Predicting Clostridium difficile toxin in hospitalized patients with antibiotic-associated diarrhea

Does this patient have Clostridioides difficile infection? A systematic review and meta-analysis

BACKGROUND

The clinical features and predictors of Clostridioides difficile infection overlap with many conditions.

OBJECTIVES

We performed a systematic review to evaluate the diagnostic utility of clinical features (clinical examination, risk factors, laboratory tests, and radiographic findings) associated with C. difficile.

METHODS

Systematic review and meta-analysis of diagnostic features for C. difficile.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, and Cochrane databases were searched up to September 2021.

STUDY ELIGIBILITY CRITERIA

Studies that reported clinical features of C. difficile, a valid reference standard test for confirming diagnosis of C. difficile, and a comparison among patients with a positive and negative test result.

PARTICIPANTS

Adult and paediatric patients across diverse clinical settings.

OUTCOMES

Sensitivity, specificity, likelihood ratios.

REFERENCE STANDARD

Stool nucleic acid amplification tests, enzyme immunoassays, cell cytotoxicity assay, and stool toxigenic culture.

ASSESSMENT OF RISK OF BIAS

Rational Clinical Examination Series and Quality Assessment of Diagnostic Accuracy Studies-2.

METHODS OF DATA SYNTHESIS

Univariate and bivariate analyses.

RESULTS

We screened 11 231 articles of which 40 were included, enabling the evaluation of 66 features for their diagnostic utility for C. difficile (10 clinical examination findings, 4 laboratory tests, 10 radiographic findings, prior exposure to 13 antibiotic types, and 29 clinical risk factors). Of the ten features identified on clinical examination, none were significantly clinically associated with increased likelihood of C. difficile infection. Some features that increased likelihood of C. difficile infection were stool leukocytes (LR+ 5.31, 95% CI 3.29-8.56) and hospital admission in the prior 3 months (LR+ 2.14, 95% CI 1.48-3.11). Several radiographic findings also strongly increased the likelihood of C. difficile infection like ascites (LR+ 2.91, 95% CI 1.89-4.49).

DISCUSSION

There is limited utility of bedside clinical examination alone in detecting C. difficile infection. Accurate diagnosis of C. difficile infection requires thoughtful clinical assessment for interpretation of microbiologic testing in all suspected cases.

Predictors of hospital-onset Clostridioides difficile infection in children with antibiotic-associated diarrhea

BACKGROUND

This study aimed to determine the predictors of hospital-onset Clostridioides difficile infection (CDI) in pediatric patients with antibiotic-associated diarrhea (AAD) and to develop a predictive scoring system to identify at-risk patients.

METHODS

This retrospective case-control study included patients aged ≥2-18 years with AAD who underwent C. difficile polymerase chain reaction testing >3 days after hospital admission. Patients with hospital-onset CDI were selected as cases and matched with the control patients without CDI. Univariate and multivariate logistic regressions were used to determine predictors of CDI and to construct a prediction score for the outcomes of interest.

RESULTS

Sixty-five patients with hospital-onset CDI and 130 controls were enrolled. Independent predictors for CDI identified and combined into the prediction score included abdominal pain (adjusted odds ratio [95% confidence interval]: 7.940 [3.254-19.374]), hospitalization for ≥14 days before the onset of diarrhea (3.441 [1.034-11.454]), antibiotic use for ≥10 days before the onset of diarrhea (6.775 [1.882-24.388]), receipt of meropenem (4.001 [1.098-14.577]) and clindamycin (14.842 [4.496-49.000]). The area under the receiver operating characteristic curve for this score was 0.883.

CONCLUSIONS

The presented scoring system can be easily applied by clinicians at the bedside to decide which patients with AAD are likely to have CDI.

Risk Factors, Diagnosis, and Management of Clostridioides difficile Infection in Patients with Inflammatory Bowel Disease

Clostridioides difficile infection (CDI) and inflammatory bowel disease (IBD) are two pathologies that share a bidirectional causal nexus, as CDI is known to have an aggravating effect on IBD and IBD is a known risk factor for CDI. The colonic involvement in IBD not only renders the host more prone to an initial CDI development but also to further recurrences. Furthermore, IBD flares, which are predominantly set off by a CDI, not only create a need for therapy escalation but also prolong hospital stay. For these reasons, adequate and comprehensive management of CDI is of paramount importance in patients with IBD. Microbiological diagnosis, correct evaluation of clinical status, and consideration of different treatment options (from antibiotics and fecal microbiota transplantation to monoclonal antibodies) carry pivotal importance. Thus, the aim of this article is to review the risk factors, diagnosis, and management of CDI in patients with IBD.

Association of Household Pets, Common Dietary Factors, and Lifestyle Factors with Clostridium difficile Infection

BACKGROUND

Clostridium difficile infection (CDI) is one of the most common hospital-acquired infections and is associated with significant morbidity and mortality. Since owning a cat or dog could enrich the gut microbiome, we hypothesized that it would be protective against CDI.

AIMS

We conducted a survey study on patients tested for CDI in order to assess whether living in the presence of a pet is associated with a decreased risk of CDI.

METHODS

We surveyed subjects aged 18-90 over a 14-month period using a retrospective case-control design. Subjects with CDI were matched by gender and age to patients who tested negative and had no prior history of CDI. A web-based survey was provided to subjects by mail or assisted by phone. Conditional logistic regression was used to assess for associations between CDI and the various risk factors.

RESULTS

205 CDI positive and 205 CDI negative subjects (response rate of 50.2%) were included. After matching for age and sex, living with a cat or dog was not associated with negative CDI testing. Exploratory multivariable modeling identified an unexpected association between positive CDI testing and high meat intake (OR 2.13, 95% CI 1.21-3.77) as well as between positive CDI testing and cat allergies (OR 1.88, 95% CI 1.02-3.46).

CONCLUSION

Living with a cat or dog was not associated with negative CDI testing. Several novel risk factors for CDI have been identified including high meat intake and cat allergies.

Identification of patients at risk of Clostridioides difficile infection for enrollment in vaccine clinical trials

BACKGROUND

Clostridioides difficile infection (CDI) is an important cause of diarrheal disease associated with increasing morbidity and mortality. Efforts to develop a preventive vaccine are ongoing. The goal of this study was to develop an algorithm to identify patients at high risk of CDI for enrollment in a vaccine efficacy trial.

METHODS

We conducted a 2-stage retrospective study of patients aged ≥ 50 within the US Department of Veterans Affairs Health system between January 1, 2009 and December 31, 2013. Included patients had at least 1 visit in each of the 2 years prior to the study, with no CDI in the past year. We used multivariable logistic regression with elastic net regularization to identify predictors of CDI in months 2-12 (i.e., days 31 - 365) to allow time for antibodies to develop. Performance was measured using the positive predictive value (PPV) and the area under the curve (AUC).

RESULTS

Elements of the predictive algorithm included age, baseline comorbidity score, acute renal failure, recent infections or high-risk antibiotic use, hemodialysis in the last month, race, and measures of recent healthcare utilization. The final algorithm resulted in an AUC of 0.69 and a PPV of 3.4%.

CONCLUSIONS

We developed a predictive algorithm to identify a patient population with increased risk of CDI over the next 2-12 months. Our algorithm can be used prospectively with clinical and administrative data to facilitate the feasibility of conducting efficacy studies in a timely manner in an appropriate population.

Clostridioides difficile Infection in Children With Inflammatory Bowel Disease

BACKGROUND

The study's objective was to investigate the incidence and risk factors associated with Clostridioides difficile (previously known as Clostridium) infection (CDI) in children with inflammatory bowel disease (IBD) in the province of Manitoba.

METHODS

Our longitudinal population-based cohort was comprised of all children and young adults aged <17 years diagnosed with IBD in the Canadian province of Manitoba between 2011 and 2019. The diagnosis of CDI was confirmed based on the Triage C. difficile immunoassay and polymerase chain reaction assay to detect the presence of toxigenic C. difficile. The Fisher exact test was used to examine the relationship between categorical variables. A Cox regression model was used to estimate the risk of CDI development in IBD patients.

RESULTS

Among 261 children with IBD, 20 (7.7%) developed CDI with an incidence rate of 5.04 cases per 1000 person-years, and the median age at diagnosis (interquartile range) was 12.96 (9.33-15.81) years. The incidence rates of CDI among UC and CD patients were 4.16 cases per 1000 person-years and 5.88 cases per 1000 person-years, respectively (P = 0.46). Compared with children without CDI, those who had CDI were at increased risk of future exposure to systemic corticosteroids (adjusted hazard ratio [aHR], 4.38; 95% confidence interval [CI], 1.46-13.10) and anti-tumor necrosis factor (anti-TNF) biologics (aHR, 3.31; 95% CI, 1.11-9.90). The recurrence rate of CDI in our pediatric IBD population was 25%.

CONCLUSIONS

Our findings confirm that children with IBD are at high risk of developing CDI, which may predict future escalation of IBD therapy.

Nonalcoholic fatty liver disease as a risk factor for Clostridium difficile-associated diarrhea

AIMS

Clostridium difficile is the most common cause of infectious nosocomial diarrhea among adults in developed countries. Nonalcoholic fatty liver disease (NAFLD) is considered the most common chronic liver disease and it is associated with bacterial infections. Our goal was to assess whether NAFLD considered a risk factor for C. difficile-associated diarrhea (CDAD).

METHODS

We conducted a retrospective study of patients admitted with CDAD at Baruch Padeh Medical Center, Poria, Israel during a period of four years. Data on demographic characteristics, clinical signs, underlying conditions, presence of fatty liver based on computed tomography/ultrasonography imaging and several risk factors for CDI were collected. The control group included patients with diarrhea who were negative for CDT and had been hospitalized during the same period. The controls were matched for age (±5 years) and gender.

RESULTS

Totally, 115/164 patients with CDAD met the inclusion criteria. The control group was consisted of 115 hospitalized patients with non-CDAD. The mean age of all the participants (230) was 69.57 ± 18 years. NAFLD was found in 76/115 (66%) patients with CDAD vs. 35/115 (30.4%) in the control group, P < 0.001. Moreover, we found significant associations between CDAD group and metabolic syndrome, prior use of antibiotic in the last 3 months, NAFLD and high serum levels of C-reactive protein. Multivariate analysis showed that NAFLD, odds ratio 1.51, 95% confidence interval 1.2-1.95, P = 0.05 was significantly associated with CDAD.

CONCLUSIONS

This retrospective study showed that NAFLD is a risk factor for CDAD. Moreover, metabolic syndrome and high serum levels of C-reactive protein were significantly associated with the risk of CDAD.

Stress Ulcer Prophylaxis in Neurocritical Care

Stress ulcer prophylaxis (SUP) with acid-suppressive drug therapy is widely utilized in critically ill patients following neurologic injury for the prevention of clinically important stress-related gastrointestinal bleeding (CIB). Data supporting SUP, however, largely originates from studies conducted during an era where practices were vastly different than what is considered routine by today's standard. This is particularly true in neurocritical care patients. In fact, the routine provision of SUP has been challenged due to an increasing prevalence of adverse drug events with acid-suppressive therapy and the perception that CIB rates are sparse. This narrative review will discuss current controversies with SUP as they apply to neurocritical care patients. Specifically, the pathophysiology, prevalence, and risk factors for CIB along with the comparative efficacy, safety, and cost-effectiveness of acid-suppressive therapy will be described.

Risk Factors Associated with Clostridium difficile Infection in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

BACKGROUND AND AIM

Clostridium difficile infection [CDI] is a significant concern in inflammatory bowel disease [IBD]. Risk factors and consequences associated with CDI in inflammatory bowel disease [IBD] patients are important to characterize. The aim of this research was to perform a systematic review and meta-analysis on risk factors and outcomes associated with CDI in IBD patients.

METHODS

Multiple databases were searched for studies investigating risk factors, colectomy and mortality risk in IBD patients with and without CDI. This was stratified by short [<3 months] and long-term [>1 year] outcomes. Summary estimates were calculated using a random-effects model. Quality assessment used the Newcastle-Ottawa scale.

RESULTS

Twenty-two studies met inclusion criteria. Antibiotics use within 30 days of diagnosis was associated with CDIs (odds ratio [OR]: 1.85, 95% confidence interval [CI]:1.36, 2.52). Colonic involvement in Crohn's disease patients was associated with significantly higher CDI rates [OR: 2.76, 95% CI: 1.75, 4.35]. There was a significant association between biologic medication use and CDI [OR: 1.65, 95% CI: 1.18, 2.30], with minimal heterogeneity [I2 = 4.0%]. The long-term colectomy risk was significantly higher for IBD patients with CDI compared with that for IBD patients without CDI [OR: 2.22, 95% CI: 1.17, 4.18]. Significantly higher mortality was found for CDI in IBD patients both short-term [OR: 3.84, 95% CI: 2.62, 5.61] and long-term [OR: 3.65, 95% CI: 1.58, 8.44]. Substantial heterogeneity existed. Most studies were of moderate quality.

CONCLUSION

Colonic involvement, and biologic and antibiotic use appear to be risk factors associated with CDI among IBD patients. CDI is associated with increased short- and long-term mortality.

Proton pump inhibitors therapy and risk of Clostridium difficile infection: Systematic review and meta-analysis

AIM

To perform a systematic review and meta-analysis on proton pump inhibitors (PPIs) therapy and the risk of Clostridium difficile infection (CDI).

METHODS

We conducted a systematic search of MEDLINE/PubMed and seven other databases through January 1990 to March 2017 for published studies that evaluated the association between PPIs and CDI. Adult case-control and cohort studies providing information on the association between PPI therapy and the development of CDI were included. Pooled odds ratios (ORs) estimates with 95% confidence intervals (CIs) were calculated using the random effect. Heterogeneity was assessed by I² test and Cochran’s Q statistic. Potential publication bias was evaluated via funnel plot, and quality of studies by the Newcastle-Otawa Quality Assessment Scale (NOS).

RESULTS

Fifty-six studies (40 case-control and 16 cohort) involving 356683 patients met the inclusion criteria and were analyzed. Both the overall pooled estimates and subgroup analyses showed increased risk for CDI despite substantial statistical heterogeneity among studies. Meta-analysis of all studies combined showed a significant association between PPI users and the risk of CDI (pooled OR = 1.99, CI: 1.73-2.30, P < 0.001) as compared with non-users. The association remained significant in subgroup analyses: by design-case-control (OR = 2.00, CI: 1.68-2.38, P < 0.0001), and cohort (OR = 1.98, CI: 1.51-2.59, P < 0.0001); adjusted (OR = 1.95, CI: 1.67-2.27, P < 0.0001) and unadjusted (OR = 2.02, CI: 1.41-2.91, P < 0.0001); unicenter (OR = 2.18, CI: 1.72-2.75, P < 0.0001) and multicenter (OR = 1.82, CI: 1.51-2.19, P < 0.0001); age ≥ 65 years (OR = 1.93, CI: 1.40-2.68, P < 0.0001) and < 65 years (OR = 2.06, CI: 1.11-3.81, P < 0.01). No significant differences were found in subgroup analyses (test for heterogeneity): P = 0.93 for case-control vs cohort, P = 0.85 for adjusted vs unadjusted, P = 0.24 for unicenter vs multicenter, P = 0.86 for age ≥ 65 years and < 65 years. There was significant heterogeneity across studies (I² = 85.4%, P < 0.001) as well as evidence of publication bias (funnel plot asymmetry test, P = 0.002).

CONCLUSION

This meta-analysis provides further evidence that PPI use is associated with an increased risk for development of CDI. Further high-quality, prospective studies are needed to assess whether this association is causal.

Fecal microbiota transplantation for Clostridium difficile infection in patients with ileal pouches

Background:Clostridium difficile infection (CDI) in patients with ileal pouch-anal anastomosis (IPAA) has been increasingly recognized. The aim of this study was to evaluate the outcome of fecal microbiota transplantation (FMT) in patients with pouch and CDI. Methods: All consecutive patients that underwent FMT for CDI from 2012 to 2016 were extracted from our IRB-approved, prospectively maintained Registry of Pouch Disorders. The primary outcome was negative stool tests for Clostridium difficile after FMT and the secondary outcomes were symptomatic and endoscopic responses. Results: A total of 13 patients were included in this study, with 10 being Caucasian males (76.9%). All patients had underlying ulcerative colitis for J pouch surgery. After a mean of 2.8±0.8 courses of antibiotic treatments was given and failed, 22 sessions of FMT were administered with an average of 1.7±1.1 sessions each. Within the 22 sessions, 16 were given via pouchoscopy, 4 via esophagogastroduodenoscopy and 2 via enemas. All patients tested negative on C. difficile polymerase chain reaction (PCR) after the initial FMT with a total of 7/12 (58.3%) documented patients showed symptomatic improvements and 3/11 (27.3%) patients showed endoscopic improvement according to the modified Pouchitis Disease Activity Index. During the follow-up of 1.2±1.1 years, there were a total of five patients (38.5%) that had recurrence after the successful initial treatment and four of them were successfully treated again with FMT. Conclusions: FMT appeared to be effective in eradication of CDI in patients with ileal pouches. However, FMT had a modest impact on endoscopic inflammation and recurrence after FMT and recurrence was common.

Development and validation of a Clostridium difficile risk assessment tool

The incidence of Clostridium difficile infection has increased rapidly during the past decade, increasing lengths of stays in the hospital, costs, and mortality rates. To address this increased incidence, we performed a retrospective case-control study using known risk factors to develop a tool to determine which patients are at risk for infection. Multivariate analysis generated a combination of risk factors associated with development of infection including prior admission, endoscopy within 30 days, cephalosporin/fluoroquinolone use, length of stay 7 days or longer, age 65 years or older, body mass index less than 25, and albumin level less than 2.7 g/dL. A weighted scoring tool was created that predicted disease with a sensitivity of 86% and a specificity of 44% in the derivation sample, and 92% sensitivity and a specificity of 39% when applied to the validation sample. Application of this 8-item tool by nurses in multiple settings could aid in the determination of patients who are at risk, allowing prophylactic treatment, prompt isolation of patients, restricted antibiotic use, and decreased testing of low-risk patients.

Development and Validation of a Clostridium difficile Health-related Quality-of-Life Questionnaire

GOALS AND BACKGROUND

Patients with Clostridium difficile infection (CDI) can experience long-term symptoms and poor quality of life due to the disease. Despite this, a health-related quality of life (HRQOL) instrument specific for patients with CDI does not exist. The aim of this study was to develop and validate a disease-specific instrument to assess HRQOL in patients with CDI.

STUDY

A systematic literature review was conducted to identify HRQOL instruments and questions related to general health (n=3) or gastrointestinal disease (n=12) potentially related to CDI HRQOL. Removing duplicate questions and using direct patient or clinician interviews, a 36-item survey was developed. The survey was then tested using 98 patients with CDI and compared with the RAND Short-Form 36 (SF-36) Health Survey. Psychometric analysis techniques were used to identify domains and remove redundant items.

RESULTS

Exploratory factor analysis identified 3 major domains (physical, mental, and social) with 4 associated subdomains. Survey overall and domain scores displayed good internal consistency (Cronbach α coefficient >0.87) and concurrent validity evidenced by significant correlation with SF-36 scores. The C. difficile survey scores were better able than the SF-36 to discriminate quality-of-life score differences in patients with primary versus recurrent CDI and increasing time since last episode of CDI. The final version contained 32 items related to the physical, mental, and social health of CDI patients.

CONCLUSION

The properties of the newly developed Cdiff32 should make it appropriate to assess changes over time in HRQOL in patients with CDI.

The effect of statins on the outcome of Clostridium difficile infection in hospitalized patients

Several studies have shown an association between exposure to statins and favorable clinical outcomes for various types of infections. We aimed to assess the impact of statin use on mortality, disease severity and complications among hospitalized patients with Clostridium difficile infection (CDI). Data were analyzed from a retrospectively collected database of 499 patients diagnosed with CDI during 2009-2014. We compared infection outcomes between 178 statin (36 %) users and 321 (64 %) non-users. On multivariate analysis, we found that statin use did not have a significant impact on 30-day mortality (OR = 1.54; 95 % CI, 0.85-2.79; p = 0.15) or any significant effect on CDI severity and complication. Concomitant statin use has no significant impact on short-term mortality or effect on CDI severity and complications among hospitalized patients with CDI. However, patients in the statin group were older and had higher Charlson score compared with the non-statin group. Whether these factors affected a possible impact of statins on the disease course remains to be investigated.

KEY MESSAGES

• Clostridium difficile is the most common cause of infectious nosocomial diarrhea among hospitalized adult patients in the developed countries. • There is an increasing morbidity and mortality of CDI patients due to the emergence of new strains of high virulence. • Recent studies demonstrated that prior statin use has protective and ameliorating effects on morbidity and mortality among CDI patients. • Our study showed that concomitant statin use has no significant impact on short-term mortality, CDI severity and its complications.

Spectrum of Clostridium difficile infections: Particular clinical situations

Incidence, pathogenesis, diagnostic techniques and therapeutic management of CDI have prompted abundant and adequate recent literature. However, report on clinical manifestations of CDI is frequently biased by the type of patients selected, the retrospective nature of many papers, the epidemic or endemic characteristics of the population reported. This article seeks to review some less discussed clinical and epidemiological aspects of CDI trying to include the clinical manifestations of this disease in unselected populations and also including discussion of CDI in specific groups of patients such as patients without colon and rectum, pediatric and critical care patients.

A Review of Clostridium difficile Infection at the University Hospital of the West Indies, Jamaica

OBJECTIVES

This study examined the frequency of Clostridium difficile infection (CDI) among hospital admission and diarrhoeal stool samples over a six-year period.

METHODS

A review of all suspected cases of C difficile positive patients from 2007 to 2012 at the University Hospital of the West Indies (UHWI), Jamaica, was performed. Clostridium difficile infection was confirmed by clinical features and a positive enzyme-linked immunosorbent assay (ELISA) stool test for Clostridium Toxins A and B. The demographics, clinical features, risk factors, treatment and outcomes were also examined.

RESULTS

There were 56 patients reviewed. The most commonly affected age group was 40-59 years of age. The proportion of CDI cases per total stool samples increased from 0.5% in 2007 to 5.9% in 2010 then fell to 2.2% in 2011 but increased again to 4.3% in 2012. The proportion of cases per total UHWI admissions also increased from 0.12 cases per 1000 admissions in 2007 to 1.16 in 2010 and 1.36 in 2012 (p < 0.001). Most CDI cases were nosocomial (76% males, 48.6% females). Co-morbidities included hypertension and end-stage renal disease. Ceftazidime was the most common antibiotic associated with the development of CDI. Resolution occurred in 62.5% of patients. Duration of hospital stay was longer in males than females (≥ 21 versus < 7 days) and males had more adverse outcomes, with death in 23.8% versus 11.4%.

CONCLUSION

There has been an increase in the frequency of CDI at UHWI with a greater than expected frequency of community acquired CDI. Increased awareness is needed of the increasing risk for CDI and measures must be taken to prevent the disease, especially in hospitalized patients.

Clostridium difficile infection in the postcolectomy patient

Clostridium difficile infection (CDI) after total colectomy has been increasingly recognized over the past decade. C. difficile enteritis (CDE) is a rare occurrence, whereas C. difficile pouchitis (CDP) has been reported in approximately 10% of symptomatic patients seen at a referral center for pouch dysfunction. Similar to colonic CDI in the general population, antibiotic use and comorbid diseases may be risk factors for CDE. In contrast, the postoperative use of antibiotics does not seem to be associated with CDP, whereas male gender, recent hospitalization, and presurgery antibiotic use were shown to be risk factors for CDP. C. difficile is capable of colonizing all intestinal sites, including the ileal pouch. Similarities with the colon at physiological and cellular levels may contribute to the susceptibility of the ileal pouch to CDI. Postcolectomy CDI likely represents a disease spectrum from asymptomatic colonization to severe symptomatic infection. CDI should be considered in ostomy patients with fever and increased ileostomy output and in ileal pouch patients with a change in "normal" symptom pattern or chronic antibiotic-refractory pouchitis. Sensitive and specific methods for detection of CDI are available, and endoscopy is useful in evaluating the patient with suspected CDE or CDP, although pseudomembranes are typically absent. Vancomycin is used as the first-line therapy for CDP and may be warranted for patients with inflammatory bowel disease with CDE. Fecal microbiota transplantation has found its use in the management of severe or antibiotic refractory CDP, but this approach requires evaluation for the management of refractory CDE.

Missed diagnosis of Clostridium difficile infection; a prospective evaluation of unselected stool samples

BACKGROUND

Clostridium difficile infection (CDI) is the leading cause of hospital-acquired diarrhoea in developed countries, however a high proportion of CDI episodes go undiagnosed, either because physicians do not request identification of toxigenic C. difficile or microbiologists do not perform the appropriate tests.

OBJECTIVE

To investigate the clinical characteristics of patients with CDI within a non-selected population and to determine risk factors for clinical underdiagnosis.

METHODS

We conducted a prospective study in which systematic testing for toxigenic C. difficile on all diarrhoeic stool samples was performed regardless of the clinician's request. Patients aged >2 years positive for toxigenic C. difficile and diarrhoea were enrolled (Jan-June 2013) and monitored at least 2 months after their last episode.

RESULTS

We identified 204 cases of CDI, of which three-quarters were healthcare-associated. Most cases were mild to moderate (83.8%), the recurrence rate was 16.2%, and CDI-related mortality was low (2.5%). A significant proportion (12.7%) of CDI cases would have been missed owing to lack of clinical suspicion. Community-acquired cases and young age were risk factors for clinical underdiagnosis.

CONCLUSION

Our data support the introduction of a systematic search for toxigenic C. difficile in all diarrhoeic stools from inpatients and outpatients older than 2 years.

Development and Validation of a Clostridium Difficile Risk Assessment Tool

The incidence of Clostridium difficile infection has increased rapidly during the past decade, increasing lengths of stays in the hospital, costs, and mortality rates. To address this increased incidence, we performed a retrospective case-control study using known risk factors to develop a tool to determine which patients are at risk for infection. Multivariate analysis generated a combination of risk factors associated with development of infection including prior admission, endoscopy within 30 days, cephalosporin/fluoroquinolone use, length of stay 7 days or longer, age 65 years or older, body mass index less than 25, and albumin level less than 2.7 g/dL. A weighted scoring tool was created that predicted disease with a sensitivity of 86% and a specificity of 44% in the derivation sample, and 92% sensitivity and a specificity of 39% when applied to the validation sample. Application of this 8-item tool by nurses in multiple settings could aid in the determination of patients who are at risk, allowing prophylactic treatment, prompt isolation of patients, restricted antibiotic use, and decreased testing of low-risk patients.

Clostridium difficile infection in patients with ileal pouches

Clostridium difficile (C. difficile) infection (CDI) following total proctocolectomy and ileal pouch-anal anastomosis has been increasingly recognized over the past 5 years. CDI of the ileal pouch has been recognized in ∼10% of symptomatic patients seen at a tertiary referral center for pouch dysfunction. In contrast to colonic CDI in the general population or in patients with inflammatory bowel disease, postoperative antibiotic exposure and the use of immunosuppressive agents or proton pump inhibitors do not appear to be associated with CDI of the pouch. Male gender, recent hospitalization, and presurgery antibiotic use were shown to be risk factors for ileal pouch CDI. The ileal pouch may be susceptible to CDI owing to similarities with the colon at physiological and structural levels. Postcolectomy CDI likely represents a spectrum of disease processes, varying from asymptomatic colonization to severe symptomatic infection. CDI should be considered in any patient with an ileal pouch presenting with a change in "normal" symptom pattern or treatment-refractory disease. Sensitive and specific methods for the detection of CDI are available, and pouchoscopy is a valuable tool in the evaluation of the patient with symptomatic CDI of the pouch. At a referral center for pouch dysfunction, vancomycin is used as the first-line therapy for ileal pouch CDI. Fecal microbiota transplantation may find use in the management of severe or antibiotic refractory CDI-related pouchitis.

Obesity as a risk factor for Clostridium difficile infection

BACKGROUND

Obesity and Clostridium difficile infection (CDI) are both related to an increased Firmicutes/Bacteroidetes ratio in the intestinal microbiota. However, an association between obesity and CDI is unknown. We aimed to assess the association between obesity and CDI in hospitalized patients.

METHODS

We conducted a retrospective case-control study. From January to December 2011, all consecutive patients hospitalized with CDI, in 2 internal medical departments in 2 hospitals, were included. Patients with CDI were compared to hospitalized patients without diarrhea, during the same period and in the same departments, and matched by age, sex, Charlson score, length of hospitalization, and antibiotic use during the last 3 months.

RESULTS

Of the 6300 patients hospitalized, 178 were diagnosed with CDI. CDI prevalence was 2.8% (178/6300). Thirty patients were excluded from the study. The 148 cases with CDI were compared to 148 hospitalized controls. Mean body mass index (BMI) in the CDI group was 33.6 (SD, 4.3) versus 28.9 (SD, 5.4) in the control group (P = .001). The multivariable model of conditional logistic regression for matched pairs showed that a history of intra-abdominal surgery (odds ratio [OR] = 2.865; 95% confidence interval [CI], 1.26-6.52) and a high BMI value (OR = 1.196 per 1-unit increase in the BMI scale; 95% CI, 1.12-1.27) were the only variables found to be significantly associated with CDI.

CONCLUSIONS

Our findings suggest that obesity is associated with the risk of CDI. Further studies are needed to reveal the exact mechanisms underlying this association.

Do statins protect against the development of Clostridium difficile-associated diarrhoea?

OBJECTIVES

To assess whether prior statin use protects against the development of Clostridium difficile-associated diarrhoea (CDAD) in hospitalized patients.

PATIENTS AND METHODS

A retrospective case-control study conducted in three hospitals included all hospitalized patients diagnosed with CDAD in the Internal Medicine Departments (IMDs) during a 1 year period. Subjects were determined to have CDAD if their stool sample was positive for C. difficile toxin in the context of diarrhoea at the time of diagnosis. Patients with CDAD were compared with patients without CDAD, hospitalized during the same period and in the same departments, matched for age, gender, comorbidities (Charlson score), length of hospitalization and antibiotic use during the last 3 months.

RESULTS

Prevalence of CDAD was 2.87% (197/6850 patients hospitalized in the IMDs). The 197 cases with CDAD were compared with 169 hospitalized patient controls. Sixty-four out of 197 (32.5%) patients in the CDAD group were statin users versus 87/169 (51.5%) of the controls (P = 0.02). Multivariate analysis showed that a Charlson score >3 [OR = 2.2 (95% CI 1.8-2.8), P = 0.024], chemotherapy during the last 6 months [OR = 3.09 (95% CI 1.95-3.91), P = 0.002], a history of intra-abdominal surgery [OR = 2.99 (95% CI 2.58-3.24), P = 0.003] and no statin use [OR = 2.2 (95% CI 1.82-2.73), P = 0.034] were associated with CDAD.

CONCLUSIONS

Prior statin use may provide protection against CDAD. Further studies are warranted to evaluate this association.

The association between histamine 2 receptor antagonist use and Clostridium difficile infection: a systematic review and meta-analysis

BACKGROUND

Clostridium difficile infection (CDI) is a major health problem. Epidemiological evidence suggests that there is an association between acid suppression therapy and development of CDI.

PURPOSE

We sought to systematically review the literature that examined the association between histamine 2 receptor antagonists (H2RAs) and CDI.

DATA SOURCE

We searched Medline, Current Contents, Embase, ISI Web of Science and Elsevier Scopus from 1990 to 2012 for all analytical studies that examined the association between H2RAs and CDI.

STUDY SELECTION

Two authors independently reviewed the studies for eligibility.

DATA EXTRACTION

Data about studies characteristics, adjusted effect estimates and quality were extracted.

DATA SYNTHESIS

Thirty-five observations from 33 eligible studies that included 201834 participants were analyzed. Studies were performed in 6 countries and nine of them were multicenter. Most studies did not specify the type or duration of H2RAs therapy. The pooled effect estimate was 1.44, 95% CI (1.22-1.7), I(2) = 70.5%. This association was consistent across different subgroups (by study design and country) and there was no evidence of publication bias. The pooled effect estimate for high quality studies was 1.39 (1.15-1.68), I2 = 72.3%. Meta-regression analysis of 10 study-level variables did not identify sources of heterogeneity. In a speculative analysis, the number needed to harm (NNH) with H2RAs at 14 days after hospital admission in patients receiving antibiotics or not was 58, 95% CI (37, 115) and 425, 95% CI (267, 848), respectively. For the general population, the NNH at 1 year was 4549, 95% CI (2860, 9097).

CONCLUSION

In this rigorous systematic review and meta-analysis, we observed an association between H2RAs and CDI. The absolute risk of CDI associated with H2RAs is highest in hospitalized patients receiving antibiotics.

A cohort study for derivation and validation of a clinical prediction scale for hospital-onset Clostridium difficile infection

OBJECTIVE

To develop and validate a clinical prediction scale for hospital-onset Clostridium difficile infection (CDI).

METHODS

A community-based, 360-bed hospital located in the suburbs of a metropolitan area in the United States served as the setting for the present retrospective cohort study. The cohort consisted of patients admitted to the adult medical service over a six-year period from October 2005 to September 2011. The cohort was divided into derivation (October 2005 to September 2009) and validation (October 2009 to September 2011) groups. The primary outcome measure was hospital-onset CDIs identified as stool positive for C difficile after 48 h of hospital admission ordered for new-onset unformed stool by the treating physician.

RESULTS

In the derivation phase, 35,588 patients were admitted to the medical service and 21,541 stayed in hospital beyond 48 h. A total of 266 cases of CDI were identified, 121 of which were hospital onset. The developed clinical prediction scale included the onset of unformed stool (5 points), length of hospital stay beyond seven days (4 points), age >65 years (3 points), long-term care facility residence (2 points), high-risk antibiotic use (1 point) and hypoalbuminemia (1 point). The scale had an area under the receiver operating curve (AUC) of 0.93 (95% CI 0.82 to 0.94) in predicting hospital-onset CDI, with a sensitivity of 0.94 (95% CI 0.88 to 0.97) and a specificity of 0.80 (95% CI 0.79 to 0.80) at a cut-off score of 9 on the scale. During the validation phase, 16,477 patients were admitted, of whom 10,793 stayed beyond 48 h and 58 acquired CDI during hospitalization. The predictive performance of the score was maintained in the validation cohort (AUC 0.95 [95% CI 0.93 to 0.96]) and the goodness-to-fit model demonstrated good calibration.

CONCLUSION

The authors developed and validated a simple clinical prediction scale for hospital-onset CDI. This score can be used for periodical evaluation of hospitalized patients for early initiation of contact precautions and empirical treatment once it is validated externally in a prospective manner.

Risk factors associated with complications and mortality in patients with Clostridium difficile infection

BACKGROUND

Clostridium difficile infection (CDI) has increased in frequency and severity over the past decade. An understanding of the modifiable risk factors for disease severity has considerable clinical applicability.

METHODS

We performed a retrospective case review of 485 cases in patients aged 1-99 years at the Naval Medical Center San Diego from November 2004 through December 2008. We compared potential risk factors for association with complications (megacolon, surgery, intensive care unit stay, and death) or mortality alone with use of univariable and multivariable logistic regression modeling.

RESULTS

Forty-seven patients (9.8%) developed ≥1 complication, and 23 (4.7%) died. We found independent associations between complications and acid suppression (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.2-4.79), admission for CDI (OR, 4.14; 95% CI, 2.17-7.92), older age (≥80 years; OR, 3.14; 95% CI, 1.46-6.73), and corticosteroid use (OR, 2.09; 95% CI, 1.01-4.35). Age ≥80 years (OR, 5.51; 95% CI, 2.25-13.49) and acid suppression (OR, 4.74; 95% CI, 1.57-14.37) were associated with increased odds of death.

CONCLUSIONS

Data published elsewhere have suggested that acid suppression therapy is a risk factor for CDI acquisition and relapse. These findings suggest an additional role in increased severity of disease, including mortality, and merit further study.

Clostridium difficile-associated disease acquired in the neurocritical care unit

BACKGROUND

Clostridium difficile is an important cause of nosocomial infection on the intensive care unit. Little is known about infection rates on the neurocritical care unit (NICU). The purpose of this study was to determine the prevalence, severity, and outcome associated with Clostridium difficile-associated disease (CDAD) acquired on the NICU.

METHODS

Patients on NICU with a positive stool Clostridium difficile toxin assay, from August 2004 to February 2008, were identified by the Department of Microbiology. Each patient's medical notes and charts were reviewed in turn. Patients with a positive assay within 48 h of NICU admission were excluded.

RESULTS

Twenty-one (0.6%) NICU patients developed CDAD. All were emergency admissions, 18 (86.0%) were neurosurgical. Subarachnoid hemorrhage was the most common diagnosis, 5 (23.8%) patients. Median age and APACHE II score on admission were 55 (IQR 40-66) and 21 (IQR 16-24), respectively. Thirteen (61.9%) patients were female. Median interval between NICU admission and diarrhea onset and CDAD diagnosis were 5 (3-8) days and 7 (4-12) days, respectively. At the time of diagnosis most, 11 (52.4%) patients, had moderate CDAD. Previously identified risk factors for ICU-acquired CDAD comprised: age > 65 (6), antibiotics (21), and medical device requirements (21). Five (23.8%) patients deteriorated clinically as a result of CDAD. The overall in-hospital mortality for those with NICU acquired CDAD was 19%.

CONCLUSIONS

Although CDAD is rarely acquired on the NICU, up to one quarter of affected patients may experience complications. Prospective validation of severity definitions and treatment guidelines may help to reduce the complication rates.

Safety of the long-term use of proton pump inhibitors

The proton pump inhibitors (PPIs) as a class are remarkably safe and effective for persons with peptic ulcer disorders. Serious adverse events are extremely rare for PPIs, with case reports of interstitial nephritis with omeprazole, hepatitis with omeprazole and lansoprazole, and disputed visual disturbances with pantoprazole and omeprazole. PPI use is associated with the development of fundic gland polyps (FGP); stopping PPIs is associated with regression of FGP. In the absence of Helicobacter pylori infection, the long-term use of PPIs has not been convincingly proven to cause or be associated with the progression of pre-existing chronic gastritis or gastric atrophy or intestinal metaplasia. Mild/modest hypergastrinemia is a physiological response to the reduction in gastric acid secretion due to any cause. The long-term use of PPIs has not been convincingly proven to cause enterochromaffin-like cell hyperplasia or carcinoid tumors. PPIs increase the risk of community acquired pneumonia, but not of hospital acquired (nosocomial) pneumonia. There is no data to support particular care in prescribing PPI therapy due to concerns about risk of hip fracture with the long-term use of PPIs. Long-term use of PPIs does not lead to vitamin B12 deficiencies, except possibly in the elderly, or in persons with Zollinger-Ellison Syndrome who are on high doses of PPI for prolonged periods of time. There is no convincingly proven data that PPIs increase the risk of Clostridium difficile-associated diarrhea in persons in the community. The discontinuation of PPIs may result in rebound symptoms requiring further and even continuous PPI use for suppression of symptoms. As with all medications, the key is to use PPIs only when clearly indicated, and to reassess continued use so that long-term therapy is used judiciously. Thus, in summary, the PPIs are a safe class of medications to use long-term in persons in whom there is a clear need for the maintenance of extensive acid inhibition.

Clostridium difficile infection in the intensive care unit

Clostridium difficile infection (CDI) is becoming more common worldwide. The morbidity and mortality associated with C difficile is also increasing at an alarming rate. Critically ill patients are at particularly high risk for CDI because of the prevalence of multiple risk factors in this patient population. Treatment of C difficile continues to be a difficult problem in patients with severe or recurrent disease. This article seeks to provide a broad understanding of CDI in the intensive care unit, with special emphasis on risk factor identification, treatment options, and disease prevention.

Automated system to identify Clostridium difficile infection among hospitalised patients

The purpose of this study was to assess whether data on stool frequency collected electronically could identify patients at high risk for Clostridium difficile infection (CDI). All patients with reports of diarrhoea were assessed prospectively for number of stools per day and number of diarrhoea days. C. difficile testing was requested independently from study investigators. Number of days with diarrhoea and maximum number of unformed stools was assessed as a CDI predictor. A total of 605 patients were identified with active diarrhoea of whom 64 (10.6%) were diagnosed with CDI. In univariate analysis, the maximum number of stools and number of diarrhoea days was associated with increased risk of CDI. Compared to patients with three diarrhoea stools per day (CDI incidence: 6.3%), CDI increased to 13.4% in patients with four or more diarrhoea stools per day [odds ratio (OR): 2.3; 95% confidence interval (CI): 1.3-4.2; P=0.0054]. Compared to patients with one day of diarrhoea (CDI incidence: 6.3%), CDI increased to 17.4% in patients with two diarrhoea days (OR: 3.1; 95% CI: 1.7-5.6) and to 27.1% in patients with three or more diarrhoea days (OR: 5.5; 95% CI: 2.6-11.7). These results were validated using logistic regression with number of days with diarrhoea identified as the most important predictor. Using an electronic data capture technique, number of days of diarrhoea and maximum number of diarrhoea stools in a 24h time period were able to identify a patient population at high risk for CDI.

Renewed interest in a difficult disease: Clostridium difficile infections--epidemiology and current treatment strategies

PURPOSE OF REVIEW

Renewed interest in Clostridium difficile infections (CDI) is stimulating research into the pathogenesis and virulence factors for this pathogen. This review summarizes recent progress in the field, particularly in relation to the changing epidemiologic trends and new investigational treatments.

RECENT FINDINGS

Elucidation of the role of different toxins of C. difficile (tcdA, tcdB and binary toxin) is deepening our understanding of CDI. Stain typing of C. difficile isolates is documenting the spread of an emergent strain (BI/NAP1/027) associated with large outbreaks of severe disease. Typing of isolates around the world shows global spread of this strain. Reliance upon metronidazole is questioned due to a lower response rate and newer investigational therapies are reported.

SUMMARY

After being considered a manageable pathogen for decades, C. difficile recently caused large outbreaks of severe disease. Refocused research is determining patients who are at risk for CDI, what methods are more effective in diagnosing CDI and what new treatments may be effective. This article reviews the recent findings in the literature regarding this difficult and challenging pathogen.

Antibiotic-associated diarrhea: epidemiology, trends and treatment

A common complication of antibiotic use is the development of gastrointestinal disease. This complication ranges from mild diarrhea to pseudomembranous colitis. Outbreaks of antibiotic-associated diarrhea (AAD) may also occur in healthcare settings, usually caused by Clostridium difficile. AAD typically occurs in 5-35% of patients taking antibiotics and varies depending upon the specific type of antibiotic, the health of the host and exposure to pathogens. The pathogenesis of AAD may be mediated through the disruption of the normal microbiota resulting in pathogen overgrowth or metabolic imbalances. The key to addressing AAD is prompt diagnosis followed by effective treatment and institution of control measures. Areas of active research include the search for other etiologies and more effective treatments.

Tolevamer, an anionic polymer, neutralizes toxins produced by the BI/027 strains of Clostridium difficile

Clostridium difficile-associated diarrhea (CDAD) is caused by the toxins the organism produces when it overgrows in the colon as a consequence of antibiotic depletion of normal flora. Conventional antibiotic treatment of CDAD increases the likelihood of recurrent disease by again suppressing normal bacterial flora. Tolevamer, a novel toxin-binding polymer, was developed to ameliorate the disease without adversely affecting normal flora. In the current study, tolevamer was tested for its ability to neutralize clostridial toxins produced by the epidemic BI/027 strains, thereby preventing toxin-mediated tissue culture cell rounding. The titers of toxin-containing C. difficile culture supernatants were determined using confluent cell monolayers, and then the supernatants were used in assays containing dilutions of tolevamer to determine the lowest concentration of tolevamer that prevented > or =90% cytotoxicity. Tolevamer neutralized toxins in the supernatants of all C. difficile strains tested. Specific antibodies against the large clostridial toxins TcdA and TcdB also neutralized the cytopathic effect, suggesting that tolevamer is specifically neutralizing these toxins and that the binary toxin (whose genes are carried by the BI/027 strains) is not a significant source of cytopathology against tissue culture cells in vitro.

The changing face of Clostridium difficile: what treatment options remain?

In this issue of the Journal, an article by Pepin et al. documents the shifting sands of the modern-day Clostridium difficile epidemic as seen in Quebec. Pepin and coauthors' observation that the superior activity of vancomycin over metronidazole has been lost since the emergence there of the hypervirulent strain NAP1/027 in 2003 has implications for the future treatment of C. difficile-associated diarrhea (CDAD). This editorial explores these, particularly in complicated cases and high-risk populations.