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Kunishima H, Ichiki K, Ohge H, Sakamoto F, Sato Y, Suzuki H, Nakamura A, Fujimura S, Matsumoto K, Mikamo H, Mizutani T, Morinaga Y, Mori M, Yamagishi Y, Yoshizawa S. Japanese Society for infection prevention and control guide to Clostridioides difficile infection prevention and control. J Infect Chemother 2024; 30:673-715. [PMID: 38714273 DOI: 10.1016/j.jiac.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 05/09/2024]
Affiliation(s)
- Hiroyuki Kunishima
- Department of Infectious Diseases. St. Marianna University School of Medicine, Japan.
| | - Kaoru Ichiki
- Department of Infection Control and Prevention, Hyogo Medical University Hospital, Japan
| | - Hiroki Ohge
- Department of Infectious Diseases, Hiroshima University Hospital, Japan
| | - Fumie Sakamoto
- Quality Improvement and Safety Center, Itabashi Chuo Medical Center, Japan
| | - Yuka Sato
- Department of Infection Control and Nursing, Graduate School of Nursing, Aichi Medical University, Japan
| | - Hiromichi Suzuki
- Department of Infectious Diseases, University of Tsukuba School of Medicine and Health Sciences, Japan
| | - Atsushi Nakamura
- Department of Infection Prevention and Control, Graduate School of Medical Sciences, Nagoya City University, Japan
| | - Shigeru Fujimura
- Division of Clinical Infectious Diseases and Chemotherapy, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Japan
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, Japan
| | - Hiroshige Mikamo
- Department of Clinical Infectious Diseases, Aichi Medical University, Japan
| | | | - Yoshitomo Morinaga
- Department of Microbiology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
| | - Minako Mori
- Department of Infection Control, Hiroshima University Hospital, Japan
| | - Yuka Yamagishi
- Department of Clinical Infectious Diseases, Kochi Medical School, Kochi University, Japan
| | - Sadako Yoshizawa
- Department of Laboratory Medicine/Department of Microbiology and Infectious Diseases, Faculty of Medicine, Toho University, Japan
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Olson B, Ship N, Butera ML, Warm K, Oen R, Howard J. Clostridioides difficile infection in a skilled nursing facility (SNF): cost savings of an automated, standardized probiotic antimicrobial stewardship programme (ASP) policy. JAC Antimicrob Resist 2023; 5:dlad102. [PMID: 37680882 PMCID: PMC10481250 DOI: 10.1093/jacamr/dlad102] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/21/2023] [Indexed: 09/09/2023] Open
Abstract
Background With multiple comorbidities and frequent exposures to antibiotics, patients in skilled nursing facilities (SNFs) are much more vulnerable to healthcare-acquired infections. We conducted a quality-improvement, retrospective analysis of all patients with Clostridioides difficile infection (CDI) from 2009 to 2021 at an SNF. Probiotics were initially added to a bundle of antimicrobial stewardship programme (ASP) CDI prevention strategies. Formulations and durations of probiotics were standardized for both oral and enteral administration. To reach all eligible patients, an ASP probiotic policy provided probiotics with every antibiotic course. Objectives To assess the value of providing probiotic therapy to SNF patients at risk for CDI. Patients and methods Patients receiving oral or enteral feeding with antibiotics ordered were eligible to receive probiotics. The incremental cost of CDI prevention, treatment and related care were calculated and compared for each phase of probiotic policy change and feeding type. ASP records for the oral probiotic and level of treatment were used in modelling the cost-effectiveness. Results From quality improvement initiatives aimed at preventing facility-onset (FO) CDI, to ASP policies, probiotic formulations and delegation of ordering authority, the days of acute care treatment required was significantly reduced over the different phases of implementation [152 to 48, OR = 0.22 (0.16-0.31) to 4, OR = 0.08 (0.03-0.23)] after reducing total CDI from 5.8 to 0.3 cases per 10 000 patient-days. The annual cost of oral probiotics increased from $6019 to $14 652 but the modelled net annual savings for the facility was $72 544-$154 085. Conclusions With optimization, the use of probiotics for CDI prevention at an SNF was safe, efficacious and cost-effective.
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Affiliation(s)
- Bridget Olson
- Department of Pharmacy, Sharp Coronado Hospital & Villa Long Term Care, Sharp HealthCare, 250 Prospect Place, Coronado, CA 92118, USA
| | - Noam Ship
- Research and Development, Bio-K Plus International Inc., 495 Armand-Frappier Boulevard, Laval, Quebec H7V4B3, Canada
| | - Michael L Butera
- Medical Staff, Sharp Coronado Hospital & Villa Long Term Care, Sharp HealthCare, 250 Prospect Place, Coronado, CA 92118, USA
| | - Kenneth Warm
- Medical Staff, Sharp Coronado Hospital & Villa Long Term Care, Sharp HealthCare, 250 Prospect Place, Coronado, CA 92118, USA
| | - Roger Oen
- Medical Staff, Sharp Coronado Hospital & Villa Long Term Care, Sharp HealthCare, 250 Prospect Place, Coronado, CA 92118, USA
| | - John Howard
- Department of Pharmacy, Sharp Coronado Hospital & Villa Long Term Care, Sharp HealthCare, 250 Prospect Place, Coronado, CA 92118, USA
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Pal R, Athamneh AI, Deshpande R, Ramirez JAR, Adu KT, Muthuirulan P, Pawar S, Biazzo M, Apidianakis Y, Sundekilde UK, de la Fuente-Nunez C, Martens MG, Tegos GP, Seleem MN. Probiotics: insights and new opportunities for Clostridioides difficile intervention. Crit Rev Microbiol 2023; 49:414-434. [PMID: 35574602 PMCID: PMC9743071 DOI: 10.1080/1040841x.2022.2072705] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 04/17/2022] [Accepted: 04/28/2022] [Indexed: 02/08/2023]
Abstract
Clostridioides difficile infection (CDI) is a life-threatening disease caused by the Gram-positive, opportunistic intestinal pathogen C. difficile. Despite the availability of antimicrobial drugs to treat CDI, such as vancomycin, metronidazole, and fidaxomicin, recurrence of infection remains a significant clinical challenge. The use of live commensal microorganisms, or probiotics, is one of the most investigated non-antibiotic therapeutic options to balance gastrointestinal (GI) microbiota and subsequently tackle dysbiosis. In this review, we will discuss major commensal probiotic strains that have the potential to prevent and/or treat CDI and its recurrence, reassess the efficacy of probiotics supplementation as a CDI intervention, delve into lessons learned from probiotic modulation of the immune system, explore avenues like genome-scale metabolic network reconstructions, genome sequencing, and multi-omics to identify novel strains and understand their functionality, and discuss the current regulatory framework, challenges, and future directions.
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Affiliation(s)
- Rusha Pal
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA, 24061, USA
| | - Ahmad I.M. Athamneh
- Department of Comparative Pathobiology, College of Veterinary Medicine, Purdue University, West Lafayette, IN 47907, USA
| | | | - Jose A. R Ramirez
- ProbioWorld Consulting Group, James Cook University, 4811, Queensland, Australia
| | - Kayode T. Adu
- ProbioWorld Consulting Group, James Cook University, 4811, Queensland, Australia
- Cann Group, Walter and Eliza Hall Institute, La Trobe University, Victoria 3083, Australia
| | | | - Shrikant Pawar
- The Anlyan Center Yale Center for Genomic Analysis, Yale School of Medicine, New Haven CT USA
| | - Manuele Biazzo
- The Bioarte Ltd Laboratories at Life Science Park, San Gwann, Malta
| | | | | | - Cesar de la Fuente-Nunez
- Machine Biology Group, Departments of Psychiatry and Microbiology, Institute for Biomedical Informatics, Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Departments of Bioengineering and Chemical and Biomolecular Engineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Penn Institute for Computational Science, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Mark G. Martens
- Reading Hospital, Tower Health, West Reading, PA 19611, USA
- Drexel University College of Medicine, Philadelphia, PA, 19129, USA
| | - George P. Tegos
- Drexel University College of Medicine, Philadelphia, PA, 19129, USA
| | - Mohamed N. Seleem
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA, 24061, USA
- Center for Emerging, Zoonotic and Arthropod-borne Pathogens, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061, USA
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Mitigating hospital-onset Clostridioides difficile: The impact of an optimized environmental hygiene program in eight hospitals. Infect Control Hosp Epidemiol 2023; 44:440-446. [PMID: 35718355 PMCID: PMC10015263 DOI: 10.1017/ice.2022.84] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To evaluate the impact of a standardized, process-validated intervention utilizing daily hospital-wide patient-zone sporicidal disinfectant cleaning on incidence density of healthcare-onset Clostridioides difficile infection (HO-CDI) standardized infection ratios (SIRs). DESIGN Multi-site, quasi-experimental study, with control hospitals and a nonequivalent dependent variable. SETTING The study was conducted across 8 acute-care hospitals in 6 states with stable endemic HO-CDI SIRs. METHODS Following an 18-month preintervention control period, each site implemented a program of daily hospital-wide sporicidal disinfectant patient zone cleaning. After a wash-in period, thoroughness of disinfection cleaning (TDC) was monitored prospectively and optimized with performance feedback utilizing a previously validated process improvement program. Mean HO-CDI SIRs were calculated by quarter for the pre- and postintervention periods for both the intervention and control hospitals. We used a difference-in-differences analysis to estimate the change in the average HO-CDI SIR and HO-CAUTI SIR for the pre- and postintervention periods. RESULTS Following the wash-in period, the TDC improved steadily for all sites and by 18 months was 93.6% for the group. The mean HO-CDI SIRs decreased from 1.03 to 0.6 (95% CI, 0.13-0.75; P = .009). In the adjusted difference-in-differences analysis in comparison to controls, there was a 0.55 reduction (95% CI, -0.77 to -0.32) in HO-CDI (P < .001) or a 50% relative decrease from baseline. CONCLUSIONS This study represents the first multiple-site, quasi-experimental study with control hospitals and a nonequivalent dependent variable to evaluate a 4-component intervention on HO-CDI. Following ongoing improvement in cleaning thoroughness, there was a sustained 50% decrease in HO-CDI SIRs compared to controls.
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5
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Shah PJ, Halawi H, Kay J, Akogun A, Wise S, Aly S, Daoura N, Putney D. A Single-Center, Retrospective Cohort Study Evaluating the Use of Probiotics for the Prevention of Hospital-Onset Clostridioides difficile Infection in Hospitalized Patients Receiving Intravenous Antibiotics. Hosp Pharm 2023; 58:57-61. [PMID: 36644740 PMCID: PMC9837316 DOI: 10.1177/00185787221120153] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Background Exposure to antimicrobials is a known risk factor for Clostridioides difficile infection (CDI). Antimicrobials cause collateral damage by disrupting the natural intestinal microbiota allowing for C. difficile to thrive and production of C. difficile toxins. Probiotics could modulate the onset and course of CDI. However, the data on probiotics for the prevention of CDI is conflicting. Objective To evaluate the rates of hospital-onset Clostridioides difficile infection (HO-CDI) among patients who received intravenous (IV) antibiotics plus probiotics versus IV antibiotics alone. Design Retrospective, single-center cohort study. Methods We included adult patients that received at least 1 dose of IV antibiotics and had a hospital length of stay of at least 3 days between August 2017 and July 2020. Patients were separated into 2 cohorts, either receipt of probiotics or non-receipt of probiotics. Patients with positive C. difficile toxin test prior to antibiotic therapy, or receipt of only C. difficile active treatment were excluded. The primary outcome was incidence of HO-CDI in patients who received IV antibiotics plus probiotics compared to those that received IV antibiotics alone. Logistic regression was performed to account for confounding variables. Results We identified 17 598 patients that received IV antibiotics alone and 2659 patients received IV antibiotics plus probiotics. HO-CDI occurred in 46 (0.26%) of those that received antibiotics alone compared to 5 (0.19%) of those that received probiotics with IV antibiotics (OR 0.72, 95% CI 0.28-1.81). ICU admission (OR 1.81, 95% CI 1.02-3.19) and history of CDI (OR 3.37, 95% CI 1.07-10.97) in the past 12 months were associated with a higher incidence of HO-CDI. Conclusion The addition of probiotics did not reduce the incidence of HO-CDI among inpatients receiving IV antibiotics.
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Affiliation(s)
| | - Hala Halawi
- Houston Methodist Hospital, Houston, TX, USA
| | - Jessica Kay
- Houston Methodist Sugar Land Hospital, Sugar Land, TX, USA
| | - Adanma Akogun
- Houston Methodist Sugar Land Hospital, Sugar Land, TX, USA
| | - Silvia Wise
- Houston Methodist Sugar Land Hospital, Sugar Land, TX, USA
| | - Sarfraz Aly
- Houston Methodist Sugar Land Hospital, Sugar Land, TX, USA
| | - Nicolas Daoura
- Houston Methodist Sugar Land Hospital, Sugar Land, TX, USA
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Dohrendorf CM, Unkel S, Scheithauer S, Kaase M, Meier V, Fenz D, Sasse J, Wappler M, Schweer-Herzig J, Friede T, Reichard U, Eiffert H, Nau R, Seele J. Reduced Clostridioides difficile infections in hospitalised older people through multiple quality improvement strategies. Age Ageing 2021; 50:2123-2132. [PMID: 34473822 DOI: 10.1093/ageing/afab169] [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: 02/09/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To reduce infections with Clostridioides difficile (CDI) in geriatric patients by interventions easily implementable in standard clinical care. METHODS Prevalence and incidence of CDI between January 2015 and February 2020 were analysed (n = 25,311 patients). Pre-intervention status was assessed from April 2016 to March 2017 (n = 4,922). Between May 2017 and August 2019, a monocentric interventional crossover study (n = 4,655) was conducted including standard care and three interventions: (A) sporicidal cleaning of hospital wards, (B) probiotics and (C) improvement in personal hygiene for CDI patients. This was followed by a multicentric comparison of the interventional bundle (A + B + C) between September 2019 and February 2020 (n = 2,593) with the pre-intervention phase. In 98 CDI cases and matched controls individual risk factors for the development of CDI were compared. RESULTS Time series analyses of CDI cases revealed a reduction in the prevalence of CDI in all three participating centres prior to the multicentric intervention phase. In the monocentric phase, no effect of individual interventions on CDI prevalence was identified. However, an aggregated analysis of CDI cases comparing the pre-intervention and the multicentric phase revealed a significant reduction in CDI prevalence. Risk factors for the development of CDI included use of antibiotics, anticoagulants, previous stay in long-term care facilities, prior hospital admissions, cardiac and renal failure, malnutrition and anaemia. CONCLUSIONS The observed reduction in CDI may be attributed to heightened awareness of the study objectives and specific staff training. Individual interventions did not appear to reduce CDI prevalence. A further randomised trial would be necessary to confirm whether the bundle of interventions is truly effective.
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Affiliation(s)
- Carla Maria Dohrendorf
- Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, Göttingen, Germany
- Department of Neuropathology, University Medical Center Göttingen, Göttingen, Germany
| | - Steffen Unkel
- Department of Medical Statistics, University Medical Center Göttingen; Göttingen, Germany
| | - Simone Scheithauer
- Institute for Infection Control and Infectious Diseases, University Medical Center Göttingen; Göttingen, Germany
| | - Martin Kaase
- Institute for Infection Control and Infectious Diseases, University Medical Center Göttingen; Göttingen, Germany
| | - Volker Meier
- Hospital hygiene, Evangelisches Krankenhaus Göttingen-Weende; Göttingen, Germany
| | - Diana Fenz
- Institute for Infection Control and Infectious Diseases, University Medical Center Göttingen; Göttingen, Germany
| | - Jürgen Sasse
- Clinic for Geriatric Medicine, DRK Kliniken-Nordhessen; Kaufungen, Germany
| | - Manfred Wappler
- Clinic for Geriatric Medicine, Evangelisches Krankenhaus Gesundbrunnen Hofgeismar; Hofgeismar, Germany
| | - Jutta Schweer-Herzig
- Clinic for Geriatric Medicine, Evangelisches Krankenhaus Gesundbrunnen Hofgeismar; Hofgeismar, Germany
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen; Göttingen, Germany
| | - Utz Reichard
- MVZ Wagnerstibbe for Medical Microbiology, Göttingen, Germany
| | - Helmut Eiffert
- MVZ Wagnerstibbe for Medical Microbiology, Göttingen, Germany
| | - Roland Nau
- Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, Göttingen, Germany
- Department of Neuropathology, University Medical Center Göttingen, Göttingen, Germany
| | - Jana Seele
- Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, Göttingen, Germany
- Department of Neuropathology, University Medical Center Göttingen, Göttingen, Germany
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Maziade PJ, Ship N, Sniffen JC, Goldstein EJC. Enhanced Clostridioides difficile infection prevention with a pharmacy-controlled policy that adds a three-strain Lactobacillus probiotic concomitantly to antibiotic therapy. Clin Infect Dis 2021; 73:1524-1527. [PMID: 33966076 PMCID: PMC8528394 DOI: 10.1093/cid/ciab414] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Indexed: 01/13/2023] Open
Abstract
When 70% of antibiotic users took a 3-strain Lactobacillus probiotic preparation the hospital-wide rate of healthcare-associated Clostridioides difficile infection improved significantly. The incidence of C. difficile infection for those taking the probiotic along with multiple antibiotics or a single high-risk antibiotic was decreased by at least half.
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Affiliation(s)
- Pierre-Jean Maziade
- Microbiology and Infectious Diseases, Centre Intégré de Santé et de Services Sociaux de Lanaudière, Terrebonne, Canada
| | - Noam Ship
- Research and Development, Bio-K Plus International Inc., Laval, Canada
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8
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The Acid-Dependent and Independent Effects of Lactobacillus acidophilus CL1285, Lacticaseibacillus casei LBC80R, and Lacticaseibacillus rhamnosus CLR2 on Clostridioides difficile R20291. Probiotics Antimicrob Proteins 2021; 13:949-956. [PMID: 33492661 DOI: 10.1007/s12602-020-09729-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2020] [Indexed: 10/22/2022]
Abstract
Clostridioides difficile infections (CDI) result from antibiotic use and cause severe diarrhea which is life threatening and costly. A specific probiotic containing Lactobacillus acidophilus CL1285, Lacticaseibacillus casei LBC80R, and Lacticaseibacillus rhamnosus CLR2 has demonstrated a strong inhibitory effect on the growth of several nosocomial C. difficile strains by production of antimicrobial metabolites during fermentation. Though there are several lactobacilli shown to inhibit C. difficile growth by processes relying on acidification, this probiotic has demonstrated potency for CDI prevention among hospitalized patients. Here, we describe the acid-dependent and independent mechanisms by which these strains impair the cytotoxicity of a hypervirulent strain, C. difficile R20291 (CD). These bacteria were co-cultured in a series of experiments under anaerobic conditions in glucose-rich and no-sugar medium to inhibit or stimulate CD toxin production, respectively. In glucose-rich medium, there was low CD toxin production, but sufficient amounts to cause cytotoxic damage to human fibroblast cells. In co-culture, there was acidification by the lactobacilli resulting in growth inhibition as well as ≥ 99% reduced toxin A and B production and no observable cytotoxicity. In the absence of glucose, CD produced much more toxin. In co-culture, the lactobacilli did not acidify the medium and CD growth was unaffected; yet, the amount of detected toxin A and B was decreased by 20% and 41%, respectively. Despite the high concentration of toxin, cells exposed to the supernatant from the co-culture were able to survive. These results suggest that in addition to known acid-dependent effects, the combination of L. acidophilus CL1285, L. casei LBC80R, and L. rhamnosus CLR2 can interfere with CD pathogenesis without acidification: (1) reduced toxin A and B production and (2) toxin neutralization. This might explain the strain specificity of this probiotic in potently preventing C. difficile-associated diarrhea in antibiotic-treated patients compared with other probiotic formulae.
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9
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Murray B, Wolfe C, Marra A, Pillar C, Shinabarger D. In vitro activity of the novel antibacterial agent ibezapolstat (ACX-362E) against Clostridioides difficile. J Antimicrob Chemother 2020; 75:2149-2155. [PMID: 32285102 DOI: 10.1093/jac/dkaa134] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 03/10/2020] [Accepted: 03/14/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Ibezapolstat (ACX-362E) is the first DNA polymerase IIIC inhibitor undergoing clinical development for the oral treatment of Clostridioides difficile infection (CDI). METHODS In this study, the in vitro activity of ibezapolstat was evaluated against a panel of 104 isolates of C. difficile, including those with characterized ribotypes (e.g. 027 and 078) and those producing toxin A or B and was shown to have similar activity to those of comparators against these strains. RESULTS The overall MIC50/90 (mg/L) for ibezapolstat against evaluated C. difficile was 2/4, compared with 0.5/4 for metronidazole, 1/4 for vancomycin and 0.5/2 for fidaxomicin. In addition, the bactericidal activity of ibezapolstat was evaluated against actively growing C. difficile by determining the MBC against three C. difficile isolates. Time-kill kinetic assays were additionally performed against the three C. difficile isolates, with metronidazole and vancomycin as comparators. CONCLUSIONS The killing of C. difficile by ibezapolstat was observed to occur at concentrations similar to its MIC, as demonstrated by MBC:MIC ratios and reflected in time-kill kinetic assays. This activity highlights the therapeutic potential of ibezapolstat for the treatment of CDI.
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Affiliation(s)
- Beverly Murray
- Micromyx, Inc, 4717 Campus Drive, Kalamazoo, MI 49008, USA
| | | | - Andrea Marra
- Micromyx, Inc, 4717 Campus Drive, Kalamazoo, MI 49008, USA
| | - Chris Pillar
- Micromyx, Inc, 4717 Campus Drive, Kalamazoo, MI 49008, USA
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10
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Bundling Probiotics With Antimicrobial Stewardship Programs for the Prevention of Clostridiodes difficile Infections in Acute Care Hospitals. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2020. [DOI: 10.1097/ipc.0000000000000853] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Abstract
Clostridium (reclassified as " Clostridioides ") difficile infection (CDI) is a healthcare-associated infection and significant source of potentially preventable morbidity, recurrence, and death, particularly among hospitalized older adults. Additional risk factors include antibiotic use and severe underlying illness. The increasing prevalence of community-associated CDI is gaining recognition as a novel source of morbidity in previously healthy patients. Even after recovery from initial infection, patients remain at risk for recurrence or reinfection with a new strain. Some pharmaco-epidemiologic studies have suggested an increased risk associated with proton pump inhibitors and protective effect from statins, but these findings have not been uniformly reproduced in all studies. Certain ribotypes of C. difficile , including the BI/NAP1/027, 106, and 018, are associated with increased antibiotic resistance and potential for higher morbidity and mortality. CDI remains a high-morbidity healthcare-associated infection, and better understanding of ribotypes and medication risk factors could help to target treatment, particularly for patients with high recurrence risk.
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Affiliation(s)
- Ana C. De Roo
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Scott E. Regenbogen
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
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Rohde JM, Jones K, Padron N, Olmsted RN, Chopra V, Dubberke ER. A Tiered Approach for Preventing Clostridioides difficile Infection. Ann Intern Med 2019; 171:S45-S51. [PMID: 31569223 DOI: 10.7326/m18-3444] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jeffrey M Rohde
- University of Michigan Medical School, Ann Arbor, Michigan (J.M.R., K.J.)
| | - Karen Jones
- University of Michigan Medical School, Ann Arbor, Michigan (J.M.R., K.J.)
| | - Norma Padron
- Health Research & Educational Trust, American Hospital Association, Chicago, Illinois (N.P.)
| | - Russell N Olmsted
- Integrated Clinical Services, Trinity Health, Livonia, Michigan (R.N.O.)
| | - Vineet Chopra
- University of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (V.C.)
| | - Erik R Dubberke
- Washington University School of Medicine, St. Louis, Missouri (E.R.D.)
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13
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Kamiyama D, Weng BH, Donnelley MA, Zhu E, Brown J. Use of a Clostridium difficileclinical prediction rule to facilitate antimicrobial stewardship. J Infect Prev 2019. [DOI: 10.1177/1757177419846589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
In this study, we assessed whether a Clostridium difficile clinical prediction rule could be used to facilitate antimicrobial stewardship in an acute care hospital. We found that patients with higher scores were more likely to receive unnecessary antimicrobials and had the greatest potential for antimicrobial stewardship interventions. This novel method has the potential to expedite antimicrobial stewardship efforts, particularly for complex patients, in health care institutions.
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Affiliation(s)
- Davin Kamiyama
- Department of Pharmacy, University of California, Davis Medical Center, Sacramento, USA
| | - Bruce H Weng
- Division of Infectious Diseases, University of California, Davis Medical Center, Sacramento, USA
| | - Monica A Donnelley
- Department of Pharmacy, University of California, Davis Medical Center, Sacramento, USA
| | - Elizabeth Zhu
- Department of Pharmacy, University of California, Davis Medical Center, Sacramento, USA
| | - Jennifer Brown
- Division of Infectious Diseases, University of California, Davis Medical Center, Sacramento, USA
- Department of Hospital Epidemiology and Infection Prevention, University of California, Davis Medical Center, Sacramento, USA
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14
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Ship N, Millette M, Carrière S. Rhetoric or Rhetoric: Interpreting Cross-Sectional Data When There Are Disparate Control Groups. Open Forum Infect Dis 2019; 6:ofz127. [PMID: 31041342 PMCID: PMC6483136 DOI: 10.1093/ofid/ofz127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 03/06/2019] [Indexed: 01/26/2023] Open
Affiliation(s)
- Noam Ship
- Research and Development, Bio-K Plus International, Inc., Laval, Canada
| | - Mathieu Millette
- Research and Development, Bio-K Plus International, Inc., Laval, Canada
| | - Serge Carrière
- Research and Development, Bio-K Plus International, Inc., Laval, Canada
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Quigley L, Coakley M, Alemayehu D, Rea MC, Casey PG, O’Sullivan Ó, Murphy E, Kiely B, Cotter PD, Hill C, Ross RP. Lactobacillus gasseri APC 678 Reduces Shedding of the Pathogen Clostridium difficile in a Murine Model. Front Microbiol 2019; 10:273. [PMID: 30842760 PMCID: PMC6391587 DOI: 10.3389/fmicb.2019.00273] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 02/01/2019] [Indexed: 01/09/2023] Open
Abstract
Clostridium difficile is a common cause of health-care acquired diarrhea, resulting in a spectrum of disease from mild diarrhea to life-threatening illness. Sixty Lactobacillus strains were screened for anti-C. difficile activity using a co-culture method. Based on their ability to inhibit C. difficile, L. gasseri APC 678 and L. rhamnosus DPC 6111 were selected for study in a murine model of C. difficile infection. L. gasseri ATCC 33323, was included as a control. It was established that, relative to control mice not fed Lactobacillus, feeding with L. gasseri APC 678 resulted in a significant reduction by day 7 (8-fold, p = 0.017) of viable C. difficile VPI 10463 in the feces of mice. In contrast, neither L. rhamnosus DPC 6111 nor L. gasseri ATCC 33323 significantly reduced fecal C. difficile shedding. Sequencing of the cecal microbiota showed that in mice fed L. gasseri APC 678 there was a significant increase in bacterial diversity across a number of indices when compared to the control or other Lactobacillus-fed groups. There was no significant change in the relative abundance of Firmicutes or Bacteroidetes in the group fed L. gasseri APC 678 relative to the control, while the groups fed L. rhamnosus DPC 6111 or L. gasseri ATCC 33323 showed a significant decrease in the relative abundance of Firmicutes (p = 0.002 and p = 0.019, respectively) and a significant increase in Bacteroidetes (p = 0.002 and p = 0.023, respectively). These results highlight the potential of L. gasseri APC 678 as a live therapeutic agent to target C. difficile infection.
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Affiliation(s)
- Lisa Quigley
- Teagasc Food Research Centre, Moorepark, Fermoy, Co. Cork, Ireland
- APC Microbiome Ireland, University College Cork, Cork, Ireland
| | - Mairéad Coakley
- Teagasc Food Research Centre, Moorepark, Fermoy, Co. Cork, Ireland
- APC Microbiome Ireland, University College Cork, Cork, Ireland
| | - Debebe Alemayehu
- Teagasc Food Research Centre, Moorepark, Fermoy, Co. Cork, Ireland
- APC Microbiome Ireland, University College Cork, Cork, Ireland
| | - Mary C. Rea
- Teagasc Food Research Centre, Moorepark, Fermoy, Co. Cork, Ireland
- APC Microbiome Ireland, University College Cork, Cork, Ireland
| | - Patrick G. Casey
- APC Microbiome Ireland, University College Cork, Cork, Ireland
- School of Microbiology, University College Cork, Cork, Ireland
| | - Órla O’Sullivan
- Teagasc Food Research Centre, Moorepark, Fermoy, Co. Cork, Ireland
- APC Microbiome Ireland, University College Cork, Cork, Ireland
| | | | | | - Paul D. Cotter
- Teagasc Food Research Centre, Moorepark, Fermoy, Co. Cork, Ireland
- APC Microbiome Ireland, University College Cork, Cork, Ireland
| | - Colin Hill
- APC Microbiome Ireland, University College Cork, Cork, Ireland
- School of Microbiology, University College Cork, Cork, Ireland
| | - R. Paul Ross
- Teagasc Food Research Centre, Moorepark, Fermoy, Co. Cork, Ireland
- APC Microbiome Ireland, University College Cork, Cork, Ireland
- School of Microbiology, University College Cork, Cork, Ireland
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Costs of hospital-acquired infection for patients hospitalized in intensive care unit of an Iranian referral hospital. Med J Islam Repub Iran 2019; 32:67. [PMID: 30643742 PMCID: PMC6325278 DOI: 10.14196/mjiri.32.67] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Indexed: 11/23/2022] Open
Abstract
Background: Hospital infections have affected millions of people around the world and are considered as one of the most important issues related to patient safety. Therefore, this study was conducted to estimate the extra costs caused by hospital-acquired infections in
hospitals.
Methods: This retrospective cohort study was conducted in Tehran province, Iran, in 2017. Medical records of 235 patients hospitalized in one of Tehran hospitals were reviewed for the study. They were divided into case (90 patients) and control (145 patients) groups. Data were analyzed using SPSS and STATA software.
Results: Results revealed no significant relationship between age and gender with the incidence of nosocomial infection (p>0.05). However, the chance of nosocomial infection is most affected by length of hospital stay and costs paid by patients. Moreover, nosocomial infection increases the length of hospital stay up to 25 days. Our results revealed that the mean±SD hospital stay of infected and non-infected patients were 15.8±17.2 and 40.8±19.1 days, respectively. Furthermore, the total cost of patients without any hospital infection was 2451±3098 USD (83 674 480±105 765 500 Rials). On the other hand, the cost for infected patients was 3264±6078 USD (207 497 500±111 430 700 Rials).
Conclusion: Hospital-acquired infections can impose great costs on both patients and the health system. The results of this study indicated the importance of taking specific measures for infection control in hospitals.
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Leedahl DD, Personett HA, Nagpal A, Barreto EF. Prevention of Clostridium difficile Infection in Critically Ill Adults. Pharmacotherapy 2019; 39:399-407. [PMID: 30506900 DOI: 10.1002/phar.2200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The incidence and severity of Clostridium difficile infection (CDI) remain high across intensive care units in the United States despite national efforts to decrease this escalating health care burden. Most published literature and guidelines address treatment rather than prevention, yet this approach may be too downstream to limit morbidity and mortality from the disease and its complications. Mechanisms to prevent CDI successfully include reducing modifiable risk factors and minimizing horizontal transmission of C. difficile spores between patients and the health care environment. Because CDI prevention is characterized by a bundled approach, it is difficult to quantify the individual impact of any one element; however, a number of patient- and facility-level strategies can be considered for CDI prevention. Robust hygiene strategies, diagnostic and antimicrobial stewardship, and particular prophylaxis maneuvers such as continuation of oral vancomycin or fidaxomicin in the setting of systemic antibiotics have all demonstrated benefit. The preventive roles of deprescribing acid suppressants, routine use of probiotics, or early fecal microbiota transplantation remain unclear. The focus of this review is to summarize the evidence related to primary and secondary CDI prevention in critically ill adults and provide a concise implementation pathway for clinicians and policymakers.
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Affiliation(s)
- David D Leedahl
- Pharmacy Services, Sanford Medical Center, Fargo, North Dakota
| | | | - Avish Nagpal
- Infectious Diseases, Sanford Medical Center, Fargo, North Dakota
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
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Box MJ, Ortwine KN, Goicoechea M. No Impact of Probiotics to Reduce Clostridium difficile Infection in Hospitalized Patients: A Real-world Experience. Open Forum Infect Dis 2018; 5:ofy192. [PMID: 30568976 PMCID: PMC6291414 DOI: 10.1093/ofid/ofy192] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 08/22/2018] [Indexed: 12/28/2022] Open
Abstract
We assessed the effectiveness of a Lactobacillus probiotic on rates of health care facility-onset Clostridium difficile infection (HO-CDI) in patients receiving antibiotics. A total of 1576 patients were evaluated. There was no difference in the HO-CDI incidence between those who received probiotics and those who did not (1.8% vs 0.9%; P = .16).
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Affiliation(s)
- Maggie J Box
- Department of Pharmacy, Scripps Health, San Diego, California
| | | | - Miguel Goicoechea
- Division of Infectious Diseases, Scripps Health, San Diego, California
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Grimmond T, Neelakanta A, Miller B, Saiyed A, Gill P, Cadnum J, Olmsted R, Donskey C, Pate K, Miller K. A microbiological study to investigate the carriage and transmission-potential of Clostridium difficile spores on single-use and reusable sharps containers. Am J Infect Control 2018; 46:1154-1159. [PMID: 29801963 DOI: 10.1016/j.ajic.2018.04.206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 04/09/2018] [Accepted: 04/09/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND A 2015 study matching use of disposable and reusable sharps containers (DSCs, RSCs) with Clostridium difficile infection (CDI) incidence found a decreased incidence with DSCs. We conducted microbiologic samplings and examined the literature and disease-transmission principles to evaluate the scientific feasibility of such an association. METHODS (i) 197 RSCs were sampled for C. difficile at processing facilities; (ii) RSCs were challenged with high C. difficile densities to evaluate efficacy of automated decontamination; and (iii) 50 RSCs and 50 DSCs were sampled in CDI patient rooms in 7 hospitals. Results were coupled with epidemiologic studies, clinical requirements, and chain-of-infection principles, and tests of evidence of disease transmission were applied. RESULTS C. difficile spores were found on 9 of 197 (4.6%) RSCs prior to processing. Processing completely removed C. difficile. In CDI patient rooms, 4 of 50 RSCs (8.0%) and 8 of 50 DSCs (16.0%) had sub-infective counts of C. difficile (P = .27). DSCs were in permanent wall cabinets; RSCs were removed and decontaminated frequently. CONCLUSION With C. difficile bioburden being sub-infective on both DSCs and RSCs, sharps containers being no-touch, and glove removal required after sharps disposal, we found 2 links in the chain of infection to be broken and 5 of 7 tests of evidence to be unmet. We conclude that sharps containers pose no risk of C. difficile transmission.
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Affiliation(s)
| | - Anu Neelakanta
- Department of Infectious Diseases, Carolinas Medical Center, Charlotte, NC
| | - Barbara Miller
- Environmental Health and Safety Department, Carolinas Health System, Charlotte, NC
| | - Asif Saiyed
- Infection Control, Sinai Health System, Chicago, IL
| | - Pam Gill
- Infection Prevention, Iredell Health System, Statesville, NC
| | - Jennifer Cadnum
- Research Services, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
| | - Russell Olmsted
- Infection Prevention & Control, Trinity Health Unified Clinical Organization, Livonia, MI
| | - Curtis Donskey
- Infection Control Department, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH; Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
| | - Kimberly Pate
- Surgical-Trauma Division, Carolinas Medical Center, Charlotte, NC
| | - Katherine Miller
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC
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20
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Alberda C, Marcushamer S, Hewer T, Journault N, Kutsogiannis D. Feasibility of a Lactobacillus casei Drink in the Intensive Care Unit for Prevention of Antibiotic Associated Diarrhea and Clostridium difficile. Nutrients 2018; 10:nu10050539. [PMID: 29701662 PMCID: PMC5986419 DOI: 10.3390/nu10050539] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 04/17/2018] [Accepted: 04/20/2018] [Indexed: 12/13/2022] Open
Abstract
Background: Over 70% of patients are prescribed antibiotics during their intensive care (ICU) admission. The gut microbiome is dramatically altered early in an ICU stay, increasing the risk for antibiotic associated diarrhea (AAD) and Clostridium difficile infections (CDI). Evidence suggests that some probiotics are effective in the primary prevention of AAD and CDI. Aim: To demonstrate safety and feasibility of a probiotic drink in ICU patients. Methods: ICU patients initiated on antibiotics were recruited, and matched with contemporary controls. Study patients received two bottles daily of a drink containing 10 billion Lactobacillus casei which was bolused via feeding tube. Tolerance to probiotics and enteral nutrition, development of adverse events, and incidence of AAD was recorded. CDI rates were followed for 30 days post antibiotic treatment. Results: Thirty-two patients participated in the trial. There were no serious adverse events in the probiotic group, compared to three in the control group. AAD was documented in 12.5% of the probiotic group and 31.3% in the control group. One patient in the probiotic group developed CDI compared to three in the control group. Discussion: A probiotic containing drink can safely be delivered via feeding tube and should be considered as a preventative measure for AAD and CDI in ICU.
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Affiliation(s)
- Cathy Alberda
- Alberta Health Services, 670 CSC Royal Alexandra Hospital, Edmonton, AB T5H 3V9, Canada.
| | - Sam Marcushamer
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, Edmonton, AB T5H 3V9, Canada.
| | - Tayne Hewer
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T5H 3V9, Canada.
| | - Nicole Journault
- Alberta Health Services, 670 CSC Royal Alexandra Hospital, Edmonton, AB T5H 3V9, Canada.
| | - Demetrios Kutsogiannis
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, Edmonton, AB T5H 3V9, Canada.
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21
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McFarland LV, Ship N, Auclair J, Millette M. Primary prevention of Clostridium difficile infections with a specific probiotic combining Lactobacillus acidophilus, L. casei, and L. rhamnosus strains: assessing the evidence. J Hosp Infect 2018; 99:443-452. [PMID: 29702133 DOI: 10.1016/j.jhin.2018.04.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 04/18/2018] [Indexed: 02/07/2023]
Abstract
Clostridium difficile infection (CDI) has become the leading healthcare-associated infection and cause of outbreaks around the world. Although various innovative treatments have been developed, preventive strategies using multi-faceted infection control programmes have not been successful in reducing CDI rates. The major risk factor for CDI is the disruption of the normally protective gastrointestinal microbiota, typically by antibiotic use. Supplementation with specific probiotics has been effective in preventing various negative outcomes, including antibiotic-associated diarrhoea and CDI. However, a consensus of which probiotic strains might prevent CDI has not been reached and meta-analyses report high degrees of heterogeneity when studies of different probiotic products are pooled together. We searched the literature for probiotics with sufficient evidence to assess clinical efficacy for the prevention of CDI and focused on one specific probiotic formulation comprised of three lactobacilli strains (Lactobacillus acidophilus CL1285, Lactobacillus casei LBC80R, Lactobacillus rhamnosus CLR2, Bio-K+) for its ability to prevent CDI in healthcare settings. A literature search on this probiotic formulation was conducted using electronic databases (PubMed, Google Scholar), abstracts from infectious disease and infection control meetings, and communications from the probiotic company. Supporting evidence was found for its mechanisms of action against CDI and that it has an excellent safety and tolerability profile. Evidence from randomized controlled trials and facility-level interventions that administer Bio-K+ show reduced incidence rates of CDI. This probiotic formulation may have a role in primary prevention of healthcare-associated CDI when administered to patients who receive antibiotics.
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Affiliation(s)
- L V McFarland
- Department of Medicinal Chemistry, School of Pharmacy, University of Washington, Seattle, WA, USA.
| | - N Ship
- Research and Development, Bio-K Plus International Inc., Laval, Quebec, Canada
| | - J Auclair
- Research and Development, Bio-K Plus International Inc., Laval, Quebec, Canada
| | - M Millette
- Research and Development, Bio-K Plus International Inc., Laval, Quebec, Canada
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22
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Faust AC, Echevarria KL, Attridge RL, Sheperd L, Restrepo MI. Prophylactic Acid-Suppressive Therapy in Hospitalized Adults: Indications, Benefits, and Infectious Complications. Crit Care Nurse 2018; 37:18-29. [PMID: 28572098 DOI: 10.4037/ccn2017720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Acid-suppressive therapy for prophylaxis of stress ulcer bleeding is commonly prescribed for hospitalized patients. Although its use in select, at-risk patients may reduce clinically significant gastrointestinal bleeding, the alteration in gastric pH and composition may place these patients at a higher risk of infection. Although any pharmacologic alteration of the gastric pH and composition is associated with an increased risk of infection, the risk appears to be highest with proton pump inhibitors, perhaps owing to the potency of this class of drugs in increasing the gastric pH. With the increased risk of infection, universal provision of pharmacologic acid suppression to all hospitalized patients, even all critically ill patients, is inappropriate and should be confined to patients meeting specific criteria. Nurses providing care in critical care areas may be instrumental in screening for appropriate use of acid-suppressive therapy and ensuring the drugs are discontinued upon transfer out of intensive care or when risk factors are no longer present.
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Affiliation(s)
- Andrew C Faust
- Andrew C. Faust is a critical care clinical pharmacist primarily working in the medical intensive care unit, Department of Pharmacy, Texas Health Presbyterian Hospital Dallas, Dallas, Texas. .,Kelly L. Echevarria is an infectious diseases and critical care clinical pharmacist, Department of Pharmacy, South Texas Veterans Health Care System, San Antonio, Texas. .,Rebecca L. Attridge is an associate professor, Department of Pharmacy Practice, University of the Incarnate Word Feik School of Pharmacy, and an adjunct assistant professor, Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, UT Health San Antonio, San Antonio, Texas. .,Lyndsay Sheperd is a critical care clinical pharmacist primarily working in the surgical-trauma intensive care unit, Department of Pharmacy, Texas Health Presbyterian Hospital Dallas, Dallas, Texas. .,Marcos I. Restrepo is an associate professor in pulmonary and critical care medicine, Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of Texas Health Science Center at San Antonio, and Veterans Evidence-Based Research Dissemination Implementation Center, South Texas Veterans Health Care System, San Antonio, Texas.
| | - Kelly L Echevarria
- Andrew C. Faust is a critical care clinical pharmacist primarily working in the medical intensive care unit, Department of Pharmacy, Texas Health Presbyterian Hospital Dallas, Dallas, Texas.,Kelly L. Echevarria is an infectious diseases and critical care clinical pharmacist, Department of Pharmacy, South Texas Veterans Health Care System, San Antonio, Texas.,Rebecca L. Attridge is an associate professor, Department of Pharmacy Practice, University of the Incarnate Word Feik School of Pharmacy, and an adjunct assistant professor, Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, UT Health San Antonio, San Antonio, Texas.,Lyndsay Sheperd is a critical care clinical pharmacist primarily working in the surgical-trauma intensive care unit, Department of Pharmacy, Texas Health Presbyterian Hospital Dallas, Dallas, Texas.,Marcos I. Restrepo is an associate professor in pulmonary and critical care medicine, Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of Texas Health Science Center at San Antonio, and Veterans Evidence-Based Research Dissemination Implementation Center, South Texas Veterans Health Care System, San Antonio, Texas
| | - Rebecca L Attridge
- Andrew C. Faust is a critical care clinical pharmacist primarily working in the medical intensive care unit, Department of Pharmacy, Texas Health Presbyterian Hospital Dallas, Dallas, Texas.,Kelly L. Echevarria is an infectious diseases and critical care clinical pharmacist, Department of Pharmacy, South Texas Veterans Health Care System, San Antonio, Texas.,Rebecca L. Attridge is an associate professor, Department of Pharmacy Practice, University of the Incarnate Word Feik School of Pharmacy, and an adjunct assistant professor, Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, UT Health San Antonio, San Antonio, Texas.,Lyndsay Sheperd is a critical care clinical pharmacist primarily working in the surgical-trauma intensive care unit, Department of Pharmacy, Texas Health Presbyterian Hospital Dallas, Dallas, Texas.,Marcos I. Restrepo is an associate professor in pulmonary and critical care medicine, Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of Texas Health Science Center at San Antonio, and Veterans Evidence-Based Research Dissemination Implementation Center, South Texas Veterans Health Care System, San Antonio, Texas
| | - Lyndsay Sheperd
- Andrew C. Faust is a critical care clinical pharmacist primarily working in the medical intensive care unit, Department of Pharmacy, Texas Health Presbyterian Hospital Dallas, Dallas, Texas.,Kelly L. Echevarria is an infectious diseases and critical care clinical pharmacist, Department of Pharmacy, South Texas Veterans Health Care System, San Antonio, Texas.,Rebecca L. Attridge is an associate professor, Department of Pharmacy Practice, University of the Incarnate Word Feik School of Pharmacy, and an adjunct assistant professor, Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, UT Health San Antonio, San Antonio, Texas.,Lyndsay Sheperd is a critical care clinical pharmacist primarily working in the surgical-trauma intensive care unit, Department of Pharmacy, Texas Health Presbyterian Hospital Dallas, Dallas, Texas.,Marcos I. Restrepo is an associate professor in pulmonary and critical care medicine, Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of Texas Health Science Center at San Antonio, and Veterans Evidence-Based Research Dissemination Implementation Center, South Texas Veterans Health Care System, San Antonio, Texas
| | - Marcos I Restrepo
- Andrew C. Faust is a critical care clinical pharmacist primarily working in the medical intensive care unit, Department of Pharmacy, Texas Health Presbyterian Hospital Dallas, Dallas, Texas.,Kelly L. Echevarria is an infectious diseases and critical care clinical pharmacist, Department of Pharmacy, South Texas Veterans Health Care System, San Antonio, Texas.,Rebecca L. Attridge is an associate professor, Department of Pharmacy Practice, University of the Incarnate Word Feik School of Pharmacy, and an adjunct assistant professor, Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, UT Health San Antonio, San Antonio, Texas.,Lyndsay Sheperd is a critical care clinical pharmacist primarily working in the surgical-trauma intensive care unit, Department of Pharmacy, Texas Health Presbyterian Hospital Dallas, Dallas, Texas.,Marcos I. Restrepo is an associate professor in pulmonary and critical care medicine, Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of Texas Health Science Center at San Antonio, and Veterans Evidence-Based Research Dissemination Implementation Center, South Texas Veterans Health Care System, San Antonio, Texas
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Wombwell E, Chittum ME, Leeser KR. Inpatient Proton Pump Inhibitor Administration and Hospital-Acquired Clostridium difficile Infection: Evidence and Possible Mechanism. Am J Med 2018; 131:244-249. [PMID: 29122635 DOI: 10.1016/j.amjmed.2017.10.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/02/2017] [Accepted: 10/19/2017] [Indexed: 12/26/2022]
Abstract
The incidence of Clostridium difficile infection continues to increase globally. Particularly concerning are hospital-acquired cases that attribute significant morbidity, mortality, and expenditures to the health care system. Proton pump inhibitors, which are widely prescribed and generally considered to have minimal adverse effects, have recently come under scrutiny for positive associations with C. difficile infection development. This article will specifically review the current state of evidence demonstrating a positive association between nosocomial proton pump inhibitor administration and the incidence of hospital-acquired C. difficile infection. In addition, the article delivers state-of-the-art knowledge relative to mechanisms by which proton pump inhibitor exposure may propagate the manifestation of C. difficile infection.
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Affiliation(s)
- Eric Wombwell
- Department of Pharmacy, Centerpoint Medical Center, Independence, Mo; Division of Pharmacy Practice and Administration, University of Missouri - Kansas City School of Pharmacy, Kansas City.
| | - Megan E Chittum
- Department of Pharmacy Services, Saint Louis University Hospital, St. Louis, Mo
| | - Kayla R Leeser
- UMKC School of Pharmacy Drug Information Center, Kansas City, Mo
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Clostridium Difficile Infection in Acute Care Hospitals: Systematic Review and Best Practices for Prevention. Infect Control Hosp Epidemiol 2018; 38:476-482. [PMID: 28300019 DOI: 10.1017/ice.2016.324] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Prevention of Clostridium difficile infection (CDI) in acute-care hospitals is a priority for hospitals and clinicians. We performed a qualitative systematic review to update the evidence on interventions to prevent CDI published since 2009. DESIGN We searched Ovid, MEDLINE, EMBASE, The Cochrane Library, CINAHL, the ISI Web of Knowledge, and grey literature databases from January 1, 2009 to August 1, 2015. SETTING We included studies performed in acute-care hospitals. PATIENTS OR PARTICIPANTS We included studies conducted on hospitalized patients that investigated the impact of specific interventions on CDI rates. INTERVENTIONS We used the QI-Minimum Quality Criteria Set (QI-MQCS) to assess the quality of included studies. Interventions were grouped thematically: environmental disinfection, antimicrobial stewardship, hand hygiene, chlorhexidine bathing, probiotics, bundled approaches, and others. A meta-analysis was performed when possible. RESULTS Of 3,236 articles screened, 261 met the criteria for full-text review and 46 studies were ultimately included. The average quality rating was 82% according to the QI-MQCS. The most effective interventions, resulting in a 45% to 85% reduction in CDI, included daily to twice daily disinfection of high-touch surfaces (including bed rails) and terminal cleaning of patient rooms with chlorine-based products. Bundled interventions and antimicrobial stewardship showed promise for reducing CDI rates. Chlorhexidine bathing and intensified hand-hygiene practices were not effective for reducing CDI rates. CONCLUSIONS Daily and terminal cleaning of patient rooms using chlorine-based products were most effective in reducing CDI rates in hospitals. Further studies are needed to identify the components of bundled interventions that reduce CDI rates. Infect Control Hosp Epidemiol 2017;38:476-482.
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25
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Use acid-suppressing drugs appropriately with an individualized approach to minimize the risk of infection. DRUGS & THERAPY PERSPECTIVES 2018. [DOI: 10.1007/s40267-017-0473-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
This narrative review summarises the benefits, risks and appropriate use of acid-suppressing drugs (ASDs), proton pump inhibitors and histamine-2 receptor antagonists, advocating a rationale balanced and individualised approach aimed to minimise any serious adverse consequences. It focuses on current controversies on the potential of ASDs to contribute to infections-bacterial, parasitic, fungal, protozoan and viral, particularly in the elderly, comprehensively and critically discusses the growing body of observational literature linking ASD use to a variety of enteric, respiratory, skin and systemic infectious diseases and complications (Clostridium difficile diarrhoea, pneumonia, spontaneous bacterial peritonitis, septicaemia and other). The proposed pathogenic mechanisms of ASD-associated infections (related and unrelated to the inhibition of gastric acid secretion, alterations of the gut microbiome and immunity), and drug-drug interactions are also described. Both probiotics use and correcting vitamin D status may have a significant protective effect decreasing the incidence of ASD-associated infections, especially in the elderly. Despite the limitations of the existing data, the importance of individualised therapy and caution in long-term ASD use considering the balance of benefits and potential harms, factors that may predispose to and actions that may prevent/attenuate adverse effects is evident. A six-step practical algorithm for ASD therapy based on the best available evidence is presented.
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Abstract
PURPOSE OF REVIEW Gastrointestinal outbreaks in the healthcare setting cause increased morbidity and mortality in an already vulnerable population. Optimization of infection prevention measures can be a challenge in healthcare settings. This review describes new literature that may change the traditional infection prevention approach to such outbreaks. RECENT FINDINGS Asymptomatic carriers of both norovirus and Clostridium difficile can pose risk of transmission to others and the environment. Rapid recognition and diagnosis can decrease the extent of an outbreak. No-touch technologies for environmental disinfection are new and effective tools. Infection prevention consultant services and systems redesign can augment efforts to control baseline infection rates and outbreaks. Antimicrobial stewardship continues to be essential to prevent C. difficile infection. SUMMARY New approaches are needed to stem the tide of norovirus and C. difficile clusters and outbreaks in healthcare settings. Accurate recognition, testing, and implementation of infection prevention measures can be supported with rapid testing modalities, access to updated guidelines and no-touch disinfection systems. The work-environment culture should be carefully assessed and restructured using human engineering models to promote effective infection prevention practices. Antimicrobial stewardship initiatives are needed at the bedside and at national levels.
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Squellati R. Evidence-Based Practice in the Treatment for Antibiotic-Associated Diarrhea in the Intensive Care Unit. Crit Care Nurs Clin North Am 2017; 30:87-99. [PMID: 29413218 DOI: 10.1016/j.cnc.2017.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Unit nurses provide care to patients with serious health conditions. Often antibiotics are recommended to fight infections. Sometimes patients are on proton pump inhibitors (PPI). Antibiotics and PPIs may lead to diarrhea, causing the patient more discomfort, and possibly leading to a more serious infection. One serious infection is caused by Clostridium difficile, which causes death in some cases. About 75% of patients on antibiotics may not need antibiotics. Several studies showed less diarrhea in patients on probiotics. However, probiotics cause harm to some patients, which needs to be considered. Nurses need to ensure that antibiotic stewardship is followed.
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Clostridium difficile disease: Diagnosis, pathogenesis, and treatment update. Surgery 2017; 162:325-348. [DOI: 10.1016/j.surg.2017.01.018] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 01/25/2017] [Indexed: 12/16/2022]
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Shen NT, Leff JA, Schneider Y, Crawford CV, Maw A, Bosworth B, Simon MS. Cost-Effectiveness Analysis of Probiotic Use to Prevent Clostridium difficile Infection in Hospitalized Adults Receiving Antibiotics. Open Forum Infect Dis 2017; 4:ofx148. [PMID: 29230429 PMCID: PMC5692276 DOI: 10.1093/ofid/ofx148] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 07/17/2017] [Indexed: 02/07/2023] Open
Abstract
Background Systematic reviews with meta-analyses and meta-regression suggest that timely probiotic use can prevent Clostridium difficile infection (CDI) in hospitalized adults receiving antibiotics, but the cost effectiveness is unknown. We sought to evaluate the cost effectiveness of probiotic use for prevention of CDI versus no probiotic use in the United States. Methods We programmed a decision analytic model using published literature and national databases with a 1-year time horizon. The base case was modeled as a hypothetical cohort of hospitalized adults (mean age 68) receiving antibiotics with and without concurrent probiotic administration. Projected outcomes included quality-adjusted life-years (QALYs), costs (2013 US dollars), incremental cost-effectiveness ratios (ICERs; $/QALY), and cost per infection avoided. One-way, two-way, and probabilistic sensitivity analyses were conducted, and scenarios of different age cohorts were considered. The ICERs less than $100000 per QALY were considered cost effective. Results Probiotic use dominated (more effective and less costly) no probiotic use. Results were sensitive to probiotic efficacy (relative risk <0.73), the baseline risk of CDI (>1.6%), the risk of probiotic-associated bactermia/fungemia (<0.26%), probiotic cost (<$130), and age (>65). In probabilistic sensitivity analysis, at a willingness-to-pay threshold of $100000/QALY, probiotics were the optimal strategy in 69.4% of simulations. Conclusions Our findings suggest that probiotic use may be a cost-effective strategy to prevent CDI in hospitalized adults receiving antibiotics age 65 or older or when the baseline risk of CDI exceeds 1.6%.
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Affiliation(s)
- Nicole T Shen
- Division of Gastroenterology and Hepatology, Department of Medicine
| | - Jared A Leff
- Department of Healthcare Policy and Research, and
| | | | - Carl V Crawford
- Division of Gastroenterology and Hepatology, Department of Medicine
| | - Anna Maw
- Hospitalist Medicine Section, Division of General Internal Medicine, Department of Medicine, University of Colorado, Denver
| | - Brian Bosworth
- Division of Gastroenterology, Department of Medicine, New York University, New York
| | - Matthew S Simon
- Department of Healthcare Policy and Research, and.,Division of Infectious Diseases, Department of Medicine, Weill Cornell Medical College, New York, New York
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The Effect of Ultraviolet Light on Clostridium difficile Spore Recovery Versus Bleach Alone. Infect Control Hosp Epidemiol 2017; 38:1116-1117. [PMID: 28669367 DOI: 10.1017/ice.2017.126] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Nyc O, Tejkalova R, Kriz Z, Ruzicka F, Kubicek L, Matejkova J, Kuijper E, Krutova M. Two Clusters of Fluoroquinolone and Clindamycin-ResistantClostridium difficilePCR Ribotype 001 Strain Recognized by Capillary Electrophoresis Ribotyping and Multilocus Variable Tandem Repeat Analysis. Microb Drug Resist 2017; 23:609-615. [DOI: 10.1089/mdr.2016.0159] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Otakar Nyc
- Department of Medical Microbiology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Praha, Czech Republic
| | - Renata Tejkalova
- Department of Medical Microbiology, St. Anne's University Hospital, and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Zdenek Kriz
- 2nd Department of Surgery, St. Anne's University Hospital, and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Filip Ruzicka
- Department of Medical Microbiology, St. Anne's University Hospital, and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Lubos Kubicek
- 2nd Department of Surgery, St. Anne's University Hospital, and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jana Matejkova
- Department of Medical Microbiology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Praha, Czech Republic
| | - Ed Kuijper
- Leiden University Medical Centre, Leiden, the Netherlands
| | - Marcela Krutova
- Department of Medical Microbiology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Praha, Czech Republic
- DNA Laboratory, Department of Pediatric Neurology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Praha, Czech Republic
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Mallina R, Craik J, Briffa N, Ahluwalia V, Clarke J, Cobb AG. Probiotic containing Lactobacillus casei, Lactobacillus bulgaricus, and Streptococcus thermophiles (ACTIMEL) for the prevention of Clostridium difficile associated diarrhoea in the elderly with proximal femur fractures. J Infect Public Health 2017; 11:85-88. [PMID: 28652125 DOI: 10.1016/j.jiph.2017.04.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Revised: 03/12/2017] [Accepted: 04/28/2017] [Indexed: 12/30/2022] Open
Abstract
The incidence of Clostridium difficile associated diarrhoea (CDAD) is greater in elderly patients. Probiotics may have a beneficial effect in the prevention of CDAD. However, their effect in elderly orthopaedic patients has not been previously reported. Between April 2013 and April 2014, 105 patients admitted with femoral neck fractures, and who required 3days of antibiotics for infection of any cause, were prescribed the probiotic ACTIMEL until 3days after the last antibiotic dose. The incidence of CDAD was compared with historical controls (April 2011¬タモApril 2012). There was no significant reduction in the incidence of CDAD in patients receiving probiotics (OR: 0.9; 95% CI 0.27¬タモ2.91; p=0.8) and therefore we cannot recommend the use of ACTIMEL containing Lactobacillus casei, Lactobacillus bulgaricus, and Streptococcus thermophiles for this purpose in this patient group.
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Affiliation(s)
- Ravi Mallina
- Department of Trauma & Orthopaedic Surgery, Epsom & St. Helier¬タルs Hospital, Carshalton, SM5 1AA, UK.
| | - J Craik
- Department of Trauma & Orthopaedic Surgery, Epsom & St. Helier¬タルs Hospital, Carshalton, SM5 1AA, UK
| | - N Briffa
- Department of Trauma & Orthopaedic Surgery, Epsom & St. Helier¬タルs Hospital, Carshalton, SM5 1AA, UK
| | - Viren Ahluwalia
- Academic Foundation Trainee, St George¬タルs Hospital, Tooting, London SW17 0QT, UK
| | - J Clarke
- Department of Microbiology, Epsom & St. Helier¬タルs Hospital, Carshalton, SM5 1AA, UK
| | - A G Cobb
- Department of Trauma & Orthopaedic Surgery, Epsom & St. Helier¬タルs Hospital, Carshalton, SM5 1AA, UK
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Abstract
C. difficile infections (CDI) have been a challenging disease to treat, much less to prevent, for decades. Efforts for primary prevention have mainly focused on improving infection control practices, but CDI outbreaks continue to plague healthcare facilities. Areas covered: A literature search from 1970-December 2016 found 13 facility-level and 2 patient-level strategies that were evidence-based. The aim of this manuscript is to assess the current state of the literature on primary prevention of CDI and offer insights into which strategies may be more effective. Expert commentary: The strongest evidence for primary prevention is based on multi-faceted infection control bundles, while there is promising moderate evidence involving facility-wide use of specific probiotics. Moderate-level evidence was found for patient-level use of specific probiotics and low level evidence for vaccines. Future suggestions include use of consistent outcome metrics, measurements of implementation compliance and program sustainability.
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Affiliation(s)
- Lynne V McFarland
- a Medicinal Chemistry , University of Washington, Puget Sound VA HCS , Seattle , WA , USA
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Shen NT, Maw A, Tmanova LL, Pino A, Ancy K, Crawford CV, Simon MS, Evans AT. Timely Use of Probiotics in Hospitalized Adults Prevents Clostridium difficile Infection: A Systematic Review With Meta-Regression Analysis. Gastroenterology 2017; 152:1889-1900.e9. [PMID: 28192108 DOI: 10.1053/j.gastro.2017.02.003] [Citation(s) in RCA: 186] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 01/28/2017] [Accepted: 02/03/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Systematic reviews have provided evidence for the efficacy of probiotics in preventing Clostridium difficile infection (CDI), but guidelines do not recommend probiotic use for prevention of CDI. We performed an updated systematic review to help guide clinical practice. METHODS We searched MEDLINE, EMBASE, International Journal of Probiotics and Prebiotics, and The Cochrane Library databases for randomized controlled trials evaluating use of probiotics and CDI in hospitalized adults taking antibiotics. Two reviewers independently extracted data and assessed risk of bias and overall quality of the evidence. Primary and secondary outcomes were incidence of CDI and adverse events, respectively. Secondary analyses examined the effects of probiotic species, dose, timing, formulation, duration, and study quality. RESULTS We analyzed data from 19 published studies, comprising 6261 subjects. The incidence of CDI in the probiotic cohort, 1.6% (54 of 3277), was lower than of controls, 3.9% (115 of 2984) (P < .001). The pooled relative risk of CDI in probiotic users was 0.42 (95% confidence interval, 0.30-0.57; I2 = 0.0%). Meta-regression analysis demonstrated that probiotics were significantly more effective if given closer to the first antibiotic dose, with a decrement in efficacy for every day of delay in starting probiotics (P = .04); probiotics given within 2 days of antibiotic initiation produced a greater reduction of risk for CDI (relative risk, 0.32; 95% confidence interval, 0.22-0.48; I2 = 0%) than later administration (relative risk, 0.70; 95% confidence interval, 0.40-1.23; I2 = 0%) (P = .02). There was no increased risk for adverse events among patients given probiotics. The overall quality of the evidence was high. CONCLUSIONS In a systematic review with meta-regression analysis, we found evidence that administration of probiotics closer to the first dose of antibiotic reduces the risk of CDI by >50% in hospitalized adults. Future research should focus on optimal probiotic dose, species, and formulation. Systematic Review Registration: PROSPERO CRD42015016395.
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Affiliation(s)
- Nicole T Shen
- Division of Gastroenterology and Hepatology, Weill Department of Medicine, Weill Cornell Medicine, New York, New York.
| | - Anna Maw
- Hospitalist Medicine Section, Division of General Internal Medicine, Department of Medicine, University of Colorado, Denver, Colorado
| | - Lyubov L Tmanova
- Samuel J. Wood Library and CV Starr Biomedical Information Center, Weill Cornell Medical College, New York, New York
| | - Alejandro Pino
- NewYork-Presbyterian-Weill Cornell Medical Center, New York, New York
| | - Kayley Ancy
- NewYork-Presbyterian-Weill Cornell Medical Center, New York, New York
| | - Carl V Crawford
- Division of Gastroenterology and Hepatology, Weill Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Matthew S Simon
- Section of Hospital Medicine, Division of General Internal Medicine, Weill Department of Medicine, Weill Cornell Medicine, New York, New York; Division of Infectious Diseases, Weill Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Arthur T Evans
- Section of Hospital Medicine, Division of General Internal Medicine, Weill Department of Medicine, Weill Cornell Medicine, New York, New York
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Goldstein EJC, Johnson SJ, Maziade PJ, Evans CT, Sniffen JC, Millette M, McFarland LV. Probiotics and prevention of Clostridium difficile infection. Anaerobe 2016; 45:114-119. [PMID: 27988389 DOI: 10.1016/j.anaerobe.2016.12.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 12/04/2016] [Accepted: 12/07/2016] [Indexed: 12/16/2022]
Abstract
The role of probiotics as adjunctive measures in the prevention of Clostridium difficile infection (CDI) has been controversial. However, a growing body of evidence has suggested that they have a role in primary prevention of CDI. Elements of this controversy are reviewed and the proposed mechanisms of action, the value and cost effectiveness of probiotics are addressed with a focus on three agents, Saccharomyces boulardii, Lactobacillus rhamnosus GG and the combination of Lactobacillus acidophilus CL1285, Lactobacillus casei LBC80R, Lactobacillus rhamnosus CLR2 (Bio-K+).
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Affiliation(s)
- E J C Goldstein
- R M Alden Research Laboratory, Santa Monica, CA, USA; UCLA School of Medicine, Los Angeles, CA, USA.
| | | | | | - C T Evans
- Department of Preventive Medicine and Center for Healthcare Studies, Northwestern University, Chicago, IL, USA; Edward Hines Jr VA Hospital, Chicago, IL, USA
| | | | - M Millette
- Bio-K Plus International Inc., Laval, Canada
| | - L V McFarland
- Department of Medicinal Chemistry, University of Washington, Seattle, WA, USA
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Bui C, Zhu E, Donnelley MA, Wilson MD, Morita M, Cohen SH, Brown J. Antimicrobial stewardship programs that target only high-cost, broad-spectrum antimicrobials miss opportunities to reduce Clostridium difficile infections. Am J Infect Control 2016; 44:1684-1686. [PMID: 27908435 DOI: 10.1016/j.ajic.2016.06.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/03/2016] [Accepted: 06/06/2016] [Indexed: 12/21/2022]
Abstract
Antimicrobial stewardship programs are promoted as a strategy to reduce Clostridium difficile infections. We implemented an antimicrobial stewardship program comprised of formulary restriction plus prospective audit with feedback for high-cost and broad-spectrum antimicrobials. Subsequently, we reviewed all heath care facility-onset, health care facility-associated C difficile infections. We found that most of these infections were associated with the antecedent receipt of nonaudited, and often unnecessary, antimicrobials.
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Affiliation(s)
- Christine Bui
- Department of Pharmacy, University of California, Davis Medical Center, Sacramento, CA
| | - Elizabeth Zhu
- Department of Pharmacy, University of California, Davis Medical Center, Sacramento, CA
| | - Monica A Donnelley
- Department of Pharmacy, University of California, Davis Medical Center, Sacramento, CA
| | - Machelle D Wilson
- Division of Biostatistics, University of California, Davis Medical Center, Sacramento, CA
| | - Margaret Morita
- Department of Hospital Epidemiology and Infection Prevention, University of California, Davis Medical Center, Sacramento, CA
| | - Stuart H Cohen
- Department of Internal Medicine, Division of Infectious Diseases, University of California, Davis Medical Center, Sacramento, CA
| | - Jennifer Brown
- Department of Internal Medicine, Division of Infectious Diseases, University of California, Davis Medical Center, Sacramento, CA.
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38
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Elliott SL. The Microbiology Effect: A Call for Education Research. JOURNAL OF MICROBIOLOGY & BIOLOGY EDUCATION 2016; 17:325-326. [PMID: 28101255 PMCID: PMC5134932 DOI: 10.1128/jmbe.v17i3.1252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
In this letter from the Editor, Dr. Samantha Elliott calls for more research into the ways in which microbiology courses impact the behaviors of pre-nursing students.
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Balsells E, Filipescu T, Kyaw MH, Wiuff C, Campbell H, Nair H. Infection prevention and control of Clostridium difficile: a global review of guidelines, strategies, and recommendations. J Glob Health 2016; 6:020410. [PMID: 28028434 PMCID: PMC5140074 DOI: 10.7189/jogh.06.020410] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Clostridium difficile is the leading cause of health care-associated infections. Given the high incidence of C. difficile infection (CDI) and the lack of primary prevention through immunization, health care professionals should be aware of the most current guidance, as well as strengths and limitations of the evidence base underpinning this guidance. METHODS We identified publicly available national or organizational guidelines related to CDI infection and prevention control (IPC) published between 2000 and 2015 and for any health care setting through an internet search using the Google search engine. We reviewed CDI-targeted IPC recommendations and describe the assessment of evidence in available guidelines. RESULTS We identified documents from 28 countries/territories, mainly from acute care hospitals in North America, the Western Pacific, and Europe (18 countries). We identified only a few specific recommendations for long-term care facilities (LTCFs) and from countries in South America (Uruguay and Chile), South East Asia (Thailand), and none for Africa or Eastern Mediterranean. Of 10 IPC areas, antimicrobial stewardship was universally recognized as essential and supported by high quality evidence. Five other widely reported "strong" recommendations were: effective environment cleaning (including medical equipment), case isolation, use of personal protective equipment, surveillance, and education. Several unresolved and emerging issues were documented and currently available evidence was classified mainly as of mixed quality. CONCLUSION Our review underlines the need for targeted CDI IPC guidelines in several countries and for LTCFs. International harmonisation on the assessment of the evidence for best practices is needed as well as more robust evidence to support targeted recommendations.
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Affiliation(s)
- Evelyn Balsells
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland (UK)
| | - Teodora Filipescu
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland (UK)
| | | | | | - Harry Campbell
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland (UK); Joint last authorship
| | - Harish Nair
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland (UK); Public Health Foundation of India, New Delhi, India; Joint last authorship
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40
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Davies K, Davis G, Barbut F, Eckert C, Petrosillo N, Wilcox MH. Variability in testing policies and impact on reported Clostridium difficile infection rates: results from the pilot Longitudinal European Clostridium difficile Infection Diagnosis surveillance study (LuCID). Eur J Clin Microbiol Infect Dis 2016; 35:1949-1956. [PMID: 27590621 PMCID: PMC5138271 DOI: 10.1007/s10096-016-2746-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 08/02/2016] [Indexed: 01/05/2023]
Abstract
Lack of standardised Clostridium difficile testing is a potential confounder when comparing infection rates. We used an observational, systematic, prospective large-scale sampling approach to investigate variability in C. difficile sampling to understand C. difficile infection (CDI) incidence rates. In-patient and institutional data were gathered from 60 European hospitals (across three countries). Testing methodology, testing/CDI rates and case profiles were compared between countries and institution types. The mean annual CDI rate per hospital was lowest in the UK and highest in Italy (1.5 vs. 4.7 cases/10,000 patient bed days [pbds], p < 0.001). The testing rate was highest in the UK compared with Italy and France (50.7/10,000 pbds vs. 31.5 and 30.3, respectively, p < 0.001). Only 58.4 % of diarrhoeal samples were tested for CDI across all countries. Overall, only 64 % of hospitals used recommended testing algorithms for laboratory testing. Small hospitals were significantly more likely to use standalone toxin tests (SATTs). There was an inverse correlation between hospital size and CDI testing rate. Hospitals using SATT or assays not detecting toxin reported significantly higher CDI rates than those using recommended methods, despite testing similar testing frequencies. These data are consistent with higher false-positive rates in such (non-recommended) testing scenarios. Cases in Italy and those diagnosed by SATT or methods NOT detecting toxin were significantly older. Testing occurred significantly earlier in the UK. Assessment of testing practice is paramount to the accurate interpretation and comparison of CDI rates.
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Affiliation(s)
- K Davies
- Healthcare Associated Infections Research Group, University of Leeds, Leeds, UK.
- Microbiology, Old Medical School, Leeds General Infirmary, Leeds, LS1 3EX, W. Yorks, UK.
| | - G Davis
- Healthcare Associated Infections Research Group, University of Leeds, Leeds, UK
| | - F Barbut
- National Reference Laboratory for Clostridium difficile, Saint-Antoine Hospital, Paris, France
| | - C Eckert
- National Reference Laboratory for Clostridium difficile, Saint-Antoine Hospital, Paris, France
| | - N Petrosillo
- National Institute for Infectious Diseases, Rome, Italy
| | - M H Wilcox
- Healthcare Associated Infections Research Group, University of Leeds, Leeds, UK
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41
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Barnes D, Yeh AM. Bugs and Guts: Practical Applications of Probiotics for Gastrointestinal Disorders in Children. Nutr Clin Pract 2016; 30:747-59. [PMID: 26538058 DOI: 10.1177/0884533615610081] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Probiotics are foods or products that contain live microorganisms that benefit the host when administered. In this clinical review, we evaluate the literature associated with using probiotics in common pediatric gastrointestinal disorders, focusing specifically on antibiotic-associated diarrhea, acute gastroenteritis, Clostridium difficile infection (CDI), colic, inflammatory bowel disease, and functional gastrointestinal diseases. Meta-analysis of several randomized controlled trials have confirmed benefit for the administration of Lactobacillus rhamnosus GG and Saccharomyces boulardii to prevent antibiotic-associated diarrhea and to treat acute infectious diarrhea. Individual studies have also suggested benefit of probiotics to prevent acute gastroenteritis and serve as an adjunct in ulcerative colitis, pouchitis, antibiotic-associated diarrhea, CDI, functional abdominal pain, irritable bowel syndrome, and colic in breastfed babies. Although promising, larger well-designed studies need to confirm these findings. There is currently insufficient evidence to recommend probiotics for the treatment of constipation-predominant irritable bowel syndrome or Crohn's disease.
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Affiliation(s)
- Danielle Barnes
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford Children's Health, Stanford University, Palo Alto, California
| | - Ann Ming Yeh
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford Children's Health, Stanford University, Palo Alto, California
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A Regional Outbreak of Clostridium difficile PCR-Ribotype 027 Infections in Southeastern France from a Single Long-Term Care Facility. Infect Control Hosp Epidemiol 2016; 37:1337-1341. [PMID: 27484769 DOI: 10.1017/ice.2016.164] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To describe and analyze a large outbreak of Clostridium difficile 027 (CD-027) infections. METHODS Confirmed CD-027 cases were defined as CD infection plus real-time polymerase chain reaction assay (PCR) positive for CD-027. Clinical and microbiological data on patients with CD-027 infection were collected from January 2013 to December 2015 in the Provence-Alpes-Côte-d'Azur region (southeastern France). RESULTS In total, 19 healthcare facilities reported 144 CD-027 infections (112 confirmed and 32 probable CD-027 infections) during a 22-month period outbreak. Although the incidence rate per 10,000 bed days was lower in long-term care facilities (LTCFs) than in acute care facilities (0.05 vs 0.14; P<.001), cases occurred mainly in LTCFs, one of which was the probable source of this outbreak. After centralization of CD testing, the rate of confirmed CD-027 cases from LTCFs or residential-care homes increased significantly (69% vs 92%; P<.001). Regarding confirmed CD-027 patients, the sex ratio and the median age were 0.53 and 84.2 years, respectively. The 30-day crude mortality rate was 31%. Most patients (96%) had received antibiotics within 3 months prior to the CD colitis diagnosis. During the study period, the rate of patients with CD-027 (compared with all patients tested in the point-of-care laboratories) decreased significantly (P=.03). CONCLUSIONS A large CD-027 outbreak occurred in southeastern France as a consequence of an initial cluster of cases in a single LTCF. Successful interventions included rapid isolation and testing of residents with potentially infectious diarrhea and cohorting of case patients in a specialized infectious diseases ward to optimize management. Infect Control Hosp Epidemiol 2016;1-5.
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43
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Spinler JK, Brown A, Ross CL, Boonma P, Conner ME, Savidge TC. Administration of probiotic kefir to mice with Clostridium difficile infection exacerbates disease. Anaerobe 2016; 40:54-7. [PMID: 27180007 PMCID: PMC4969211 DOI: 10.1016/j.anaerobe.2016.05.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 04/27/2016] [Accepted: 05/02/2016] [Indexed: 01/05/2023]
Abstract
Lifeway(®) kefir, a fermented milk product containing 12 probiotic organisms, is reported to show promise as an alternative to fecal microbiota transplantation for recurrent Clostridium difficile infection (CDI). We employed a murine CDI model to study the probiotic protective mechanisms and unexpectedly determined that kefir drastically increased disease severity. Our results emphasize the need for further independent clinical testing of kefir as alternative therapy in recurrent CDI.
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Affiliation(s)
- Jennifer K Spinler
- Texas Children's Microbiome Center, Department of Pathology, Texas Children's Hospital, 1102 Bates Ave., Houston, TX, USA; Department of Pathology & Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA.
| | - Aaron Brown
- Texas Children's Microbiome Center, Department of Pathology, Texas Children's Hospital, 1102 Bates Ave., Houston, TX, USA; Department of Pathology & Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA
| | - Caná L Ross
- Texas Children's Microbiome Center, Department of Pathology, Texas Children's Hospital, 1102 Bates Ave., Houston, TX, USA; Department of Pathology & Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA
| | - Prapaporn Boonma
- Texas Children's Microbiome Center, Department of Pathology, Texas Children's Hospital, 1102 Bates Ave., Houston, TX, USA; Department of Pathology & Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA
| | - Margaret E Conner
- Department of Molecular Virology & Microbiology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Tor C Savidge
- Texas Children's Microbiome Center, Department of Pathology, Texas Children's Hospital, 1102 Bates Ave., Houston, TX, USA; Department of Pathology & Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA
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High morbidity and mortality of Clostridium difficile infection and its associations with ribotype 002 in Hong Kong. J Infect 2016; 73:115-22. [PMID: 27246801 DOI: 10.1016/j.jinf.2016.05.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 04/15/2016] [Accepted: 05/23/2016] [Indexed: 02/06/2023]
Abstract
OBJECTIVES We aim to study the disease burden, risk factors and severity of Clostridium difficile infection (CDI) in Hong Kong. METHODS We conducted a prospective, case-control study in three acute-care hospitals in Hong Kong. Adult inpatients who developed CDI diarrhoea confirmed by PCR (n = 139) were compared with the non-CDI controls (n = 114). Ribotyping of isolates and antimicrobial susceptibility testing were performed. RESULTS The estimated crude annual incidence of CDI was 23-33/100,000 population, and 133-207/100,000 population among those aged ≥65 years. The mean age of CDI patients was 71.5. Nursing home care, recent hospitalization, antibiotics exposure (adjusted OR 3.0, 95% CI 1.3-7.1) and proton-pump inhibitors use (adjusted OR 2.2, 95% CI 1.2-3.9) were risk factors. Severe CDI occurred in 41.7%. Overall mortality was 16.5% (among severe CDI, 26.5%). The commonest ribotypes were 002 (22.8%), 014 (14.1%), 012 and 046; ribotype 027 was absent. Ribotype 002 was associated with fluoroquinolone resistance and higher mortality (47.6% vs. 12.7%; adjusted HR 2.8, 95% CI 1.1-7.0). CONCLUSIONS Our findings show high morbidity and mortality of CDI in the older adults, and identify ribotype 002 as a possible virulent strain causing serious infections in this cohort.
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Spinler JK, Ross CL, Savidge TC. Probiotics as adjunctive therapy for preventing Clostridium difficile infection - What are we waiting for? Anaerobe 2016; 41:51-57. [PMID: 27180657 DOI: 10.1016/j.anaerobe.2016.05.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 05/06/2016] [Accepted: 05/10/2016] [Indexed: 12/14/2022]
Abstract
With the end of the golden era of antibiotic discovery, the emergence of a new post-antibiotic age threatens to thrust global health and modern medicine back to the pre-antibiotic era. Antibiotic overuse has resulted in the natural evolution and selection of multi-drug resistant bacteria. One major public health threat, Clostridium difficile, is now the single leading cause of hospital-acquired bacterial infections and is by far the most deadly enteric pathogen for the U.S. POPULATION Due to the high morbidity and mortality and increasing incidence that coincides with antibiotic use, non-traditional therapeutics are ideal alternatives to current treatment methods and also provide an avenue towards prevention. Despite the need for alternative therapies to antibiotics and the safety of most probiotics on the market, researchers are inundated with regulatory issues that hinder the translational science required to push these therapies forward. This review discusses the regulatory challenges of probiotic research, expert opinion regarding the application of probiotics to C. difficile infection and the efficacy of probiotics in preventing this disease.
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Affiliation(s)
- Jennifer K Spinler
- Texas Children's Microbiome Center, Department of Pathology, Texas Children's Hospital, 1102 Bates Ave., Houston, TX, USA; Department of Pathology & Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA.
| | - Caná L Ross
- Texas Children's Microbiome Center, Department of Pathology, Texas Children's Hospital, 1102 Bates Ave., Houston, TX, USA; Department of Pathology & Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA
| | - Tor C Savidge
- Texas Children's Microbiome Center, Department of Pathology, Texas Children's Hospital, 1102 Bates Ave., Houston, TX, USA; Department of Pathology & Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA
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Abstract
Clostridium difficile (C. difficile) infection (CDI) is the most common cause of healthcare-associated infections in US hospitals. The epidemic strain NAP1/BI/ribotype 027 accounts for outbreaks worldwide, with increasing mortality and severity. CDI is acquired from an endogenous source or from spores in the environment, most easily acquired during the hospital stay. The use of antimicrobials disrupts the intestinal microflora enabling C. difficile to proliferate in the colon and produce toxins. Clinical diagnosis in symptomatic patients requires toxin detection from stool specimens and rarely in combination with stool culture to increase sensitivity. However, stool culture is essential for epidemiological studies. Oral metronidazole is the recommended therapy for milder cases of CDI and oral vancomycin or fidaxomicin for more severe cases. Treatment of first recurrence involves the use of the same therapy used in the initial CDI. In the event of a second recurrence oral vancomycin often given in a tapered dose or intermittently, or fidaxomicin may be used. Fecal transplantation is playing an immense role in therapy of recurrent CDI with remarkable results. Fulminant colitis and toxic megacolon warrant surgical intervention. Novel approaches including new antibiotics and immunotherapy against CDI or its toxins appear to be of potential value.
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Affiliation(s)
- Andrew Ofosu
- Department of Medicine, Jefferson Medical College, Philadelphia, USA
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McFarland LV, Ozen M, Dinleyici EC, Goh S. Comparison of pediatric and adult antibiotic-associated diarrhea and Clostridium difficile infections. World J Gastroenterol 2016; 22:3078-3104. [PMID: 27003987 PMCID: PMC4789985 DOI: 10.3748/wjg.v22.i11.3078] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 01/12/2016] [Accepted: 02/22/2016] [Indexed: 02/06/2023] Open
Abstract
Antibiotic-associated diarrhea (AAD) and Clostridum difficile infections (CDI) have been well studied for adult cases, but not as well in the pediatric population. Whether the disease process or response to treatments differs between pediatric and adult patients is an important clinical concern when following global guidelines based largely on adult patients. A systematic review of the literature using databases PubMed (June 3, 1978-2015) was conducted to compare AAD and CDI in pediatric and adult populations and determine significant differences and similarities that might impact clinical decisions. In general, pediatric AAD and CDI have a more rapid onset of symptoms, a shorter duration of disease and fewer CDI complications (required surgeries and extended hospitalizations) than in adults. Children experience more community-associated CDI and are associated with smaller outbreaks than adult cases of CDI. The ribotype NAP1/027/BI is more common in adults than children. Children and adults share some similar risk factors, but adults have more complex risk factor profiles associated with more co-morbidities, types of disruptive factors and a wider range of exposures to C. difficile in the healthcare environment. The treatment of pediatric and adult AAD is similar (discontinuing or switching the inciting antibiotic), but other treatment strategies for AAD have not been established. Pediatric CDI responds better to metronidazole, while adult CDI responds better to vancomycin. Recurrent CDI is not commonly reported for children. Prevention for both pediatric and adult AAD and CDI relies upon integrated infection control programs, antibiotic stewardship and may include the use of adjunctive probiotics. Clinical presentation of pediatric AAD and CDI are different than adult AAD and CDI symptoms. These differences should be taken into account when rating severity of disease and prescribing antibiotics.
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Abstract
INTRODUCTION Clostridium difficile infections are a leading cause of healthcare facility outbreaks of gastrointestinal illness that may have serious complications and a high rate of recurrent disease. Despite the availability of standard antibiotic treatments, data from national surveillance programs indicate that the incidence of this disease continues to increase, placing a heavy burden on healthcare systems. New emerging strategies are being tested to replace or augment these standard antibiotics. AREAS COVERED Thirty-two current investigational agents focusing on different strategies for both prevention and treatment of C. difficile infections are reviewed. Data was gathered from a literature search of public databases for published trials from 1999-November 13, 2015 and from the author's compendium of knowledge. Agents reviewed included 13 antibiotics, two antibiotic inactivators, seven bacteria or yeasts acting to enhance the normal microbiome, seven immunizing agents and three toxin binders. Of the 32 investigational treatments reviewed, 8 (25%) showed significant efficacy in phase II or III clinical trials and are actively being developed as new therapies for C. difficile infections. EXPERT OPINION A number of potential treatments have floundered during their development process, while others have shown promising results. The strongest efficacy has been in the areas of newer antibiotics, probiotics, monoclonal antibodies and vaccines. By targeting the pathogenic pathway of C. difficile infections, multiple strategies for prevention and treatment have been developed.
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Affiliation(s)
- Lynne V McFarland
- a Dept of Medicinal Chemistry , University of Washington , Seattle , WA , USA
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Jarrad AM, Blaskovich MAT, Lyras D, Cooper MA. Clostridium difficile Infection: Current and Emerging Therapeutics. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2015. [DOI: 10.1007/s40506-015-0062-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Wenzler E, Mulugeta SG, Danziger LH. The Antimicrobial Stewardship Approach to Combating Clostridium Difficile. Antibiotics (Basel) 2015; 4:198-215. [PMID: 27025621 PMCID: PMC4790327 DOI: 10.3390/antibiotics4020198] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 06/10/2015] [Accepted: 06/15/2015] [Indexed: 12/14/2022] Open
Abstract
Clostridium difficile remains a major public health threat and continues to contribute to excess morbidity, mortality and healthcare costs. Antimicrobial stewardship programs have demonstrated success in combating C. difficile, primarily through antibiotic restrictive strategies. As the incidence and prevalence of C. difficile associate disease continues to increase both in the hospital and community setting, additional stewardship approaches are needed. This manuscript reviews stewardship interventions that have been successful against C. difficile associated disease and proposes future tactics that antimicrobial stewardship programs may employ to develop a more global approach to combat this difficult pathogen.
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Affiliation(s)
- Eric Wenzler
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL 60612, USA.
| | - Surafel G Mulugeta
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL 60612, USA.
| | - Larry H Danziger
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL 60612, USA.
- College of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA.
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