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Zaidi SMH, Haider R, Kazmi SAB, Husnain A, Khan S, Merchant S, Tayyab H, Wazeen FR, Chaudhary AJ. Beyond Antibiotics: Novel Approaches in the Treatment of Recurrent Clostridioides difficile Infection. ACG Case Rep J 2024; 11:e01333. [PMID: 39081300 PMCID: PMC11286250 DOI: 10.14309/crj.0000000000001333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/06/2024] [Indexed: 08/02/2024] Open
Affiliation(s)
| | - Ramsha Haider
- Karachi Medical and Dental College, Karachi, Pakistan
| | | | - Ali Husnain
- Department of Medicine, King Edward Medical University, Lahore, Pakistan
| | - Saniah Khan
- Department of Medicine, King Edward Medical University, Lahore, Pakistan
| | | | - Hamnah Tayyab
- Department of Medicine, King Edward Medical University, Lahore, Pakistan
| | - Fazl Rahim Wazeen
- Department of Medicine, Greater Baltimore Medical Center, Towson, MD
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Stămăteanu LO, Pleşca CE, Miftode IL, Bădescu AC, Manciuc DC, Hurmuzache ME, Roșu MF, Miftode RȘ, Obreja M, Miftode EG. " Primum, non nocere": The Epidemiology of Toxigenic Clostridioides difficile Strains in the Antibiotic Era-Insights from a Prospective Study at a Regional Infectious Diseases Hospital in Eastern Europe. Antibiotics (Basel) 2024; 13:461. [PMID: 38786189 PMCID: PMC11117487 DOI: 10.3390/antibiotics13050461] [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: 04/11/2024] [Revised: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 05/25/2024] Open
Abstract
Clostridioides difficile infection (CDI), though identified nearly five decades ago, still remains a major challenge, being associated with significant mortality rates. The strains classified as hypervirulent, notably 027/NAP1/BI, have garnered substantial attention from researchers and clinicians due to their direct correlation with the severity of the disease. Our study aims to elucidate the significance of toxigenic Clostridioides difficile (CD) strains in the clinical and therapeutic aspects of managing patients diagnosed with CDI. We conducted a single-center prospective study, including patients with CDI from north-eastern Romania. We subsequently conducted molecular biology testing to ascertain the prevalence of the presumptive 027/NAP1/BI strain within aforementioned geographic region. The patients were systematically compared and assessed both clinically and biologically, employing standardized and comparative methodologies. The study enrolled fifty patients with CDI admitted between January 2020 and June 2020. Among the investigated patients, 43 (86%) exhibited infection with toxigenic CD strains positive for toxin B genes (tcdB), binary toxin genes (cdtA and cdtB), and deletion 117 in regulatory genes (tcdC), while the remaining 7 (14%) tested negative for binary toxin genes (cdtA and cdtB) and deletion 117 in tcdC. The presence of the presumptive 027/NAP1/BI strains was linked to a higher recurrence rate (35.56%, p = 0.025), cardiovascular comorbidities (65.1% vs. 14.2%, p = 0.016), and vancomycin treatment (55.8% vs. 14.3%, p = 0.049). The findings of our investigation revealed an elevated incidence of colitis attributed to presumptive 027/NAP1/BI. Despite the prevalence of the presumptive 027 strain and its associated heightened inflammation among the patients studied, no significant differences were observed regarding the clinical course or mortality outcomes.
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Affiliation(s)
- Lidia Oana Stămăteanu
- Department of Infectious Diseases, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (L.O.S.); (D.C.M.); (M.E.H.); (M.O.); (E.G.M.)
- “St. Parascheva” Clinical Hospital of Infectious Diseases, 700116 Iasi, Romania; (A.C.B.); (M.F.R.)
| | - Claudia Elena Pleşca
- Department of Infectious Diseases, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (L.O.S.); (D.C.M.); (M.E.H.); (M.O.); (E.G.M.)
- “St. Parascheva” Clinical Hospital of Infectious Diseases, 700116 Iasi, Romania; (A.C.B.); (M.F.R.)
| | - Ionela Larisa Miftode
- Department of Infectious Diseases, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (L.O.S.); (D.C.M.); (M.E.H.); (M.O.); (E.G.M.)
- “St. Parascheva” Clinical Hospital of Infectious Diseases, 700116 Iasi, Romania; (A.C.B.); (M.F.R.)
| | - Aida Corina Bădescu
- “St. Parascheva” Clinical Hospital of Infectious Diseases, 700116 Iasi, Romania; (A.C.B.); (M.F.R.)
- Department of Preventive Medicine and Interdisciplinarity, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Doina Carmen Manciuc
- Department of Infectious Diseases, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (L.O.S.); (D.C.M.); (M.E.H.); (M.O.); (E.G.M.)
- “St. Parascheva” Clinical Hospital of Infectious Diseases, 700116 Iasi, Romania; (A.C.B.); (M.F.R.)
| | - Mihnea Eudoxiu Hurmuzache
- Department of Infectious Diseases, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (L.O.S.); (D.C.M.); (M.E.H.); (M.O.); (E.G.M.)
- “St. Parascheva” Clinical Hospital of Infectious Diseases, 700116 Iasi, Romania; (A.C.B.); (M.F.R.)
| | - Manuel Florin Roșu
- “St. Parascheva” Clinical Hospital of Infectious Diseases, 700116 Iasi, Romania; (A.C.B.); (M.F.R.)
- Surgical (Dentoalveolar and Maxillofacial Surgery) Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Radu Ștefan Miftode
- Department of Internal Medicine I (Cardiology), “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Maria Obreja
- Department of Infectious Diseases, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (L.O.S.); (D.C.M.); (M.E.H.); (M.O.); (E.G.M.)
- “St. Parascheva” Clinical Hospital of Infectious Diseases, 700116 Iasi, Romania; (A.C.B.); (M.F.R.)
| | - Egidia Gabriela Miftode
- Department of Infectious Diseases, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (L.O.S.); (D.C.M.); (M.E.H.); (M.O.); (E.G.M.)
- “St. Parascheva” Clinical Hospital of Infectious Diseases, 700116 Iasi, Romania; (A.C.B.); (M.F.R.)
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Kutsuna S, Ohbe H, Matsui H, Yasunaga H. Analysis of the effectiveness of combination antimicrobial therapy for Legionnaires' disease: A nationwide inpatient database study. Int J Infect Dis 2024; 142:106965. [PMID: 38367954 DOI: 10.1016/j.ijid.2024.02.008] [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: 11/16/2023] [Revised: 02/11/2024] [Accepted: 02/12/2024] [Indexed: 02/19/2024] Open
Abstract
OBJECTIVES The effectiveness of monotherapy and combination therapy with quinolones and macrolides for treating Legionnaires' disease remains uncertain; this study aimed to assess the comparative effectiveness of three treatment approaches. METHODS Using a nationwide inpatient database, we analyzed 3560 eligible patients hospitalized for Legionnaires' disease between April 1, 2014, and March 31, 2021; patients were divided into combination therapy, quinolone monotherapy, and macrolide monotherapy groups according to the antibiotics administered within 2 days of admission. We compared in-hospital mortality, total hospitalization costs, and length of stay across these groups using multiple propensity score analysis with inverse probability of treatment weighting. RESULTS Of the 3560 patients, there were 564 (15.8%), 2221 (62.4%), and 775 (21.8%) patients in the combination therapy, quinolone monotherapy, and macrolide monotherapy groups, respectively. No significant differences were observed in in-hospital mortality between combination therapy and quinolone monotherapy groups, and between combination therapy and macrolide monotherapy groups. There were no significant differences in total hospitalization costs or length of stay among the three groups. CONCLUSION The study suggests that there may not be a significant advantage in using a combination of quinolones and macrolides over monotherapy for the treatment of Legionnaires' disease. Given the potential for increased side effects, careful consideration is advised when choosing this combination therapy.
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Affiliation(s)
- Satoshi Kutsuna
- Department of Infection Control, Department of Infection Control, Graduate School of Medicine Faculty of Medicine, Osaka University, Osaka, Japan.
| | - Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan; Department of Emergency and Critical Care Medicine, Tohoku University Hospital, Aoba-ku, Sendai, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
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Vandervelde R, Mlynarek ME, Ramesh M, Patel N, Veve MP, August BA. Impact of time to treatment in first occurrence, non-severe Clostridioides difficile infection for elderly patients: are we waiting too long to treat? ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e59. [PMID: 38698948 PMCID: PMC11062792 DOI: 10.1017/ash.2024.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 03/03/2024] [Accepted: 03/07/2024] [Indexed: 05/05/2024]
Abstract
Objective Data evaluating timeliness of antibiotic therapy in Clostridioides difficile infections (CDI) are not well established. The study's purpose was to evaluate the impact of time-to-CDI treatment on disease progression. Methods A case-control study was performed among hospitalized patients with CDI from 1/2018 to 2/2022. Inclusion criteria were age ≥65 years, first occurrence, non-severe CDI at symptom onset, and CDI treatment for ≥72 hours. Cases included patients who progressed to severe or fulminant CDI; controls were patients without CDI progression. Time to CDI treatment was evaluated in three ways: a classification and regression tree (CART)-defined threshold, time as a continuous variable, and time as a categorical variable. Results 272 patients were included; 136 with CDI progression, 136 patients without. The median (IQR) age was 74 (69-81) years, 167 (61%) were women, and 108 (40%) were immunosuppressed. CDI progression patients more commonly were toxin positive (66 [49%] vs 52 [38%], P = .087) with hospital-acquired disease (57 [42%] vs 29 [21%], P < 0.001). A CART-derived breakpoint for optimal time-to-CDI treatment of 64 hours established early (184, 68%) and delayed treatment (88, 32%). When accounting for confounding variables, delayed CDI treatment was associated with disease progression (adjOR, 4.6; 95%CI, 2.6-8.2); this was observed regardless of how time-to-CDI-active therapy was evaluated (continuous adjOR, 1.02; categorical adjOR, 2.11). Conclusion Delayed CDI treatment was associated with disease progression and could represent an important antimicrobial stewardship measure with future evaluation.
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Affiliation(s)
| | | | - Mayur Ramesh
- Department of Infectious Diseases, Henry Ford Hospital, Detroit, MI, USA
| | - Nimish Patel
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, CA, USA
| | - Michael P. Veve
- Department of Pharmacy, Henry Ford Hospital, Detroit, MI, USA
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA
| | - Benjamin A. August
- Department of Pharmacy, Henry Ford Hospital, Detroit, MI, USA
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA
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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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Tartof SY, Schmidt MA, Contreras R, Angulo FJ, Florea A, Barreras JL, Donald J, Zamparo J, Grant DL, Shuster E, Gonzalez E, Kuntz JL. Burden of Medically Attended Diarrhea and Outpatient Clostridioides difficile Infection Among Persons in 2 Large Integrated Healthcare Settings, 2016-2021. Open Forum Infect Dis 2024; 11:ofad680. [PMID: 38250203 PMCID: PMC10798856 DOI: 10.1093/ofid/ofad680] [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: 10/02/2023] [Indexed: 01/23/2024] Open
Abstract
Background Identification of Clostridioides difficile infection (CDI) in the community setting is increasing. We describe testing for CDI among patients with medically attended diarrhea (MAD) in the outpatient setting, and the incidence of outpatient CDI. Methods This was a retrospective cohort study among members ≥18 years of age from Kaiser Permanente Southern California and Kaiser Permanente Northwest from 1 January 2016 through 31 December 2021. MAD was identified by outpatient diarrheal International Classification of Diseases, Tenth Revision diagnosis codes, and CDI through positive laboratory results. Outpatient CDI was defined by no hospitalization ≤7 days after specimen collection. Incidence rates (IRs) of outpatient CDI were stratified by select demographic and clinical variables. Outpatient CDI burden 12 months following index date was measured by CDI-associated healthcare visits, and CDI testing and treatment. Results We identified 777 533 MAD episodes; 12.1% (93 964/777 533) were tested for CDI. Of those tested, 10.8% (10 110/93 964) were positive. Outpatient CDI IR was 51.0 (95% confidence interval [CI], 49.8-52.2) per 100 000 person-years, decreasing from 58.2 (95% CI, 55.7-60.7) in 2016 to 45.7 (95% CI, 43.7-47.8) in 2021. Approximately 44% (n = 4200) received an antibiotic 30 days prior to index date and 84.1% (n = 8006) CDIs were "community-associated" (no hospitalizations 12 weeks prior to index date). Of outpatient CDIs, 6.7% (n = 526) had a CDI-associated hospitalization ≤12 months. Conclusions There was a high incidence of outpatient CDI despite infrequent CDI testing among patients with MAD. The majority of those with outpatient CDI had no recent antibiotic use and no recent hospitalization. Further studies are needed to understand the source and management of medically attended outpatient CDI.
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Affiliation(s)
- Sara Y Tartof
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Mark A Schmidt
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
- Science Programs Department, Kaiser Permanente Northwest Center for Health Research, Portland, Oregon, USA
| | - Richard Contreras
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Frederick J Angulo
- Vaccines, Antivirals, and Evidence Generation, Pfizer Inc, NewYork, New York, USA
| | - Ana Florea
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Joanna L Barreras
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Judy Donald
- Science Programs Department, Kaiser Permanente Northwest Center for Health Research, Portland, Oregon, USA
| | - Joann Zamparo
- Vaccines, Antivirals, and Evidence Generation, Pfizer Inc, NewYork, New York, USA
| | - Deborah Ling Grant
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Elizabeth Shuster
- Science Programs Department, Kaiser Permanente Northwest Center for Health Research, Portland, Oregon, USA
| | - Elisa Gonzalez
- Vaccines, Antivirals, and Evidence Generation, Pfizer Inc, NewYork, New York, USA
| | - Jennifer L Kuntz
- Science Programs Department, Kaiser Permanente Northwest Center for Health Research, Portland, Oregon, USA
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Miller AC, Arakkal AT, Sewell DK, Segre AM, Tholany J, Polgreen PM. Comparison of Different Antibiotics and the Risk for Community-Associated Clostridioides difficile Infection: A Case-Control Study. Open Forum Infect Dis 2023; 10:ofad413. [PMID: 37622034 PMCID: PMC10444966 DOI: 10.1093/ofid/ofad413] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 07/31/2023] [Indexed: 08/26/2023] Open
Abstract
Background Antibiotics are the greatest risk factor for Clostridioides difficile infection (CDI). Risk for CDI varies across antibiotic types and classes. Optimal prescribing and stewardship recommendations require comparisons of risk across antibiotics. However, many prior studies rely on aggregated antibiotic categories or are underpowered to detect significant differences across antibiotic types. Using a large database of real-world data, we evaluate community-associated CDI risk across individual antibiotic types. Methods We conducted a matched case-control study using a large database of insurance claims capturing longitudinal health care encounters and medications. Case patients with community-associated CDI were matched to 5 control patients by age, sex, and enrollment period. Antibiotics prescribed within 30 days before the CDI diagnosis along with other risk factors, including comorbidities, health care exposures, and gastric acid suppression were considered. Conditional logistic regression and a Bayesian analysis were used to compare risk across individual antibiotics. A sensitivity analysis of antibiotic exposure windows between 30 and 180 days was conducted. Results We identified 159 404 cases and 797 020 controls. Antibiotics with the greatest risk for CDI included clindamycin and later-generation cephalosporins, and those with the lowest risk included minocycline and doxycycline. We were able to differentiate and order individual antibiotics in terms of their relative level of associated risk for CDI. Risk estimates varied considerably with different exposure windows considered. Conclusions We found wide variation in CDI risk within and between classes of antibiotics. These findings ordering the level of associated risk across antibiotics can help inform tradeoffs in antibiotic prescribing decisions and stewardship efforts.
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Affiliation(s)
- Aaron C Miller
- University of Iowa, Carver College of Medicine, Iowa City, Iowa, USA
| | - Alan T Arakkal
- University of Iowa, College of Public Health, Iowa City, Iowa, USA
| | - Daniel K Sewell
- University of Iowa, College of Public Health, Iowa City, Iowa, USA
| | - Alberto M Segre
- Department of Computer Science, University of Iowa, Iowa City, Iowa, USA
| | - Joseph Tholany
- University of Iowa, Carver College of Medicine, Iowa City, Iowa, USA
| | - Philip M Polgreen
- University of Iowa, Carver College of Medicine, Iowa City, Iowa, USA
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AlKhormi A, Altheyabi AM, AlGhamdi SA, Alshahrani O, Alotay AA, Deeb A. The prevalence and clinical characteristics of Clostridium difficile infection in Saudi patients admitted with inflammatory bowel disease: A case-control study. Saudi J Gastroenterol 2023; 29:251-255. [PMID: 37282448 PMCID: PMC10445497 DOI: 10.4103/sjg.sjg_476_22] [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] [Received: 11/07/2022] [Revised: 12/22/2022] [Accepted: 05/04/2023] [Indexed: 06/08/2023] Open
Abstract
Background Inflammatory bowel disease (IBD) patients are at increased risk of Clostridium difficile infection (CDI), causing significant morbidity and mortality. This study examined CDI's prevalence, predisposing factors, and clinical outcomes in Saudi hospitalized IBD patients. Methods : A retrospective case-control study was conducted at a tertiary medical city in Riyadh, Saudi Arabia. All Saudi adult patients with IBD, admitted over the preceding four years were identified from the hospital's database. Eligible patients were divided into those with CDI and those without CDI. Binary logistic regression was used to determine the predisposing factors for CDI among admitted IBD patients. Results During the study period, 95 patients were admitted with IBD. Crohn's disease (CD) was the predominant type (71.6%), whereas 28.4% of the patients were with ulcerative colitis (UC). Only 16 (16.8%) patients had positive CDI. CDI-positive patients tend to have hypertension and previous use of steroids. Patients with UC tend to have a higher risk of CDI than those with CD. Most patients recovered from the CDI (81.3%) with a median time to CDI clearance of 14 days. Three patients (18.8%) had recurrent CDI; among them, one died. Conclusion The prevalence of CDI in Saudi IBD patients is similar to that reported elsewhere. UC, steroid treatment, and hypertension are risk factors for CDI in IBD patients. Recurrence of CDI in IBD patients is common and associated with a poor prognosis.
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Affiliation(s)
- Abdulrahman AlKhormi
- Department of Internal Medicine, Gastroenterology Division, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
- Division of Gastroenterology, Department of Internal Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abdullah M. Altheyabi
- Department of Internal Medicine, Gastroenterology Division, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
- Division of Gastroenterology, Department of Internal Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Saud A. AlGhamdi
- Department of Internal Medicine, Gastroenterology Division, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Osama Alshahrani
- Department of Internal Medicine, Gastroenterology Division, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Abdulwahed A. Alotay
- Department of Medicine, College of Medicine, Imam Mohammad Bin Saud Islamic University, Riyadh, Saudi Arabia
| | - Ahmad Deeb
- Division of Gastroenterology, Department of Internal Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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Olsen MA, Stwalley D, Tipping AD, Keller MR, Yu H, Dubberke ER. Trends in the incidence of Clostridioides difficile infection in adults and the elderly insured by Medicaid compared to commercial insurance or Medicare only. Infect Control Hosp Epidemiol 2023; 44:1076-1084. [PMID: 36082779 PMCID: PMC9995604 DOI: 10.1017/ice.2022.208] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Few data are available to quantify the Clostridioides difficile infection (CDI) burden in US adults depending on Medicaid insurance status; thus, we sought to contribute to this body of information. METHODS Retrospective cohort study to identify adults with codes for CDI from 2011 to 2017 in MarketScan commercial and Medicaid databases (for those aged 25-64 years) and the CMS Medicare database (for those aged ≥65 years). CDI was categorized as healthcare-facility-associated (HCA-CDI) and community-associated CDI (CA-CDI). CDI incidence rates were compared by year, insurer, and age group. RESULTS The overall CDI incidence in the elderly was 3.1-fold higher in persons insured by Medicare plus Medicaid than in those insured by Medicare only (1,935 vs 618 per 100,000 person years (PY)), and the CDI incidence was 2.7-fold higher in younger adults with Medicaid compared to commercial insurance (195 vs 73 per 100,000 PY). From 2011 to 2017, HCA-CDI rates declined in the younger Medicaid population (124.0 to 95.2 per 100,000 PY; P < .001) but were stable in those commercially insured (25.9 to 24.8 per 100,000 PY; P = .33). In the elderly HCA-CDI rates declined from 2011 to 2017 in the Medicare-only population (403 to 318 per 100,000 PY; P < .001) and the Medicare plus Medicaid population (1,770 to 1,163 per 100,000 PY; P < .002). Persons with chronic medical conditions and those with immunocompromising conditions insured by Medicaid had 2.8- and 2.7-fold higher CDI incidence compared to the commercially insured population, respectively. The incidence of CDI was lowest in Medicaid and commercially insured younger adults without chronic medical or immunosuppressive conditions (67.5 and 45.6 per 100,000 PY, respectively). CONCLUSIONS Although HCA-CDI incidence decreased from 2011 to 2017 in elderly and younger adults insured by Medicaid, the burden of CDI remains much higher in low-income adults insured by Medicaid.
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Affiliation(s)
- Margaret A. Olsen
- Department of Medicine, Washington University School of Medicine, St. Louis, MO
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Dustin Stwalley
- Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Andrew D. Tipping
- Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Matthew R. Keller
- Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | | | - Erik R. Dubberke
- Department of Medicine, Washington University School of Medicine, St. Louis, MO
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Wrynn AF. An overview of penicillin allergies for nurses. Nursing 2023; 53:27-31. [PMID: 37074275 DOI: 10.1097/01.nurse.0000923664.66265.a4] [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: 04/20/2023]
Abstract
ABSTRACT Antibiotics are frequently reported as allergies by patients, particularly antibiotics from the penicillin family. Most of these reported allergies are benign, and the consequences of alternative therapies can be significant. This article provides background information on penicillin allergies and serves as a guide to penicillin allergy management.Reprinted with permission from Wrynn, A.F. An overview of penicillin allergies for nurses. Nurse Pract 2022; 47(9): 30-36. Copyright Wolters Kluwer. All rights reserved.
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Affiliation(s)
- Alexander F Wrynn
- Alexander F. Wrynn is an infectious diseases nurse practitioner at Allegheny Health Network in Pittsburgh, Pa
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Ciuntu BM, Balan GG, Buna-Arvinte M, Abdulan IM, Papancea A, Toma ȘL, Veliceasa B, Bădulescu OV, Ghiga G, Fătu AM, Vascu MB, Moldovanu A, Vintilă D, Vasilescu AM. Clostridium difficile Infections in an Emergency Surgical Unit from North-East Romania. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050830. [PMID: 37241061 DOI: 10.3390/medicina59050830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/19/2023] [Accepted: 04/23/2023] [Indexed: 05/28/2023]
Abstract
Background and Objectives: Colitis with Clostridium difficile is an important health problem that occurs with an intensity that varies between mild and severe. Surgical interventions are required only in fulminant forms. There is little evidence regarding the best surgical intervention in these cases. Materials and Methods: Patients with C. difficile infection were identified from the two surgery clinics from the 'Saint Spiridon' Emergency Hospital Iași, Romania. Data regarding the presentation, indication for surgery, antibiotic therapy, type of toxins, and post-operative outcomes were collected over a 3-year period. Results: From a total of 12,432 patients admitted for emergency or elective surgery, 140 (1.12%) were diagnosed with C. difficile infection. The mortality rate was 14% (20 cases). Non-survivors had higher rates of lower-limb amputations, bowel resections, hepatectomy, and splenectomy. Additional surgery was necessary in 2.8% of cases because of the complications of C. difficile colitis. In three cases, terminal colostomy was performed and as well as one case with subtotal colectomy with ileostomy. All patients who required the second surgery died within the 30-day mortality period. Conclusions: In our prospective study, the incidence was increased both in cases of patients with interventions on the colon and in those requiring limb amputations. Surgical interventions are rarely required in patients with C. difficile colitis.
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Affiliation(s)
- Bogdan Mihnea Ciuntu
- Department of General Surgery, "Grigore T. Popa" University of Medicine and Pharmacy, Universitatii Street, No. 16, 700115 Iasi, Romania
| | - Gheorghe G Balan
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, Universitatii Street, No. 16, 700115 Iasi, Romania
| | - Mihaela Buna-Arvinte
- Department of General Surgery, "Grigore T. Popa" University of Medicine and Pharmacy, Universitatii Street, No. 16, 700115 Iasi, Romania
| | - Irina Mihaela Abdulan
- Department of Medical Specialties I, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Adelina Papancea
- Department of General Surgery, "Grigore T. Popa" University of Medicine and Pharmacy, Universitatii Street, No. 16, 700115 Iasi, Romania
| | - Ștefan Lucian Toma
- Department of Materials Engineering and Industrial Security, Faculty of Materials Science and Engineering, Gheorghe Asachi Technical University of Iasi, 700050 Iasi, Romania
| | - Bogdan Veliceasa
- Department of Traumatology and Orthopaedics, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Oana Viola Bădulescu
- Department of Haematholohy, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Gabriela Ghiga
- Department of Mother and Child Medicine, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Ana Maria Fătu
- Department of Implantology Removable Denture Technology, Discipline of Ergonomy, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Mihai Bogdan Vascu
- Department of Odontology, Periodontology and Fixed Prosthesis, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Antonia Moldovanu
- Department of Odontology, Periodontology and Fixed Prosthesis, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Dan Vintilă
- Department of General Surgery, "Grigore T. Popa" University of Medicine and Pharmacy, Universitatii Street, No. 16, 700115 Iasi, Romania
| | - Alin Mihai Vasilescu
- Department of General Surgery, "Grigore T. Popa" University of Medicine and Pharmacy, Universitatii Street, No. 16, 700115 Iasi, Romania
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Stojanovic P, Harmanus C, Kuijper EJ. Community-onset Clostridioides difficile infection in south Serbia. Anaerobe 2023; 79:102669. [PMID: 36455757 DOI: 10.1016/j.anaerobe.2022.102669] [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: 09/01/2022] [Revised: 11/15/2022] [Accepted: 11/20/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Data from the past decade indicates that Clostridioides difficile infection (CDI) is not only a nosocomial infection but is also increasingly recognized as a disease in the community. OBJECTIVE We aimed to study community-onset (CO) CDI in the various age groups in south Serbia with its clinical characteristics, risk factors and microbiological characterization. METHODS The study group included 93 patients with CO-CDI (median age 62). The control group consisted of 186 patients with community-onset diarrhea and stool samples negative tested for CDI. RESULTS Of all CDI cases diagnosed with a community onset, 74.19% had a previous contact with a healthcare facility in the previous 12 weeks, but 34.40% have no record on hospitalization in the previous 12 months. Using a multivariate statistical regression model, the following risk factors for CO-CDI development were found; antacid usage (OR = 0.267, 95%C.I.:0.10-0.291, p < 0.01), chronic kidney disease (OR = 0.234, 95%C.I.:0.10-0.51, p < 0.01) and antibiotic use during the prior 2 months (OR = 0.061, 95%C.I.:0.02-0.17, p < 0.01), especially tetracycline's (OR = 0.146, 95% C.I.:0.07-0.22, p < 0.01) and cephalosporin's (OR = 0.110, 95%C.I.:0.14-0.42, p < 0.01). The most common ribotypes (RTs) detected in patients with CO-CDI were RT001 (32.3%) and RT027 (24.7%). All tested toxin producing C. difficile isolates were sensitive to metronidazole, vancomycin and tigecycline. A high rate of resistance to moxifloxacin (73.11%) and rifampicin (23.65%) was found. CONCLUSION Patients with CO-CDI had frequently contact with healthcare facility in the previous 12 weeks. Restriction of antacid usage and of high-risk antibiotics in the community may help reduce the incidence of CO-CDI.
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Affiliation(s)
- Predrag Stojanovic
- Faculty of Medicine, University of Niš, Zorana Đinđića 50, 18000, Niš, Serbia; Institute for Public Health Nis, Center of Microbiology, 18000, Niš, Serbia(1).
| | - Celine Harmanus
- Department of Medical Microbiology, Center for Infectious Diseases, National Expertise Center for Clostridioides difficile infections, National Institute of Public Health and the Environment, Leiden University Medical Center, PO Box 9600, 2300RC, Leiden, the Netherlands
| | - Ed J Kuijper
- Department of Medical Microbiology, Center for Infectious Diseases, National Expertise Center for Clostridioides difficile infections, National Institute of Public Health and the Environment, Leiden University Medical Center, PO Box 9600, 2300RC, Leiden, the Netherlands
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13
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Muñoz Cuevas C, Asencio Egea MÁ, Franco Huerta M, Huertas Vaquero M, Arias Arias Á, Carranza González R. Case-control study of Clostridioides difficile in a rural health care area. GASTROENTEROLOGIA Y HEPATOLOGIA 2023; 46:1-9. [PMID: 35104606 DOI: 10.1016/j.gastrohep.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 12/12/2021] [Accepted: 01/20/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To determine the risk and prognostic factors for Clostridioides difficile infection (CDI). PATIENTS AND METHODS Prospective, case-control study with 61 cases and 64 controls, aged ≥2 years with diarrhoea, carried out in Castilla-La Mancha Health Care Area for 14 months. The diagnosis was made by immunochromatography technics (glutamate dehydrogenase and toxin A/B), confirming discordant cases by isothermal amplification. Demographic variables, comorbidities, type of acquisition, previous administration of antibiotics, antacids and immunosuppressants, and evolution were collected. The data were analysed using the chi-square test and the effect of risk and prognostic factors was quantified using an odds ratio with 95% confidence intervals. RESULTS Hospital admission 4 weeks prior to infection, hypoalbuminemia, and previous administration of antibiotics were identified as independent risk factors for CDI. Presenting these 3 factors constitutes nearly 3-fold increase in the risk of becoming infected. A greater number of hospital admissions in the 4-12 weeks prior to CDI were found in the group of nosocomial acquisition. Although there was a greater tendency to recurrence and an unfavourable prognosis among nosocomial cases, these differences were not significant. We found that fever and hospital admission in the 4 weeks prior to infection were unfavourable prognostic factors of CDI. CONCLUSIONS The independent risk factors for CDI were: Hospital admission in the 4 weeks prior to infection, hypoalbuminemia, and previous administration of antibiotics. Fever and hospitalisation in the previous 4 weeks were also identified as prognostic factors of unfavourable evolution.
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Affiliation(s)
- Cristina Muñoz Cuevas
- Laboratorio de Microbiología, Hospital General La Mancha Centro, Ciudad Real, España
| | | | - María Franco Huerta
- Servicio de Medicina Interna, Hospital General La Mancha Centro, Ciudad Real, España
| | - María Huertas Vaquero
- Laboratorio de Microbiología, Hospital General La Mancha Centro, Ciudad Real, España
| | - Ángel Arias Arias
- Unidad de Apoyo a la Investigación, Hospital General La Mancha Centro, Ciudad Real, España
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Enkirch T, Mernelius S, Magnusson C, Kühlmann‐Berenzon S, Bengnér M, Åkerlund T, Rizzardi K. Molecular epidemiology of community- and hospital-associated Clostridioides difficile infections in Jönköping, Sweden, October 2017 - March 2018. APMIS 2022; 130:661-670. [PMID: 35980252 PMCID: PMC9826108 DOI: 10.1111/apm.13270] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 08/17/2022] [Indexed: 01/11/2023]
Abstract
Clostridioides difficile infections (CDIs) in Sweden are mostly hospital-associated (HA) with limited knowledge regarding community-associated (CA) infections. Here, we investigated the molecular epidemiology of clinical isolates of CA-CDI and HA-CDI in a Swedish county. Data and isolates (n = 156) of CDI patients (n = 122) from Jönköping county, October 2017-March 2018, were collected and classified as CA (without previous hospital care or onset ≤2 days after admission or >12 weeks after discharge from hospital) or HA (onset >3 days after hospital admission or within 4 weeks after discharge). Molecular characterization of isolates included PCR ribotyping (n = 156 isolates) and whole genome sequencing with single nucleotide polymorphisms (SNP) analysis (n = 53 isolates). We classified 47 patients (39%) as CA-CDI and 75 (61%) as HA-CDI. Between CA-CDI and HA-CDI patients, we observed no statistically significant differences regarding gender, age, 30-day mortality or recurrence. Ribotype 005 (RR 3.1; 95% CI: 1.79-5.24) and 020 (RR 2.5; 95% CI: 1.31-4.63) were significantly associated with CA-CDI. SNP analysis identified seven clusters (0-2 SNP difference) involving 17/53 isolates of both CA-CDI and HA-CDI. Molecular epidemiology differed between CA-CDI and HA-CDI and WGS analysis suggests transmission of CDI within and between hospitals and communities.
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Affiliation(s)
- Theresa Enkirch
- Public Health Agency of SwedenSolnaSweden,European Programme for Public Health Microbiology Training (EUPHEM), European Centre for Disease Prevention and Control (ECDC)StockholmSweden
| | - Sara Mernelius
- Laboratory MedicineRegion Jönköping CountyJönköpingSweden,Department of Biomedical and Clinical SciencesLinköping UniversityLinköpingSweden
| | - Cecilia Magnusson
- Department of Biomedical and Clinical SciencesLinköping UniversityLinköpingSweden,Department of Infectious DiseasesRegion Jönköping CountyJönköpingSweden
| | | | - Malin Bengnér
- Office for Control of Communicable DiseasesRegion Jönköping CountyJönköpingSweden
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Tsai BY, Chien CC, Huang SH, Zheng JY, Hsu CY, Tsai YS, Hung YP, Ko WC, Tsai PJ. The emergence of Clostridioides difficile PCR ribotype 127 at a hospital in northeastern Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2022; 55:896-909. [PMID: 35042668 DOI: 10.1016/j.jmii.2021.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 10/27/2021] [Accepted: 12/25/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Several studies have highlighted the incidence of Clostridioides difficile infections (CDIs) in Taiwan and certain ribotypes have been related to severe clinical diseases. A study was conducted to investigate the polymerase chain reaction (PCR) ribotypes and genetic relatedness of clinical C. difficile strains collected from January 2009 to December 2015 at a hospital in northeastern Taiwan. MATERIAL AND METHODS A modified two-step typing algorithm for C. difficile was used by combining a modified 8-plex and 3'-truncated tcdA screening PCR. In addition, MLVA typing was adopted for investigation of bacterial clonality and transmission. RESULTS Among a total of 86 strains, 24 (28%) were nontoxigenic and 62 (72%) had both tcdA and tcdB (A + B+). No tcdA-negative and tcdB-positive (A-B+) strains were identified. Binary toxin (CDT)-producing (cdtA+/cdtB+) strains were started to be identified in 2013. The 21 (34%) A+B+ clinical strains with binary toxin and tcdC deletion were identified as RT127 strains, which contained both RT078-lineage markers and fluoroquinolone (FQ)-resistant mutations (Thr82Ile in gyrA). Multiple loci variable-number tandem repeat analysis (MLVA) for phylogenetic relatedness of RT127 strains indicated that 20 of 21 strains belonged to a clonal complex that was identical to a clinical strain collected from southern Taiwan in 2011, suggestive of a clonal expansion in Taiwan. CONCLUSION A two-step typing method could rapidly confirm species identification and define the toxin gene profile of C. difficile isolates. The clonal expansion of RT127 strains in Taiwan indicates monitoring and surveillance of toxigenic C. difficile isolates from human, animal, and environment are critical to develop One Health prevention strategies.
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Affiliation(s)
- Bo-Yang Tsai
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Chun-Chih Chien
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan.
| | - Shu-Huan Huang
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Kee-Lung, Keelung, Taiwan.
| | - Jun-Yuan Zheng
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital at Kee-Lung, Kee-Lung, Taiwan.
| | - Chih-Yu Hsu
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Tainan, Taiwan.
| | - Yau-Sheng Tsai
- Institute of Clinical Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Yuan-Pin Hung
- Departments of Internal Medicine, Tainan Hospital, Ministry of Health & Welfare, Tainan, Taiwan; Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Pei-Jane Tsai
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Tainan, Taiwan; Center of Infectious Disease and Signaling Research, National Cheng Kung University, Tainan, Taiwan; Department of Pathology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Infectious Diseases Management in Wound Care Settings: Common Causative Organisms and Frequently Prescribed Antibiotics. Adv Skin Wound Care 2022; 35:535-543. [PMID: 36125453 DOI: 10.1097/01.asw.0000855744.86686.ea] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
GENERAL PURPOSE To provide information about the management of infected wounds in wound care settings. TARGET AUDIENCE This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES After participating in this educational activity, the participant will:1. Identify a host factor that may predispose a patient to a wound infection as well as characteristics of each stage of wound infection.2. Distinguish a common organism that causes early, acute wound infections and explain the preferred method for obtaining a wound specimen for culture.3. Apply knowledge of commonly prescribed antibiotics in wound care settings.
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Penicillin allergies: A guide for NPs. Nurse Pract 2022; 47:30-36. [PMID: 36006817 DOI: 10.1097/01.npr.0000855312.11145.78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Antibiotics are frequently reported as allergies by patients, particularly antibiotics from the penicillin family. Most of these reported allergies are benign, and the consequences of alternative therapies can be significant. This article will deliver background information on penicillin allergies and serve as a guide to penicillin allergy management.
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Kutsuna S, Ohbe H, Matsui H, Yasunaga H. Effectiveness of fluoroquinolone antimicrobials in addition to tetracyclines for Japanese spotted fever: A retrospective analysis using a national inpatient database. Int J Infect Dis 2022; 123:70-75. [PMID: 35987471 DOI: 10.1016/j.ijid.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/08/2022] [Accepted: 08/10/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES This study aim to evaluate the effectiveness of fluoroquinolone (FQ) antimicrobial therapy in combination with tetracyclines (TCs) in patients with Japanese spotted fever (JSF) using a nationwide inpatient database in Japan. METHODS We identified hospitalized patients diagnosed with JSF who were enrolled in the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2021. Patients who received FQ plus TC on the day of admission were compared with patients who received TC alone on the day of admission, using inverse probability of treatment weighting. The primary outcome was in-hospital mortality. Secondary outcomes were in-hospital complications, total hospitalization costs, and length of hospital stay. RESULTS We identified 1060 eligible patients. Of these, 434 (41%) received FQ plus TC on the day of admission and 626 (59%) received TC alone on the day of admission. Inverse probability of treatment weighting showed no statistically significant differences between the groups in in-hospital mortality, in-hospital complications, total hospitalization costs, and length of hospital stay. CONCLUSION This study did not show any significantly improved effectiveness using FQ antimicrobials in combination with TCs for treating JSF. Clinicians may need to be cautious in administering FQ and TC antimicrobials concomitantly in routine practice.
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Affiliation(s)
- Satoshi Kutsuna
- Department of Infection Control, Department of Infection Control, Graduate School of Medicine Faculty of Medicine, Osaka University, 2-2, Yamadaoka, Suita-City, Osaka, Japan.
| | - Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 1130033, Japan.
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 1130033, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 1130033, Japan
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Risk Factors, Diagnosis, and Management of Clostridioides difficile Infection in Patients with Inflammatory Bowel Disease. Microorganisms 2022; 10:microorganisms10071315. [PMID: 35889034 PMCID: PMC9319314 DOI: 10.3390/microorganisms10071315] [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: 05/05/2022] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 12/10/2022] Open
Abstract
Clostridioides difficile infection (CDI) and inflammatory bowel disease (IBD) are two pathologies that share a bidirectional causal nexus, as CDI is known to have an aggravating effect on IBD and IBD is a known risk factor for CDI. The colonic involvement in IBD not only renders the host more prone to an initial CDI development but also to further recurrences. Furthermore, IBD flares, which are predominantly set off by a CDI, not only create a need for therapy escalation but also prolong hospital stay. For these reasons, adequate and comprehensive management of CDI is of paramount importance in patients with IBD. Microbiological diagnosis, correct evaluation of clinical status, and consideration of different treatment options (from antibiotics and fecal microbiota transplantation to monoclonal antibodies) carry pivotal importance. Thus, the aim of this article is to review the risk factors, diagnosis, and management of CDI in patients with IBD.
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Lis Ł, Konieczny A, Sroka M, Ciszewska A, Krakowska K, Gołębiowski T, Hruby Z. Clinical Determinants Predicting Clostridioides difficile Infection among Patients with Chronic Kidney Disease. Antibiotics (Basel) 2022; 11:antibiotics11060785. [PMID: 35740191 PMCID: PMC9220164 DOI: 10.3390/antibiotics11060785] [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: 05/10/2022] [Revised: 06/03/2022] [Accepted: 06/08/2022] [Indexed: 11/17/2022] Open
Abstract
The majority of recently published studies indicate a greater incidence rate and mortality due to Clostridioides difficile infection (CDI) in patients with chronic kidney disease (CKD). The aim of this study was to assess the clinical determinants predicting CDI among hospitalized patients with CKD and refine methods of prevention. We evaluated the medical records of 279 patients treated at a nephrological department with symptoms suggesting CDI, of whom 93 tested positive for CDI. The survey showed that age, poor kidney function, high Padua prediction score (PPS) and patients’ classification of care at admission, treatment with antibiotics, and time of its duration were significantly higher or more frequent among patients who suffered CDI. Whereas BMI, Norton scale (ANSS) and serum albumin concentration were significantly lowered among CDI patients. In a multivariate analysis we proved the stage of CKD and length of antibiotics use increased the risk of CDI, whereas higher serum albumin concentration and ANSS have a protective impact.
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Affiliation(s)
- Łukasz Lis
- Research and Development Center, Department of Nephrology, Provincial Specialist Hospital, Kamienskiego 73a, 51-124 Wroclaw, Poland; (Ł.L.); (M.S.); (Z.H.)
- Department of Internal Medicine, University Hospital, Witosa 23, 45-401 Opole, Poland
| | - Andrzej Konieczny
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (K.K.); (T.G.)
- Correspondence: ; Tel.: +48-717332536
| | - Michał Sroka
- Research and Development Center, Department of Nephrology, Provincial Specialist Hospital, Kamienskiego 73a, 51-124 Wroclaw, Poland; (Ł.L.); (M.S.); (Z.H.)
| | - Anna Ciszewska
- Department of Intensive Care and Anesthesiology, Provincial Specialist Hospital, Kamienskiego 73a, 51-124 Wroclaw, Poland;
| | - Kornelia Krakowska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (K.K.); (T.G.)
| | - Tomasz Gołębiowski
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (K.K.); (T.G.)
| | - Zbigniew Hruby
- Research and Development Center, Department of Nephrology, Provincial Specialist Hospital, Kamienskiego 73a, 51-124 Wroclaw, Poland; (Ł.L.); (M.S.); (Z.H.)
- Department of Clinical Nursing, Wroclaw Medical University, Bartla 5, 51-618 Wroclaw, Poland
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Risk Factors for Hospital Readmission for Clostridioides difficile Infection: A Statewide Retrospective Cohort Study. Pathogens 2022; 11:pathogens11050555. [PMID: 35631075 PMCID: PMC9147200 DOI: 10.3390/pathogens11050555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/27/2022] [Accepted: 05/07/2022] [Indexed: 02/01/2023] Open
Abstract
(1) Background: Clostridioides difficile infection (CDI) is associated with a high recurrence rate, and a significant proportion of patients with CDI are readmitted following discharge. We aimed to identify the risk factors for CDI-related readmission within 90 days following an index hospital stay for CDI. (2) Methods: We analyzed the electronic medical data of admitted patients in our health system over a two-year period. A multivariate logistic regression model, supplemented with bias-corrected and accelerated confidence intervals (BCa-CI), was implemented to assess the risk factors. (3) Results: A total of 1253 adult CDI index cases were included in the analysis. The readmission rate for CDI within 90 days of discharge was 11% (140/1253). The risk factors for CDI-related readmission were fluoroquinolone exposure within 90 days before the day of index CDI diagnosis (aOR: 1.58, 95% CI: 1.05–2.37), higher Elixhauser comorbidity score (aOR: 1.05, 95% CI: 1.02–1.07), and being discharged home (aOR: 1.64, 95% CI: 1.06–2.54). In contrast, a longer length of index stay (aOR: 0.97, 95% BCa-CI: 0.95–0.99) was associated with reduced odds of readmission for CDI. (4) Conclusion: More than 1 out of 10 patients were readmitted for CDI following an index hospital stay for CDI. Patients with recent previous fluoroquinolone exposure, greater overall comorbidity burden, and those discharged home are at higher risk of readmission for CDI.
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Miller AC, Arakkal AT, Sewell DK, Segre AM, Pemmaraju SV, Polgreen PM. Risk for Asymptomatic Household Transmission of Clostridioides difficile Infection Associated with Recently Hospitalized Family Members. Emerg Infect Dis 2022; 28:932-939. [PMID: 35447064 PMCID: PMC9045444 DOI: 10.3201/eid2805.212023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
We evaluated whether hospitalized patients without diagnosed Clostridioides difficile infection (CDI) increased the risk for CDI among their family members after discharge. We used 2001–2017 US insurance claims data to compare monthly CDI incidence between persons in households with and without a family member hospitalized in the previous 60 days. CDI incidence among insurance enrollees exposed to a recently hospitalized family member was 73% greater than enrollees not exposed, and incidence increased with length of hospitalization among family members. We identified a dose-response relationship between total days of within-household hospitalization and CDI incidence rate ratio. Compared with persons whose family members were hospitalized <1 day, the incidence rate ratio increased from 1.30 (95% CI 1.19–1.41) for 1–3 days of hospitalization to 2.45 (95% CI 1.66–3.60) for >30 days of hospitalization. Asymptomatic C. difficile carriers discharged from hospitals could be a major source of community-associated CDI cases.
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Chang CK, Chien WC, Hsu WF, Chiao HY, Chung CH, Tzeng YS, Huang SW, Ou KL, Wang CC, Chen SJ, Wang DS. Positive Association Between Fluoroquinolone Exposure and Tendon Disorders: A Nationwide Population-Based Cohort Study in Taiwan. Front Pharmacol 2022; 13:814333. [PMID: 35387340 PMCID: PMC8978711 DOI: 10.3389/fphar.2022.814333] [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] [Received: 12/03/2021] [Accepted: 02/23/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction: Fluoroquinolone exposure is reportedly associated with a higher risk of tendon disorders, tendonitis, or tendon rupture. However, studies in East Asian populations have not confirmed these risks in patients with comorbidities or concomitant medication use. This cohort study was designed to investigate the associations among fluoroquinolone exposure, comorbidities, medication use, and tendon disorders in Taiwan. Materials and Methods: This population-based, nationwide, observational, cohort study used data from the National Health Insurance Research database in Taiwan, a nationwide claims database that covers more than 99% of the Taiwanese population. The study period was from January 2000 to December 2015, and the median follow-up time was 11.05 ± 10.91 years. Patients who were exposed to fluoroquinolones for more than three consecutive days were enrolled, and patients without fluoroquinolone exposure who were matched by age, sex, and index year were enrolled as controls. The associations of comorbidities and concomitant medication use with tendon disorder occurrence were analyzed using Cox regression models. Results: The incidence of tendon disorders were 6.61 and 3.34 per 105 person-years in patients with and without fluoroquinolone exposure, respectively (adjusted hazard ratio, 1.423; 95% confidence interval [1.02,1.87]; p = 0.021). Sensitivity analyses yielded similar results. Patients under 18 and over 60 years with fluoroquinolone exposure; those with chronic kidney disease, diabetes, rheumatologic disease, cardiac disease, lipid disorder, or obesity; and those who concomitantly used statins, aromatase inhibitors, or glucocorticoids, had a significantly higher risk of tendon disorders. Conclusion: The long-term risk of tendon disorders was higher in patients with fluoroquinolone exposure than in those without fluoroquinolone exposure. Clinicians should assess the benefits and risks of fluoroquinolone use in patients at high risk of tendon disorders who require fluoroquinolone administration.
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Affiliation(s)
- Chun-Kai Chang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,Department of Surgery, Zouying Branch of Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
| | - Wu-Chien Chien
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,School of Public Health, National Defense Medical Center, Taipei, Taiwan.,Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Wan-Fu Hsu
- Department of Pediatrics, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Hao-Yu Chiao
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chi-Hsiang Chung
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,School of Public Health, National Defense Medical Center, Taipei, Taiwan.,Taiwanese Injury Prevention and Safety Promotion Association, Taipei, Taiwan
| | - Yuan-Sheng Tzeng
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shao-Wei Huang
- Department of Pediatrics, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Kuang-Ling Ou
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Chien Wang
- Department of Pediatrics, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Shyi-Jou Chen
- Department of Pediatrics, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Der-Shiun Wang
- Department of Pediatrics, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
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24
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Forrester JD, Cao S, Schaps D, Liou R, Patil A, Stave C, Sokolow SH, Leo GD. Influence of Socioeconomic and Environmental Determinants of Health on Human Infection and Colonization with Antibiotic-Resistant and Antibiotic-Associated Pathogens: A Scoping Review. Surg Infect (Larchmt) 2022; 23:209-225. [DOI: 10.1089/sur.2021.348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Joseph D. Forrester
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Siqi Cao
- School of Medicine, Stanford University, Stanford, California, USA
| | - Diego Schaps
- School of Medicine, Duke University, Durham, North Carolina, USA
| | - Raymond Liou
- School of Medicine, Stanford University, Stanford, California, USA
| | | | - Christopher Stave
- School of Medicine, Stanford University, Stanford, California, USA
- Lane Medical Library, Stanford University, Stanford, California, USA
| | - Susanne H. Sokolow
- Woods Institute for the Environment, Stanford University, Stanford, California, USA
- Marine Science Institute, University of California Santa Barbara, Santa Barbara, California, USA
| | - Giulio De Leo
- Woods Institute for the Environment, Stanford University, Stanford, California, USA
- Hopkins Marine Station, Stanford University, Stanford, California, USA
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25
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Flock G, Yin HB, Chen CH, Pellissery AJ, Venkitanarayanan K. Survivability of Clostridioides difficile spores in fermented pork summer sausage during refrigerated storage. Vet World 2022; 15:162-167. [PMID: 35369600 PMCID: PMC8924379 DOI: 10.14202/vetworld.2022.162-167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 12/23/2021] [Indexed: 01/05/2023] Open
Abstract
Background and Aim: Clostridioides difficile is a spore-forming pathogen that causes serious enteric disease in humans. Strains have been isolated from food animals and meat, including pork, which suggest a potential for foodborne transmission. Pork summer sausage is a popular fermented meat product, which is consumed cooked or cooked to a lower internal temperature due to acidification of the product. The effect of acidity and cooking on the viability of C. difficile spores in a fermented meat product has not been determined. Therefore, the aim was to study the survivability of C. difficile spores in fermented pork summer sausage. Materials and Methods: Fermented pork sausages were prepared according to a commercial recipe with or without starter culture and C. difficile spores followed by fermentation at 37°C for ~12 h under 85% relative humidity until pH 5.0 was reached and further processed as cooked (>57°C) or uncooked (≤57°C) and stored at 4°C. C. difficile spores in sausages were enumerated at 1 h following inoculation and on days 0, 1, 7, 14, 21, 30, 60, and 90 of storage. Results: It was observed that C. difficile spore viability in control unfermented treatment was significantly different on day 0 from the fermented, fermented cooked, and control unfermented cooked treatments (p<0.05); however, there was no significant difference among the latter three treatment groups throughout 90 days of storage (p>0.05). On day 90 of storage, the unfermented control sausages yielded ~4.0 log colony-forming unit (CFU)/g of C. difficile spores compared to ~3.5 log CFU/g recovered from fermented samples and the unfermented cooked control samples identifying spore viability in all treatment groups. Conclusion: C. difficile spores were found to survive the acidity and cooking of fermented pork summer sausage and storage at 4°C for 3 months, thereby highlighting the need for effective intervention strategies to reduce the risk of C. difficile contamination in pork products.
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Affiliation(s)
- Genevieve Flock
- Combat Capabilities Development Command Soldier Center, Soldier Sustainment Directorate, Combat Feeding Division, Natick 01760, Massachusetts, United States
| | - Hsin-Bai Yin
- Department of Agriculture, USDA Agricultural Research Service, Beltsville, Maryland 20705, United States
| | - Chi-Hung Chen
- Department of Agriculture, USDA Agricultural Research Service, Beltsville, Maryland 20705, United States
| | - Abraham Joseph Pellissery
- Department of Animal Science, University of Connecticut, College of Agriculture Health and Natural Resources, Mansfield 06269, Connecticut, United States
| | - Kumar Venkitanarayanan
- Department of Animal Science, University of Connecticut, College of Agriculture Health and Natural Resources, Mansfield 06269, Connecticut, United States
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26
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Feuerstadt P, Louie TJ, Lashner B, Wang EEL, Diao L, Bryant JA, Sims M, Kraft CS, Cohen SH, Berenson CS, Korman LY, Ford CB, Litcofsky KD, Lombardo MJ, Wortman JR, Wu H, Auniņš JG, McChalicher CWJ, Winkler JA, McGovern BH, Trucksis M, Henn MR, von Moltke L. SER-109, an Oral Microbiome Therapy for Recurrent Clostridioides difficile Infection. N Engl J Med 2022; 386:220-229. [PMID: 35045228 DOI: 10.1056/nejmoa2106516] [Citation(s) in RCA: 224] [Impact Index Per Article: 112.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Current therapies for recurrent Clostridioides difficile infection do not address the disrupted microbiome, which supports C. difficile spore germination into toxin-producing bacteria. SER-109 is an investigational microbiome therapeutic composed of purified Firmicutes spores for the treatment of recurrent C. difficile infection. METHODS We conducted a phase 3, double-blind, randomized, placebo-controlled trial in which patients who had had three or more episodes of C. difficile infection (inclusive of the qualifying acute episode) received SER-109 or placebo (four capsules daily for 3 days) after standard-of-care antibiotic treatment. The primary efficacy objective was to show superiority of SER-109 as compared with placebo in reducing the risk of C. difficile infection recurrence up to 8 weeks after treatment. Diagnosis by toxin testing was performed at trial entry, and randomization was stratified according to age and antibiotic agent received. Analyses of safety, microbiome engraftment, and metabolites were also performed. RESULTS Among the 281 patients screened, 182 were enrolled. The percentage of patients with recurrence of C. difficile infection was 12% in the SER-109 group and 40% in the placebo group (relative risk, 0.32; 95% confidence interval [CI], 0.18 to 0.58; P<0.001 for a relative risk of <1.0; P<0.001 for a relative risk of <0.833). SER-109 led to less frequent recurrence than placebo in analyses stratified according to age stratum (relative risk, 0.24 [95% CI, 0.07 to 0.78] for patients <65 years of age and 0.36 [95% CI, 0.18 to 0.72] for those ≥65 years) and antibiotic received (relative risk, 0.41 [95% CI, 0.22 to 0.79] with vancomycin and 0.09 [95% CI, 0.01 to 0.63] with fidaxomicin). Most adverse events were mild to moderate and were gastrointestinal in nature, with similar numbers in the two groups. SER-109 dose species were detected as early as week 1 and were associated with bile-acid profiles that are known to inhibit C. difficile spore germination. CONCLUSIONS In patients with symptom resolution of C. difficile infection after treatment with standard-of-care antibiotics, oral administration of SER-109 was superior to placebo in reducing the risk of recurrent infection. The observed safety profile of SER-109 was similar to that of placebo. (Funded by Seres Therapeutics; ECOSPOR III ClinicalTrials.gov number, NCT03183128.).
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Affiliation(s)
- Paul Feuerstadt
- From Yale University School of Medicine, New Haven, and PACT Gastroenterology Center, Hamden - both in Connecticut (P.F.); the University of Calgary and Foothills Medical Centre, Calgary, AB, Canada (T.J.L.); Cleveland Clinic, Cleveland (B.L.); Seres Therapeutics, Cambridge, MA (E.E.L.W., L.D., J.A.B., C.B.F., M.-J.L., K.D.L., J.R.W., H.W., J.G.A., C.W.J.M., J.A.W., B.H.M., M.T., M.R.H., L.M.); Beaumont Hospital, Royal Oak, Royal Oak, and Oakland University William Beaumont School of Medicine, Rochester - both in Michigan (M.S.); Emory University, Atlanta (C.S.K.); the University of California, Davis, Davis (S.H.C.); the University at Buffalo and Veterans Affairs Western New York Healthcare System - both in Buffalo (C.S.B.); and Capital Digestive Care, Washington, DC (L.Y.K.)
| | - Thomas J Louie
- From Yale University School of Medicine, New Haven, and PACT Gastroenterology Center, Hamden - both in Connecticut (P.F.); the University of Calgary and Foothills Medical Centre, Calgary, AB, Canada (T.J.L.); Cleveland Clinic, Cleveland (B.L.); Seres Therapeutics, Cambridge, MA (E.E.L.W., L.D., J.A.B., C.B.F., M.-J.L., K.D.L., J.R.W., H.W., J.G.A., C.W.J.M., J.A.W., B.H.M., M.T., M.R.H., L.M.); Beaumont Hospital, Royal Oak, Royal Oak, and Oakland University William Beaumont School of Medicine, Rochester - both in Michigan (M.S.); Emory University, Atlanta (C.S.K.); the University of California, Davis, Davis (S.H.C.); the University at Buffalo and Veterans Affairs Western New York Healthcare System - both in Buffalo (C.S.B.); and Capital Digestive Care, Washington, DC (L.Y.K.)
| | - Bret Lashner
- From Yale University School of Medicine, New Haven, and PACT Gastroenterology Center, Hamden - both in Connecticut (P.F.); the University of Calgary and Foothills Medical Centre, Calgary, AB, Canada (T.J.L.); Cleveland Clinic, Cleveland (B.L.); Seres Therapeutics, Cambridge, MA (E.E.L.W., L.D., J.A.B., C.B.F., M.-J.L., K.D.L., J.R.W., H.W., J.G.A., C.W.J.M., J.A.W., B.H.M., M.T., M.R.H., L.M.); Beaumont Hospital, Royal Oak, Royal Oak, and Oakland University William Beaumont School of Medicine, Rochester - both in Michigan (M.S.); Emory University, Atlanta (C.S.K.); the University of California, Davis, Davis (S.H.C.); the University at Buffalo and Veterans Affairs Western New York Healthcare System - both in Buffalo (C.S.B.); and Capital Digestive Care, Washington, DC (L.Y.K.)
| | - Elaine E L Wang
- From Yale University School of Medicine, New Haven, and PACT Gastroenterology Center, Hamden - both in Connecticut (P.F.); the University of Calgary and Foothills Medical Centre, Calgary, AB, Canada (T.J.L.); Cleveland Clinic, Cleveland (B.L.); Seres Therapeutics, Cambridge, MA (E.E.L.W., L.D., J.A.B., C.B.F., M.-J.L., K.D.L., J.R.W., H.W., J.G.A., C.W.J.M., J.A.W., B.H.M., M.T., M.R.H., L.M.); Beaumont Hospital, Royal Oak, Royal Oak, and Oakland University William Beaumont School of Medicine, Rochester - both in Michigan (M.S.); Emory University, Atlanta (C.S.K.); the University of California, Davis, Davis (S.H.C.); the University at Buffalo and Veterans Affairs Western New York Healthcare System - both in Buffalo (C.S.B.); and Capital Digestive Care, Washington, DC (L.Y.K.)
| | - Liyang Diao
- From Yale University School of Medicine, New Haven, and PACT Gastroenterology Center, Hamden - both in Connecticut (P.F.); the University of Calgary and Foothills Medical Centre, Calgary, AB, Canada (T.J.L.); Cleveland Clinic, Cleveland (B.L.); Seres Therapeutics, Cambridge, MA (E.E.L.W., L.D., J.A.B., C.B.F., M.-J.L., K.D.L., J.R.W., H.W., J.G.A., C.W.J.M., J.A.W., B.H.M., M.T., M.R.H., L.M.); Beaumont Hospital, Royal Oak, Royal Oak, and Oakland University William Beaumont School of Medicine, Rochester - both in Michigan (M.S.); Emory University, Atlanta (C.S.K.); the University of California, Davis, Davis (S.H.C.); the University at Buffalo and Veterans Affairs Western New York Healthcare System - both in Buffalo (C.S.B.); and Capital Digestive Care, Washington, DC (L.Y.K.)
| | - Jessica A Bryant
- From Yale University School of Medicine, New Haven, and PACT Gastroenterology Center, Hamden - both in Connecticut (P.F.); the University of Calgary and Foothills Medical Centre, Calgary, AB, Canada (T.J.L.); Cleveland Clinic, Cleveland (B.L.); Seres Therapeutics, Cambridge, MA (E.E.L.W., L.D., J.A.B., C.B.F., M.-J.L., K.D.L., J.R.W., H.W., J.G.A., C.W.J.M., J.A.W., B.H.M., M.T., M.R.H., L.M.); Beaumont Hospital, Royal Oak, Royal Oak, and Oakland University William Beaumont School of Medicine, Rochester - both in Michigan (M.S.); Emory University, Atlanta (C.S.K.); the University of California, Davis, Davis (S.H.C.); the University at Buffalo and Veterans Affairs Western New York Healthcare System - both in Buffalo (C.S.B.); and Capital Digestive Care, Washington, DC (L.Y.K.)
| | - Matthew Sims
- From Yale University School of Medicine, New Haven, and PACT Gastroenterology Center, Hamden - both in Connecticut (P.F.); the University of Calgary and Foothills Medical Centre, Calgary, AB, Canada (T.J.L.); Cleveland Clinic, Cleveland (B.L.); Seres Therapeutics, Cambridge, MA (E.E.L.W., L.D., J.A.B., C.B.F., M.-J.L., K.D.L., J.R.W., H.W., J.G.A., C.W.J.M., J.A.W., B.H.M., M.T., M.R.H., L.M.); Beaumont Hospital, Royal Oak, Royal Oak, and Oakland University William Beaumont School of Medicine, Rochester - both in Michigan (M.S.); Emory University, Atlanta (C.S.K.); the University of California, Davis, Davis (S.H.C.); the University at Buffalo and Veterans Affairs Western New York Healthcare System - both in Buffalo (C.S.B.); and Capital Digestive Care, Washington, DC (L.Y.K.)
| | - Colleen S Kraft
- From Yale University School of Medicine, New Haven, and PACT Gastroenterology Center, Hamden - both in Connecticut (P.F.); the University of Calgary and Foothills Medical Centre, Calgary, AB, Canada (T.J.L.); Cleveland Clinic, Cleveland (B.L.); Seres Therapeutics, Cambridge, MA (E.E.L.W., L.D., J.A.B., C.B.F., M.-J.L., K.D.L., J.R.W., H.W., J.G.A., C.W.J.M., J.A.W., B.H.M., M.T., M.R.H., L.M.); Beaumont Hospital, Royal Oak, Royal Oak, and Oakland University William Beaumont School of Medicine, Rochester - both in Michigan (M.S.); Emory University, Atlanta (C.S.K.); the University of California, Davis, Davis (S.H.C.); the University at Buffalo and Veterans Affairs Western New York Healthcare System - both in Buffalo (C.S.B.); and Capital Digestive Care, Washington, DC (L.Y.K.)
| | - Stuart H Cohen
- From Yale University School of Medicine, New Haven, and PACT Gastroenterology Center, Hamden - both in Connecticut (P.F.); the University of Calgary and Foothills Medical Centre, Calgary, AB, Canada (T.J.L.); Cleveland Clinic, Cleveland (B.L.); Seres Therapeutics, Cambridge, MA (E.E.L.W., L.D., J.A.B., C.B.F., M.-J.L., K.D.L., J.R.W., H.W., J.G.A., C.W.J.M., J.A.W., B.H.M., M.T., M.R.H., L.M.); Beaumont Hospital, Royal Oak, Royal Oak, and Oakland University William Beaumont School of Medicine, Rochester - both in Michigan (M.S.); Emory University, Atlanta (C.S.K.); the University of California, Davis, Davis (S.H.C.); the University at Buffalo and Veterans Affairs Western New York Healthcare System - both in Buffalo (C.S.B.); and Capital Digestive Care, Washington, DC (L.Y.K.)
| | - Charles S Berenson
- From Yale University School of Medicine, New Haven, and PACT Gastroenterology Center, Hamden - both in Connecticut (P.F.); the University of Calgary and Foothills Medical Centre, Calgary, AB, Canada (T.J.L.); Cleveland Clinic, Cleveland (B.L.); Seres Therapeutics, Cambridge, MA (E.E.L.W., L.D., J.A.B., C.B.F., M.-J.L., K.D.L., J.R.W., H.W., J.G.A., C.W.J.M., J.A.W., B.H.M., M.T., M.R.H., L.M.); Beaumont Hospital, Royal Oak, Royal Oak, and Oakland University William Beaumont School of Medicine, Rochester - both in Michigan (M.S.); Emory University, Atlanta (C.S.K.); the University of California, Davis, Davis (S.H.C.); the University at Buffalo and Veterans Affairs Western New York Healthcare System - both in Buffalo (C.S.B.); and Capital Digestive Care, Washington, DC (L.Y.K.)
| | - Louis Y Korman
- From Yale University School of Medicine, New Haven, and PACT Gastroenterology Center, Hamden - both in Connecticut (P.F.); the University of Calgary and Foothills Medical Centre, Calgary, AB, Canada (T.J.L.); Cleveland Clinic, Cleveland (B.L.); Seres Therapeutics, Cambridge, MA (E.E.L.W., L.D., J.A.B., C.B.F., M.-J.L., K.D.L., J.R.W., H.W., J.G.A., C.W.J.M., J.A.W., B.H.M., M.T., M.R.H., L.M.); Beaumont Hospital, Royal Oak, Royal Oak, and Oakland University William Beaumont School of Medicine, Rochester - both in Michigan (M.S.); Emory University, Atlanta (C.S.K.); the University of California, Davis, Davis (S.H.C.); the University at Buffalo and Veterans Affairs Western New York Healthcare System - both in Buffalo (C.S.B.); and Capital Digestive Care, Washington, DC (L.Y.K.)
| | - Christopher B Ford
- From Yale University School of Medicine, New Haven, and PACT Gastroenterology Center, Hamden - both in Connecticut (P.F.); the University of Calgary and Foothills Medical Centre, Calgary, AB, Canada (T.J.L.); Cleveland Clinic, Cleveland (B.L.); Seres Therapeutics, Cambridge, MA (E.E.L.W., L.D., J.A.B., C.B.F., M.-J.L., K.D.L., J.R.W., H.W., J.G.A., C.W.J.M., J.A.W., B.H.M., M.T., M.R.H., L.M.); Beaumont Hospital, Royal Oak, Royal Oak, and Oakland University William Beaumont School of Medicine, Rochester - both in Michigan (M.S.); Emory University, Atlanta (C.S.K.); the University of California, Davis, Davis (S.H.C.); the University at Buffalo and Veterans Affairs Western New York Healthcare System - both in Buffalo (C.S.B.); and Capital Digestive Care, Washington, DC (L.Y.K.)
| | - Kevin D Litcofsky
- From Yale University School of Medicine, New Haven, and PACT Gastroenterology Center, Hamden - both in Connecticut (P.F.); the University of Calgary and Foothills Medical Centre, Calgary, AB, Canada (T.J.L.); Cleveland Clinic, Cleveland (B.L.); Seres Therapeutics, Cambridge, MA (E.E.L.W., L.D., J.A.B., C.B.F., M.-J.L., K.D.L., J.R.W., H.W., J.G.A., C.W.J.M., J.A.W., B.H.M., M.T., M.R.H., L.M.); Beaumont Hospital, Royal Oak, Royal Oak, and Oakland University William Beaumont School of Medicine, Rochester - both in Michigan (M.S.); Emory University, Atlanta (C.S.K.); the University of California, Davis, Davis (S.H.C.); the University at Buffalo and Veterans Affairs Western New York Healthcare System - both in Buffalo (C.S.B.); and Capital Digestive Care, Washington, DC (L.Y.K.)
| | - Mary-Jane Lombardo
- From Yale University School of Medicine, New Haven, and PACT Gastroenterology Center, Hamden - both in Connecticut (P.F.); the University of Calgary and Foothills Medical Centre, Calgary, AB, Canada (T.J.L.); Cleveland Clinic, Cleveland (B.L.); Seres Therapeutics, Cambridge, MA (E.E.L.W., L.D., J.A.B., C.B.F., M.-J.L., K.D.L., J.R.W., H.W., J.G.A., C.W.J.M., J.A.W., B.H.M., M.T., M.R.H., L.M.); Beaumont Hospital, Royal Oak, Royal Oak, and Oakland University William Beaumont School of Medicine, Rochester - both in Michigan (M.S.); Emory University, Atlanta (C.S.K.); the University of California, Davis, Davis (S.H.C.); the University at Buffalo and Veterans Affairs Western New York Healthcare System - both in Buffalo (C.S.B.); and Capital Digestive Care, Washington, DC (L.Y.K.)
| | - Jennifer R Wortman
- From Yale University School of Medicine, New Haven, and PACT Gastroenterology Center, Hamden - both in Connecticut (P.F.); the University of Calgary and Foothills Medical Centre, Calgary, AB, Canada (T.J.L.); Cleveland Clinic, Cleveland (B.L.); Seres Therapeutics, Cambridge, MA (E.E.L.W., L.D., J.A.B., C.B.F., M.-J.L., K.D.L., J.R.W., H.W., J.G.A., C.W.J.M., J.A.W., B.H.M., M.T., M.R.H., L.M.); Beaumont Hospital, Royal Oak, Royal Oak, and Oakland University William Beaumont School of Medicine, Rochester - both in Michigan (M.S.); Emory University, Atlanta (C.S.K.); the University of California, Davis, Davis (S.H.C.); the University at Buffalo and Veterans Affairs Western New York Healthcare System - both in Buffalo (C.S.B.); and Capital Digestive Care, Washington, DC (L.Y.K.)
| | - Henry Wu
- From Yale University School of Medicine, New Haven, and PACT Gastroenterology Center, Hamden - both in Connecticut (P.F.); the University of Calgary and Foothills Medical Centre, Calgary, AB, Canada (T.J.L.); Cleveland Clinic, Cleveland (B.L.); Seres Therapeutics, Cambridge, MA (E.E.L.W., L.D., J.A.B., C.B.F., M.-J.L., K.D.L., J.R.W., H.W., J.G.A., C.W.J.M., J.A.W., B.H.M., M.T., M.R.H., L.M.); Beaumont Hospital, Royal Oak, Royal Oak, and Oakland University William Beaumont School of Medicine, Rochester - both in Michigan (M.S.); Emory University, Atlanta (C.S.K.); the University of California, Davis, Davis (S.H.C.); the University at Buffalo and Veterans Affairs Western New York Healthcare System - both in Buffalo (C.S.B.); and Capital Digestive Care, Washington, DC (L.Y.K.)
| | - John G Auniņš
- From Yale University School of Medicine, New Haven, and PACT Gastroenterology Center, Hamden - both in Connecticut (P.F.); the University of Calgary and Foothills Medical Centre, Calgary, AB, Canada (T.J.L.); Cleveland Clinic, Cleveland (B.L.); Seres Therapeutics, Cambridge, MA (E.E.L.W., L.D., J.A.B., C.B.F., M.-J.L., K.D.L., J.R.W., H.W., J.G.A., C.W.J.M., J.A.W., B.H.M., M.T., M.R.H., L.M.); Beaumont Hospital, Royal Oak, Royal Oak, and Oakland University William Beaumont School of Medicine, Rochester - both in Michigan (M.S.); Emory University, Atlanta (C.S.K.); the University of California, Davis, Davis (S.H.C.); the University at Buffalo and Veterans Affairs Western New York Healthcare System - both in Buffalo (C.S.B.); and Capital Digestive Care, Washington, DC (L.Y.K.)
| | - Christopher W J McChalicher
- From Yale University School of Medicine, New Haven, and PACT Gastroenterology Center, Hamden - both in Connecticut (P.F.); the University of Calgary and Foothills Medical Centre, Calgary, AB, Canada (T.J.L.); Cleveland Clinic, Cleveland (B.L.); Seres Therapeutics, Cambridge, MA (E.E.L.W., L.D., J.A.B., C.B.F., M.-J.L., K.D.L., J.R.W., H.W., J.G.A., C.W.J.M., J.A.W., B.H.M., M.T., M.R.H., L.M.); Beaumont Hospital, Royal Oak, Royal Oak, and Oakland University William Beaumont School of Medicine, Rochester - both in Michigan (M.S.); Emory University, Atlanta (C.S.K.); the University of California, Davis, Davis (S.H.C.); the University at Buffalo and Veterans Affairs Western New York Healthcare System - both in Buffalo (C.S.B.); and Capital Digestive Care, Washington, DC (L.Y.K.)
| | - Jonathan A Winkler
- From Yale University School of Medicine, New Haven, and PACT Gastroenterology Center, Hamden - both in Connecticut (P.F.); the University of Calgary and Foothills Medical Centre, Calgary, AB, Canada (T.J.L.); Cleveland Clinic, Cleveland (B.L.); Seres Therapeutics, Cambridge, MA (E.E.L.W., L.D., J.A.B., C.B.F., M.-J.L., K.D.L., J.R.W., H.W., J.G.A., C.W.J.M., J.A.W., B.H.M., M.T., M.R.H., L.M.); Beaumont Hospital, Royal Oak, Royal Oak, and Oakland University William Beaumont School of Medicine, Rochester - both in Michigan (M.S.); Emory University, Atlanta (C.S.K.); the University of California, Davis, Davis (S.H.C.); the University at Buffalo and Veterans Affairs Western New York Healthcare System - both in Buffalo (C.S.B.); and Capital Digestive Care, Washington, DC (L.Y.K.)
| | - Barbara H McGovern
- From Yale University School of Medicine, New Haven, and PACT Gastroenterology Center, Hamden - both in Connecticut (P.F.); the University of Calgary and Foothills Medical Centre, Calgary, AB, Canada (T.J.L.); Cleveland Clinic, Cleveland (B.L.); Seres Therapeutics, Cambridge, MA (E.E.L.W., L.D., J.A.B., C.B.F., M.-J.L., K.D.L., J.R.W., H.W., J.G.A., C.W.J.M., J.A.W., B.H.M., M.T., M.R.H., L.M.); Beaumont Hospital, Royal Oak, Royal Oak, and Oakland University William Beaumont School of Medicine, Rochester - both in Michigan (M.S.); Emory University, Atlanta (C.S.K.); the University of California, Davis, Davis (S.H.C.); the University at Buffalo and Veterans Affairs Western New York Healthcare System - both in Buffalo (C.S.B.); and Capital Digestive Care, Washington, DC (L.Y.K.)
| | - Michele Trucksis
- From Yale University School of Medicine, New Haven, and PACT Gastroenterology Center, Hamden - both in Connecticut (P.F.); the University of Calgary and Foothills Medical Centre, Calgary, AB, Canada (T.J.L.); Cleveland Clinic, Cleveland (B.L.); Seres Therapeutics, Cambridge, MA (E.E.L.W., L.D., J.A.B., C.B.F., M.-J.L., K.D.L., J.R.W., H.W., J.G.A., C.W.J.M., J.A.W., B.H.M., M.T., M.R.H., L.M.); Beaumont Hospital, Royal Oak, Royal Oak, and Oakland University William Beaumont School of Medicine, Rochester - both in Michigan (M.S.); Emory University, Atlanta (C.S.K.); the University of California, Davis, Davis (S.H.C.); the University at Buffalo and Veterans Affairs Western New York Healthcare System - both in Buffalo (C.S.B.); and Capital Digestive Care, Washington, DC (L.Y.K.)
| | - Matthew R Henn
- From Yale University School of Medicine, New Haven, and PACT Gastroenterology Center, Hamden - both in Connecticut (P.F.); the University of Calgary and Foothills Medical Centre, Calgary, AB, Canada (T.J.L.); Cleveland Clinic, Cleveland (B.L.); Seres Therapeutics, Cambridge, MA (E.E.L.W., L.D., J.A.B., C.B.F., M.-J.L., K.D.L., J.R.W., H.W., J.G.A., C.W.J.M., J.A.W., B.H.M., M.T., M.R.H., L.M.); Beaumont Hospital, Royal Oak, Royal Oak, and Oakland University William Beaumont School of Medicine, Rochester - both in Michigan (M.S.); Emory University, Atlanta (C.S.K.); the University of California, Davis, Davis (S.H.C.); the University at Buffalo and Veterans Affairs Western New York Healthcare System - both in Buffalo (C.S.B.); and Capital Digestive Care, Washington, DC (L.Y.K.)
| | - Lisa von Moltke
- From Yale University School of Medicine, New Haven, and PACT Gastroenterology Center, Hamden - both in Connecticut (P.F.); the University of Calgary and Foothills Medical Centre, Calgary, AB, Canada (T.J.L.); Cleveland Clinic, Cleveland (B.L.); Seres Therapeutics, Cambridge, MA (E.E.L.W., L.D., J.A.B., C.B.F., M.-J.L., K.D.L., J.R.W., H.W., J.G.A., C.W.J.M., J.A.W., B.H.M., M.T., M.R.H., L.M.); Beaumont Hospital, Royal Oak, Royal Oak, and Oakland University William Beaumont School of Medicine, Rochester - both in Michigan (M.S.); Emory University, Atlanta (C.S.K.); the University of California, Davis, Davis (S.H.C.); the University at Buffalo and Veterans Affairs Western New York Healthcare System - both in Buffalo (C.S.B.); and Capital Digestive Care, Washington, DC (L.Y.K.)
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Body mass index and risk of clostridioides difficile infection: a systematic review and meta-analysis. Infection 2022; 50:725-737. [PMID: 34985688 DOI: 10.1007/s15010-021-01749-9] [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: 09/10/2021] [Accepted: 12/21/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To comprehensively investigate the association between obesity/high body mass index (BMI) and risk of Clostridioides difficile infection (CDI) using systematic review and meta-analysis. METHODS Potentially eligible studies were identified from Medline and EMBASE databases from inception to February 2021 using search strategy consisting of terms for "Body Mass Index" and "Clostridioides Difficile". We only included studies that consist of a group of individuals with CDI and another group without CDI. Then, the studies must report their BMI or history of obesity. Odds ratio (OR) and 95% CIs of the association between BMI status and CDI were retrieved from each study and combined using the generic inverse variance method. Funnel plot was used to assess publication bias. RESULTS A total of 4609 articles were identified. After two rounds of systematic review, 17 studies met the eligibility criteria and were included into the meta-analysis. Pooled analysis showed that individuals with high BMI had a significantly decreased odds of CDI with the pooled OR of 0.88 (95% CI 0.80-0.97). This meta-analysis had high statistical heterogeneity with I2 of 74%. Funnel plot was symmetric, which was not suggestive of presence of publication bias. CONCLUSION This meta-analysis revealed a significant negative association between BMI and CDI.
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Rao K, Dubberke ER. Can prediction scores be used to identify patients at risk of Clostridioides difficile infection? Curr Opin Gastroenterol 2022; 38:7-14. [PMID: 34628418 DOI: 10.1097/mog.0000000000000793] [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] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW To describe the current state of literature on modeling risk of incident and recurrent Clostridioides difficile infection (iCDI and rCDI), to underscore limitations, and to propose a path forward for future research. RECENT FINDINGS There are many published risk factors and models for both iCDI and rCDI. The approaches include scores with a limited list of variables designed to be used at the bedside, but more recently have also included automated tools that take advantage of the entire electronic health record. Recent attempts to externally validate scores have met with mixed success. SUMMARY For iCDI, the performance largely hinges on the incidence, which even for hospitalized patients can be low (often <1%). Most scores fail to achieve high accuracy and/or are not externally validated. A challenge in predicting rCDI is the significant overlap with risk factors for iCDI, reducing the discriminatory ability of models. Automated electronic health record-based tools show promise but portability to other centers is challenging. Future studies should include external validation and consider biomarkers to augment performance.
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Affiliation(s)
- Krishna Rao
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Erik R Dubberke
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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Richards AR, Linder JA. Behavioral Economics and Ambulatory Antibiotic Stewardship: A Narrative Review. Clin Ther 2021; 43:1654-1667. [PMID: 34702589 DOI: 10.1016/j.clinthera.2021.08.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 08/05/2021] [Accepted: 08/09/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE Behavioral economics recognizes that contextual, psychological, social, and emotional factors powerfully influence decision-making. Behavioral economics has the potential to provide a better understanding of, and, through subtle environmental changes, or "nudges," improve persistent quality-of-care challenges, like ambulatory antibiotic overprescribing. Despite decades of admonitions and educational initiatives, in the United States, up to 50% of ambulatory antibiotic prescriptions remain inappropriate or not associated with a diagnosis. METHODS We conducted a Medline search and performed a narrative review that examined the use of behavioral economics to understand the rationale for, and improvement of, ambulatory antibiotic prescribing. FINDINGS Clinicians prescribe antibiotics inappropriately because of perceived patient demand, to maintain patient satisfaction, diagnostic uncertainty, or time pressure, among other reasons. Behavioral economics-informed approaches offer additional improvements in antibiotic prescribing beyond clinician education and communication training. Precommitment, in which clinicians publicize their intent to prescribe antibiotics "only when they are absolutely necessary," leverages clinicians' self-conception and a desire to act in a manner consistent with public statements. Precommitment was associated with a 20% absolute reduction in the inappropriate antibiotic prescribing for acute respiratory infections. Justification alerts, in which clinicians must provide a brief written rationale for prescribing antibiotics, leverages social accountability, redefines the status quo as an active choice, and helps clinicians to shift from fast to slow, careful thinking. With justification alerts, the absolute rate of inappropriate antibiotic prescribing decreased from 23% to 5%. Peer comparison, in which clinicians receive feedback comparing their performance to their top-performing peers, provides evidence of improved performance and leverages peoples' desire to conform to social norms. Peer comparison decreased absolute inappropriate antibiotic prescribing rates from 20% to 4%, a decrease that persisted for 12 months after the end of the intervention. Also, a one-time peer-comparison letter from a high-profile messenger to primary care practices with high rates of prescribing antibiotics, there was a 6-month, 3% decrease inantibiotic prescribing. Future directions in applying behavioral economics to the inappropriate antibiotic prescribing include paying careful attention to design details; improving intervention effectiveness and durability; making harms salient; participants' involvement in the development of interventions (the "Ikea effect"); factoring in patient satisfaction; and patient-facing nudges about antibiotic use and care-seeking. In addition, the COVID pandemic could aid in ambulatory antibiotic prescribing improvements due to changing cognitive frames around respiratory symptom evaluation and antibiotic prescribing. IMPLICATIONS To improve ambulatory antibiotic prescribing, several behavioral economics-informed approaches-especially precommitment, justification alerts, and peer comparison-have reduced the rates of inappropriate prescribing of antibiotics to low levels.
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Affiliation(s)
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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Pivazyan G, Mualem W, D'Antuono MR, Dowlati E, Nair N, Mueller KB. The Utility of Prolonged Prophylactic Systemic Antibiotics (PPSA) for Subfascial Drains After Degenerative Spine Surgery. Spine (Phila Pa 1976) 2021; 46:E1077-E1082. [PMID: 33710111 DOI: 10.1097/brs.0000000000004031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of the current investigation was to evaluate the impact of prolonged prophylactic systemic antibiotics (PPSA) on the development of surgical site infection rate (SSIR) in degenerative spine surgery. SUMMARY OF BACKGROUND DATA Surgical drains are utilized postoperatively in posterior spine surgery to help minimize the risk of seroma formation. Prophylactic antibiotics while drains are in place are frequently used to reduce SSIR, though the practice remains controversial. METHODS We performed a single center, retrospective review of all patients that underwent posterior spinal surgery for cervical and lumbar degenerative pathology over a 3.5 year period (January 2016-July 2019). Patients underwent a traditional open posterior midline procedure with postoperative placement of a subfascial surgical drain. Antibiotics were administered for the duration of the drain (PPSA group) or for 24 hours postoperatively (non-PPSA group). The number of surgical site infections, organism, and Clostridium difficile infections was recorded. RESULTS Three hundred thirty six patients were identified, 168 patients in the PPSA group and 168 in the non-PPSA groups. The overall SSIR was 5.36% (18/336). The SSIR for the non-PPSA and PPSA groups were 7.14% (12/168) and 3.57% (6/168), respectively (P = 0.146). While difference of SSIR between the groups was two-fold, it was not statistically significant. For the non-PPSA and PPSA groups, the SSIR for cervical (5.95% [5/84] vs. 2.38% [2/84], P = 0.443) and lumbar (8.33% [7/84], vs. 4.76% [4/84], P = 0.535) regions were not significantly different. C. difficile cases in the PPSA and non-PPSA groups were 1/168 and 0/168 respectively (P = 1.00). CONCLUSION Our series demonstrate a two-fold reduction of SSI with implementation of PPSA regimen. This benefit was demonstrated separately for both cervical and lumbar regions. Randomized trials and increase in sample size are warranted to elucidate the significance of PPSA in posterior spinal surgery.Level of Evidence: 3.
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Affiliation(s)
- Gnel Pivazyan
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC
| | - William Mualem
- Georgetown University School of Medicine, Washington, DC
| | | | - Ehsan Dowlati
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC
| | - Nathan Nair
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC
| | - Kyle B Mueller
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC
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Skrobarcek KA, Mu Y, Ahern J, Basiliere E, Beldavs ZG, Brousseau G, Dumyati G, Fridkin S, Holzbauer SM, Johnston H, Kainer MA, Meek J, Ocampo VLS, Parker E, Perlmutter R, Phipps EC, Winston L, Guh A. Association between Socioeconomic Status and Incidence of Community-Associated Clostridioides difficile Infection - United States, 2014-2015. Clin Infect Dis 2021; 73:722-725. [PMID: 33462596 DOI: 10.1093/cid/ciab042] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 01/15/2021] [Indexed: 01/11/2023] Open
Abstract
We evaluated the association between socioeconomic status (SES) and community-associated Clostridioides difficile infection (CA-CDI) incidence across 2474 census tracts in 10 states. Highly correlated community-level SES variables were transformed into distinct factors using factor analysis. We found low SES communities were associated with higher CA-CDI incidence.
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Affiliation(s)
- Kimberly A Skrobarcek
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Yi Mu
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jennifer Ahern
- University of California at Berkeley, Berkeley, California, USA
| | | | | | - Geoffrey Brousseau
- Colorado Department of Public Health and Environment, Denver, Colorado, USA
| | - Ghinwa Dumyati
- New York Emerging Infections Program at the University of Rochester Medical Center, Rochester, New York, USA
| | - Scott Fridkin
- Department of Medicine, Emory University School of Medicine and Georgia Emerging Infections Program, Atlanta, Georgia, USA
| | | | - Helen Johnston
- Colorado Department of Public Health and Environment, Denver, Colorado, USA
| | - Marion A Kainer
- Tennessee Department of Public Health, Nashville, Tennessee, USA
| | - James Meek
- Yale School of Public Health, Connecticut Emerging Infections Program, New Haven, Connecticut, USA
| | | | - Erin Parker
- California Emerging Infections Program, Oakland, California, USA
| | - Rebecca Perlmutter
- Maryland Department of Health and Mental Hygiene, Baltimore, Maryland, USA
| | - Erin C Phipps
- University of New Mexico, New Mexico Emerging Infections Program, Albuquerque, New Mexico, USA
| | - Lisa Winston
- University of California, San Francisco and Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Alice Guh
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Tydeman F, Craine N, Kavanagh K, Adams H, Reynolds R, McClure V, Hughes H, Hickman M, Robertson C. Incidence of Clostridioides difficile infection (CDI) related to antibiotic prescribing by GP surgeries in Wales. J Antimicrob Chemother 2021; 76:2437-2445. [PMID: 34151964 PMCID: PMC8361358 DOI: 10.1093/jac/dkab204] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/24/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Clostridioides difficile infection (CDI) is a healthcare-acquired infection (HAI) causing significant morbidity and mortality. Welsh CDI rates are high in comparison with those in England and Scotland. OBJECTIVES This retrospective ecological study used aggregated disease surveillance data to understand the impact of total and high-risk Welsh GP antibiotic prescribing on total and stratified inpatient/non-inpatient CDI incidence. METHODS All cases of confirmed CDI, during the financial years 2014-15 to 2017-18, were linked to aggregated rates of antibiotic prescribing in their GP surgery and classified as 'inpatient', 'non-inpatient' or 'unknown' by Public Health Wales. Multivariable negative-binomial regression models, comparing CDI incidence with antibiotic prescribing rates, were adjusted for potential confounders: location; age; social deprivation; comorbidities (estimated from prevalence of key health indicators) and proton pump inhibitor (PPI) prescription rates. RESULTS There were 4613 confirmed CDI cases, with an incidence (95% CI) of 1.44 (1.40-1.48) per 1000 registered patients. Unadjusted analysis showed that an increased risk of total CDI incidence was associated with higher total antibiotic prescribing [relative risk (RR) (95% CI) = 1.338 (1.170-1.529) per 1000 items per 1000 specific therapeutic group age-sex related GP prescribing units (STAR-PU)] and that high-risk antibiotic classes were positively associated with total CDI incidence. Location, age ≥65 years and diabetes were associated with increased risk of CDI. After adjusting for confounders, prescribing of clindamycin showed a positive association with total CDI incidence [RR (95% CI) = 1.079 (1.001-1.162) log items per 1000 registered patients]. CONCLUSIONS An increased risk of CDI is demonstrated at a primary care practice population level, reflecting their antibiotic prescribing rates, particularly clindamycin, and population demographics.
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Affiliation(s)
- Florence Tydeman
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow G1 1XH, Scotland
- Corresponding author. E-mail:
| | - Noel Craine
- CDSC, Public Health Wales, Ysbyty Gwynedd, Bangor LL57 2PW, Wales
| | - Kimberley Kavanagh
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow G1 1XH, Scotland
| | - Helen Adams
- Betsi Cadwaladr University Health Board, Ysbyty Gwynedd, Bangor LL57 2PW, Wales
| | - Rosy Reynolds
- Population Health Sciences, Bristol Medical School, University of Bristol BS8 2PS, England
| | - Victoria McClure
- CDSC, Public Health Wales, Ysbyty Gwynedd, Bangor LL57 2PW, Wales
| | - Harriet Hughes
- Public Health Wales, Microbiology, University Hospital of Wales, Cardiff CF14 4XW, Wales
| | - Matt Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol BS8 2PS, England
| | - Chris Robertson
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow G1 1XH, Scotland
- Health Protection Scotland, Glasgow G2 6QE, Scotland
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Clancy CJ, Buehrle D, Vu M, Wagener MM, Nguyen MH. Impact of Revised Infectious Diseases Society of America and Society for Healthcare Epidemiology of America Clinical Practice Guidelines on the Treatment of Clostridium difficile Infections in the United States. Clin Infect Dis 2021; 72:1944-1949. [PMID: 32343766 DOI: 10.1093/cid/ciaa484] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 04/23/2020] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Our objective was to determine if oral vancomycin, fidaxomicin, and oral metronidazole use in the United States changed after publication of revised clinical practice guidelines for Clostridium difficile infection (CDI) in February 2018. METHODS We obtained US antibiotic prescription data (IQVIA) from 2006-August 2019 and used guideline-recommended dosing regimens to estimate monthly numbers of 10-day treatment courses of vancomycin, fidaxomicin and metronidazole. Interrupted time-series analyses were performed, adjusted by month. We compared linear trends for monthly numbers of treatment courses in different time periods. RESULTS Cumulative treatment courses of oral vancomycin and fidaxomicin increased by 54% (n = 226 166) and 48% (n = 18 518), respectively, in 18 months following guidelines compared with 18 months before; those of oral metronidazole decreased by 3% (n = 238 372). Monthly vancomycin and fidaxomicin use significantly increased throughout the period following revised guidelines (P < .0001 and P = .0002, respectively), whereas that of metronidazole decreased significantly (P < .0001). Monthly vancomycin use increased and metronidazole use decreased to a significantly greater extent after publication of revised guidelines than after publication of clinical trials establishing superiority of vancomycin over metronidazole (P < .0001). CONCLUSIONS Revised practice guidelines have had a significant impact on CDI treatment in the US. Clinical trial data used for the revised guidelines were available since 2007-2014 and 2011-2012 for oral vancomycin and fidaxomicin, respectively. Guidelines or guidance documents for treating CDI and other infections should be updated in more timely fashion.
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Affiliation(s)
- Cornelius J Clancy
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Deanna Buehrle
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Michelle Vu
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Marilyn M Wagener
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - M Hong Nguyen
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Inghammar M, Svanström H, Voldstedlund M, Melbye M, Hviid A, Mølbak K, Pasternak B. Proton-Pump Inhibitor Use and the Risk of Community-Associated Clostridium difficile Infection. Clin Infect Dis 2021; 72:e1084-e1089. [PMID: 33629099 PMCID: PMC8204777 DOI: 10.1093/cid/ciaa1857] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Indexed: 12/26/2022] Open
Abstract
Background Proton-pump inhibitors (PPIs) have been reported to increase the risk of community-associated Clostridium difficile infection (CDI), but the association remains disputed. Methods A nationwide cohort study among adults in Denmark, 2010–2013, linking register data on C. difficile testing, filled prescriptions, and patient characteristics. All incident episodes of community-associated CDI (ie, positive culture, molecular assay, or toxin test in individuals without previous hospitalization in the prior 12 weeks and without a positive test for C. difficile in the prior 8 weeks) were identified in the Danish National Microbiological Database. Self-controlled case-series analyses were used to estimate incidence rate ratios (IRRs) for community-associated CDI, comparing periods with and without exposure to PPIs. By design, models took fixed confounders such as chronic disease, genetics, and socioeconomic status into account; further, time-varying confounders, including hospital stay and antibiotic and corticosteroid use were adjusted for. Results 3583 episodes of community-associated CDI were identified, of which 964 occurred during current use of PPIs, 324 occurred 0–6 months after treatment cessation, 123 occurred 6–12 months after treatment cessation, and 2172 occurred during time periods without use of PPIs. The adjusted IRR was 2.03 (95% confidence interval, 1.74–2.36), comparing use of PPI with nonuse. The increased risk remained elevated in later time periods: 1.54 (1.31–1.80) for 0–6 months, 1.24 (1.00–1.53) for 6–12 months after current use. Conclusions Use of PPIs was associated with moderately increased risk of community-associated CDI. The risk remained elevated up to 1 year after PPI treatment had ended.
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Affiliation(s)
- Malin Inghammar
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark.,Section for Infection Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Henrik Svanström
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark.,Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Marianne Voldstedlund
- Division of Infectious Diseases Preparedness, Statens Serum Institut, Copenhagen, Denmark
| | - Mads Melbye
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark.,Department of Medicine, Stanford University School of Medicine, Stanford, California, USA.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anders Hviid
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Kåre Mølbak
- Division of Infectious Diseases Preparedness, Statens Serum Institut, Copenhagen, Denmark.,Department of Animal and Veterinary Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Björn Pasternak
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark.,Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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Kelly CR, Fischer M, Allegretti JR, LaPlante K, Stewart DB, Limketkai BN, Stollman NH. ACG Clinical Guidelines: Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections. Am J Gastroenterol 2021; 116:1124-1147. [PMID: 34003176 DOI: 10.14309/ajg.0000000000001278] [Citation(s) in RCA: 225] [Impact Index Per Article: 75.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 03/25/2021] [Indexed: 02/06/2023]
Abstract
Clostridioides difficile infection occurs when the bacterium produces toxin that causes diarrhea and inflammation of the colon. These guidelines indicate the preferred approach to the management of adults with C. difficile infection and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation process. In instances where the evidence was not appropriate for Grading of Recommendations Assessment, Development, and Evaluation but there was consensus of significant clinical merit, key concept statements were developed using expert consensus. These guidelines are meant to be broadly applicable and should be viewed as the preferred, but not the only, approach to clinical scenarios.
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Affiliation(s)
- Colleen R Kelly
- Division of Gastroenterology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Monika Fischer
- Division of Gastroenterology, Indiana University, Indianapolis, Indiana, USA
| | - Jessica R Allegretti
- Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kerry LaPlante
- Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston, Rhode Island, USA
| | - David B Stewart
- Department of Surgery, University of Arizona Health Sciences, Tucson, Arizona, USA
| | - Berkeley N Limketkai
- Division of Digestive Diseases, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Neil H Stollman
- Division of Gastroenterology, Alta Bates Summit Medical Center, East Bay Center for Digestive Health, Oakland, California, USA
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Clostridioides difficile Infection. Dis Colon Rectum 2021; 64:650-668. [PMID: 33769319 DOI: 10.1097/dcr.0000000000002047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Fu Y, Luo Y, Grinspan AM. Epidemiology of community-acquired and recurrent Clostridioides difficile infection. Therap Adv Gastroenterol 2021; 14:17562848211016248. [PMID: 34093740 PMCID: PMC8141977 DOI: 10.1177/17562848211016248] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 04/19/2021] [Indexed: 02/06/2023] Open
Abstract
Clostridioides difficile infection is a leading cause of healthcare-associated infections with significant morbidity and mortality. For the past decade, the bulk of infection prevention and epidemiologic surveillance efforts have been directed toward mitigating hospital-acquired C. difficile. However, the incidence of community-associated infection is on the rise. Patients with community-associated C. difficile tend to be younger and have lower mortality rate. Rates of recurrent C. difficile infection overall have decreased in the United States, but future research and public health endeavors are needed to standardize and improve disease detection, stratify risk factors in large-scale population studies, and to identify regional and local variations in strain types, reservoirs and transmission routes to help characterize and combat the changing epidemiology of C. difficile.
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Affiliation(s)
- Yichun Fu
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yuying Luo
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Gotshal D, Azrad M, Hamo Z, Nitzan O, Peretz A. IL-16 and BCA-1 Serum Levels Are Associated with Disease Severity of C. difficile Infection. Pathogens 2021; 10:631. [PMID: 34065379 PMCID: PMC8161220 DOI: 10.3390/pathogens10050631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/14/2021] [Accepted: 05/19/2021] [Indexed: 12/19/2022] Open
Abstract
Clostridioides difficile infection (CDI) is associated with a high risk for complications and death, which requires identifying severe patients and treating them accordingly. We examined the serum level of six cytokines and chemokines (IL-16, IL-21, IL-23, IL-33, BCA-1, TRAIL) and investigated the association between them and patients' disease severity. Concentrations of six cytokines and chemokines were measured using the MILLIPLEX®MAP kit (Billerica, MA, USA) in serum samples attained from CDI patients within 24-48 h after laboratory confirmation of C. difficile presence. Demographic and clinical data were collected from medical records. The disease severity score was determined according to guidelines of the "Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America" (SHEA-IDSA). Out of 54 patients, 20 (37%) had mild to moderate disease and 34 (63%) had severe disease. IL-16 (p = 0.005) and BCA-1 (p = 0.012) were associated with a more severe disease. In conclusion, IL-16 and BCA-1, along with other cytokines and chemokines, may serve as biomarkers for the early prediction of CDI severity in the future. An improved and more accessible assessment of CDI severity will contribute to the adjustment of the medical treatment, which will lead to a better patient outcome.
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Affiliation(s)
- Dor Gotshal
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel; (D.G.); (Z.H.); (O.N.)
| | - Maya Azrad
- Clinical Microbiology Laboratory, The Baruch Padeh Medical Center, Poriya, Tiberias 1528001, Israel;
| | - Zohar Hamo
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel; (D.G.); (Z.H.); (O.N.)
| | - Orna Nitzan
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel; (D.G.); (Z.H.); (O.N.)
- Unit of Infectious Diseases, The Baruch Padeh Medical Center, Poriya, Tiberias 1528001, Israel
| | - Avi Peretz
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel; (D.G.); (Z.H.); (O.N.)
- Clinical Microbiology Laboratory, The Baruch Padeh Medical Center, Poriya, Tiberias 1528001, Israel;
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St Louis J, Okere AN. Clinical impact of pharmacist-led antibiotic stewardship programs in outpatient settings in the United States: A scoping review. Am J Health Syst Pharm 2021; 78:1426-1437. [PMID: 33889930 PMCID: PMC8083201 DOI: 10.1093/ajhp/zxab178] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose To provide an overview of the impact of pharmacist interventions on antibiotic prescribing and the resultant clinical outcomes in an outpatient antibiotic stewardship program (ASP) in the United States. Methods Reports on studies of pharmacist-led ASP interventions implemented in US outpatient settings published from January 2000 to November 2020 and indexed in PubMed or Google Scholar were included. Additionally, studies documented at the ClinicalTrials.gov website were evaluated. Study selection was based on predetermined inclusion criteria; only randomized controlled trials, observational studies, nonrandomized controlled trials, and case-control studies conducted in outpatient settings in the United States were included. The primary outcome was the observed differences in antibiotic prescribing or clinical benefits between pharmacist-led ASP interventions and usual care. Results Of the 196 studies retrieved for full-text review, a cumulative total of 15 studies were included for final evaluation. Upon analysis, we observed that there was no consistent methodology in the implementation of ASPs and, in most cases, the outcome of interest varied. Nonetheless, there was a trend toward improvement in antibiotic prescribing with pharmacist interventions in ASPs compared with that under usual care (P < 0.05). However, the results of these studies are not easily generalizable. Conclusion Our findings suggest a need for a consistent approach for the practical application of outpatient pharmacist-led ASPs. Managed care organizations could play a significant role in ensuring the successful implementation of pharmacist-led ASPs in outpatient settings.
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Affiliation(s)
- James St Louis
- Florida A&M University College of Pharmacy and Pharmaceutical Sciences, Institute of Public Health, Tallahassee, FL,USA
| | - Arinze Nkemdirim Okere
- Florida A&M University College of Pharmacy and Pharmaceutical Sciences, Institute of Public Health, Tallahassee, FL,USA
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Sayood SJ, Botros M, Suda KJ, Foraker R, Durkin MJ. Attitudes toward using clinical decision support in community pharmacies to promote antibiotic stewardship. J Am Pharm Assoc (2003) 2021; 61:565-571. [PMID: 33962894 DOI: 10.1016/j.japh.2021.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 04/04/2021] [Accepted: 04/08/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Outpatient antibiotic prescriptions drive antibiotic overuse in humans, and the Centers for Disease Control and Prevention has identified community pharmacies as potential partners in outpatient stewardship efforts. Clinical decision support (CDS) tools can potentially be used at community pharmacies to aid in outpatient stewardship efforts. OBJECTIVES We sought to determine community pharmacist attitudes toward using a computerized CDS tool to evaluate and manage common complaints and thus promote appropriate antibiotic prescribing. METHODS We conducted in-depth semistructured interviews of community pharmacists to determine attitudes toward using CDS tools in their practice and identify potential barriers in implementation. Thematic analysis was used to identify common themes and subthemes in the pharmacist responses. RESULTS We interviewed 21 pharmacists and identified 5 themes and 14 subthemes in our interviews. The pharmacists reported that patients frequently presented with complaints of acute infections and that they (the pharmacists) were universally supportive of a CDS intervention that would allow them to assess such patients and, in turn, guide appropriate antibiotic prescribing. They noted that communication difficulties with prescribing physicians and lack of information sharing currently made it difficult to implement stewardship interventions, and they stated that they were interested in any intervention that could help overcome these barriers. CONCLUSION Community pharmacies represent an important point of contact for patients and are a potentially valuable setting for outpatient stewardship interventions. Pharmacists were overwhelmingly supportive of using CDS tools to evaluate patients and promote antimicrobial stewardship. These results suggest that it would be feasible to pilot such an intervention in the community pharmacy setting.
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Vollmer NJ, Rivera CG, Stevens RW, Oravec CP, Mara KC, Suh GA, Osmon DR, Beam EN, Abdel MP, Virk A. Safety and Tolerability of Fluoroquinolones in Patients with Staphylococcal Periprosthetic Joint Infections. Clin Infect Dis 2021; 73:850-856. [PMID: 33606003 DOI: 10.1093/cid/ciab145] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Fluoroquinolones (FQs) are known to be accompanied by significant risks. However, the incidence of adverse events (ADE) resulting in unplanned drug discontinuation when used for periprosthetic joint infections (PJI) is currently unknown. METHODS This study included 156 patients over the age of 18 treated for staphylococcal PJI with debridement, antibiotics, and implant retention (DAIR), between January 1, 2007 and November 21, 2019. Of the 156 patients, 64 had total hip arthroplasty (THA) and 92 had total knee arthroplasty (TKA) infections. The primary outcome was rate of unplanned drug discontinuation. Secondary outcomes included incidence of severe ADE, unplanned rifamycin discontinuation, mean time to unplanned regimen discontinuation, and all-cause mortality. RESULTS Overall, unplanned drug discontinuation occurred in 35.6% of patients in the FQ group and 3% of patients in the non-FQ group. The rate of unplanned discontinuation of FQ regimens as compared to non-FQ regimens was 27.5% vs 4.2% (p=0.021) in THA infections and 42% vs 2.4% (p<0.001) in TKA infections. There was no significant difference in severe ADEs between FQ and non-FQ regimens in both THA and TKA infections. The overall rate of non-severe ADEs in FQ compared to non-FQ regimens was 43.3% vs 6.1% (p<0.001). FQs were associated with tendinopathy, myalgia, arthralgia, and nausea. CONCLUSIONS A significantly higher rate of unplanned drug discontinuation was associated with FQ as compared to non-FQ regimens. This provides a real-world view of the implications of FQ related adverse events on unplanned discontinuation when used in prolonged durations for the management of staphylococcal PJIs.
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Affiliation(s)
| | | | - Ryan W Stevens
- Department of Pharmacy; Mayo Clinic Hospital-Rochester, MN, USA
| | - Caitlin P Oravec
- Division of Infectious Diseases; Mayo Clinic Hospital-Rochester, MN, USA
| | - Kristin C Mara
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics; Mayo Clinic Hospital-Rochester, MN, USA
| | - Gina A Suh
- Division of Infectious Diseases; Mayo Clinic Hospital-Rochester, MN, USA
| | - Douglas R Osmon
- Division of Infectious Diseases; Mayo Clinic Hospital-Rochester, MN, USA
| | - Elena N Beam
- Division of Infectious Diseases; Mayo Clinic Hospital-Rochester, MN, USA
| | - Matthew P Abdel
- Department of Orthopedics; Mayo Clinic Hospital-Rochester, MN, USA
| | - Abinash Virk
- Division of Infectious Diseases; Mayo Clinic Hospital-Rochester, MN, USA
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Zacharioudakis IM, Zervou FN, Phillips MS, Aguero-Rosenfeld ME. Rate and consequences of missed Clostridioides (Clostridium) difficile infection diagnosis from nonreporting of Clostridioides difficile results of the multiplex GI PCR panel: experience from two-hospitals. Diagn Microbiol Infect Dis 2021; 100:115346. [PMID: 33647544 DOI: 10.1016/j.diagmicrobio.2021.115346] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 01/18/2021] [Accepted: 02/09/2021] [Indexed: 01/28/2023]
Abstract
INTRODUCTION It is common among microbiology laboratories to blind the Clostridioides difficile (C. difficile) BioFire FilmArray GI Panel result in fear of overdiagnosis. METHODS We examined the rate of missed community-onset C. difficile infection (CDI) diagnosis and associated outcomes. Adult patients with FilmArray GI Panel positive for C. difficile on hospital admission who lacked dedicated C. difficile testing were included. RESULTS Among 144 adults with a FilmArray Panel positive for C. difficile, 18 did not have concurrent dedicated C. difficile testing. Eight patients were categorized as possible, 5 as probable and 4 as definite cases of missed CDI diagnosis. We observed associated delays in initiation of appropriate therapy, intensive care unit admissions, hospital readmissions, colorectal surgery and death/discharge to hospice. Five out of 17 lacked risk factors for CDI. CONCLUSION The practice of concealing C. difficile FilmArray GI Panel results needs to be reconsidered in patients presenting with community-onset colitis.
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Affiliation(s)
- Ioannis M Zacharioudakis
- Division of Infectious Diseases and Immunology, Department of Medicine, NYU School of Medicine, New York, NY, USA.
| | - Fainareti N Zervou
- Division of Infectious Diseases and Immunology, Department of Medicine, NYU School of Medicine, New York, NY, USA
| | - Michael S Phillips
- Division of Infectious Diseases and Immunology, Department of Medicine, NYU School of Medicine, New York, NY, USA
| | - Maria E Aguero-Rosenfeld
- Division of Infectious Diseases and Immunology, Department of Medicine, NYU School of Medicine, New York, NY, USA; Department of Pathology, NYU School of Medicine, New York, NY, USA
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Aukes L, Fireman B, Lewis E, Timbol J, Hansen J, Yu H, Cai B, Gonzalez E, Lawrence J, Klein NP. A Risk Score to Predict Clostridioides difficile Infection. Open Forum Infect Dis 2021; 8:ofab052. [PMID: 33738316 PMCID: PMC7953654 DOI: 10.1093/ofid/ofab052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 01/31/2021] [Indexed: 02/04/2023] Open
Abstract
Background Clostridioides difficile infection (CDI) is a major cause of severe diarrhea. In this retrospective study, we identified CDI risk factors by comparing demographic and clinical characteristics for Kaiser Permanente Northern California members ≥18 years old with and without laboratory-confirmed incident CDI. Methods We included these risk factors in logistic regression models to develop 2 risk scores that predict future CDI after an Index Date for Risk Score Assessment (IDRSA), marking the beginning of a period for which we estimated CDI risk. Results During May 2011 to July 2014, we included 9986 CDI cases and 2 230 354 members without CDI. The CDI cases tended to be older, female, white race, and have more hospitalizations, emergency department and office visits, skilled nursing facility stays, antibiotic and proton pump inhibitor use, and specific comorbidities. Using hospital discharge as the IDRSA, our risk score model yielded excellent performance in predicting the likelihood of developing CDI in the subsequent 31–365 days (C-statistic of 0.848). Using a random date as the IDRSA, our model also predicted CDI risk in the subsequent 31–365 days reasonably well (C–statistic 0.722). Conclusions These results can be used to identify high-risk populations for enrollment in C difficile vaccine trials and facilitate study feasibility regarding sample size and time to completion.
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Affiliation(s)
- Laurie Aukes
- Kaiser Permanente Vaccine Study Center, Oakland, California, USA
| | - Bruce Fireman
- Kaiser Permanente Vaccine Study Center, Oakland, California, USA
| | - Edwin Lewis
- Kaiser Permanente Vaccine Study Center, Oakland, California, USA
| | - Julius Timbol
- Kaiser Permanente Vaccine Study Center, Oakland, California, USA
| | - John Hansen
- Kaiser Permanente Vaccine Study Center, Oakland, California, USA
| | - Holly Yu
- Pfizer, Inc., Collegeville, Pennsylvania, USA
| | - Bing Cai
- Pfizer, Inc., Collegeville, Pennsylvania, USA
| | | | | | - Nicola P Klein
- Kaiser Permanente Vaccine Study Center, Oakland, California, USA
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Azimirad M, Krutova M, Yadegar A, Shahrokh S, Olfatifar M, Aghdaei HA, Fawley WN, Wilcox MH, Zali MR. Clostridioides difficile ribotypes 001 and 126 were predominant in Tehran healthcare settings from 2004 to 2018: a 14-year-long cross-sectional study. Emerg Microbes Infect 2021; 9:1432-1443. [PMID: 32520657 PMCID: PMC7473134 DOI: 10.1080/22221751.2020.1780949] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Clostridioides difficile infection (CDI) remains a major healthcare problem worldwide, however, little is known about CDI epidemiology in Iran. Between December 2004 and November 2018, 3649 stool samples were collected from patients in 69 hospitals and medical centres in Tehran and were cultured for the presence of C. difficile; isolates were characterized by PCR ribotyping and toxin genes detection. A total of 582 C. difficile isolates were obtained and the overall CDI prevalence was 15.9%; 290 (49.8%) cases were healthcare-associated (HA) and 292 (50.2%) cases were community-associated (CA). Of these, DNA of 513 isolates submitted for ribotyping. The ribotype and/or WEBRIBO type could be assessed in 366 (62.9%) isolates. The most frequent RTs were 001 (n = 75, 12.9%), 126 (n = 65, 11.2%) and 084 (n = 19, 3.3%); the toxin gene profile tcdA + B + /cdtA + B + (n = 112, 19.2%) was the most common. Fifteen C. difficile isolates (2.6%) did not carry any toxin genes. There was no difference between frequently found RTs in HA-CDI and CA-CDI, except for RT 029 which was more likely to be associated with healthcare origin (12/15, p-value = 0.02). No isolate of RTs 027 or 078 was identified. Importantly, RTs 031, 038, 039, 084, 085 reported previously as RTs with an absence of toxin genes, revealed the presence of toxin genes in our study. Using Simpson's reciprocal index of diversity, we found that RT diversity decreased as the prevalence of the RT 084 increased (R = -0.78, p-value = 0.041). Different patterns in CDI epidemiology underscore the importance of local surveillance and infection control measures in Tehran healthcare settings.
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Affiliation(s)
- Masoumeh Azimirad
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Marcela Krutova
- Department of Medical Microbiology, Charles University, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic.,European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Clostridioides Difficile (ESGCD)
| | - Abbas Yadegar
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shabnam Shahrokh
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Meysam Olfatifar
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Asadzadeh Aghdaei
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Warren N Fawley
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Clostridioides Difficile (ESGCD).,Healthcare Associated Infections Research Group, Leeds Teaching Hospitals NHS Trust & University of Leeds, Leeds, UK
| | - Mark H Wilcox
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Clostridioides Difficile (ESGCD).,Healthcare Associated Infections Research Group, Leeds Teaching Hospitals NHS Trust & University of Leeds, Leeds, UK
| | - Mohammad Reza Zali
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Pike CM, Theriot CM. Mechanisms of Colonization Resistance Against Clostridioides difficile. J Infect Dis 2020; 223:S194-S200. [PMID: 33326565 DOI: 10.1093/infdis/jiaa408] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Clostridioides difficile is an urgent antimicrobial-resistant bacterium, causing mild to moderate and sometimes life-threatening disease. Commensal gut microbes are critical for providing colonization resistance against C difficile and can be leveraged as non-antibiotic alternative therapeutics for the prevention and treatment of C difficile infection.
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Affiliation(s)
- Colleen M Pike
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Casey M Theriot
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
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Korhonen L, Cohen J, Gregoricus N, Farley MM, Perlmutter R, Holzbauer SM, Dumyati G, Beldavs Z, Paulick A, Vinjé J, Limbago BM, Lessa FC, Guh AY. Evaluation of viral co-infections among patients with community-associated Clostridioides difficile infection. PLoS One 2020; 15:e0240549. [PMID: 33075113 PMCID: PMC7571680 DOI: 10.1371/journal.pone.0240549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 09/28/2020] [Indexed: 02/04/2023] Open
Abstract
We assessed viral co-infections in 155 patients with community-associated Clostridioides difficile infection in five U.S. sites during December 2012–February 2013. Eighteen patients (12%) tested positive for norovirus (n = 10), adenovirus (n = 4), rotavirus (n = 3), or sapovirus (n = 1). Co-infected patients were more likely than non-co-infected patients to have nausea or vomiting (56% vs 31%; p = 0.04), suggesting that viral co-pathogens contributed to symptoms in some patients. There were no significant differences in prior healthcare or medication exposures or in CDI complications.
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Affiliation(s)
- Lauren Korhonen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Jessica Cohen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
- Atlanta Research and Education Foundation, Atlanta, Georgia, United States of America
| | - Nicole Gregoricus
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Monica M. Farley
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- Veterans Affairs Medical Center, Atlanta, Georgia, United States of America
| | - Rebecca Perlmutter
- Maryland Department of Health, Baltimore, Maryland, United States of America
| | - Stacy M. Holzbauer
- Minnesota Department of Health, St Paul, Minnesota, United States of America
- Career Epidemiology Field Officer Program, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Ghinwa Dumyati
- New York Emerging Infections Program and University of Rochester Medical Center, Rochester, New York, United States of America
| | - Zintars Beldavs
- Oregon Health Authority, Portland, Oregon, United States of America
| | - Ashley Paulick
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Jan Vinjé
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Brandi M. Limbago
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Fernanda C. Lessa
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Alice Y. Guh
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
- * E-mail:
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Wang D, Dong D, Wang C, Cui Y, Jiang C, Ni Q, Su T, Wang G, Mao E, Peng Y. Risk factors and intestinal microbiota: Clostridioides difficile infection in patients receiving enteral nutrition at Intensive Care Units. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:426. [PMID: 32660525 PMCID: PMC7359293 DOI: 10.1186/s13054-020-03119-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 06/29/2020] [Indexed: 12/16/2022]
Abstract
Background Clostridioides difficile infection (CDI) is a leading cause of nosocomial diarrhea. Patients receiving enteral nutrition (EN) in the intensive care unit (ICU) are potentially at high risk of CDI. In the present study, we assessed the risk factors and intestinal microbiome of patients to better understand the occurrence and development of CDI. Methods Patients were screened for C. difficile every week after starting EN, and their clinical records were collected for risk factor identification. Fecal samples were analyzed using 16S rRNA sequencing to evaluate the intestinal microbiota. Results Overall incidence of CDI was 10.7% (18/168 patients). History of cerebral infarction was significantly associated with CDI occurrence (OR, 9.759; 95% CI, 2.140–44.498), and treatment with metronidazole was identified to be protective (OR, 0.287; 95% CI, 0.091–0.902). Patients with EN had lower bacterial richness and diversity, accompanied by a remarkable decrease in the abundance of Bacteroides, Prevotella_9, Ruminococcaceae, and Lachnospiraceae. Of these patients, acquisition of C. difficile resulted in a transient increase in microbial diversity, along with consistent alterations in the proportion of some bacterial taxa, especially Ruminococcaceae and Lachnospiraceae. Upon initiation of EN, patients who were positive for C. difficile later showed an enhanced load of Bacteroides, which was negatively correlated with the abundance of C. difficile when CDI developed. Conclusion ICU patients receiving EN have a high prevalence of CDI and a fragile intestinal microbial environment. History of cerebral infarction and prior treatment with metronidazole are considered as vital risk and protective factors, respectively. We propose that the emergence of CDI could cause a protective alteration of the intestinal microbiota. Additionally, Bacteroides loads seem to be closely related to the occurrence and development of CDI.
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Affiliation(s)
- Daosheng Wang
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin ER Road, Shanghai, 200025, China
| | - Danfeng Dong
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin ER Road, Shanghai, 200025, China
| | - Chen Wang
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin ER Road, Shanghai, 200025, China
| | - Yingchao Cui
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin ER Road, Shanghai, 200025, China
| | - Cen Jiang
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin ER Road, Shanghai, 200025, China
| | - Qi Ni
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin ER Road, Shanghai, 200025, China
| | - Tongxuan Su
- Faculty of Medical Laboratory Science, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin ER Road, Shanghai, 200025, China
| | - Guanzheng Wang
- Faculty of Medical Laboratory Science, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin ER Road, Shanghai, 200025, China
| | - Enqiang Mao
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No.197 Ruijin ER Road, Shanghai, 200025, China
| | - Yibing Peng
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin ER Road, Shanghai, 200025, China. .,Faculty of Medical Laboratory Science, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin ER Road, Shanghai, 200025, China.
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Kelly CR, Fischer M, Grinspan A, Allegretti JR. Patients Eligible for Trials of Microbe-Based Therapeutics Do Not Represent the Population With Recurrent Clostridioides difficile Infection. Clin Gastroenterol Hepatol 2020; 18:1099-1101. [PMID: 31254675 DOI: 10.1016/j.cgh.2019.06.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 06/05/2019] [Accepted: 06/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Although there are many industry-funded trials of microbe-based therapeutics for Clostridioides (formerly Clostridium) difficile infection (CDI), not all patients are eligible for these trials, due to their strict enrollment criteria. Furthermore, given the widespread availability of fecal microbiota transplantation (FMT) and overwhelming evidence to support its efficacy, patients might refuse enrollment in trials with a placebo group. We analyzed willingness and eligibility of patients with recurrent CDI to participate in randomized controlled trials of microbe-based therapeutic agents. METHODS We performed a retrospective study of 199 patients referred to 4 tertiary referral centers for treatment of CDI from August 1, 2018 through January 31, 2019. We collected data on eligibility for FMT and enrollment in randomized controlled trials. RESULTS Of 130 patients deemed appropriate for FMT, 98 patients (75%) were ineligible for participation in a randomized controlled trial and 16 patients (17%) were eligible but refused to enroll. Immune compromise and inflammatory bowel diseases were the most common reasons for exclusion from trials. CONCLUSIONS Most patients with CDI who meet the guideline criteria for FMT are ineligible or unwilling to participate in randomized controlled trials of microbe-based therapeutics. Trial populations therefore do not represent the population of patients with CDI.
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Affiliation(s)
- Colleen R Kelly
- Division of Gastroenterology, Brown University, Providence, Rhode Island.
| | - Monika Fischer
- Division of Gastroenterology, Indiana University, Indianapolis, Indiana
| | - Ari Grinspan
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jessica R Allegretti
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts
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Guh AY, Mu Y, Winston LG, Johnston H, Olson D, Farley MM, Wilson LE, Holzbauer SM, Phipps EC, Dumyati GK, Beldavs ZG, Kainer MA, Karlsson M, Gerding DN, McDonald LC. Trends in U.S. Burden of Clostridioides difficile Infection and Outcomes. N Engl J Med 2020; 382:1320-1330. [PMID: 32242357 PMCID: PMC7861882 DOI: 10.1056/nejmoa1910215] [Citation(s) in RCA: 481] [Impact Index Per Article: 120.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Efforts to prevent Clostridioides difficile infection continue to expand across the health care spectrum in the United States. Whether these efforts are reducing the national burden of C. difficile infection is unclear. METHODS The Emerging Infections Program identified cases of C. difficile infection (stool specimens positive for C. difficile in a person ≥1 year of age with no positive test in the previous 8 weeks) in 10 U.S. sites. We used case and census sampling weights to estimate the national burden of C. difficile infection, first recurrences, hospitalizations, and in-hospital deaths from 2011 through 2017. Health care-associated infections were defined as those with onset in a health care facility or associated with recent admission to a health care facility; all others were classified as community-associated infections. For trend analyses, we used weighted random-intercept models with negative binomial distribution and logistic-regression models to adjust for the higher sensitivity of nucleic acid amplification tests (NAATs) as compared with other test types. RESULTS The number of cases of C. difficile infection in the 10 U.S. sites was 15,461 in 2011 (10,177 health care-associated and 5284 community-associated cases) and 15,512 in 2017 (7973 health care-associated and 7539 community-associated cases). The estimated national burden of C. difficile infection was 476,400 cases (95% confidence interval [CI], 419,900 to 532,900) in 2011 and 462,100 cases (95% CI, 428,600 to 495,600) in 2017. With accounting for NAAT use, the adjusted estimate of the total burden of C. difficile infection decreased by 24% (95% CI, 6 to 36) from 2011 through 2017; the adjusted estimate of the national burden of health care-associated C. difficile infection decreased by 36% (95% CI, 24 to 54), whereas the adjusted estimate of the national burden of community-associated C. difficile infection was unchanged. The adjusted estimate of the burden of hospitalizations for C. difficile infection decreased by 24% (95% CI, 0 to 48), whereas the adjusted estimates of the burden of first recurrences and in-hospital deaths did not change significantly. CONCLUSIONS The estimated national burden of C. difficile infection and associated hospitalizations decreased from 2011 through 2017, owing to a decline in health care-associated infections. (Funded by the Centers for Disease Control and Prevention.).
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Affiliation(s)
- Alice Y Guh
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Yi Mu
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Lisa G Winston
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Helen Johnston
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Danyel Olson
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Monica M Farley
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Lucy E Wilson
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Stacy M Holzbauer
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Erin C Phipps
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Ghinwa K Dumyati
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Zintars G Beldavs
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Marion A Kainer
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Maria Karlsson
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Dale N Gerding
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - L Clifford McDonald
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
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Bouza E, Aguado JM, Alcalá L, Almirante B, Alonso-Fernández P, Borges M, Cobo J, Guardiola J, Horcajada JP, Maseda E, Mensa J, Merchante N, Muñoz P, Pérez Sáenz JL, Pujol M, Reigadas E, Salavert M, Barberán J. Recommendations for the diagnosis and treatment of Clostridioides difficile infection: An official clinical practice guideline of the Spanish Society of Chemotherapy (SEQ), Spanish Society of Internal Medicine (SEMI) and the working group of Postoperative Infection of the Spanish Society of Anesthesia and Reanimation (SEDAR). REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2020; 33:151-175. [PMID: 32080996 PMCID: PMC7111242 DOI: 10.37201/req/2065.2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 01/26/2020] [Indexed: 12/12/2022]
Abstract
This document gathers the opinion of a multidisciplinary forum of experts on different aspects of the diagnosis and treatment of Clostridioides difficile infection (CDI) in Spain. It has been structured around a series of questions that the attendees considered relevant and in which a consensus opinion was reached. The main messages were as follows: CDI should be suspected in patients older than 2 years of age in the presence of diarrhea, paralytic ileus and unexplained leukocytosis, even in the absence of classical risk factors. With a few exceptions, a single stool sample is sufficient for diagnosis, which can be sent to the laboratory with or without transportation media for enteropathogenic bacteria. In the absence of diarrhoea, rectal swabs may be valid. The microbiology laboratory should include C. difficile among the pathogens routinely searched in patients with diarrhoea. Laboratory tests in different order and sequence schemes include GDH detection, presence of toxins, molecular tests and toxigenic culture. Immediate determination of sensitivity to drugs such as vancomycin, metronidazole or fidaxomycin is not required. The evolution of toxin persistence is not a suitable test for follow up. Laboratory diagnosis of CDI should be rapid and results reported and interpreted to clinicians immediately. In addition to the basic support of all diarrheic episodes, CDI treatment requires the suppression of antiperistaltic agents, proton pump inhibitors and antibiotics, where possible. Oral vancomycin and fidaxomycin are the antibacterials of choice in treatment, intravenous metronidazole being restricted for patients in whom the presence of the above drugs in the intestinal lumen cannot be assured. Fecal material transplantation is the treatment of choice for patients with multiple recurrences but uncertainties persist regarding its standardization and safety. Bezlotoxumab is a monoclonal antibody to C. difficile toxin B that should be administered to patients at high risk of recurrence. Surgery is becoming less and less necessary and prevention with vaccines is under research. Probiotics have so far not been shown to be therapeutically or preventively effective. The therapeutic strategy should be based, rather than on the number of episodes, on the severity of the episodes and on their potential to recur. Some data point to the efficacy of oral vancomycin prophylaxis in patients who reccur CDI when systemic antibiotics are required again.
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Affiliation(s)
- E Bouza
- Emilio Bouza MD, PhD, Instituto de Investigación Sanitaria Gregorio Marañón, Servicio de Microbiología Clínica y E. Infecciosas C/ Dr. Esquerdo, 46 - 28007 Madrid, Spain.
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