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Manthey CF, Epple HJ, Keller KM, Lübbert C, Posovszky C, Ramharter M, Reuken P, Suerbaum S, Vehreschild M, Weinke T, Addo MM, Stallmach A, Lohse AW. S2k-Leitlinie Gastrointestinale Infektionen der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1090-1149. [PMID: 38976986 DOI: 10.1055/a-2240-1428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Affiliation(s)
- Carolin F Manthey
- I. Medizinische Klinik und Poliklinik - Schwerpunkt Gastroenterologie; Sektionen Infektions- und Tropenmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
- Gemeinschaftspraxis Innere Medizin Witten, Witten, Deutschland
| | - Hans-Jörg Epple
- Antibiotic Stewardship, Vorstand Krankenversorgung, Universitätsmedizin Berlin, Berlin, Deutschland
| | - Klaus-Michael Keller
- Klinik für Kinder- und Jugendmedizin, Helios Dr. Horst Schmidt Kliniken, Klinik für Kinder- und Jugendmedizin, Wiesbaden, Deutschland
| | - Christoph Lübbert
- Bereich Infektiologie und Tropenmedizin, Medizinische Klinik I (Hämatologie, Zelltherapie, Infektiologie und Hämostaseologie), Universitätsklinikum Leipzig, Leipzig, Deutschland
| | | | - Michael Ramharter
- I. Medizinische Klinik und Poliklinik - Schwerpunkt Gastroenterologie; Sektionen Infektions- und Tropenmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Philipp Reuken
- Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie, Infektiologie, Zentrale Endoskopie), Universitätsklinikum Jena, Jena, Deutschland
| | - Sebastian Suerbaum
- Universität München, Max von Pettenkofer-Institut für Hygiene und Medizinische Mikrobiologie, München, Deutschland
| | - Maria Vehreschild
- Medizinische Klinik II, Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Thomas Weinke
- Klinik für Gastroenterologie und Infektiologie, Klinikum Ernst von Bergmann, Potsdam, Deutschland
| | - Marylyn M Addo
- I. Medizinische Klinik und Poliklinik - Schwerpunkt Gastroenterologie; Sektionen Infektions- und Tropenmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
- Institut für Infektionsforschung und Impfstoffentwicklung Sektion Infektiologie, I. Med. Klinik, Zentrum für Innere Medizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Andreas Stallmach
- Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie, Infektiologie, Zentrale Endoskopie), Universitätsklinikum Jena, Jena, Deutschland
| | - Ansgar W Lohse
- I. Medizinische Klinik und Poliklinik - Schwerpunkt Gastroenterologie; Sektionen Infektions- und Tropenmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
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Spigaglia P, Mastrantonio P, Barbanti F. Antibiotic Resistances of Clostridioides difficile. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1435:169-198. [PMID: 38175476 DOI: 10.1007/978-3-031-42108-2_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
The rapid evolution of antibiotic resistance in Clostridioides difficile and the consequent effects on prevention and treatment of C. difficile infections (CDIs) are a matter of concern for public health. Antibiotic resistance plays an important role in driving C. difficile epidemiology. Emergence of new types is often associated with the emergence of new resistances, and most of the epidemic C. difficile clinical isolates is currently resistant to multiple antibiotics. In particular, it is to worth to note the recent identification of strains with reduced susceptibility to the first-line antibiotics for CDI treatment and/or for relapsing infections. Antibiotic resistance in C. difficile has a multifactorial nature. Acquisition of genetic elements and alterations of the antibiotic target sites, as well as other factors, such as variations in the metabolic pathways or biofilm production, contribute to the survival of this pathogen in the presence of antibiotics. Different transfer mechanisms facilitate the spread of mobile elements among C. difficile strains and between C. difficile and other species. Furthermore, data indicate that both genetic elements and alterations in the antibiotic targets can be maintained in C. difficile regardless of the burden imposed on fitness, and therefore resistances may persist in C. difficile population in absence of antibiotic selective pressure.
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Affiliation(s)
- Patrizia Spigaglia
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy.
| | - Paola Mastrantonio
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Fabrizio Barbanti
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
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Chaar A, Damianos J, Rizwan R, Al-Nahhas H, Mansoor MS, Sharma P, Malik U, Feuerstadt P. First Clostridioides difficile Recurrence Is Highest Following Concomitant Antimicrobial Administration During and Within 30 Days of Treatment. Dig Dis Sci 2023; 68:4221-4229. [PMID: 37665427 DOI: 10.1007/s10620-023-08091-0] [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] [Received: 02/21/2023] [Accepted: 08/21/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Clostridioides difficile infection (CDI) is an epidemic with the strongest risk factor being antibiotic usage. Patients who get CDI frequently require concomitant antibiotics for other indications around the time of their infection. AIMS To assess the recurrence of CDI (rCDI) in patients receiving concomitant antibiotics at the same time or shortly thereafter treatment of CDI. METHODS We retrospectively reviewed records for patients with their first inpatient CDI episode. Patients were grouped into those who didn't receive concomitant antibiotics (noABx), those receiving antibiotics at the same time as treatment of CDI (ABxDURING), those receiving antibiotics within 30-days of completion of CDI therapy (ABxAFTER) and those who received antibiotics both during and after CDI treatment (ABxDuringAfter). Our primary outcome was recurrence within 14-90 days; other outcomes included ICU stay at the time of diagnosis, 30-day ICU transfer, 30-day colectomy, and readmission. RESULTS 457 patients had CDI during admission (mean age: 66.4 years, 51.9% female). 64.1% were exposed to concomitant antibiotics. Recurrence rates were 4.3%, 6.1%, 13.8% and 19.1%, for noABx, ABxDURING, ABxAFTER and ABxDuringAfter, respectively. Patients with ABxDuringAfter had the highest rates of rCDI when compared to noABx [OR 5.67, 95% CI (2.18-14.72)]. CONCLUSIONS There is a high rate of utilization of non-CDI antibiotics during or shortly after completing CDI treatment with high rates of recurrence within 90-days. Concomitant antimicrobials alter the opportunity for the microbiota to re-grow and worsens dysbiosis leading to increases in recurrence. Concomitant antimicrobial stewardship remains important in patients being treated for CDI and shortly after treatment.
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Affiliation(s)
- Abdelkader Chaar
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Medicine, Yale-New Haven Hospital, New Haven, CT, USA
| | - John Damianos
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Rabia Rizwan
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Medicine, Yale-New Haven Hospital, New Haven, CT, USA
| | | | | | - Prabin Sharma
- Department of Gastroenterology, Hartford Healthcare, St Vincent's Medical Center, Bridgeport, CT, USA
| | - Umer Malik
- Division of Gastroenterology, Albany Medical Center, Albany, NY, USA
| | - Paul Feuerstadt
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA.
- PACT-Gastroenterology Center, 2200 Whitney Avenue, Hamden, CT, 06518, USA.
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4
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Olaitan AO, Dureja C, Youngblom MA, Topf MA, Shen WJ, Gonzales-Luna AJ, Deshpande A, Hevener KE, Freeman J, Wilcox MH, Palmer KL, Garey KW, Pepperell CS, Hurdle JG. Decoding a cryptic mechanism of metronidazole resistance among globally disseminated fluoroquinolone-resistant Clostridioides difficile. Nat Commun 2023; 14:4130. [PMID: 37438331 DOI: 10.1038/s41467-023-39429-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 06/13/2023] [Indexed: 07/14/2023] Open
Abstract
Severe outbreaks and deaths have been linked to the emergence and global spread of fluoroquinolone-resistant Clostridioides difficile over the past two decades. At the same time, metronidazole, a nitro-containing antibiotic, has shown decreasing clinical efficacy in treating C. difficile infection (CDI). Most metronidazole-resistant C. difficile exhibit an unusual resistance phenotype that can only be detected in susceptibility tests using molecularly intact heme. Here, we describe the mechanism underlying this trait. We find that most metronidazole-resistant C. difficile strains carry a T-to-G mutation (which we term PnimBG) in the promoter of gene nimB, resulting in constitutive transcription. Silencing or deleting nimB eliminates metronidazole resistance. NimB is related to Nim proteins that are known to confer resistance to nitroimidazoles. We show that NimB is a heme-dependent flavin enzyme that degrades nitroimidazoles to amines lacking antimicrobial activity. Furthermore, occurrence of the PnimBG mutation is associated with a Thr82Ile substitution in DNA gyrase that confers fluoroquinolone resistance in epidemic strains. Our findings suggest that the pandemic of fluoroquinolone-resistant C. difficile occurring over the past few decades has also been characterized by widespread resistance to metronidazole.
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Affiliation(s)
- Abiola O Olaitan
- Center for Infectious and Inflammatory Diseases, Institute of Biosciences and Technology, Texas A&M Health Science Center, Houston, TX, USA
- Department of Biology, University of Waterloo, Waterloo, ON, Canada
| | - Chetna Dureja
- Center for Infectious and Inflammatory Diseases, Institute of Biosciences and Technology, Texas A&M Health Science Center, Houston, TX, USA
| | - Madison A Youngblom
- Microbiology Doctoral Training Program, University of Wisconsin-Madison, Madison, WI, USA
| | - Madeline A Topf
- Microbiology Doctoral Training Program, University of Wisconsin-Madison, Madison, WI, USA
| | - Wan-Jou Shen
- Center for Infectious and Inflammatory Diseases, Institute of Biosciences and Technology, Texas A&M Health Science Center, Houston, TX, USA
| | - Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Aditi Deshpande
- Center for Infectious and Inflammatory Diseases, Institute of Biosciences and Technology, Texas A&M Health Science Center, Houston, TX, USA
| | - Kirk E Hevener
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jane Freeman
- Department of Microbiology, Leeds Teaching Hospitals Trust, Leeds, UK
- Healthcare Associated Infection Research Group, School of Medicine, University of Leeds, Leeds, UK
| | - Mark H Wilcox
- Department of Microbiology, Leeds Teaching Hospitals Trust, Leeds, UK
- Healthcare Associated Infection Research Group, School of Medicine, University of Leeds, Leeds, UK
| | - Kelli L Palmer
- Department of Biological Sciences, University of Texas at Dallas, Richardson, TX, USA
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Caitlin S Pepperell
- Department of Medical Microbiology and Immunology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA.
- Department of Medicine, Division of Infectious Diseases, University of Wisconsin-Madison, Madison, WI, USA.
| | - Julian G Hurdle
- Center for Infectious and Inflammatory Diseases, Institute of Biosciences and Technology, Texas A&M Health Science Center, Houston, TX, USA.
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Medaglia AA, Mancuso A, Albano C, Zinna G, Pipitò L, Calà C, Immordino R, Rubino R, Bonura S, Canino B, Calamusa G, Colomba C, Almasio PL, Cascio A. Clostridioides difficile Infection in an Italian Tertiary Care University Hospital: A Retrospective Analysis. Antibiotics (Basel) 2023; 12:antibiotics12050837. [PMID: 37237740 DOI: 10.3390/antibiotics12050837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/26/2023] [Accepted: 04/27/2023] [Indexed: 05/28/2023] Open
Abstract
Clostridioides difficile infection (CDI) is a significant cause of morbidity and mortality, mostly in frail patients. Notification is not mandatory in Italy, and data on incidence, risk of death, and recurrence are lacking. The purpose of this study was to determine CDI incidence and risk factors for mortality and recurrence. The "ICD-9 00845" code in hospital-standardized discharged forms (H-SDF) and microbiology datasets were used to retrieve CDI cases at Policlinico Hospital, Palermo between 2013 and 2022. Incidence, ward distribution, recurrence rate, mortality, and coding rate were considered. The risk of death and recurrence was predicted through multivariable analysis. There were 275 CDIs, 75% hospital-acquired, the median time between admission and diagnosis was 13 days, and the median stay was 21 days. Incidence increased from 0.3 to 5.6% (an 18.7-fold increase) throughout the decade. Only 48.1% of cases were coded in H-SDF. The rate of severe/severe-complicated cases increased 1.9 times. Fidaxomicin was used in 17.1% and 24.7% of cases overall and since 2019. Overall and attributable mortalities were 11.3% and 4.7%, respectively. Median time between diagnosis and death was 11 days, and recurrence rate was 4%. Bezlotoxumab was administered in 64% of recurrences. Multivariable analysis revealed that only hemodialysis was associated with mortality. No statistically significant association in predicting recurrence risk emerged. We advocate for CDI notification to become mandatory and recommend coding CDI diagnosis in H-SDF to aid in infection rate monitoring. Maximum attention should be paid to preventing people on hemodialysis from getting CDI.
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Affiliation(s)
- Alice Annalisa Medaglia
- Infectious and Tropical Diseases Unit, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
- Antimicrobial Stewardship Team, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
| | - Alessandro Mancuso
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, 90127 Palermo, Italy
| | - Chiara Albano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, 90127 Palermo, Italy
| | - Giuseppe Zinna
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, 90127 Palermo, Italy
| | - Luca Pipitò
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, 90127 Palermo, Italy
| | - Cinzia Calà
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, 90127 Palermo, Italy
- Microbiology and Virology Unit, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
| | - Rita Immordino
- Microbiology and Virology Unit, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
| | - Raffaella Rubino
- Infectious and Tropical Diseases Unit, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
- Antimicrobial Stewardship Team, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
| | - Silvia Bonura
- Infectious and Tropical Diseases Unit, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
- Antimicrobial Stewardship Team, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
| | - Baldassare Canino
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, 90127 Palermo, Italy
| | - Giuseppe Calamusa
- Antimicrobial Stewardship Team, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, 90127 Palermo, Italy
| | - Claudia Colomba
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, 90127 Palermo, Italy
| | - Pier Luigi Almasio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, 90127 Palermo, Italy
| | - Antonio Cascio
- Infectious and Tropical Diseases Unit, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
- Antimicrobial Stewardship Team, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, 90127 Palermo, Italy
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McKechnie T, Khamar J, Lee Y, Tessier L, Passos E, Doumouras A, Hong D, Eskicioglu C. Total Abdominal Colectomy Versus Diverting Loop Ileostomy and Antegrade Colonic Lavage for Fulminant Clostridioides Colitis: Analysis of the National Inpatient Sample 2016-2019. J Gastrointest Surg 2023:10.1007/s11605-023-05682-0. [PMID: 37081220 DOI: 10.1007/s11605-023-05682-0] [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] [Received: 01/23/2023] [Accepted: 04/10/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND When surgery is indicated for fulminant Clostridioides difficile infection (CDI), total abdominal colectomy (TAC) is the most common approach. Diverting loop ileostomy (DLI) with antegrade colonic lavage has been introduced as a colon-sparing surgical approach. Prior analyses of National Inpatient Sample (NIS) data suggested equivalent postoperative outcomes between groups but did not evaluate healthcare resource utilization. As such, we aimed to analyze a more recent NIS cohort to compare these two approaches in terms of both postoperative outcomes and healthcare resource utilization. METHODS A retrospective analysis of the NIS from 2016 to 2019 was conducted. The primary outcome was postoperative in-hospital morbidity. Secondary outcomes included postoperative in-hospital mortality, system-specific postoperative complications, total admission cost, and length of stay (LOS). Univariable and multivariable regressions were utilized to compare the two operative approaches. RESULTS In total, 886 patients underwent TAC and 409 patients underwent DLI with antegrade colonic lavage. Adjusted analyses demonstrated no difference between groups in postoperative in-hospital morbidity (aOR 0.96, 95%CI 0.64-1.44, p = 0.851) or in-hospital mortality (aOR 1.15, 95%CI 0.81-1.64, p = 0.436). Patients undergoing TAC experienced significantly decreased total admission cost (MD $79,715.34, 95%CI 133,841-25,588, p = 0.004) and shorter postoperative LOS (MD 4.06 days, 95%CI 6.96-1.15, p = 0.006). CONCLUSIONS There are minimal differences between TAC and DLI with antegrade colonic lavage for fulminant CDI in terms of postoperative morbidity and mortality. Healthcare resource utilization, however, is significantly improved when patients undergo TAC as evidenced by clinically important decreases in total admission cost and postoperative LOS.
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Affiliation(s)
- Tyler McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, L8N 4A6, Canada
| | - Jigish Khamar
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Yung Lee
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, L8N 4A6, Canada
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Léa Tessier
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Edward Passos
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, L8N 4A6, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Aristithes Doumouras
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, L8N 4A6, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Dennis Hong
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, L8N 4A6, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, L8N 4A6, Canada.
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.
- Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, Ontario, Canada.
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7
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Kunishima H, Ohge H, Suzuki H, Nakamura A, Matsumoto K, Mikamo H, Mori N, Morinaga Y, Yanagihara K, Yamagishi Y, Yoshizawa S. Japanese Clinical Practice Guidelines for Management of Clostridioides (Clostridium) difficile infection. J Infect Chemother 2022; 28:1045-1083. [PMID: 35618618 DOI: 10.1016/j.jiac.2021.12.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/16/2021] [Accepted: 12/13/2021] [Indexed: 12/19/2022]
Affiliation(s)
- Hiroyuki Kunishima
- Department of Infectious Diseases, St. Marianna University School of Medicine, Japan.
| | - Hiroki Ohge
- Department of Infectious Diseases, Hiroshima University Hospital, Japan
| | - Hiromichi Suzuki
- Division of Infectious Diseases, Department of Medicine, Tsukuba Medical Center Hospital, Japan
| | - Atsushi Nakamura
- Division of Infection Control and Prevention, Nagoya City University Hospital, Japan
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, Japan
| | - Hiroshige Mikamo
- Clinical Infectious Diseases, Graduate School of Medicine, Aichi Medical University, Japan
| | - Nobuaki Mori
- Division of General Internal Medicine and Infectious Diseases, National Hospital Organization Tokyo Medical Center, Japan
| | - Yoshitomo Morinaga
- Department of Microbiology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
| | - Katsunori Yanagihara
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Yuka Yamagishi
- Clinical Infectious Diseases, Graduate School of Medicine, Aichi Medical University, Japan
| | - Sadako Yoshizawa
- Department of Clinical Laboratory/Department of Microbiology and Infectious Diseases, Toho University School of Medicine, Japan
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Cruz KCP, Enekegho LO, Stuart DT. Bioengineered Probiotics: Synthetic Biology Can Provide Live Cell Therapeutics for the Treatment of Foodborne Diseases. Front Bioeng Biotechnol 2022; 10:890479. [PMID: 35656199 PMCID: PMC9152101 DOI: 10.3389/fbioe.2022.890479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 04/29/2022] [Indexed: 11/15/2022] Open
Abstract
The rising prevalence of antibiotic resistant microbial pathogens presents an ominous health and economic challenge to modern society. The discovery and large-scale development of antibiotic drugs in previous decades was transformational, providing cheap, effective treatment for what would previously have been a lethal infection. As microbial strains resistant to many or even all antibiotic drug treatments have evolved, there is an urgent need for new drugs or antimicrobial treatments to control these pathogens. The ability to sequence and mine the genomes of an increasing number of microbial strains from previously unexplored environments has the potential to identify new natural product antibiotic biosynthesis pathways. This coupled with the power of synthetic biology to generate new production chassis, biosensors and “weaponized” live cell therapeutics may provide new means to combat the rapidly evolving threat of drug resistant microbial pathogens. This review focuses on the application of synthetic biology to construct probiotic strains that have been endowed with functionalities allowing them to identify, compete with and in some cases kill microbial pathogens as well as stimulate host immunity. Weaponized probiotics may have the greatest potential for use against pathogens that infect the gastrointestinal tract: Vibrio cholerae, Staphylococcus aureus, Clostridium perfringens and Clostridioides difficile. The potential benefits of engineered probiotics are highlighted along with the challenges that must still be met before these intriguing and exciting new therapeutic tools can be widely deployed.
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Chen YC, Kuo YC, Chen MC, Zhang YD, Chen CL, Le PH, Chiu CH. Case–Control Study of Clostridium innocuum Infection, Taiwan. Emerg Infect Dis 2022. [DOI: 10.3201/2803.204421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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10
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Chen YC, Kuo YC, Chen MC, Zhang YD, Chen CL, Le PH, Chiu CH. Case-Control Study of Clostridium innocuum Infection, Taiwan. Emerg Infect Dis 2022; 28:599-607. [PMID: 35195517 PMCID: PMC8888209 DOI: 10.3201/eid2803.204421] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Vancomycin-resistant Clostridium innocuum was recently identified as an etiologic agent for antibiotic-associated diarrhea in humans. We conducted a case–control study involving 152 C. innocuum-infected patients during 2014–2019 in Taiwan, using 304 cases of Clostridioides difficile infection (CDI) matched by diagnosis year, age (+2 years), and sex as controls. The baseline characteristics were similar between the 2 groups. C. innocuum–infected patients experienced more extraintestinal clostridial infection and gastrointestinal tract–related complications than did patients with CDI. The 30-day mortality rate among C. innocuum–infected patients was 14.5%, and the overall rate was 23.0%. Chronic kidney disease, solid tumor, intensive care unit admission, and shock status were 4 independent risk factors for death. C. innocuum identified from clinical specimens should be recognized as a pathogen requiring treatment, and because of its intrinsic vancomycin resistance, precise identification is necessary to guide appropriate and timely antimicrobial therapy.
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11
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Non-inferiority of metronidazole to vancomycin in the treatment of first episode non-severe Clostridioides difficile infection: a single center retrospective cohort study. Infection 2022; 50:973-980. [PMID: 35192148 DOI: 10.1007/s15010-022-01778-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 02/07/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVES We sought to assess the effectiveness of oral vancomycin compared to metronidazole on recurrence and mortality among hospitalized patients with non-severe Clostridioides difficile infection (CDI). METHODS A single center retrospective cohort study was conducted, including adult patients hospitalized between 2015 and 2020 with a first episode of non-severe CDI, treated with metronidazole or vancomycin as monotherapy for at least 10 days. We assessed recurrence of CDI requiring hospitalization (primary outcome) and all-cause mortality up to 8 weeks, post discharge. RESULTS Overall, 160 patients were treated with vancomycin and 149 treated with metronidazole. Re-hospitalization within 8 weeks due to CDI occurred in 10 (6.2%) patients in the vancomycin group, and 13 (8.7%) in the metronidazole group (P value = 0.407). Eight-week mortality occurred in 39 patients (26.2%) in the metronidazole group and 46 patients (28.8%) in the vancomycin group (P value = 0.61). After adjusting for age, gender, Ischemic heart disease, white blood cell count, neutrophile count and CRP, there was no significant difference between the two treatments (Re-hospitalization in 8 weeks due to CDI P = 0.5059; In-hospital death P = 0.7950; 4-week mortality P = 0.2988; 8-week mortality P = 0.8237). CONCLUSION There is no benefit of using vancomycin compared to metronidazole concerning recurrence rate requiring hospitalization, in-hospital and up to 4- and 8-week mortality rate in non-severe first episode of CDI.
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van Prehn J, Reigadas E, Vogelzang EH, Bouza E, Hristea A, Guery B, Krutova M, Norén T, Allerberger F, Coia JE, Goorhuis A, van Rossen TM, Ooijevaar RE, Burns K, Scharvik Olesen BR, Tschudin-Sutter S, Wilcox MH, Vehreschild MJGT, Fitzpatrick F, Kuijper EJ. European Society of Clinical Microbiology and Infectious Diseases: 2021 update on the treatment guidance document for Clostridioides difficile infection in adults. Clin Microbiol Infect 2021; 27 Suppl 2:S1-S21. [PMID: 34678515 DOI: 10.1016/j.cmi.2021.09.038] [Citation(s) in RCA: 220] [Impact Index Per Article: 73.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 09/23/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022]
Abstract
SCOPE In 2009, the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) published the first treatment guidance document for Clostridioides difficile infection (CDI). This document was updated in 2014. The growing literature on CDI antimicrobial treatment and novel treatment approaches, such as faecal microbiota transplantation (FMT) and toxin-binding monoclonal antibodies, prompted the ESCMID study group on C. difficile (ESGCD) to update the 2014 treatment guidance document for CDI in adults. METHODS AND QUESTIONS Key questions on CDI treatment were formulated by the guideline committee and included: What is the best treatment for initial, severe, severe-complicated, refractory, recurrent and multiple recurrent CDI? What is the best treatment when no oral therapy is possible? Can prognostic factors identify patients at risk for severe and recurrent CDI and is there a place for CDI prophylaxis? Outcome measures for treatment strategy were: clinical cure, recurrence and sustained cure. For studies on surgical interventions and severe-complicated CDI the outcome was mortality. Appraisal of available literature and drafting of recommendations was performed by the guideline drafting group. The total body of evidence for the recommendations on CDI treatment consists of the literature described in the previous guidelines, supplemented with a systematic literature search on randomized clinical trials and observational studies from 2012 and onwards. The Grades of Recommendation Assessment, Development and Evaluation (GRADE) system was used to grade the strength of our recommendations and the quality of the evidence. The guideline committee was invited to comment on the recommendations. The guideline draft was sent to external experts and a patients' representative for review. Full ESCMID endorsement was obtained after a public consultation procedure. RECOMMENDATIONS Important changes compared with previous guideline include but are not limited to: metronidazole is no longer recommended for treatment of CDI when fidaxomicin or vancomycin are available, fidaxomicin is the preferred agent for treatment of initial CDI and the first recurrence of CDI when available and feasible, FMT or bezlotoxumab in addition to standard of care antibiotics (SoC) are preferred for treatment of a second or further recurrence of CDI, bezlotoxumab in addition to SoC is recommended for the first recurrence of CDI when fidaxomicin was used to manage the initial CDI episode, and bezlotoxumab is considered as an ancillary treatment to vancomycin for a CDI episode with high risk of recurrence when fidaxomicin is not available. Contrary to the previous guideline, in the current guideline emphasis is placed on risk for recurrence as a factor that determines treatment strategy for the individual patient, rather than the disease severity.
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Affiliation(s)
- Joffrey van Prehn
- Department of Medical Microbiology, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Elena Reigadas
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Erik H Vogelzang
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Adriana Hristea
- University of Medicine and Pharmacy Carol Davila, National Institute for Infectious Diseases Prof Dr Matei Bals, Romania
| | - Benoit Guery
- Infectious Diseases Specialist, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Marcela Krutova
- Department of Medical Microbiology, Charles University in Prague and Motol University Hospital, Czech Republic
| | - Torbjorn Norén
- Faculty of Medicine and Health, Department of Laboratory Medicine, National Reference Laboratory for Clostridioides difficile, Clinical Microbiology, Örebro University Hospital, Örebro, Sweden
| | | | - John E Coia
- Department of Clinical Microbiology, Hospital South West Jutland and Department of Regional Health Research IRS, University of Southern Denmark, Esbjerg, Denmark
| | - Abraham Goorhuis
- Department of Infectious Diseases, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Tessel M van Rossen
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Rogier E Ooijevaar
- Department of Gastroenterology, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Karen Burns
- Departments of Clinical Microbiology, Beaumont Hospital & Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Sarah Tschudin-Sutter
- Department of Infectious Diseases and Infection Control, University Hospital Basel, University Basel, Universitatsspital, Basel, Switzerland
| | - Mark H Wilcox
- Department of Microbiology, Old Medical, School Leeds General Infirmary, Leeds Teaching Hospitals & University of Leeds, Leeds, United Kingdom
| | - Maria J G T Vehreschild
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany; Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Fidelma Fitzpatrick
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland; Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ed J Kuijper
- Department of Medical Microbiology, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands; National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands.
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Markovic S, Jankovic M, Kalaba A, Zogovic B, Sreckovic SS. Infliximab Rescue in Acute Severe Ulcerative Colitis Complicated by Clostridium Difficile Infection: A Case Series. Cureus 2021; 13:e19019. [PMID: 34824934 PMCID: PMC8611478 DOI: 10.7759/cureus.19019] [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: 10/25/2021] [Indexed: 11/05/2022] Open
Abstract
Relapses in inflammatory bowel disease (IBD) complicated by Clostridium difficile infection (CDI) are associated with significant morbidity and mortality. CDI can exacerbate the course of IBD and may result in prolonged hospitalizations, admissions to intensive care, surgical interventions, or even death. Early detection and aggressive treatment with systemic corticosteroids or biologics such as infliximab are often needed in severe presentations. Five cases of relapsed ulcerative colitis complicated by fulminant CDI were retrospectively reviewed. Biological therapy with infliximab was initiated upon multidisciplinary team assessment as the cases were resistant to standard IBD therapy. All five patients improved clinically and avoided early surgical intervention. Some required prolonged therapy with infliximab to achieve remission. Early recognition of CDI and aggressive therapy with biologics may be required to avoid complications in the IBD patients experiencing a relapse. Infliximab therapy should be considered early on, especially where the disease is resistant to standard therapy.
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Affiliation(s)
- Srdjan Markovic
- Gastroenterology and Hepatology, University Hospital Medical Center "Zvezdara", Belgrade, SRB
| | - Marijana Jankovic
- Gastroenterology and Hepatology, University Hospital Medical Center "Zvezdara", Belgrade, SRB
| | - Ana Kalaba
- Gastroenterology and Hepatology, University Hospital Medical Center "Zvezdara", Belgrade, SRB
| | - Branimir Zogovic
- Department of General Surgery, Royal Prince Alfred Hospital, New South Wales, AUS
| | - Slobodan S Sreckovic
- Gastroenterology and Hepatology, University Hospital Medical Center "Zvezdara", Belgrade, SRB
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van Rossen TM, Ooijevaar RE, Vandenbroucke-Grauls CMJE, Dekkers OM, Kuijper EJ, Keller JJ, van Prehn J. Prognostic factors for severe and recurrent Clostridioides difficile infection: a systematic review. Clin Microbiol Infect 2021; 28:321-331. [PMID: 34655745 DOI: 10.1016/j.cmi.2021.09.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/24/2021] [Accepted: 09/25/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Clostridioides difficile infection (CDI), its subsequent recurrences (rCDIs), and severe CDI (sCDI) provide a significant burden for both patients and the healthcare system. Identifying patients diagnosed with initial CDI who are at increased risk of developing sCDI/rCDI could lead to more cost-effective therapeutic choices. In this systematic review we aimed to identify clinical prognostic factors associated with an increased risk of developing sCDI or rCDI. METHODS PubMed, Embase, Emcare, Web of Science and COCHRANE Library databases were searched from database inception through March, 2021. The study eligibility criteria were cohort and case-control studies. Participants were patients ≥18 years old diagnosed with CDI, in which clinical or laboratory factors were analysed to predict sCDI/rCDI. Risk of bias was assessed by using the Quality in Prognostic Research (QUIPS) tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool modified for prognostic studies. Study selection was performed by two independent reviewers. Overview tables of prognostic factors were constructed to assess the number of studies and the respective effect direction and statistical significance of an association. RESULTS 136 studies were included for final analysis. Greater age and the presence of multiple comorbidities were prognostic factors for sCDI. Identified risk factors for rCDI were greater age, healthcare-associated CDI, prior hospitalization, proton pump inhibitors (PPIs) started during or after CDI diagnosis, and previous rCDI. CONCLUSIONS Prognostic factors for sCDI and rCDI could aid clinicians to make treatment decisions based on risk stratification. We suggest that future studies use standardized definitions for sCDI/rCDI and systematically collect and report the risk factors assessed in this review, to allow for meaningful meta-analysis of risk factors using data of high-quality trials.
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Affiliation(s)
- Tessel M van Rossen
- Amsterdam UMC, VU University Medical Center, Medical Microbiology & Infection Control, Amsterdam Infection & Immunity, Amsterdam, the Netherlands.
| | - Rogier E Ooijevaar
- Amsterdam UMC, VU University Medical Center, Gastroenterology & Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands.
| | - Christina M J E Vandenbroucke-Grauls
- Amsterdam UMC, VU University Medical Center, Medical Microbiology & Infection Control, Amsterdam Infection & Immunity, Amsterdam, the Netherlands; Aarhus University, Clinical Epidemiology, Aarhus, Denmark
| | - Olaf M Dekkers
- Leiden University Medical Center, Clinical Epidemiology, Leiden, the Netherlands
| | - Ed J Kuijper
- Leiden University Medical Center, Center for Infectious Diseases, Medical Microbiology, Leiden, the Netherlands
| | - Josbert J Keller
- Haaglanden Medical Center, Gastroenterology & Hepatology, The Hague, the Netherlands; Leiden University Medical Center, Gastroenterology & Hepatology, Leiden, the Netherlands
| | - Joffrey van Prehn
- Leiden University Medical Center, Center for Infectious Diseases, Medical Microbiology, Leiden, the Netherlands
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Risk Factors for Recurrence of Clostridioides difficile in Hospitalized Patients. J Infect Public Health 2021; 14:1642-1649. [PMID: 34627059 DOI: 10.1016/j.jiph.2021.09.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 09/02/2021] [Accepted: 09/16/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Diarrhea and pseudomembranous colitis associated with Clostridioides difficile - a spore-forming anaerobic Gram-positive bacillus - is a major infection in hospitalized patients with a profound impact on clinical and economic outcomes. Recurrence (rCDI) is common and predisposes to further episodes with poor outcomes. METHOD We aimed to identify a wide range of risk factors for recurrence to guide stewardship initiatives. After ethical approval, we commenced collecting demographic and clinical data of patients older than 18 years with clinically and microbiologically confirmed C. difficile infection. Data were statistically analyzed using R software. RESULTS Of 204 patients included in the analysis, 36 (18%) suffered 90-day recurrence, rCDI was higher among females (23%) compared to males (13%), overall age median (IQR) was 66 (51-77), and for rCDI cases 81 (69-86) years. Among 26 variables analyzed to evaluate their association with rCDI, prior clindamycin exposure, concurrent use of aztreonam, patients >76 years, total hospital length of stay, and LOS before diagnosis ≤7 days, WBC ≤ 9.85 × 103 at discharge were more likely to experience rCDI. CONCLUSION As identified in this analysis, patients with risk factors for rCDI could be candidates for close monitoring, a high index of suspicion, and risk mitigation interventions to avoid rCDI and improve clinical outcomes.
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Clostridioides difficile Infection in Patients with Chronic Kidney Disease: A Systematic Review. BIOMED RESEARCH INTERNATIONAL 2021; 2021:5466656. [PMID: 34557546 PMCID: PMC8455215 DOI: 10.1155/2021/5466656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/24/2021] [Indexed: 11/17/2022]
Abstract
Clostridioides difficile infection (CDI) is a health issue of utmost significance in Europe and North America, due to its high prevalence, morbidity, and mortality rate. The clinical spectrum of CDI is broad, ranging from asymptomatic to deadly fulminant colitis. When associated with chronic kidney disease (CKD), CDI is more prevalent and more severe than in the general population, due to specific risk factors such as impaired immune system, intestinal dysmotility, high antibiotic use leading to disturbed microbiota, frequent hospitalization, and PPI use. We performed a systematic review on the issue of prevention and treatment of CDI in the CKD population, analysing the suitable randomized controlled cohort studies published between 2000 and 2021. The results show that the most important aspect of prevention is isolation and disinfection with chlorine-based solution and hydrogen peroxide vapour to stop the spread of bacteria. In terms of prevention, using Lactobacillus plantarum (LP299v) proved to be more efficient than disinfection measures in transplant patients, leading to higher cure rates and less recurrent episodes of CDI. Treatment with oral fidaxomycin is more effective than with oral vancomycin for the initial episode of CDI in CKD patients. Faecal microbiota transplantation (FMT) is more effective than vancomycin in recurrent CDI in CKD patients. More large-sample RCTs are necessary to conclude on the best treatment and prevention strategy of CDI in CKD patients.
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Fong A, Ross M, Boudreau J, Nokhbeh R, Tilbe K, Lee H. Raja 42, a novel gamma lactam compound, is effective against Clostridioides difficile. PLoS One 2021; 16:e0257143. [PMID: 34492076 PMCID: PMC8423298 DOI: 10.1371/journal.pone.0257143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 08/24/2021] [Indexed: 01/05/2023] Open
Abstract
Clostridioides difficile infection (CDI) is the primary cause of hospital-acquired diarrhea, and responsible for over 500,000 enteric infections a year in the United States alone. Although most patients with CDI are successfully treated with metronidazole or vancomycin, the high rate of recurrence is still a serious problem, in which case these antibiotics are usually not very effective. The primary objective of this research is to develop a potentially effective therapeutic agent against C. difficile that are resistant to metronidazole or vancomycin. The susceptibility to metronidazole and vancomycin was examined with 194 C. difficile clinical isolates. Sixty of these isolates chosen based on a variety of criteria were examined for their susceptibility against the 4-chloro-1-piperidin-1ylmethyl-1H-indole-2,3-dione compound (Raja 42), a novel isatin-benzothiazole analogue containing a gamma-lactam structure, as we previously found that this novel compound is effective against a variety of different bacteria. Most of the 60 isolates were resistant to ceftriaxone and ciprofloxacin, raising the possibility that they might have been exposed previously to these or structurally similar antibiotics (e.g., β-lactam and quinolone compounds). Among the isolates, 48 (80%) and 54 (90%) were susceptible to metronidazole and vancomycin, respectively. Raja 42 was found to be effective against most of the isolates, especially so against metronidazole-resistant C. difficile. Most importantly, five isolates that show resistance to metronidazole and vancomycin were sensitive to Raja 42. Thus, Raja 42, a gamma lactam antibiotic, has the potential to effectively control C. difficile strains that are resistant to metronidazole and vancomycin.
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Affiliation(s)
- Alexis Fong
- Health Sciences North Research Institute, Sudbury, Ontario, Canada
- Biomolecular Sciences Program, Laurentian University, Sudbury, Ontario, Canada
| | - Megan Ross
- Health Sciences North Research Institute, Sudbury, Ontario, Canada
| | - Justin Boudreau
- Health Sciences North Research Institute, Sudbury, Ontario, Canada
| | - Reza Nokhbeh
- Health Sciences North Research Institute, Sudbury, Ontario, Canada
- Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Kim Tilbe
- Health Sciences North Research Institute, Sudbury, Ontario, Canada
- Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Hoyun Lee
- Health Sciences North Research Institute, Sudbury, Ontario, Canada
- Biomolecular Sciences Program, Laurentian University, Sudbury, Ontario, Canada
- Department of Medicine, the University of Ottawa Medical School, Ottawa, Ontario, Canada
- * E-mail:
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Gonzales-Luna AJ, Olaitan AO, Shen WJ, Deshpande A, Carlson TJ, Dotson KM, Lancaster C, Begum K, Alam MJ, Hurdle JG, Garey KW. Reduced Susceptibility to Metronidazole Is Associated With Initial Clinical Failure in Clostridioides difficile Infection. Open Forum Infect Dis 2021; 8:ofab365. [PMID: 34381844 PMCID: PMC8351808 DOI: 10.1093/ofid/ofab365] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 07/07/2021] [Indexed: 12/15/2022] Open
Abstract
Background Clinical studies have demonstrated inferior cure rates when metronidazole (MTZ) is used to treat Clostridioides difficile infection (CDI). We hypothesized that a newly identified, heme-inducible form of reduced MTZ susceptibility in C. difficile leads to higher odds of initial clinical failure in patients with CDI treated with MTZ. Methods This multicenter cohort study included adults diagnosed with CDI between 2017 and 2018. C. difficile isolated from stool samples underwent agar dilution MTZ susceptibility testing with incorporation of fresh heme. Blinded investigators reviewed medical records for initial clinical failure and other relevant clinical variables. Classification and regression tree (CART) analysis was used to identify the MTZ minimum inhibitory concentration (MIC) breakpoint that was predictive of initial clinical failure. Results were confirmed using univariate and multivariable logistic regression analyses to account for potential confounders. Results Of the 356 patients included, 72% received MTZ-based therapy and 27% experienced initial clinical failure. CART analysis identified an MTZ MIC ≥1 µg/mL above which patients had a higher rate of initial clinical failure. MTZ MICs ranged from 0.25 to 8 µg/mL (MIC50/90 = 0.25/2 µg/mL), and approximately 18% of isolates had MTZ MICs ≥1 µg/mL. In multivariable analysis, an MTZ MIC ≥1 µg/mL was an independent predictor of initial clinical failure in patients receiving an MTZ-based treatment regimen (odds ratio, 2.27 [95% confidence interval, 1.18–4.34]). Conclusions Using a reproducible method to determine C. difficile MICs to MTZ, a breakpoint of ≥1 µg/mL identified patients at higher risk of initial clinical failure.
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Affiliation(s)
- Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Abiola O Olaitan
- Center for Infectious and Inflammatory Diseases, Institute of Biosciences and Technology, Texas A&M Health Science Center, Houston, Texas, USA
| | - Wan-Jou Shen
- Center for Infectious and Inflammatory Diseases, Institute of Biosciences and Technology, Texas A&M Health Science Center, Houston, Texas, USA
| | - Aditi Deshpande
- Center for Infectious and Inflammatory Diseases, Institute of Biosciences and Technology, Texas A&M Health Science Center, Houston, Texas, USA
| | - Travis J Carlson
- Department of Clinical Sciences, High Point University Fred Wilson School of Pharmacy, High Point, North Carolina, USA
| | | | - Chris Lancaster
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Khurshida Begum
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - M Jahangir Alam
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Julian G Hurdle
- Center for Infectious and Inflammatory Diseases, Institute of Biosciences and Technology, Texas A&M Health Science Center, Houston, Texas, USA
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
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Šamadan L, Jeličić M, Vince A, Papić N. Nonalcoholic Fatty Liver Disease-A Novel Risk Factor for Recurrent Clostridioides difficile Infection. Antibiotics (Basel) 2021; 10:antibiotics10070780. [PMID: 34198964 PMCID: PMC8300633 DOI: 10.3390/antibiotics10070780] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/23/2021] [Accepted: 06/25/2021] [Indexed: 12/17/2022] Open
Abstract
Recurrent Clostridioides difficile infections (rCDI) have a substantial impact on healthcare systems, with limited and often expensive therapeutic options. Nonalcoholic fatty liver disease (NAFLD) affects about 25% of the adult population and is associated with metabolic syndrome, changes in gut microbiome and bile acids biosynthesis, all possibly related with rCDI. The aim of this study was to determine whether NAFLD is a risk factor associated with rCDI. A retrospective cohort study included patients ≥ 60 years hospitalized with CDI. The cohort was divided into two groups: those who were and were not readmitted with CDI within 3 months of discharge. Of the 329 patients included, 107 patients (32.5%) experienced rCDI. Patients with rCDI were older, had higher Charlson Age-Comorbidity Index (CACI) and were more frequently hospitalized within 3 months. Except for chronic kidney disease and NAFLD, which were more frequent in the rCDI group, there were no differences in other comorbidities, antibiotic classes used and duration of antimicrobial therapy. Multivariable Cox regression analysis showed that age >75 years, NAFLD, CACI >6, chronic kidney disease, statins and immobility were associated with rCDI. In conclusion, our study identified NAFLD as a possible new host-related risk factor associated with rCDI.
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Affiliation(s)
- Lara Šamadan
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia; (L.Š.); (A.V.)
| | - Mia Jeličić
- University Hospital for Infectious Diseases, 10000 Zagreb, Croatia;
| | - Adriana Vince
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia; (L.Š.); (A.V.)
- University Hospital for Infectious Diseases, 10000 Zagreb, Croatia;
| | - Neven Papić
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia; (L.Š.); (A.V.)
- University Hospital for Infectious Diseases, 10000 Zagreb, Croatia;
- Correspondence:
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A Review of Clostridioides difficile Infection and Antibiotic-Associated Diarrhea. Gastroenterol Clin North Am 2021; 50:323-340. [PMID: 34024444 DOI: 10.1016/j.gtc.2021.02.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Antibiotic-associated diarrhea and Clostridioides difficile infection (CDI) occur frequently among adults. The pathophysiology of CDI is related to disruption of normal gut flora and risk factors include hospitalization, use of antibiotic therapy, and older age. Clinical manifestations can range from mild disease to toxic megacolon. Diagnosis is challenging and is based on a combination of clinical symptoms and diagnostic tests. Therapy includes cessation of antibiotics, or use of other agents depending on the severity of illness. Many novel agents for the treatment and prevention of CDI show promise and are under investigation.
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21
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Clostridioides difficile Infection. Dis Colon Rectum 2021; 64:650-668. [PMID: 33769319 DOI: 10.1097/dcr.0000000000002047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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22
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Chaar A, Feuerstadt P. Evolution of clinical guidelines for antimicrobial management of Clostridioides difficile infection. Therap Adv Gastroenterol 2021; 14:17562848211011953. [PMID: 33995583 PMCID: PMC8111514 DOI: 10.1177/17562848211011953] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 03/31/2021] [Indexed: 02/04/2023] Open
Abstract
Clostridioides difficile infection (CDI) has been an epidemic for many years. Our biggest challenge in treating CDI is preventing recurrence, which is seen in approximately 25% of patients with initial infection and in 40-60% of those with subsequent episodes. Given the major disease burden of this infection, appropriate data-driven treatment remains essential. Clinical treatment guidelines provide an unbiased critical analysis of the literature, integrating the quality of the available data to make recommendations. As CDI has been evolving and more research has become available, the frequency of guideline issue from various global societies has increased, as has the detail of the recommendations to fit more relevant clinical scenarios. In this review, we will discuss clinical guideline recommendations over three time periods: The Initial Guidelines 1995-1997, The Second Wave 2009-2013, and The Modern Era 2014-present. We see the changing recommendations from metronidazole or vancomycin for initial infection during earlier times to preferential treatment with fidaxomicin within the Infectious Diseases Society of America (IDSA) and Society of Healthcare Epidemiology of America (SHEA) joint guidelines provisional update in late 2020. The recommended treatments for first recurrence were initially with the same antimicrobial as the first episode but have since changed to having multiple options for one or more recurrences. We have also seen the addition of immune boosting treatments, including fecal microbiota transplantation (FMT)/microbiota restoration therapy (MRT) and bezlotoxumab in the more modern recommendations. As the guidelines are evolving with the times, it remains important to understand the differences among them so we can apply this information clinically and optimize patient outcomes.
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Affiliation(s)
- Abdelkader Chaar
- Section of Internal Medicine, Yale-New Haven Hospital, New Haven, CT, USA
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Bouza E, Cobo J, Rodríguez-Hernández MJ, Salavert M, Horcajada JP, Iribarren JA, Obi E, Lozano V, Maratia S, Cuesta M, Uría E, Limón E. Economic burden of recurrent Clostridioides difficile infection in adults admitted to Spanish hospitals. A multicentre retrospective observational study. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2021; 34:126-135. [PMID: 33618513 PMCID: PMC8019457 DOI: 10.37201/req/135.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/09/2020] [Accepted: 01/07/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Clostridioides difficile infection (CDI) is associated with increased hospital stays and mortality and a high likelihood of rehospitalization, leading to increased health resource use and costs. The objective was to estimate the economic burden of recurrent CDI (rCDI). METHODS Observational, retrospective study carried out in six hospitals. Adults aged ≥18 years with ≥1 confirmed diagnosis (primary or secondary) of rCDI between January 2010 and May 2018 were included. rCDI-related resource use included days of hospital stay (emergency room, ward, isolation and ICU), tests and treatments. For patients with primary diagnosis of rCDI, the complete hospital stay was attributed to rCDI. When diagnosis of rCDI was secondary, hospital stay attributed to rCDI was estimated using 1:1 propensity score matching as the difference in hospital stay compared to controls. Controls were hospitalizations without CDI recorded in the Spanish National Hospital Discharge Database. The cost was calculated by multiplying the natural resource units by the unit cost. Costs (euros) were updated to 2019. RESULTS We included 282 rCDI episodes (188 as primary diagnosis): 66.31% of patients were aged ≥65 years and 57.80% were female. The mean hospital stay (SD) was 17.18 (23.27) days: 86.17% of rCDI episodes were isolated for a mean (SD) of 10.30 (9.97) days. The total mean cost (95%-CI) per episode was €10,877 (9,499-12,777), of which the hospital stay accounted for 92.56. CONCLUSIONS There is high cost and resource use associated with rCDI, highlighting the importance of preventing rCDI to the Spanish National Health System.
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Affiliation(s)
| | | | | | | | | | | | | | - V Lozano
- Virginia Lozano, Merck Sharp-Dohme, Calle de Josefa Valcárcel, 38, 28027, Madrid, Spain.
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Granata G, Petrosillo N, Adamoli L, Bartoletti M, Bartoloni A, Basile G, Bassetti M, Bonfanti P, Borromeo R, Ceccarelli G, De Luca AM, Di Bella S, Fossati S, Franceschini E, Gentile I, Giacobbe DR, Giacometti E, Ingrassia F, Lagi F, Lobreglio G, Lombardi A, Lupo LI, Luzzati R, Maraolo AE, Mikulska M, Mondelli MU, Mularoni A, Mussini C, Oliva A, Pandolfo A, Rogati C, Trapani FF, Venditti M, Viale P, Caraffa E, Cataldo MA. Prospective Study on Incidence, Risk Factors and Outcome of Recurrent Clostridioides difficile Infections. J Clin Med 2021; 10:jcm10051127. [PMID: 33800334 PMCID: PMC7962640 DOI: 10.3390/jcm10051127] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/03/2021] [Accepted: 02/19/2021] [Indexed: 12/14/2022] Open
Abstract
Background: Limited and wide-ranging data are available on the recurrent Clostridioides difficile infection (rCDI) incidence rate. Methods: We performed a cohort study with the aim to assess the incidence of and risk factors for rCDI. Adult patients with a first CDI, hospitalized in 15 Italian hospitals, were prospectively included and followed-up for 30 d after the end of antimicrobial treatment for their first CDI. A case–control study was performed to identify risk factors associated with 30-day onset rCDI. Results: Three hundred nine patients with a first CDI were included in the study; 32% of the CDI episodes (99/309) were severe/complicated; complete follow-up was available for 288 patients (19 died during the first CDI episode, and 2 were lost during follow-up). At the end of the study, the crude all-cause mortality rate was 10.7% (33 deaths/309 patients). Two hundred seventy-one patients completed the follow-up; rCDI occurred in 21% of patients (56/271) with an incidence rate of 72/10,000 patient-days. Logistic regression analysis identified exposure to cephalosporin as an independent risk factor associated with rCDI (RR: 1.7; 95% CI: 1.1–2.7, p = 0.03). Conclusion: Our study confirms the relevance of rCDI in terms of morbidity and mortality and provides a reliable estimation of its incidence.
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Affiliation(s)
- Guido Granata
- Clinical and Research Department for Infectious Diseases, National Institute for Infectious Diseases L. Spallanzani IRCCS, 00149 Rome, Italy; (G.G.); (E.C.); (M.A.C.)
| | - Nicola Petrosillo
- Clinical and Research Department for Infectious Diseases, National Institute for Infectious Diseases L. Spallanzani IRCCS, 00149 Rome, Italy; (G.G.); (E.C.); (M.A.C.)
- Correspondence: ; Tel.: +39-0655-170-432
| | - Lucia Adamoli
- Infectious Diseases ISMETT IRCCS, 90127 Palermo, Italy; (L.A.); (A.M.D.L.); (A.M.)
| | - Michele Bartoletti
- Department of Medical and Surgical Sciences, “Alma Mater Studiorum”, IRCCS S. Orsola Teaching Hospital, University of Bologna, 40126 Bologna, Italy; (M.B.); (F.F.T.); (P.V.)
| | - Alessandro Bartoloni
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy; (A.B.); (G.B.); (F.L.)
| | - Gregorio Basile
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy; (A.B.); (G.B.); (F.L.)
| | - Matteo Bassetti
- Department of Health Sciences (DISSAL), University of Genoa, 16126 Genoa, Italy; (M.B.); (D.R.G.); (M.M.)
- Infectious Diseases Unit, San Martino Polyclinic Hospital—IRCCS, 16132 Genoa, Italy
- Infectious Diseases Clinic, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, 33100 Udine, Italy;
| | - Paolo Bonfanti
- Department of Infectious Diseases, San Gerardo Hospital, Monza—University of Milano-Bicocca, 20126 Milan, Italy;
| | | | - Giancarlo Ceccarelli
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Policlinico Umberto I, 00185 Rome, Italy; (G.C.); (A.O.); (M.V.)
| | - Anna Maria De Luca
- Infectious Diseases ISMETT IRCCS, 90127 Palermo, Italy; (L.A.); (A.M.D.L.); (A.M.)
| | - Stefano Di Bella
- Infectious Diseases Department, Azienda Sanitaria Universitaria Integrata di Trieste, 34128 Trieste, Italy; (S.D.B.); (S.F.); (R.L.)
| | - Sara Fossati
- Infectious Diseases Department, Azienda Sanitaria Universitaria Integrata di Trieste, 34128 Trieste, Italy; (S.D.B.); (S.F.); (R.L.)
| | - Erica Franceschini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, 41121 Modena, Italy; (E.F.); (C.M.); (C.R.)
| | - Ivan Gentile
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80138 Naples, Italy; (I.G.); (A.E.M.)
| | - Daniele Roberto Giacobbe
- Department of Health Sciences (DISSAL), University of Genoa, 16126 Genoa, Italy; (M.B.); (D.R.G.); (M.M.)
- Infectious Diseases Unit, San Martino Polyclinic Hospital—IRCCS, 16132 Genoa, Italy
| | - Enrica Giacometti
- Infectious Diseases Clinic, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, 33100 Udine, Italy;
| | | | - Filippo Lagi
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy; (A.B.); (G.B.); (F.L.)
| | | | - Andrea Lombardi
- Division of Infectious Diseases and Immunology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (A.L.); (M.U.M.)
| | | | - Roberto Luzzati
- Infectious Diseases Department, Azienda Sanitaria Universitaria Integrata di Trieste, 34128 Trieste, Italy; (S.D.B.); (S.F.); (R.L.)
| | - Alberto Enrico Maraolo
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80138 Naples, Italy; (I.G.); (A.E.M.)
| | - Malgorzata Mikulska
- Department of Health Sciences (DISSAL), University of Genoa, 16126 Genoa, Italy; (M.B.); (D.R.G.); (M.M.)
- Infectious Diseases Unit, San Martino Polyclinic Hospital—IRCCS, 16132 Genoa, Italy
| | - Mario Umberto Mondelli
- Division of Infectious Diseases and Immunology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (A.L.); (M.U.M.)
| | - Alessandra Mularoni
- Infectious Diseases ISMETT IRCCS, 90127 Palermo, Italy; (L.A.); (A.M.D.L.); (A.M.)
| | - Cristina Mussini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, 41121 Modena, Italy; (E.F.); (C.M.); (C.R.)
| | - Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Policlinico Umberto I, 00185 Rome, Italy; (G.C.); (A.O.); (M.V.)
| | | | - Carlotta Rogati
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, 41121 Modena, Italy; (E.F.); (C.M.); (C.R.)
| | - Filippo Fabio Trapani
- Department of Medical and Surgical Sciences, “Alma Mater Studiorum”, IRCCS S. Orsola Teaching Hospital, University of Bologna, 40126 Bologna, Italy; (M.B.); (F.F.T.); (P.V.)
| | - Mario Venditti
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Policlinico Umberto I, 00185 Rome, Italy; (G.C.); (A.O.); (M.V.)
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, “Alma Mater Studiorum”, IRCCS S. Orsola Teaching Hospital, University of Bologna, 40126 Bologna, Italy; (M.B.); (F.F.T.); (P.V.)
| | - Emanuela Caraffa
- Clinical and Research Department for Infectious Diseases, National Institute for Infectious Diseases L. Spallanzani IRCCS, 00149 Rome, Italy; (G.G.); (E.C.); (M.A.C.)
| | - Maria Adriana Cataldo
- Clinical and Research Department for Infectious Diseases, National Institute for Infectious Diseases L. Spallanzani IRCCS, 00149 Rome, Italy; (G.G.); (E.C.); (M.A.C.)
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Kulecka M, Waker E, Ambrozkiewicz F, Paziewska A, Skubisz K, Cybula P, Targoński Ł, Mikula M, Walewski J, Ostrowski J. Higher genome variability within metabolism genes associates with recurrent Clostridium difficile infection. BMC Microbiol 2021; 21:36. [PMID: 33509087 PMCID: PMC7842062 DOI: 10.1186/s12866-021-02090-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/08/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Clostridium difficile (C. difficile) is a major source of healthcare-associated infection with a high risk of recurrence, attributable to many factors such as usage of antibiotics, older age and immunocompromised status of the patients. C. difficile has also a highly diverse genome, which may contribute to its high virulence. Herein we examined whether the genome conservation, measured as non-synonymous to synonymous mutations ratio (dN/dS) in core genes, presence of single genes, plasmids and prophages increased the risk of reinfection in a subset of 134 C. difficile isolates from our previous study in a singly hemato-oncology ward. METHODS C. difficile isolates were subjected to whole-genome sequencing (WGS) on Ion Torrent PGM sequencer. Genomes were assembled with MIRA5 and annotated with prokka and VRprofile. Logistic regression was used to asses the relationship between single gene presence and the odds of infection recurrence. DN/dS ratios were computed with codeml. Functional annotation was conducted with eggNOG-Mapper. RESULTS We have found that the presence of certain genes, associated with carbon metabolism and oxidative phosphorylation, increased the odds of infection recurrence. More core genes were under positive selective pressure in recurrent disease isolates - they were mostly associated with the metabolism of aminoacids. Finally, prophage elements were more prevalent in single infection isolates and plasmids did not influence the odds of recurrence. CONCLUSIONS Our findings suggest higher genetic plasticity in isolates causing recurrent infection, associated mainly with metabolism. On the other hand, the presence of prophages seems to reduce the isolates' virulence.
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Affiliation(s)
- Maria Kulecka
- Department of Genetics, Maria Sklodowska-Curie National Research Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, 02-781, Warsaw, Poland
| | - Edyta Waker
- Department of Clinical Microbiology, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781, Warsaw, Poland
| | - Filip Ambrozkiewicz
- Department of Genetics, Maria Sklodowska-Curie National Research Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | - Agnieszka Paziewska
- Department of Genetics, Maria Sklodowska-Curie National Research Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, 02-781, Warsaw, Poland
| | - Karolina Skubisz
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, 02-781, Warsaw, Poland
| | - Patrycja Cybula
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, 02-781, Warsaw, Poland
| | - Łukasz Targoński
- Department of Lymphoproliferative Diseases, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781, Warsaw, Poland
| | - Michał Mikula
- Department of Genetics, Maria Sklodowska-Curie National Research Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | - Jan Walewski
- Department of Lymphoproliferative Diseases, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781, Warsaw, Poland
| | - Jerzy Ostrowski
- Department of Genetics, Maria Sklodowska-Curie National Research Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland.
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, 02-781, Warsaw, Poland.
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26
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Zhang G, Zhang C, Sun J, Xiong Y, Wang L, Chen D. Phytochemical Regulation of RNA in Treating Inflammatory Bowel Disease and Colon Cancer: Inspirations from Cell and Animal Studies. J Pharmacol Exp Ther 2021; 376:464-472. [PMID: 33397676 DOI: 10.1124/jpet.120.000354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 12/30/2020] [Indexed: 12/14/2022] Open
Abstract
Recent studies suggest an important role for RNA, especially noncoding RNA, in inflammatory bowel disease (IBD) and colon cancer. Drug development based on regulating RNA rather than protein is a promising new area. Phytochemicals are naturally occurring plant-derived compounds with chemical diversity, biologic activity, easy availability, and low toxicity. Many phytochemicals have been shown to exert protective effects on IBD and colon cancer through modulation of RNAs. The aim of this study was to summarize the advancements of phytochemicals in regulating RNA for the treatment of IBD and colon cancer. This review involves many phytochemicals, including polyphenols, flavones, and alkaloids, which can influence various types of RNAs, including microRNA, long noncoding RNA, as well as messenger RNA, by influencing a variety of upstream molecules or regulating epigenetic processes. The limitation for many current studies is that the specific mechanisms of phytochemicals regulating RNA have not been fully uncovered. Accompanied by more identified functions of RNAs, especially noncoding RNA functions, the screening of RNA-regulating phytochemicals has presented challenges as well as opportunities for the prevention and treatment of IBD and colon cancer. SIGNIFICANCE STATEMENT: Noncoding RNAs, which constitute the majority of the human transcriptional genome, play a key role in the disease state and are considered as important therapeutic targets in inflammatory bowel disease (IBD) and colon cancer. Recent studies have shown that phytochemicals regulate the expression of many noncoding RNAs involved in IBD and colon cancer. Therefore, identifying the specific molecular mechanism of phytochemicals regulating noncoding RNA in disease models may result in novel and effective therapeutic opportunities.
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Affiliation(s)
- Guolin Zhang
- Comparative Medicine Department of Researching and Teaching, Dalian Medical University, Dalian City, China (G.Z., C.Z., J.S., L.W., D.C.) and Central Laboratory, First Affiliated Hospital of Dalian Medical University, Dalian, China (Y.X.)
| | - Chi Zhang
- Comparative Medicine Department of Researching and Teaching, Dalian Medical University, Dalian City, China (G.Z., C.Z., J.S., L.W., D.C.) and Central Laboratory, First Affiliated Hospital of Dalian Medical University, Dalian, China (Y.X.)
| | - Jia'ao Sun
- Comparative Medicine Department of Researching and Teaching, Dalian Medical University, Dalian City, China (G.Z., C.Z., J.S., L.W., D.C.) and Central Laboratory, First Affiliated Hospital of Dalian Medical University, Dalian, China (Y.X.)
| | - Yongjian Xiong
- Comparative Medicine Department of Researching and Teaching, Dalian Medical University, Dalian City, China (G.Z., C.Z., J.S., L.W., D.C.) and Central Laboratory, First Affiliated Hospital of Dalian Medical University, Dalian, China (Y.X.)
| | - Liang Wang
- Comparative Medicine Department of Researching and Teaching, Dalian Medical University, Dalian City, China (G.Z., C.Z., J.S., L.W., D.C.) and Central Laboratory, First Affiliated Hospital of Dalian Medical University, Dalian, China (Y.X.)
| | - Dapeng Chen
- Comparative Medicine Department of Researching and Teaching, Dalian Medical University, Dalian City, China (G.Z., C.Z., J.S., L.W., D.C.) and Central Laboratory, First Affiliated Hospital of Dalian Medical University, Dalian, China (Y.X.)
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Gupta A, Ananthakrishnan AN. Economic burden and cost-effectiveness of therapies for Clostridiodes difficile infection: a narrative review. Therap Adv Gastroenterol 2021; 14:17562848211018654. [PMID: 34104214 PMCID: PMC8170348 DOI: 10.1177/17562848211018654] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/30/2021] [Indexed: 02/04/2023] Open
Abstract
Clostridioides difficile is the most common cause of healthcare-associated diarrhea. Disease complications as well as recurrent infections contribute significantly to morbidity and mortality. Over the past decades, there has been a rapid increase in the incidence of C. difficile infection (CDI), with a rise in the number of community-acquired cases. CDI has a profound economic impact on both the healthcare system and patients, secondary to recurrences, hospitalization, prolonged length of stay, cost of treatment, and indirect societal costs. With emergence of newer treatment options, the standard of care is shifting from metronidazole and vancomycin towards fidaxomicin and fecal microbiota transplantation (FMT), which despite being more expensive, are more efficacious in preventing recurrences and hence overall are more beneficial forms of therapy per cost-effectiveness analyses. Data regarding preferred route of FMT, timing of FMT, and non-conventional therapies such as bezlotoxumab is scant. There is a need for further studies to elucidate the true attributable costs of CDI as well as continued cost-effectiveness research to reduce the economic burden associated with the disease and improve clinical practice.
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Affiliation(s)
- Akshita Gupta
- Department of Medicine, Massachusetts General
Hospital, Boston, MA, USA
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Naclerio GA, Abutaleb NS, Li D, Seleem MN, Sintim HO. Ultrapotent Inhibitor of Clostridioides difficile Growth, Which Suppresses Recurrence In Vivo. J Med Chem 2020; 63:11934-11944. [PMID: 32960605 DOI: 10.1021/acs.jmedchem.0c01198] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Clostridioides difficile is the leading cause of healthcare-associated infection in the U.S. and considered an urgent threat by the Centers for Disease Control and Prevention (CDC). Only two antibiotics, vancomycin and fidaxomicin, are FDA-approved for the treatment of C. difficile infection (CDI), but these therapies still suffer from high treatment failure and recurrence. Therefore, new chemical entities to treat CDI are needed. Trifluoromethylthio-containing N-(1,3,4-oxadiazol-2-yl)benzamides displayed very potent activities [sub-μg/mL minimum inhibitory concentration (MIC) values] against Gram-positive bacteria. Here, we report remarkable antibacterial activity enhancement via halogen substitutions, which afforded new anti-C. difficile agents with ultrapotent activities [MICs as low as 0.003 μg/mL (0.007 μM)] that surpassed the activity of vancomycin against C. difficile clinical isolates. The most promising compound in the series, HSGN-218, is nontoxic to mammalian colon cells and is gut-restrictive. In addition, HSGN-218 protected mice from CDI recurrence. Not only does this work provide a potential clinical lead for the development of C. difficile therapeutics but also highlights dramatic drug potency enhancement via halogen substitution.
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Affiliation(s)
- George A Naclerio
- Chemistry Department, Institute for Drug Discovery, Purdue University, West Lafayette, Indiana 47907, United States
| | - Nader S Abutaleb
- Department of Comparative Pathobiology, Purdue University College of Veterinary Medicine, West Lafayette, Indiana 47907, United States
| | - Daoyi Li
- Department of Comparative Pathobiology, Purdue University College of Veterinary Medicine, West Lafayette, Indiana 47907, United States
| | - Mohamed N Seleem
- Department of Comparative Pathobiology, Purdue University College of Veterinary Medicine, West Lafayette, Indiana 47907, United States.,Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, Virginia 24060, United States.,Purdue Institute of Inflammation, Immunology, and Infectious Disease, West Lafayette, Indiana 47907, United States
| | - Herman O Sintim
- Chemistry Department, Institute for Drug Discovery, Purdue University, West Lafayette, Indiana 47907, United States.,Purdue Institute of Inflammation, Immunology, and Infectious Disease, West Lafayette, Indiana 47907, United States
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Mild or Malign: Clinical Characteristics and Outcomes of Clostridium difficile Infection in Thailand. J Clin Microbiol 2020; 58:JCM.01217-20. [PMID: 32580954 DOI: 10.1128/jcm.01217-20] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 06/22/2020] [Indexed: 01/02/2023] Open
Abstract
Little is known about the clinical characteristics of Clostridium difficile infection (CDI) in Asia in general, and Thailand specifically, with a few studies suggesting that the disease may be milder than elsewhere. This study aimed to describe CDI in Thailand, evaluate treatment options and their outcomes, and explore possible protective factors responsible for any unique disease characteristics. From 2015 to 2018, 469 patients were included in the study. All patients had their stools tested for the tcdB gene by direct PCR and detection of toxigenic C. difficile by culture. C. difficile isolates were subjected to toxin gene profiling and ribotyping, and patient medical records were reviewed retrospectively. There were 248 and 221 patients included in CDI and control groups, respectively. The CDI group had a higher overall 30-day mortality rate than the control group (21% versus 14%, P = 0.046), but only 2 deaths (1%) were directly attributable to CDI. Metronidazole treatment was not inferior to vancomycin in this population, and vancomycin was associated with a higher 30-day mortality rate (P = 0.047). The prevalence of severe CDI and disease outcomes were not different between patients infected with A-B+ C. difficile and A+B+ C. difficile strains or between patients with and without colonization by nontoxigenic C. difficile Besides C. difficile-specific tests, neither a single laboratory result nor a combination of results was predictive of CDI. In conclusion, CDI in Thailand was relatively mild, and metronidazole remained an effective treatment option for these mild infections.
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Murray B, Wolfe C, Marra A, Pillar C, Shinabarger D. In vitro activity of the novel antibacterial agent ibezapolstat (ACX-362E) against Clostridioides difficile. J Antimicrob Chemother 2020; 75:2149-2155. [PMID: 32285102 DOI: 10.1093/jac/dkaa134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 03/10/2020] [Accepted: 03/14/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Ibezapolstat (ACX-362E) is the first DNA polymerase IIIC inhibitor undergoing clinical development for the oral treatment of Clostridioides difficile infection (CDI). METHODS In this study, the in vitro activity of ibezapolstat was evaluated against a panel of 104 isolates of C. difficile, including those with characterized ribotypes (e.g. 027 and 078) and those producing toxin A or B and was shown to have similar activity to those of comparators against these strains. RESULTS The overall MIC50/90 (mg/L) for ibezapolstat against evaluated C. difficile was 2/4, compared with 0.5/4 for metronidazole, 1/4 for vancomycin and 0.5/2 for fidaxomicin. In addition, the bactericidal activity of ibezapolstat was evaluated against actively growing C. difficile by determining the MBC against three C. difficile isolates. Time-kill kinetic assays were additionally performed against the three C. difficile isolates, with metronidazole and vancomycin as comparators. CONCLUSIONS The killing of C. difficile by ibezapolstat was observed to occur at concentrations similar to its MIC, as demonstrated by MBC:MIC ratios and reflected in time-kill kinetic assays. This activity highlights the therapeutic potential of ibezapolstat for the treatment of CDI.
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Affiliation(s)
- Beverly Murray
- Micromyx, Inc, 4717 Campus Drive, Kalamazoo, MI 49008, USA
| | | | - Andrea Marra
- Micromyx, Inc, 4717 Campus Drive, Kalamazoo, MI 49008, USA
| | - Chris Pillar
- Micromyx, Inc, 4717 Campus Drive, Kalamazoo, MI 49008, USA
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Oral vancomycin prophylaxis for the prevention of Clostridium difficile infection: A systematic review and meta-analysis. Infect Control Hosp Epidemiol 2020; 41:1302-1309. [PMID: 32594929 DOI: 10.1017/ice.2020.277] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Recently, oral vancomycin prophylaxis (OVP) has been suggested for the prevention of Clostridium difficile infection (CDI). We conducted a systematic review and meta-analysis to investigate the efficacy and safety of this approach. DESIGN Systematic review and meta-analysis. METHODS We conducted a computerized search of MEDLINE, EMBASE, and Cochrane databases from inception to March 2019 for publications investigating OVP for CDI prevention. Results were screened for eligibility. Relevant data were extracted and analyzed. Publication bias was assessed using the Egger test. RESULTS Ultimately, 8 retrospective studies and 1 prospective study examining 2174 patients, published between 2016 and 2019 were included in the review. OVP was associated with decreased CDI (odds ratio, 0.263; 95% confidence interval, 0.13-0.52) with considerable heterogeneity (I2 = 61%). Meta-regression showed that total daily dose of OVP correlated with CDI, explaining 100% of heterogeneity between studies. Furthermore, 3 studies evaluated the risk of vancomycin-resistant enterococci (VRE) infection after OVP and found no significant increase. CONCLUSION Our results suggest that OVP might decrease CDI rates in at-risk populations, although this conclusion should be interpreted with caution. Higher daily doses of OVP might increase CDI. Although the use of OVP in high-risk patients may reduce CDI, this suggestion has yet to be validated by prospective blinded randomized controlled trials.
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Connor KA, Conn KM. Analysis of the impact of secondary prophylaxis on Clostridioides difficile recurrence in critically ill adults. SAGE Open Med 2020; 8:2050312120930898. [PMID: 32587690 PMCID: PMC7294487 DOI: 10.1177/2050312120930898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/11/2020] [Indexed: 12/02/2022] Open
Abstract
Introduction: Clostridioides (formerly Clostridium) difficile infection recurrence in patients re-exposed to antibiotics for treatment of a non-Clostridioides difficile infection is high at approximately 33%. Low-dose per os vancomycin (e.g. 125 mg q12 h) or metronidazole (e.g. 500 mg intravenous/per osq8 h) may help prevent recurrences, but study of secondary prophylaxis in critically ill patients is needed. Objectives: To determine whether critically ill adults receiving low-dose per os vancomycin for secondary Clostridioides difficile infection prophylaxis have fewer recurrences of Clostridioides difficile infection in 90 days compared with patients receiving metronidazole for secondary Clostridioides difficile infection prophylaxis or control (no secondary prophylaxis). Methods: This was a retrospective, two-center, observational study in a large academic medical center and affiliated community hospital. Included patients had a history of Clostridioides difficile infection within 1 year of receiving antibiotics for clinical care. We compared patients receiving secondary prophylaxis with vancomycin or metronidazole and control patients; in addition, an unplanned fourth group (vancomycin/metronidazole combination) was identified and analyzed. The primary outcome was Clostridioides difficile infection recurrence within 90 days of a course of broad-spectrum antibiotic therapy. Fisher’s exact, analysis of variance, and Kruskal–Wallis tests were used to compare Clostridioides difficile infection recurrence with prophylaxis group and additional contributing factors. Results: Eighty-two patients were included: 38 control (46.3%), 20 metronidazole (24.4%), 17 vancomycin (20.7%), and 7 combination (8.5%). Ten of 82 patients (12.2%) had at least one Clostridioides difficile infection recurrence; 8/38 patients in the control group (21.1%), 1/7 patients in the combination group (14.3%), 1/17 patients in the per os vancomycin group (5.9%), and 0/20 in the metronidazole group (0%; p = 0.073). As a post hoc secondary analysis, the three prophylaxis groups were coalesced into one group and compared with control (4.5% vs 21%; p = 0.039). Additional factors (e.g. age, obesity, immunosuppression, acid suppression) were not significantly associated with Clostridioides difficile infection recurrence or with prophylaxis group. Conclusion: There was no difference in Clostridioides difficile infection recurrence between prophylaxis groups, however, given the low recurrence rate, prospective evaluation with a larger sample of critically ill patients is necessary.
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Affiliation(s)
- Kathryn A Connor
- Department of Pharmacy Practice and Administration, Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY, USA
| | - Kelly M Conn
- Department of Pharmacy Practice and Administration, Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY, USA
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Bundling Probiotics With Antimicrobial Stewardship Programs for the Prevention of Clostridiodes difficile Infections in Acute Care Hospitals. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2020. [DOI: 10.1097/ipc.0000000000000853] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cho JM, Pardi DS, Khanna S. Update on Treatment of Clostridioides difficile Infection. Mayo Clin Proc 2020; 95:758-769. [PMID: 32247350 DOI: 10.1016/j.mayocp.2019.08.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/30/2019] [Accepted: 08/12/2019] [Indexed: 02/06/2023]
Abstract
Clostridioides difficile infection (CDI) is the leading cause of health care-associated infections in the United States. The increasing incidence and recurrence rates of CDI together with its associated morbidity and mortality are great concerns. Newer treatment methods, such as narrow-spectrum antibiotics, monoclonal antibodies, and microbial replacement therapies, are being developed and implemented. We searched PubMed to identify published literature from 2010 to 2018 using the following keywords: Clostridium difficile, treatment, and therapy. Cited references were also used to identify relevant literature. This review focuses on the current standard of therapy and emerging therapies for CDI and summarizes the updated guidelines on treatment of CDI.
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Affiliation(s)
- Janice M Cho
- Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Sahil Khanna
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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Mutters R, Walger P, Lübbert C. Calculated initial parenteral treatment of bacterial infections: Bacterial gastrointestinal infections. GMS INFECTIOUS DISEASES 2020; 8:Doc06. [PMID: 32373431 PMCID: PMC7186808 DOI: 10.3205/id000050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This is the fourteenth chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. Bacterial gastrointestinal infections are still the leading cause of death worldwide. The chapter describes the etiology of bacterial gastrointestinal infections in Germany and their frequency. Recommendations are given for the calculated therapy of these infections and for targeted antibiotic therapy for known pathogens. Particular attention is paid to Clostridium difficile. The diagnostic and therapeutic options of antibiotic therapy of the various infection patterns in this pathogen are discussed.
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Affiliation(s)
- Reinier Mutters
- Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Philipps-Universität Marburg, Germany
| | - Peter Walger
- Verbund Katholischer Kliniken Düsseldorf, Zentralbereich Hygiene, Infektionsmanagement und ABS, Düsseldorf, Germany
| | - Christoph Lübbert
- Klinik und Poliklinik für Gastroenterologie und Rheumatologie, Universitätsklinikum Leipzig, Germany
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Lau VI, Rochwerg B, Xie F, Johnstone J, Basmaji J, Balakumaran J, Iansavichene A, Cook DJ. Probiotics in hospitalized adult patients: a systematic review of economic evaluations. Can J Anaesth 2020; 67:247-261. [PMID: 31721100 PMCID: PMC7222908 DOI: 10.1007/s12630-019-01525-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 09/05/2019] [Accepted: 09/06/2019] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Probiotics may prevent healthcare-associated infections, such as ventilator-associated pneumonia, Clostridioides difficile-associated diarrhea, and other adverse outcomes. Despite their potential benefits, there are no summative data examining the cost-effectiveness of probiotics in hospitalized patients. This systematic review summarized studies evaluating the economic impact of using probiotics in hospitalized adult patients. METHODS We searched MEDLINE, EMBASE, CENTRAL, ACP Journal Club, and other EBM reviews (inception to January 31, 2019) for health economics evaluations examining the use of probiotics in hospitalized adults. Independently and in duplicate, we extracted data study characteristics, risk of bias, effectiveness and total costs (medications, diagnostics/procedures, devices, personnel, hospital) associated with healthcare-associated infections (ventilator-associated pneumonia, Clostridioides difficile-associated diarrhea and antibiotic-associated diarrhea). We used Grading of Recommendations Assessment, Development and Evaluation methods to assess certainty in the overall cost-effectiveness evidence. RESULTS Of 721 citations identified, we included seven studies. For the clinical outcomes of interest, there was one randomized-controlled trial (RCT)-based health economic evaluation, and six model-based health economic evaluations. Probiotics showed favourable cost-effectiveness in six of seven (86%) economic evaluations. Three of the seven studies were manufacturer-supported, all which suggested cost-effectiveness. Certainty of cost-effectiveness evidence was very low because of risk of bias, imprecision, and inconsistency. CONCLUSION Probiotics may be an economically attractive intervention for preventing ventilator-associated pneumonia, Clostridioides difficile-associated diarrhea, and antibiotic-associated diarrhea in hospitalized adult patients. Nevertheless, certainty about their cost-effectiveness evidence is very low. Future RCTs examining probiotics should incorporate cost data to inform bedside practice, clinical guidelines, and healthcare policy. TRIAL REGISTRATION PROSPERO CRD42019129929; Registered 25 April, 2019.
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Affiliation(s)
- Vincent I Lau
- Department of Medicine, Division of Critical Care Medicine, Western University, London, ON, Canada.
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada.
- Department of Medicine, Division of Critical Care, Schulich School of Medicine and Dentistry, Western University, 800 Commissioners Road East, London, ON, Canada.
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - Feng Xie
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - Jennie Johnstone
- Public Health Ontario, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - John Basmaji
- Department of Medicine, Division of Critical Care Medicine, Western University, London, ON, Canada
| | - Jana Balakumaran
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Deborah J Cook
- Department of Medicine, Division of Critical Care Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
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Validation of the SHEA/IDSA severity criteria to predict poor outcomes among inpatients and outpatients with Clostridioides difficile infection. Infect Control Hosp Epidemiol 2020; 41:510-516. [PMID: 31996280 DOI: 10.1017/ice.2020.8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To determine whether the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) Clostridioides difficile infection (CDI) severity criteria adequately predicts poor outcomes. DESIGN Retrospective validation study. SETTING AND PARTICIPANTS Patients with CDI in the Veterans’ Affairs Health System from January 1, 2006, to December 31, 2016. METHODS For the 2010 criteria, patients with leukocytosis or a serum creatinine (SCr) value ≥1.5 times the baseline were classified as severe. For the 2018 criteria, patients with leukocytosis or a SCr value ≥1.5 mg/dL were classified as severe. Poor outcomes were defined as hospital or intensive care admission within 7 days of diagnosis, colectomy within 14 days, or 30-day all-cause mortality; they were modeled as a function of the 2010 and 2018 criteria separately using logistic regression. RESULTS We analyzed data from 86,112 episodes of CDI. Severity was unclassifiable in a large proportion of episodes diagnosed in subacute care (2010, 58.8%; 2018, 49.2%). Sensitivity ranged from 0.48 for subacute care using 2010 criteria to 0.73 for acute care using 2018 criteria. Areas under the curve were poor and similar (0.60 for subacute care and 0.57 for acute care) for both versions, but negative predictive values were >0.80. CONCLUSIONS Model performances across care settings and criteria versions were generally poor but had reasonably high negative predictive value. Many patients in the subacute-care setting, an increasing fraction of CDI cases, could not be classified. More work is needed to develop criteria to identify patients at risk of poor outcomes.
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Rauseo AM, Olsen MA, Reske KA, Dubberke ER. Strategies to prevent adverse outcomes following Clostridioides difficile infection in the elderly. Expert Rev Anti Infect Ther 2020; 18:203-217. [PMID: 31976779 DOI: 10.1080/14787210.2020.1717950] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Clostridioides difficile remains the most common cause of healthcare-associated infections in the US, and it disproportionately affects the elderly. Older patients are more susceptible and have a greater risk of adverse outcomes from C. difficile infection (CDI), despite advances in treatment and prevention.Areas covered: The epidemiology and pathogenesis of CDI, as well as risk factors in the aging host, will be reviewed. The importance of antimicrobial stewardship and infection prevention in order to avoid acquisition and transmission will be discussed, as well as strategies to prevent adverse outcomes and recurrent CDI, through optimization of CDI treatment s,election.Expert opinion: Appropriate CDI-prevention strategies to avoid adverse outcomes in this susceptible population involve antimicrobial stewardship and methods to prevent C. difficile transmission in healthcare settings. Management strategies to prevent adverse outcomes include initiation of supportive therapy and proper selection of CDI specific treatments. Many patients may also benefit from adjunctive therapies or additional procedures.
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Affiliation(s)
- Adriana M Rauseo
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO, USA
| | - Margaret A Olsen
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO, USA
| | - Kimberly A Reske
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO, USA
| | - Erik R Dubberke
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO, USA
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Lomeli BK, Galbraith H, Schettler J, Saviolakis GA, El-Amin W, Osborn B, Ravel J, Hazleton K, Lozupone CA, Evans RJ, Bell SJ, Ochsner UA, Jarvis TC, Baqar S, Janjic N. Multiple-Ascending-Dose Phase 1 Clinical Study of the Safety, Tolerability, and Pharmacokinetics of CRS3123, a Narrow-Spectrum Agent with Minimal Disruption of Normal Gut Microbiota. Antimicrob Agents Chemother 2019; 64:e01395-19. [PMID: 31685472 PMCID: PMC7187627 DOI: 10.1128/aac.01395-19] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 10/09/2019] [Indexed: 12/26/2022] Open
Abstract
CRS3123 is a novel small molecule that potently inhibits methionyl-tRNA synthetase of Clostridioides difficile, inhibiting C. difficile toxin production and spore formation. CRS3123 has been evaluated in a multiple-ascending-dose placebo-controlled phase 1 trial. Thirty healthy subjects, ages 18 to 45 years, were randomized into three cohorts of 10 subjects each, receiving either 200, 400, or 600 mg of CRS3123 (8 subjects per cohort) or placebo (2 subjects per cohort) by oral administration twice daily for 10 days. CRS3123 was generally safe and well tolerated, with no serious adverse events (SAEs) or severe treatment-emergent adverse events (TEAEs) reported. All subjects completed their assigned treatment and follow-up visits, and there were no trends in systemic, vital sign, or laboratory TEAEs. There were no QTcF interval changes or any clinically significant changes in other electrocardiogram (ECG) intervals or morphology. CRS3123 showed limited but detectable systemic uptake; although absorption increased with increasing dose, the increase was less than dose proportional. Importantly, the bulk of the oral dose was not absorbed, and fecal concentrations were substantially above the MIC90 value of 1 μg/ml at all dosages tested. Subjects receiving either of the two lower doses of CRS3123 exhibited minimal disruption of normal gut microbiota after 10 days of twice-daily dosing. CRS3123 was inactive against important commensal anaerobes, including Bacteroides, bifidobacteria, and commensal clostridia. Microbiome data showed favorable differentiation compared to other CDI therapeutics. These results support further development of CRS3123 as an oral agent for the treatment of CDI. (This study has been registered at Clinicaltrials.gov under identifier NCT02106338.).
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Affiliation(s)
| | - Hal Galbraith
- Quintiles Phase One Services, Overland Park, Kansas, USA
| | | | | | - Wael El-Amin
- DynPort Vaccine Company LLC, Frederick, Maryland, USA
| | - Blaire Osborn
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Jacques Ravel
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Keith Hazleton
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Catherine A Lozupone
- Division of Biomedical Informatics and Personalized Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | | | | | | | - Shahida Baqar
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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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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Shao X, AbdelKhalek A, Abutaleb NS, Velagapudi UK, Yoganathan S, Seleem MN, Talele TT. Chemical Space Exploration around Thieno[3,2- d]pyrimidin-4(3 H)-one Scaffold Led to a Novel Class of Highly Active Clostridium difficile Inhibitors. J Med Chem 2019; 62:9772-9791. [PMID: 31584822 DOI: 10.1021/acs.jmedchem.9b01198] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Clostridium difficile infection (CDI) is the leading cause of healthcare-associated infection in the United States. Therefore, development of novel treatments for CDI is a high priority. Toward this goal, we began in vitro screening of a structurally diverse in-house library of 67 compounds against two pathogenic C. difficile strains (ATCC BAA 1870 and ATCC 43255), which yielded a hit compound, 2-methyl-8-nitroquinazolin-4(3H)-one (2) with moderate potency (MIC = 312/156 μM). Optimization of 2 gave lead compound 6a (2-methyl-7-nitrothieno[3,2-d]pyrimidin-4(3H)-one) with improved potency (MIC = 19/38 μM), selectivity over normal gut microflora, CC50s > 606 μM against mammalian cell lines, and acceptable stability in simulated gastric and intestinal fluid. Further optimization of 6a at C2-, N3-, C4-, and C7-positions resulted in a library of >50 compounds with MICs ranging from 3 to 800 μM against clinical isolates of C. difficile. Compound 8f (MIC = 3/6 μM) was identified as a promising lead for further optimization.
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Affiliation(s)
- Xuwei Shao
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences , St. John's University , Queens , New York 11439-0001 , United States
| | - Ahmed AbdelKhalek
- Department of Comparative Pathobiology , Purdue University College of Veterinary Medicine , West Lafayette , Indiana 47907-2027 , United States
| | - Nader S Abutaleb
- Department of Comparative Pathobiology , Purdue University College of Veterinary Medicine , West Lafayette , Indiana 47907-2027 , United States
| | - Uday Kiran Velagapudi
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences , St. John's University , Queens , New York 11439-0001 , United States
| | - Sabesan Yoganathan
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences , St. John's University , Queens , New York 11439-0001 , United States
| | - Mohamed N Seleem
- Department of Comparative Pathobiology , Purdue University College of Veterinary Medicine , West Lafayette , Indiana 47907-2027 , United States.,Purdue Institute of Inflammation, Immunology, and Infectious Disease , West Lafayette , Indiana 47907-2027 , United States
| | - Tanaji T Talele
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences , St. John's University , Queens , New York 11439-0001 , United States
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Peng Z, Simeon R, Mitchell SB, Zhang J, Feng H, Chen Z. Designed Ankyrin Repeat Protein (DARPin) Neutralizers of TcdB from Clostridium difficile Ribotype 027. mSphere 2019; 4:e00596-19. [PMID: 31578248 PMCID: PMC6796971 DOI: 10.1128/msphere.00596-19] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 09/11/2019] [Indexed: 02/08/2023] Open
Abstract
Clostridium difficile infection (CDI) is a leading cause of hospital-acquired diarrhea. In recent decades, the emergence of the "hypervirulent" BI/NAP1/027 strains of C. difficile significantly increased the morbidity and mortality of CDI. The pathogenesis of CDI is primarily mediated by the action of two toxins, TcdA and TcdB, with TcdB being the major virulent factor in humans. In this report, we describe the engineering of a panel of designed ankyrin repeat proteins (DARPins) that potently neutralize TcdB from the BI/NAP1/027 strains (e.g., TcdBUK1). The most effective DARPin, D16, inhibits TcdBUK1 with a 50% effective concentration (EC50) of 0.5 nM, which is >66-fold lower than that of the FDA-approved anti-TcdB antibody bezlotoxumab (EC50, ∼33 nM). Competitive enzyme-linked immunosorbent assays (ELISAs) showed that D16 blocks interactions between TcdB and its receptor, chondroitin sulfate proteoglycan 4 (CSPG4). The dimeric DARPin U3D16, which pairs D16 with DARPin U3, a disrupter of the interaction of TcdB with Frizzled 1/2/7 receptor, exhibits 10-fold-to-20-fold-enhanced neutralization potency against TcdB from C. difficile strains VPI 10463 (laboratory strain) and M68 (CF/NAP9/017) but identical activity against TcdBUK1 relative to D16. Subsequent ELISAs revealed that TcdBUK1 did not significantly interact with Frizzled 1/2/7. Computation modeling revealed 4 key differences at the Frizzled 1/2/7 binding interface which are likely responsible for the significantly reduced binding affinity.IMPORTANCE We report the engineering and characterization of designed ankyrin proteins as potent neutralizers of TcdB toxin secreted by a hypervirulent ribotype 027 strain of Clostridium difficile We further show that although TcdB toxins from both ribotype 027 and VPI 10461 interact efficiently with TcdB receptors CSPG4 and Pvrl3, TcdB027 lacks significant ability to bind the only known physiologically relevant TcdB receptor, Frizzled 1/2/7.
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Affiliation(s)
- Zeyu Peng
- Department of Microbial Pathogenesis and Immunology, Texas A&M University Health Science Center, College Station, Texas, USA
| | - Rudo Simeon
- Department of Microbial Pathogenesis and Immunology, Texas A&M University Health Science Center, College Station, Texas, USA
| | - Samuel B Mitchell
- Department of Microbial Pathogenesis and Immunology, Texas A&M University Health Science Center, College Station, Texas, USA
| | - Junjie Zhang
- Department of Biochemistry and Biophysics, Texas A&M University, College Station, Texas, USA
| | - Hanping Feng
- Department of Microbial Pathogenesis, University of Maryland Dental School, Baltimore, Maryland, USA
| | - Zhilei Chen
- Department of Microbial Pathogenesis and Immunology, Texas A&M University Health Science Center, College Station, Texas, USA
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Chiu CY, Sarwal A, Feinstein A, Hennessey K. Effective Dosage of Oral Vancomycin in Treatment for Initial Episode of Clostridioides difficile Infection: A Systematic Review and Meta-Analysis. Antibiotics (Basel) 2019; 8:antibiotics8040173. [PMID: 31581576 PMCID: PMC6963925 DOI: 10.3390/antibiotics8040173] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 09/08/2019] [Accepted: 09/25/2019] [Indexed: 12/23/2022] Open
Abstract
Background: Oral vancomycin is a first line treatment for an initial episode of Clostridioides difficile infection. However, the comparative efficacy of different dosing regimens is lacking evidence in the current literature. Methods: We searched PubMed, Embase, Cochrane Library, and ClinicalTrials.gov. from inception to May 2019. Only articles published in English are reviewed. This meta-analysis compares the effects of low dose oral vancomycin (<2 g per day) versus high dose vancomycin (2 g per day) for treatment of initial Clostridioides difficile infection. Results: One randomized controlled trial and two retrospective cohort studies are included. A total of 137 patients are identified, 53 of which were treated with low dose oral vancomycin (39%) and 84 with high dose oral vancomycin (61%). There is no significant reduction in recurrence rates with high dose vancomycin compared to low dose vancomycin for treating initial episodes of non-fulminant Clostridioides difficile infection ((odds ratio (OR) 2.058, 95%, confidence interval (CI): 0.653 to 6.489). Conclusions: Based on limited data in the literature, low dose vancomycin is no different than high dose vancomycin for treatment of an initial episode of Clostridioides difficile infection in terms of recurrence rate. Additional large clinical trials comparing the different dosages of vancomycin in initial Clostridioides difficile infection are warranted.
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Affiliation(s)
- Chia-Yu Chiu
- Department of Internal Medicine, Lincoln Medical Center, New York, NY 10451, USA.
| | - Amara Sarwal
- Department of Internal Medicine, Lincoln Medical Center, New York, NY 10451, USA.
| | - Addi Feinstein
- Department of Internal Medicine, Section of Infectious Diseases, Lincoln Medical Center, New York, NY 10451, USA.
| | - Karen Hennessey
- Department of Internal Medicine, Section of Infectious Diseases, Lincoln Medical Center, New York, NY 10451, USA.
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Kouhsari E, Douraghi M, Krutova M, Fakhre Yaseri H, Talebi M, Baseri Z, Moqarabzadeh V, Sholeh M, Amirmozafari N. The emergence of metronidazole and vancomycin reduced susceptibility in Clostridium difficile isolates in Iran. J Glob Antimicrob Resist 2019; 18:28-33. [PMID: 30703583 DOI: 10.1016/j.jgar.2019.01.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 12/17/2018] [Accepted: 01/21/2019] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Clostridium difficile (C. difficile) is the main causative agent of antibiotic-associated diarrhoea (AAD) and pseudomembranous colitis. The accumulation of antimicrobial resistance in C. difficile strains can drive C. difficile infection (CDI) epidemiology. This study was undertaken to evaluate the antimicrobial resistance patterns of toxigenic C. difficile isolates cultured from diarrhoeal stool samples of hospitalised patients with suspected CDI in three tertiary care hospitals in Tehran, Iran. METHODS Two hundred and fifty diarrhoeal stool samples were investigated by toxigenic culture using cycloserine-cefoxitin-fructose agar and the VERO cell line. Antimicrobial susceptibility to metronidazole, vancomycin, clindamycin, tetracycline, and moxifloxacin was performed by disk diffusion and Etest methods on Brucella Blood Agar supplemented with hemin and vitamin K. RESULTS Thirty-five stool samples (14.0%) proved positive using C. difficile toxigenic culture. According to Clinical and Laboratory Standards Institute breakpoints, the following resistance was identified in C. difficile isolates: metronidazole (2 of 35); moxifloxacin (7 of 35); clindamycin (18 of 35); and tetracycline (5 of 35). Using European Committee on Antimicrobial Susceptibility Testing breakpoints, three of 35 isolates showed reduced-susceptibility for vancomycin and 14 of 35 for metronidazole. In addition, the results showed a good correlation between the inhibition zone diameter (disk diffusion) and MIC values (Etest); Pearson correlation coefficient 0.7400.95 (P< 0.001). CONCLUSIONS Multidrug resistance was observed in Iranian clinical toxigenic C. difficile isolates, including reduced susceptibility to first-line CDI treatment drugs. In addition, disk diffusion can be used as a cost-effective option for the antimicrobial susceptibility testing of C. difficile isolates.
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Affiliation(s)
- Ebrahim Kouhsari
- Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran; Clinical Microbiology Research Center, Ilam University of Medical Sciences, Ilam, Iran; Laboratory Sciences Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - Masoumeh Douraghi
- Division of Microbiology, Department of Pathobiology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Marcela Krutova
- Department of Medical Microbiology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Hashem Fakhre Yaseri
- Research Center for Gastroenterology and Liver Disease, Firouzgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Malihe Talebi
- Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Zohreh Baseri
- Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Vahid Moqarabzadeh
- Department of Biostatistics, School of Health, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mohammad Sholeh
- Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Nour Amirmozafari
- Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
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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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Hasan N, Yang H. Factors affecting the composition of the gut microbiota, and its modulation. PeerJ 2019; 7:e7502. [PMID: 31440436 PMCID: PMC6699480 DOI: 10.7717/peerj.7502] [Citation(s) in RCA: 306] [Impact Index Per Article: 61.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 07/17/2019] [Indexed: 12/13/2022] Open
Abstract
Gut microbiota have important functions in the body, and imbalances in the composition and diversity of those microbiota can cause several diseases. The host fosters favorable microbiota by releasing specific factors, such as microRNAs, and nonspecific factors, such as antimicrobial peptides, mucus and immunoglobulin A that encourage the growth of specific types of bacteria and inhibit the growth of others. Diet, antibiotics, and age can change gut microbiota, and many studies have shown the relationship between disorders of the microbiota and several diseases and reported some ways to modulate that balance. In this review, we highlight how the host shapes its gut microbiota via specific and nonspecific factors, how environmental and nutritional factors affect it, and how to modulate it using prebiotics, probiotics, and fecal microbiota transplantation.
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Affiliation(s)
- Nihal Hasan
- Department of Microbiology, Northeast Forestry University, Harbin, Heilongjiang, China.,Faculty of Health Science, Al-Baath University, Homs, Syria
| | - Hongyi Yang
- Department of Microbiology, Northeast Forestry University, Harbin, Heilongjiang, China
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Saha S, Kapoor S, Tariq R, Schuetz AN, Tosh PK, Pardi DS, Khanna S. Increasing antibiotic resistance in Clostridioides difficile: A systematic review and meta-analysis. Anaerobe 2019; 58:35-46. [PMID: 31330183 DOI: 10.1016/j.anaerobe.2019.102072] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/14/2019] [Accepted: 07/15/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Decreases in clinical response of Clostridioides difficile to antibiotics used for its treatment have raised concerns regarding antibiotic resistance. We conducted a systematic review and meta-analysis to study the resistance rates of C. difficile to various antibiotics over time. METHODS We systematically searched MEDLINE, Embase, and Web of Science from inception through 03/31/2017 for observational studies assessing antibiotic resistance rates in C. difficile. Weighted summary estimates were calculated using inverse variance heterogeneity models [MetaXL software (v. 5.3)]. A priori subgroup analyses were done (by study year, continent, susceptibility testing method, origin of isolates); ribotype 027 strains were analyzed separately. RESULTS From 1982 to 2017, 60 studies (8336 isolates) were analyzed. Fifty-three studies reported vancomycin resistance; weighted pooled resistance (WPR), 2.1% (95% CI, 0%-5.1%; I2 = 95%). Fifty-five studies reported metronidazole resistance; WPR, 1.9% (95% CI, 0.5%-3.6%; I2 = 89%). Compared to the period before 2012, vancomycin resistance increased by 3.6% (95% CI, 2.9%-4.2%; P < 0.001) after 2012, and metronidazole resistance decreased by 0.8% (95% CI, 0.1%-1.5%; P = 0.02). No isolates were resistant to fidaxomicin. CONCLUSION Resistance of C. difficile to vancomycin is increasing, with a smaller, declining resistance to metronidazole; there is significant heterogeneity between studies. Ongoing monitoring of resistance to commonly used antibiotics is required.
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Affiliation(s)
- Srishti Saha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Saloni Kapoor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Raseen Tariq
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Audrey N Schuetz
- Division of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Pritish K Tosh
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN, 55905, USA
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Sahil Khanna
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA.
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Major G, Bradshaw L, Boota N, Sprange K, Diggle M, Montgomery A, Jawhari A, Spiller RC. Follow-on RifAximin for the Prevention of recurrence following standard treatment of Infection with Clostridium Difficile (RAPID): a randomised placebo controlled trial. Gut 2019; 68:1224-1231. [PMID: 30254135 PMCID: PMC6582824 DOI: 10.1136/gutjnl-2018-316794] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) recurs after initial treatment in approximately one in four patients. A single-centre pilot study suggested that this could be reduced using 'follow-on' rifaximin treatment. We aimed to assess the efficacy of rifaximin treatment in preventing recurrence. METHODS A multisite, parallel group, randomised, placebo controlled trial recruiting patients aged ≥18 years immediately after resolution of CDI through treatment with metronidazole or vancomycin. Participants received either rifaximin 400 mg three times a day for 2 weeks, reduced to 200 mg three times a day for a further 2 weeks or identical placebo. The primary endpoint was recurrence of CDI within 12 weeks of trial entry. RESULTS Between December 2012 and March 2016, 151 participants were randomised to either rifaximin or placebo. Primary outcome data were available on 130. Mean age was 71.9 years (SD 15.3). Recurrence within 12 weeks was 29.5% (18/61) among participants allocated to placebo compared with 15.9% (11/69) among those allocated to rifaximin, a difference between groups of 13.7% (95% CI -28.1% to 0.7%, p=0.06). The risk ratio was 0.54 (95% CI 0.28 to 1.05, p=0.07). During 6-month safety follow-up, nine participants died in each group (12%). Adverse event rates were similar between groups. CONCLUSION While 'follow-on' rifaximin after CDI appeared to halve recurrence rate, we failed to reach our recruitment target in this group of frail elderly patients, so the estimated effect of rifaximin lacks precision. A meta-analysis including a previous trial suggests that rifaximin may be effective; however, further, larger confirmatory studies are needed.
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Affiliation(s)
- Giles Major
- Nottingham Digestive Diseases Centre and NIHR Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust, the University of Nottingham, Nottingham, Notts, UK
| | - Lucy Bradshaw
- Nottingham Clinical Trials Unit (NCTU), University of Nottingham, Nottingham, UK
| | - Nafisa Boota
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Kirsty Sprange
- Nottingham Clinical Trials Unit (NCTU), University of Nottingham, Nottingham, UK
| | - Mathew Diggle
- Clinical Microbiology Department, Nottingham University Hospitals NHS Trust, Nottingham, Nottinghamshire, UK
| | - Alan Montgomery
- Nottingham Clinical Trials Unit (NCTU), University of Nottingham, Nottingham, UK
| | - Aida Jawhari
- Clinical Microbiology Department, Nottingham University Hospitals NHS Trust, Nottingham, Nottinghamshire, UK
| | - Robin C Spiller
- Nottingham Digestive Diseases Centre and NIHR Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust, the University of Nottingham, Nottingham, Notts, UK
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Song JH, Kim YS. Recurrent Clostridium difficile Infection: Risk Factors, Treatment, and Prevention. Gut Liver 2019; 13:16-24. [PMID: 30400734 PMCID: PMC6346998 DOI: 10.5009/gnl18071] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 03/12/2018] [Accepted: 03/22/2018] [Indexed: 12/15/2022] Open
Abstract
The most common cause of antibiotic-associated diarrhea is Clostridium difficile infection (CDI). Recurrent C. difficile infection (rCDI) often occurs after successful treatment of CDI. Due to the increased incidence and the difficulty in treating rCDI, it is becoming an important clinical issue. Identifying risk factors is helpful for early detection, treatment, and prevention of rCDI. Advanced age, use of antibiotics, gastric acid suppression, and infection with a hypervirulent strain are currently regarded as the major risk factors for rCDI. Several treatment modalities, including vancomycin, fidaxomicin, and fecal microbiota transplant (FMT), are suggested for rCDI treatment. However, there is currently no definitive treatment method with sufficient evidence for rCDI. Recent studies have focused on FMT and have shown positive results for rCDI. Prevention of rCDI by measures such as hand washing and isolation of patients is very important. However, these preventive measures are often overlooked in clinical practice. Here, we review the risk factors, treatment, and prevention of rCDI.
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Affiliation(s)
- Jung Hoon Song
- Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, Korea
| | - You Sun Kim
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
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50
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Alimolaei M, Rahimi HR, Ezatkhah M, Shamsaddini Bafti M, Afzali S. Prevalence, characteristics and antimicrobial susceptibility patterns of Clostridioides difficile isolated from hospitals in Iran. J Glob Antimicrob Resist 2019; 19:22-27. [PMID: 30825696 DOI: 10.1016/j.jgar.2019.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 02/13/2019] [Accepted: 02/19/2019] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Clostridioides (previously Clostridium) difficile is a major growing cause of nosocomial diarrhoea known as C. difficile infection (CDI). This study investigated the prevalence and antimicrobial resistance patterns of C. difficile isolated from patients suffering from diarrhoea in Iran between 2016-2018. METHODS A total of 151 stool specimens were collected and were screened for the presence of C. difficile. Specimens were examined for toxins by culture, enzyme immunoassay (EIA) and PCR. Antimicrobial susceptibility testing was performed for 12 antibiotics (metronidazole, vancomycin, clindamycin, tetracycline, erythromycin, ciprofloxacin, levofloxacin, moxifloxacin, fusidic acid, piperacillin, piperacillin/tazobactam and rifampicin) by the disk diffusion method according to the guidelines of the CLSI, EUCAST and CA-SFM. RESULTS Of 151 stool specimens, 66 (43.7%) were positive for C. difficile by PCR, whereas 2 (1.3%) were only positive for C. difficile toxins based on EIA. A total of 292 clostridial isolates were obtained from specimens by culture, of which 133 (45.5%) were finally confirmed as C. difficile by PCR. Of 121 isolates resistant to at least one antibiotic, 107 (88.4%) were resistant to three or more antimicrobials and thus were defined as multidrug-resistant (MDR). Different and diverse resistance patterns to the antimicrobial drugs were seen among the isolates. CONCLUSION This is the first report of the isolation of C. difficile from different governmental hospitals of Iran and indicates that CDI might be an important nosocomial infection in different hospital wards. Moreover, this study provides a comprehensive picture of the MDR phenotype characteristics of C. difficile isolates in Iran.
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Affiliation(s)
- Mojtaba Alimolaei
- Pharmaceutics Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran; Department of Research and Technology, Kerman Branch, Razi Vaccine and Serum Research Institute, Agricultural Research, Education and Extension Organization (AREEO), Kerman, Iran.
| | - Hamid-Reza Rahimi
- Department of Toxicology and Pharmacology, School of Pharmacy, Kerman University of Medical Sciences, Kerman, Iran
| | - Majid Ezatkhah
- Department of Anaerobic Bacterial Vaccine Research and Production, Kerman Branch, Razi Vaccine and Serum Research Institute, Agricultural Research, Education and Extension Organization (AREEO), Kerman, Iran
| | - Mehrdad Shamsaddini Bafti
- Department of Anaerobic Bacterial Vaccine Research and Production, Kerman Branch, Razi Vaccine and Serum Research Institute, Agricultural Research, Education and Extension Organization (AREEO), Kerman, Iran
| | - Sadegh Afzali
- Department of Research and Technology, Kerman Branch, Razi Vaccine and Serum Research Institute, Agricultural Research, Education and Extension Organization (AREEO), Kerman, Iran
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