1
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Montgomery G, Patel A, Pfeil S. Treatment and Management of Gastrointestinal Disorders. Med Clin North Am 2024; 108:777-794. [PMID: 39084834 DOI: 10.1016/j.mcna.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
This article reviews the evaluation and management of several gastrointestinal disorders that are commonly encountered by gastroenterologists and primary care physicians. With a focus on newer therapies, we discuss the management of chronic constipation, irritable bowel syndrome, Clostridioides difficile infection, gastroparesis, steatotic liver disease, and diverticulitis.
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Affiliation(s)
- Garren Montgomery
- Division of Gastroenterology, Hepatology, and Nutrition, Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Arsheya Patel
- Division of Gastroenterology, Hepatology, and Nutrition, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sheryl Pfeil
- Division of Gastroenterology, Hepatology, and Nutrition, Ohio State University Medical Center, Columbus, OH, USA
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2
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Bernabè G, Castagliuolo I, Porzionato A, Casarotto G, Monte RD, Carpi A, Brun P. Insoluble polysaccharides produced in plant cell cultures protect from Clostridioides difficile colitis. Microbiol Res 2024; 286:127812. [PMID: 38954992 DOI: 10.1016/j.micres.2024.127812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 05/18/2024] [Accepted: 06/16/2024] [Indexed: 07/04/2024]
Abstract
Clostridioides difficile infection (CDI) poses a significant health threat due to high recurrence rates. Antimicrobial agents are commonly used to manage CDI-related diarrhoea; however, by aggravating intestinal dysbiosis, antibiotics enable C. difficile spores germination and production of toxins, the main virulence factors. Therefore, the binding of exotoxins using adsorbents represents an attractive alternative medication for the prevention and treatment of relapses. In this study, we provided evidence that the natural insoluble polysaccharides, named ABR119, extracted by plant cell cultures, effectively trap C. difficile toxins. In our experiments, ABR119 exhibited no cytotoxicity in vitro and was safely administered in vivo. In the animal model of C. difficile-associated colitis, ABR119 (50 mg/kg body weight) significantly reduced the colonic myeloperoxidase activity and severity of inflammation, preventing body weight loss. These effects were not evident when we treated animals with wheat bran polysaccharides. We did not detect bacterial killing effects of ABR119 against C. difficile nor against bacterial species of the normal gut microbiota. Moreover, ABR119 did not interfere in vitro with the antimicrobial activities of most clinically used antibiotics. In summary, ABR119 holds promise for treating and preventing C. difficile colitis by trapping the bacterial toxins, warranting further studies to assess the ABR119 potential in human infections caused by C. difficile.
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Affiliation(s)
- Giulia Bernabè
- University of Padova, Department of Molecular Medicine via A. Gabelli, 63, Padova 35121, Italy
| | - Ignazio Castagliuolo
- University of Padova, Department of Molecular Medicine via A. Gabelli, 63, Padova 35121, Italy; Microbiology Unit of Padua University Hospital, via N. Giustiniani, 2, Padova 35128, Italy
| | - Andrea Porzionato
- University of Padova, Department of Neurosciences, via A. Gabelli, 65, Padova 35121, Italy
| | - Gino Casarotto
- Active Botanicals Research, Via dell'Impresa, 1, Brendola, Vicenza 36040, Italy
| | - Renzo Dal Monte
- Active Botanicals Research, Via dell'Impresa, 1, Brendola, Vicenza 36040, Italy
| | - Andrea Carpi
- Active Botanicals Research, Via dell'Impresa, 1, Brendola, Vicenza 36040, Italy
| | - Paola Brun
- University of Padova, Department of Molecular Medicine via A. Gabelli, 63, Padova 35121, Italy.
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3
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Xu L, Gurung B, Gu C, Wang S, Gu T. A New Convenient Method to Assess Antibiotic Resistance and Antimicrobial Efficacy against Pathogenic Clostridioides difficile Biofilms. Antibiotics (Basel) 2024; 13:728. [PMID: 39200028 PMCID: PMC11350819 DOI: 10.3390/antibiotics13080728] [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: 06/30/2024] [Revised: 07/31/2024] [Accepted: 08/01/2024] [Indexed: 09/01/2024] Open
Abstract
Clostridioides difficile is a widely distributed anaerobic pathogen. C. difficile infection is a serious problem in healthcare. Its biofilms have been found to exhibit biocorrosivity, albeit very little, but sufficient for it to correlate with biofilm growth/health. This work demonstrated the use of a disposable electrochemical biofilm test kit using two solid-state electrodes (a 304 stainless steel working electrode, and a graphite counter electrode, which also served as the reference electrode) in a 10 mL serum vial. It was found that the C. difficile 630∆erm Adp-4 mutant had a minimum inhibitory concentration (MIC) for vancomycin twice that of the 630∆erm wild type strain in biofilm prevention (2 ppm vs. 1 ppm by mass) on 304 stainless steel. Glutaraldehyde, a commonly used hospital disinfectant, was found ineffective at 2% (w/w) for the prevention of C. difficile 630∆erm wild type biofilm formation, while tetrakis(hydroxymethyl)phosphonium sulfate (THPS) disinfectant was very effective at 100 ppm for both biofilm prevention and biofilm killing. These antimicrobial efficacy data were consistent with sessile cell count and biofilm imaging results. Furthermore, the test kit provided additional transient biocide treatment information. It showed that vancomycin killed C. difficile 630∆erm wild type biofilms in 2 d, while THPS only required minutes.
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Affiliation(s)
- Lingjun Xu
- Department of Chemical & Biomolecular Engineering, Edison Biotechnology Institute, Ohio University, Athens, OH 45701, USA
| | - Bijay Gurung
- Department of Biomedical Sciences, Ohio University Heritage College of Osteopathic Medicine, Ohio University, Athens, OH 45071, USA
| | - Chris Gu
- Department of Biomedical Sciences, Ohio University Heritage College of Osteopathic Medicine, Ohio University, Athens, OH 45071, USA
| | - Shaohua Wang
- Department of Biomedical Sciences, Ohio University Heritage College of Osteopathic Medicine, Ohio University, Athens, OH 45071, USA
- Infectious and Tropical Disease Institute, Ohio University, Athens, OH 45071, USA
| | - Tingyue Gu
- Department of Chemical & Biomolecular Engineering, Edison Biotechnology Institute, Ohio University, Athens, OH 45701, USA
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4
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Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, Todi SK, Mohan A, Hegde A, Jagiasi BG, Krishna B, Rodrigues C, Govil D, Pal D, Divatia JV, Sengar M, Gupta M, Desai M, Rungta N, Prayag PS, Bhattacharya PK, Samavedam S, Dixit SB, Sharma S, Bandopadhyay S, Kola VR, Deswal V, Mehta Y, Singh YP, Myatra SN. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024; 28:S104-S216. [PMID: 39234229 PMCID: PMC11369928 DOI: 10.5005/jp-journals-10071-24677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 03/20/2024] [Indexed: 09/06/2024] Open
Abstract
How to cite this article: Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, et al. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024;28(S2):S104-S216.
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Affiliation(s)
- Gopi C Khilnani
- Department of Pulmonary, Critical Care and Sleep Medicine, PSRI Hospital, New Delhi, India
| | - Pawan Tiwari
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India
| | - Saurabh Mittal
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India
| | - Atul P Kulkarni
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Dhruva Chaudhry
- Department of Pulmonary and Critical Care Medicine, University of Health Sciences, Rohtak, Haryana, India
| | - Kapil G Zirpe
- Department of Neuro Trauma Unit, Grant Medical Foundation, Pune, Maharashtra, India
| | - Subhash K Todi
- Department of Critical Care, AMRI Hospital, Kolkata, West Bengal, India
| | - Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India
| | - Ashit Hegde
- Department of Medicine & Critical Care, P D Hinduja National Hospital, Mumbai, India
| | - Bharat G Jagiasi
- Department of Critical Care, Kokilaben Dhirubhai Ambani Hospital, Navi Mumbai, Maharashtra, India
| | - Bhuvana Krishna
- Department of Critical Care Medicine, St John's Medical College and Hospital, Bengaluru, India
| | - Camila Rodrigues
- Department of Microbiology, P D Hinduja National Hospital, Mumbai, India
| | - Deepak Govil
- Department of Critical Care and Anesthesia, Medanta – The Medicity, GuruGram, Haryana, India
| | - Divya Pal
- Department of Critical Care and Anesthesia, Medanta – The Medicity, GuruGram, Haryana, India
| | - Jigeeshu V Divatia
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Manju Sengar
- Department of Medical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Mansi Gupta
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Mukesh Desai
- Department of Immunology, Pediatric Hematology and Oncology Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Narendra Rungta
- Department of Critical Care & Anaesthesiology, Rajasthan Hospital, Jaipur, India
| | - Parikshit S Prayag
- Department of Transplant Infectious Diseases, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
| | - Pradip K Bhattacharya
- Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Srinivas Samavedam
- Department of Critical Care, Ramdev Rao Hospital, Hyderabad, Telangana, India
| | - Subhal B Dixit
- Department of Critical Care, Sanjeevan and MJM Hospital, Pune, Maharashtra, India
| | - Sudivya Sharma
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Susruta Bandopadhyay
- Department of Critical Care, AMRI Hospitals Salt Lake, Kolkata, West Bengal, India
| | - Venkat R Kola
- Department of Critical Care Medicine, Yashoda Hospitals, Hyderabad, Telangana, India
| | - Vikas Deswal
- Consultant, Infectious Diseases, Medanta - The Medicity, Gurugram, Haryana, India
| | - Yatin Mehta
- Department of Critical Care and Anesthesia, Medanta – The Medicity, GuruGram, Haryana, India
| | - Yogendra P Singh
- Department of Critical Care, Max Super Speciality Hospital, Patparganj, New Delhi, India
| | - Sheila N Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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5
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Quan M, Zhang X, Fang Q, Lv X, Wang X, Zong Z. Fighting against Clostridioides difficile infection: Current medications. Int J Antimicrob Agents 2024; 64:107198. [PMID: 38734214 DOI: 10.1016/j.ijantimicag.2024.107198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 04/18/2024] [Accepted: 05/04/2024] [Indexed: 05/13/2024]
Abstract
Clostridioides difficile (formerly Clostridium difficile) has been regarded as an 'urgent threat' and a significant global health problem, as life-threatening diarrhoea and refractory recurrence are common in patients with C. difficile infection (CDI). Unfortunately, the available anti-CDI drugs are limited. Recent guidelines recommend fidaxomicin and vancomycin as first-line drugs to treat CDI, bezlotoxumab to prevent recurrence, and faecal microbiota transplantation for rescue treatment. Currently, researchers are investigating therapeutic antibacterial drugs (e.g. teicoplanin, ridinilazole, ibezapolstat, surotomycin, cadazolid, and LFF571), preventive medications against recurrence (e.g. Rebyota, Vowst, VP20621, VE303, RBX7455, and MET-2), primary prevention strategies (e.g. vaccine, ribaxamase, and DAV132) and other anti-CDI medications in the preclinical stage (e.g. Raja 42, Myxopyronin B, and bacteriophage). This narrative review summarises current medications, including newly marketed drugs and products in development against CDI, to help clinicians treat CDI appropriately and to call for more research on innovation.
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Affiliation(s)
- Min Quan
- Center for Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Xiaoxia Zhang
- Center for Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Qingqing Fang
- Center for Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Xiaoju Lv
- Center for Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China; Division of Infectious Diseases, State Key Laboratory of Biotherapy, West China Hospital of Sichuan University, Chengdu, China
| | - Xiaohui Wang
- Center for Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China; Division of Infectious Diseases, State Key Laboratory of Biotherapy, West China Hospital of Sichuan University, Chengdu, China.
| | - Zhiyong Zong
- Center for Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China; Division of Infectious Diseases, State Key Laboratory of Biotherapy, West China Hospital of Sichuan University, Chengdu, China
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6
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Chioti VT, McWhorter KL, Blue TC, Li Y, Xu F, Jeffrey PD, Davis KM, Seyedsayamdost MR. Potent and specific antibiotic combination therapy against Clostridioides difficile. Nat Chem Biol 2024; 20:924-933. [PMID: 38942968 PMCID: PMC11306116 DOI: 10.1038/s41589-024-01651-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/15/2024] [Indexed: 06/30/2024]
Abstract
Keratinicyclins and keratinimicins are recently discovered glycopeptide antibiotics. Keratinimicins show broad-spectrum activity against Gram-positive bacteria, while keratinicyclins form a new chemotype by virtue of an unusual oxazolidinone moiety and exhibit specific antibiosis against Clostridioides difficile. Here we report the mechanism of action of keratinicyclin B (KCB). We find that steric constraints preclude KCB from binding peptidoglycan termini. Instead, KCB inhibits C. difficile growth by binding wall teichoic acids (WTAs) and interfering with cell wall remodeling. A computational model, guided by biochemical studies, provides an image of the interaction of KCB with C. difficile WTAs and shows that the same H-bonding framework used by glycopeptide antibiotics to bind peptidoglycan termini is used by KCB for interacting with WTAs. Analysis of KCB in combination with vancomycin (VAN) shows highly synergistic and specific antimicrobial activity, and that nanomolar combinations of the two drugs are sufficient for complete growth inhibition of C. difficile, while leaving common commensal strains unaffected.
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Affiliation(s)
| | | | - Tamra C Blue
- Department of Chemistry, Emory University, Atlanta, GA, USA
| | - Yuchen Li
- Department of Chemistry, Princeton University, Princeton, NJ, USA
| | - Fei Xu
- Institute of Pharmaceutical Biotechnology and Department of Gastroenterology of the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Philip D Jeffrey
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | | | - Mohammad R Seyedsayamdost
- Department of Chemistry, Princeton University, Princeton, NJ, USA.
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA.
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7
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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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8
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Cun WY, Keller PA, Pyne SG. Current and Ongoing Developments in Targeting Clostridioides difficile Infection and Recurrence. Microorganisms 2024; 12:1206. [PMID: 38930588 PMCID: PMC11205563 DOI: 10.3390/microorganisms12061206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/11/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024] Open
Abstract
Clostridioides difficile is a Gram-positive, spore-forming anaerobic bacterial pathogen that causes severe gastrointestinal infection in humans. This review provides background information on C. difficile infection and the pathogenesis and toxigenicity of C. difficile. The risk factors, causes, and the problem of recurrence of disease and current therapeutic treatments are also discussed. Recent therapeutic developments are reviewed including small molecules that inhibit toxin formation, disrupt the cell membrane, inhibit the sporulation process, and activate the host immune system in cells. Other treatments discussed include faecal microbiota treatment, antibody-based immunotherapies, probiotics, vaccines, and violet-blue light disinfection.
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Affiliation(s)
- Wendy Y. Cun
- School of Chemistry and Molecular Science, Molecular Horizons Institute, University of Wollongong, Wollongong, NSW 2522, Australia;
| | | | - Stephen G. Pyne
- School of Chemistry and Molecular Science, Molecular Horizons Institute, University of Wollongong, Wollongong, NSW 2522, Australia;
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9
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Di Bella S, Sanson G, Monticelli J, Zerbato V, Principe L, Giuffrè M, Pipitone G, Luzzati R. Clostridioides difficile infection: history, epidemiology, risk factors, prevention, clinical manifestations, treatment, and future options. Clin Microbiol Rev 2024; 37:e0013523. [PMID: 38421181 PMCID: PMC11324037 DOI: 10.1128/cmr.00135-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
SUMMARYClostridioides difficile infection (CDI) is one of the major issues in nosocomial infections. This bacterium is constantly evolving and poses complex challenges for clinicians, often encountered in real-life scenarios. In the face of CDI, we are increasingly equipped with new therapeutic strategies, such as monoclonal antibodies and live biotherapeutic products, which need to be thoroughly understood to fully harness their benefits. Moreover, interesting options are currently under study for the future, including bacteriophages, vaccines, and antibiotic inhibitors. Surveillance and prevention strategies continue to play a pivotal role in limiting the spread of the infection. In this review, we aim to provide the reader with a comprehensive overview of epidemiological aspects, predisposing factors, clinical manifestations, diagnostic tools, and current and future prophylactic and therapeutic options for C. difficile infection.
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Affiliation(s)
- Stefano Di Bella
- Clinical Department of
Medical, Surgical and Health Sciences, Trieste
University, Trieste,
Italy
| | - Gianfranco Sanson
- Clinical Department of
Medical, Surgical and Health Sciences, Trieste
University, Trieste,
Italy
| | - Jacopo Monticelli
- Infectious Diseases
Unit, Trieste University Hospital
(ASUGI), Trieste,
Italy
| | - Verena Zerbato
- Infectious Diseases
Unit, Trieste University Hospital
(ASUGI), Trieste,
Italy
| | - Luigi Principe
- Microbiology and
Virology Unit, Great Metropolitan Hospital
“Bianchi-Melacrino-Morelli”,
Reggio Calabria, Italy
| | - Mauro Giuffrè
- Clinical Department of
Medical, Surgical and Health Sciences, Trieste
University, Trieste,
Italy
- Department of Internal
Medicine (Digestive Diseases), Yale School of Medicine, Yale
University, New Haven,
Connecticut, USA
| | - Giuseppe Pipitone
- Infectious Diseases
Unit, ARNAS Civico-Di Cristina
Hospital, Palermo,
Italy
| | - Roberto Luzzati
- Clinical Department of
Medical, Surgical and Health Sciences, Trieste
University, Trieste,
Italy
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10
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Patel P, Robinson PD, Fisher BT, Phillips R, Morgan JE, Lehrnbecher T, Kuczynski S, Koenig C, Haeusler GM, Esbenshade A, Elgarten C, Duong N, Diorio C, Castagnola E, Beauchemin MP, Ammann RA, Dupuis LL, Sung L. Guideline for the management of Clostridioides difficile infection in pediatric patients with cancer and hematopoietic cell transplantation recipients: 2024 update. EClinicalMedicine 2024; 72:102604. [PMID: 38680517 PMCID: PMC11046252 DOI: 10.1016/j.eclinm.2024.102604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/28/2024] [Accepted: 04/03/2024] [Indexed: 05/01/2024] Open
Abstract
Our objective was to update a clinical practice guideline for the prevention and treatment of Clostridioides difficile infection (CDI) in pediatric patients with cancer and hematopoietic cell transplantation recipients. We reconvened an international multi-disciplinary panel. A systematic review of randomized controlled trials (RCTs) for the prevention or treatment of CDI in any population was updated and identified 31 new RCTs. Strong recommendations were made to use either oral metronidazole or oral vancomycin for non-severe CDI treatment, and to use either oral vancomycin or oral fidaxomicin for severe CDI. A strong recommendation that fecal microbiota transplantation should not be routinely used to treat CDI was also made. The panel made two new good practice statements to follow infection control practices including isolation in patients experiencing CDI, and to minimize systemic antibacterial administration where feasible, especially in patients who have experienced CDI.
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Affiliation(s)
- Priya Patel
- Pediatric Oncology Group of Ontario, 480 University Ave, Suite 1014, Toronto, ON, M5G 1V2, Canada
- Department of Pharmacy, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Paula D. Robinson
- Pediatric Oncology Group of Ontario, 480 University Ave, Suite 1014, Toronto, ON, M5G 1V2, Canada
| | - Brian T. Fisher
- Division of Infectious Diseases, Children's Hospital of Philadelphia, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Robert Phillips
- Centre for Reviews and Dissemination, University of York, York, YO10 5DD, UK
- Department of Paediatric Haematology and Oncology, Leeds Children's Hospital, Leeds, LS1 3EX, UK
| | - Jessica E. Morgan
- Centre for Reviews and Dissemination, University of York, York, YO10 5DD, UK
- Department of Paediatric Haematology and Oncology, Leeds Children's Hospital, Leeds, LS1 3EX, UK
| | - Thomas Lehrnbecher
- Department of Pediatrics, Division of Hematology, Oncology and Hemostaseology, Goethe University Frankfurt, Theodor-W.-Adorno-Platz 1, 60629, Frankfurt am Main, Germany
| | | | - Christa Koenig
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 20, 3010, Bern, Switzerland
| | - Gabrielle M. Haeusler
- Infectious Diseases Unit, Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria, 3052, Australia
| | - Adam Esbenshade
- Vanderbilt-Ingram Cancer Centre, 2220 Pierce Ave, Nashville, TN, 37232, USA
| | - Caitlin Elgarten
- Division of Oncology, Children's Hospital of Philadelphia, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | | | - Caroline Diorio
- Division of Oncology, Children's Hospital of Philadelphia, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Elio Castagnola
- Infectious Diseases Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, 16147, Genova, Italy
| | - Melissa P. Beauchemin
- Columbia University Irving Medical Center/Herbert Irving Comprehensive Cancer Center, Columbia University School of Nursing, 1130 St Nicholas Ave, 2nd Floor, New York, NY, 10032, USA
| | - Roland A. Ammann
- StatConsult Ammann, Pleerweg 92, 3400, Burgdorf, Switzerland
- Kinderarztpraxis KurWerk, Poststrasse 9, 3400, Burgdorf, Switzerland
| | - L. Lee Dupuis
- Department of Pharmacy, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, ON, M5S 3M2, Canada
| | - Lillian Sung
- Child Health Evaluative Sciences, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
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11
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Rampedi PN, Ogunrombi MO, Adeleke OA. Leading Paediatric Infectious Diseases-Current Trends, Gaps, and Future Prospects in Oral Pharmacotherapeutic Interventions. Pharmaceutics 2024; 16:712. [PMID: 38931836 PMCID: PMC11206886 DOI: 10.3390/pharmaceutics16060712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 05/17/2024] [Accepted: 05/21/2024] [Indexed: 06/28/2024] Open
Abstract
Paediatric infectious diseases contribute significantly to global health challenges. Conventional therapeutic interventions are not always suitable for children, as they are regularly accompanied with long-standing disadvantages that negatively impact efficacy, thus necessitating the need for effective and child-friendly pharmacotherapeutic interventions. Recent advancements in drug delivery technologies, particularly oral formulations, have shown tremendous progress in enhancing the effectiveness of paediatric medicines. Generally, these delivery methods target, and address challenges associated with palatability, dosing accuracy, stability, bioavailability, patient compliance, and caregiver convenience, which are important factors that can influence successful treatment outcomes in children. Some of the emerging trends include moving away from creating liquid delivery systems to developing oral solid formulations, with the most explored being orodispersible tablets, multiparticulate dosage forms using film-coating technologies, and chewable drug products. Other ongoing innovations include gastro-retentive, 3D-printed, nipple-shield, milk-based, and nanoparticulate (e.g., lipid-, polymeric-based templates) drug delivery systems, possessing the potential to improve therapeutic effectiveness, age appropriateness, pharmacokinetics, and safety profiles as they relate to the paediatric population. This manuscript therefore highlights the evolving landscape of oral pharmacotherapeutic interventions for leading paediatric infectious diseases, crediting the role of innovative drug delivery technologies. By focusing on the current trends, pointing out gaps, and identifying future possibilities, this review aims to contribute towards ongoing efforts directed at improving paediatric health outcomes associated with the management of these infectious ailments through accessible and efficacious drug treatments.
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Affiliation(s)
- Penelope N. Rampedi
- Department of Clinical Pharmacology and Therapeutics, School of Medicine, Sefako Makgatho Health Science University, Pretoria 0208, South Africa; (P.N.R.); (M.O.O.)
| | - Modupe O. Ogunrombi
- Department of Clinical Pharmacology and Therapeutics, School of Medicine, Sefako Makgatho Health Science University, Pretoria 0208, South Africa; (P.N.R.); (M.O.O.)
| | - Oluwatoyin A. Adeleke
- Preclinical Laboratory for Drug Delivery Innovations, College of Pharmacy, Faculty of Health, Dalhousie University, Halifax, NS B3H 4R2, Canada
- School of Biomedical Engineering, Faculty of Medicine, Dalhousie University, Halifax, NS B3H 3J5, Canada
- School of Pharmacy, Sefako Makgatho Health Science University, Pretoria 0208, South Africa
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12
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Angulo FJ, Ghia C, Fletcher MA, Ozbilgili E, Morales GDC. The burden of Clostridioides difficile infections in South-East Asia and the Western Pacific: A narrative review. Anaerobe 2024; 86:102821. [PMID: 38336258 DOI: 10.1016/j.anaerobe.2024.102821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/16/2024] [Accepted: 01/18/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Clostridioides difficile (formerly Clostridium difficile) is well-documented in Europe and North America to be a common cause of healthcare-associated gastrointestinal tract infections. In contrast, C difficile infection (CDI) is infrequently reported in literature from Asia, which may reflect a lack of clinician awareness. We conducted a narrative review to better understand CDI burden in Asia. METHODS We searched the PubMed database for English language articles related to C difficile, Asia, epidemiology, and molecular characteristics (eg, ribotype, antimicrobial resistance). RESULTS Fifty-eight articles that met eligibility criteria were included. C difficile prevalence ranged from 7.1% to 45.1 % of hospitalized patients with diarrhea, and toxigenic strains among all C difficile in these patients ranged from 68.2% to 91.9 % in China and from 39.0% to 60.0 % outside of China. Widespread C difficile ribotypes were RT017, RT014/020, RT012, and RT002. Recurrence in patients with CDI ranged from 3.0% to 17.2 %. Patients with CDI typically had prior antimicrobial use recently. High rates of resistance to ciprofloxacin, clindamycin, and erythromycin were frequently reported. CONCLUSION The regional CDI burden in Asia is still incompletely documented, seemingly due to low awareness and limited laboratory testing. Despite this apparent under recognition, the current CDI burden highlights the need for broader surveillance and for application of preventative measures against CDI in Asia.
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Affiliation(s)
- Frederick J Angulo
- Medical Development and Scientific/Clinical Affairs, Vaccines, Antivirals, and Evidence Generation, Pfizer Inc., 500 Arcola Rd., Collegeville, PA, 19426, USA.
| | - Canna Ghia
- Pfizer Ltd 70, G Block Rd, Bandra Kurla Complex, Mumbai, Maharashtra 400051, India.
| | - Mark A Fletcher
- Emerging Markets Medical Affairs, Vaccines, Pfizer, 23-25 avenue du Docteur Lannelongue, 75014 Paris, France.
| | - Egemen Ozbilgili
- Emerging Markets Medical Affairs, Vaccines, Pfizer Pte Ltd., 31 Tuas South Ave 6, 637578, Singapore.
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13
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Piekarska A, Sadowska-Klasa A, Mensah-Glanowska P, Sobczyk-Kruszelnicka M, Drozd-Sokołowska J, Waszczuk-Gajda A, Kujawska J, Wilk M, Tomaszewska A, Zaucha JM, Giebel S, Gil L. Effective treatment of Clostridioides difficile infection improves survival and affects graft-versus-host disease: a multicenter study by the Polish Adult Leukemia Group. Sci Rep 2024; 14:5947. [PMID: 38467719 PMCID: PMC10928209 DOI: 10.1038/s41598-024-56336-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 03/05/2024] [Indexed: 03/13/2024] Open
Abstract
Clostridioides difficile infection (CDI) is the most common cause of infectious diarrhea after allogeneic hematopoietic cell transplantation (allo-HCT). The impact of CDI and its treatment on allo-HCT outcomes and graft-versus-host disease (GVHD), including gastrointestinal GVHD (GI-GVHD) is not well established. This multicenter study assessed real-life data on the first-line treatment of CDI and its impact on allo-HCT outcomes. Retrospective and prospective data of patients with CDI after allo-HCT were assessed. We noted statistically significant increase in the incidence of acute GVHD and acute GI-GVHD after CDI (P = 0.005 and P = 0.016, respectively). The first-line treatment for CDI included metronidazole in 34 patients, vancomycin in 64, and combination therapy in 10. Treatment failure was more common with metronidazole than vancomycin (38.2% vs. 6.2%; P < 0.001). The need to administer second-line treatment was associated with the occurrence or exacerbation of GVHD (P < 0.05) and GI-GVHD (P < 0.001) and reduced overall survival (P < 0.05). In the multivariate analysis, the risk of death was associated with acute GVHD presence before CDI (hazard ratio [HR], 3.19; P = 0.009) and the need to switch to second-line treatment (HR, 4.83; P < 0.001). The efficacy of the initial CDI treatment affects survival and occurrence of immune-mediated GI-GVHD after allo-HCT. Therefore, agents with higher efficacy than metronidazole (vancomycin or fidaxomicin) should be administered as the first-line treatment.
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Affiliation(s)
- Agnieszka Piekarska
- Department of Hematology and Transplantology, Medical University of Gdańsk and University Clinical Center, ul. Smoluchowskiego 17, 80-214, Gdańsk, Poland.
| | - Alicja Sadowska-Klasa
- Department of Hematology and Transplantology, Medical University of Gdańsk and University Clinical Center, ul. Smoluchowskiego 17, 80-214, Gdańsk, Poland
| | - Patrycja Mensah-Glanowska
- Department of Hematology, Jagiellonian University Collegium Medicum, University Hospital in Cracow, Cracow, Poland
| | - Małgorzata Sobczyk-Kruszelnicka
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Institute - Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Joanna Drozd-Sokołowska
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Anna Waszczuk-Gajda
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Joanna Kujawska
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznań, Poland
| | - Mateusz Wilk
- Department of Hematology, University Hospital in Cracow, Cracow, Poland
| | - Agnieszka Tomaszewska
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Jan M Zaucha
- Department of Hematology and Transplantology, Medical University of Gdańsk and University Clinical Center, ul. Smoluchowskiego 17, 80-214, Gdańsk, Poland
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Institute - Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Lidia Gil
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznań, Poland
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14
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Baldassarre L, Quach-Thanh C, Mouajou Feujio V, Tadount F, Deyirmendjian C, Lefebvre MA, Thampi N, Schneider O, Fabri-Karam I, O'Donnell S, Okeny-Owere J, Audy N, Desmarais N. Incidence and risk factors for recurrent Clostridioides difficile infection in pediatric at-risk groups in selected Pediatric Investigators Collaborative Network on Infections in Canada (PICNIC) hospitals. Infect Control Hosp Epidemiol 2024; 45:182-187. [PMID: 37700539 DOI: 10.1017/ice.2023.174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
OBJECTIVES Incidence and risk factors for recurrent Clostridioides difficile infection (rCDI) are well established in adults, though data are lacking in pediatrics. We aimed to determine incidence of and risk factors for rCDI in pediatrics. METHODS This retrospective cohort study of pediatric patients was conducted at 3 tertiary-care hospitals in Canada with laboratory-confirmed CDI between April 1, 2012, and March 31, 2017. rCDI was defined as an episode of CDI occurring 8 weeks or less from diagnostic test date of the primary episode. We used logistic regression to determine and quantify risk factors significantly associated with rCDI. RESULTS In total, 286 patients were included in this study. The incidence proportion for rCDI was 12.9%. Among hospitalized patients, the incidence rate was estimated at 2.6 cases of rCDI per 1,000 hospital days at risk (95% confidence interval [CI], 1.7-3.9). Immunocompromised patients had higher incidence of rCDI (17.5%; P = .03) and higher odds of developing rCDI independently of antibiotic treatment given for the primary episode (odds ratio [OR], 2.31; 95% CI, 1.12-5.09). Treatment with vancomycin monotherapy did not show statistically significant protection from rCDI, independently of immunocompromised status (OR, 0.33; 95% CI, 0.05-1.15]). CONCLUSIONS The identification of increased risk of rCDI in immunocompromised pediatric patients warrants further research into alternative therapies, prophylaxis, and prevention strategies to prevent recurrent disease burden within these groups. Treatment of the initial episode with vancomycin did not show statistically significant protection from rCDI.
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Affiliation(s)
- Lucila Baldassarre
- Department of Microbiology, Infectious Disease, and Immunology, University of Montreal, Montreal, Québec, Canada
| | - Caroline Quach-Thanh
- Department of Microbiology, Infectious Disease, and Immunology, University of Montreal, Montreal, Québec, Canada
- Centre Hospitalier Universitaire Sainte Justine Research Centre, Montreal, Québec, Canada
| | - Verinsa Mouajou Feujio
- Department of Microbiology, Infectious Disease, and Immunology, University of Montreal, Montreal, Québec, Canada
| | - Fazia Tadount
- Centre Hospitalier Universitaire Sainte Justine Research Centre, Montreal, Québec, Canada
| | - Claudia Deyirmendjian
- Department of Microbiology, Infectious Disease, and Immunology, University of Montreal, Montreal, Québec, Canada
| | - Marie-Astrid Lefebvre
- Division of Infectious Diseases, Department of Paediatrics, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Québec, Canada
| | - Nisha Thampi
- Children's Hospital of Eastern Ontario, Division of Infectious Diseases, Immunology and Allergy, Department of Pediatrics, Ottawa, Ontario, Canada
| | - Oliver Schneider
- Department of Family Medicine and Emergency Medicine, University of Montreal, Montreal, Québec, Canada
| | - Isabela Fabri-Karam
- Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
| | - Shauna O'Donnell
- Infection Prevention & Control, Centre Hospitalier Universitaire Sainte Justine, Montreal, Québec, Canada
| | - James Okeny-Owere
- Children's Hospital of Eastern Ontario, Division of Infectious Diseases, Immunology and Allergy, Department of Pediatrics, Ottawa, Ontario, Canada
| | - N Audy
- Infection Prevention & Control, Centre Hospitalier Universitaire Sainte Justine, Montreal, Québec, Canada
| | - Nadia Desmarais
- Infection Prevention & Control, Centre Hospitalier Universitaire Sainte Justine, Montreal, Québec, Canada
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15
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Markantonis JE, Fallon JT, Madan R, Alam MZ. Clostridioides difficile Infection: Diagnosis and Treatment Challenges. Pathogens 2024; 13:118. [PMID: 38392856 PMCID: PMC10891949 DOI: 10.3390/pathogens13020118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 02/25/2024] Open
Abstract
Clostridioides difficile is the most important cause of healthcare-associated diarrhea in the United States. The high incidence and recurrence rates of C. difficile infection (CDI), associated with high morbidity and mortality, pose a public health challenge. Although antibiotics targeting C. difficile bacteria are the first treatment choice, antibiotics also disrupt the indigenous gut flora and, therefore, create an environment that is favorable for recurrent CDI. The challenge of treating CDI is further exacerbated by the rise of antibiotic-resistant strains of C. difficile, placing it among the top five most urgent antibiotic resistance threats in the USA. The evolution of antibiotic resistance in C. difficile involves the acquisition of new resistance mechanisms, which can be shared among various bacterial species and different C. difficile strains within clinical and community settings. This review provides a summary of commonly used diagnostic tests and antibiotic treatment strategies for CDI. In addition, it discusses antibiotic treatment and its resistance mechanisms. This review aims to enhance our current understanding and pinpoint knowledge gaps in antimicrobial resistance mechanisms in C. difficile, with an emphasis on CDI therapies.
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Affiliation(s)
- John E. Markantonis
- Department of Pathology and Laboratory Medicine, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Greenville, NC 27834, USA; (J.E.M.); (J.T.F.)
| | - John T. Fallon
- Department of Pathology and Laboratory Medicine, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Greenville, NC 27834, USA; (J.E.M.); (J.T.F.)
| | - Rajat Madan
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA;
- Veterans Affairs Medical Center, Cincinnati, OH 45220, USA
| | - Md Zahidul Alam
- Department of Pathology and Laboratory Medicine, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Greenville, NC 27834, USA; (J.E.M.); (J.T.F.)
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16
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Adukauskienė D, Mickus R, Dambrauskienė A, Vanagas T, Adukauskaitė A. Improving Clostridioides difficile Infectious Disease Treatment Response via Adherence to Clinical Practice Guidelines. Antibiotics (Basel) 2024; 13:51. [PMID: 38247610 PMCID: PMC10812669 DOI: 10.3390/antibiotics13010051] [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: 10/27/2023] [Revised: 12/29/2023] [Accepted: 01/02/2024] [Indexed: 01/23/2024] Open
Abstract
Clostridioides difficile (C. difficile) is a predominant nosocomial infection, and guidelines for improving diagnosis and treatment were published in 2017. We conducted a single-center, retrospective 10-year cohort study of patients with primary C. difficile infectious disease (CDID) at the largest referral Lithuanian university hospital, aiming to evaluate the clinical and laboratory characteristics of CDID and their association with the outcomes, as well as implication of concordance with current Clinical Practice Guidelines. The study enrolled a total of 370 patients. Cases with non-concordant CDID treatment resulted in more CDID-related Intensive Care Unit (ICU) admissions (7.5 vs. 1.8%) and higher CDID-related mortality (13.0 vs. 1.8%) as well as 30-day all-cause mortality (61.0 vs. 36.1%) and a lower 30-day survival compared with CDID cases with concordant treatment (p < 0.05). Among cases defined by two criteria for severe CDID, only patients with non-concordant metronidazole treatment had refractory CDID (68.8 vs. 0.0%) compared with concordant vancomycin treatment. In the presence of non-concordant metronidazole treatment for severe CDID, only cases defined by two severity criteria had more CDID-related ICU admissions (18.8 vs. 0.0%) and higher CDID-related mortality (25.0 vs. 2.0%, p < 0.05) compared with cases defined by one criterion. Severe comorbidities and the continuation of concomitant antibiotics administered at CDID onset reduced (p < 0.05) the 30-day survival and increased (p = 0.053) 30-day all-cause mortality, with 57.6 vs. 10.7% and 52.0 vs. 25.0%, respectively. Conclusions: CDID treatment non-concordant with the guidelines was associated with various adverse outcomes. In CDID with leukocytes ≥ 15 × 109/L and serum creatinine level > 133 µmol/L (>1.5 mg/dL), enteral vancomycin should be used to avoid refractory response, as metronidazole use was associated with CDID-related ICU admission and CDID-related mortality. Severe comorbidities worsened the outcomes as they were associated with reduced 30-day survival. The continuation of concomitant antibiotic therapy increased 30-day all-cause mortality; thus, it needs to be reasonably justified, deescalated or stopped.
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Affiliation(s)
- Dalia Adukauskienė
- Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (A.D.); (T.V.)
| | - Rytis Mickus
- Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (A.D.); (T.V.)
| | - Asta Dambrauskienė
- Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (A.D.); (T.V.)
| | - Tomas Vanagas
- Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (A.D.); (T.V.)
| | - Agnė Adukauskaitė
- Department of Cardiology and Angiology, University Hospital of Innsbruck, 6020 Innsbruck, Austria;
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17
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Yakout A, Bi Y, Harris DM. Clostridioides Difficile: A Concise Review of Best Practices and Updates. J Prim Care Community Health 2024; 15:21501319241249645. [PMID: 38726585 PMCID: PMC11085020 DOI: 10.1177/21501319241249645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/05/2024] [Accepted: 04/09/2024] [Indexed: 05/12/2024] Open
Abstract
Clostridioides difficile infection (CDI) is one of the most common and severe nosocomial infections worldwide. It can also affect healthy individuals in the community. The incidence of CDI has been on the rise globally for the past decade, necessitating a proactive approach to combat its spread; new strategies are being developed to enhance diagnostic accuracy and optimize treatment outcomes. Implementing the 2-step testing has increased diagnostic specificity, reducing the usage of CD-specific antibiotics with no concomitant increase in surgical complication rates. In 2021, the Infectious Diseases Society of America/Society for Healthcare Epidemiology of America (IDSA/SHEA) shifted its preference for initial treatment to fidaxomicin over vancomycin and metronidazole due to its lower recurrence rate. It also prioritized fidaxomicin for the treatment of recurrent CDI. There are new developments on the frontiers of fecal microbiota therapies, with RBX2660 and SER-109 approved recently by the FDA for prevention, with other microbiome-based therapies in various development and clinical trials. This review offers providers an updated and practical guide for CDI management.
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Affiliation(s)
| | - Yan Bi
- Mayo Clinic, Jacksonville, FL, USA
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18
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Stabholz Y, Paul M. The effect of antibiotic therapy for Clostridioides difficile infection on mortality and other patient-relevant outcomes: a systematic review and meta-analysis. Clin Microbiol Infect 2024; 30:51-58. [PMID: 37690610 DOI: 10.1016/j.cmi.2023.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 08/28/2023] [Accepted: 09/03/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Current practice guidelines favour fidaxomicin over vancomycin and exclude metronidazole from the recommended standard regimen for Clostridioides difficile infection (CDI), based on lower recurrence rates with fidaxomicin, giving little weight to mortality or the clinical implications of recurrences. OBJECTIVES To compile the effects of metronidazole, glycopeptides (vancomycin or teicoplanin), and fidaxomicin for CDI on mortality and other patient-relevant outcomes. DATA SOURCES PubMed, the Cochrane Library, ClinicalTrials.gov, conference proceedings, and Google Scholar, until August 2023. STUDY ELIGIBILITY CRITERIA Randomized controlled trials (RCTs). PARTICIPANTS Adult patients experiencing primary or recurrent CDI. INTERVENTIONS Glycopeptides versus fidaxomicin or metronidazole (comparators). ASSESSMENT OF RISK OF BIAS We used the Risk of Bias 2 (RoB 2) tool for randomized trials, focusing on the outcome of all-cause mortality. METHODS OF DATA SYNTHESIS Random effects meta-analyses were performed for dichotomous outcomes. Outcomes were summarized preferentially for all randomly assigned patients. RESULTS Thirteen trials were included. There was no significant difference in all-cause mortality (risk ratio [RR] < 1 favouring the comparator) between vancomycin and fidaxomicin (RR 0.86, 95% CI 0.64-1.14, 8 RCTs, 1951 patients) or metronidazole (RR 0.78, 95% CI 0.46-1.32, 4 RCTs, 808 patients), with low and very low certainty of evidence, respectively. No significant difference in initial treatment failure between fidaxomicin and vancomycin was found, however, initial treatment failure was higher with metronidazole (RR 1.58, 95% CI 1.10-2.27, 5 RCTs, 843 patients). No study reported on symptomatic recurrence necessitating re-treatment among all randomly assigned patients. Among initially cured patients, symptomatic recurrence necessitating re-treatment was lower with fidaxomicin than with vancomycin (RR 0.54, 95% CI 0.42-0.71, 6 RCTs, 1617 patients). None of the studies reported on other CDI complications or the burden of infection on daily activities. CONCLUSIONS Setting patient-relevant outcomes for CDI independently of the RCT definitions and results might lead to less confidence in the guidance for CDI management.
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Affiliation(s)
- Yoav Stabholz
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; Department of Internal Medicine B, Rambam Health Care Campus, Haifa, Israel.
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
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19
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Fitzpatrick F, Brennan R, van Prehn J, Skally M, Brady M, Burns K, Rooney C, Wilcox MH. European Practice for CDI Treatment. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1435:57-84. [PMID: 38175471 DOI: 10.1007/978-3-031-42108-2_4] [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
Clostridioides difficile infection (CDI) remains a significant cause of morbidity and mortality worldwide. Historically, two antibiotics (metronidazole and vancomycin) and a recent third (fidaxomicin) have been used for CDI treatment; convincing data are now available showing that metronidazole is the least efficacious agent. The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) management guidance for CDI were updated in 2021. This guidance document outlines the treatment options for a variety of CDI clinical scenarios and for non-antimicrobial management (e.g., faecal microbiota transplantation, FMT). One of the main changes is that metronidazole is no longer recommended as first-line CDI treatment. Rather, fidaxomicin is preferred on the basis of reduced recurrence rates with vancomycin as an acceptable alternative. Recommended options for recurrent CDI now include bezlotoxumab as well as FMT.A 2017 survey of 20 European countries highlighted variation internationally in CDI management strategies. A variety of restrictions were in place in 65% countries prior to use of new anti-CDI treatments, including committee/infection specialist approval or economic review/restrictions. This survey was repeated in November 2022 to assess the current landscape of CDI management practices in Europe. Of 64 respondents from 17 countries, national CDI guidelines existed in 14 countries, and 11 have already/plan to incorporate the ESCMID 2021 CDI guidance, though implementation has not been surveyed in 6. Vancomycin is the most commonly used first-line agent for the treatment of CDI (n = 42, 66%), followed by fidaxomicin (n = 30, 47%). Six (9%) respondents use metronidazole as first-line agent for CDI treatment, whereas 22 (34%) only in selected low-risk patient groups. Fidaxomicin is more likely to be used in high-risk patient groups. Availability of anti-CDI therapy influenced prescribing in six respondents (9%). Approval pre-prescription was required before vancomycin (n = 3, 5%), fidaxomicin (n = 10, 6%), bezlotoxumab (n = 11, 17%) and FMT (n = 10, 6%). Implementation of CDI guidelines is rarely audited.Novel anti-CDI agents are being evaluated; it is not yet clear what will be the roles of these agents. The treatment of recurrent CDI is particularly troublesome, and several different live biotherapeutics are being developed, in addition to FMT.
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Affiliation(s)
- Fidelma Fitzpatrick
- Department of Clinical Microbiology, The Royal College of Surgeons in Ireland, Dublin, Ireland.
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland.
| | - Robert Brennan
- Department of Clinical Microbiology, The Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Joffrey van Prehn
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Mairead Skally
- Department of Clinical Microbiology, The Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
| | - Melissa Brady
- Health Protection Surveillance Centre (HPSC), Dublin, Ireland
| | - Karen Burns
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
| | - Christopher Rooney
- Microbiology, Leeds Teaching Hospitals, Leeds, UK
- University of Leeds, Leeds, UK
| | - Mark H Wilcox
- University of Leeds, Leeds, UK.
- Leeds Teaching Hospitals and Leeds Regional Public Health Laboratory, UK Health Security Agency (UKHSA), Leeds, UK.
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20
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Normington C, Chilton CH, Buckley AM. Clostridioides difficile infections; new treatments and future perspectives. Curr Opin Gastroenterol 2024; 40:7-13. [PMID: 37942659 PMCID: PMC10715702 DOI: 10.1097/mog.0000000000000989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
PURPOSE OF REVIEW As a significant cause of global morbidity and mortality, Clostridioides difficile infections (CDIs) are listed by the Centres for Disease Control and prevention as one of the top 5 urgent threats in the USA. CDI occurs from gut microbiome dysbiosis, typically through antibiotic-mediated disruption; however, antibiotics are the treatment of choice, which can result in recurrent infections. Here, we highlight new treatments available and provide a perspective on different classes of future treatments. RECENT FINDINGS Due to the reduced risk of disease recurrence, the microbiome-sparing antibiotic Fidaxomicin has been recommended as the first-line treatment for C. difficile infection. Based on the success of faecal microbiota transplantations (FMT) in treating CDI recurrence, defined microbiome biotherapeutics offer a safer and more tightly controlled alterative as an adjunct to antibiotic therapy. Given the association between antibiotic-mediated dysbiosis of the intestinal microbiota and the recurrence of CDI, future prospective therapies aim to reduce the dependence on antibiotics for the treatment of CDI. SUMMARY With current first-in-line antibiotic therapy options associated with high levels of recurrent CDI, the availability of new generation targeted therapeutics can really impact treatment success. There are still unknowns about the long-term implications of these new CDI therapeutics, but efforts to expand the CDI treatment toolbox can offer multiple solutions for clinicians to treat this multifaceted infectious disease to reduce patient suffering.
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Affiliation(s)
- Charmaine Normington
- Healthcare Associated Infections Research Group, School of Medicine, Faculty of Health and Medicine, University of Leeds
- Leeds Teaching Hospital Trust, Leeds General Infirmary
| | - Caroline H. Chilton
- Healthcare Associated Infections Research Group, School of Medicine, Faculty of Health and Medicine, University of Leeds
- Leeds Teaching Hospital Trust, Leeds General Infirmary
| | - Anthony M. Buckley
- Microbiome and Nutritional Sciences Group, School of Food Science & Nutrition, Faculty of Environment, University of Leeds, Leeds, UK
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Mo S, Thursky K, Chronas A, Hall L, James R, Ierano C. Metronidazole prescribing practices in Australian hospitals: Measuring guideline compliance and appropriateness to support antimicrobial stewardship. J Infect Public Health 2023; 16 Suppl 1:90-96. [PMID: 37926594 DOI: 10.1016/j.jiph.2023.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 10/25/2023] [Accepted: 10/30/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Metronidazole is a commonly prescribed antimicrobial in Australian hospitals. Inappropriate use may increase risks to patient care, such as toxicities and antimicrobial resistance. To date, there is limited information on the quality of metronidazole prescriptions to inform antimicrobial stewardship and quality improvement initiatives. This study aims to describe the quality of metronidazole prescribing practices in Australian hospitals. METHODS Retrospective data analysis of the Hospital National Antimicrobial Prescribing Survey (Hospital NAPS). Data were collected by auditors at each participating hospital using a standardised auditing tool. All data from 2013 to 2021 were de-identified and analysed descriptively. Variables included were antimicrobial prescribed, indication, guideline compliance and appropriateness. RESULTS Metronidazole was the fifth most prescribed antimicrobial in the Hospital NAPS dataset (2013-2021), accounting for 5.7 % (n = 14,197) of all antimicrobial prescriptions (n = 250,863). The proportion of metronidazole prescriptions declined by 2 % from 2013 to 2021 (p < 0.001). The most common indications were surgical prophylaxis (15.3 %), diverticulitis (9.4 %), aspiration pneumonia (7.3 %). Over half (53.5 %) of metronidazole prescriptions were deemed compliant with prescribing guidelines and 67.8 % were deemed appropriate. These rates were comparatively lower than the overall results of all antimicrobials. The primary documented reason for inappropriateness was that the spectrum was too broad (34.2 %). Surgical prophylaxis had the lowest rates of guideline compliance (53.8 %) and appropriateness (54.3 %). CONCLUSIONS Metronidazole remains widely used in Australian hospitals with suboptimal rates of guideline compliance and appropriateness. A noted area for improvement that we identified was using metronidazole when its spectrum was too broad, possibly when anaerobic therapy is unnecessary. With increasing international adoption of the Hospital NAPS programme, future comparative studies will be critical to identify global trends of antimicrobial prescribing quality. Antimicrobial stewardship (AMS) programmes have proven to be effective in improving prescribing quality and should be considered to specifically target improvements in metronidazole prescribing.
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Affiliation(s)
- Simone Mo
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, 300 Grattan St, Parkville, Victoria, Australia
| | - Karin Thursky
- National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Victoria, Australia; Royal Melbourne Hospital Guidance Group, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Australia
| | - Alexandros Chronas
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, 300 Grattan St, Parkville, Victoria, Australia
| | - Lisa Hall
- Royal Melbourne Hospital Guidance Group, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Australia; School of Public Health, The University of Queensland, 266 Herston Rd, Herston, Queensland, Australia
| | - Rodney James
- National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Victoria, Australia; Royal Melbourne Hospital Guidance Group, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Australia
| | - Courtney Ierano
- National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Victoria, Australia; Royal Melbourne Hospital Guidance Group, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Australia.
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Sinnathamby ES, Mason JW, Flanagan CJ, Pearl NZ, Burroughs CR, De Witt AJ, Wenger DM, Klapper VG, Ahmadzadeh S, Varrassi G, Shekoohi S, Kaye AD. Clostridioides difficile Infection: A Clinical Review of Pathogenesis, Clinical Considerations, and Treatment Strategies. Cureus 2023; 15:e51167. [PMID: 38283489 PMCID: PMC10811429 DOI: 10.7759/cureus.51167] [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: 12/01/2023] [Accepted: 12/27/2023] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND Clostridioides difficile infection (CDI) is a common nosocomial infection. Risk factors for developing CDI include prior hospitalization, being older than 65 years old, antibiotic use, and chronic disease. It is linked with diarrhea and colitis and can vary in severity. It is a major cause of increased morbidity and mortality among hospitalized patients. However, community-acquired CDI is also increasing. Proper diagnosis and determination of severity are crucial for the treatment of CDI. Depending on how severe the CDI is, the patient may endorse different symptoms and physical exam findings. The severity of CDI will determine how aggressively it is treated. Management and treatment: Laboratory studies can be helpful in the diagnosis of CDI. In this regard, common labs include complete blood count, stool assays, and, in certain cases, radiography and endoscopy. Mild-to-moderate colitis is treated with antibiotics, but severe colitis requires a different approach, which may include surgery. Several alternative therapies for CDI exist and have shown promising results. This review will touch upon these therapies, which include fecal transplants, intravenous immunoglobulin, and the use of cholestyramine and tigecycline. CONCLUSION Prevention of CDI can be achieved by proper hygiene, vaccinations, and detecting the infection early. Proper hygiene is indeed noted to be one of the best ways to prevent CDI in the hospital setting. Overprescribing antibiotics is also another huge reason why CDI occurs. Proper prescription of antibiotics can also help reduce the chances of acquiring CDI.
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Affiliation(s)
- Evan S Sinnathamby
- School of Medicine, Louisiana State University Health Sciences Center (LSUHSC) New Orleans, New Orleans, USA
| | - Joseph W Mason
- School of Medicine, Louisiana State University Health Sciences Center (LSUHSC) New Orleans, New Orleans, USA
| | - Chelsi J Flanagan
- School of Medicine, University of the Incarnate Word School of Osteopathic Medicine, San Antonio, USA
| | - Nathan Z Pearl
- School of Medicine, Louisiana State University Health Sciences Center (LSUHSC) New Orleans, New Orleans, USA
| | - Caroline R Burroughs
- School of Medicine, Louisiana State University Health Shreveport, Shreveport, USA
| | - Audrey J De Witt
- School of Medicine, Louisiana State University Health Shreveport, Shreveport, USA
| | - Danielle M Wenger
- Department of Medicine, University of Arizona College of Medicine - Phoenix, Phoenix, USA
| | - Vincent G Klapper
- Department of Internal Medicine, Louisiana State University Health Shreveport, Shreveport, USA
| | - Shahab Ahmadzadeh
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, USA
| | | | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, USA
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Reasoner SA, Nicholson MR. Clostridioides difficile Infection in Pediatric Inflammatory Bowel Disease. Curr Gastroenterol Rep 2023; 25:316-322. [PMID: 37646895 PMCID: PMC10843265 DOI: 10.1007/s11894-023-00890-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE OF REVIEW Children with inflammatory bowel disease (IBD) are at increased risk of C. difficile infection (CDI) and experience worse outcomes associated with an infection. In this article, we review recent research on the incidence, diagnosis, complications, and treatment options for CDI in children with IBD. RECENT FINDINGS Children with IBD have an elevated incidence of CDI, but their CDI risk does not associate with established risk factors in adults with IBD. Existing testing methodologies are inadequate at differentiating CDI from C. difficile colonization in children with IBD. Fecal microbiota transplantation offers a durable cure for recurrent CDI. CDI remains a frequent occurrence in children with IBD. Careful clinical monitoring should be used to diagnose CDI and patients with co-occurring IBD and CDI require careful surveillance for worse outcomes. Future research should explore the optimal diagnosis and treatment modalities in this unique patient population.
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Affiliation(s)
- Seth A Reasoner
- Division of Molecular Pathogenesis, Department of Pathology, Microbiology & Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Maribeth R Nicholson
- Immunology & Inflammation (VI4), Vanderbilt Institute for Infection, Vanderbilt University Medical Center, Nashville, TN, USA.
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Monroe Carrell Junior Children's Hospital at Vanderbilt, Nashville, TN, USA.
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Lee P, Nemati K, Silver EJ, Cacace J, Goldman DL. Risk factors for Recurrent Clostridioides Difficile Infection in Children. Hosp Pediatr 2023; 13:1010-1017. [PMID: 37877183 DOI: 10.1542/hpeds.2023-007154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
OBJECTIVE The aims of this study were to determine the epidemiologic and treatment factors associated with recurrent C. difficile infection in children. METHODS We conducted a 13-year retrospective review of pediatric C. difficile infections at our institution focusing on the epidemiologic, clinical, and treatment factors associated with recurrent disease. Repeat episodes occurring between 4 weeks and 2 months after initial infection were defined as early recurrences, whereas repeat episodes between 2 and 12 months after initial infection were defined as late recurrences. RESULTS We identified 303 children with C. difficile infection. Recurrent infections were limited to children with chronic conditions, affecting 27.4% (68 of 248) of this cohort. Early and late recurrences occurred in 36.8 and 63.2% of children, respectively. Among children with a chronic condition, female sex and initial use of metronidazole (as opposed to vancomycin) were associated with recurrent disease in bivariate and multivariate analyses. Overall, there was a high treatment failure rate (34 of 102, 33.3%) once children had developed recurrent disease. CONCLUSIONS Findings from this study demonstrate the importance of underlying chronic conditions in the development of recurrent C. difficile disease and the shortcomings of current treatment options for recurrent cases. Additionally, our findings indicate that initial treatment selection may impact the likelihood of future disease, with metronidazole usage being associated with higher recurrence rates than vancomycin. These findings highlight the need for additional studies to better understand the implications of C. difficile treatment strategies.
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Affiliation(s)
- Philip Lee
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital at Montefiore/Albert Einstein College of Medicine
- Department of Pharmacy
| | - Koorosh Nemati
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital at Montefiore/Albert Einstein College of Medicine
| | | | | | - David L Goldman
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital at Montefiore/Albert Einstein College of Medicine
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York
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Alhameed AF, Saferuddin N, Alturkistani T, Al Musawa M, Damfu N, Alattas M. Vancomycin vs metronidazole use for the treatment of Clostridioides difficile infection in a tertiary care hospital in Saudi Arabia. Heliyon 2023; 9:e22053. [PMID: 38027991 PMCID: PMC10663888 DOI: 10.1016/j.heliyon.2023.e22053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 11/02/2023] [Accepted: 11/02/2023] [Indexed: 12/01/2023] Open
Abstract
Background The 2017 Infectious Diseases Society of America (IDSA) Clostridioides difficile infection (CDI) guidelines recommendation for oral vancomycin as preferred treatment was based on studies conducted in North America, Australia, and Europe. According to recent published data, metronidazole remains a reasonable option. No studies have been conducted in Saudi Arabia to compare prescribing patterns before and after the release of the guidelines. Due to low CDI burden in Saudi Arabia, the aim is to assess the effectiveness and outcomes of vancomycin vs metronidazole treatment options. Methods This was a retrospective cohort study conducted in a tertiary care hospital in Jeddah which was approved by the Institutional Review Board (IRB 2020-53). Data was collected from January 2017 to April 2020. Eligible patients were adults (>18 years old) diagnosed with CDI who either received oral metronidazole (500 mg 3 times daily) or oral vancomycin (125-500 mg 4 times daily). Patients who received a combination of treatment or who were diagnosed with fulminant CDI were excluded. Demographic data were collected. The primary outcome was to assess treatment response to initial therapy with oral metronidazole versus oral vancomycin. Secondary outcomes included assessing early treatment response, time to discharge after diagnosis, proportion of patients with a positive VRE surveillance culture within 6 months of diagnosis, 30-day recurrence and 30-day all-cause mortality. Chi-square or Fisher's exact test were used to examine differences in categorical variables while student t-test or Mann-Whitney test, were used to examine differences in continuous variables. P value < 0.05 was considered as significant. Results A total of 166 patients were included in the analysis. Demographic characteristics were not significantly different between the two groups. There was no difference in treatment response between vancomycin and metronidazole (96.4 % versus 94.3 %, p = 0.682). However, compared with metronidazole, vancomycin treatment was significantly associated with better early response (94.0 % versus 77.8 %, p = 0.008). Other outcomes were not significantly different between the two drug groups for time to discharge after diagnosis (P = 0.522), 30-day recurrence (P > 0.99) and 30-day all-cause mortality (P = 0.782). Of note, the vancomycin versus metronidazole use before the 2017 IDSA guidelines (26 % versus 74 %) was completely reversed after the release of the guidelines (83.3 % versus 16.7 %), p < 0.001). Conclusion The results of this study demonstrate that vancomycin and metronidazole have comparable outcomes in regards to treatment response for non-fulminant CDI. The study also reveals the high and quick impact of international guidelines on local prescription patterns. Further studies are needed in Saudi Arabia to guide the treatment of CDI.
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Affiliation(s)
- Abrar F. Alhameed
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Centre, Madinah, Saudi Arabia
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Nada Saferuddin
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Tariq Alturkistani
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Mohammed Al Musawa
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Nader Damfu
- Pharmaceutical Care Department, King Abdul Aziz Medical City, Jeddah, Saudi Arabia
| | - Majda Alattas
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
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Lo Porto D, Mularoni A, Castagnola E, Saffioti C. Clostridioides difficile infection in the allogeneic hematopoietic cell transplant recipient. Transpl Infect Dis 2023; 25 Suppl 1:e14159. [PMID: 37787395 DOI: 10.1111/tid.14159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/09/2023] [Accepted: 09/14/2023] [Indexed: 10/04/2023]
Abstract
Clostridioides difficile (CD) is one of the most important causes of diarrhea in hospitalized patients, in particular those who undergo an allogeneic hematopoietic cell transplant (allo-HCT) and who are more at risk of developing a CD infection (CDI) due to frequent hospitalizations, iatrogenic immunosuppression, and prolonged antibiotic cycles. CDI may represent a severe condition in allo-HCT patients, increasing the length of hospitalization, influencing the intestinal microbiome with a bidirectional association with graft-versus-host disease, and leading to unfavorable outcomes, including death. The diagnosis of CDI requires the exclusion of other probable causes of diarrhea in HCT patients and is based on highly sensitive and highly specific tests to distinguish colonization from infection. In adult patients, fidaxomicin is recommended as first-line, with oral vancomycin as an alternative agent. Bezlotoxumab may be used to reduce the risk of recurrence. In pediatric patients, vancomycin and metronidazole are still suggested as first-line therapy, but fidaxomicin will probably become standard in pediatrics in the near future. Because of insufficient safety data, fecal microbiota transplantation is not routinely recommended in HCT in spite of promising results for the management of recurrences in other populations.
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Affiliation(s)
- Davide Lo Porto
- Unit of Infectious Diseases, IRCCS-ISMETT Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
| | - Alessandra Mularoni
- Unit of Infectious Diseases, IRCCS-ISMETT Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
| | - Elio Castagnola
- Pediatric Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Carolina Saffioti
- Pediatric Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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Wultańska D, Karpiński P, Piotrowski M, Pituch H. The Effect of Subinhibitory Concentration of Metronidazole on the Growth and Biofilm Formation on Toxigenic Clostridioides difficile Strains Belonging to Different Ribotypes. Pathogens 2023; 12:1244. [PMID: 37887760 PMCID: PMC10609937 DOI: 10.3390/pathogens12101244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/11/2023] [Accepted: 10/12/2023] [Indexed: 10/28/2023] Open
Abstract
Clostridioides difficile is a predominant nosocomial pathogen within the healthcare setting able to produce biofilms. Sub-minimum inhibitory concentrations (sub-MICs) of antibiotics trigger mechanisms affecting bacterial virulence, including increased adhesion and biofilm formation. The aim of this study was to investigate how sub-MICs of metronidazole affect the biofilm formation of C. difficile strains. We tested 14 reference and clinical C. difficile strains, including hypervirulent strains of RT027. The MICs of metronidazole for the tested strains were determined using the broth microdilution method. Biofilm formation was evaluated using confocal laser scanning microscopy. The C. difficile strains belonging to RT027 produced the highest amounts of biofilm. The results of confocal laser scanning microscopy showed that all the tested C. difficile strains developed larger biofilms with diversified architectures upon exposure to sub-MICs of metronidazole. In our study, we reveal that sub-MIC concentrations of metronidazole affect the biofilm formation of clinical and reference strains of C. difficile. Importantly, metronidazole induces biofilm formation via hypervirulent RT027 strains.
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Affiliation(s)
- Dorota Wultańska
- Department of Medical Microbiology, Medical University of Warsaw, 02-004 Warsaw, Poland; (P.K.); (M.P.); (H.P.)
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Sukkar GA, Aga SS, Alsamadani AH, Almalki FG, Alsudais AS, Alquzi AS, Ahmed ME, Mir MA, Alasmari MM. Prevalence of Clostridium Difficile Infection (CDI) among Inflammatory Bowel Disease (IBD) Patients in Comparison to Non-IBD Patients in King Abdulaziz Medical City in Jeddah. Interdiscip Perspect Infect Dis 2023; 2023:9958104. [PMID: 37869530 PMCID: PMC10589069 DOI: 10.1155/2023/9958104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 05/23/2023] [Accepted: 10/06/2023] [Indexed: 10/24/2023] Open
Abstract
Background The prevalence of Clostridium difficile infection (CDI) as a common complication among inflammatory bowel disease (IBD) has been reported to increase worldwide and has been associated with a poor IBD outcome. Objectives In this study, our aim was to report on the prevalence of CDI among IBD vs. non-IBD patients in King Abdulaziz Medical City (KAMC). Methods This retrospective descriptive study was carried out between 2016 and 2020. Data of 89 patients reported with CDI in KAMC were analyzed for demographics and correlations between various characteristics such as BMI, personal/family history of IBD, infection with CDI, diagnosis, method of diagnosis, and treatment modalities. Results Of the total 89 CDI patients, 59 (66.3%) were adults and 30 (33.7%) were pediatric, of which 36 (40.4%) were females and 53 (59.6%) were males. PCR was the main method of choice for the diagnosis of CDI (89.9%) followed by a positive-culture result (10.0%). Seventy-eight (87.6%) CDI patients were found to be immunocompromised, with two patients diagnosed with IBDs, one with UC, and one with CD. The recurrence rate was 38.4 (30 patients) among the immunocompromised group in comparison to 27.2 (3 patients) in the immunocompetent group (p=0.584). Conclusion In this study, we found that adults were more prone to CDI infection, especially within hospital settings, and most of the CDI infections occurred in immunocompromised individuals, with cancer as the most common cause of it.
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Affiliation(s)
- Ghassan Abdulrahman Sukkar
- Department of Pediatric, Ministry of National Guard Health Affairs (NGHA), King Abdulaziz Medical City, Jeddah, Saudi Arabia
- Department of Basic Medical Sciences, College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdullah International Medical Research Center (KAIMRC), King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Syed Sameer Aga
- Department of Basic Medical Sciences, College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdullah International Medical Research Center (KAIMRC), King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Abdulrahman Hamid Alsamadani
- Department of Basic Medical Sciences, College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdullah International Medical Research Center (KAIMRC), King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Faisal Ghazi Almalki
- Department of Basic Medical Sciences, College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdullah International Medical Research Center (KAIMRC), King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Ali Saleh Alsudais
- Department of Basic Medical Sciences, College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdullah International Medical Research Center (KAIMRC), King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Abdulrahman Sulaiman Alquzi
- Department of Basic Medical Sciences, College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdullah International Medical Research Center (KAIMRC), King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Mohamed Eldigire Ahmed
- College of Science and Health Professions, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdullah International Medical Research Center (KAIMRC), Jeddah, Saudi Arabia
| | - Mushtaq Ahmad Mir
- Department of Clinical Laboratory Science, College of Applied Medical Sciences, King Khalid University, Abha, Saudi Arabia
| | - Moudi M. Alasmari
- Department of Basic Medical Sciences, College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdullah International Medical Research Center (KAIMRC), King Abdulaziz Medical City, Jeddah, Saudi Arabia
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Lan KY, Le PH, Chiu CT, Chen CC, Yeh YM, Cheng HT, Kuo CJ, Chen CL, Chen YC, Yeh PJ, Chiu CH, Chang CJ. Fecal microbiota transplantation for treatment of refractory or recurrent Clostridioides difficile infection in Taiwan: a cost-effectiveness analysis. Front Med (Lausanne) 2023; 10:1229148. [PMID: 37849493 PMCID: PMC10577297 DOI: 10.3389/fmed.2023.1229148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/13/2023] [Indexed: 10/19/2023] Open
Abstract
Background Compared to antibiotic treatment, fecal microbiota transplantation (FMT) is a more effective treatment for refractory or recurrent CDI (rCDI). Patients with inflammatory bowel disease (IBD) have a higher incidence of CDI and worse outcomes. There has been no study from Asia to evaluate the cost-effectiveness of FMT for overall rCDI patients and rCDI patients with IBD. Methods We applied a Markov model with deterministic and probabilistic sensitivity analyses to evaluate the cost and effectiveness of different treatments for rCDI patients with a time horizon of 1 year from the payer's perspective. We compared the cost and clinical outcomes of FMT through colonoscopy to two antibiotics (vancomycin and fidaxomicin) using data from Chang Gung Memorial Hospital, Taoyuan, Taiwan. Results Compared to vancomycin, FMT was cost-effective in overall rCDI patients as well as IBD patients with rCDI [USD 39356 (NT$1,101,971.98)/quality-adjusted life year (QALY) gained in overall patients; USD65490 (NT$1,833,719.14)/QALY gained in IBD patients]. Compared to fidaxomicin, FMT was only cost-effective in overall rCDI patients [USD20255 (NT$567,133.45)/QALY gained] but slightly increased QALY (0.0018 QALY gained) in IBD patients with rCDI. Conclusion FMT is cost-effective, compared to vancomycin or fidaxomicin, for the treatment of rCDI in most scenarios from the payers' perspective in Taiwan.
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Affiliation(s)
- Kai-Yen Lan
- Department of Biomedical Sciences, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Puo-Hsien Le
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Taiwan Association of the Study of Small Intestinal Disease, Taoyuan, Taiwan
- Chang Gung Microbiota Therapy Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Liver Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Cheng-Tang Chiu
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Taiwan Association of the Study of Small Intestinal Disease, Taoyuan, Taiwan
- Chang Gung Microbiota Therapy Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Chien-Chang Chen
- Chang Gung Microbiota Therapy Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Department of Pediatric Gastroenterology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Yuan-Ming Yeh
- Chang Gung Microbiota Therapy Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Hao-Tsai Cheng
- Chang Gung Microbiota Therapy Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, New Taipei Municipal Tucheng Hospital, New Taipei City, Taiwan
| | - Chia-Jung Kuo
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Taiwan Association of the Study of Small Intestinal Disease, Taoyuan, Taiwan
- Chang Gung Microbiota Therapy Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Chyi-Liang Chen
- Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Yi-Ching Chen
- Chang Gung Microbiota Therapy Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Pai-Jui Yeh
- Chang Gung Microbiota Therapy Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Department of Pediatric Gastroenterology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Cheng-Hsun Chiu
- Chang Gung Microbiota Therapy Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Chee-Jen Chang
- Department of Biomedical Sciences, Chang Gung University College of Medicine, Taoyuan, Taiwan
- Graduate Institute of Clinical Medicine, Chang Gung University College of Medicine, Taoyuan, Taiwan
- Department of Obstetrics and Gynecology, Chang Gung Memory Hospital, Linko Branch, Taoyuan, Taiwan
- Research Service Center for Health Informatics, Chang Gung University, Taoyuan, Taiwan
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Swart N, Sinha AM, Bentley A, Smethurst H, Spencer G, Ceder S, Wilcox MH. A cost-utility analysis of two Clostridioides difficile infection guideline treatment pathways. Clin Microbiol Infect 2023; 29:1291-1297. [PMID: 37356620 DOI: 10.1016/j.cmi.2023.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 06/07/2023] [Accepted: 06/14/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVES Treatment guidelines are key drivers of prescribing practice in the management of Clostridioides difficile infection (CDI), but recommendations on best practice can vary. We conducted a cost-utility analysis to compare the treatment pathway recommended by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guideline with the pathway proposed by the National Institute for Health and Care Excellence (NICE) guideline, from the perspective of the UK National Health Service. METHODS A decision tree modelling approach was adopted to reflect the treatment pathway for CDI as outlined in ESCMID and NICE guidelines. Patients experiencing a CDI infection received up to three treatments per infection to achieve a response and could subsequently experience up to two recurrences. Data on patient demographics, treatment response, recurrence, utilities, CDI-related mortality, and costs were taken from published literature. RESULTS The ESCMID treatment pathway was cost-effective versus the NICE treatment pathway at a threshold of £20 000 per quality-adjusted life year gained, with an incremental cost-effectiveness ratio of £4931. Cost-effectiveness was driven by differences in index infection recommendations (ESCMID recommends fidaxomicin as first-line treatment whereas NICE recommends vancomycin). The model results were robust to variations in inputs investigated in scenarios and sensitivity analyses, and probabilistic sensitivity analysis demonstrated that the ESCMID guideline treatment strategy had a 100% likelihood of being cost-effective versus the NICE treatment strategy. DISCUSSION Compared with the NICE guideline, the ESCMID guideline recommendations for treating an index CDI represent the most cost-effective use of healthcare resources from the perspective of the UK National Health Service.
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Affiliation(s)
| | | | | | | | | | | | - Mark H Wilcox
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom.
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Dicks LMT. Biofilm Formation of Clostridioides difficile, Toxin Production and Alternatives to Conventional Antibiotics in the Treatment of CDI. Microorganisms 2023; 11:2161. [PMID: 37764005 PMCID: PMC10534356 DOI: 10.3390/microorganisms11092161] [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: 06/29/2023] [Revised: 08/16/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open
Abstract
Clostridioides difficile is considered a nosocomial pathogen that flares up in patients exposed to antibiotic treatment. However, four out of ten patients diagnosed with C. difficile infection (CDI) acquired the infection from non-hospitalized individuals, many of whom have not been treated with antibiotics. Treatment of recurrent CDI (rCDI) with antibiotics, especially vancomycin (VAN) and metronidazole (MNZ), increases the risk of experiencing a relapse by as much as 70%. Fidaxomicin, on the other hand, proved more effective than VAN and MNZ by preventing the initial transcription of RNA toxin genes. Alternative forms of treatment include quorum quenching (QQ) that blocks toxin synthesis, binding of small anion molecules such as tolevamer to toxins, monoclonal antibodies, such as bezlotoxumab and actoxumab, bacteriophage therapy, probiotics, and fecal microbial transplants (FMTs). This review summarizes factors that affect the colonization of C. difficile and the pathogenicity of toxins TcdA and TcdB. The different approaches experimented with in the destruction of C. difficile and treatment of CDI are evaluated.
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Affiliation(s)
- Leon M T Dicks
- Department of Microbiology, Stellenbosch University, Stellenbosch 7600, South Africa
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32
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Rossier L, Matter C, Burri E, Galperine T, Hrúz P, Juillerat P, Schoepfer A, Vavricka SR, Zahnd N, Décosterd N, Seibold F. Swiss expert opinion: current approaches in faecal microbiota transplantation in daily practice. Swiss Med Wkly 2023; 153:40100. [PMID: 37769622 DOI: 10.57187/smw.2023.40100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023] Open
Abstract
INTRODUCTION Faecal microbiota transplantation (FMT) is an established therapy for recurrent C. difficile infection, and recent studies have reported encouraging results of FMT in patients with ulcerative colitis. Few international consensus guidelines exist for this therapy, and thus FMT policies and practices differ among European countries. As of 2019, stool transplants are considered a non-standardised medicinal product in Switzerland, and a standardised production process requires authorisation by the Swiss Agency for Therapeutic Products. This authorisation leads to prolonged administrative procedures and increasing costs, which reduces treatment accessibility. In particular, patients with ulcerative colitis in Switzerland can only benefit from FMT off-label, even though it is a valid therapeutic option. Therefore, this study summarised the available data on FMT and established a framework for the standardised use of FMT. METHODS A panel of Swiss gastroenterologists with a special interest in inflammatory bowel disease was established to identify the current key issues of FMT. After a comprehensive review of the literature, statements were formulated about FMT indications, donor screening, stool transplant preparation and administration, and safety aspects. The panel then voted on the statements following the Delphi process; the statements were reformulated and revoted until a consensus was reached. The manuscript was then reviewed by an infectiologist (the head of Lausanne's FMT centre). RESULTS The established statements are summarised in the supplementary tables in the appendix to this paper. The working group hopes these will help standardise FMT practice in Switzerland and contribute to making faecal microbiota transplantation a safe and accessible treatment for patients with recurrent C. difficile infections and selected patients with ulcerative colitis, as well as other indications in the future.
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Affiliation(s)
- Laura Rossier
- Intesto - Gastroenterology practice and Crohn-colitis Center, Bern, Switzerland
| | - Christoph Matter
- Intesto - Gastroenterology practice and Crohn-colitis Center, Bern, Switzerland
| | - Emanuel Burri
- Department of Gastroenterology and Hepatology, University Medical Clinic, Baselland Canton Hospital, Liestal, Switzerland
| | - Tatiana Galperine
- Fecal microbiota transplantation center, Department of infectious disease, Lausanne University Hospital, Lausanne, Switzerland
| | - Petr Hrúz
- Clarunis, Department of Gastroenterology, St Clara hospital and University hospital Basel, Basel, Switzerland
| | - Pascal Juillerat
- GastroGeb - Gastroenterology practice and Crohn-colitis Center, Lausanne - Bulle, Switzerland
| | - Alain Schoepfer
- Department of Gastroenterology, Lausanne University Hospital, Lausanne, Switzerland
| | - Stephan R Vavricka
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | | | - Natalie Décosterd
- Intesto - Gastroenterology practice and Crohn-colitis Center, Bern, Switzerland
| | - Frank Seibold
- Intesto - Gastroenterology practice and Crohn-colitis Center, Bern, Switzerland
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Murphy CK, O’Donnell MM, Hegarty JW, Schulz S, Hill C, Ross RP, Rea MC, Farquhar R, Chesnel L. Novel, non-colonizing, single-strain live biotherapeutic product ADS024 protects against Clostridioides difficile infection challenge in vivo. World J Gastrointest Pathophysiol 2023; 14:71-85. [PMID: 37727283 PMCID: PMC10505952 DOI: 10.4291/wjgp.v14.i4.71] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/02/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND The Centers for Disease Control and Prevention estimate that Clostridioides difficile (C. difficile) causes half a million infections (CDI) annually and is a major cause of total infectious disease death in the United States, causing inflammation of the colon and potentially deadly diarrhea. We recently reported the isolation of ADS024, a Bacillus velezensis (B. velezensis) strain, which demonstrated direct in vitro bactericidal activity against C. difficile, with minimal collateral impact on other members of the gut microbiota. In this study, we hypothesized that in vitro activities of ADS024 will translate in vivo to protect against CDI challenge in mouse models. AIM To investigate the in vivo efficacy of B. velezensis ADS024 in protecting against CDI challenge in mouse models. METHODS To mimic disruption of the gut microbiota, the mice were exposed to vancomycin prior to dosing with ADS024. For the mouse single-dose study, the recovery of ADS024 was assessed via microbiological analysis of intestinal and fecal samples at 4 h, 8 h, and 24 h after a single oral dose of 5 × 108 colony-forming units (CFU)/mouse of freshly grown ADS024. The single-dose study in miniature swine included groups that had been pre-dosed with vancomycin and that had been exposed to a dose range of ADS024, and a group that was not pre-dosed with vancomycin and received a single dose of ADS024. The ADS024 colonies [assessed by quantitative polymerase chain reaction (qPCR) using ADS024-specific primers] were counted on agar plates. For the 28-d miniature swine study, qPCR was used to measure ADS024 levels from fecal samples after oral administration of ADS024 capsules containing 5 × 109 CFU for 28 consecutive days, followed by MiSeq compositional sequencing and bioinformatic analyses to measure the impact of ADS024 on microbiota. Two studies were performed to determine the efficacy of ADS024 in a mouse model of CDI: Study 1 to determine the effects of fresh ADS024 culture and ADS024 spore preparations on the clinical manifestations of CDI in mice, and Study 2 to compare the efficacy of single daily doses vs dosing 3 times per day with fresh ADS024. C. difficile challenge was performed 24 h after the start of ADS024 exposure. To model the human distal colon, an anerobic fecal fermentation system was used. MiSeq compositional sequencing and bioinformatic analyses were performed to measure microbiota diversity changes following ADS024 treatment. To assess the potential of ADS024 to be a source of antibiotic resistance, its susceptibility to 18 different antibiotics was tested. RESULTS In a mouse model of CDI challenge, single daily doses of ADS024 were as efficacious as multiple daily doses in protecting against subsequent challenge by C. difficile pathogen-induced disease. ADS024 showed no evidence of colonization based on the observation that the ADS024 colonies were not recovered 24 h after single doses in mice or 72 h after single doses in miniature swine. In a 28-d repeat-dose study in miniature swine, ADS024 was not detected in fecal samples using plating and qPCR methods. Phylogenetic analysis performed in the human distal colon model showed that ADS024 had a selective impact on the healthy human colonic microbiota, similarly to the in vivo studies performed in miniature swine. Safety assessments indicated that ADS024 was susceptible to all the antibiotics tested, while in silico testing revealed a low potential for off-target activity or virulence and antibiotic-resistance mechanisms. CONCLUSION Our findings, demonstrating in vivo efficacy of ADS024 in protecting against CDI challenge in mouse models, support the use of ADS024 in preventing recurrent CDI following standard antibiotic treatment.
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Affiliation(s)
- Christopher K Murphy
- Research and Development, Adiso Therapeutics Inc., Concord, MA 01742, United States
| | | | - James W Hegarty
- Teagasc Food Research Centre, Moorepark Fermoy, Cork P61 C996, Ireland
| | - Sarah Schulz
- APC Microbiome Ireland, University College Cork, Cork T12 K8AF, Ireland
| | - Colin Hill
- APC Microbiome Ireland, University College Cork, Cork T12 K8AF, Ireland
| | - R Paul Ross
- APC Microbiome Ireland, University College Cork, Cork T12 K8AF, Ireland
| | - Mary C Rea
- Teagasc Food Research Centre, Moorepark Fermoy, Cork P61 C996, Ireland
| | - Ronald Farquhar
- Executive Leadership Team, Adiso Therapeutics Inc., Concord, MA 01742, United States
| | - Laurent Chesnel
- Research and Development, Adiso Therapeutics Inc., Concord, MA 01742, United States
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Ivashkin VT, Lyashenko OS, Drapkina OM, Alexeeva OP, Alekseenko SA, Andreev DN, Baranovsky AY, Goloshchapov OV, Zheleznova NV, Zolnikova OY, Kliaritskaia IL, Korochanskaya NV, Lapina TL, Maev IV, Maslennikov RV, Myazin RG, Pavlov PV, Perekalina MV, Pisarenko NA, Povtoreyko AV, Poluektova EA, Sekretareva LA, Tkachev AV, Troshkina YM, Trukhmanov AS, Ulyanin AI, Filatova SG, Tsukanov VV, Shifrin OS. Clinical Practice Guidelines of the Scientific Society for the Clinical Study of Human Microbiome, of the Russian Gastroenterological Association and the Russian Society for the Prevention of Noncommunicable Diseases on the Diagnosis and Treatment of <i>Clostridioides difficile</i> (<i>C. difficile</i>)-associated Disease in Adults. RUSSIAN JOURNAL OF GASTROENTEROLOGY, HEPATOLOGY, COLOPROCTOLOGY 2023; 33:85-119. [DOI: 10.22416/1382-4376-2023-33-3-85-119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/26/2024]
Abstract
Аim: the clinical practice guidelines intended for gastroenterologists, internal medicine specialists, infectious disease specialists, general practitioners (family doctors), coloproctologists, surgeons and endoscopists present modern methods of diagnosis, prevention and treatment of C. difficile-associated disease.Key points. C. difficile-associated disease is a disease that develops when the diversity of the intestinal microbiota decreases and C. difficile excessively colonizes the colon, the toxins of which damage the intestinal muco-epithelial barrier, followed by the development of inflammation in the colon wall, with diarrhea being a characteristic clinical manifestation. The clinical presentation of the disease can vary from asymptomatic carriage, mild to moderate diarrhea that resolves on its own, to profuse watery diarrhea and pseudomembranous colitis with development of life-threatening complications. The diagnosis of C. difficile-associated disease is based on an assessment of the clinical presentation, medical history, an objective examination of the patient and laboratory stool tests. The disease severity is determined by clinical symptoms and laboratory findings. Additional diagnostic methods that are used according to indications and contribute to the assessment of severity include endoscopy of the colon and abdominal cavity imaging methods. Treatment should be initiated in cases of characteristic clinical presentation of C. difficile-associated disease and positive laboratory stool testing. The choice of drug and treatment regimen depends on the severity of the episode, the presence of complications, and whether the episode is initial, recurrent, or reinfection.Conclusion. Determination of target groups of patients for the diagnosis of clostridial infection is important in preventing overdiagnosis and subsequent unnecessary treatment. Timely diagnosis and treatment of C. difficile-associated disease help avoiding the development of life-threatening complications and improve the prognosis and quality of life of patients.
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Affiliation(s)
- V. T. Ivashkin
- I.M. Sechenov First Moscow State University (Sechenov University)
| | - O. S. Lyashenko
- I.M. Sechenov First Moscow State University (Sechenov University)
| | - O. M. Drapkina
- National Medical Research Center for Therapy and Preventive Medicine
| | | | | | - D. N. Andreev
- A.I. Yevdokimov Moscow State University of Medicine and Dentistry
| | | | | | | | - O. Yu. Zolnikova
- I.M. Sechenov First Moscow State University (Sechenov University)
| | | | | | - T. L. Lapina
- I.M. Sechenov First Moscow State University (Sechenov University)
| | - I. V. Maev
- A.I. Yevdokimov Moscow State University of Medicine and Dentistry
| | | | | | - P. V. Pavlov
- I.M. Sechenov First Moscow State University (Sechenov University)
| | | | | | | | - E. A. Poluektova
- I.M. Sechenov First Moscow State University (Sechenov University)
| | | | | | | | - A. S. Trukhmanov
- I.M. Sechenov First Moscow State University (Sechenov University)
| | - A. I. Ulyanin
- I.M. Sechenov First Moscow State University (Sechenov University)
| | | | - V. V. Tsukanov
- Federal Research Center “Krasnoyarsk Science Center of the Siberian Branch of the Russian Academy of Sciences”
| | - O. S. Shifrin
- I.M. Sechenov First Moscow State University (Sechenov University)
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Warren CA, Shin JH, Bansal EN, Costa DVDS, Wang XQ, Wu M, Swann JR, Behm BW, Targonski PV, Archbald-Pannone L. Alanyl-glutamine supplementation for Clostridioides difficile infection treatment (ACT): a double-blind randomised controlled trial study protocol. BMJ Open 2023; 13:e075721. [PMID: 37474181 PMCID: PMC10357635 DOI: 10.1136/bmjopen-2023-075721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 06/30/2023] [Indexed: 07/22/2023] Open
Abstract
INTRODUCTION Clostridioides difficile is the leading cause of healthcare-associated infections in the USA, with an estimated 1 billion dollars in excess cost to the healthcare system annually. C. difficile infection (CDI) has high recurrence rate, up to 25% after first episode and up to 60% for succeeding episodes. Preliminary in vitro and in vivo studies indicate that alanyl-glutamine (AQ) may be beneficial in treating CDI by its effect on restoring intestinal integrity in the epithelial barrier, ameliorating inflammation and decreasing relapse. METHODS AND ANALYSIS This study is a randomised, placebo-controlled, double-blind, phase II clinical trial. The trial is designed to determine optimal dose and safety of oral AQ at 4, 24 and 44 g doses administered daily for 10 days concurrent with standard treatment of non-severe or severe uncomplicated CDI in persons age 18 and older. The primary outcome of interest is CDI recurrence during 60 days post-treatment follow-up, with the secondary outcome of mortality during 60 days post-treatment follow-up. Exploratory analysis will be done to determine the impact of AQ supplementation on intestinal and systemic inflammation, as well as intestinal microbial and metabolic profiles. ETHICS AND DISSEMINATION The study has received University of Virginia Institutional Review Board approval (HSR200046, Protocol v9, April 2023). Findings will be disseminated via conference presentations, lectures and peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT04305769.
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Affiliation(s)
- Cirle A Warren
- Department of Medicine, Division of Infectious Diseases and International Health, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Jae Hyun Shin
- Department of Medicine, Division of Infectious Diseases and International Health, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Ekta N Bansal
- Department of Internal Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Deiziane V D S Costa
- Department of Medicine, Division of Infectious Diseases and International Health, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Xin Qun Wang
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Martin Wu
- Department of Biology, University of Virginia College and Graduate School of Arts and Sciences, Charlottesville, VA, USA
| | - Jonathan R Swann
- School of Human Development and Health, University of Southampton Faculty of Medicine, Southampton, UK
| | - Brian W Behm
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Paul V Targonski
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
- Department of Medicine, Division of General, Geriatric, Palliative & Hospital Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Laurie Archbald-Pannone
- Department of Medicine, Division of General, Geriatric, Palliative & Hospital Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
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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: 12] [Impact Index Per Article: 12.0] [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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Alhobayb T, Ciorba MA. Clostridium difficile in inflammatory bowel disease. Curr Opin Gastroenterol 2023; 39:257-262. [PMID: 37265220 PMCID: PMC10264153 DOI: 10.1097/mog.0000000000000949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
PURPOSE OF REVIEW The chronic inflammatory bowel diseases (IBD), Crohn's disease, and ulcerative colitis, are associated with an increased risk of symptomatic Clostridium difficile infection (CDI). CDI may also masquerade as an IBD flare and complicate IBD management. This review provides a comprehensive overview of the epidemiology, diagnosis, and treatment of CDI in IBD patients. RECENT FINDINGS CDI remains common in IBD with complications including flares in disease activity, recurrent CDI episodes, and prolonged hospital stays. Newer IBD therapeutics including vedolizumab, ustekinumab, and tofacitinib are less likely to cause severe CDI. A high index of suspicion, rapid testing via a two-step method, and prompt treatment with vancomycin or fidaxomicin are paramount to managing CDI in IBD patients. Strategies to prevent recurrent CDI (rCDI) include the monoclonal antibody bezlotoxumab as well as fecal microbiota transplantation (FMT). FMT has a robust profile of safety and effectiveness in preventing rCDI in adults and children. SUMMARY Clinicians must remain vigilant in the prompt diagnosis and treatment of CDI in IBD patients. Corticosteroids, unnecessary antibiotics, and ongoing colonic inflammatory disease are modifiable risk factors. Improved infection control measures, newer IBD medications, and using effective CDI treatments will facilitate a reduced burden of severe CDI and complications for IBD patients.
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Affiliation(s)
- Tamara Alhobayb
- Inflammatory Bowel Diseases Center and Division of Gastroenterology, Washington University School of Medicine, Saint Louis, Missouri, USA
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38
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Tashiro S, Taguchi K, Enoki Y, Matsumoto K. Antimicrobial Efficacy Evaluations of Metronidazole against Clostridioides difficile Infection using Fecal Pharmacokinetic and Pharmacodynamic Analyses. Pharm Res 2023; 40:1799-1806. [PMID: 37226025 DOI: 10.1007/s11095-023-03537-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/13/2023] [Indexed: 05/26/2023]
Abstract
OBJECTIVES The pharmacokinetics/pharmacodynamics (PK/PD) characteristics of metronidazole (MNZ) in Clostridioides difficile infection (CDI) remain unclear. We aimed to determine the PK/PD characteristics of MNZ using a fecal PK/PD analysis model. METHODS Susceptibility testing, time-kill studies, and post-antibiotic effect (PAE) measurements were performed to evaluate in vitro PD profiles. MNZ was subcutaneously administered to mice infected with C. difficile ATCC® 43255 to evaluate in vivo PK and PD profiles, followed by determining fecal PK/PD indices with target value. RESULTS MNZ exerted concentration-dependent bactericidal activities with minimum inhibitory concentration (MIC) and PAE being 0.79 µg/mL and 4.8 h, respectively, against C. difficile ATCC® 43255. The reduction in vegetative cells in feces and treatment outcomes were most closely correlated with the ratio of the area under the fecal drug concentration-time curve from 0 to 24 h to the MIC (fecal AUC24/MIC). The target value of fecal AUC24/MIC to achieve a 1 log10 reduction in vegetative cells was 188. Upon meeting the target value, high survival rates (94.5%) and low clinical sickness score grading (5.2) were achieved in the CDI mouse models. CONCLUSIONS The PK/PD index and its target value of MNZ for CDI treatment was fecal AUC24/MIC ≥ 188. These findings may contribute to the effective clinical use of MNZ.
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Affiliation(s)
- Sho Tashiro
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Kazuaki Taguchi
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan.
| | - Yuki Enoki
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
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Gonzales-Luna AJ, Skinner AM, Alonso CD, Bouza E, Cornely OA, de Meij TGJ, Drew RJ, Garey KW, Gerding DN, Johnson S, Kahn SA, Kato H, Kelly CP, Kelly CR, Kociolek LK, Kuijper EJ, Louie T, Riley TV, Sandora TJ, Vehreschild MJGT, Wilcox MH, Dubberke ER. Redefining Clostridioides difficile infection antibiotic response and clinical outcomes. THE LANCET. INFECTIOUS DISEASES 2023; 23:e259-e265. [PMID: 37062301 DOI: 10.1016/s1473-3099(23)00047-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/04/2023] [Accepted: 01/09/2023] [Indexed: 04/18/2023]
Abstract
With the approval and development of narrow-spectrum antibiotics for the treatment of Clostridioides difficile infection (CDI), the primary endpoint for treatment success of CDI antibiotic treatment trials has shifted from treatment response at end of therapy to sustained response 30 days after completed therapy. The current definition of a successful response to treatment (three or fewer unformed bowel movements [UBMs] per day for 1-2 days) has not been validated, does not reflect CDI management, and could impair assessments for successful treatment at 30 days. We propose new definitions to optimise trial design to assess sustained response. Primarily, we suggest that the initial response at the end of treatment be defined as (1) three or fewer UBMs per day, (2) a reduction in UBMs of more than 50% per day, (3) a decrease in stool volume of more than 75% for those with ostomy, or (4) attainment of bowel movements of Bristol Stool Form Scale types 1-4, on average, by day 2 after completion of primary CDI therapy (ie, assessed on day 11 and day 12 of a 10-day treatment course) and following an investigator determination that CDI treatment can be ceased.
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Affiliation(s)
- Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Andrew M Skinner
- Department of Medicine, Loyola University Medical Center, Maywood, IL, USA; Department of Medicine and Department of Research, Edward Hines Jr Veterans Administration Hospital, Hines, IL, USA
| | - Carolyn D Alonso
- Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Emilio Bouza
- Department of Microbiology and Infectious Diseases, Universidad Complutense, Madrid, Spain
| | - Oliver A Cornely
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Disease, Translational Research, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and Excellence Center for Medical Mycology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Clinical Trials Centre Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; German Centre for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany
| | - Tim G J de Meij
- Department of Pediatric Gastroenterology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Richard J Drew
- Clinical Innovation Unit, Rotunda Hospital and Children's Health Ireland, Dublin, Ireland; Irish Meningitis and Sepsis Reference Laboratory, Children's Health Ireland at Temple Street, Dublin, Ireland; Department of Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Dale N Gerding
- Department of Medicine and Department of Research, Edward Hines Jr Veterans Administration Hospital, Hines, IL, USA
| | - Stuart Johnson
- Department of Medicine and Department of Research, Edward Hines Jr Veterans Administration Hospital, Hines, IL, USA
| | - Stacy A Kahn
- Division of Gastroenterology, Hepatology & Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Haru Kato
- Antimicrobial Resistance Research Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - Ciaran P Kelly
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Colleen R Kelly
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Larry K Kociolek
- Division of Pediatric Infectious Diseases, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Ed J Kuijper
- Department of Medical Microbiology, Leiden University Medical Centre, Leiden, Netherlands
| | - Thomas Louie
- Infectious Diseases, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Thomas V Riley
- School of Biomedical Sciences, The University of Western Australia, Crawley, WA, Australia
| | - Thomas J Sandora
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Maria J G T Vehreschild
- Infectious Diseases, Department of Internal Medicine, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Mark H Wilcox
- Microbiology, Old Medical School, Leeds General Infirmary, Leeds, UK
| | - Erik R Dubberke
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO, USA.
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Stămăteanu LO, Miftode IL, Pleșca CE, Dorneanu OS, Roșu MF, Miftode ID, Obreja M, Miftode EG. Symptoms, Treatment, and Outcomes of COVID-19 Patients Coinfected with Clostridioides difficile: Single-Center Study from NE Romania during the COVID-19 Pandemic. Antibiotics (Basel) 2023; 12:1091. [PMID: 37508187 PMCID: PMC10375993 DOI: 10.3390/antibiotics12071091] [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: 05/23/2023] [Revised: 06/11/2023] [Accepted: 06/20/2023] [Indexed: 07/30/2023] Open
Abstract
The Coronavirus disease 2019 (COVID-19) pandemic has brought new challenges across medical disciplines, particularly in infectious disease medicine. In Romania, the incidence of SARS-CoV-2 (Severe acute respiratory syndrome coronavirus 2) infection increased dramatically since March 2020 until March 2022. Antibiotic administration for pulmonary superinfections in COVID-19 intensified and, consequently, increased rates of Clostridioides difficile infection (CDI) were hypothesized. We conducted a single-center, retrospective, observational study on patients from North-Eastern Romania to assess clinical characteristics and outcomes of COVID-19 and Clostridioides difficile (CD) coinfection, and to identify risk factors for CDI in COVID-19 patients. The study enrolled eighty-six CDI and COVID-19 coinfected patients admitted during March 2020-February 2021 (mean age 59.14 years, 53.49% men, 67.44% urban residents) and a group of eighty-six COVID-19 patients. On admission, symptoms were more severe in mono-infected patients, while coinfected patients associated a more intense acute inflammatory syndrome. The main risk factors for severe COVID-19 were smoking, diabetes mellitus, and antibiotic administration. Third generation cephalosporins (55%) and carbapenems (24%) were the main antibiotics used, and carbapenems were significantly associated with severe COVID-19 in patients coinfected with CD during hospitalization. Coinfection resulted in longer hospitalization and poorer outcomes. The extensive use of antibiotics in COVID-19, particularly carbapenems, contributed substantially to CD coinfection.
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Affiliation(s)
- Lidia Oana Stămăteanu
- Department of Internal Medicine II, Faculty of Medicine, University of Medicine and Pharmacy Gr. T. Popa, 700115 Iași, Romania
- "St. Parascheva" Clinical Hospital of Infectious Diseases, 700116 Iași, Romania
| | - Ionela Larisa Miftode
- Department of Internal Medicine II, Faculty of Medicine, University of Medicine and Pharmacy Gr. T. Popa, 700115 Iași, Romania
- "St. Parascheva" Clinical Hospital of Infectious Diseases, 700116 Iași, Romania
| | - Claudia Elena Pleșca
- Department of Internal Medicine II, Faculty of Medicine, University of Medicine and Pharmacy Gr. T. Popa, 700115 Iași, Romania
- "St. Parascheva" Clinical Hospital of Infectious Diseases, 700116 Iași, Romania
| | - Olivia Simona Dorneanu
- "St. Parascheva" Clinical Hospital of Infectious Diseases, 700116 Iași, Romania
- Department of Preventive Medicine and Interdisciplinarity, Faculty of Medicine, University of Medicine and Pharmacy Gr. T. Popa, 700115 Iași, Romania
| | - Manuel Florin Roșu
- "St. Parascheva" Clinical Hospital of Infectious Diseases, 700116 Iași, Romania
- Department of Intensive Care Unit, Infectious Diseases Clinical Hospital, 700115 Iași, Romania
| | - Ioana Diandra Miftode
- Department of Radiology, "St. Spiridon" Emergency Clinical Hospital, 700111 Iași, Romania
| | - Maria Obreja
- Department of Internal Medicine II, Faculty of Medicine, University of Medicine and Pharmacy Gr. T. Popa, 700115 Iași, Romania
- "St. Parascheva" Clinical Hospital of Infectious Diseases, 700116 Iași, Romania
| | - Egidia Gabriela Miftode
- Department of Internal Medicine II, Faculty of Medicine, University of Medicine and Pharmacy Gr. T. Popa, 700115 Iași, Romania
- "St. Parascheva" Clinical Hospital of Infectious Diseases, 700116 Iași, Romania
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41
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Naz F, Petri WA. Host Immunity and Immunization Strategies for Clostridioides difficile Infection. Clin Microbiol Rev 2023; 36:e0015722. [PMID: 37162338 PMCID: PMC10283484 DOI: 10.1128/cmr.00157-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023] Open
Abstract
Clostridioides difficile infection (CDI) represents a significant challenge to public health. C. difficile-associated mortality and morbidity have led the U.S. CDC to designate it as an urgent threat. Moreover, recurrence or relapses can occur in up to a third of CDI patients, due in part to antibiotics being the primary treatment for CDI and the major cause of the disease. In this review, we summarize the current knowledge of innate immune responses, adaptive immune responses, and the link between innate and adaptive immune responses of the host against CDI. The other major determinants of CDI, such as C. difficile toxins, the host microbiota, and related treatments, are also described. Finally, we discuss the known therapeutic approaches and the current status of immunization strategies for CDI, which might help to bridge the knowledge gap in the generation of therapy against CDI.
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Affiliation(s)
- Farha Naz
- Division of Infectious Diseases and International Health, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - William A. Petri
- Division of Infectious Diseases and International Health, University of Virginia School of Medicine, Charlottesville, Virginia, USA
- Department of Pathology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
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Drapkina OM, Lazebnik LB, Bakulin IG, Zhuravleva MS, Bakulina NV, Skazyvaeva EV, Sitkin SI, Skalinskaya MI, Solovyeva OI, Eremina EY, Tikhonov SV, Fil' TS, Pilat TL, Kuznetsova YG, Khanferyan RA, Livzan MA, Osipenko MF, Abdulganieva DI, Tarasova LV, Khavkin AI. <i>Clostridioides difficile</i> infection: diagnosis, treatment, and prevention Clinical guidelines of the Russian Scientific Medical Society of Internal Medicine, the Gastroenterological Scientific Society of Russia, and the North- West Society of Gastroenterologists and Hepatologists. EXPERIMENTAL AND CLINICAL GASTROENTEROLOGY 2023:4-32. [DOI: 10.31146/1682-8658-ecg-210-2-4-32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
Clostridioides difficile infection (CDI) is the most common cause of antibiotic-associated diarrhea, and an important cause of nosocomial infection. Since the publication of the National Guidelines (2016, 2017), new data have been accumulated on the genetic structure and pathogenic properties of the most common causative agent of severe forms of antibiotic- associated diarrhea, which has led to the reclassifi cation of the pathogen, formerly known as Clostridium diffi cile, to Clostridioides difficile. Laboratory algorithms have been developed to diagnose CDI and determine the toxigenicity of strains reliably. New data on the effectiveness of antibacterials have been published, monoclonal antibodies to toxin B (bezlotoxumab) have been introduced into clinical practice to prevent CDI recurrence, and fecal microbiota transplantation has been proposed. Over the past 5 years, many international guidelines on the management of adult patients with CDI have also been updated (USA, EU). In the last decade, including due to the COVID-19 pandemic, there has been an increase in CDI incidence. Considering therelevance of CDI, new data on the pathogen, and domestic features, the Russian Scientific Medical Society of Internal Medicine, the Gastroenterological Scientific Society of Russia, and the North-West Society of Gastroenterologists and Hepatologists developed these clinical guidelines.
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Affiliation(s)
- O. M. Drapkina
- National Medical Research Center for Therapy and Preventive Medicine
| | - L. B. Lazebnik
- A. I. Yevdokimov Moscow State University of Medicine and Dentistry
| | - I. G. Bakulin
- North-Western state medical University named after I. I. Mechnikov
| | - M. S. Zhuravleva
- North-Western state medical University named after I. I. Mechnikov
| | - N. V. Bakulina
- North-Western state medical University named after I. I. Mechnikov
| | - E. V. Skazyvaeva
- North-Western state medical University named after I. I. Mechnikov
| | - S. I. Sitkin
- North-Western state medical University named after I. I. Mechnikov; Almazov National Medical Research Centre
| | | | - O. I. Solovyeva
- North-Western state medical University named after I. I. Mechnikov
| | | | - S. V. Tikhonov
- North-Western state medical University named after I. I. Mechnikov
| | - T. S. Fil'
- North-Western state medical University named after I. I. Mechnikov
| | - T. L. Pilat
- Izmerov Research Institute of Occupational Health
| | | | | | | | | | | | | | - A. I. Khavkin
- Veltischev Research and Clinical Institute for Pediatrics and Pediatric Surgery, Pirogov Russian National Research Medical University
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Ivashkin VT, Maev IV, Andreev DN, Goloshchapov OV, Derinov AA, Zolnikova OY, Ivashkin KV, Kiseleva OY, Kiryukhin AP, Lyashenko OS, Poluektova EA, Tertychnyy AS, Trukhmanov AS, Ulyanin AI, Sheptulin AA, Shifrin OS. Modern Approaches to the Diagnosis and treatment of <i>Clostridioides difficile (C. difficile)</i>-associated Disease in Adults (literature Review and Expert Council Resolution). RUSSIAN JOURNAL OF GASTROENTEROLOGY, HEPATOLOGY, COLOPROCTOLOGY 2023; 33:19-33. [DOI: 10.22416/1382-4376-2023-33-2-19-33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Abstract
Aim: to review the modern approaches to the diagnosis and treatment ofC. difficile-associated disease in adults and present the resolution of the Expert Council held on March 25, 2023 in Moscow.General provisions.C. difficileis the most important nosocomial pathogen which spores are also commonly found in the environment. Microbiota impairment, primarily due to the use of antibacterial drugs, is a key stage in the development ofC. difficile-associated disease. A search for an infection should be carried out only in patients with diarrhea, and it is advisable to use at least 2 laboratory methods. The drug of choice for first-line treatment is vancomycin. If drug treatment is ineffective or the patient has recurrent clostridial infection, fecal microbiota transplantation should be considered. The probiotic strainSaccharomyces boulardii CNCM I-745has a direct inhibitory effect onC. difficiletoxin A, promotes normalization of the intestinal microbiota composition, and decreases the inflammatory reaction in colonic mucosa colonized with a toxigenic strain ofC. difficile.Conclusions. Addition of the probiotic strainSaccharomyces boulardii CNCM I-745to antibacterial therapy promotes both primary and secondary prevention ofC. difficile-associated disease.
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Affiliation(s)
- V. T. Ivashkin
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - I. V. Maev
- A.I. Yevdokimov Moscow State University of Medicine and Dentistry
| | - D. N. Andreev
- A.I. Yevdokimov Moscow State University of Medicine and Dentistry
| | | | - A. A. Derinov
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - O. Yu. Zolnikova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - K. V. Ivashkin
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - O. Yu. Kiseleva
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - A. P. Kiryukhin
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - O. S. Lyashenko
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - E. A. Poluektova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - A. S. Tertychnyy
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - A. S. Trukhmanov
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - A. I. Ulyanin
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - A. A. Sheptulin
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - O. S. Shifrin
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
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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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45
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Lim VW, Tomaru T, Chua B, Ma Y, Yanagihara K. Budget Impact Analysis of Adopting a One-Step Nucleic Acid Amplification Testing (NAAT) Alone Diagnostic Pathway for Clostridioides difficile in Japan Compared to a Two-Step Algorithm with Glutamate Dehydrogenase/Toxin Followed by NAAT. Diagnostics (Basel) 2023; 13:diagnostics13081463. [PMID: 37189564 DOI: 10.3390/diagnostics13081463] [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: 02/09/2023] [Revised: 04/06/2023] [Accepted: 04/15/2023] [Indexed: 05/17/2023] Open
Abstract
Clostridioides difficile infection (CDI) is a major healthcare-associated infection that leads to a significant health economic burden in Japan. Using a decision tree model, we evaluated the budget impact of adopting a one-step nucleic acid amplification test (NAAT) alone pathway compared to a two-step diagnostic algorithm with glutamate dehydrogenase (GDH) and toxin antigen, followed by NAAT. The analysis was conducted from the government payer's perspective for 100,000 symptomatic, hospitalized adults requiring a CDI diagnostic test. One-way sensitivity analysis was conducted for all data inputs. The NAAT alone strategy costed JPY 225,886,360 (USD 2,424,714) more, but was more effective, resulting in 1749 more patients accurately diagnosed and 91 fewer deaths compared to the two-step algorithm. Additionally, the NAAT alone pathway costed JPY 26,146 (USD 281) less per true positive CDI diagnosed. The total budget impact, and cost per CDI diagnosed was most sensitive to GDH sensitivity in one-way sensitivity analysis, where a lower GDH sensitivity resulted in greater cost savings with the NAAT alone pathway. Findings from this budget impact analysis can guide the adoption of a NAAT alone pathway for CDI diagnosis in Japan.
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Affiliation(s)
- Vanessa W Lim
- Health Economics and Outcomes Research, Becton Dickinson Holdings Pte. Ltd., 2 International Business Park Road, Singapore 609930, Singapore
| | - Takeshi Tomaru
- Health Economics and Outcomes Research, Nippon Becton Dickinson Company, Ltd., Akasaka Garden City 15-1, Akasaka 4-Chome, Minato-ku, Tokyo 107-0052, Japan
| | - Brandon Chua
- Health Economics and Outcomes Research, Becton Dickinson Holdings Pte. Ltd., 2 International Business Park Road, Singapore 609930, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, #10-02, Singapore 117549, Singapore
| | - Yan Ma
- Health Economics and Outcomes Research, Becton Dickinson Holdings Pte. Ltd., 2 International Business Park Road, Singapore 609930, Singapore
| | - Katsunori Yanagihara
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki University Hospital, Sakamoto 1-12-4, Nagasaki City 852-8523, Japan
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Tashiro S, Mihara T, Okawa R, Tanaka Y, Samura M, Enoki Y, Taguchi K, Matsumoto K, Yamagishi Y. Optimal therapeutic recommendation for Clostridioides difficile infection in pediatric and adolescent populations: a systematic review and meta-analysis. Eur J Pediatr 2023:10.1007/s00431-023-04944-y. [PMID: 37000258 DOI: 10.1007/s00431-023-04944-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/15/2023] [Accepted: 03/22/2023] [Indexed: 04/01/2023]
Abstract
We conducted a systematic review and meta-analysis to examine the efficacy profiles of metronidazole (MNZ) and vancomycin (VCM) in pediatric and adolescent patients with Clostridioides difficile infection (CDI). A systematic review and meta-analysis was conducted using four electronic databases (PubMed, Cochrane Library, Web of Science, and Clinicaltrials.gov) through July 6, 2022. We analyzed the clinical cure and recurrence rates to determine the efficacy of MNZ and VCM. The clinical cure rates in all included studies were not significantly different between MNZ and VCM (OR = 0.63; 95% CI = 0.36-1.10; I2 = 0%; P = 0.10). Subgroup analyses were performed separately for each region to account for regional differences in the CDI. MNZ treatment achieved significantly lower clinical cure rates than did VCM in the United States of America (USA) and Europe (OR = 0.42, 95% CI = 0.19-0.93, I2 = 0%, P = 0.03). Recurrence rates were not significantly different between MNZ and VCM (OR = 1.48, 95% CI = 0.62-3.53, I2 = 28%, P = 0.38). Conclusion: MNZ exhibited significantly lower clinical cure rates than did VCM in the US and Europe; therefore, it is not recommended for the management of CDI in pediatric and adolescent populations. What is Known: • The unavailability of robust data on recommendations of therapeutic agents for the management of Clostridioides difficile infections in children precludes effective antibiotic choice. What is New: • Metronidazole exhibited significantly lower clinical cure rates than did vancomycin in the United States of America and Europe and recurrence rate was not significantly different between metronidazole and vancomycin; therefore, it is not recommended for the management of Clostridioides difficile infection in children.
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Affiliation(s)
- Sho Tashiro
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Takayuki Mihara
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Rikiya Okawa
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Yoko Tanaka
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Masaru Samura
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Yuki Enoki
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan.
| | - Kazuaki Taguchi
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Yuka Yamagishi
- Department of Clinical Infectious Diseases, Kochi Medical School, Kochi, Japan
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47
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Sabino YNV, Cotter PD, Mantovani HC. Anti-virulence compounds against Staphylococcus aureus associated with bovine mastitis: A new therapeutic option? Microbiol Res 2023; 271:127345. [PMID: 36889204 DOI: 10.1016/j.micres.2023.127345] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/22/2023] [Accepted: 02/26/2023] [Indexed: 03/05/2023]
Abstract
Bovine mastitis represents a major economic burden faced by the dairy industry. S. aureus is an important and prevalent bovine mastitis-associated pathogen in dairy farms worldwide. The pathogenicity and persistence of S. aureus in the bovine mammary gland are associated with the expression of a range of virulence factors involved in biofilm formation and the production of several toxins. The traditional therapeutic approach to treating bovine mastitis includes the use of antibiotics, but the emergence of antibiotic-resistant strains has caused therapeutic failure. New therapeutic approaches targeting virulence factors of S. aureus rather than cell viability can have several advantages including lower selective pressure towards the development of resistance and little impact on the host commensal microbiota. This review summarizes the potential of anti-virulence therapies to control S. aureus associated with bovine mastitis focusing on anti-toxin, anti-biofilm, and anti-quorum sensing compounds. It also points to potential sources of new anti-virulence inhibitors and presents screening strategies for identifying these compounds.
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Affiliation(s)
| | | | - Hilario C Mantovani
- Department of Animal and Dairy Sciences, University of Wisconsin-Madison, Madison, WI, USA.
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48
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Impact of Nucleic Acid Amplification Test on Clinical Outcomes in Patients with Clostridioides difficile Infection. Antibiotics (Basel) 2023; 12:antibiotics12030428. [PMID: 36978295 PMCID: PMC10044602 DOI: 10.3390/antibiotics12030428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 02/06/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023] Open
Abstract
A nucleic acid amplification test (NAAT) is recommended to determine whether or not patients have a Clostridioides difficile infection (CDI) when the glutamate dehydrogenase activity assay is positive and the rapid membrane enzyme immunoassays for toxins is negative. In our hospital, a NAAT was introduced to diagnose CDI precisely in April 2020. This study aimed to investigate the impact of a NAAT on the clinical outcomes in patients with CDI at our hospital. Seventy-one patients diagnosed with CDI between April 2017 and March 2022 were included in our study. Patients with CDI were divided into two groups: before (pre-NAAT) and after (post-NAAT) the introduction of NAAT. The clinical outcome was compared between the two groups. Of the 71 patients with CDI, 41 were sorted into the pre-NAAT group and 30 into the post-NAAT group. The clinical cure rate was significantly higher in the post-NAAT group compared to the pre-NAAT group (76.7% vs. 48.8%, p = 0.018). In the multivariable analysis, the clinical cure was significantly associated with the introduction of NAAT (p = 0.022). Our findings suggest that the introduction of NAAT can improve the clinical outcomes in CDI patients.
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49
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Bainum TB, Reveles KR, Hall RG, Cornell K, Alvarez CA. Controversies in the Prevention and Treatment of Clostridioides difficile Infection in Adults: A Narrative Review. Microorganisms 2023; 11:387. [PMID: 36838352 PMCID: PMC9963748 DOI: 10.3390/microorganisms11020387] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
Clostridioides difficile remains a problematic pathogen resulting in significant morbidity and mortality, especially for high-risk groups that include immunocompromised patients. Both the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America (IDSA/SHEA), as well as the American College of Gastroenterology (ACG) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) recently provided guideline updates for C. difficile infection (CDI). In this narrative review, the authors reviewed available literature regarding the prevention or treatment of CDI in adults and focused on disagreements between the IDSA/SHEA and ACG guidelines, as well as articles that have been published since the updates. Several options for primary prophylaxis are available, including probiotics and antibiotics (vancomycin, fidaxomicin). The literature supporting fidaxomicin is currently quite limited. While there are more studies evaluating probiotics and vancomycin, the optimal patient populations and regimens for their use have yet to be defined. While the IDSA/SHEA guidelines discourage metronidazole use for mild CDI episodes, evidence exists that it may remain a reasonable option for these patients. Fidaxomicin has an advantage over vancomycin in reducing recurrences, but its use is limited by cost. Despite this, recent studies suggest fidaxomicin's cost-effectiveness as a first-line therapy, though this is highly dependent on institutional contracts and payment structures. Secondary prophylaxis should focus on non-antimicrobial options to lessen the impact on the microbiome. The oral option of fecal microbiota transplantation (FMT), SER109, and the now FDA-approved RBX2660 represent exciting new options to correct dysbiosis. Bezlotoxumab is another attractive option to prevent recurrences. Further head-to-head studies of newer agents will be needed to guide selection of the optimal therapies for CDI primary and secondary prophylaxis.
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Affiliation(s)
- Taryn B. Bainum
- Jerry H. Hodge School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA
| | - Kelly R. Reveles
- College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
- Pharmacotherapy Education and Research Center, University of Texas Health San Antonio, San Antonio, TX 78229, USA
| | - Ronald G. Hall
- Jerry H. Hodge School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA
| | - Kelli Cornell
- Jerry H. Hodge School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA
| | - Carlos A. Alvarez
- Jerry H. Hodge School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA
- Center of Excellence in Real-World Evidence, Texas Tech University Health Sciences Center, Dallas, TX 75235, USA
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50
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Emerging Options for the Prevention and Management of Clostridioides difficile Infection. Drugs 2023; 83:105-116. [PMID: 36645620 PMCID: PMC9841950 DOI: 10.1007/s40265-022-01832-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2022] [Indexed: 01/17/2023]
Abstract
Agents in development for the prevention or treatment of Clostridioides difficile infection can be split into three broad categories: antibiotics, microbiome restoration, and vaccines. Given the extensive list of agents currently in development, this narrative review will focus on agents that have progressed into late-stage clinical trials, defined as having a Phase III clinical trial registered on ClinicalTrials.gov. These agents include one antibiotic (ridinilazole), three live biotherapeutic products (LBPs) (CP101, RBX2660, and SER109), and two toxoid vaccines (PF06425090 and a second toxoid vaccine). As new prevention and treatment strategies enter the market, clinicians and administrators will need knowledge of these products to make rational decisions on how best to adopt them into clinical practice.
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