosing schedules for oral vancomycin and vancomycin enemas are not clearly defined due to widely varying results in clinical studies. Large, comparative multicenter trials are urgently needed to define the role of high dose vancomycin in C. difficile infection.
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Affiliation(s)
- Mazen S Bader
- Faculty of Health Sciences, Department of Medicine, Division of Infectious Diseases, McMaster University, Hamilton, Canada.,Hamilton Health Sciences, Juravinski Hospital and Cancer Centre, Hamilton, Canada
| | - John Hawboldt
- Faculty of Medicine, School of Pharmacy, Memorial University of Newfoundland and Labrador, St John's, Canada
| | - Cheryl Main
- Departments of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
| | - Dominik Mertz
- Department of Medicine, Pathology and Molecular Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Mark Loeb
- Department of Medicine, Pathology and Molecular Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Alison Farrell
- Public Services Librarian HSL, Memorial University of Newfoundland, St John's, Canada
| | - Joanna Joyce
- Department of Medicine, Division of Infectious Diseases, Memorial University, St John's, Canada
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7
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Bermejo Boixareu C, Tutor-Ureta P, Ramos Martínez A. [Updated review of Clostridium difficile infection in elderly]. Rev Esp Geriatr Gerontol 2020; 55:225-235. [PMID: 32423602 DOI: 10.1016/j.regg.2019.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 12/10/2019] [Accepted: 12/19/2019] [Indexed: 06/11/2023]
Abstract
Clostridium difficile infection is the most common cause of health care-associated diarrhoea, and its incidence increases with age. Clinical challenges, risk of resistance to treatment, risk of recurrence, and treatment responses are different in elderly. The aim of this review is to discuss the updated epidemiology, pathophysiology, diagnosis, and therapeutic management of C. difficile infection in elderly with the available data.
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Affiliation(s)
| | - Pablo Tutor-Ureta
- Servicio de Medicina Interna, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | - Antonio Ramos Martínez
- Servicio de Medicina Interna, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
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Abstract
The objective of this study of a retrospective case series was to determine factors associated with survival after surgical intervention in pseudomembranous colitis (PMC). The study was conducted at a tertiary care medical center and comprised 36 patients who underwent colectomy for fulminant PMC from 1995 to 2006. Patients including 21 females ranged from 40 to 89 years of age (mean, 70 years). Comorbidities included diabetes (39%), cardiovascular disease (77%), chronic obstructive pulmonary disease (47%), and intake of immunosuppressive medications (45%). Seventy-two per cent received antibiotics in the previous 2 months. Only patients with a confirmation of PMC on pathology specimens were included in the study. All patients underwent colectomy. Patients were stratified into two groups: survivors and nonsurvivors. Various clinical factors/parameters used in the management of patients with PMC were studied in these two groups. Survival was correlated with mean white blood cell count (23,000 survivors versus 40,000 nonsurvivors, P < 0.01); multisystem organ failure (16 per cent survivors versus 47 per cent nonsurvivors, P < 0.05); and preoperative pressors (16 per cent survivors versus 47 per cent nonsurvivors, P < 0.05). Overall mortality for the study period was 47 per cent. Mortality rate analysis revealed a lower rate for the more recent years (32 per cent for 2000 to 2006 versus 65 per cent for 1995 to 1999, P < 0.05). In the more recent years, the time elapsing before colectomy was also lower (1.4 days versus 2.5 days, nonsignificant), and patients had less preoperative hemodynamic instability (70 per cent versus 31 per cent, P < 0.03). In one institution, survival after surgery for PMC was found to be associated with a mean white blood cell count (<37,000), nondependence on preoperative vasopressors, and surgical intervention before the onset of hemodynamic instability.
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Affiliation(s)
- Syed O. Ali
- University of Connecticut Integrated General Surgery Program, Farmington, Connecticut
| | - John P. Welch
- Connecticut Surgical Group, Hartford, Connecticut, Hartford Hospital, Hartford, Connecticut, the Department of Surgery, University of Connecticut School of Medicine, Farmington, Connecticut, and the Department of Surgery, Dartmouth Medical School, Hanover, New Hampshire; and
| | - Robert J. Dring
- North Shore University Hospital, Manhasset, New York, Long Island Jewish Hospital, New Hyde Park, New York, St. Francis Hospital, Roslyn, New York, and Winthrop University Hospital, Mineola, New York
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9
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Wu KS, Syue LS, Cheng A, Yen TY, Chen HM, Chiu YH, Hsu YL, Chiu CH, Su TY, Tsai WL, Chen WY, Huang CH, Hung HM, Huang LJ, Kuo HJ, Lin PC, Yang CH, Hong PL, Lee SSJ, Chen YS, Liu YC, Huang LM. Recommendations and guidelines for the treatment of Clostridioides difficile infection in Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2020; 53:191-208. [PMID: 32169531 DOI: 10.1016/j.jmii.2020.02.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 01/19/2020] [Accepted: 02/01/2020] [Indexed: 12/13/2022]
Abstract
Clostridioides difficile infection (CDI) is a major enteric disease associated with antibiotic use and a leading cause of hospital-acquired infections worldwide. This is the first guideline for treatment of CDI in Taiwan, aiming to optimize medical care for patients with CDI. The target audience of this document includes all healthcare personnel who are involved in the medical care of patients with CDI. The 2018 Guidelines Recommendations for Evidence-based Antimicrobial agents use in Taiwan (GREAT) working group was formed, comprising of infectious disease specialists from 13 medical centers in Taiwan, to review the evidence and draft recommendations using the grading of recommendations assessment, development, and evaluation (GRADE) methodology. A nationwide expert panel reviewed the recommendations during a consensus meeting in March 2019. The recommendation is endorsed by the Infectious Diseases Society of Taiwan (IDST). This guideline describes the epidemiology and risk factors of CDI, and provides recommendations for treatment of CDI in both adults and children. Recommendations for treatment of the first episode of CDI, first recurrence, second and subsequent recurrences of CDI, severe CDI, fulminant CDI, and pediatric CDI are provided.
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Affiliation(s)
- Kuan-Sheng Wu
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ling-Shan Syue
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Aristine Cheng
- Division of Infectious Diseases, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ting-Yu Yen
- Departments of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hsien-Meng Chen
- Division of Infectious Disease, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Yu-Hsin Chiu
- Division of Infectious Diseases, Chi-Mei Medical Center, Tainan, Taiwan
| | - Yu-Lung Hsu
- Division of Pediatric Infectious Diseases, China Medical University Children's Hospital, China Medical University, Taichung, Taiwan
| | - Chun-Hsiang Chiu
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ting-Yi Su
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Wan-Lin Tsai
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Wei-Yu Chen
- Division of General Medicine, Infectious Disease, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Chung-Hao Huang
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Huei-Min Hung
- Department of Pediatrics, Chang Gung Children's Hospital, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ling-Ju Huang
- Division of General Medicine, Infectious Diseases, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hong-Jie Kuo
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Pei-Chin Lin
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Department of Pharmacy, School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Hsiang Yang
- Department of Pharmacy, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Pi-Lien Hong
- Department of Pharmacy, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Susan Shin-Jung Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Yao-Shen Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yung-Ching Liu
- Division of Infectious Diseases, Taipei Medical University Shuang Ho Hospital, Taipei, Taiwan
| | - Li-Ming Huang
- Departments of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
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10
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Antonelli M, Martin-Loeches I, Dimopoulos G, Gasbarrini A, Vallecoccia MS. Clostridioides difficile (formerly Clostridium difficile) infection in the critically ill: an expert statement. Intensive Care Med 2020; 46:215-224. [PMID: 31938827 DOI: 10.1007/s00134-019-05873-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 11/16/2019] [Indexed: 02/07/2023]
Abstract
Clostridioides difficile (formerly Clostridium difficile) infection (CDI) represents a worrisome condition, often underestimated, with severe clinical presentations, frequently requiring intensive care unit (ICU) admission. The aim of the present expert statement was to give an overview of the management of CDI in critically ill patients, for whom CDI represents a redoubtable problem, in large part related to the use and abuse of antibiotics. The available knowledge about pathophysiology, risk factors, diagnosis and treatment concerning critical care patients affected by CDI has been reviewed, even though most of the existing information come from studies performed outside the ICU and the evidence on several issues in this specific context is scarce. The adoption of potential preventive and therapeutic strategies aimed to stem the phenomenon were discussed, including the faecal microbiota transplantation. This possibility could represent a highly interesting option in critically ill patients, but current evidence is limited and future well designed studies are needed. A special insight on the specific challenges that the ICU physicians may face caring for the critically ill patients with CDI was also proposed.
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Affiliation(s)
- Massimo Antonelli
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
- Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, St James Street, Dublin 8, Dublin, Ireland
- Hospital Clinic, IDIBAPS, Universidad de Barcelona, Ciberes, Barcelona, Spain
| | - George Dimopoulos
- Critical Care Department, ATTIKON University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonio Gasbarrini
- Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria Sole Vallecoccia
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
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11
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Dinu V, Lu Y, Weston N, Lithgo R, Coupe H, Channell G, Adams GG, Torcello Gómez A, Sabater C, Mackie A, Parmenter C, Fisk I, Phillips-Jones MK, Harding SE. The antibiotic vancomycin induces complexation and aggregation of gastrointestinal and submaxillary mucins. Sci Rep 2020; 10:960. [PMID: 31969624 PMCID: PMC6976686 DOI: 10.1038/s41598-020-57776-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 12/19/2019] [Indexed: 01/14/2023] Open
Abstract
Vancomycin, a branched tricyclic glycosylated peptide antibiotic, is a last-line defence against serious infections caused by staphylococci, enterococci and other Gram-positive bacteria. Orally-administered vancomycin is the drug of choice to treat pseudomembranous enterocolitis in the gastrointestinal tract. However, the risk of vancomycin-resistant enterococcal infection or colonization is significantly associated with oral vancomycin. Using the powerful matrix-free assay of co-sedimentation analytical ultracentrifugation, reinforced by dynamic light scattering and environmental scanning electron microscopy, and with porcine mucin as the model mucin system, this is the first study to demonstrate strong interactions between vancomycin and gastric and intestinal mucins, resulting in very large aggregates and depletion of macromolecular mucin and occurring at concentrations relevant to oral dosing. In the case of another mucin which has a much lower degree of glycosylation (~60%) - bovine submaxillary mucin - a weaker but still demonstrable interaction is observed. Our demonstration - for the first time - of complexation/depletion interactions for model mucin systems with vancomycin provides the basis for further study on the implications of complexation on glycopeptide transit in humans, antibiotic bioavailability for target inhibition, in situ generation of resistance and future development strategies for absorption of the antibiotic across the mucus barrier.
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Affiliation(s)
- Vlad Dinu
- National Centre for Macromolecular Hydrodynamics, School of Biosciences, University of Nottingham, Sutton Bonington, LE12 5RD, UK
- Division of Food Science, School of Biosciences, Sutton Bonington, LE12 5RD, UK
| | - Yudong Lu
- National Centre for Macromolecular Hydrodynamics, School of Biosciences, University of Nottingham, Sutton Bonington, LE12 5RD, UK
| | - Nicola Weston
- Nottingham Nanoscale and Microscale Research Centre, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Ryan Lithgo
- National Centre for Macromolecular Hydrodynamics, School of Biosciences, University of Nottingham, Sutton Bonington, LE12 5RD, UK
| | - Hayley Coupe
- National Centre for Macromolecular Hydrodynamics, School of Biosciences, University of Nottingham, Sutton Bonington, LE12 5RD, UK
| | - Guy Channell
- National Centre for Macromolecular Hydrodynamics, School of Biosciences, University of Nottingham, Sutton Bonington, LE12 5RD, UK
- Division of Food Science, School of Biosciences, Sutton Bonington, LE12 5RD, UK
| | - Gary G Adams
- National Centre for Macromolecular Hydrodynamics, School of Biosciences, University of Nottingham, Sutton Bonington, LE12 5RD, UK
- School of Health Sciences, University of Nottingham, Nottingham, NG7 2HA, UK
| | | | - Carlos Sabater
- School of Food Science & Nutrition, University of Leeds, Leeds, LS2 9JT, UK
- Department of Bioactivity and Food Analysis, Institute of Food Science Research (CSIC-UAM), Nicolás Cabrera 9, 28049, Madrid, Spain
| | - Alan Mackie
- School of Food Science & Nutrition, University of Leeds, Leeds, LS2 9JT, UK
| | - Christopher Parmenter
- Nottingham Nanoscale and Microscale Research Centre, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Ian Fisk
- Division of Food Science, School of Biosciences, Sutton Bonington, LE12 5RD, UK
| | - Mary K Phillips-Jones
- National Centre for Macromolecular Hydrodynamics, School of Biosciences, University of Nottingham, Sutton Bonington, LE12 5RD, UK.
| | - Stephen E Harding
- National Centre for Macromolecular Hydrodynamics, School of Biosciences, University of Nottingham, Sutton Bonington, LE12 5RD, UK.
- Kulturhistorisk Museum, Universitetet i Oslo, Postboks 6762, St. Olavs plass, 0130, Oslo, Norway.
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12
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McDonald LC, Gerding DN, Johnson S, Bakken JS, Carroll KC, Coffin SE, Dubberke ER, Garey KW, Gould CV, Kelly C, Loo V, Shaklee Sammons J, Sandora TJ, Wilcox MH. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2019; 66:e1-e48. [PMID: 29462280 DOI: 10.1093/cid/cix1085] [Citation(s) in RCA: 1239] [Impact Index Per Article: 247.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.
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Affiliation(s)
| | | | - Stuart Johnson
- Edward Hines Jr Veterans Administration Hospital, Hines.,Loyola University Medical Center, Maywood, Illinois
| | | | - Karen C Carroll
- Johns Hopkins University School of Medicine, Baltimore, Maryl
| | | | - Erik R Dubberke
- Washington University School of Medicine, St Louis, Missouri
| | | | - Carolyn V Gould
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ciaran Kelly
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Vivian Loo
- McGill University Health Centre, McGill University, Montréal, Québec, Canada
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13
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Thabit AK, Alsolami MH, Baghlaf NA, Alsharekh RM, Almazmumi HA, Alselami AS, Alsubhi FA. Comparison of three current Clostridioides difficile infection guidelines: IDSA/SHEA, ESCMID, and ACG guidelines. Infection 2019; 47:899-909. [PMID: 31428991 DOI: 10.1007/s15010-019-01348-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 08/10/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE Clostridioides difficile infection (CDI) is a widely recognized condition associated with comorbidity and decreased patient quality of life. Certain professional medical organizations develop clinical practice guidelines for major diseases. This is done in an effort to streamline the universal clinical practice and ensure that a more accurate diagnosis and better treatments are offered to respective patients for optimal outcomes. However, as new data evolve, constant update of these guidelines becomes essential. While these guidelines provide up-to-date recommendations, they are not published around the same time; thus, their recommendations may vary depending on evidence available prior to guidelines preparation and publication. METHODS Recommendations and corresponding justifications from three major CDI guidelines between 2013 and 2017 were pooled and compared, and notable differences were highlighted while providing an insight and a final recommendation from a clinical standpoint. RESULTS Most recommendations were consistent among all three guidelines. One notable difference was in the specification of candidates for CDI diagnosis, where it would be recommended to mainly test patients with three or more diarrheal episodes over 24 h, if they had no other clear reason for the diarrhea. Another conflicting point was regarding the treatment of non-severe CDI where vancomycin can be considered for older or sicker patients; however, metronidazole still remains a reasonable option based on recent data, some of which were not cited in the most recent guidelines of IDSA/SHEA. CONCLUSION Overall, it is prudent to follow these guidelines with critical appraisal to fulfill the goal of achieving optimum patient outcomes.
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Affiliation(s)
- Abrar K Thabit
- Pharmacy Practice Department, Faculty of Pharmacy, King Abdulaziz University, 7027 Abdullah Al-Sulaiman Rd, Jeddah, 22254-2265, Saudi Arabia.
| | - Mawadah H Alsolami
- Pharmacy Practice Department, Faculty of Pharmacy, King Abdulaziz University, 7027 Abdullah Al-Sulaiman Rd, Jeddah, 22254-2265, Saudi Arabia
| | - Nojoud A Baghlaf
- Pharmacy Practice Department, Faculty of Pharmacy, King Abdulaziz University, 7027 Abdullah Al-Sulaiman Rd, Jeddah, 22254-2265, Saudi Arabia
- Jeddah Clinic Hospital, Jeddah, Saudi Arabia
| | - Raghad M Alsharekh
- Pharmacy Practice Department, Faculty of Pharmacy, King Abdulaziz University, 7027 Abdullah Al-Sulaiman Rd, Jeddah, 22254-2265, Saudi Arabia
| | - Hadeel A Almazmumi
- Pharmacy Practice Department, Faculty of Pharmacy, King Abdulaziz University, 7027 Abdullah Al-Sulaiman Rd, Jeddah, 22254-2265, Saudi Arabia
| | - Afrah S Alselami
- Pharmacy Practice Department, Faculty of Pharmacy, King Abdulaziz University, 7027 Abdullah Al-Sulaiman Rd, Jeddah, 22254-2265, Saudi Arabia
| | - Fatmah A Alsubhi
- Pharmacy Practice Department, Faculty of Pharmacy, King Abdulaziz University, 7027 Abdullah Al-Sulaiman Rd, Jeddah, 22254-2265, Saudi Arabia
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14
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Bozkurt HS, Kara B. Combination of oral vancomycin and intra-colonic vancomycin: Successful treatment of complicated pseudomembranous colitis in a child patient. SAGE Open Med Case Rep 2019; 7:2050313X19838442. [PMID: 30911393 PMCID: PMC6425522 DOI: 10.1177/2050313x19838442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 02/27/2019] [Indexed: 02/04/2023] Open
Abstract
The Clostridium difficile infection–related disease varies from mild diarrhoea to pseudomembranouscolitis. Although C. difficile infection is commonly considered to be a hospital-acquired infection, a significant number of cases are community acquired. Community-acquired C. difficile infection can exhibit itself as ileus or toxic megacolon. Severe C. difficile infection that is unresponsive to intravenous metronidazole therapy requires more aggressive medical management and even surgical intervention. We present our case results for which vancomycin was administered both orally and intra-colonically. With this method, we treated the community acquired C. difficile infection patient who was presented as ileus.
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Affiliation(s)
- Hüseyin Sancar Bozkurt
- Clinic of Gastroenterology, Medical Faculty Internal Medicine, Maltepe University, Maltepe, Turkey
| | - Banu Kara
- Clinic of Gastroenterology, Adana City Research and Education Hospital, University of Health Sciences, Adana, Turkey
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15
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Fawley J, Napolitano LM. Vancomycin Enema in the Treatment of Clostridium difficile Infection. Surg Infect (Larchmt) 2019; 20:311-316. [PMID: 30716016 DOI: 10.1089/sur.2018.238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: Current guidelines for the treatment of Clostridium difficile infections (CDIs) recommend vancomycin enemas for patients with adynamic ileus. There is significant variability in guideline recommendations for vancomycin dose and enema volume and whether a retention enema should be used. The most recent (2017) guidelines from the Infectious Diseases Society of America/Society for Healthcare Epidemiology of America recommend rectal instillation of 500 mg of vancomycin in 100 mL of physiologic saline every 6 hours as a retention enema. Methods: Published studies regarding vancomycin enema use in CDI (1990-present) were reviewed to compare drug dose, volume, and whether a retention enema was used in order to determine the efficacy and make recommendations for optimal dosing. Results: Case series with higher vancomycin dose, higher enema volume, and use of retention enema demonstrated greater efficacy. Use of smaller volumes and lower doses (100 mL; 125-250 mg q 6 hours) demonstrated no efficacy of intracolonic vancomycin. Conclusion: We recommend revision of the current CDI guideline recommendations for patients with adynamic ileus to the following: Vancomycin per rectum (500 mg in a volume of 500 mL q 6 hours) by retention enema (18F Foley catheter with 30-cc balloon inserted into the rectum, balloon inflated, solution instilled, and catheter clamped for 60 minutes) for optimal efficacy.
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Affiliation(s)
- Jason Fawley
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Lena M Napolitano
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
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16
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Pharmacologic Approach to Management of Clostridium difficile Infection. Crit Care Nurs Q 2018; 42:2-11. [PMID: 30507659 DOI: 10.1097/cnq.0000000000000232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Clostridium difficile is a gram-positive, anaerobic, spore-forming bacterium that is the leading cause of nosocomial infections in hospitals in the United States. Critically ill patients are at high risk for C. difficile infection (CDI) and face potentially detrimental effects, including prolonged hospitalization, risk of recurrent disease, complicated surgery, and death. CDI requires a multidisciplinary approach to decrease hospital transmission and improve treatment outcomes. This article briefly reviews the current literature and guideline recommendations for treatment and prevention of CDI, with a focus on antibiotic treatment considerations including dosing, routes of administration, efficacy data, adverse effects, and monitoring parameters.
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17
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Management of adult Clostridium difficile digestive contaminations: a literature review. Eur J Clin Microbiol Infect Dis 2018; 38:209-231. [PMID: 30498879 DOI: 10.1007/s10096-018-3419-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 10/30/2018] [Indexed: 02/08/2023]
Abstract
Clostridium difficile infections (CDI) dramatically increased during the last decade and cause a major public health problem. Current treatments are limited by the high disease recurrence rate, severity of clinical forms, disruption of the gut microbiota, and colonization by vancomycin-resistant enterococci (VRE). In this review, we resumed current treatment options from official recommendation to promising alternatives available in the management of adult CDI, with regard to severity and recurring or non-recurring character of the infection. Vancomycin remains the first-line antibiotic in the management of mild to severe CDI. The use of metronidazole is discussed following the latest US recommendations that replaced it by fidaxomicin as first-line treatment of an initial episode of non-severe CDI. Fidaxomicin, the most recent antibiotic approved for CDI in adults, has several advantages compared to vancomycin and metronidazole, but its efficacy seems limited in cases of multiple recurrences. Innovative therapies such as fecal microbiota transplantation (FMT) and antitoxin antibodies were developed to limit the occurrence of recurrence of CDI. Research is therefore very active, and new antibiotics are being studied as surotomycin, cadazolid, and rinidazole.
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18
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DuPont HL. Search for the optimal antimicrobial therapy of Clostridium difficile infection. THE LANCET. INFECTIOUS DISEASES 2018; 18:936-937. [PMID: 30025912 DOI: 10.1016/s1473-3099(18)30308-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 05/08/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Herbert L DuPont
- Center of Infectious Diseases, Department of Epidemiology and Department of Internal Medicine, University of Texas Medical School and School of Public Health, Houston, TX 77030, USA; Kelsey Research Foundation, Houston, TX, USA.
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19
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Loo VG, Davis I, Embil J, Evans GA, Hota S, Lee C, Lee TC, Longtin Y, Louie T, Moayyedi P, Poutanen S, Simor AE, Steiner T, Thampi N, Valiquette L. Association of Medical Microbiology and Infectious Disease Canada treatment practice guidelines for Clostridium difficile infection. ACTA ACUST UNITED AC 2018. [DOI: 10.3138/jammi.2018.02.13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Vivian G Loo
- McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Ian Davis
- Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - John Embil
- Health Sciences Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gerald A Evans
- Kingston Health Sciences Centre, Queen’s University, Kingston, Ontario, Canada
| | - Susy Hota
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Christine Lee
- St. Joseph’s Healthcare, McMaster University, Hamilton, Ontario, Canada
| | - Todd C Lee
- McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Yves Longtin
- Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | - Thomas Louie
- Peter Lougheed Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Paul Moayyedi
- Health Sciences Centre, McMaster University, Hamilton, Ontario, Canada
| | - Susan Poutanen
- Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Andrew E Simor
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Theodore Steiner
- Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nisha Thampi
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Louis Valiquette
- Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Québec, Canada
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20
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Abstract
BACKGROUND Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. Early recognition and treatment are the cornerstones of management. METHODS Review of the English-language literature. RESULTS For both sepsis and septic shock "antimicrobials [should be] be initiated as soon as possible and within one hour" (Surviving Sepsis Campaign). The risk of progression from severe sepsis to septic shock increases 8% for each hour before antibiotics are started. Selection of antimicrobial agents is based on a combination of patient factors, predicted infecting organism(s), and local microbial resistance patterns. The initial drugs should have activity against typical gram-positive and gram-negative causative micro-organisms. Anaerobic coverage should be provided for intra-abdominal infections or others where anaerobes are significant pathogens. Empiric antifungal or antiviral therapy may be warranted. For patients with healthcare-associated infections, resistant micro-organisms will further complicate the choice of empiric antimicrobials. Recommendations are given for specific infections. CONCLUSION Early administration of broad-spectrum antimicrobial drugs is one of the most important, if not the most important, treatment for patients with sepsis or septic shock. Drugs should be initiated as soon as possible, and the choice of should take into account patient factors, common local pathogens, hospital antibiograms and resistance patterns, and the suspected source of infection. Antimicrobial agent therapy should be de-escalated as soon as possible.
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Affiliation(s)
- Sara A Buckman
- Department of Surgery, Washington University School of Medicine in St. Louis , St. Louis, Missouri
| | - Isaiah R Turnbull
- Department of Surgery, Washington University School of Medicine in St. Louis , St. Louis, Missouri
| | - John E Mazuski
- Department of Surgery, Washington University School of Medicine in St. Louis , St. Louis, Missouri
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21
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Evolving Treatment Strategies for Severe Clostridium difficile Colitis: Defining the Therapeutic Window. HOT TOPICS IN ACUTE CARE SURGERY AND TRAUMA 2018. [DOI: 10.1007/978-3-319-59704-1_15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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22
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Schmidt-Hieber M, Bierwirth J, Buchheidt D, Cornely OA, Hentrich M, Maschmeyer G, Schalk E, Vehreschild JJ, Vehreschild MJGT. Diagnosis and management of gastrointestinal complications in adult cancer patients: 2017 updated evidence-based guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). Ann Hematol 2018; 97:31-49. [PMID: 29177551 PMCID: PMC5748412 DOI: 10.1007/s00277-017-3183-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 11/11/2017] [Indexed: 12/15/2022]
Abstract
Cancer patients frequently suffer from gastrointestinal complications. In this manuscript, we update our 2013 guideline on the diagnosis and management of gastrointestinal complications in adult cancer patients by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). An expert group was put together by the AGIHO to update the existing guideline. For each sub-topic, a literature search was performed in PubMed, Medline, and Cochrane databases, and strengths of recommendation and the quality of the published evidence for major therapeutic strategies were categorized using the 2015 European Society for Clinical Microbiology and Infectious Diseases (ESCMID) criteria. Final recommendations were approved by the AGIHO plenary conference. Recommendations were made with respect to non-infectious and infectious gastrointestinal complications. Strengths of recommendation and levels of evidence are presented. A multidisciplinary approach to the diagnosis and management of gastrointestinal complications in cancer patients is mandatory. Evidence-based recommendations are provided in this updated guideline.
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Affiliation(s)
- M Schmidt-Hieber
- Clinic for Hematology, Oncology, Tumor Immunology and Palliative Care, HELIOS Klinikum Berlin-Buch, Berlin, Germany
| | - J Bierwirth
- Deutsches Beratungszentrum für Hygiene, BZH GmbH, Freiburg, Germany
| | - D Buchheidt
- 3rd Department of Internal Medicine - Hematology and Oncology - Mannheim University Hospital, University of Heidelberg, Heidelberg, Germany
| | - O A Cornely
- 1st Department of Internal Medicine, University of Cologne, Cologne, Germany
- German Center for Infection Research (DZIF), partner site Bonn-Cologne, Cologne, Germany
- Clinical Trials Centre Cologne, ZKS Köln, University of Cologne, Cologne, Germany
| | - M Hentrich
- Department III for Internal Medicine, Hematology and Oncology, Rotkreuzklinikum München, Munich, Germany
| | - G Maschmeyer
- Department of Hematology, Oncology and Palliative Care, Ernst-von-Bergmann Klinikum, Potsdam, Germany
| | - E Schalk
- Department of Hematology and Oncology, Medical Center, Otto-von-Guericke University, Magdeburg, Germany
| | - J J Vehreschild
- 1st Department of Internal Medicine, University of Cologne, Cologne, Germany
- German Center for Infection Research (DZIF), partner site Bonn-Cologne, Cologne, Germany
| | - Maria J G T Vehreschild
- 1st Department of Internal Medicine, University of Cologne, Cologne, Germany.
- German Center for Infection Research (DZIF), partner site Bonn-Cologne, Cologne, Germany.
- 1st Department of Internal Medicine, Hospital of the University of Cologne, Kerpener Str. 62, 50937, Köln, Germany.
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23
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Abstract
Clostridium difficile is an anaerobic, Gram-positive, spore-forming, toxin-secreting bacillus that has long been recognized to be the most common etiologic pathogen of antibiotic-associated diarrhea. C. difficile infection (CDI) is now the most common cause of health care-associated infections in the United States and accounts for 12% of these infections (Magill SS et al., N Engl J Med370:1198-1208, 2014). Among emerging pathogens of public health importance in the United States, CDI has the highest population-based incidence, estimated at 147 per 100,000 (Lessa FC et al., N Engl J Med372:825-834, 2015). In a report on antimicrobial resistance, C. difficile has been categorized by the Centers for Disease Control and Prevention as one of three "urgent" threats (http://www.cdc.gov/drugresistance/threat-report-2013/). Although C. difficile was first described in the late 1970s, the past decade has seen the emergence of hypertoxigenic strains that have caused increased morbidity and mortality worldwide. Pathogenic strains, host susceptibility, and other regional factors vary and may influence the clinical manifestation and approach to intervention. In this article, we describe the global epidemiology of CDI featuring the different strains in circulation outside of North America and Europe where strain NAP1/027/BI/III had originally gained prominence. The elderly population in health care settings has been disproportionately affected, but emergence of CDI in children and healthy young adults in community settings has, likewise, been reported. New approaches in management, including fecal microbiota transplantation, are discussed.
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24
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Trubiano JA, Cheng AC, Korman TM, Roder C, Campbell A, May MLA, Blyth CC, Ferguson JK, Blackmore TK, Riley TV, Athan E. Australasian Society of Infectious Diseases updated guidelines for the management of Clostridium difficile infection in adults and children in Australia and New Zealand. Intern Med J 2017; 46:479-93. [PMID: 27062204 DOI: 10.1111/imj.13027] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 01/19/2016] [Accepted: 01/19/2016] [Indexed: 12/16/2022]
Abstract
The incidence of Clostridium difficile infection (CDI) continues to rise, whilst treatment remains problematic due to recurrent, refractory and potentially severe nature of disease. The treatment of C. difficile is a challenge for community and hospital-based clinicians. With the advent of an expanding therapeutic arsenal against C. difficile since the last published Australasian guidelines, an update on CDI treatment recommendations for Australasian clinicians was required. On behalf of the Australasian Society of Infectious Diseases, we present the updated guidelines for the management of CDI in adults and children.
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Affiliation(s)
- J A Trubiano
- Infectious Diseases Department, Austin Health, Melbourne, Western Australia.,Infectious Diseases Department, Peter MacCallum Cancer Centre, Melbourne, Western Australia
| | - A C Cheng
- Infectious Diseases Department, Alfred Health, Melbourne, Western Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Western Australia.,Infection Prevention and Healthcare Epidemiology Unit, Alfred Hospital, Melbourne, Western Australia
| | - T M Korman
- Monash Infectious Diseases, Monash Health, Monash University, Melbourne, Western Australia
| | - C Roder
- School of Medicine, Deakin University, Geelong, Victoria, Western Australia.,Geelong Centre for Emerging Infectious Diseases, Barwon Health, Geelong, Victoria, Western Australia
| | - A Campbell
- Infectious Diseases Department, Princess Margaret Hospital for Children, Queen Elizabeth II Medical Centre, Perth, Western Australia
| | - M L A May
- Infection Management and Prevention Service, Lady Cilento Children's Hospital and Sullivan Nicolaides Pathology, Brisbane, Queensland
| | - C C Blyth
- Infectious Diseases Department, Princess Margaret Hospital for Children, Queen Elizabeth II Medical Centre, Perth, Western Australia.,School of Paediatrics and Child Health, The University of Western Australia, Queen Elizabeth II Medical Centre, Perth, Western Australia.,Department of Microbiology, PathWest Laboratory Medicine, Princess Margaret Hospital, Queen Elizabeth II Medical Centre, Perth, Western Australia
| | - J K Ferguson
- Pathology North, NSW Pathology, Wellington South, New Zealand.,Immunology and Infectious Diseases Unit, John Hunter Hospital, Wellington South, New Zealand.,Universities of New England and Newcastle, Newcastle, New South Wales, Australia
| | - T K Blackmore
- Laboratory Services, Wellington Regional Hospital, Wellington South, New Zealand
| | - T V Riley
- Microbiology and Immunology, School of Pathology and Laboratory Medicine, The University of Western Australia, Queen Elizabeth II Medical Centre, Perth, Western Australia.,Department of Microbiology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Perth, Western Australia
| | - E Athan
- School of Medicine, Deakin University, Geelong, Victoria, Western Australia.,Department of Infectious Disease, Barwon Health, Geelong, Victoria, Western Australia
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25
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Chiu LM, Domagala BM, Park JM. Management of Opportunistic Infections in Solid-Organ Transplantation. Prog Transplant 2016; 14:114-29. [PMID: 15264456 DOI: 10.1177/152692480401400206] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Solid-organ transplantation is often the last alternative in many patients with end-stage organ disease. Although advances in immunosuppressive regimens, surgical techniques, organ preservation, and overall management of transplant recipients have improved graft and patient survival, infectious complications remain problematic. Bacterial, fungal, viral, and parasitic infections are implicated after transplantation depending on numerous factors, such as degree of immunosuppression, type of organ transplant, host factors, and period after transplantation. Proper prophylactic and treatment strategies are imperative in the face of chronic immunosuppression, nosocomial and community pathogens, emerging drug resistance, drug-drug interactions, and medication toxicities. This review summarizes the pathophysiology, incidence, prevention, and treatment strategies of common post-transplant infections.
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Affiliation(s)
- Loretta M Chiu
- University of Washington Medical Center, Seattle, Washington, USA
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26
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Akamine CM, Ing MB, Jackson CS, Loo LK. The efficacy of intracolonic vancomycin for severe Clostridium difficile colitis: a case series. BMC Infect Dis 2016; 16:316. [PMID: 27388627 PMCID: PMC4937541 DOI: 10.1186/s12879-016-1657-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 06/16/2016] [Indexed: 01/05/2023] Open
Abstract
Background Clostridium difficile infection (CDI) unresponsive to the standard treatments of metronidazole and oral vancomycin requires aggressive medical management and possible surgical intervention including colectomy. Intracolonic vancomycin therapy has been reported to be particularly promising in the setting of severe CDI in the presence of ileus. This is a descriptive case series exploring the effect of adjunctive intracolonic vancomycin therapy on the morbidity and mortality in patients with moderate to severe CDI. Methods A retrospective chart review was conducted on 696 patients with CDI seen at a single institution. Each patient was assigned a severity score and 127 patients with moderate to severe CDI were identified. We describe the clinical presentation, risk factors and hospital course comparing those that received adjunctive intracolonic vancomycin to those that only received standard therapy. Results The group that received adjunctive intracolonic vancomycin had higher rates of toxic megacolon, intensive care unit (ICU) admission, and colectomy, and yet maintained a similar mortality rate as the group that received only standard treatment. Conclusion The intracolonic vancomycin group experienced more complications but showed a similar mortality rate to the standard therapy group, suggesting that intracolonic vancomycin may impart a protective effect. This study adds further evidence for the need of a randomized controlled study using intracolonic vancomycin as adjunctive therapy in patients presenting with severe CDI.
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Affiliation(s)
- Christine M Akamine
- Department of Medicine, Loma Linda University School of Medicine, 11234 Anderson Street, Loma Linda, CA, 92354, USA
| | - Michael B Ing
- Department of Medicine, Loma Linda University School of Medicine, 11234 Anderson Street, Loma Linda, CA, 92354, USA.,Section of Infectious Disease, VA Loma Linda Healthcare System, 11201 Benton Street, Loma Linda, CA, 92357, USA
| | - Christian S Jackson
- Department of Medicine, Loma Linda University School of Medicine, 11234 Anderson Street, Loma Linda, CA, 92354, USA.,Section of Gastroenterology, VA Loma Linda Healthcare System, 11201 Benton Street, Loma Linda, CA, 92357, USA
| | - Lawrence K Loo
- Department of Medicine, Loma Linda University School of Medicine, 11234 Anderson Street, Loma Linda, CA, 92354, USA.
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Epidemiology, Diagnosis, and Management of Clostridium difficile Infection in Patients with Inflammatory Bowel Disease. Inflamm Bowel Dis 2016; 22:1744-54. [PMID: 27120571 PMCID: PMC4911291 DOI: 10.1097/mib.0000000000000793] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Clostridium difficile infection (CDI) is a major source of morbidity and mortality for the U.S. health care system and frequently complicates the course of inflammatory bowel disease (IBD). Patients with IBD are more likely to be colonized with C. difficile and develop active infection than the general population. They are also more likely to have severe CDI and develop subsequent complications such as IBD flare, colectomy, or death. Even after successful initial treatment and recovery, recurrent CDI is common. Management of CDI in IBD is fraught with diagnostic and therapeutic challenges because the clinical presentations of CDI and IBD flare have considerable overlap. Fecal microbiota transplantation can be successful in curing recurrent CDI when other treatments have failed, but may also trigger IBD flare and this warrants caution. New experimental treatments including vaccines, monoclonal antibodies, and nontoxigenic strains of C. difficile offer promise but are not yet available for clinicians. A better understanding of the complex relationship between the gut microbiota, CDI, and IBD is needed.
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Abstract
Clostridium difficile (C. difficile) infection (CDI) is the most common cause of healthcare-associated infections in US hospitals. The epidemic strain NAP1/BI/ribotype 027 accounts for outbreaks worldwide, with increasing mortality and severity. CDI is acquired from an endogenous source or from spores in the environment, most easily acquired during the hospital stay. The use of antimicrobials disrupts the intestinal microflora enabling C. difficile to proliferate in the colon and produce toxins. Clinical diagnosis in symptomatic patients requires toxin detection from stool specimens and rarely in combination with stool culture to increase sensitivity. However, stool culture is essential for epidemiological studies. Oral metronidazole is the recommended therapy for milder cases of CDI and oral vancomycin or fidaxomicin for more severe cases. Treatment of first recurrence involves the use of the same therapy used in the initial CDI. In the event of a second recurrence oral vancomycin often given in a tapered dose or intermittently, or fidaxomicin may be used. Fecal transplantation is playing an immense role in therapy of recurrent CDI with remarkable results. Fulminant colitis and toxic megacolon warrant surgical intervention. Novel approaches including new antibiotics and immunotherapy against CDI or its toxins appear to be of potential value.
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Affiliation(s)
- Andrew Ofosu
- Department of Medicine, Jefferson Medical College, Philadelphia, USA
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29
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Marra F, Ng K. Controversies Around Epidemiology, Diagnosis and Treatment of Clostridium difficile Infection. Drugs 2016; 75:1095-118. [PMID: 26113167 DOI: 10.1007/s40265-015-0422-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Clostridium difficile infection is a major public health problem. However, in recent years the epidemiology, risk factors, diagnosis, and treatment of C. difficile infection have undergone a significant change. The incidence of C. difficile has increased, not only in the healthcare sector but also in the community. Hospital-acquired infection and community-acquired disease have different risk factors, with the latter occurring in children and younger individuals without a history of antibiotic use or previous infections. From a clinician's perspective, a quick efficient diagnosis is required for patient treatment; however, the old method of using enzyme immunoassays is insensitive and not very specific. Recent literature around diagnostic testing for C. difficile infection suggests using PCR or a two-step algorithm to improve sensitivity and specificity. More failures and recurrence with metronidazole have led to treatment algorithms suggesting its use for mild infections and switching to vancomycin if there is no clinical improvement. Alternatively, if signs and symptoms suggest severe infection, then oral vancomycin is recommended as a first-line agent. The addition of a new but costly agent, fidaxomicin, has seen some disparity between the European and North American guidelines with regard to when it should be used. Lastly, rapid developments and good results with fecal microbial transplantation have also left clinicians wondering about its place in therapy. This article reviews the literature around some of the recent controversies in the field of C. difficile infection.
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Affiliation(s)
- Fawziah Marra
- University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada,
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Fulminant Pseudomembranous Colitis Presenting as Sigmoid Stricture and Severe Polyposis with Clinical Response to Intracolonic Vancomycin. Case Rep Med 2016; 2016:4609824. [PMID: 27034681 PMCID: PMC4789425 DOI: 10.1155/2016/4609824] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 02/16/2016] [Indexed: 02/07/2023] Open
Abstract
Clostridium difficile infection (CDI) is the most common cause of antibiotic-associated diarrhea. Severe diseases carry significant morbidities such as septic shock, acute kidney injury, bowel perforation, and mortality. Immunocompromising conditions increase the risk of developing the disease but whether these individuals suffer a more fulminant course or warrant a more potent first-line treatment is still controversial issue. Hereby we report a case of a cirrhotic patient with life-threatening pseudomembranous colitis complicated by colonic stricture, initially refractory to standard treatment but with subsequent improvement on intracolonic vancomycin.
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Postma N, Kiers D, Pickkers P. The challenge of Clostridium difficile infection: Overview of clinical manifestations, diagnostic tools and therapeutic options. Int J Antimicrob Agents 2015; 46 Suppl 1:S47-50. [DOI: 10.1016/j.ijantimicag.2015.11.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Shahani L, Koirala J. Use of intravenous immunoglobulin in severe Clostridium difficile-associated diarrhea. Hosp Pract (1995) 2015; 43:154-157. [PMID: 26189489 DOI: 10.1080/21548331.2015.1071636] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE Clostridium difficile infection is an increasingly common cause of healthcare-acquired diarrhea. There remains substantial morbidity and mortality, even with current modalities of treatment. The aim of our study was to investigate the role of intravenous immunoglobulin (IVIG) on mortality in patients with severe Clostridium difficile-associated diarrhea (CDAD). METHODS A retrospective chart review of 21 patients with severe CDAD treated with IVIG in our affiliated hospitals from January 2000 to December 2012 was conducted. As a matching control group, we randomly selected 21 patients meeting the definition of severe CDAD from the same period. Data were compared between these groups using appropriate statistical tests. RESULTS Patients in the IVIG group were older (69.8 vs 60.9 years, p = 0.05) and had a higher severity score (5.4 vs 3.9, p = 0.02). Mortality was lower among those who received IVIG as compared to the group who did not receive IVIG; however not statistically significant (18.2 vs 22.7%, p = 0.51). CONCLUSION Our data demonstrate that although the patients who received IVIG had significantly severe infection, there was no difference in the mortality rate. Prospective controlled studies are needed to assess the true benefit of IVIG in patient with severe Clostridium difficle infection.
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Affiliation(s)
- Lokesh Shahani
- Department of Internal Medicine, Division of Infectious Disease, Baylor College of Medicine , 6620 Main Street, Houston, TX , USA
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Malamood M, Nellis E, Ehrlich AC, Friedenberg FK. Vancomycin Enemas as Adjunctive Therapy for Clostridium difficile Infection. J Clin Med Res 2015; 7:422-7. [PMID: 25883704 PMCID: PMC4394914 DOI: 10.14740/jocmr2117w] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2015] [Indexed: 12/20/2022] Open
Abstract
Background For severe, complicated Clostridium difficile infection (CDI), concomitant treatment with IV metronidazole and oral vancomycin is usually prescribed. Sometimes vancomycin per rectum (VPR) is added to increase colonic drug delivery. Our purpose was to examine clinical outcomes of patients with CDI treated with VPR and compare results to a matched control group. Methods This was a retrospective case-control study in a setting of tertiary-care ICU on diarrhea patients with a positive toxin test for C. difficile. We identified all ICU patients prescribed VPR from January 2003 to December 2013. The dose of VPR mixed in 100 cc of tap water ranged from 125 to 250 mg Q 6 - 8 hours. All patients had diarrhea and a positive test for C. difficile toxin. Included patients received ≥ 4 doses of VPR. The primary outcome was the combined endpoint of colon surgery or death. We matched VPR cases 1:2 with CDI controls that had identical APACHE II scores. Results We identified 24 CDI patients who received VPR and met inclusion criteria: 11 male, mean age 61.8 ± 15.9 years. All patients received concomitant CDI therapy. Four patients (16.7%) required colectomy, and overall mortality was 45.8%. For the 48 controls, need for surgery was identical (16.7%; P = 1.00). The mortality rate also did not differ (41.7%; P = 0.74). For the combined outcome of surgery or death, the rate was 45.8% for the controls and 50.0% for the VPR group (P = 0.73). Conclusion In a case-control study, the use of VPR was not demonstrated to reduce the need for colectomy or decrease mortality. Based on our modest sample size and failure to show efficacy, we cannot strongly advocate for the use of VPR.
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Affiliation(s)
- Mark Malamood
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, PA, USA
| | - Eric Nellis
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, PA, USA
| | - Adam C Ehrlich
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, PA, USA
| | - Frank K Friedenberg
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, PA, USA
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Bassetti M, De Waele JJ, Eggimann P, Garnacho-Montero J, Kahlmeter G, Menichetti F, Nicolau DP, Paiva JA, Tumbarello M, Welte T, Wilcox M, Zahar JR, Poulakou G. Preventive and therapeutic strategies in critically ill patients with highly resistant bacteria. Intensive Care Med 2015; 41:776-95. [PMID: 25792203 PMCID: PMC7080151 DOI: 10.1007/s00134-015-3719-z] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 02/24/2015] [Indexed: 01/06/2023]
Abstract
The antibiotic pipeline continues to diminish and the majority of the public remains unaware of this critical situation. The cause of the decline of antibiotic development is multifactorial and currently most ICUs are confronted with the challenge of multidrug-resistant organisms. Antimicrobial multidrug resistance is expanding all over the world, with extreme and pandrug resistance being increasingly encountered, especially in healthcare-associated infections in large highly specialized hospitals. Antibiotic stewardship for critically ill patients translated into the implementation of specific guidelines, largely promoted by the Surviving Sepsis Campaign, targeted at education to optimize choice, dosage, and duration of antibiotics in order to improve outcomes and reduce the development of resistance. Inappropriate antimicrobial therapy, meaning the selection of an antibiotic to which the causative pathogen is resistant, is a consistent predictor of poor outcomes in septic patients. Therefore, pharmacokinetically/pharmacodynamically optimized dosing regimens should be given to all patients empirically and, once the pathogen and susceptibility are known, local stewardship practices may be employed on the basis of clinical response to redefine an appropriate regimen for the patient. This review will focus on the most severely ill patients, for whom substantial progress in organ support along with diagnostic and therapeutic strategies markedly increased the risk of nosocomial infections.
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Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Division, Santa Maria Misericordia University Hospital, Udine, Italy,
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Abstract
IMPORTANCE Since 2000, the incidence and severity of Clostridium difficile infection (CDI) have increased. OBJECTIVE To review current evidence regarding best practices for the diagnosis and treatment of CDI in adults (age ≥ 18 years). EVIDENCE REVIEW Ovid MEDLINE and Cochrane databases were searched using keywords relevant to the diagnosis and treatment of CDI in adults. Articles published between January 1978 and October 31, 2014, were selected for inclusion based on targeted keyword searches, manual review of bibliographies, and whether the article was a guideline, systematic review, or meta-analysis published within the past 10 years. Of 4682 articles initially identified, 196 were selected for full review. Of these, the most pertinent 116 articles were included. Clinical trials, large observational studies, and more recently published articles were prioritized in the selection process. FINDINGS Laboratory testing cannot distinguish between asymptomatic colonization and symptomatic infection with C difficile. Diagnostic approaches are complex due to the availability of multiple testing strategies. Multistep algorithms using polymerase chain reaction (PCR) for the toxin gene(s) or single-step PCR on liquid stool samples have the best test performance characteristics (for multistep: sensitivity was 0.68-1.00 and specificity was 0.92-1.00; and for single step: sensitivity was 0.86-0.92 and specificity was 0.94-0.97). Vancomycin and metronidazole are first-line therapies for most patients, although treatment failures have been associated with metronidazole in severe or complicated cases of CDI. Recent data demonstrate clinical success rates of 66.3% for metronidazole vs 78.5% for vancomycin for severe CDI. Newer therapies show promising results, including fidaxomicin (similar clinical cure rates to vancomycin, with lower recurrence rates for fidaxomicin, 15.4% vs vancomycin, 25.3%; P = .005) and fecal microbiota transplantation (response rates of 83%-94% for recurrent CDI). CONCLUSIONS AND RELEVANCE Diagnostic testing for CDI should be performed only in symptomatic patients. Treatment strategies should be based on disease severity, history of prior CDI, and the individual patient's risk of recurrence. Vancomycin is the treatment of choice for severe or complicated CDI, with or without adjunctive therapies. Metronidazole is appropriate for mild disease. Fidaxomicin is a therapeutic option for patients with recurrent CDI or a high risk of recurrence. Fecal microbiota transplantation is associated with symptom resolution of recurrent CDI but its role in primary and severe CDI is not established.
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Affiliation(s)
- Natasha Bagdasarian
- Division of Infectious Disease and Department of Infection Control, St John Hospital and Medical Center, Detroit, Michigan
- Wayne State University, Department of Internal Medicine, Detroit, Michigan
| | - Krishna Rao
- University of Michigan Medical School, Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Health System, Ann Arbor, Michigan
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Preeti N. Malani
- University of Michigan Medical School, Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Health System, Ann Arbor, Michigan
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
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Mathur H, Rea MC, Cotter PD, Ross RP, Hill C. The potential for emerging therapeutic options for Clostridium difficile infection. Gut Microbes 2015; 5:696-710. [PMID: 25564777 PMCID: PMC4615897 DOI: 10.4161/19490976.2014.983768] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Clostridium difficile is mainly a nosocomial pathogen and is a significant cause of antibiotic-associated diarrhea. It is also implicated in the majority of cases of pseudomembranous colitis. Recently, advancements in next generation sequencing technology (NGS) have highlighted the extent of damage to the gut microbiota caused by broad-spectrum antibiotics, often resulting in C. difficile infection (CDI). Currently the treatment of choice for CDI involves the use of metronidazole and vancomycin. However, recurrence and relapse of CDI, even after rounds of metronidazole/vancomycin administration is a problem that must be addressed. The efficacy of alternative antibiotics such as fidaxomicin, rifaximin, nitazoxanide, ramoplanin and tigecycline, as well as faecal microbiota transplantation has been assessed and some have yielded positive outcomes against C. difficile. Some bacteriocins have also shown promising effects against C. difficile in recent years. In light of this, the potential for emerging treatment options and efficacy of anti-C. difficile vaccines are discussed in this review.
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Key Words
- ATCC, American Type Culture Collection
- CDI, Clostridium difficile infection
- CdtLoc, binary toxin locus
- Clostridium difficile
- DNA, deoxyribonucleic acid
- DPC, Dairy Products Collection
- ESCMID, European Society of Clinical Microbiology and Infectious Diseases
- ETEC, enterotoxigenic E. coli
- FDA, Food and Drug Administration
- FMT, faecal microbiota transplantation
- GIT, gastrointestinal tract
- HIV, human immunodeficiency virus
- IDSA, Infectious Diseases Society of America
- IgG, immunoglobulin G
- LTA, lipoteichoic acid
- M21V, methionine to valine substitution at residue 21
- MIC, minimum inhibitory concentration
- NGS, next generation sequencing
- NVB, Novacta Biosystems Ltd
- PMC, pseudomembranous colitis
- PaLoc, pathogenicity locus
- R027, ribotype 027
- RBD
- RBS, ribosome binding site
- RNA, ribonucleic acid
- SHEA, Society for Healthcare Epidemiology of America
- V15F, valine to phenylalanine substitution at residue 15
- antibiotics
- faecal microbiota transplantation
- receptor binding domain
- toxins
- vaccines
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Affiliation(s)
- Harsh Mathur
- School of Microbiology; University College Cork; Cork, Ireland,Teagasc Food Research Center; Moorepark; Fermoy, Ireland
| | - Mary C Rea
- Teagasc Food Research Center; Moorepark; Fermoy, Ireland,Alimentary Pharmabiotic Center; University College Cork; Cork, Ireland
| | - Paul D Cotter
- Teagasc Food Research Center; Moorepark; Fermoy, Ireland,Alimentary Pharmabiotic Center; University College Cork; Cork, Ireland,Correspondence to: Colin Hill; ; Paul D Cotter;
| | - R Paul Ross
- Alimentary Pharmabiotic Center; University College Cork; Cork, Ireland,College of Science; Engineering and Food Science; University College Cork; Cork, Ireland
| | - Colin Hill
- School of Microbiology; University College Cork; Cork, Ireland,Alimentary Pharmabiotic Center; University College Cork; Cork, Ireland,Correspondence to: Colin Hill; ; Paul D Cotter;
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Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC, Pepin J, Wilcox MH. Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol 2015; 31:431-55. [PMID: 20307191 DOI: 10.1086/651706] [Citation(s) in RCA: 2180] [Impact Index Per Article: 242.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Since publication of the Society for Healthcare Epidemiology of America position paper onClostridium difficileinfection in 1995, significant changes have occurred in the epidemiology and treatment of this infection.C. difficileremains the most important cause of healthcare-associated diarrhea and is increasingly important as a community pathogen. A more virulent strain ofC. difficilehas been identified and has been responsible for more-severe cases of disease worldwide. Data reporting the decreased effectiveness of metronidazole in the treatment of severe disease have been published. Despite the increasing quantity of data available, areas of controversy still exist. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, and infection control and environmental management.
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Affiliation(s)
- Stuart H Cohen
- Department of Internal Medicine, Division of Infectious and Immunologic Diseases, University of California Davis Medical Center, Sacramento, California, USA
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Luciano JA, Zuckerbraun BS. Clostridium difficile infection: prevention, treatment, and surgical management. Surg Clin North Am 2014; 94:1335-49. [PMID: 25440127 DOI: 10.1016/j.suc.2014.08.006] [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] [Indexed: 12/29/2022]
Abstract
Clostridium difficile is increasing in both incidence and severity. Although metronidazole and vancomycin remain the gold standard for medical management, and surgical colectomy the gold standard for surgical management, new treatment alternatives, including the creation of a diverting loop ileostomy along with colonic lavage and vancomycin enemas, are being investigated that may lead to changes in the current treatment algorithms. The most exciting development in the treatment options for C difficile infection, however, is likely to be novel immunologic agents, which hold the potential to reduce the incidence, mortality, and costs associated with C difficile.
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Affiliation(s)
- Jason A Luciano
- Department of Surgery, University of Pittsburgh, 200 Lothrop St, Pittsburgh, PA 15213, USA
| | - Brian S Zuckerbraun
- Department of Surgery, University of Pittsburgh, 200 Lothrop St, Pittsburgh, PA 15213, USA; Department of Surgery, VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA 15240, USA.
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Outcomes from rectal vancomycin therapy in patients with Clostridium difficile infection. Am J Gastroenterol 2014; 109:924-5. [PMID: 24896763 DOI: 10.1038/ajg.2014.80] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Toxicidad antibacterianos: farmacocinética-farmacodinamia: prevención y manejo. REVISTA MÉDICA CLÍNICA LAS CONDES 2014. [DOI: 10.1016/s0716-8640(14)70061-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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IV ECO, III ECO, Johnson DA. Clinical update for the diagnosis and treatment of Clostridium difficile infection. World J Gastrointest Pharmacol Ther 2014; 5:1-26. [PMID: 24729930 PMCID: PMC3951810 DOI: 10.4292/wjgpt.v5.i1.1] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Revised: 10/06/2013] [Accepted: 12/09/2013] [Indexed: 02/06/2023] Open
Abstract
Clostridium difficile infection (CDI) presents a rapidly evolving challenge in the battle against hospital-acquired infections. Recent advances in CDI diagnosis and management include rapid changes in diagnostic approach with the introduction of newer tests, such as detection of glutamate dehydrogenase in stool and polymerase chain reaction to detect the gene for toxin production, which will soon revolutionize the diagnostic approach to CDI. New medications and multiple medical society guidelines have introduced changing concepts in the definitions of severity of CDI and the choice of therapeutic agents, while rapid expansion of data on the efficacy of fecal microbiota transplantation heralds a revolutionary change in the management of patients suffering multiple relapses of CDI. Through a comprehensive review of current medical literature, this article aims to offer an intensive review of the current state of CDI diagnosis, discuss the strengths and limitations of available laboratory tests, compare both current and future treatments options and offer recommendations for best practice strategies.
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Goudarzi M, Seyedjavadi SS, Goudarzi H, Mehdizadeh Aghdam E, Nazeri S. Clostridium difficile Infection: Epidemiology, Pathogenesis, Risk Factors, and Therapeutic Options. SCIENTIFICA 2014; 2014:916826. [PMID: 24991448 PMCID: PMC4058799 DOI: 10.1155/2014/916826] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 05/11/2014] [Indexed: 05/09/2023]
Abstract
The incidence and mortality rate of Clostridium difficile infection have increased remarkably in both hospital and community settings during the last two decades. The growth of infection may be caused by multiple factors including inappropriate antibiotic usage, poor standards of environmental cleanliness, changes in infection control practices, large outbreaks of C. difficile infection in hospitals, alteration of circulating strains of C. difficile, and spread of hypervirulent strains. Detection of high-risk populations could be helpful for prompt diagnosis and consequent treatment of patients suffering from C. difficile infection. Metronidazole and oral vancomycin are recommended antibiotics for the treatment of initial infection. Current treatments for C. difficile infection consist of supportive care, discontinuing the unnecessary antibiotic, and specific antimicrobial therapy. Moreover, novel approaches include fidaxomicin therapy, monoclonal antibodies, and fecal microbiota transplantation mediated therapy. Fecal microbiota transplantation has shown relevant efficacy to overcome C. difficile infection and reduce its recurrence.
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Affiliation(s)
- Mehdi Goudarzi
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Sima Sadat Seyedjavadi
- Department of Pharmaceutical Biotechnology, Pasteur Institute of Iran (IPI), No. 358, 12th Farwardin Avenue, Jomhhoori Street, Tehran 1316943551, Iran
- *Sima Sadat Seyedjavadi:
| | - Hossein Goudarzi
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Elnaz Mehdizadeh Aghdam
- Department of Pharmaceutical Biotechnology, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Saeed Nazeri
- Department of Pharmaceutical Biotechnology, Pasteur Institute of Iran (IPI), No. 358, 12th Farwardin Avenue, Jomhhoori Street, Tehran 1316943551, Iran
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Clostridium difficile: epidemiology, diagnostic and therapeutic possibilities-a systematic review. Tech Coloproctol 2013; 18:223-32. [PMID: 24178946 PMCID: PMC3950610 DOI: 10.1007/s10151-013-1081-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Accepted: 10/09/2013] [Indexed: 02/08/2023]
Abstract
This literature review looks at the epidemiology, clinical manifestations, diagnostics and current medical and surgical management of Clostridium difficile (C. difficile) infection. A literature search of PubMed and Cochrane database regarding C. difficile infection was performed. Information was extracted from 43 published articles from 2000 to the present day which met inclusion criteria. C. difficile is a gram-positive, anaerobic bacillus, which is widely found in the environment, especially in the soil. The occurrence of more resistant strains, which is mainly connected with the wide use of antibiotics, resulted in the rapid spread of the bacteria to different hospital departments. Particularly, elderly patients in surgical wards and intensive care units are at significant risk of developing C. difficile infection, which greatly increases morbidity and mortality. Symptoms of infection with C. difficile vary greatly. At one end of the spectrum, there are asymptomatic carriers, at the other patients with life-threatening toxic megacolon. Metronidazole is considered to be the drug of choice, but recent guidelines recommend Vancomycin. Fulminant colitis and toxic megacolon warrant surgical intervention. The optimal time for surgery is within 48 h of initiating conservative treatment without seeing a response, the development of multiple organ failure or a bowel perforation. A factor that has become increasingly important and relevant is the escalating expense of treatment for patients with C. difficile infection. It is, therefore, highly recommended to consider reviewing all hospital antibiotic policies and clinical guidelines that may contribute to the prevention of the infection.
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Ebigbo A, Messmann H. [Challenges of Clostridium difficile infection]. Med Klin Intensivmed Notfmed 2013; 108:624-7. [PMID: 24129852 DOI: 10.1007/s00063-013-0258-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 09/05/2013] [Indexed: 12/29/2022]
Abstract
Clostridium difficile infections remain a problem especially for patients in the intensive care unit. The fact that C. difficile infections are strongly associated with antibiotic therapy calls for more caution in the use of antibiotics, especially in patients with a high risk of developing C. difficle infections. Severe infections and recurrent episodes are usually difficult to manage and therapeutic options are often limited. The method of stool transplantation, though not new, has received more attention in recent years, with studies showing stool transplantation to be a promising and easy method which has high clinical cure rates even for recurrent C. difficile infections. However, more randomised and controlled trials are needed to further study the efficacy of stool transplantation in patients with C. difficile infection.
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Affiliation(s)
- A Ebigbo
- III. Medizinische Klinik, Klinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland,
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Portela F, Lago P. Fulminant colitis. Best Pract Res Clin Gastroenterol 2013; 27:771-82. [PMID: 24160933 DOI: 10.1016/j.bpg.2013.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Revised: 07/26/2013] [Accepted: 08/11/2013] [Indexed: 01/31/2023]
Abstract
Fulminant colitis is an ill-defined entity that is usually viewed as the most severe form of uncomplicated acute colitis. It usually occurs in the course of ulcerative colitis and infectious colitis, but can also be seen in other forms of colitis. Every patient with clinical criteria for severe or fulminant colitis should be approached in a systematic way, based on two premises - intense medical treatment and early surgery in non-responders.
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Pant C, Deshpande A, Altaf MA, Minocha A, Sferra TJ. Clostridium difficile infection in children: a comprehensive review. Curr Med Res Opin 2013; 29:967-84. [PMID: 23659563 DOI: 10.1185/03007995.2013.803058] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To provide a comprehensive review of the literature relating to Clostridium difficile (C. difficile) infection (CDI) in the pediatric population. METHODS Two investigators conducted independent searches of PubMed, Web of Science, and Scopus until March 31st, 2013. All databases were searched using the terms 'Clostridium difficile infection', 'Clostridium difficile associated diarrhea' 'antibiotic associated diarrhea', 'C. difficile', in combination with 'pediatric' and 'paediatric'. Articles which discussed pediatric CDI were reviewed and relevant cross references also read and evaluated for inclusion. Selection bias could be a possible limitation of this approach. FINDINGS There is strong evidence for an increased incidence of pediatric CDI. Increasingly, the infection is being acquired from the community, often without a preceding history of antibiotic use. The severity of the disease has remained unchanged. Several medical conditions may be associated with the development of pediatric CDI. Infection prevention and control with antimicrobial stewardship are of paramount importance. It is important to consider the age of the child while testing for CDI. Traditional therapy with metronidazole or vancomycin remains the mainstay of treatment. Newer antibiotics such as fidaxomicin appear promising especially for the treatment of recurrent infection. Conservative surgical options may be a life-saving measure in severe or fulminant cases. CONCLUSIONS Pediatric providers should be cognizant of the increased incidence of CDI in children. Early and judicious testing coupled with the timely institution of therapy will help to secure better outcomes for this disease.
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Affiliation(s)
- Chaitanya Pant
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Abstract
Clostridium difficile is emerging as a common cause of infectious diarrhea. Incidence has increased dramatically since 2000, associated with a new strain that features both increased toxin production and increased resistance to antibiotics. For patients with mild to moderate disease, oral metronidazole is usually the first choice of treatment, and those with severe disease should be treated with vancomycin, with additional intravenous metronidazole in some cases. Fecal microbiota transplantation is a potentially promising therapy for patients with multiple recurrences of C difficile infection. Prevention of nosocomial transmission is crucial to reducing disease outbreaks in health care settings.
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Affiliation(s)
- Christopher L Knight
- Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, 4245 Roosevelt Way Northeast, Box 354760, Seattle, WA 98109, USA.
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Kim PK, Huh HC, Cohen HW, Feinberg EJ, Ahmad S, Coyle C, Teperman S, Boothe H. Intracolonic vancomycin for severe Clostridium difficile colitis. Surg Infect (Larchmt) 2013; 14:532-9. [PMID: 23560732 DOI: 10.1089/sur.2012.158] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Clostridium difficile colitis is associated with increased age, antibiotic usage, and hospitalization. Severe C. difficile colitis refractory to medical therapy may require surgical intervention including subtotal colectomy. We initiated an adjuvant intracolonic vancomycin (ICV) enema protocol for inpatients with severe C. difficile colitis and compared the response to this therapy in patients from the community and nursing homes. METHODS A single-hospital, retrospective chart review was done on 47 consecutive patients with C. difficile colitis treated with ICV (1 g/500 mL normal saline q6h) from January 2007 through October 2009. The proportions of patients with the outcomes of response to the ICV protocol, need for subtotal colectomy, and death were described. Associations of patient characteristics with these outcomes were examined with bivariate tests and multivariable logistic models with adjustment for age, hypoalbuminemia, acidosis, and nursing-home status. RESULTS Thirty-three of 47 patients (70%) with severe C. difficile colitis responded to adjunct ICV with complete resolution without surgery. Incomplete responders who had surgery were more likely to survive than those patients who did not undergo subtotal colectomy (p<0.01). Seven of nine patients who underwent surgery survived >90 d, and overall, 37 of 47 patients (79%) survived after ICV therapy. Nursing-home residence, acidosis, and hypoalbuminemia were significantly associated with the non-resolution of colitis in bivariate analyses (all p<0.01), whereas nursing-home residence and hypoalbuminemia showed non-significant trends toward association with death (p=0.07 and p=0.06, respectively). Multivariate logistic-regression models showed significant associations of acidosis with an incomplete response to ICV (p=0.02), of older age with death (p=0.04), and of hypoalbuminemia with both an incomplete response to ICV and death (both p=0.04). No complications were attributable to ICV. CONCLUSION Complete resolution without surgery was achieved in 70% in this series of patients with severe C. difficile colitis who received adjunct ICV therapy. A clinical trial will be needed to determine whether ICV as compared with standard therapy alone can reduce the need for surgery with non-inferior or superior outcomes.
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Affiliation(s)
- Peter K Kim
- 1 Department of Surgery, Albert Einstein College of Medicine and Jacobi Medical Center , Bronx, New York
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Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH, McFarland LV, Mellow M, Zuckerbraun BS. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol 2013; 108:478-98; quiz 499. [PMID: 23439232 DOI: 10.1038/ajg.2013.4] [Citation(s) in RCA: 1143] [Impact Index Per Article: 103.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Clostridium difficile infection (CDI) is a leading cause of hospital-associated gastrointestinal illness and places a high burden on our health-care system. Patients with CDI typically have extended lengths-of-stay in hospitals, and CDI is a frequent cause of large hospital outbreaks of disease. This guideline provides recommendations for the diagnosis and management of patients with CDI as well as for the prevention and control of outbreaks while supplementing previously published guidelines. New molecular diagnostic stool tests will likely replace current enzyme immunoassay tests. We suggest treatment of patients be stratified depending on whether they have mild-to-moderate, severe, or complicated disease. Therapy with metronidazole remains the choice for mild-to-moderate disease but may not be adequate for patients with severe or complicated disease. We propose a classification of disease severity to guide therapy that is useful for clinicians. We review current treatment options for patients with recurrent CDI and recommendations for the control and prevention of outbreaks of CDI.
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Affiliation(s)
- Christina M Surawicz
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, WA 98104, USA.
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