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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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Di Bella S, Sanson G, Monticelli J, Zerbato V, Principe L, Giuffrè M, Pipitone G, Luzzati R. Clostridioides difficile infection: history, epidemiology, risk factors, prevention, clinical manifestations, treatment, and future options. Clin Microbiol Rev 2024; 37:e0013523. [PMID: 38421181 DOI: 10.1128/cmr.00135-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
SUMMARYClostridioides difficile infection (CDI) is one of the major issues in nosocomial infections. This bacterium is constantly evolving and poses complex challenges for clinicians, often encountered in real-life scenarios. In the face of CDI, we are increasingly equipped with new therapeutic strategies, such as monoclonal antibodies and live biotherapeutic products, which need to be thoroughly understood to fully harness their benefits. Moreover, interesting options are currently under study for the future, including bacteriophages, vaccines, and antibiotic inhibitors. Surveillance and prevention strategies continue to play a pivotal role in limiting the spread of the infection. In this review, we aim to provide the reader with a comprehensive overview of epidemiological aspects, predisposing factors, clinical manifestations, diagnostic tools, and current and future prophylactic and therapeutic options for C. difficile infection.
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Affiliation(s)
- Stefano Di Bella
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Trieste, Italy
| | - Gianfranco Sanson
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Trieste, Italy
| | - Jacopo Monticelli
- Infectious Diseases Unit, Trieste University Hospital (ASUGI), Trieste, Italy
| | - Verena Zerbato
- Infectious Diseases Unit, Trieste University Hospital (ASUGI), Trieste, Italy
| | - Luigi Principe
- Microbiology and Virology Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Mauro Giuffrè
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Trieste, Italy
- Department of Internal Medicine (Digestive Diseases), Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Giuseppe Pipitone
- Infectious Diseases Unit, ARNAS Civico-Di Cristina Hospital, Palermo, Italy
| | - Roberto Luzzati
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Trieste, Italy
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Clarke LM, Allegretti JR. Review article: The epidemiology and management of Clostridioides difficile infection-A clinical update. Aliment Pharmacol Ther 2024; 59:1335-1349. [PMID: 38534216 DOI: 10.1111/apt.17975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 01/01/2024] [Accepted: 03/16/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Clostridioides difficile is the most common cause of healthcare-associated infection, and severe cases can result in significant complications. While anti-microbial therapy is central to infection management, adjunctive therapies may be utilised as preventative strategies. AIM This article aims to review updates in the epidemiology, diagnosis, and management, including treatment and prevention, of C. difficile infections. METHODS A narrative review was performed to evaluate the current literature between 1986 and 2023. RESULTS The incidence of C. difficile infection remains significantly high in both hospital and community settings, though with an overall decline in recent years and similar surveillance estimates globally. Vancomycin and fidaxomicin remain the first line antibiotics for treatment of non-severe C. difficile infection, though due to lower recurrence rates, infectious disease society guidelines now favour use of fidaxomicin. Faecal microbiota transplantation should still be considered to prevent recurrent C. difficile infection. However, in the past year the field has had a significant advancement with the approval of the first two live biotherapeutic products-faecal microbiota spores-live brpk, an oral capsule preparation, and faecal microbiota live-jslm-both indicated for the prevention of recurrent C. difficile infection, with additional therapies on the horizon. CONCLUSION Although the prevalence of C. difficile infection remains high, there have been significant advances in the development of novel therapeutics and preventative measures following changes in recent practice guidelines, and will continue to evolve in the future.
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Affiliation(s)
- Lindsay M Clarke
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jessica R Allegretti
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Wood L, Hughes J, Trussell M, Bishop AL, Griffin R. Fasting before Intra-Gastric Dosing with Antigen Improves Intestinal Humoral Responses in Syrian Hamsters. Vaccines (Basel) 2024; 12:572. [PMID: 38932302 DOI: 10.3390/vaccines12060572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 05/15/2024] [Accepted: 05/21/2024] [Indexed: 06/28/2024] Open
Abstract
Oral vaccines, unlike injected, induce intestinal secretory immunoglobulin A (sIgA) mimicking our natural defense against gut pathogens. We previously observed sIgA responses after administering the Clostridioides difficile colonisation factor CD0873 orally in enteric capsules to hamsters. Enteric-coated capsules are designed to resist dissolution in the stomach and disintegrate only at the higher pH of the small intestine. However, the variable responses between animals led us to speculate suboptimal transit of antigens to the small intestine. The rate of gastric emptying is a controlling factor in the passage of oral drugs for subsequent availability in the small intestine for absorption. Whilst in humans, food delays gastric emptying, in rats, capsules can empty quicker from fed stomachs than from fasted. To test in hamsters if fasting improves the delivery of antigens to the small intestine, as inferred from the immune responses generated, 24 animals were dosed intragastrically with enteric capsules containing recombinant CD0873. Twelve hamsters were fasted for 12 h prior to each dose and the other 12 fed. Significantly higher sIgA titres, with significantly greater bacterial-adherence-blocking activity, were detected in small intestinal lavages in the fasted group. We conclude that fasting in hamsters improves intestinal delivery leading to more robust responses.
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Affiliation(s)
- Liam Wood
- Vaccines and Therapeutics Group, School of Life Sciences, The University of Nottingham Biodiscovery Institute, University Park, Nottingham NG7 2RD, UK
- Clostridia Research Group, Synthetic Biology Research Centre (SBRC), The University of Nottingham Biodiscovery Institute, University Park, Nottingham NG7 2RD, UK
| | - Jaime Hughes
- School of Life Sciences, The University of Nottingham Biodiscovery Institute, University Park, Nottingham NG7 2RD, UK
| | - Mark Trussell
- Bio Support Unit, The University of Nottingham Medical School, Nottingham NG7 2UH, UK
| | - Anne L Bishop
- Parasites and Microbes Programme, Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridge CB10 1SA, UK
| | - Ruth Griffin
- Vaccines and Therapeutics Group, School of Life Sciences, The University of Nottingham Biodiscovery Institute, University Park, Nottingham NG7 2RD, UK
- Clostridia Research Group, Synthetic Biology Research Centre (SBRC), The University of Nottingham Biodiscovery Institute, University Park, Nottingham NG7 2RD, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, The University of Nottingham, Nottingham NG7 2UH, UK
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Singh KB, Khouri A, Singh D, Prieto J, Dutta P, Nnadozie MC, Clanton C, Morrison E, Sonnier W. Testing and Diagnosis of Clostridioides difficile Infection in Special Scenarios: A Systematic Review. Cureus 2024; 16:e59016. [PMID: 38800338 PMCID: PMC11127751 DOI: 10.7759/cureus.59016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2024] [Indexed: 05/29/2024] Open
Abstract
INTRODUCTION Clostridioides difficile infection (CDI) is a clinical and laboratory diagnosis. Populations at higher risk of developing disease require a high clinical index of suspicion for laboratory testing to avoid incorrect assumptions of colonization. Common risk factors include recent antibiotic use, elderly (>65 years old), and immunocompromised patients. C. difficile assays should be ordered in an algorithm approach to diagnose an infection rather than colonization. Screening tests are widely available in hospital systems, but novel molecular testing may aid in diagnosis in patients with inconclusive or discordant antigen and toxin test results. Methods: Data was extracted from PubMed, Scopus, and Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases based on the keywords "clostridioides difficile", "toxin assay", and "toxic megacolon". The data extracted is based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. A total of 27 reports were included in this systematic review. RESULTS Testing patients with a significant gastrointestinal surgical history, hypogammaglobulinemia, inflammatory bowel disease, intensive care unit, and immunocompromised patients for CDI is highly recommended. Diarrhea in these subsets of patients requires correlation of clinical context and an understanding of assay results to avoid over- and under-treating. CONCLUSION CDI should be considered in all patients with traditional risk factors. Heightened clinical suspicion of CDI is required in patients with hypogammaglobulinemia, transplant recipients, patients with gastrointestinal surgical history, and inflammatory bowel disease. Testing should be limited to patients with clinical manifestations of CDI to ensure a high pretest probability for test interpretation. Healthcare workers should adhere to testing algorithms to optimize yield in the appropriate clinical context. Diagnostic assays should follow a sequential, stepwise approach to categorize the toxin expression status of the bacteria accurately.
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Affiliation(s)
- Karan B Singh
- Internal Medicine, Frederick P. Whiddon College of Medicine at the University of South Alabama, Mobile, USA
| | - Anas Khouri
- Internal Medicine, Frederick P. Whiddon College of Medicine at the University of South Alabama, Mobile, USA
| | - Deepak Singh
- Internal Medicine, Caribbean Medical University, Willemstad, CUW
| | - Jose Prieto
- Internal Medicine, Loyola University MacNeal Hospital, Berwyn, USA
| | - Priyata Dutta
- Internal Medicine, Trinity Health St. Joseph Mercy Ann Arbor, Ann Arbor, USA
| | - Maduka C Nnadozie
- Internal Medicine, AtlantiCare Regional Medical Center, Atlantic City, USA
| | - Clista Clanton
- Biomedical Research, Frederick P. Whiddon College of Medicine at the University of South Alabama, Mobile, USA
| | - Esther Morrison
- Infectious Diseases, Frederick P. Whiddon College of Medicine at the University of South Alabama, Mobile, USA
| | - William Sonnier
- Gastroenterology and Hepatology, Frederick P. Whiddon College of Medicine at the University of South Alabama, Mobile, USA
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Aguilar AG, Canals PC, Tian M, Miller KA, Piper BJ. Decreases and Pronounced Geographic Variability in Antibiotic Prescribing in Medicaid. PHARMACY 2024; 12:46. [PMID: 38525726 PMCID: PMC10961814 DOI: 10.3390/pharmacy12020046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/15/2024] [Accepted: 02/18/2024] [Indexed: 03/26/2024] Open
Abstract
Antibiotic resistance is a persistent and growing concern. Our objective was to analyze antibiotic prescribing in the United States (US) in the Medical Expenditure Panel System (MEPS) and to Medicaid patients. We obtained MEPS prescriptions for eight antibiotics from 2013 to 2020. We extracted prescribing rates per 1000 Medicaid enrollees for two years, 2018 and 2019, for four broad-spectrum (azithromycin, ciprofloxacin, levofloxacin, and moxifloxacin) and four narrow-spectrum (amoxicillin, cephalexin, doxycycline, and trimethoprim-sulfamethoxazole) antibiotics. Antibiotic prescriptions in MEPS decreased from 2013 to 2020 by 38.7%, with a larger decline for the broad (-53.7%) than narrow (-23.5%) spectrum antibiotics. Antibiotic prescriptions in Medicaid decreased by 6.7%. Amoxicillin was the predominant antibiotic, followed by azithromycin, cephalexin, trimethoprim-sulfamethoxazole, doxycycline, ciprofloxacin, levofloxacin, and moxifloxacin. Substantial geographic variation in prescribing existed, with a 2.8-fold difference between the highest (Kentucky = 855/1000) and lowest (Oregon = 299) states. The South prescribed 52.2% more antibiotics (580/1000) than the West (381/1000). There were significant correlations across states (r = 0.81 for azithromycin and amoxicillin). This study identified sizable disparities by geography in the prescribing rates of eight antibiotics with over three-fold state-level differences. Areas with high prescribing rates, particularly for outpatients, may benefit from stewardship programs to reduce potentially unnecessary prescribing.
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Affiliation(s)
- Alexia G. Aguilar
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA 17822, USA; (A.G.A.); (P.C.C.); (M.T.); (K.A.M.)
| | - Priscilla C. Canals
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA 17822, USA; (A.G.A.); (P.C.C.); (M.T.); (K.A.M.)
| | - Maria Tian
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA 17822, USA; (A.G.A.); (P.C.C.); (M.T.); (K.A.M.)
| | - Kimberly A. Miller
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA 17822, USA; (A.G.A.); (P.C.C.); (M.T.); (K.A.M.)
| | - Brian J. Piper
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA 17822, USA; (A.G.A.); (P.C.C.); (M.T.); (K.A.M.)
- Center for Pharmacy Innovation and Outcomes, Danville, PA 17822, USA
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Bai AD, Srivastava S, Digby GC, Girard V, Razak F, Verma AA. Anaerobic Antibiotic Coverage in Aspiration Pneumonia and the Associated Benefits and Harms: A Retrospective Cohort Study. Chest 2024:S0012-3692(24)00260-5. [PMID: 38387648 DOI: 10.1016/j.chest.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/08/2024] [Accepted: 02/19/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Antibiotics with extended anaerobic coverage are used commonly to treat aspiration pneumonia, which is not recommended by current guidelines. RESEARCH QUESTION In patients admitted to hospital for community-acquired aspiration pneumonia, does a difference exist between antibiotic therapy with limited anaerobic coverage (LAC) vs antibiotic therapy with extended anaerobic coverage (EAC) in terms of in-hospital mortality and risk of Clostridioides difficile colitis? STUDY DESIGN AND METHODS We conducted a multicenter retrospective cohort study across 18 hospitals in Ontario, Canada, from January 1, 2015, to January 1, 2022. Patients were included if the physician diagnosed aspiration pneumonia and prescribed guideline-concordant first-line community-acquired pneumonia parenteral antibiotic therapy to the patient within 48 h of admission. Patients then were categorized into the LAC group if they received ceftriaxone, cefotaxime, or levofloxacin. Patients were categorized into the EAC group if they received amoxicillin-clavulanate, moxifloxacin, or any of ceftriaxone, cefotaxime, or levofloxacin in combination with clindamycin or metronidazole. The primary outcome was all-cause in-hospital mortality. Secondary outcomes included incident C difficile colitis occurring after admission. Overlap weighting of propensity scores was used to balance baseline prognostic factors. RESULTS The LAC and EAC groups included 2,683 and 1,316 patients, respectively. In hospital, 814 patients (30.3%) and 422 patients (32.1%) in the LAC and EAC groups died, respectively. C difficile colitis occurred in five or fewer patients (≤ 0.2%) and 11 to 15 patients (0.8%-1.1%) in the LAC and EAC groups, respectively. After overlap weighting of propensity scores, the adjusted risk difference of EAC minus LAC was 1.6% (95% CI, -1.7% to 4.9%) for in-hospital mortality and 1.0% (95% CI, 0.3%-1.7%) for C difficile colitis. INTERPRETATION Extended anaerobic coverage likely is unnecessary in aspiration pneumonia because it is associated with no additional mortality benefit, only an increased risk of C difficile colitis.
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Affiliation(s)
- Anthony D Bai
- Division of Infectious Diseases, Department of Medicine, Queen's University, Kingston, ON, Canada.
| | - Siddhartha Srivastava
- Division of General Internal Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Geneviève C Digby
- Division of Respirology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Vincent Girard
- Internal Medicine Residency Program, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Fahad Razak
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Amol A Verma
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
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Vintila BI, Arseniu AM, Morgovan C, Butuca A, Bîrluțiu V, Dobrea CM, Rus LL, Ghibu S, Bereanu AS, Arseniu R, Roxana Codru I, Sava M, Gabriela Gligor F. A Real-World Study on the Clinical Characteristics, Outcomes, and Relationship between Antibiotic Exposure and Clostridioides difficile Infection. Antibiotics (Basel) 2024; 13:144. [PMID: 38391530 PMCID: PMC10885986 DOI: 10.3390/antibiotics13020144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/24/2024] [Accepted: 01/30/2024] [Indexed: 02/24/2024] Open
Abstract
Clostridioides difficile is a Gram-positive bacteria that causes nosocomial infections, significantly impacting public health. In the present study, we aimed to describe the clinical characteristics, outcomes, and relationship between antibiotic exposure and Clostridioides difficile infection (CDI) in patients based on reports from two databases. Thus, we conducted a retrospective study of patients diagnosed with CDI from Sibiu County Clinical Emergency Hospital (SCCEH), Romania, followed by a descriptive analysis based on spontaneous reports submitted to the EudraVigilance (EV) database. From 1 January to 31 December 2022, we included 111 hospitalized patients with CDI from SCCEH. Moreover, 249 individual case safety reports (ICSRs) from EVs were analyzed. According to the data collected from SCCEH, CDI was most frequently reported in patients aged 65-85 years (66.7%) and in females (55%). In total, 71.2% of all patients showed positive medical progress. Most cases were reported in the internal medicine (n = 30, 27%), general surgery (n = 26, 23.4%), and infectious disease (n = 22, 19.8%) departments. Patients were most frequently exposed to ceftriaxone (CFT) and meropenem (MER). Also, in the EV database, most CDI-related ADRs were reported for CFT, PIP/TAZ (piperacillin/tazobactam), MER, and CPX (ciprofloxacin). Understanding the association between previous antibiotic exposure and the risk of CDI may help update antibiotic stewardship protocols and reduce the incidence of CDI by lowering exposure to high-risk antibiotics.
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Affiliation(s)
- Bogdan Ioan Vintila
- Clinical Surgical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
- County Clinical Emergency Hospital, 550245 Sibiu, Romania
| | - Anca Maria Arseniu
- Preclinical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
| | - Claudiu Morgovan
- Preclinical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
| | - Anca Butuca
- Preclinical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
| | - Victoria Bîrluțiu
- County Clinical Emergency Hospital, 550245 Sibiu, Romania
- Clinical Medical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
| | - Carmen Maximiliana Dobrea
- Preclinical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
| | - Luca Liviu Rus
- Preclinical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
| | - Steliana Ghibu
- Department of Pharmacology, Physiology and Pathophysiology, Faculty of Pharmacy, "Iuliu Hatieganu" University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Alina Simona Bereanu
- Clinical Surgical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
- County Clinical Emergency Hospital, 550245 Sibiu, Romania
| | - Rares Arseniu
- County Emergency Clinical Hospital "Pius Brînzeu", 300723 Timișoara, Romania
| | - Ioana Roxana Codru
- Clinical Surgical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
- County Clinical Emergency Hospital, 550245 Sibiu, Romania
| | - Mihai Sava
- Clinical Surgical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
- County Clinical Emergency Hospital, 550245 Sibiu, Romania
| | - Felicia Gabriela Gligor
- Preclinical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
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Eeuwijk J, Ferreira G, Yarzabal JP, Robert-Du Ry van Beest Holle M. A Systematic Literature Review on Risk Factors for and Timing of Clostridioides difficile Infection in the United States. Infect Dis Ther 2024; 13:273-298. [PMID: 38349594 PMCID: PMC10904710 DOI: 10.1007/s40121-024-00919-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/10/2024] [Indexed: 02/25/2024] Open
Abstract
INTRODUCTION Clostridioides difficile infection (CDI) is a major public health threat. Up to 40% of patients with CDI experience recurrent CDI (rCDI), which is associated with increased morbidity. This study aimed to define an at-risk population by obtaining a detailed understanding of the different factors leading to CDI, rCDI, and CDI-related morbidity and of time to CDI. METHODS We conducted a systematic literature review (SLR) of MEDLINE (using PubMed) and EMBASE for relevant articles published between January 1, 2016, and November 11, 2022, covering the US population. RESULTS Of the 1324 articles identified, 151 met prespecified inclusion criteria. Advanced patient age was a likely risk factor for primary CDI within a general population, with significant risk estimates identified in nine of 10 studies. Older age was less important in specific populations with comorbidities usually diagnosed at earlier age, such as bowel disease and cancer. In terms of comorbidities, the established factors of infection, kidney disease, liver disease, cardiovascular disease, and bowel disease along with several new factors (including anemia, fluid and electrolyte disorders, and coagulation disorders) were likely risk factors for primary CDI. Data on diabetes, cancer, and obesity were mixed. Other primary CDI risk factors were antibiotics, proton pump inhibitors, female sex, prior hospitalization, and the length of stay in hospital. Similar factors were identified for rCDI, but evidence was limited. Older age was a likely risk factor for mortality. Timing of primary CDI varied depending on the population: 2-3 weeks in patients receiving stem cell transplants, within 3 weeks for patients undergoing surgery, and generally more than 3 weeks following solid organ transplant. CONCLUSION This SLR uses recent evidence to define the most important factors associated with CDI, confirming those that are well established and highlighting new ones that could help to identify patient populations at high risk.
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Affiliation(s)
- Jennifer Eeuwijk
- Pallas Health Research and Consultancy, a P95 Company, Rotterdam, Netherlands
| | | | - Juan Pablo Yarzabal
- GSK, Wavre, Belgium.
- GSK, B43, Rue de l'Institut, 89, 1330, Rixensart, Belgium.
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Aiman S, Farooq QUA, Han Z, Aslam M, Zhang J, Khan A, Ahmad A, Li C, Ali Y. Core-genome-mediated promising alternative drug and multi-epitope vaccine targets prioritization against infectious Clostridium difficile. PLoS One 2024; 19:e0293731. [PMID: 38241420 PMCID: PMC10798517 DOI: 10.1371/journal.pone.0293731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/18/2023] [Indexed: 01/21/2024] Open
Abstract
Prevention of Clostridium difficile infection is challenging worldwide owing to its high morbidity and mortality rates. C. difficile is currently being classified as an urgent threat by the CDC. Devising a new therapeutic strategy become indispensable against C. difficile infection due to its high rates of reinfection and increasing antimicrobial resistance. The current study is based on core proteome data of C. difficile to identify promising vaccine and drug candidates. Immunoinformatics and vaccinomics approaches were employed to construct multi-epitope-based chimeric vaccine constructs from top-ranked T- and B-cell epitopes. The efficacy of the designed vaccine was assessed by immunological analysis, immune receptor binding potential and immune simulation analyses. Additionally, subtractive proteomics and druggability analyses prioritized several promising and alternative drug targets against C. difficile. These include FMN-dependent nitroreductase which was prioritized for pharmacophore-based virtual screening of druggable molecule databases to predict potent inhibitors. A MolPort-001-785-965 druggable molecule was found to exhibit significant binding affinity with the conserved residues of FMN-dependent nitroreductase. The experimental validation of the therapeutic targets prioritized in the current study may worthy to identify new strategies to combat the drug-resistant C. difficile infection.
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Affiliation(s)
- Sara Aiman
- Faculty of Environmental and Life Sciences, Beijing University of Technology, Beijing, China
| | - Qurrat ul Ain Farooq
- Faculty of Environmental and Life Sciences, Beijing University of Technology, Beijing, China
| | - Zhongjie Han
- Faculty of Environmental and Life Sciences, Beijing University of Technology, Beijing, China
| | - Muneeba Aslam
- Department of Biochemistry, Abdul Wali Khan University Mardan, Mardan, Pakistan
| | - Jilong Zhang
- Faculty of Environmental and Life Sciences, Beijing University of Technology, Beijing, China
| | - Asifullah Khan
- Department of Biochemistry, Abdul Wali Khan University Mardan, Mardan, Pakistan
| | - Abbas Ahmad
- Department of Biotechnology, Abdul Wali Khan University Mardan, Mardan, KP, Pakistan
| | - Chunhua Li
- Faculty of Environmental and Life Sciences, Beijing University of Technology, Beijing, China
| | - Yasir Ali
- School of Biomedical Sciences, Chinese University of Hong Kong, Hong Kong, Hong Kong
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Varma S, Trudeau SJ, Li J, Freedberg DE. Proton pump Inhibitors and Risk of Enteric Infection in Inflammatory Bowel Disease: A Self-controlled Case Series. Inflamm Bowel Dis 2024; 30:38-44. [PMID: 36917215 DOI: 10.1093/ibd/izad035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Indexed: 03/16/2023]
Abstract
BACKGROUND We tested whether proton pump inhibitors (PPIs) are associated with enteric infections among those with inflammatory bowel disease (IBD), after adequately accounting for baseline differences between PPI users and nonusers. METHODS This was a self-controlled case series, with each patient serving as their own control. Ambulatory patients with IBD were included if they were tested for enteric infection by multiplex polymerase chain reaction testing panel (GIPCR) and/or Clostridoides difficile toxin PCR from 2015 to 2019 and received PPIs for some but not all of this period. Rates of enteric infections were compared between the PPI-exposed period vs pre- and post-PPI periods identical in duration to the exposed period. Conditional Poisson regression was used to adjust for time-varying factors. RESULTS Two hundred twenty-one IBD patients were included (49% ulcerative colitis, 46% Crohn's disease, and 5% indeterminate colitis). The median PPI duration was 7 months (interquartile range 4 to 11 months). A total of 25 (11%) patients had a positive GIPCR or C. difficile test in the PPI period, 9 (4%) in the pre-PPI period, and 8 (4%) in the post-PPI period. Observed incidence rates for enteric infections were 2.5, 7.4, and 2.2 per 100 person years for the pre-PPI, PPI, and post-PPI periods, respectively (adjusted incidence rate ratios, 2.8; 95% confidence interval [CI] 1.3-6.0) for PPI vs pre-PPI and 2.9 (95% CI, 1.3-6.4) for PPI vs post-PPI). The adjusted absolute excess risk associated with PPIs was 4.9 infections per 100 person years. CONCLUSIONS Proton pump inhibitors were associated with a 3-fold increased risk for enteric infection among those with IBD but had a modest absolute risk.
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Affiliation(s)
- Sanskriti Varma
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Stephen J Trudeau
- Columbia Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Jianhua Li
- Biomedical Informatics, Columbia University Irving Medical Center, New York, NY, USA
| | - Daniel E Freedberg
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
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12
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Adukauskienė D, Mickus R, Dambrauskienė A, Vanagas T, Adukauskaitė A. Improving Clostridioides difficile Infectious Disease Treatment Response via Adherence to Clinical Practice Guidelines. Antibiotics (Basel) 2024; 13:51. [PMID: 38247610 PMCID: PMC10812669 DOI: 10.3390/antibiotics13010051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/29/2023] [Accepted: 01/02/2024] [Indexed: 01/23/2024] Open
Abstract
Clostridioides difficile (C. difficile) is a predominant nosocomial infection, and guidelines for improving diagnosis and treatment were published in 2017. We conducted a single-center, retrospective 10-year cohort study of patients with primary C. difficile infectious disease (CDID) at the largest referral Lithuanian university hospital, aiming to evaluate the clinical and laboratory characteristics of CDID and their association with the outcomes, as well as implication of concordance with current Clinical Practice Guidelines. The study enrolled a total of 370 patients. Cases with non-concordant CDID treatment resulted in more CDID-related Intensive Care Unit (ICU) admissions (7.5 vs. 1.8%) and higher CDID-related mortality (13.0 vs. 1.8%) as well as 30-day all-cause mortality (61.0 vs. 36.1%) and a lower 30-day survival compared with CDID cases with concordant treatment (p < 0.05). Among cases defined by two criteria for severe CDID, only patients with non-concordant metronidazole treatment had refractory CDID (68.8 vs. 0.0%) compared with concordant vancomycin treatment. In the presence of non-concordant metronidazole treatment for severe CDID, only cases defined by two severity criteria had more CDID-related ICU admissions (18.8 vs. 0.0%) and higher CDID-related mortality (25.0 vs. 2.0%, p < 0.05) compared with cases defined by one criterion. Severe comorbidities and the continuation of concomitant antibiotics administered at CDID onset reduced (p < 0.05) the 30-day survival and increased (p = 0.053) 30-day all-cause mortality, with 57.6 vs. 10.7% and 52.0 vs. 25.0%, respectively. Conclusions: CDID treatment non-concordant with the guidelines was associated with various adverse outcomes. In CDID with leukocytes ≥ 15 × 109/L and serum creatinine level > 133 µmol/L (>1.5 mg/dL), enteral vancomycin should be used to avoid refractory response, as metronidazole use was associated with CDID-related ICU admission and CDID-related mortality. Severe comorbidities worsened the outcomes as they were associated with reduced 30-day survival. The continuation of concomitant antibiotic therapy increased 30-day all-cause mortality; thus, it needs to be reasonably justified, deescalated or stopped.
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Affiliation(s)
- Dalia Adukauskienė
- Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (A.D.); (T.V.)
| | - Rytis Mickus
- Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (A.D.); (T.V.)
| | - Asta Dambrauskienė
- Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (A.D.); (T.V.)
| | - Tomas Vanagas
- Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (A.D.); (T.V.)
| | - Agnė Adukauskaitė
- Department of Cardiology and Angiology, University Hospital of Innsbruck, 6020 Innsbruck, Austria;
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13
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Hillyer MM, Jaggi P, Chanani NK, Fernandez AJ, Zaki H, Fundora MP. Antimicrobial Stewardship and Improved Antibiotic Utilization in the Pediatric Cardiac Intensive Care Unit. Pediatr Qual Saf 2024; 9:e710. [PMID: 38322295 PMCID: PMC10843537 DOI: 10.1097/pq9.0000000000000710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 11/22/2023] [Indexed: 02/08/2024] Open
Abstract
Background We developed a multidisciplinary antimicrobial stewardship team to optimize antimicrobial use within the Pediatric Cardiac Intensive Care Unit. A quality improvement initiative was conducted to decrease unnecessary broad-spectrum antibiotic use by 20%, with sustained change over 12 months. Methods We conducted this quality improvement initiative within a quaternary care center. PDSA cycles focused on antibiotic overuse, provider education, and practice standardization. The primary outcome measure was days of therapy (DOT)/1000 patient days. Process measures included electronic medical record order-set use. Balancing measures focused on alternative antibiotic use, overall mortality, and sepsis-related mortality. Data were analyzed using statistical process control charts. Results A significant and sustained decrease in DOT was observed for vancomycin and meropenem. Vancomycin use decreased from a baseline of 198 DOT to 137 DOT, a 31% reduction. Meropenem use decreased from 103 DOT to 34 DOT, a 67% reduction. These changes were sustained over 24 months. The collective use of gram-negative antibiotics, including meropenem, cefepime, and piperacillin-tazobactam, decreased from a baseline of 323 DOT to 239 DOT, a reduction of 26%. There was no reciprocal increase in cefepime or piperacillin-tazobactam use. Key interventions involved electronic medical record changes, including automatic stop times and empiric antibiotic standardization. All-cause mortality remained unchanged. Conclusions The initiation of a dedicated antimicrobial stewardship initiative resulted in a sustained reduction in meropenem and vancomycin usage. Interventions did not lead to increased utilization of alternative broad-spectrum antimicrobials or increased mortality. Future interventions will target additional broad-spectrum antimicrobials.
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Affiliation(s)
- Margot M. Hillyer
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine
| | - Preeti Jaggi
- Division of Infectious Disease, Department of Pediatrics, Emory University School of Medicine
| | - Nikhil K. Chanani
- Division of Cardiology, Department of Pediatrics, Emory University School of Medicine
| | | | - Hania Zaki
- Department of Pharmacy, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Michael P. Fundora
- Division of Cardiology, Department of Pediatrics, Emory University School of Medicine
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14
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Fonseca F, Forrester M, Advinha AM, Coutinho A, Landeira N, Pereira M. Clostridioides difficile Infection in Hospitalized Patients-A Retrospective Epidemiological Study. Healthcare (Basel) 2023; 12:76. [PMID: 38200982 PMCID: PMC10779218 DOI: 10.3390/healthcare12010076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 12/15/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024] Open
Abstract
Clostridioides difficile infection (CDI) is the main source of healthcare and antibiotic-associated diarrhea in hospital context and long-term care units, showing significant morbidity and mortality. This study aimed to analyze the epidemiological context, describing the severity and outcomes of this event in patients admitted to our hospital, thus confirming the changing global epidemiological trends in comparison with other cohorts. We conducted a single-center, observational, and retrospective study at the Hospital do Espírito Santo (HESE), Évora, in Portugal, analyzing the incidence of CDI in patients meeting eligibility criteria from January to December 2018. During this period, an annual incidence rate of 20.7 cases per 10,000 patients was documented. The studied population average age was 76.4 ± 12.9 years, 83.3% over 65. Most episodes were healthcare-acquired, all occurring in patients presenting multiple risk factors, with recent antibiotic consumption being the most common. Regarding severity, 23.3% of cases were classified as severe episodes. Recurrences affected 16.7% of participants, predominantly female patients over 80 years old, all of whom were healthcare-acquired. Mortality rate was disproportionately high among the older population. Our investigation documented an overall incidence rate of over 10.4-fold the number of cases identified in the year 2000 at the same hospital, more recently and drastically, in community-associated episodes.
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Affiliation(s)
- Frederico Fonseca
- Pharmaceutical Services, Hospital do Espírito Santo, 7000-811 Évora, Portugal; (N.L.); (M.P.)
| | - Mario Forrester
- Sociedade Portuguesa dos Farmacêuticos dos Cuidados de Saúde, 3030-320 Coimbra, Portugal;
- Faculty of Health Sciences, UBI—Universidade da Beira Interior, 6200-506 Covilhã, Portugal
- UFUP—Unidade de Farmacovigilância da Universidade do Porto, 4200-450 Porto, Portugal
| | - Ana Margarida Advinha
- CHRC—Comprehensive Health Research Centre, University of Evora, 7000-811 Évora, Portugal;
- Department of Health and Medical Sciences, School of Health and Human Development, University of Evora, 7000-671 Évora, Portugal
| | - Adriana Coutinho
- Laboratory Services, Microbiology Department, Hospital do Espírito Santo, 7000-811 Évora, Portugal;
| | - Nuno Landeira
- Pharmaceutical Services, Hospital do Espírito Santo, 7000-811 Évora, Portugal; (N.L.); (M.P.)
| | - Maria Pereira
- Pharmaceutical Services, Hospital do Espírito Santo, 7000-811 Évora, Portugal; (N.L.); (M.P.)
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15
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Doyle H, Valek AL, Murillo T, Ayres AM, Slaughter J, Berg ML, Snyder GM. A novel approach to correcting attribution of Clostridioides difficile in a healthcare setting. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e246. [PMID: 38156213 PMCID: PMC10753511 DOI: 10.1017/ash.2023.516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/09/2023] [Accepted: 11/13/2023] [Indexed: 12/30/2023]
Abstract
Objective To describe a novel attribution metric estimating the causal source location of healthcare-associated Clostridioides difficile and compare it with the current US National Healthcare Safety Network (NHSN) surveillance reporting standard. Design Quality improvement study. Setting Two acute care facilities. Methods A novel attribution metric assigned days of attribution to locations where patients were located for 14 days before and the day of their C. difficile diagnosis. We correlated the NHSN-assigned unit attribution with the novel attribution measure and compared the proportion of attribution assigned to inpatient units. Results During a 30-month period, there were 727 NHSN C. difficile healthcare-associated infections (HAIs) and 409 non-HAIs; the novel metric attributed 17,034 days. The correlation coefficients for NHSN and novel attributions among non-ICU units were 0.79 (95% CI, 0.76-0.82) and 0.74 (95% CI, 0.70-0.78) and among ICU units were 0.70 (95% CI, 0.63-0.76) and 0.69 (95% CI, 0.60-0.77) at facilities A and B, respectively. The distribution of difference in percent attribution showed higher inpatient unit attribution using NHSN measure than the novel attribution metric: 38% of ICU units and 15% of non-ICU units in facility A, and 20% of ICU units and 25% of non-ICU units in facility B had a median difference >0; no inpatient units showed a greater attribution using the novel attribution metric. Conclusion The novel attribution metric shifts attribution from inpatient units to other settings and correlates modestly with NHSN methodology of attribution. If validated, the attribution metric may more accurately target C. difficile reduction efforts.
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Affiliation(s)
- Hunter Doyle
- Department of Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Abby L. Valek
- Department of Infection Prevention and Control, UPMC Presbyterian/Shadyside, Pittsburgh, PA, USA
| | - Theresa Murillo
- Department of Infection Prevention and Control, UPMC Senior Communities, Pittsburgh, PA, USA
| | - Ashley M. Ayres
- Department of Infection Prevention and Control, UPMC Presbyterian/Shadyside, Pittsburgh, PA, USA
| | - Julie Slaughter
- Department of Infection Prevention and Control, UPMC Presbyterian/Shadyside, Pittsburgh, PA, USA
| | - Madeline L. Berg
- Department of Infection Prevention and Control, UPMC Presbyterian/Shadyside, Pittsburgh, PA, USA
| | - Graham M. Snyder
- Department of Infection Prevention and Control, UPMC Presbyterian/Shadyside, Pittsburgh, PA, USA
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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16
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de Nies L, Kobras CM, Stracy M. Antibiotic-induced collateral damage to the microbiota and associated infections. Nat Rev Microbiol 2023; 21:789-804. [PMID: 37542123 DOI: 10.1038/s41579-023-00936-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2023] [Indexed: 08/06/2023]
Abstract
Antibiotics have transformed medicine, saving millions of lives since they were first used to treat a bacterial infection. However, antibiotics administered to target a specific pathogen can also cause collateral damage to the patient's resident microbial population. These drugs can suppress the growth of commensal species which provide protection against colonization by foreign pathogens, leading to an increased risk of subsequent infection. At the same time, a patient's microbiota can harbour potential pathogens and, hence, be a source of infection. Antibiotic-induced selection pressure can cause overgrowth of resistant pathogens pre-existing in the patient's microbiota, leading to hard-to-treat superinfections. In this Review, we explore our current understanding of how antibiotic therapy can facilitate subsequent infections due to both loss of colonization resistance and overgrowth of resistant microorganisms, and how these processes are often interlinked. We discuss both well-known and currently overlooked examples of antibiotic-associated infections at various body sites from various pathogens. Finally, we describe ongoing and new strategies to overcome the collateral damage caused by antibiotics and to limit the risk of antibiotic-associated infections.
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Affiliation(s)
- Laura de Nies
- Sir William Dunn School of Pathology, University of Oxford, Oxford, UK
| | - Carolin M Kobras
- Sir William Dunn School of Pathology, University of Oxford, Oxford, UK
| | - Mathew Stracy
- Sir William Dunn School of Pathology, University of Oxford, Oxford, UK.
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17
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Rajakumar I, Jaber R, Ali R, Rennert-May E, Sabuda D. Impact of Clostridioides difficile length of treatment on rates of recurrence in patients on concurrent antibiotics. Am J Infect Control 2023; 51:1213-1217. [PMID: 37105356 DOI: 10.1016/j.ajic.2023.04.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 04/13/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Clostridioides difficile infection (CDI) is principally health care-associated, with a substantial impact on morbidity and mortality. The guidelines recommend CDI therapy for 10 days; however, it is often extended in practice when concurrent antibiotics are used. The impact of the extended duration of therapy remains unclear. OBJECTIVE To compare the rates of CDI recurrence in patients receiving standard duration of therapy (SDT) with those receiving extended duration of therapy (EDT) for the treatment of hospital-acquired CDI (HA-CDI) while receiving concurrent antibiotics. METHODS A retrospective chart review was conducted between October 2017 and 2019. Adult HA-CDI patients who received a minimum 10 days of CDI therapy and were on concurrent antibiotics were stratified into SDT and EDT groups. Rates of CDI recurrence (at 90 and 180 days) and incidence of new-onset vancomycin-resistant enterococcus (VRE) were compared. RESULTS Two hundred twenty-three patients met the inclusion criteria (SD-106, EDT-117). CDI recurrence rates at 90 and 180 days were not statistically significant between SDT and EDT groups (22% vs 26%, P = .40% and 26% vs 31%, P = .47). Although the incidence of VRE within the extended group was higher, it was not statistically significant (6% vs 9%, P = .29). CONCLUSIONS No significant difference in rates of recurrence or new-onset VRE was observed between SDT and EDT in HA-CDI patients.
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Affiliation(s)
- Irina Rajakumar
- Department of Pharmacy, Foothill Medical Center, Alberta Health Services, Calgary, Alberta, Canada.
| | - Rami Jaber
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Raafi Ali
- Department of Pharmacy, Foothill Medical Center, Alberta Health Services, Calgary, Alberta, Canada
| | - Elissa Rennert-May
- Department of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Deana Sabuda
- Department of Pharmacy, Foothill Medical Center, Alberta Health Services, Calgary, Alberta, Canada
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18
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Quartuccio KS, Golden K, Tesini B, Stern J, Seligman NS. Impact of antimicrobial stewardship interventions on peripartum antibiotic prescribing in patients with penicillin allergy. Am J Obstet Gynecol MFM 2023; 5:101074. [PMID: 37499906 DOI: 10.1016/j.ajogmf.2023.101074] [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: 03/27/2023] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Beta-lactam antibiotics (eg, penicillins, cephalosporins, and carbapenems) are preferred for group B streptococcus prophylaxis, intra-amniotic infection, and cesarean surgical site infection prophylaxis. Non-beta-lactam alternatives are associated with inferior efficacy and contribute to higher rates of surgical site infection and longer lengths of stay. Most patients who report a penicillin allergy can tolerate penicillins without any adverse reaction. There are low rates of cross-reactivity between penicillins and other beta-lactams, including cephalosporins and carbapenems. Efforts to evaluate penicillin allergy and promote the use of beta-lactams are needed. OBJECTIVE This study aimed to evaluate whether an antimicrobial stewardship intervention improved the use of first-line antibiotics for peripartum indications in patients with a reported penicillin allergy, following updates to institutional guidelines. STUDY DESIGN This was a retrospective study of adult patients presenting for vaginal or cesarean delivery at 2 hospitals within a healthcare system. Patients received at least 1 dose of antibiotics for a peripartum indication between May 1, 2018, and October 31, 2018 (preintervention group) and May 1, 2020, to October 31, 2020 (postintervention group). The stewardship intervention bundle, which was implemented between March 2019 and April 2020, included updates to institutional antibiotic guidelines, reclassification of severe penicillin allergy, development of obstetrical prophylaxis and treatment order sets, promotion of allergy referral services, and establishment of a physician champion. The primary outcome was the composite rates of patients with reported penicillin allergy who received a preferred antibiotic for a peripartum indication. The secondary measures included maternal and neonatal outcomes. RESULTS A total of 192 patients with a history of documented penicillin allergy were evaluated (96 patients in the preintervention group and 96 patients in the postintervention group). Hives were the most commonly reported index symptom in both groups (40/96 [41.7%] vs 39/96 [40.6%]; P=.883). After stewardship interventions, there was a significant increase in the rate of preferred antibiotic use (33/96 [34.3%] vs 81/96 [84.3%]; P<.001). The effect was the greatest in patients with nonsevere allergy (14/76 [18.4%] vs 68/82 [82.9%]; P<.001). There was no difference in the rates of postpartum endometritis, 30-day readmission, 90-day surgical site infection, or neonatal early-onset sepsis between the pre- and postintervention groups. Of note, 1 patient in the postintervention group experienced itching, and another patient developed a rash, both of which resolved with medical management. CONCLUSION A comprehensive antibiotic stewardship intervention was associated with a 50% increase in the use of preferred antibiotics for peripartum indications in patients with penicillin allergy. Allergic reactions with first-line beta-lactams were minimal and manageable.
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Affiliation(s)
- Katelyn S Quartuccio
- Department of Pharmacy, Highland Hospital, University of Rochester Medical Center, Rochester, NY (Drs Quartuccio and Golden)
| | - Kelly Golden
- Department of Pharmacy, Highland Hospital, University of Rochester Medical Center, Rochester, NY (Drs Quartuccio and Golden)
| | - Brenda Tesini
- Departments of Medicine (Dr Tesini) and Allergy, Immunology, and Rheumatology (Dr Stern), University of Rochester School of Medicine, Rochester, NY
| | - Jessica Stern
- Departments of Medicine (Dr Tesini) and Allergy, Immunology, and Rheumatology (Dr Stern), University of Rochester School of Medicine, Rochester, NY
| | - Neil S Seligman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Rochester School of Medicine, Rochester, NY (Dr Seligman).
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19
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San-Juan R, Origuen J, Campion K, Fernández-Ruiz M, Diaz-Pollan B, Callejas-Diaz A, Candela G, Orellana MA, Lora D, Llorente Muñoz I, Garcia MT, Martinez-Uña M, Ferrari JM, Aguado JM. Evaluation of the effectiveness and safety of oral vancomycin versus placebo in the prevention of recurrence of Clostridioides difficile infection in patients under systemic antibiotic therapy: a phase III, randomised, double-blind clinical trial. BMJ Open 2023; 13:e072121. [PMID: 37709311 PMCID: PMC11148698 DOI: 10.1136/bmjopen-2023-072121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/16/2023] Open
Abstract
INTRODUCTION Clostridioides difficile infection (CDI) is the most prevalent cause of nosocomial bacterial diarrhoea and it is strongly associated with antibiotic use. The recurrence of CDI is a growing medical problem. Data from real-life studies and one open label randomised clinical trial (RCT) suggest that secondary prophylaxis with oral vancomycin (SPV) during subsequent courses of systemic antibiotics is a promising approach for reducing the risk of CDI recurrence. Our aim is to confirm the role of SPV through a double-blind RCT. METHODS AND ANALYSIS We will perform a phase III, multicentre, placebo-controlled RCT (PREVAN trial) in a 2:1 ratio in favour of SPV (experimental treatment), in four tertiary care hospitals in Spain. Adult patients (≥18 years) with a previous history of CDI in the previous 180 days and with requirement for hospitalisation and systemic antibiotic therapy will be randomly allocated to receive either 125 mg of oral vancomycin or placebo every 6 hours for 10 days. Patients will be followed for 60 days after the end of treatment to verify a reduction in the rate of CDI recurrence in the experimental group. We assume a recurrence rate of 5% in the experimental group versus 25% in the placebo group. Accepting an alpha risk of 0.05 and a beta risk of 0.2 in a two-sided test, 104 subjects will be required in total (68 assigned to the SPV group and 34 to the placebo group). ETHICS AND DISSEMINATION Ethical approval has been obtained from the Ethic Committee for Research with medicinal products of the University Hospital '12 de Octubre' (AC069/18) and from the Spanish Medicines and Healthcare Product Regulatory Agency (AEMPS, AC069/18), which is valid for all participating centres under existing Spanish legislation. The results will be presented at international meetings and will be made available to patients and funders. TRIAL REGISTRATION NUMBER NCT05320068.
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Affiliation(s)
- Rafael San-Juan
- Department of Infectious Diseases, Hospital Universitario "12 de Octubre", Madrid, Spain
- CIBERINFEC, ISCIII - CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Investigacion Biomedica del Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Julia Origuen
- Department of Infectious Diseases, Hospital Universitario "12 de Octubre", Madrid, Spain
| | - Karen Campion
- Department of Infectious Diseases, Hospital Universitario "12 de Octubre", Madrid, Spain
| | - Mario Fernández-Ruiz
- Department of Infectious Diseases, Hospital Universitario "12 de Octubre", Madrid, Spain
- CIBERINFEC, ISCIII - CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Investigacion Biomedica del Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Alejandro Callejas-Diaz
- Department of Internal Medicine, Puerta de Hierro University Hospital of Majadahonda, Majadahonda, Spain
| | - Giancarlo Candela
- Department of Internal Medicine, Severo Ochoa University Hospital, Leganes, Spain
| | | | - David Lora
- Clinical Research Unit (I+12), Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Irene Llorente Muñoz
- SCREN, Fundacion para la Investigacion Biomedica del Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Maria Teresa Garcia
- SCREN, Fundacion para la Investigacion Biomedica del Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Maite Martinez-Uña
- Department of Pharmacy, Hospital Universitario "12 de Octubre", Madrid, Spain
| | - Jose Miguel Ferrari
- Department of Pharmacy, Hospital Universitario "12 de Octubre", Madrid, Spain
| | - Jose M Aguado
- Department of Infectious Diseases, Hospital Universitario "12 de Octubre", Madrid, Spain
- CIBERINFEC, ISCIII - CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Investigacion Biomedica del Hospital Universitario 12 de Octubre, Madrid, Spain
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20
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Rohde AM, Mischnik A, Behnke M, Dinkelacker A, Eisenbeis S, Falgenhauer J, Gastmeier P, Häcker G, Herold S, Imirzalioglu C, Käding N, Kramme E, Peter S, Piepenbrock E, Rupp J, Schneider C, Schwab F, Seifert H, Steib-Bauert M, Tacconelli E, Trauth J, Vehreschild MJGT, Walker SV, Kern WV, Jazmati N. Association of ward-level antibiotic consumption with healthcare-associated Clostridioides difficile infections: an ecological study in five German university hospitals, 2017-2019. J Antimicrob Chemother 2023; 78:2274-2282. [PMID: 37527398 DOI: 10.1093/jac/dkad232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/09/2023] [Indexed: 08/03/2023] Open
Abstract
OBJECTIVES To analyse the influence of antibiotic consumption on healthcare-associated healthcare onset (HAHO) Clostridioides difficile infection (CDI) in a German university hospital setting. METHODS Monthly ward-level antibiotic consumption measured in DDD/100 patient days (pd) and CDI surveillance data from five university hospitals in the period 2017 through 2019 were analysed. Uni- and multivariable analyses were performed with generalized estimating equation models. RESULTS A total of 225 wards with 7347 surveillance months and 4 036 602 pd participated. With 1184 HAHO-CDI cases, there was a median incidence density of 0.17/1000 pd (IQR 0.03-0.43) across all specialties, with substantial differences among specialties. Haematology-oncology wards showed the highest median incidence density (0.67/1000 pd, IQR 0.44-1.01), followed by medical ICUs (0.45/1000 pd, IQR 0.27-0.73) and medical general wards (0.32/1000 pd, IQR 0.18-0.53). Multivariable analysis revealed carbapenem (mostly meropenem) consumption to be the only antibiotic class associated with increased HAHO-CDI incidence density. Each carbapenem DDD/100 pd administered increased the HAHO-CDI incidence density by 1.3% [incidence rate ratio (IRR) 1.013; 95% CI 1.006-1.019]. Specialty-specific analyses showed this influence only to be valid for haematological-oncological wards. Overall, factors like ward specialty (e.g. haematology-oncology ward IRR 2.961, 95% CI 2.203-3.980) or other CDI cases on ward had a stronger influence on HAHO-CDI incidence density (e.g. community-associated CDI or unknown association case in same month IRR 1.476, 95% CI 1.242-1.755) than antibiotic consumption. CONCLUSIONS In the German university hospital setting, monthly ward-level carbapenem consumption seems to increase the HAHO-CDI incidence density predominantly on haematological-oncological wards. Furthermore, other patient-specific factors seem to be equally important to control HAHO-CDI.
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Affiliation(s)
- Anna M Rohde
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- Institute for Hygiene and Environmental Medicine, Charité - University Medicine Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Hindenburgdamm 27, 12203 Berlin, Germany
| | - Alexander Mischnik
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- Department of Infectious Diseases and Microbiology, University Hospital Schleswig-Holstein/Campus Lübeck, Lübeck, Germany
- Division of Infectious Diseases, Department of Medicine II, University Medical Centre and Faculty of Medicine, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Michael Behnke
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- Institute for Hygiene and Environmental Medicine, Charité - University Medicine Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Hindenburgdamm 27, 12203 Berlin, Germany
| | - Ariane Dinkelacker
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany
| | - Simone Eisenbeis
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- Division of Infectious Diseases, Department of Internal Medicine 1, University Hospital Tübingen, Tübingen, Germany
| | - Jane Falgenhauer
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- Institute of Medical Microbiology, Justus Liebig University Giessen, Giessen, Germany
| | - Petra Gastmeier
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- Institute for Hygiene and Environmental Medicine, Charité - University Medicine Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Hindenburgdamm 27, 12203 Berlin, Germany
| | - Georg Häcker
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- Institute for Medical Microbiology and Hygiene, University Medical Centre Freiburg, University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Susanne Herold
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- University Hospital Giessen and Marburg, Department of Medicine V (Internal Medicine, Infectious Diseases and Infection Control), Justus-Liebig-University Giessen, Giessen, Germany, member of the German Centre for Lung Research (DZL), member of the German Centre for Infection Research (DZIF) Department of Internal Medicine (Infectiology)
| | - Can Imirzalioglu
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- Institute of Medical Microbiology, Justus Liebig University Giessen, Giessen, Germany
| | - Nadja Käding
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- Department of Infectious Diseases and Microbiology, University Hospital Schleswig-Holstein/Campus Lübeck, Lübeck, Germany
| | - Evelyn Kramme
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- Department of Infectious Diseases and Microbiology, University Hospital Schleswig-Holstein/Campus Lübeck, Lübeck, Germany
| | - Silke Peter
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany
| | - Ellen Piepenbrock
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jan Rupp
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- Department of Infectious Diseases and Microbiology, University Hospital Schleswig-Holstein/Campus Lübeck, Lübeck, Germany
| | - Christian Schneider
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- Institute for Medical Microbiology and Hygiene, University Medical Centre Freiburg, University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Frank Schwab
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- Institute for Hygiene and Environmental Medicine, Charité - University Medicine Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Hindenburgdamm 27, 12203 Berlin, Germany
| | - Harald Seifert
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Michaela Steib-Bauert
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- Division of Infectious Diseases, Department of Medicine II, University Medical Centre and Faculty of Medicine, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Evelina Tacconelli
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- Division of Infectious Diseases, Department of Internal Medicine 1, University Hospital Tübingen, Tübingen, Germany
| | - Janina Trauth
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- University Hospital Giessen and Marburg, Department of Medicine V (Internal Medicine, Infectious Diseases and Infection Control), Justus-Liebig-University Giessen, Giessen, Germany, member of the German Centre for Lung Research (DZL), member of the German Centre for Infection Research (DZIF) Department of Internal Medicine (Infectiology)
| | - Maria J G T Vehreschild
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Department of Internal Medicine, Infectious Diseases, Goethe University, Frankfurt am Main, Germany
| | - Sarah V Walker
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Winfried V Kern
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- Division of Infectious Diseases, Department of Medicine II, University Medical Centre and Faculty of Medicine, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Nathalie Jazmati
- German Centre for Infection Research (DZIF), Healthcare-Associated and Antibiotic-Resistant Bacterial Infections, Braunschweig, Germany
- Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Labor Dr. Wisplinghoff, Cologne, Germany
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21
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Widere JC, Davis CL, Loomba JJ, Bell TD, Enfield KB, Barros AJ. Early Empiric Antibiotic Use in Patients Hospitalized With COVID-19: A Retrospective Cohort Study. Crit Care Med 2023; 51:1168-1176. [PMID: 37125800 PMCID: PMC10426778 DOI: 10.1097/ccm.0000000000005901] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
OBJECTIVE To investigate temporal trends and outcomes associated with early antibiotic prescribing in patients hospitalized with COVID-19. DESIGN Retrospective propensity-matched cohort study using the National COVID Cohort Collaborative (N3C) database. SETTING Sixty-six health systems throughout the United States that were contributing to the N3C database. Centers that had fewer than 500 admissions in their dataset were excluded. PATIENTS Patients hospitalized with COVID-19 were included. Patients were defined to have early antibiotic use if they received at least 3 calendar days of intravenous antibiotics within the first 5 days of admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 322,867 qualifying first hospitalizations, 43,089 patients received early empiric antibiotics. Antibiotic use declined across all centers in the data collection period, from March 2020 (23%) to June 2022 (9.6%). Average rates of early empiric antibiotic use (EEAU) also varied significantly between centers (deviance explained 7.33% vs 20.0%, p < 0.001). Antibiotic use decreased slightly by day 2 of hospitalization and was significantly reduced by day 5. Mechanical ventilation before day 2 (odds ratio [OR] 3.57; 95% CI, 3.42-3.72), extracorporeal membrane oxygenation before day 2 (OR 2.14; 95% CI, 1.75-2.61), and early vasopressor use (OR 1.85; 95% CI, 1.78-1.93) but not region of residence was associated with EEAU. After propensity matching, EEAU was associated with an increased risk for in-hospital mortality (OR 1.27; 95% CI, 1.23-1.33), prolonged mechanical ventilation (OR 1.65; 95% CI, 1.50-1.82), late broad-spectrum antibiotic exposure (OR 3.24; 95% CI, 2.99-3.52), and late Clostridium difficile infection (OR 1.60; 95% CI, 1.37-1.87). CONCLUSIONS Although treatment of COVID-19 patients with empiric antibiotics has declined during the pandemic, the frequency of use remains high. There is significant inter-center variation in antibiotic prescribing practices and evidence of potential harm. Our findings are hypothesis-generating and future work should prospectively compare outcomes and adverse events.
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Affiliation(s)
| | - Claire Leilani Davis
- Division of Pulmonary and Critical Care, Department of Medicine, University of Virginia, Charlottesville, VA
| | - Johanna Jean Loomba
- Integrated Translational Health Research Institute of Virginia, University of Virginia, Charlottesville, VA
| | - Taison D Bell
- Division of Pulmonary and Critical Care, Department of Medicine, University of Virginia, Charlottesville, VA
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, VA
| | - Kyle B Enfield
- Division of Pulmonary and Critical Care, Department of Medicine, University of Virginia, Charlottesville, VA
| | - Andrew Julio Barros
- Division of Pulmonary and Critical Care, Department of Medicine, University of Virginia, Charlottesville, VA
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22
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Rossier L, Matter C, Burri E, Galperine T, Hrúz P, Juillerat P, Schoepfer A, Vavricka SR, Zahnd N, Décosterd N, Seibold F. Swiss expert opinion: current approaches in faecal microbiota transplantation in daily practice. Swiss Med Wkly 2023; 153:40100. [PMID: 37769622 DOI: 10.57187/smw.2023.40100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023] Open
Abstract
INTRODUCTION Faecal microbiota transplantation (FMT) is an established therapy for recurrent C. difficile infection, and recent studies have reported encouraging results of FMT in patients with ulcerative colitis. Few international consensus guidelines exist for this therapy, and thus FMT policies and practices differ among European countries. As of 2019, stool transplants are considered a non-standardised medicinal product in Switzerland, and a standardised production process requires authorisation by the Swiss Agency for Therapeutic Products. This authorisation leads to prolonged administrative procedures and increasing costs, which reduces treatment accessibility. In particular, patients with ulcerative colitis in Switzerland can only benefit from FMT off-label, even though it is a valid therapeutic option. Therefore, this study summarised the available data on FMT and established a framework for the standardised use of FMT. METHODS A panel of Swiss gastroenterologists with a special interest in inflammatory bowel disease was established to identify the current key issues of FMT. After a comprehensive review of the literature, statements were formulated about FMT indications, donor screening, stool transplant preparation and administration, and safety aspects. The panel then voted on the statements following the Delphi process; the statements were reformulated and revoted until a consensus was reached. The manuscript was then reviewed by an infectiologist (the head of Lausanne's FMT centre). RESULTS The established statements are summarised in the supplementary tables in the appendix to this paper. The working group hopes these will help standardise FMT practice in Switzerland and contribute to making faecal microbiota transplantation a safe and accessible treatment for patients with recurrent C. difficile infections and selected patients with ulcerative colitis, as well as other indications in the future.
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Affiliation(s)
- Laura Rossier
- Intesto - Gastroenterology practice and Crohn-colitis Center, Bern, Switzerland
| | - Christoph Matter
- Intesto - Gastroenterology practice and Crohn-colitis Center, Bern, Switzerland
| | - Emanuel Burri
- Department of Gastroenterology and Hepatology, University Medical Clinic, Baselland Canton Hospital, Liestal, Switzerland
| | - Tatiana Galperine
- Fecal microbiota transplantation center, Department of infectious disease, Lausanne University Hospital, Lausanne, Switzerland
| | - Petr Hrúz
- Clarunis, Department of Gastroenterology, St Clara hospital and University hospital Basel, Basel, Switzerland
| | - Pascal Juillerat
- GastroGeb - Gastroenterology practice and Crohn-colitis Center, Lausanne - Bulle, Switzerland
| | - Alain Schoepfer
- Department of Gastroenterology, Lausanne University Hospital, Lausanne, Switzerland
| | - Stephan R Vavricka
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | | | - Natalie Décosterd
- Intesto - Gastroenterology practice and Crohn-colitis Center, Bern, Switzerland
| | - Frank Seibold
- Intesto - Gastroenterology practice and Crohn-colitis Center, Bern, Switzerland
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23
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Werner M, Ishii PE, Pilla R, Lidbury JA, Steiner JM, Busch-Hahn K, Unterer S, Suchodolski JS. Prevalence of Clostridioides difficile in Canine Feces and Its Association with Intestinal Dysbiosis. Animals (Basel) 2023; 13:2441. [PMID: 37570250 PMCID: PMC10417777 DOI: 10.3390/ani13152441] [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] [Received: 07/12/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
The role of Clostridioides (C.) difficile as an enteropathogen in dogs is controversial. In humans, intestinal bile acid-dysmetabolism is associated with C. difficile prevalence. The relationship between fecal qPCR-based dysbiosis index (DI) and especially the abundance of bile acid-converting Clostridium hiranonis with the presence of C. difficile in dogs was explored across the following 4 cohorts: 358 fecal samples submitted for routine diagnostic work-up, 33 dogs with chronic enteropathy, 14 dogs with acute diarrhea, and 116 healthy dogs. Dogs that tested positive for C. difficile had significantly higher DI (median, 4.4 (range from 0.4 to 8.6)) and lower C. hiranonis (median, 0.1 (range from 0.0 to 7.5) logDNA/g) than dogs that tested negative for C. difficile (median DI, -1 (range from -7.2 to 8.9); median C. hiranonis abundance, 6.2 (range from 0.1 to 7.5) logDNA/g; p < 0.0001, respectively). In 33 dogs with CE and 14 dogs with acute diarrhea, the treatment response did not differ between C. difficile-positive and -negative dogs. In the group of clinically healthy dogs, 9/116 tested positive for C. difficile, and 6/9 of these had also an abnormal DI. In conclusion, C. difficile is strongly linked to intestinal dysbiosis and lower C. hiranonis levels in dogs, but its presence does not necessitate targeted treatment.
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Affiliation(s)
- Melanie Werner
- Clinic for Small Animal Internal Medicine, Vetsuisse Faculty, 8057 Zurich, Switzerland
| | - Patricia Eri Ishii
- Gastrointestinal Laboratory, Department of Small Animal Clinical Sciences, School of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 4474, USA
| | - Rachel Pilla
- Gastrointestinal Laboratory, Department of Small Animal Clinical Sciences, School of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 4474, USA
| | - Jonathan A. Lidbury
- Gastrointestinal Laboratory, Department of Small Animal Clinical Sciences, School of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 4474, USA
| | - Joerg M. Steiner
- Gastrointestinal Laboratory, Department of Small Animal Clinical Sciences, School of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 4474, USA
| | - Kathrin Busch-Hahn
- Clinic of Small Animal Internal Medicine, Centre for Clinical Veterinary Medicine, Ludwig Maximilians University, 80539 Munich, Germany
| | - Stefan Unterer
- Clinic for Small Animal Internal Medicine, Vetsuisse Faculty, 8057 Zurich, Switzerland
| | - Jan S. Suchodolski
- Gastrointestinal Laboratory, Department of Small Animal Clinical Sciences, School of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 4474, USA
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24
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Flack T, Oaxaca DM, Olson CM, Pafford C, Strachan CC, Epperson DW, Reyes J, Akinrotimi D, Ho L, Hunter BR. Association of a sepsis initiative on broad spectrum antibiotic use and outcomes in an ED population: A retrospective cohort study. Am J Emerg Med 2023; 71:169-174. [PMID: 37421813 DOI: 10.1016/j.ajem.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 05/07/2023] [Accepted: 06/09/2023] [Indexed: 07/10/2023] Open
Abstract
INTRODUCTION Sepsis identification and treatment is a priority for emergency department (ED) providers and payors alike. However, aggressive metrics aimed at improving sepsis care could have unintended consequences for patients who do not have sepsis. METHODS All ED patient visits for a one month period before and after a quality initiative to increase early antibiotic use in septic patients were included. Overall broad spectrum (BS) antibiotic use, admission rates, and mortality were compared in the 2 time periods. A more detailed chart review was performed on those who received BS antibiotics in the before and after cohorts. Patient were excluded for pregnancy, age < 18, COVID-19 infection, hospice patients, left ED against medical advice, and if antibiotics were given for prophylaxis. In BS antibiotic treated patients, we sought to determine mortality, rates of subsequent multidrug resistant (MDR) or Clostridium Difficile (CDiff) infections and rates of non-infected patients receiving BS antibiotics. RESULTS There were 7967 and 7407 ED visits in the pre- and post-implementation periods, respectively. Of those, BS antibiotics were administered in a total of 3.9% pre-implementation and 6.2% post-implementation (p ≤ 0.00001). Admission was more common in the post-implementation period, but overall mortality was unchanged (0.9% pre-implementation and 0.8% post-implementation, p = 0.41). After exclusions, 654 patients treated with BS antibiotics were included in the secondary analyses. Baseline characteristics were similar between the pre-implementation and post-implementation cohorts. There was no difference in the rate of CDiff infection or the proportion of patients receiving BS antibiotics who were not infected, but there was an increase in the post-implementation period in MDR infections after ED BS antibiotics, 0.72% vs. 0.35% of the entire ED cohorts, p = 0.0009. CONCLUSIONS We found that a QI sepsis initiative was associated with an increase in the proportion of patients who received BS antibiotics in the ED, and a small absolute increase in associated subsequent MDR infections, with no apparent effect on mortality in all ED patients or the subset treated with BS antibiotics. Further research is needed to assess the impact on all patients affected by aggressive sepsis protocols and initiatives, rather than only those with sepsis.
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Affiliation(s)
- Tara Flack
- Indiana University Health, 1701 N. Senate Avenue, Indianapolis, IN 46202, USA
| | - Derrick M Oaxaca
- Department of Emergency Medicine, Indiana University School of Medicine, 1701 N. Senate Avenue, Indianapolis, IN 46202, USA; Vituity, Indianapolis, IN, USA
| | - Chris M Olson
- Department of Emergency Medicine, Indiana University School of Medicine, 1701 N. Senate Avenue, Indianapolis, IN 46202, USA
| | - Carl Pafford
- Department of Emergency Medicine, Indiana University School of Medicine, 1701 N. Senate Avenue, Indianapolis, IN 46202, USA
| | - Christian C Strachan
- Department of Emergency Medicine, Indiana University School of Medicine, 1701 N. Senate Avenue, Indianapolis, IN 46202, USA
| | - Daniel W Epperson
- Department of Emergency Medicine, Indiana University School of Medicine, 1701 N. Senate Avenue, Indianapolis, IN 46202, USA
| | - Jessica Reyes
- Department of Emergency Medicine, Indiana University School of Medicine, 1701 N. Senate Avenue, Indianapolis, IN 46202, USA
| | - Demilade Akinrotimi
- Department of Emergency Medicine, Indiana University School of Medicine, 1701 N. Senate Avenue, Indianapolis, IN 46202, USA
| | - Luke Ho
- Department of Emergency Medicine, Indiana University School of Medicine, 1701 N. Senate Avenue, Indianapolis, IN 46202, USA
| | - Benton R Hunter
- Department of Emergency Medicine, Indiana University School of Medicine, 1701 N. Senate Avenue, Indianapolis, IN 46202, USA.
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25
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Bocchetti M, Ferraro MG, Melisi F, Grisolia P, Scrima M, Cossu AM, Yau TO. Overview of current detection methods and microRNA potential in Clostridioides difficile infection screening. World J Gastroenterol 2023; 29:3385-3399. [PMID: 37389232 PMCID: PMC10303512 DOI: 10.3748/wjg.v29.i22.3385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/23/2023] [Accepted: 05/04/2023] [Indexed: 06/06/2023] Open
Abstract
Clostridioides difficile (formerly called Clostridium difficile, C. difficile) infection (CDI) is listed as an urgent threat on the 2019 antibiotic resistance threats report in the United States by the Centers for Disease Control and Prevention. Early detection and appropriate disease management appear to be essential. Meanwhile, although the majority of cases are hospital-acquired CDI, community-acquired CDI cases are also on the rise, and this vulnerability is not limited to immunocompromised patients. Gastrointestinal treatments and/or gastrointestinal tract surgeries may be required for patients diagnosed with digestive diseases. Such treatments could suppress or interfere with the patient’s immune system and disrupt gut flora homeostasis, creating a suitable microecosystem for C. difficile overgrowth. Currently, stool-based non-invasive screening is the first-line approach to CDI diagnosis, but the accuracy is varied due to different clinical microbiology detection methods; therefore, improving reliability is clearly required. In this review, we briefly summarised the life cycle and toxicity of C. difficile, and we examined existing diagnostic approaches with an emphasis on novel biomarkers such as microRNAs. These biomarkers can be easily detected through non-invasive liquid biopsy and can yield crucial information about ongoing pathological phenomena, particularly in CDI.
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Affiliation(s)
- Marco Bocchetti
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli,” Naples 80138, Italy
- Department of Molecular Oncology, Precision Medicine Laboratory and COVID19 Laboratory, Biogem Scarl, Ariano Irpino 83031, Italy
| | - Maria Grazia Ferraro
- School of Infection and Immunity, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow G12 8QQ, United Kingdom
- Department of Pharmacy, School of Medicine and Surgery, University of Naples “Federico II,” Naples 80131, Italy
| | - Federica Melisi
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli,” Naples 80138, Italy
- Department of Molecular Oncology, Precision Medicine Laboratory and COVID19 Laboratory, Biogem Scarl, Ariano Irpino 83031, Italy
| | - Piera Grisolia
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli,” Naples 80138, Italy
- Department of Molecular Oncology, Precision Medicine Laboratory and COVID19 Laboratory, Biogem Scarl, Ariano Irpino 83031, Italy
| | - Marianna Scrima
- Department of Molecular Oncology, Precision Medicine Laboratory and COVID19 Laboratory, Biogem Scarl, Ariano Irpino 83031, Italy
| | - Alessia Maria Cossu
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli,” Naples 80138, Italy
- Department of Molecular Oncology, Precision Medicine Laboratory and COVID19 Laboratory, Biogem Scarl, Ariano Irpino 83031, Italy
| | - Tung On Yau
- School of Science and Technology, Nottingham Trent University, Nottingham NG11 8NS, United Kingdom
- Department of Rural Land Use, Scotland’s Rural College, Aberdeen AB21 9YA, Scotland, United Kingdom
- Department of Health Science, University of the People, Pasadena, CA 9110112, United States
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26
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Kim JH, Mason J, Toyoda AY, Ji CS, Gandhi RG, Solomon EJ. Analysis of the use of empiric antimicrobial prophylaxis for temporary cardiac devices at a large academic medical center. Perfusion 2023:2676591231182249. [PMID: 37285484 DOI: 10.1177/02676591231182249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Varying rates of access site infections with temporary percutaneous cardiac devices have been reported in the literature. The purpose of this study is to determine the impact of a change in institutional practice in utilizing antimicrobial prophylaxis to prevent access site infections in patients with these devices. METHODS This observational, pre-post implementation analysis evaluated the benefit of prophylactic antimicrobial therapy in adult patients with temporary percutaneous cardiac devices admitted to cardiac intensive care units. Patients in the pre-cohort received prophylactic antibiotics for the duration of device insertion. Patients in the post-cohort received a single dose of intravenous antibiotics for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or Impella® 5.5 device placement, and no antimicrobial prophylaxis for all other devices placed. The primary endpoint was the incidence of definitive access site infection. Secondary endpoints included the incidence of Clostridium difficile infection and initiation of broad-spectrum antibiotics. RESULTS Fifty patients in the pre-cohort and 45 patients in the post-cohort were evaluated. Devices included intra-aortic balloon pumps, VA-ECMO, Impella® CP and Impella® 5.5. The median duration of device insertion was four days. No significant difference in the primary outcome was seen between the two groups. A significant reduction in prophylactic antimicrobial utilization and total days of antimicrobial exposure was observed in the post-implementation cohort. CONCLUSION Based on the results of our study, the implemented guideline reduces the utilization of antimicrobial prophylaxis in patients with temporary percutaneous cardiac devices and does not result in an increased rate of infections.
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Affiliation(s)
- Ju Hee Kim
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Jessica Mason
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | | | - Christine S Ji
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | | | - Edmond J Solomon
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
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Schönherr S, Jung L, Lübbert C. [Clostridioides difficile - New Insights and Therapy Recommendations]. Dtsch Med Wochenschr 2023; 148:752-758. [PMID: 37257477 DOI: 10.1055/a-1970-9211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
After an increase in Clostridioides difficile infections (CDI) until 2013 due to epidemic ribotypes such as 027 and 078, CDI incidence in Germany is now declining, as confirmed by recent epidemiological data. Despite this success through antimicrobial stewardship and hospital hygiene, the burden of disease remains high, especially in older patients (>65 years) with comorbidities. The main risk factor for CDI is the use of broad-spectrum antibiotics, which disrupt the gut microbiota, allowing C. difficile colonization. Coinfection with other intestinal pathogens such as enterococci can further increase the virulence of C. difficile. The updated 2021 ESCMID guidelines recommend fidaxomicin instead of vancomycin as the antibiotic of choice for the treatment of CDI because of its lower recurrence rate. Vancomycin remains a good alternative; however, metronidazole should only be used if neither antibiotic is available. In the future, ridinilazole may be available as another therapeutic option that has a narrow spectrum of activity and low intestinal absorption. For the treatment of recurrent CDI, the new guidelines also include the use of the monoclonal antibody bezlotoxumab. In addition, a new oral microbiome therapy, SER-109 (capsules containing purified Firmicutes spores), which showed promising results in a phase 3 study, may provide an easy-to-administer alternative to fecal microbiota transplantation. Hopes for a well-performing toxoid vaccine for primary and secondary prevention of CDI have unfortunately not been fulfilled in the CLOVER trial.
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Affiliation(s)
- Sebastian Schönherr
- Bereich Infektiologie und Tropenmedizin, Klinik und Poliklinik für Hämatologie, Zelltherapie, Hämostaseologie und Infektiologie, Universitätsklinikum Leipzig, Leipzig
- Interdisziplinäres Zentrum für Infektionsmedizin, Universitätsklinikum Leipzig, Leipzig
| | - Laura Jung
- Bereich Infektiologie und Tropenmedizin, Klinik und Poliklinik für Hämatologie, Zelltherapie, Hämostaseologie und Infektiologie, Universitätsklinikum Leipzig, Leipzig
- Interdisziplinäres Zentrum für Infektionsmedizin, Universitätsklinikum Leipzig, Leipzig
| | - Christoph Lübbert
- Bereich Infektiologie und Tropenmedizin, Klinik und Poliklinik für Hämatologie, Zelltherapie, Hämostaseologie und Infektiologie, Universitätsklinikum Leipzig, Leipzig
- Interdisziplinäres Zentrum für Infektionsmedizin, Universitätsklinikum Leipzig, Leipzig
- Klinik für Infektiologie und Tropenmedizin, Klinikum St. Georg, Leipzig
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Markovska R, Dimitrov G, Gergova R, Boyanova L. Clostridioides difficile, a New “Superbug”. Microorganisms 2023; 11:microorganisms11040845. [PMID: 37110267 PMCID: PMC10140992 DOI: 10.3390/microorganisms11040845] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/19/2023] [Accepted: 03/24/2023] [Indexed: 03/29/2023] Open
Abstract
Clostridioides difficile is a Gram-positive, spore-forming, anaerobic bacterium. The clinical features of C. difficile infections (CDIs) can vary, ranging from the asymptomatic carriage and mild self-limiting diarrhoea to severe and sometimes fatal pseudomembranous colitis. C. difficile infections (CDIs) are associated with disruption of the gut microbiota caused by antimicrobial agents. The infections are predominantly hospital-acquired, but in the last decades, the CDI patterns have changed. Their prevalence increased, and the proportion of community-acquired CDIs has also increased. This can be associated with the appearance of hypervirulent epidemic isolates of ribotype 027. The COVID-19 pandemic and the associated antibiotic overuse could additionally change the patterns of infections. Treatment of CDIs is a challenge, with only three appropriate antibiotics for use. The wide distribution of C. difficile spores in hospital environments, chronic persistence in some individuals, especially children, and the recent detection of C. difficile in domestic pets can furthermore worsen the situation. “Superbugs” are microorganisms that are both highly virulent and resistant to antibiotics. The aim of this review article is to characterise C. difficile as a new member of the “superbug” family. Due to its worldwide spread, the lack of many treatment options and the high rates of both recurrence and mortality, C. difficile has emerged as a major concern for the healthcare system.
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Jaber RH, Beahm NP. Daptomycin for the treatment of acute bacterial meningitis: a narrative review. Int J Antimicrob Agents 2023; 61:106770. [PMID: 36870402 DOI: 10.1016/j.ijantimicag.2023.106770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 01/21/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND There is a growing interest in the utilization of daptomycin for the treatment of multi-drug resistant, Gram-positive infections. Pharmacokinetic studies suggest that daptomycin could penetrate into the cerebrospinal fluid, albeit to a small extent. The objective of this review was to evaluate the available clinical evidence for daptomycin use in acute bacterial meningitis of both pediatric and adult patients. METHODS Electronic databases were searched up to June 2022 for studies published on the topic. The inclusion criteria were met if the study reported the use of intravenous daptomycin (more than a single dose) for the treatment of diagnosed acute bacterial meningitis. RESULTS A total of 21 case reports were identified that met the inclusion criteria. These suggest that daptomycin could be safe and effective alternative in achieving clinical cure of meningitis. In these studies, daptomycin was used in the event of treatment failure, patient intolerance, or bacterial resistance to first-line agents. CONCLUSIONS Daptomycin has potential to be an alternative to standard care for meningitis caused by Gram-positive bacteria in the future; however, more robust research is required to establish an optimal dosing regimen, duration of therapy, and place in therapy for the management of meningitis.
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Affiliation(s)
- Rami H Jaber
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Nathan P Beahm
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada.
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Antimicrobial stewardship experiences in acute-care hospitals of Northern Italy: Assessment of structure, process and outcome indicators, 2017-2019. Am J Infect Control 2023; 51:282-288. [PMID: 35709971 DOI: 10.1016/j.ajic.2022.06.006] [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] [Received: 03/08/2022] [Revised: 06/06/2022] [Accepted: 06/08/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Antimicrobial stewardship (AMS) programs are effective strategies for optimizing antimicrobial use. We aimed to assess AMS programs implemented in acute-care trusts of the region of Piedmont, Northern Italy. METHODS AMS programs were investigated via a survey addressing structure, process and outcome indicators. For outcome indicators, annual means for the years 2017-2019 were considered, as well as the percentage change between 2017 and 2019. Outcome indicators were investigated in relation to structure and process scores using Spearman correlation. RESULTS In total, 25 AMS programs were surveyed. Higher scores were achieved for process over structure indicators. Improvements in alcohol-based handrub usage (+30%), total antimicrobial usage (-4%), and percentages of methicillin-resistant Staphylococcus aureus and carbapenem-resistant Enterobacteriaceae over invasive isolates (respectively -16 and -23%) were found between 2017 and 2019. Significant correlations were found between structure score and percentage change in total antimicrobial usage and carbapenem-resistant Enterobacteriaceae over invasive isolates (Spearman's ρ -0.603, P .006 and ρ -0.433, P .044 respectively). DISCUSSION This study identified areas for improvement: accountability, microbiological laboratory quality management and feedback to clinicians. Improving the organization of AMS programs in particular should be prioritized. CONCLUSION Repeated measurements of structure and process indicators will be important to guide continuing quality improvement efforts.
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Abstract
Clostridioides difficile is a common cause of community-associated and health care-associated infections. Older adults are disproportionately affected, and long-term care facilities (LTCFs) have borne a substantial proportion of the burden of C difficile infection (CDI). Recurrences of CDI are common in older adults and have substantial adverse effects on quality of life. Appropriate diagnostic testing and management is essential for older adults in the community and in LTCFs. This review focuses on current concepts related to the epidemiology, diagnosis, and management of CDI in older adults.
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Affiliation(s)
- Curtis J Donskey
- Geriatric Research Education and Clinical Center, Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA; Case Western Reserve University School of Medicine, Cleveland, OH, USA.
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32
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Petroianu GA, Aloum L, Adem A. Neuropathic pain: Mechanisms and therapeutic strategies. Front Cell Dev Biol 2023; 11:1072629. [PMID: 36727110 PMCID: PMC9884983 DOI: 10.3389/fcell.2023.1072629] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 01/06/2023] [Indexed: 01/18/2023] Open
Abstract
The physiopathology and neurotransmission of pain are of an owe inspiring complexity. Our ability to satisfactorily suppress neuropathic or other forms of chronic pain is limited. The number of pharmacodynamically distinct and clinically available medications is low and the successes achieved modest. Pain Medicine practitioners are confronted with the ethical dichotomy imposed by Hippocrates: On one hand the mandate of primum non nocere, on the other hand, the promise of heavenly joys if successful divinum est opus sedare dolorem. We briefly summarize the concepts associated with nociceptive pain from nociceptive input (afferents from periphery), modulatory output [descending noradrenergic (NE) and serotoninergic (5-HT) fibers] to local control. The local control is comprised of the "inflammatory soup" at the site of pain origin and synaptic relay stations, with an ATP-rich environment promoting inflammation and nociception while an adenosine-rich environment having the opposite effect. Subsequently, we address the transition from nociceptor pain to neuropathic pain (independent of nociceptor activation) and the process of sensitization and pain chronification (transient pain progressing into persistent pain). Having sketched a model of pain perception and processing we attempt to identify the sites and modes of action of clinically available drugs used in chronic pain treatment, focusing on adjuvant (co-analgesic) medication.
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Chung YS, Lin YC, Hung MS, Ho MC, Fang YH. Clinical Impact of Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitor Associated Clostridioides difficile Infection Among Patients with Lung Cancer. Onco Targets Ther 2022; 15:1563-1571. [PMID: 36597497 PMCID: PMC9805707 DOI: 10.2147/ott.s386807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 12/21/2022] [Indexed: 12/29/2022] Open
Abstract
Aim Epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKIs)-associated Clostridioides difficile infection (CDI) among lung cancer patients have been reported in case reports and adverse events reporting system databases in the United States and Japan, but clinical data remained insufficient. This study aims to evaluate CDI in lung cancer patients receiving EGFR-TKIs. Methods We conducted a retrospective cohort study using multi-institutional electronic medical records database. We included patients aged older than 20 years diagnosed with lung cancer and treated with EGFR-TKIs (gefitinib, erlotinib, afatinib). We defined EGFR-TKI initiation date as the index date and occurrence of diarrhea with CDI or without CDI as the event date. We followed patients from the index date until the event date, ICU admission, death, or 12/31/2019. Results We included 2242 diarrhea patients, 51 were EGFR-TKI with CDI cohort, and 2191 were diarrhea without CDI cohort. Patients who were concurrently taking antibiotics (hazard ratio [HR], 3.30; 95% CI, 1.67-6.5) and systemic steroids (HR, 4.9; 95% CI, 2.65-9.06) had an increased risk of CDI. First-generation EGFR-TKIs tended to be associated with an increased risk of CDI compared with afatinib (HR, 1.81, 95% CI, 0.94-3.47). EGFR-TKI with CDI had a higher ICU admission rate (HR, 3.42, 95% CI, 1.98-5.91) and mortality rate (HR, 2.34, 95% CI, 1.67-3.28) than diarrhea without CDI. Conclusion Patients with CDI had higher ICU admission rates and mortality rates than those without CDI. Concurrent use of antibiotics and systemic steroids were risk factors for CDI among patients with lung cancer receiving EGFR-TKIs. Afatinib was not associated with a higher risk of CDI than first-generation EGFR-TKIs.
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Affiliation(s)
- Ying-Shan Chung
- Department of Pharmacy, Chang Gung Memorial Hospital, Puzi City, Taiwan, Republic of China,Department of Nursing, Chang Gung University of Science and Technology, Puzi City, Taiwan, Republic of China
| | - Yu-Ching Lin
- Division of Thoracic Oncology, Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Puzi City, Taiwan, Republic of China,Department of Respiratory Care, Chang Gung University of Science and Technology, Puzi City, Taiwan, Republic of China
| | - Ming-Szu Hung
- Division of Thoracic Oncology, Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Puzi City, Taiwan, Republic of China,Department of Respiratory Care, Chang Gung University of Science and Technology, Puzi City, Taiwan, Republic of China,School of Medicine, College of Medicine, Chang Gung University; Guishan Township, Taoyuan, Taiwan, Republic of China
| | - Meng-Chin Ho
- Division of Thoracic Oncology, Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Puzi City, Taiwan, Republic of China
| | - Yu-Hung Fang
- Department of Nursing, Chang Gung University of Science and Technology, Puzi City, Taiwan, Republic of China,Division of Thoracic Oncology, Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Puzi City, Taiwan, Republic of China,Correspondence: Yu-Hung Fang, Division of Thoracic Oncology, Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Chiayi Branch, No. 6, W. Sec., Jiapu Road, Puzi City, Chiayi County, 61363, Taiwan, Republic of China, Tel +886-5-362-1000 ext. 2762, Fax +886-5-362-3005, Email
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Boeriu A, Roman A, Dobru D, Stoian M, Voidăzan S, Fofiu C. The Impact of Clostridioides Difficile Infection in Hospitalized Patients: What Changed during the Pandemic? Diagnostics (Basel) 2022; 12:diagnostics12123196. [PMID: 36553203 PMCID: PMC9778033 DOI: 10.3390/diagnostics12123196] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/03/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
(1) Background: Clostridioides difficile (C. difficile) and SARS-CoV-2 coronavirus represent significant health threats. Our study focused on the impact of concurrent infections on patient outcomes against the backdrop of changes imposed by the pandemic. (2) Materials and methods. We performed a retrospective analysis and included patients diagnosed with CDI who were admitted in our hospital before and during the pandemic. We compared patient exposure to risk factors for CDI in both groups and patient negative outcomes: need for ICU care, prolonged hospitalization, organ failure, toxic megacolon, and death. (3) Results. Overall, 188 patients were included, of which 100 had CDI (the pre-pandemic group), and 88 patients presented both CDI and COVID-19 (the pandemic group). Patients in the pandemic group were significantly older, with a higher Charlson Comorbidity Index (CCI) and a greater exposure to antibiotics and corticosteroids, and were more likely to develop organ dysfunction, to require ICU care and have prolonged hospitalization. The severity of COVID-19, leukocytosis and increased D-dimer levels were indicators of poor prognosis in the pandemic group. Higher CCI scores and leukocytosis increased the risk for negative outcomes in CDI alone patients. (4) Conclusions. The study highlights the negative impact of associated infections on patient outcome. The severity of COVID-19 directly influences the prognosis of patients with concurrent infections.
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Affiliation(s)
- Alina Boeriu
- Gastroenterology Department, University of Medicine Pharmacy, Sciences, and Technology “George Emil Palade” Targu Mures, 540142 Targu Mures, Romania
- Gastroenterology Department, Mureș County Clinical Hospital, 540103 Targu Mures, Romania
| | - Adina Roman
- Gastroenterology Department, University of Medicine Pharmacy, Sciences, and Technology “George Emil Palade” Targu Mures, 540142 Targu Mures, Romania
- Gastroenterology Department, Mureș County Clinical Hospital, 540103 Targu Mures, Romania
- Correspondence: (A.R.); (D.D.); Tel.: +40-(75)-2934465 (A.R.)
| | - Daniela Dobru
- Gastroenterology Department, University of Medicine Pharmacy, Sciences, and Technology “George Emil Palade” Targu Mures, 540142 Targu Mures, Romania
- Gastroenterology Department, Mureș County Clinical Hospital, 540103 Targu Mures, Romania
- Correspondence: (A.R.); (D.D.); Tel.: +40-(75)-2934465 (A.R.)
| | - Mircea Stoian
- Intensive Care Unit Department, University of Medicine Pharmacy, Sciences, and Technology “George Emil Palade” Targu Mures, 540142 Targu Mures, Romania
- Intensive Care Unit Department, Mureș County Clinical Hospital, 540103 Targu Mures, Romania
| | - Septimiu Voidăzan
- Epidemiology Department, University of Medicine Pharmacy, Sciences, and Technology “George Emil Palade” Targu Mures, 540142 Targu Mures, Romania
| | - Crina Fofiu
- Gastroenterology Department, University of Medicine Pharmacy, Sciences, and Technology “George Emil Palade” Targu Mures, 540142 Targu Mures, Romania
- Internal Medicine Department, Bistrița County Hospital, 420094 Bistrița, Romania
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Lilley D, Munthali P. Analysis of the management of ventriculitis cases at a UK neurosurgery centre. Infect Prev Pract 2022; 4:100240. [PMID: 36060478 PMCID: PMC9437802 DOI: 10.1016/j.infpip.2022.100240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 07/13/2022] [Indexed: 11/19/2022] Open
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Magnusson C, Mernelius S, Bengnér M, Norén T, Serrander L, Forshell S, Matussek A. Characterization of a Clostridioides difficile outbreak caused by PCR ribotype 046, associated with increased mortality. Emerg Microbes Infect 2022; 11:850-859. [PMID: 35240942 PMCID: PMC8942542 DOI: 10.1080/22221751.2022.2049981] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study describes a large nosocomial outbreak of Clostridioides difficile infections (CDI) dominated by ribotype (RT) 046 in a Swedish hospital. The present study aimed to examine the pathogenicity of this RT, explore epidemiological links by whole genome sequencing (WGS), and evaluate different interventions implemented to stop the outbreak. Clinical isolates (n = 366) collected during and after the outbreak were ribotyped and 246 isolates were subjected to WGS. Medical records of patients infected with the seven most common RTs were evaluated. RT046 was spread effectively throughout the hospital and was the most common among the 44 different RTs found (114/366 isolates). Infection with RT046 was associated with higher mortality compared to other strains (20.2% to 7.8%), although there were no differences in concomitant disease, age or antibiotic treatment. To control the outbreak, several measures were successfully implemented.
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Affiliation(s)
- Cecilia Magnusson
- Department of Infectious Diseases, Region Jönköping County, Jönköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Sara Mernelius
- Laboratory Medicine, Region Jönköping County, Jönköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Malin Bengnér
- Office for control of Communicable Diseases, Region Jönköping County, Jönköping, Sweden
| | - Torbjörn Norén
- Faculty of Medicine and Health, Department of Laboratory Medicine, National Reference Laboratory for Clostridioides difficile, Clinical Microbiology, Örebro University, Örebro, Sweden
| | - Lena Serrander
- Division of Clinical Microbiology, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | - Sophie Forshell
- Department of Infectious Diseases, Region Jönköping County, Jönköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Andreas Matussek
- Laboratory Medicine, Region Jönköping County, Jönköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Division of Laboratory Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Division of Laboratory Medicine, Oslo University Hospital, Oslo, Norway
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Fitzpatrick F, Safdar N, van Prehn J, Tschudin-Sutter S. How can patients with Clostridioides difficile infection on concomitant antibiotic treatment be best managed? THE LANCET. INFECTIOUS DISEASES 2022; 22:e336-e340. [PMID: 35617982 DOI: 10.1016/s1473-3099(22)00274-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/16/2022] [Accepted: 04/20/2022] [Indexed: 06/15/2023]
Abstract
Antibiotics are modifiable risk factors for Clostridioides difficile infection (CDI), driving pathogenesis via gut microbiome disruption. The management of patients with CDI prescribed concomitant non-CDI antibiotics is problematic and influences CDI outcome and recurrence risk. Though an assessment of the ongoing requirement for concomitant antibiotics is essential, discontinuation is often not possible. Antibiotics for other reasons might also need to be commenced during CDI therapy. Attempts to minimise the number and duration of antibiotics with a change to a low-risk class are recommended. Fidaxomicin might be preferable to vancomycin due to it having less effect on the gut microbiome; however, vancomycin is also acceptable. Metronidazole should be avoided and proton pump inhibitors discontinued. Access to fidaxomicin might be limited; hence, it should be prioritised for patients at high risk of recurrence. There is insufficient evidence to support extending anti-CDI therapy duration and concerns regarding microbiome effect remain. The addition of bezlotoxumab might be considered if multiple additional risk factors for recurrent CDI exist, though the amount of evidence is low. Investigational approaches to reduce the effect of concomitant antibiotics on the gut microbiome could further optimise CDI treatment in the presence of concomitant antibiotic use in the future.
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Affiliation(s)
- Fidelma Fitzpatrick
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Microbiology, Beaumont Hospital, Dublin, Ireland; ESCMID (European Society of Clinical Microbiology and Infectious Diseases), Basel, Switzerland
| | - Nasia Safdar
- Department of Medicine, University of Wisconsin-Madison and the William S Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Joffrey van Prehn
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, Netherlands; ESCMID (European Society of Clinical Microbiology and Infectious Diseases), Basel, Switzerland
| | - Sarah Tschudin-Sutter
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland; Department of Acute Medicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland; ESCMID (European Society of Clinical Microbiology and Infectious Diseases), Basel, Switzerland.
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Calatayud M, Duysburgh C, Van den Abbeele P, Franckenstein D, Kuchina-Koch A, Marzorati M. Long-Term Lactulose Administration Improves Dysbiosis Induced by Antibiotic and C. difficile in the PathoGut TM SHIME Model. Antibiotics (Basel) 2022; 11:1464. [PMID: 36358119 PMCID: PMC9686563 DOI: 10.3390/antibiotics11111464] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 09/28/2023] Open
Abstract
Clostridioides difficile infection (CDI) is the leading cause of antibiotic-associated diarrhea and an important nosocomial infection with different severity degrees. Disruption of the gut microbiota by broad-spectrum antibiotics creates a proper environment for C. difficile colonization, proliferation, and clinical disease onset. Restoration of the gut microbial ecosystem through prebiotic interventions can constitute an effective complementary treatment of CDI. Using an adapted simulator of the human gut microbial ecosystem, the PathoGutTM SHIME, the effect of different long-term and repeated dose lactulose treatments was tested on C. difficile germination and growth in antibiotic-induced dysbiotic gut microbiota environments. The results showed that lactulose reduced the growth of viable C. difficile cells following clindamycin treatment, shifted the antibiotic-induced dysbiotic microbial community, and stimulated the production of health-promoting metabolites (especially butyrate). Recovery of the gut microenvironment by long-term lactulose administration following CDI was also linked to lactate production, decrease in pH and modulation of bile salt metabolism. At a structural level, lactulose showed a significant bifidogenic potential and restored key commensal members of the gut ecosystem such as Lactobacillaceae, Veillonellaceae and Lachnospiraceae. These results support further human intervention studies aiming to validate the in vitro beneficial effects of lactulose on gut microbiome recovery during antibiotic exposure and CDI.
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Affiliation(s)
- Marta Calatayud
- ProDigest BV, Technologiepark 82, 9052 Ghent, Belgium
- Center of Microbial Ecology and Technology (CMET), Ghent University, Coupure Links 653, 9000 Ghent, Belgium
| | | | | | | | | | - Massimo Marzorati
- ProDigest BV, Technologiepark 82, 9052 Ghent, Belgium
- Center of Microbial Ecology and Technology (CMET), Ghent University, Coupure Links 653, 9000 Ghent, Belgium
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Risk factors for Clostridioides difficile infection in children: A systematic review and meta-analysis. J Hosp Infect 2022; 130:112-121. [PMID: 36108754 DOI: 10.1016/j.jhin.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Clostridioides difficile infection (CDI) is considered an urgent threat to human health by the US Centers for Disease Control and Prevention. In recent years, C. difficile is increasingly being reported as a cause of gastrointestinal diseases in children, and the prevalence of hospital-acquired CDI (HA-CDI) and community-acquired CDI (CA-CDI) in children is increasing. AIM To perform a systematic review and meta-analysis of risk factors for Clostridioides difficile infection (CDI) in children. METHODS MEDLINE/PubMed, EMBASE, Web of Science, Scopus, OVID, China National Knowledge Infrastructure, Wanfang (Chinese), SinoMed (Chinese), and Weipu (Chinese) databases were searched from inception through January 12, 2022. Observational studies (cohort, case-control, and cross-sectional) on CDI in children were included in the analysis. Data were pooled using a fixed or random-effects model, and odds ratios (ORs) were calculated. FINDINGS A total of 25 observational studies were included in the analysis. Prior antibiotic exposure (OR, 1.93; 95% confidence interval (CI), 1.25-2.97), prolonged hospitalization (OR, 14.68; 95% CI, 13.24-16.28), hospitalization history (OR, 3.67; 95% CI, 1.91-7.06), gastric acid suppressants (OR, 1.96; 95% CI, 1.41-2.73), male gender (OR, 1.18; 95% CI, 1.05-1.32), neoplastic disease (OR, 3.40; 95% CI, 2.85-4.07), immunodeficiency (OR, 4.18; 95% CI, 3.25-5.37), solid organ transplantation (OR, 4.56; 95% CI, 3.95-5.27) and enteral feeding (OR, 2.21; 95% CI, 1.15-4.62) were associated with an increased risk of CDI. CONCLUSION This systematic review and meta-analysis provides further evidence for the susceptibility factors of CDI to improve clinicians' awareness of CDI and effectively prevent C. difficile associated diarrhoea in children.
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Perić A, Rančić N, Dragojević-Simić V, Milenković B, Ljubenović N, Rakonjac B, Begović-Kuprešanin V, Šuljagić V. Association between Antibiotic Use and Hospital-Onset Clostridioides difficile Infection in University Tertiary Hospital in Serbia, 2011–2021: An Ecological Analysis. Antibiotics (Basel) 2022; 11:antibiotics11091178. [PMID: 36139957 PMCID: PMC9495030 DOI: 10.3390/antibiotics11091178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 08/24/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022] Open
Abstract
This ecological study is the largest to date examining the association between rates of antibiotic use (AU) and hospital-onset (HO) Clostridioides difficile infection (CDI) in a tertiary university hospital in Serbia. There was no clear trend in the incidence of HO-CDI over time. Total utilization of antibacterials for systemic use increased from 38.57 DDD/100 bed-days (BD) in 2011 to 56.39 DDD/100 BD in 2021. The most commonly used antibiotics were third-generation cephalosporins, especially ceftriaxone, with maximum consumption in 2021 (19.14 DDD/100 BD). The share of the Access group in the total utilization of antibiotics ranged from 29.95% to 42.96% during the observed period. The utilization of the Reserve group of antibiotics indicated a statistically significant increasing trend (p = 0.034). A statistically significant difference in the consumption of medium-risk antibiotics from 2011 to 2021 was shown for penicillins and a combination of sulfamethoxazole and trimethoprim. The consumption of cefotaxime showed a statistically significant negative association with the rate of HO-CDI (r = −0.647; p = 0.031). Ampicillin and the combination of amoxicilline with clavulanic acid have shown a negative statistically significant correlation with the ID of HO-CDI (r = −0.773 and r = −0.821, respectively). Moreover, there was a statistically significant negative correlation between consumption of “medium-risk antibiotics” and the rate of HO-CDI (r = −0.677). The next challenging step for the hospital multidisciplinary team for antimicrobials is to modify the antibiotic list according to the Access, Watch, and Reserve classification, in such a way that at least 60% of the AU should be from the Access group, according to the World Health Organization recommendation.
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Affiliation(s)
- Aneta Perić
- Department for Pharmacy, Military Medical Academy, 11000 Belgrade, Serbia
- Medical Faculty, Military Medical Academy, University of Defence, 11000 Belgrade, Serbia
| | - Nemanja Rančić
- Medical Faculty, Military Medical Academy, University of Defence, 11000 Belgrade, Serbia
- Centre for Clinical Pharmacology, Military Medical Academy, 11000 Belgrade, Serbia
- Correspondence:
| | - Viktorija Dragojević-Simić
- Medical Faculty, Military Medical Academy, University of Defence, 11000 Belgrade, Serbia
- Centre for Clinical Pharmacology, Military Medical Academy, 11000 Belgrade, Serbia
| | - Bojana Milenković
- Department for Pharmacy, Military Medical Academy, 11000 Belgrade, Serbia
| | - Nenad Ljubenović
- Institute of Epidemiology, Military Medical Academy, 11000 Belgrade, Serbia
| | - Bojan Rakonjac
- Institute of Medical Microbiology, Military Medical Academy, 11000 Belgrade, Serbia
| | - Vesna Begović-Kuprešanin
- Medical Faculty, Military Medical Academy, University of Defence, 11000 Belgrade, Serbia
- Clinic for Infectious and Tropic Diseases, Military Medical Academy, 11000 Belgrade, Serbia
| | - Vesna Šuljagić
- Medical Faculty, Military Medical Academy, University of Defence, 11000 Belgrade, Serbia
- Department of Healthcare-Related Infection Control, Military Medical Academy, 11000 Belgrade, Serbia
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Risk of antibiotics associated with Clostridioides difficile infection: Antibiotic stewardship in action. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e146. [PMID: 36483417 PMCID: PMC9726489 DOI: 10.1017/ash.2022.286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/15/2022] [Accepted: 07/18/2022] [Indexed: 02/08/2023]
Abstract
We examined risk associated with antibiotics used for Clostridioides difficile infection (CDI) at a single site from 2018 through 2020. Overall, 78 patients had nonrecurrent infections. Among inpatient antibiotics, intravenous meropenem had the highest CDI rate (3.56 per 1,000 days of therapy; n = 2 cases). Among outpatient antibiotics, metronidazole had the highest rate (0.071 per 1,000 pills dispensed; n = 3 cases).
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Risk of Gastrointestinal Infections After Initiating Vedolizumab and Anti-TNFα Agents for Ulcerative Colitis. J Clin Gastroenterol 2022:00004836-990000000-00040. [PMID: 36156528 PMCID: PMC9898464 DOI: 10.1097/mcg.0000000000001733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/20/2022] [Indexed: 02/06/2023]
Abstract
GOALS Characterize and compare the risk of Clostridioides difficile infection (CDI) and cytomegalovirus colitis (CMVC) after initiation of vedolizumab or anti-tumor necrosis factor (TNF)α agents for ulcerative colitis (UC). BACKGROUND Immunosuppression is a risk factor for gastrointestinal infections including CDI and CMVC among patients with UC; however, the risk according to the biological class is poorly understood. STUDY A retrospective cohort study of adults with UC involving the initiation of vedolizumab or anti-TNFα agents during June 1, 2014 to December 31, 2020 was conducted at a large academic health system. The primary outcomes for both CDI and CMVC analyses were first CDI or CMVC after biological initiation. The secondary outcome for the CDI analysis was severe CDI (>10,000 white blood cells or serum creatinine >1.5 mg/dL). Independent variables included demographics and UC history/severity factors. Inverse probability of treatment weighted Cox regression was performed to assess the hazard of CDI by biological group. Due to few outcomes, CMVC was reported descriptively. RESULTS A total of 805 UC patients initiated vedolizumab (n=195) or anti-TNFα agents (n=610). There were 43 CDIs and 11 severe CDIs over 1436 patient-years. The inverse probability of treatment weighted Cox regression demonstrated no association between CDI and vedolizumab versus anti-TNFα (hazard ratio 0.33, 95% confidence interval 0.05-2.03), but identified a significantly lower hazard of severe CDI for vedolizumab versus anti-TNFα (hazard ratio 0.10, 95% confidence interval 0.01-0.76). There were 5 cases of CMVC, all in the anti-TNFα group. CONCLUSIONS There was a lower adjusted risk of severe CDI but not total CDI associated with vedolizumab. CMVC was not observed after initiating vedolizumab. These findings may provide reassurance regarding the use of vedolizumab when also considering the risk of gastrointestinal infections.
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Squire N, Lux C, Tolbert K, Lidbury J, Sun X, Suchodolski JS. Characterization of the Fecal Microbiome in Dogs Receiving Medical Management for Congenital Portosystemic Shunts. Front Vet Sci 2022; 9:897760. [PMID: 35968011 PMCID: PMC9366551 DOI: 10.3389/fvets.2022.897760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 06/20/2022] [Indexed: 12/02/2022] Open
Abstract
Background The GI microbiome has not been characterized in dogs being medically managed for congenital portosystemic shunts (CPSS). Objectives To characterize the fecal microbiome in a population of dogs being medically managed for CPSS. Animals 27 client-owned dogs. Methods Prospective cohort study enrollment of fecal samples was performed with follow-up data collected retrospectively. The overall fecal dysbiosis index (DI) and individual bacterial abundances were determined using real-time qPCR. Medical management, clinical findings, clinicopathologic, and outcome variables were collected, and logistic regression analyses were performed to evaluate associations between these variables and overall DI and bacterial abundances. Numerical variables were evaluated with general linear models for normality and equal variance using Shapiro-Wilk test and Levene's test, respectively. Results All dogs were administered a hepatic diet and lactulose, while antibiotics were used in 22 (81.5%) and acid suppressants in 7 (25.9%). Seventeen dogs (63.0%) had a DI >2. The median DI in this population was 3.02 (range 4.23–8.42), and the median DI in dogs receiving and not receiving antibiotics was 4.3 (range −4.23–8.42) and 1.52 (range −1.62–5.43), respectively. No significant association between any of the analyzed variables and the DI was identified. There was a significant association between the use of metronidazole and a larger abundance of E. coli (p = 0.024). Conclusions and Clinical Importance Dysbiosis appears to be common in dogs that are being medically managed for CPSS, though the clinical significance remains unclear.
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Affiliation(s)
- Nathan Squire
- Department of Small Animal Clinical Sciences, University of Tennessee College of Veterinary Medicine, Knoxville, TN, United States
| | - Cassie Lux
- Department of Small Animal Clinical Sciences, University of Tennessee College of Veterinary Medicine, Knoxville, TN, United States
- *Correspondence: Cassie Lux
| | - Katie Tolbert
- Department of Veterinary Small Animal Clinical Sciences, Texas A&M College of Veterinary Medicine and Biomedical Sciences, College Station, TX, United States
| | - Jonathan Lidbury
- Department of Veterinary Small Animal Clinical Sciences, Texas A&M College of Veterinary Medicine and Biomedical Sciences, College Station, TX, United States
| | - Xiaocun Sun
- Office of Information and Technology, University of Tennessee Knoxville, Knoxville, TN, United States
| | - Jan S. Suchodolski
- Department of Veterinary Small Animal Clinical Sciences, Texas A&M College of Veterinary Medicine and Biomedical Sciences, College Station, TX, United States
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Poran I, Elbaz M, Turjeman A, Huberman Samuel M, Eliakim-Raz N, Nashashibi J, Paul M, Leibovici L. Predicting In-Hospital Antibiotic Use in the Medical Department: Derivation and Validation Study. Antibiotics (Basel) 2022; 11:antibiotics11060813. [PMID: 35740219 PMCID: PMC9219723 DOI: 10.3390/antibiotics11060813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/12/2022] [Accepted: 06/13/2022] [Indexed: 11/16/2022] Open
Abstract
Background: The rise of multi-drug-resistant pathogens and nosocomial infections among hospitalized patients is partially attributed to the increased use of antibiotic therapy. A prediction model for in-hospital antibiotic treatment could be valuable to target preventive strategies. Methods: This was a retrospective cohort study, including patients admitted in 2018 to medical departments and not treated with antibiotics during the first 48 h. Data available at hospital admission were used to develop a logistic model to predict the probability of antibiotic treatment during hospitalization. The performance of the model was evaluated in two independent validation cohorts. Results: In the derivation cohort, antibiotic treatment was initiated in 454 (8.1%) out of 5592 included patients. Male gender, lower functional capacity, prophylactic antibiotic treatment, medical history of atrial fibrillation, peripheral vascular disease, solid organ transplantation, chronic use of a central venous catheter, urinary catheter and nasogastric tube, albumin level, mental status and vital signs at presentation were identified as predictors for antibiotic use during hospitalization and were included in the prediction model. The area under the ROC curve (AUROC) was 0.72 (95% CI 0.70–0.75). In the highest probability group, the percentage of antibiotic treatment was 18.2% (238/1,307). In the validation cohorts, the AUROC was 0.73 (95% CI 0.68–0.77) and 0.75 (95% CI 0.72–0.78). In the highest probability group, the percentage of antibiotic treatment was 12.5% (66/526) and 20.7% (244/1179) of patients. Conclusions: Our prediction model performed well in the validation cohorts and was able to identify a subgroup of patients at high risk for antibiotic treatment.
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Affiliation(s)
- Itamar Poran
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petach Tikva 4941492, Israel; (M.E.); (A.T.); (M.H.S.); (N.E.-R.); (L.L.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Correspondence: ; Tel.: +972-524881870; Fax: +972-3-9376512
| | - Michal Elbaz
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petach Tikva 4941492, Israel; (M.E.); (A.T.); (M.H.S.); (N.E.-R.); (L.L.)
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah Tikva 4941492, Israel
| | - Adi Turjeman
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petach Tikva 4941492, Israel; (M.E.); (A.T.); (M.H.S.); (N.E.-R.); (L.L.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Maayan Huberman Samuel
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petach Tikva 4941492, Israel; (M.E.); (A.T.); (M.H.S.); (N.E.-R.); (L.L.)
| | - Noa Eliakim-Raz
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petach Tikva 4941492, Israel; (M.E.); (A.T.); (M.H.S.); (N.E.-R.); (L.L.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah Tikva 4941492, Israel
| | - Jeries Nashashibi
- Department of Medicine D, Rambam Health Care Campus, Haifa 3436212, Israel;
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa 3436212, Israel;
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3436212, Israel
| | - Leonard Leibovici
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petach Tikva 4941492, Israel; (M.E.); (A.T.); (M.H.S.); (N.E.-R.); (L.L.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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Tinelli M, Rossini A, Scudeller L, Zabzuni D, Errico G, Fogato E, D'Angelo R, Gentiloni Silverj F, Cesana E, Bergamaschini LC, Pasi F, Monaco M, Cerquetti M, Pantosti A, Giufrè M. Dynamics of carbapenemase-producing Enterobacterales intestinal colonisation in the elderly population after hospital discharge, Italy, 2018-2020. Int J Antimicrob Agents 2022; 59:106594. [PMID: 35483624 DOI: 10.1016/j.ijantimicag.2022.106594] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 04/12/2022] [Accepted: 04/17/2022] [Indexed: 02/03/2023]
Abstract
Carbapenemase-producing Enterobacterales (CPE) represent a serious threat to public health worldwide. Elderly patients are at increased risk of colonisation/infection with CPE. This study aimed to evaluate the persistence of CPE colonisation and the genotypic characteristics of persistent strains in elderly people discharged from Italian hospitals. A longitudinal study was conducted in two Italian cities (March 2018 to September 2020) enrolling 137 patients aged ≥65 years with CPE intestinal colonisation at hospital discharge. CPE colonisation was evaluated after 4, 8 and 12 months. Competing risk analysis was used to explore the association between baseline characteristics and persistence at 4 months. For all isolates, carbapenemase typing and multilocus sequence typing were performed. Persistent isolates underwent whole-genome sequencing. Of 137 patients, 91% carried carbapenemase-producing Klebsiella pneumoniae (CP-KP) and 8.8% carried carbapenemase-producing Escherichia coli. Although a large number of patients were lost to follow-up owing to death or withdrawal, 28/65 patients (43.1%) remained colonised at Month 4; 16/42 (38.1%) and 5/28 (17.9%) were found colonised up to Months 8 and 12, respectively. Colonisation persistence was more frequent in patients with bacteraemia or complicated urinary tract infection while in hospital and in those staying in long-term care facilities (LTCFs). Clonal characteristics of CP-KP isolates did not appear to influence persistence. Isolates obtained from each persistent carrier were identical or highly related by SNP phylogenetic analysis. Identification of patients at higher risk of persistent intestinal carriage after hospital discharge can prompt control measures to limit the transmission of CPE in the community, especially in LTCF settings.
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Affiliation(s)
- Marco Tinelli
- Italian Society of Infectious and Tropical Diseases (SIMIT), Prato, Italy; IRCCS Istituto Auxologico Italiano, San Luca Hospital, Milan, Italy
| | | | - Luigia Scudeller
- Research and Innovation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Dorjan Zabzuni
- IRCCS Istituto Auxologico Italiano, San Luca Hospital, Milan, Italy
| | - Giulia Errico
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Elena Fogato
- Laboratory of Clinical Microbiology, ASP 'Golgi-Redaelli', Milan, Italy
| | - Roberto D'Angelo
- Laboratory of Clinical Microbiology, ASP 'Golgi-Redaelli', Milan, Italy
| | | | | | | | - Francesca Pasi
- Medical Oncology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Monica Monaco
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Marina Cerquetti
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Annalisa Pantosti
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Maria Giufrè
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy.
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Waqas M, Mohib K, Saleem A, LNU M, Arjumand S, Khalil HHUR, Nosheen R, Abbas S, Maqsood KM, Abbas K. Rifaximin Therapy for Patients With Metronidazole-Unresponsive Clostridium difficile Infection. Cureus 2022; 14:e24140. [PMID: 35582554 PMCID: PMC9107305 DOI: 10.7759/cureus.24140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2022] [Indexed: 11/27/2022] Open
Abstract
Background Clostridium difficile infection (CDI) is a leading cause of hospital-acquired diarrhea. Rifaximin is an antibiotic that offers marginal resistance to C. difficile bacteria. This study was conducted to evaluate the efficacy of rifaximin in metronidazole non-responsive CDI patients. Methods A cross-sectional study was performed from August 2019 to May 2020 at the Lahore General Hospital, Lahore, Pakistan. A total of 200 cases were included. Patients who developed diarrhea after receiving antibiotics for seven days and a positive C. difficile toxin stool test as detected by the enzyme immunoassay (BioCheck, Inc., CA) were diagnosed with CDI. Only patients who were unresponsive to metronidazole therapy were enrolled in our analysis. Two groups were formed. The intervention group was administered 200 mg tablets of rifaximin three times a day for 10 days. For patients in the control group, no new treatment was started. The efficacy of rifaximin was defined in terms of the resolution of diarrhea after two weeks of therapy and a negative stool test. All data were recorded in a predefined pro forma. Results The mean age of 45.41 ± 8.54 years was found in the intervention group. The majority of the patients were aged 35-50 years. The majority of the patients had watery diarrhea, abdominal cramping, and loss of appetite on presentation. Rifaximin was found to be significantly effective in the resolution of symptoms of CDI, which was previously unresponsive to metronidazole (p<0.00001). it was found that the duration of diarrhea of more than three weeks was significantly associated with failure of therapy (p=0.03). Conclusion We concluded that rifaximin therapy is effective for patients of CDI non-responsive to metronidazole in more than 65% of the cases. Even though several new developments are made to address the concerned subject, such as microbiota transplantation, antibiotics, and immunotherapy, rifaximin can be considered for patients with metronidazole non-responsive CDI.
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Colonization of the live biotherapeutic product VE303 and modulation of the microbiota and metabolites in healthy volunteers. Cell Host Microbe 2022; 30:583-598.e8. [PMID: 35421353 DOI: 10.1016/j.chom.2022.03.016] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 12/22/2021] [Accepted: 03/10/2022] [Indexed: 11/20/2022]
Abstract
Manipulation of the gut microbiota via fecal microbiota transplantation (FMT) has shown clinical promise in diseases such as recurrent Clostridioides difficile infection (rCDI). However, the variable nature of this approach makes it challenging to describe the relationship between fecal strain colonization, corresponding microbiota changes, and clinical efficacy. Live biotherapeutic products (LBPs) consisting of defined consortia of clonal bacterial isolates have been proposed as an alternative therapeutic class because of their promising preclinical results and safety profile. We describe VE303, an LBP comprising 8 commensal Clostridia strains under development for rCDI, and its early clinical development in healthy volunteers (HVs). In a phase 1a/b study in HVs, VE303 is determined to be safe and well-tolerated at all doses tested. VE303 strains optimally colonize HVs if dosed over multiple days after vancomycin pretreatment. VE303 promotes the establishment of a microbiota community known to provide colonization resistance.
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In-hospital delay of surgery increases the rate of complicated appendicitis in patients presenting with short duration of symptoms: a retrospective cohort study. Eur J Trauma Emerg Surg 2022; 48:3879-3886. [PMID: 35211772 DOI: 10.1007/s00068-022-01912-3] [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: 09/29/2021] [Accepted: 01/29/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Current practice allows for surgery for acute appendicitis to be delayed up to 24 h in the belief that there will be no increase in complicated appendicitis rates. We evaluated the combined effect of Patient Time (between symptom onset and hospital admission) and Hospital Time (between hospital admission and surgery) on the surgical outcome. We hypothesized that in patients with a short Patient Time, increased Hospital Times will be associated with a higher rate of complicated appendicitis, even in patients operated within 24 h. METHODS Retrospective evaluation of medical files of patients operated for acute appendicitis between 12/2006 and 12/2016. RESULTS Of 2749 patients with acute appendicitis included in this analysis, 818 (29.8%) were admitted with symptom onset the same day as admission, 577 (21.0%) reported symptom onset had started the previous day but less than 24 h before admission, and 1354 (49.3%) had over 24 h of symptoms. In patients with symptom onset the same day, a gradual increase in the rate of complicated appendicitis was noted with increasing Hospital Times (≤ 6 h-6.3%; 6-12 h-9.9%; 12-18 h-14.7%; and 18-24 h-12.7%; p = 0.017). In all other patients no differences in the rate of complicated appendicitis were noted as long as the patients were operated within 24 h of admission. CONCLUSION In patients with a short Patient Time, delaying operation is associated with an increased rate of complicated appendicitis and this group of patients should be prioritized for early surgery. CLINICAL TRIALS Study registered as ClinicalTrials.gov Identifier: NCT04689906 ( https://clinicaltrials.gov/ct2/show/NCT04689906?term=ashkenazi+itamar&draw=2&rank=2 ).
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Whittle E, Yonkus JA, Jeraldo P, Alva-Ruiz R, Nelson H, Kendrick ML, Grys TE, Patel R, Truty MJ, Chia N. Optimizing Nanopore Sequencing for Rapid Detection of Microbial Species and Antimicrobial Resistance in Patients at Risk of Surgical Site Infections. mSphere 2022; 7:e0096421. [PMID: 35171692 PMCID: PMC8849348 DOI: 10.1128/msphere.00964-21] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Surgical site infections (SSI) are a significant burden to patients and health care systems. We evaluated the use of Nanopore sequencing (NS) to rapidly detect microbial species and antimicrobial resistance (AMR) genes present in intraoperative bile aspirates. Bile aspirates from 42 patients undergoing pancreatic head resection were included. Three methods of DNA extraction using mechanical cell lysis or protease cell lysis were compared to determine the optimum method of DNA extraction. The impact of host DNA depletion, sequence run duration, and use of different AMR gene databases was also assessed. To determine clinical value, NS results were compared to standard culture (SC) results. NS identified microbial species in all culture positive samples. Mechanical lysis improved NS detection of cultured species from 60% to 76%, enabled detection of fungal species, and increased AMR predictions. Host DNA depletion improved detection of streptococcal species and AMR correlation with SC. Selection of AMR database influenced the number of AMR hits and resistance profile of 13 antibiotics. AMR prediction using CARD and ResFinder 4.1 correctly predicted 79% and 81% of the bile antibiogram, respectively. Sequence run duration positively correlated with detection of AMR genes. A minimum of 6 h was required to characterize the biliary microbes, resulting in a turnaround time of 14 h. Rapid identification of microbial species and AMR genes can be achieved by NS. NS results correlated with SC, suggesting that NS may be useful in guiding early antimicrobial therapy postsurgery. IMPORTANCE Surgical site infections (SSI) are a significant burden to patients and health care systems. They increase mortality rates, length of hospital stays, and associated health care costs. To reduce the risk of SSI, surgical patients are administered broad-spectrum antibiotics that are later adapted to target microbial species detected at the site of surgical incision. Use of broad-spectrum antibiotics can be harmful to the patient. We wanted to develop a rapid method of detecting microbial species and their antimicrobial resistance phenotypes. We developed a method of detecting microbial species and predicting resistance phenotypes using Nanopore sequencing. Results generated using Nanopore sequencing were similar to current methods of detection but were obtained in a significantly shorter amount of time. This suggests that Nanopore sequencing could be used to tailor antibiotics in surgical patients and reduce use of broad-spectrum antibiotics.
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Affiliation(s)
- Emma Whittle
- Division of Surgical Research, Department of Surgery, Mayo Clinicgrid.66875.3a, Rochester, Minnesota, USA
| | - Jennifer A. Yonkus
- Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, Mayo Clinicgrid.66875.3a, Rochester, Minnesota, USA
| | - Patricio Jeraldo
- Division of Surgical Research, Department of Surgery, Mayo Clinicgrid.66875.3a, Rochester, Minnesota, USA
| | - Roberto Alva-Ruiz
- Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, Mayo Clinicgrid.66875.3a, Rochester, Minnesota, USA
| | - Heidi Nelson
- Division of Research and Optimal Patient Care, Cancer Programs, American College of Surgeonsgrid.417954.a, Chicago, Illinois, USA
| | - Michael L. Kendrick
- Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, Mayo Clinicgrid.66875.3a, Rochester, Minnesota, USA
| | - Thomas E. Grys
- Department of Laboratory Medicine and Pathology, Mayo Clinicgrid.66875.3a, Phoenix, Arizona, USA
| | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinicgrid.66875.3a, Rochester, Minnesota, USA
| | - Mark J. Truty
- Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, Mayo Clinicgrid.66875.3a, Rochester, Minnesota, USA
| | - Nicholas Chia
- Division of Surgical Research, Department of Surgery, Mayo Clinicgrid.66875.3a, Rochester, Minnesota, USA
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Carlson TJ, Gonzales-Luna AJ, Garey KW. Fulminant Clostridioides difficile Infection: A Review of Treatment Options for a Life-Threatening Infection. Semin Respir Crit Care Med 2022; 43:28-38. [PMID: 35172356 DOI: 10.1055/s-0041-1740973] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Fulminant Clostridioides difficile infection (FCDI) encompasses 3 to 5% of all CDI cases with associated mortality rates between 30 and 40%. Major treatment modalities include surgery and medical management with antibiotic and nonantibiotic therapies. However, identification of patients with CDI that will progress to FCDI is difficult and makes it challenging to direct medical management and identify those who may benefit from surgery. Furthermore, since it is difficult to study such a critically ill population, data investigating treatment options are limited. Surgical management with diverting loop ileostomy (LI) instead of a total abdominal colectomy (TAC) with end ileostomy has several appealing advantages, and studies have not consistently demonstrated a clinical benefit with this less-invasive strategy, so both LI and TAC remain acceptable surgical options. Successful medical management of FCDI is complicated by pharmacokinetic changes that occur in critically ill patients, and there is an absence of high-quality studies that included patients with FCDI. Recommendations accordingly include a combination of antibiotics administered via multiple routes to ensure adequate drug concentrations in the colon: intravenous metronidazole, high-dose oral vancomycin, and rectal vancomycin. Although fidaxomicin is now recommended as first-line therapy for non-FCDI, there are limited clinical data to support its use in FCDI. Several nonantibiotic therapies, including fecal microbiota transplantation and intravenous immunoglobulin, have shown success as adjunctive therapies, but they are unlikely to be effective alone. In this review, we aim to summarize diagnosis and treatment options for FCDI.
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Affiliation(s)
- Travis J Carlson
- Department of Clinical Sciences, High Point University Fred Wilson School of Pharmacy, High Point, North Carolina
| | - Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas
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