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Khanafer N, Daneman N, Greene T, Simor A, Vanhems P, Samore M, Brown KA. Susceptibilities of clinical Clostridium difficile isolates to antimicrobials: a systematic review and meta-analysis of studies since 1970. Clin Microbiol Infect 2017; 24:110-117. [PMID: 28750918 DOI: 10.1016/j.cmi.2017.07.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 07/10/2017] [Accepted: 07/13/2017] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Although exposure to antibiotics can cause Clostridium difficile infection, certain antibiotics are used to treat C. difficile. Measurements of antimicrobial C. difficile activity could help to identify antibiotic risk and emergent resistance. Here, we describe publication patterns relating to C. difficile susceptibilities and estimate minimum inhibitory concentrations (MIC) for antibiotic classes in the published literature between January 1970 and June 2014. METHODS We queried PUBMED and EMBASE for studies reporting antibiotic C. difficile MIC in English or French. We used mixed-effects models to obtain pooled estimates of antibiotic class median MIC (MIC50), 90th percentile of MIC (MIC90), and MIC90:MIC50 ratio. RESULTS Our search identified 182 articles that met our inclusion criteria, of which 27 were retained for meta-analysis. Aminoglycosides (MIC50 120 mg/L, 95% CI 62-250), 3rd (MIC50 75 mg/L, 95% CI 39-130) and 2nd generation cephalosporins (MIC50 64 mg/L, 95% CI 27-140) had the least C. difficile activity. Rifamycins (MIC50 0.034 mg/L, 95% CI 0.012-0.099) and tetracyclines (MIC50 0.29 mg/L, 95% CI 0.054-1.7) had the highest level of activity. The activity of 3rd generation cephalosporins was more than three times lower than that of 1st generation agents (MIC50 19 mg/L, 95% CI 7.0-54). Time-trends in MIC50 were increasing for carbapenems (70% increase per 10 years) while decreasing for tetracyclines (51% decrease per 10 years). CONCLUSIONS We found a 3500-fold variation in antibiotic C. difficile MIC50, with aminoglycosides as the least active agents and rifamycins as the most active. Further research is needed to determine how in vitro measures can help assess patient C. difficile risk and guide antimicrobial stewardship.
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Affiliation(s)
- N Khanafer
- Service d'Hygiène, Épidémiologie et Prévention, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France; Centre International de Recherche en Infectiologie, Institut national de la santé et de la recherche médicale U1111, Centre National de la Recherche Scientifique UMR5308, Ecole Normale Supérieure de Lyon, Université Claude Bernard 1, Lyon, France.
| | - N Daneman
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - T Greene
- Division of Epidemiology, University of Utah, UT, USA
| | - A Simor
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - P Vanhems
- Service d'Hygiène, Épidémiologie et Prévention, Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon, France; Centre International de Recherche en Infectiologie, Institut national de la santé et de la recherche médicale U1111, Centre National de la Recherche Scientifique UMR5308, Ecole Normale Supérieure de Lyon, Université Claude Bernard 1, Lyon, France
| | - M Samore
- Division of Epidemiology, University of Utah, UT, USA; Salt Lake City Veterans Affairs Health Care System, Salt Lake City, UT, USA
| | - K A Brown
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada; Division of Epidemiology, University of Utah, UT, USA; Salt Lake City Veterans Affairs Health Care System, Salt Lake City, UT, USA; Public Health Ontario, Ontario, Canada.
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Johanesen PA, Mackin KE, Hutton ML, Awad MM, Larcombe S, Amy JM, Lyras D. Disruption of the Gut Microbiome: Clostridium difficile Infection and the Threat of Antibiotic Resistance. Genes (Basel) 2015; 6:1347-60. [PMID: 26703737 PMCID: PMC4690045 DOI: 10.3390/genes6041347] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 12/09/2015] [Accepted: 12/10/2015] [Indexed: 12/15/2022] Open
Abstract
Clostridium difficile is well recognized as the leading cause of antibiotic-associated diarrhea, having a significant impact in both health-care and community settings. Central to predisposition to C. difficile infection is disruption of the gut microbiome by antibiotics. Being a Gram-positive anaerobe, C. difficile is intrinsically resistant to a number of antibiotics. Mobile elements encoding antibiotic resistance determinants have also been characterized in this pathogen. While resistance to antibiotics currently used to treat C. difficile infection has not yet been detected, it may be only a matter of time before this occurs, as has been seen with other bacterial pathogens. This review will discuss C. difficile disease pathogenesis, the impact of antibiotic use on inducing disease susceptibility, and the role of antibiotic resistance and mobile elements in C. difficile epidemiology.
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Affiliation(s)
- Priscilla A Johanesen
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton 3800, Australia.
| | - Kate E Mackin
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton 3800, Australia.
| | - Melanie L Hutton
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton 3800, Australia.
| | - Milena M Awad
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton 3800, Australia.
| | - Sarah Larcombe
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton 3800, Australia.
| | - Jacob M Amy
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton 3800, Australia.
| | - Dena Lyras
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton 3800, Australia.
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What can we learn from each other in infection control? Experience in Europe compared with the USA. J Hosp Infect 2013; 83:173-84. [DOI: 10.1016/j.jhin.2012.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 12/06/2012] [Indexed: 11/22/2022]
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Kim J, Kang JO, Pai H, Choi TY. Association between PCR ribotypes and antimicrobial susceptibility among Clostridium difficile isolates from healthcare-associated infections in South Korea. Int J Antimicrob Agents 2012; 40:24-9. [PMID: 22578765 DOI: 10.1016/j.ijantimicag.2012.03.015] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Revised: 03/20/2012] [Accepted: 03/22/2012] [Indexed: 01/26/2023]
Abstract
In this study, the association between antimicrobial susceptibility, PCR ribotype and presence of the ermB gene in clinical isolates of Clostridium difficile was investigated. PCR ribotyping and ermB gene PCR were performed on 131 C. difficile isolates. The susceptibility of these isolates to metronidazole, vancomycin, piperacillin/tazobactam (TZP), clindamycin, moxifloxacin and rifaximin was also determined. Use of antibiotics within the previous 2 months was documented. Resistance rates to clindamycin, moxifloxacin and rifaximin were 67.9%, 62.6% and 19.1%, respectively. No metronidazole, vancomycin or TZP resistance was detected. Previous exposure to moxifloxacin was significantly correlated with resistance to this antibiotic, but prior use of clindamycin was not significantly correlated with clindamycin resistance. Sixty-four strains (48.9%) carried the ermB gene, of which all but one (98.5%) were resistant to clindamycin. The clindamycin resistance rates of the common PCR ribotypes (018, 017 and 001) were 91.4%, 100% and 84.2%, respectively, and their moxifloxacin resistance rates were 91.4%, 95.0% and 78.9%, respectively. Resistance rates to rifaximin were 5.7% and 95.0% in ribotype 018 and 017 strains, whilst none of the 001 strains were resistant to rifaximin. In conclusion, the common ribotypes 018, 017 and 001 of C. difficile have high rates of resistance to clindamycin and moxifloxacin, but differ greatly in the frequency of rifaximin resistance.
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Affiliation(s)
- Jieun Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, South Korea
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Norén T, Alriksson I, Åkerlund T, Burman L, Unemo M. In vitro susceptibility to 17 antimicrobials of clinical Clostridium difficile isolates collected in 1993–2007 in Sweden. Clin Microbiol Infect 2010; 16:1104-10. [DOI: 10.1111/j.1469-0691.2009.03048.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Quasiexperimental study of the effects of antibiotic use, gastric acid-suppressive agents, and infection control practices on the incidence of Clostridium difficile-associated diarrhea in hospitalized patients. Antimicrob Agents Chemother 2009; 53:2082-8. [PMID: 19289520 DOI: 10.1128/aac.01214-08] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
The objective of this study was to evaluate the effects of antimicrobial drug use, gastric acid-suppressive agent use, and infection control practices on the incidence of Clostridium difficile-associated diarrhea (CDAD) in a 426-bed general teaching hospital in Northern Ireland. The study was retrospective and ecological in design. A multivariate autoregressive integrated moving average (time-series analysis) model was built to relate CDAD incidence with antibiotic use, gastric acid-suppressive agent use, and infection control practices within the hospital over a 5-year period (February 2002 to March 2007). The findings of this study showed that temporal variation in CDAD incidence followed temporal variations in expanded-spectrum cephalosporin use (average delay = 2 months; variation of CDAD incidence = 0.01/100 bed-days), broad-spectrum cephalosporin use (average delay = 2 months; variation of CDAD incidence = 0.02/100 bed-days), fluoroquinolone use (average delay = 3 months; variation of CDAD incidence = 0.004/100 bed-days), amoxicillin-clavulanic acid use (average delay = 1 month; variation of CDAD incidence = 0.002/100 bed-days), and macrolide use (average delay = 5 months; variation of CDAD incidence = 0.002/100 bed-days). Temporal relationships were also observed between CDAD incidence and use of histamine-2 receptor antagonists (H2RAs; average delay = 1 month; variation of CDAD incidence = 0.001/100 bed-days). The model explained 78% of the variance in the monthly incidence of CDAD. The findings of this study highlight a temporal relationship between certain classes of antibiotics, H2RAs, and CDAD incidence. The results of this research can help hospitals to set priorities for restricting the use of specific antibiotic classes, based on the size-effect of each class and the delay necessary to observe an effect.
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Persson S, Torpdahl and M, Olsen K. New multiplex PCR method for the detection of Clostridium difficile toxin A (tcdA) and toxin B (tcdB) and the binary toxin (cdtA/cdtB) genes applied to a Danish strain collection. Clin Microbiol Infect 2008; 14:1057-64. [DOI: 10.1111/j.1469-0691.2008.02092.x] [Citation(s) in RCA: 215] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Vonberg RP, Kuijper EJ, Wilcox MH, Barbut F, Tüll P, Gastmeier P, van den Broek PJ, Colville A, Coignard B, Daha T, Debast S, Duerden BI, van den Hof S, van der Kooi T, Maarleveld HJH, Nagy E, Notermans DW, O'Driscoll J, Patel B, Stone S, Wiuff C. Infection control measures to limit the spread of Clostridium difficile. Clin Microbiol Infect 2008; 14 Suppl 5:2-20. [PMID: 18412710 DOI: 10.1111/j.1469-0691.2008.01992.x] [Citation(s) in RCA: 185] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Clostridium difficile-associated diarrhoea (CDAD) presents mainly as a nosocomial infection, usually after antimicrobial therapy. Many outbreaks have been attributed to C. difficile, some due to a new hyper-virulent strain that may cause more severe disease and a worse patient outcome. As a result of CDAD, large numbers of C. difficile spores may be excreted by affected patients. Spores then survive for months in the environment; they cannot be destroyed by standard alcohol-based hand disinfection, and persist despite usual environmental cleaning agents. All these factors increase the risk of C. difficile transmission. Once CDAD is diagnosed in a patient, immediate implementation of appropriate infection control measures is mandatory in order to prevent further spread within the hospital. The quality and quantity of antibiotic prescribing should be reviewed to minimise the selective pressure for CDAD. This article provides a review of the literature that can be used for evidence-based guidelines to limit the spread of C. difficile. These include early diagnosis of CDAD, surveillance of CDAD cases, education of staff, appropriate use of isolation precautions, hand hygiene, protective clothing, environmental cleaning and cleaning of medical equipment, good antibiotic stewardship, and specific measures during outbreaks. Existing local protocols and practices for the control of C. difficile should be carefully reviewed and modified if necessary.
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Affiliation(s)
- R-P Vonberg
- Institute for Medical Microbiology and Hospital Epidemiology, Medical School Hannover, Hannover, Germany.
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Vernaz N, Sax H, Pittet D, Bonnabry P, Schrenzel J, Harbarth S. Temporal effects of antibiotic use and hand rub consumption on the incidence of MRSA and Clostridium difficile. J Antimicrob Chemother 2008; 62:601-7. [PMID: 18468995 DOI: 10.1093/jac/dkn199] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES The aim of this study was to determine the temporal relation between the use of antibiotics and alcohol-based hand rubs (ABHRs) and the incidence of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. METHODS An interventional time-series analysis was performed to evaluate the impact of two promotion campaigns on the consumption of ABHRs and to assess their effect on the incidence of non-duplicate clinical isolates of MRSA and C. difficile from February 2000 through September 2006. This analysis was combined with a transfer function model of aggregated data on antibiotic use. RESULTS Consumption of ABHRs correlated with MRSA, but not with C. difficile. The final model demonstrated the immediate effect of the second hand hygiene promotion campaign and an additional temporal effect of fluoroquinolone (time lag, 1 month; i.e. antibiotic effect delayed for 1 month), macrolide (lag 1 and 4 months), broad-spectrum cephalosporins (lag 3, 4 and 5 months) and piperacillin/tazobactam (lag 3 months) use. The final model explained 57% of the MRSA variance over time. In contrast, the model for C. difficile showed only an effect for broad-spectrum cephalosporins (lag 1 month). CONCLUSIONS We observed an aggregate-level relation between the monthly MRSA incidence and the use of different antibiotic classes and increased consumption of ABHR after a successful hand hygiene campaign, while no association with ABHR use was detected for C. difficile.
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Affiliation(s)
- Nathalie Vernaz
- Pharmacy Department, University of Geneva Hospitals and Medical School, Geneva, Switzerland
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McFarland LV, Beneda HW, Clarridge JE, Raugi GJ. Implications of the changing face of Clostridium difficile disease for health care practitioners. Am J Infect Control 2007; 35:237-53. [PMID: 17482995 DOI: 10.1016/j.ajic.2006.06.004] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2006] [Revised: 06/19/2006] [Accepted: 06/20/2006] [Indexed: 01/19/2023]
Abstract
Recent reported outbreaks of Clostridium difficile-associated disease in Canada have changed the profile of C difficile infections. Historically, C difficile disease was thought of mainly as a nosocomial disease associated with broad-spectrum antibiotics, and the disease was usually not life threatening. The emergence of an epidemic strain, BI/NAP1/027, which produces a binary toxin in addition to the 2 classic C difficile toxins A and B and is resistant to some fluoroquinolones, was associated with large numbers of cases with high rates of mortality. Recently, C difficile has been reported more frequently in nonhospital-based settings, such as community-acquired cases. The C difficile disease is also being reported in populations once considered of low risk (children and young healthy women). In addition, poor response to metronidazole treatment is increasing. Faced with an increasing incidence of C difficile infections and the changing profile of patients who become infected, this paper will reexamine the current concepts on the epidemiology and treatment of C difficile-associated disease, present new hypotheses for risk factors, examine the role of spores in the transmission of C difficile, and provide recommendations that may enhance infection control practices.
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Affiliation(s)
- Lynne V McFarland
- From the Department of Health Services Research and Development, Veterans Administration Puget Sound Health Care System, Seattle, WA 98101, USA.
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Hubert B, Loo VG, Bourgault AM, Poirier L, Dascal A, Fortin E, Dionne M, Lorange M. A portrait of the geographic dissemination of the Clostridium difficile North American pulsed-field type 1 strain and the epidemiology of C. difficile-associated disease in Québec. Clin Infect Dis 2006; 44:238-44. [PMID: 17173224 DOI: 10.1086/510391] [Citation(s) in RCA: 166] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2006] [Accepted: 09/28/2006] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND An increase in the incidence and severity of Clostridium difficile-associated disease in Québec and the United States has been associated with a hypervirulent strain referred to as North American pulsed-field type 1 (NAP1)/027. METHODS In 2005, a prospective study was conducted in 88 Québec hospitals, and 478 consecutive nosocomial isolates of C. difficile were obtained. The isolates were subjected to pulsed-field gel electrophoresis (PFGE) typing, antimicrobial susceptibility testing, and detection of binary toxin genes and tcdC gene deletion. Data on patient age and occurrence of complications were collected. RESULTS PFGE typing of 478 isolates of C. difficile yielded 61 PFGE profiles. Pulsovars A (57%), B (10%), and B1 (8%) were predominant. The PFGE profile of pulsovar A was identical to that of strain NAP1. It showed 67% relatedness with 15 other PFGE patterns, among which 11 had both binary toxin genes and a partial tcdC deletion but different antibiotic susceptibility profiles. Pulsovars B and B1 were identical to strain NAP2/ribotype 001. In hospitals showing a predominant clonal A or B-B1 PFGE pattern, incidence of C. difficile-associated disease was 2 and 1.3 times higher, respectively, than in hospitals without any predominant clonal PFGE pattern. Severe disease was twice as frequent among patients with strains possessing binary toxin genes and tcdC deletion than among patients with strains lacking these virulence factors. CONCLUSIONS This study helped to quantify the impact of strain NAP1 on the incidence and severity of C. difficile-associated disease in Québec in 2005. The identification of the geographic dissemination of this predominant strain may help to focus regional infection-control efforts.
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Affiliation(s)
- Bruno Hubert
- Institut National de Santé Publique du Québec, Québec, Canada.
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