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Tashiro S, Mihara T, Sasaki M, Shimamura C, Shimamura R, Suzuki S, Yoshikawa M, Hasegawa T, Enoki Y, Taguchi K, Matsumoto K, Ohge H, Suzuki H, Nakamura A, Mori N, Morinaga Y, Yamagishi Y, Yoshizawa S, Yanagihara K, Mikamo H, Kunishima H. Oral fidaxomicin versus vancomycin for the treatment of Clostridioides difficile infection: A systematic review and meta-analysis of randomized controlled trials. J Infect Chemother 2022; 28:1536-1545. [PMID: 35964806 DOI: 10.1016/j.jiac.2022.08.008] [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: 07/06/2022] [Revised: 07/27/2022] [Accepted: 08/04/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Fidaxomicin (FDX) has received considerable attention as a novel therapeutic alternative agent to vancomycin (VCM) for Clostridioides difficile infection (CDI). However, the superiority and efficacy profile of FDX are not sufficiently determined by high-quality evidence. This study aimed to clarify the superiority of FDX for CDI treatment through a systematic review and meta-analysis. METHODS We conducted a meta-analysis of randomized controlled trials (RCTs) which evaluated the efficacy and safety of FDX and VCM in patients with CDI. Electronic databases (PubMed, Cochrane Library, Web of Science, and Clinicaltrials.gov) were searched for studies published until October 15, 2021. The primary endpoint was global cure. The secondary endpoints were clinical cure, recurrence, and adverse event. Risk ratios (RRs), risk differences (RDs), and 95% confidence intervals were calculated using Mantel-Haenszel random-effects model. The risk of bias was assessed using Cochrane Handbook for Systematic Reviews of Interventions and Assessment Criteria. RESULTS Six RCTs were included in this meta-analysis. Compared to VCM, FDX was associated with significantly higher global cure rates (RR = 1.18, P < 0.00001; RD = 0.11, 95% CI = 0.07-0.16). In addition, clinical cure rates were comparable between FDX and VCM (P = 0.31). FDX was associated with significantly lower recurrence rates compared to VCM (RR = 0.59, P < 0.0001). In addition, adverse event rates were not significantly different between the drugs (P = 0.41). CONCLUSION FDX achieves significantly higher global cure rates and lower recurrence rates and is comparable to VCM in clinical cure rates and adverse event rates in patients with CDI. Collectively, FDX is superior to VCM as a therapeutic agent for CDI.
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Affiliation(s)
- Sho Tashiro
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Takayuki Mihara
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Moe Sasaki
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Chiaki Shimamura
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Rina Shimamura
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Shiho Suzuki
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Maiko Yoshikawa
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Tatsuki Hasegawa
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Yuki Enoki
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan.
| | - Kazuaki Taguchi
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Hiroki Ohge
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, Japan
| | - Hiromichi Suzuki
- Department of Infectious Diseases, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Atsushi Nakamura
- Department of Infection Prevention and Control, Graduate School of Medical Sciences, Nagoya City University, Aichi, Japan
| | - Nobuaki Mori
- Department of General Internal Medicine and Infectious Diseases, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yoshitomo Morinaga
- Department of Microbiology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Yuka Yamagishi
- Department of Clinical Infectious Diseases, Kochi Medical School, Kochi, Japan
| | - Sadako Yoshizawa
- Department of Clinical Laboratory / Department of Microbiology and Infectious Diseases, Toho University Faculty of Medicine, Tokyo, Japan
| | - Katsunori Yanagihara
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hiroshige Mikamo
- Department of Clinical Infectious Diseases, Aichi Medical University Hospital, Aichi, Japan
| | - Hiroyuki Kunishima
- Department of Infectious Diseases, St. Marianna University School of Medicine, Kanagawa, Japan
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Wijarnpreecha K, Panjawatanan P, Thongprayoon C, Ungprasert P. Statins & risk of Clostridium difficile infection: A meta-analysis. Indian J Med Res 2020; 150:359-364. [PMID: 31823917 PMCID: PMC6902370 DOI: 10.4103/ijmr.ijmr_1973_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background & objectives: Clostridium difficile infection is one of the most common healthcare-associated infections worldwide. Recent epidemiologic studies have suggested that statin users may have a lower risk of C. difficile infection, although the results are inconsistent. This meta-analysis was conducted with the aim of summarizing all available data to assess the risk of C. difficile infection among statin users versus non-users. Methods: A literature review was performed using the MEDLINE and EMBASE databases from inception to October 2017. Cohort, case-control and cross-sectional studies that compared the risk of C. difficile infection among statin users versus non-users were included. Pooled odds ratio (OR) and 95 per cent confidence interval (CI) were calculated using a random-effect, generic inverse variance method. Results: Six case-control studies and two cross-sectional studies met the eligibility criteria and were included in this meta-analysis. The risk of C. difficile infection among statin users was significantly lower than non-users with the pooled OR of 0.74 (95% CI, 0.61-0.89). The statistical heterogeneity of this study was high (I2=90%). Interpretation & conclusions: This meta-analysis demonstrated a decreased risk of C. difficile infection among statin users versus non-users. Further studies are required to clarify the role of statins for prevention of C. difficile infection in clinical practice.
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Affiliation(s)
- Karn Wijarnpreecha
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, New York, USA
| | | | - Charat Thongprayoon
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, New York, USA
| | - Patompong Ungprasert
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA; Department of Research & Development, Clinical Epidemiology Unit, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Abstract
Clostridium (reclassified as " Clostridioides ") difficile infection (CDI) is a healthcare-associated infection and significant source of potentially preventable morbidity, recurrence, and death, particularly among hospitalized older adults. Additional risk factors include antibiotic use and severe underlying illness. The increasing prevalence of community-associated CDI is gaining recognition as a novel source of morbidity in previously healthy patients. Even after recovery from initial infection, patients remain at risk for recurrence or reinfection with a new strain. Some pharmaco-epidemiologic studies have suggested an increased risk associated with proton pump inhibitors and protective effect from statins, but these findings have not been uniformly reproduced in all studies. Certain ribotypes of C. difficile , including the BI/NAP1/027, 106, and 018, are associated with increased antibiotic resistance and potential for higher morbidity and mortality. CDI remains a high-morbidity healthcare-associated infection, and better understanding of ribotypes and medication risk factors could help to target treatment, particularly for patients with high recurrence risk.
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Affiliation(s)
- Ana C. De Roo
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Scott E. Regenbogen
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
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Gaviola ML, Scribe EC, Leverett HN, Howard ML. Statin Effects on Incidence, Treatment Success, and Mortality of Clostridium difficile Infections. J Pharm Pract 2019; 33:497-505. [PMID: 31216928 DOI: 10.1177/0897190019854956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To review the effects of statin use in patients at risk for or diagnosed with Clostridium difficile infection (CDI) on CDI incidence, treatment success, and mortality. METHODS A literature search was performed through January 2019 using the following terms: statins, HMG-CoA inhibitors, Clostridium difficile, Clostridium difficile associated diarrhea, and Clostridium difficile infection. Additional references were identified from a review of literature citations. Studies evaluating statin effects on C difficile-related outcomes were included. RESULTS A total of 8 studies were identified for inclusion in this review. All studies were retrospective. Five studies reported the association between statin use and the development of CDI, suggesting that statins may decrease risk of CDI development in patients already on statin. In one study, there was an improved treatment response against CDI with the use of statin. Three retrospective studies evaluated statin use and mortality from CDI and only one study found significant mortality benefit in statin users. CONCLUSIONS Statin use may have a protective effect against the development of CDI and improve CDI treatment success; however, it is unclear if use confers a mortality benefit. Current data remain sparse and larger, prospective studies are needed to confirm current results and identify the specific population that may benefit the most from this intervention.
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Affiliation(s)
- Marian L Gaviola
- University of North Texas System College of Pharmacy, Fort Worth, TX, USA
| | - Emily C Scribe
- University of North Texas System College of Pharmacy, Fort Worth, TX, USA
| | - Haley N Leverett
- University of North Texas System College of Pharmacy, Fort Worth, TX, USA
| | - Meredith L Howard
- University of North Texas System College of Pharmacy, Fort Worth, TX, USA
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5
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A possible association between statin use and improved Clostridioides difficile infection mortality in veterans. PLoS One 2019; 14:e0217423. [PMID: 31136602 PMCID: PMC6538245 DOI: 10.1371/journal.pone.0217423] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 05/10/2019] [Indexed: 01/03/2023] Open
Abstract
Clostridioides difficile infection (CDI) is the most common cause of nosocomial diarrhea and places a significant burden on patients and the health care system. Statins could lead to improvements in CDI clinical response due their pleiotropic effects, including immunomodulatory and lipid-lowering effects; however, few studies have assessed this association. The primary objective of this study was to compare CDI health outcomes in statin users and non-users in a national cohort of patients. This was a retrospective cohort study of all adult CDI patients receiving care from the Veterans Health Administration from 2002 to 2014. Patients were divided into two groups based on statin exposure 90 days prior to and during their first CDI encounter. CDI health outcomes, including mortality and CDI recurrence, were compared using a propensity-score matched cohort of statin users and non-users and multivariable logistic regression. A total of 26,149 patients met study inclusion criteria, of which 173 statins-users and 173 non-users were propensity score matched. Thirty-day mortality was significantly lower among statins users with CDI (12.7%) compared to non-users (20.2%) (aOR 0.34; 95% CI 0.16-0.72). Sixty-day CDI recurrence was non-significantly lower among statin-users (9.0%) compared to non-users (16.6%) (aOR 0.68; 95% CI 0.29-1.59). In this nationally-representative study of veterans with CDI, statin use was associated with lower 30-day mortality compared to non-use. Statin use was not associated with 60-day CDI recurrence.
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Viswesh V, Hincapie AL, Yu M, Khatchatourian L, Nowak MA. Development of a bedside scoring system for predicting a first recurrence of Clostridium difficile-associated diarrhea. Am J Health Syst Pharm 2019; 74:474-482. [PMID: 28336757 DOI: 10.2146/ajhp160186] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE A scoring system for identifying patients at high or low risk for recurrent Clostridium difficile-associated diarrhea (CDAD) is described. METHODS A retrospective cohort study was performed using data on adults with CDAD admitted to a 3-hospital system from 2009 to 2014. The primary endpoint was the rate of recurrent CDAD within 60 days of clinical cure of CDAD. Risk factors for CDAD recurrence were identified, and a risk prediction tool was developed using multivariate logistic regression. RESULTS The CDAD cure rate in the study cohort (n = 340) was 92.3%; the 60-day recurrence rate was 16.9%. Five factors were significantly associated with high recurrence risk: presence of CDAD at admission, body temperature of >37.8 °C at admission, leukocytosis, nosocomial CDAD, and abdominal distention on CDAD presentation. From that information a risk prediction tool, the CDAD "recurrence score," was developed (1 point is assigned for each factor present, for a maximum score of 5). Validation testing of the recurrence score indicated an area under the receiver operating characteristic curve of 0.72 (95% confidence interval, 0.65-0.80). A score of ≥2 had a negative predictive value of 91%, while a score of ≥4 had a positive predictive value of 70%. CONCLUSION If externally validated in future studies, a tool for predicting the risk of recurrent CDAD using data readily available at the time of presentation could allow clinicians to identify patients at high risk for recurrence, address modifiable risk factors, and select tailored treatments to improve patient outcomes.
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Affiliation(s)
- Velliyur Viswesh
- College of Pharmacy, Roseman University of Health Sciences, Henderson, NV.
| | - Ana L Hincapie
- Division of Pharmacy Practice and Administrative Sciences, University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH
| | - Marie Yu
- Department of Pharmacy, Sharp Grossmont Hospital, La Mesa, CA
| | - Linda Khatchatourian
- Department of Pharmacy, University of Southern California Verdugo Hills Hospital, Glendale, CA
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Suchartlikitwong S, Laoveeravat P, Teerakanok J, Mingbunjerdsuk T, Thavaraputta S, Vutthikraivit W, Thongprayoon C, Nugent K, Cheungpasitporn W. Meta-analysis comparing the effects of statins on the risk of Clostridium difficilediarrhea. Proc (Bayl Univ Med Cent) 2018; 31:447-452. [DOI: 10.1080/08998280.2018.1472994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 04/29/2018] [Accepted: 04/30/2018] [Indexed: 10/28/2022] Open
Affiliation(s)
| | - Passisd Laoveeravat
- Department of Internal Medicine, Texas Tech University Health Sciences CenterLubbockTexas
| | - Jirapat Teerakanok
- Department of Internal Medicine, Texas Tech University Health Sciences CenterLubbockTexas
| | | | - Subhanudh Thavaraputta
- Department of Internal Medicine, Texas Tech University Health Sciences CenterLubbockTexas
| | - Wasawat Vutthikraivit
- Department of Internal Medicine, Texas Tech University Health Sciences CenterLubbockTexas
| | | | - Kenneth Nugent
- Department of Internal Medicine, Texas Tech University Health Sciences CenterLubbockTexas
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo ClinicRochesterMinnesota
- Division of Nephrology, Department of Internal Medicine, University of Mississippi Medical CenterJacksonMississippi
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8
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Tariq R, Mukhija D, Gupta A, Singh S, Pardi DS, Khanna S. Statin use and the risk of Clostridium difficile infection: a systematic review with meta-analysis. Infect Drug Resist 2018; 11:405-416. [PMID: 29559802 PMCID: PMC5856044 DOI: 10.2147/idr.s156475] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Statins have pleiotropic effects beyond cholesterol lowering by immune modulation. The association of statins with primary Clostridium difficile infection (CDI) is unclear as studies have reported conflicting findings. We performed a systematic review and meta-analysis to evaluate the association between statin use and CDI. PATIENTS AND METHODS We searched MEDLINE, Embase, and Web of Science from January 1978 to December 2016 for studies assessing the association between statin use and CDI. The Newcastle-Ottawa Scale was used to assess the methodologic quality of included studies. Weighted summary estimates were calculated using generalized inverse variance with random-effects model. RESULTS Eight studies (6 case-control and 2 cohort) were included in the meta-analysis, which comprised 156,722 patients exposed to statins and 356,185 controls, with 34,849 total cases of CDI available in 7 studies. The rate of CDI in patients with statin use was 4.3%, compared with 7.8% in patients without statin use. An overall meta-analysis of 8 studies using the random-effects model demonstrated that statins may be associated with a decreased risk of CDI (maximally adjusted odds ratio [OR], 0.80; 95% CI, 0.66-0.97; P=0.02). There was significant heterogeneity among the studies, with an I2 of 79%. No publication bias was seen. Meta-analysis of studies that adjusted for confounders revealed no protective effect of statins (adjusted OR, 0.84; 95% CI, 0.70-1.01; P=0.06, I2=75%). However, a meta-analysis of only full-text studies using the random-effects model demonstrated a decreased risk of CDI with the use of statins (OR 0.77; 95% CI, 0.61-0.99; P=0.04, I2=85%). CONCLUSION Meta-analyses of existing studies suggest that patients prescribed a statin may be at decreased risk for CDI. The results must be interpreted with caution given the significant heterogeneity and lack of benefit on analysis of studies that adjusted for confounders.
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Affiliation(s)
- Raseen Tariq
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY
| | - Dhruvika Mukhija
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH
| | - Arjun Gupta
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Siddharth Singh
- Division of Gastroenterology and Hepatology, University of California San Diego, La Jolla, CA, USA
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Sahil Khanna
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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Koon HW, Wang J, Mussatto CC, Ortiz C, Lee EC, Tran DHN, Chen X, Kelly CP, Pothoulakis C. Fidaxomicin and OP-1118 Inhibit Clostridium difficile Toxin A- and B-Mediated Inflammatory Responses via Inhibition of NF-κB Activity. Antimicrob Agents Chemother 2018; 62:e01513-17. [PMID: 29038278 PMCID: PMC5740352 DOI: 10.1128/aac.01513-17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 10/12/2017] [Indexed: 01/05/2023] Open
Abstract
Clostridium difficile causes diarrhea and colitis by releasing toxin A and toxin B. In the human colon, both toxins cause intestinal inflammation and stimulate tumor necrosis factor alpha (TNF-α) expression via the activation of NF-κB. It is well established that the macrolide antibiotic fidaxomicin is associated with reduced relapses of C. difficile infection. We showed that fidaxomicin and its primary metabolite OP-1118 significantly inhibited toxin A-mediated intestinal inflammation in mice in vivo and toxin A-induced cell rounding in vitro We aim to determine whether fidaxomicin and OP-1118 possess anti-inflammatory effects against toxin A and toxin B in the human colon and examine the mechanism of this response. We used fresh human colonic explants, NCM460 human colonic epithelial cells, and RAW264.7 mouse macrophages to study the mechanism of the activity of fidaxomicin and OP-1118 against toxin A- and B-mediated cytokine expression and apoptosis. Fidaxomicin and OP-1118 dose-dependently inhibited toxin A- and B-induced TNF-α and interleukin-1β (IL-1β) mRNA expression and histological damage in human colonic explants. Fidaxomicin and OP-1118 inhibited toxin A-mediated NF-κB phosphorylation in human and mouse intestinal mucosae. Fidaxomicin and OP-1118 also inhibited toxin A-mediated NF-κB phosphorylation and TNF-α expression in macrophages, which was reversed by the NF-κB activator phorbol myristate acetate (PMA). Fidaxomicin and OP-1118 prevented toxin A- and B-mediated apoptosis in NCM460 cells, which was reversed by the addition of PMA. PMA reversed the cytoprotective effect of fidaxomicin and OP-1118 in toxin-exposed human colonic explants. Fidaxomicin and OP-1118 inhibit C. difficile toxin A- and B-mediated inflammatory responses, NF-κB phosphorylation, and tissue damage in the human colon.
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Affiliation(s)
- Hon Wai Koon
- Center for Inflammatory Bowel Diseases, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA
| | - Jiani Wang
- Center for Inflammatory Bowel Diseases, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang City, Liaoning Province, China
| | - Caroline C Mussatto
- Center for Inflammatory Bowel Diseases, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA
| | - Christina Ortiz
- Center for Inflammatory Bowel Diseases, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA
| | - Elaine C Lee
- Center for Inflammatory Bowel Diseases, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA
| | - Diana Hoang-Ngoc Tran
- Center for Inflammatory Bowel Diseases, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA
| | - Xinhua Chen
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ciaran P Kelly
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Charalabos Pothoulakis
- Center for Inflammatory Bowel Diseases, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA
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A Surgical Clostridium-Associated Risk of Death Score Predicts Mortality After Colectomy for Clostridium difficile. Dis Colon Rectum 2017; 60:1285-1290. [PMID: 29112564 DOI: 10.1097/dcr.0000000000000920] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND A Clostridium difficile-associated risk of death score was recently developed and validated by using a national cohort of both nonsurgical and surgical patients admitted with C difficile infection. However, risk scores specifically derived from surgical cohorts and designed for patients with C difficile infection are currently unavailable. OBJECTIVE The aim of this study was to develop a risk of death score for patients with C difficile infection who are being considered for total abdominal colectomy because of the failure of medical therapy. DESIGN This is a retrospective cohort study. SETTINGS This study was conducted with the use of a national database. PATIENTS All patients undergoing total colectomy for C difficile infection were identified in the National Surgical Quality Improvement Program database from 2005 to 2014. MAIN OUTCOME MEASURES Variables similar to the original scoring system were used in multivariable analyses to determine the risk of 30-day mortality for patients, and a model was constructed to estimate the predicted probability of mortality after surgery. RESULTS Of 532 patients who underwent surgery, 32.7% experienced 30-day postoperative mortality. Patient covariates associated with significantly increased mortality included age greater than 80 years (OR 5.5, p = 0.003), need for preoperative mechanical ventilation (OR 3.1, p < 0.001), chronic steroid use (OR 2.9, p < 0.001), underlying cardiopulmonary disease (OR 2.0, p = 0.001), and acute renal failure (OR=1.7, p = 0.03). These and other comorbidities, including hepatic disease, a cancer diagnosis, and both insulin- and noninsulin-dependent diabetes mellitus, were used to construct a model to estimate the predicted probability of mortality, which ranged from 8.0% to 96.1% based on individual comorbidity profiles. These estimates differed substantially when compared with those obtained using the National Surgical Quality Improvement Program risk calculator, which estimated the risk of mortality among surgical patients as being consistently lower. LIMITATIONS This study was limited by its retrospective design. CONCLUSIONS Our surgical scoring system allows preoperative risk stratification for patients being evaluated for colectomy for C difficile infection, potentially helping to avoid futile surgery. See Video Abstract at http://links.lww.com/DCR/A434.
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11
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Mulki R, Baumann AJ, Alnabelsi T, Sandhu N, Alhamshari Y, Wheeler DS, Perloff S, Katz PO. Body mass index greater than 35 is associated with severe Clostridium difficile infection. Aliment Pharmacol Ther 2017; 45:75-81. [PMID: 27790736 DOI: 10.1111/apt.13832] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 08/02/2016] [Accepted: 09/27/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Obesity has been implicated in the acquisition of Clostridium difficile infections (CDI), however, no study has investigated whether there is a correlation between body mass index (BMI) and CDI severity. AIM To determine whether obesity, as measured by BMI correlates with severe hospital-onset or community-onset CDI. METHODS Patients admitted with CDI at a tertiary-care center from January 2013 to June 2015 were identified. The cohort was stratified by onset of disease using the National Healthcare Safety Network criteria, and by severity using the 2013 American College of Gastroenterology guidelines. Multivariate logistic regression was used to determine independent predictors of severe CDI. RESULTS A total of 196 met the inclusion criteria, of which 57.1% (112) met criteria for severe disease. Overall, BMI >35 kg/m2 was 1.7-fold more likely to be associated with severe CDI compared to a BMI 20-35 kg/m2 (P < 0.005), and was an independent predictor of severe CDI (P = 0.038). In patients with community-onset-CDI and hospital-onset-CDI, a BMI >35 kg/m2 was associated with a 1.96-fold and 1.48 greater rate of severe CDI compared to a BMI 20-35 kg/m2 (P = 0.004 and 0.048), and was an independent predictor of severe CDI in these cohorts (P = 0.039 and 0.027) respectively. CONCLUSION This study has identified an association between body mass index and Clostridium difficile infection severity. A BMI>35 kg/m2 is an independent risk factor for severe community-onset and hospital-onset Clostridium difficile infections.
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Affiliation(s)
- R Mulki
- Department of Internal Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - A J Baumann
- Department of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
| | - T Alnabelsi
- Department of Internal Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - N Sandhu
- Department of Internal Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Y Alhamshari
- Department of Internal Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - D S Wheeler
- Department of Internal Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - S Perloff
- Division of Infectious Disease, Einstein Medical Center, Philadelphia, PA, USA
| | - P O Katz
- Division of Gastroenterology and Hepatology, Einstein Medical Center, Philadelphia, PA, USA
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12
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Factors Predicting Recurrence of Clostridium difficile Infection (CDI) in Hospitalized Patients: Retrospective Study of More Than 2000 Patients. J Investig Med 2016; 63:747-51. [PMID: 25871748 DOI: 10.1097/jim.0000000000000188] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Clostridium difficile infection (CDI) has increased in incidence and severity worldwide, causing direct costs estimated to range from US $3.2 billion to $4.8 billion. The aim of this study was to investigate and identify factors that predict recurrence of CDI. METHODS This was a retrospective case-control study between 2007 and 2013 on patients admitted with CDI. Recurrent CDI is defined as a new episode of diarrhea within 90 days confirmed by a positive stool C. difficile toxin assay or polymerase chain reaction, after resolution of the initial CDI episode for at least 10 days and after discontinuation of the CDI therapy. RESULTS Three thousand twenty patients were diagnosed with CDI between January 2007 and December 2013. Two hundred nine of 2019 patients in the study had a recurrence of CDI within 90 days of the end of the initial CDI episode (10.3%). Multivariate analysis showed that most of the recurrences occurred in patients with comorbidities, particularly chronic kidney disease (odds ratio, 1.3; 95% confidence interval [CI], 1.0-2.4; P = 0.039). In addition, a higher percentage of patients in the recurrence group were prescribed proton-pump inhibitors (odds ratio, 1.65; 95% CI, 1.0-1.7; P = 0.002) and steroids (odds ratio, 1.65; 95% CI, 1.0-1.5; P = 0.047). CONCLUSIONS Our data suggest that the use of glucocorticoids, use of proton-pump inhibitors, and having end-stage renal disease are significant risk factors associated with recurrent CDI.
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Nolan JA, Kinsella M, Hill C, Joyce SA, Gahan CGM. Analysis of the Impact of Rosuvastatin on Bacterial Mevalonate Production Using a UPLC-Mass Spectrometry Approach. Curr Microbiol 2016; 73:1-8. [DOI: 10.1007/s00284-016-1014-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 01/22/2016] [Indexed: 10/22/2022]
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Kassam Z, Fabersunne CC, Smith MB, Alm EJ, Kaplan GG, Nguyen GC, Ananthakrishnan AN. Clostridium difficile associated risk of death score (CARDS): a novel severity score to predict mortality among hospitalised patients with C. difficile infection. Aliment Pharmacol Ther 2016; 43:725-33. [PMID: 26849527 PMCID: PMC5094350 DOI: 10.1111/apt.13546] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 11/14/2015] [Accepted: 01/12/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a public health threat and associated with significant mortality. However, there is a paucity of objectively derived CDI severity scoring systems to predict mortality. AIM To develop a novel CDI risk score to predict mortality entitled: Clostridium difficile associated risk of death score (CARDS). METHODS We obtained data from the United States 2011 Nationwide Inpatient Sample (NIS) database. All CDI-associated hospitalisations were identified using discharge codes (ICD-9-CM, 008.45). Multivariate logistic regression was utilised to identify independent predictors of mortality. Clostridium difficile associated risk of death score was calculated by assigning a numeric weight to each parameter based on their odds ratio in the final logistic model. Predictive properties of model discrimination were assessed using the c-statistic and validated in an independent sample using the 2010 NIS database. RESULTS We identified 77 776 hospitalisations, yielding an estimate of 374 747 cases with an associated diagnosis of CDI in the US, 8% of whom died in the hospital. The eight severity score predictors were identified on multivariate analysis: age, cardiopulmonary disease, malignancy, diabetes, inflammatory bowel disease, acute renal failure, liver disease and ICU admission, with weights ranging from -1 (for diabetes) to 5 (for ICU admission). The overall risk score in the cohort ranged from 0 to 18. Mortality increased significantly as CARDS increased. CDI-associated mortality was 1.2% with a CARDS of 0 compared to 100% with CARDS of 18. The model performed equally well in our validation cohort. CONCLUSION Clostridium difficile associated risk of death score is a promising simple severity score to predict mortality among those hospitalised with C. difficile infection.
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Affiliation(s)
- Zain Kassam
- Massachusetts Institute of Technology, Cambridge, MA, United States,OpenBiome, Medford, MA, United States
| | - Camila Cribb Fabersunne
- Harvard Medical School, Boston, MA, United States,Harvard School of Public Health, Boston, MA, United States
| | - Mark B. Smith
- Massachusetts Institute of Technology, Cambridge, MA, United States,OpenBiome, Medford, MA, United States
| | - Eric J. Alm
- Massachusetts Institute of Technology, Cambridge, MA, United States
| | | | - Geoffrey C. Nguyen
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, University of Toronto, Toronto, ON, Canada
| | - Ashwin N. Ananthakrishnan
- Harvard Medical School, Boston, MA, United States,Massachusetts General Hospital, Boston, MA, United States
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The effect of statins on the outcome of Clostridium difficile infection in hospitalized patients. Eur J Clin Microbiol Infect Dis 2016; 35:779-84. [PMID: 26864041 DOI: 10.1007/s10096-016-2597-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 01/25/2016] [Indexed: 01/09/2023]
Abstract
UNLABELLED Several studies have shown an association between exposure to statins and favorable clinical outcomes for various types of infections. We aimed to assess the impact of statin use on mortality, disease severity and complications among hospitalized patients with Clostridium difficile infection (CDI). Data were analyzed from a retrospectively collected database of 499 patients diagnosed with CDI during 2009-2014. We compared infection outcomes between 178 statin (36 %) users and 321 (64 %) non-users. On multivariate analysis, we found that statin use did not have a significant impact on 30-day mortality (OR = 1.54; 95 % CI, 0.85-2.79; p = 0.15) or any significant effect on CDI severity and complication. Concomitant statin use has no significant impact on short-term mortality or effect on CDI severity and complications among hospitalized patients with CDI. However, patients in the statin group were older and had higher Charlson score compared with the non-statin group. Whether these factors affected a possible impact of statins on the disease course remains to be investigated. KEY MESSAGES • Clostridium difficile is the most common cause of infectious nosocomial diarrhea among hospitalized adult patients in the developed countries. • There is an increasing morbidity and mortality of CDI patients due to the emergence of new strains of high virulence. • Recent studies demonstrated that prior statin use has protective and ameliorating effects on morbidity and mortality among CDI patients. • Our study showed that concomitant statin use has no significant impact on short-term mortality, CDI severity and its complications.
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A Comprehensive Assessment Across the Healthcare Continuum: Risk of Hospital-Associated Clostridium difficile Infection Due to Outpatient and Inpatient Antibiotic Exposure. Infect Control Hosp Epidemiol 2015; 36:1409-16. [PMID: 26387888 DOI: 10.1017/ice.2015.220] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Limitations in sample size, overly inclusive antibiotic classes, lack of adjustment of key risk variables, and inadequate assessment of cases contribute to widely ranging estimates of risk factors for Clostridium difficile infection (CDI). OBJECTIVE To incorporate all key CDI risk factors in addition to 27 antibiotic classes into a single comprehensive model. DESIGN Retrospective cohort study. SETTING Kaiser Permanente Southern California. PATIENTS Members of Kaiser Permanente Southern California at least 18 years old admitted to any of its 14 hospitals from January 1, 2011, through December 31, 2012. METHODS Hospital-acquired CDI cases were identified by polymerase chain reaction assay. Exposure to major outpatient antibiotics (10 classes) and those administered during inpatient stays (27 classes) was assessed. Age, sex, self-identified race/ethnicity, Charlson Comorbidity Score, previous hospitalization, transfer from a skilled nursing facility, number of different antibiotic classes, statin use, and proton pump inhibitor use were also assessed. Poisson regression estimated adjusted risk of CDI. RESULTS A total of 401,234 patients with 2,638 cases of incident CDI (0.7%) were detected. The final model demonstrated highest CDI risk associated with increasing age, exposure to multiple antibiotic classes, and skilled nursing facility transfer. Factors conferring the most reduced CDI risk were inpatient exposure to tetracyclines and first-generation cephalosporins, and outpatient macrolides. CONCLUSIONS Although type and aggregate antibiotic exposure are important, the factors that increase the likelihood of environmental spore acquisition should not be underestimated. Operationally, our findings have implications for antibiotic stewardship efforts and can inform empirical and culture-driven treatment approaches.
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Vassallo A, Tran MCN, Goldstein EJC. Clostridium difficile: improving the prevention paradigm in healthcare settings. Expert Rev Anti Infect Ther 2014; 12:1087-102. [DOI: 10.1586/14787210.2014.942284] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Angela Vassallo
- Department of Infection Prevention, Providence Saint John’s Health Center,
2121 Santa Monica Blvd, Santa Monica, CA 90404, USA
| | - Mai-Chi N Tran
- Department of Pharmacy, Providence Saint John’s Health Center,
2121 Santa Monica Blvd, Santa Monica, CA 90404, USA
| | - Ellie JC Goldstein
- Department of Infectious Diseases, Providence Saint John’s Health Center,
2121 Santa Monica Blvd, Santa Monica, CA 90404, USA
- The UCLA School of Medicine,
Los Angeles, CA 90073, USA
- The R M Alden Research Laboratory,
Santa Monica CA, 90404, USA
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Saliba W, Barnett-Griness O, Elias M, Rennert G. Statins use and risk of mortality in patient with Clostridium difficile infection. Clin Microbiol Infect 2014; 20:1061-6. [PMID: 24816303 DOI: 10.1111/1469-0691.12672] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 04/28/2014] [Accepted: 05/03/2014] [Indexed: 12/29/2022]
Abstract
Current evidence suggests that statins may improve outcome in infectious diseases. This study aims to assess whether statins use is associated with reduced risk of 30-day mortality in Clostridium difficile infection (CDI). Using the computerized database of Clalit, the largest healthcare provider in Israel, we identified a cohort of adult subjects (age ≥40 years) who tested positive on a C. difficile toxin assay performed between January 2011 and December 2012. Subjects were defined as current statins users if they filled at least one prescription during the 90 days before the laboratory assay date. Current users were classified into long-term users if at least one additional prescription was filled during the previous 91-180 days; otherwise they were defined as short-term users. A total 1888 patients with CDI were included. Of them, 340 (18.0%) died during the first 30 days after diagnosis. The 30-day mortality rate was lower among current statins users 89/669 (13.3%) compared with 251/1219 (20.6%) in non-users (p <0.001). A significant reduced risk of 30-day mortality existed after adjustment for potential confounders; adjusted OR = 0.57 (95% CI 0.42-0.79) and was unique to long-term users; 0.53 (0.38-0.73) but not short-term users; 1.15 (0.56-2.34). The risk of 30-day mortality decreased with increasing number of filled statins prescriptions; adjusted OR = 0.77 (95% CI 0.67-0.89) for each additional prescription. Current aspirin use was also independently associated with reduced mortality; adjusted OR = 0.64 (95% CI 0.43-0.88). In conclusion, current statins use, particularly long-term use, has a dose-response protective effect on mortality in patients with CDI.
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Affiliation(s)
- W Saliba
- Department of Community Medicine and Epidemiology, Carmel Medical Centre, Clalit Health Services, Haifa, Israel; Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Internal Medicine C, Ha'emek Medical Centre, Afula, Israel
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Wan YD, Sun TW, Kan QC, Guan FX, Zhang SG. Effect of statin therapy on mortality from infection and sepsis: a meta-analysis of randomized and observational studies. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R71. [PMID: 24725598 PMCID: PMC4056771 DOI: 10.1186/cc13828] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Accepted: 03/25/2014] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Observational data have suggested that statin therapy may reduce mortality in patients with infection and sepsis; however, results from randomized studies are contradictory and do not support the use of statins in this context. Here, we performed a meta-analysis to investigate the effects of statin therapy on mortality from infection and sepsis. METHODS We searched electronic databases (PubMed and Embase) for articles published before November 2013. Randomized or observational studies reporting the effects of statin therapy on mortality in patients with infection or sepsis were eligible. Randomized and observational studies were separately pooled with relative risks (RRs) and random-effects models. RESULTS We examined 5 randomized controlled trials with 867 patients and 27 observational studies with 337,648 patients. Among the randomized controlled trials, statins did not significantly decrease in-hospital mortality (RR, 0.98; 95% confidence interval (CI), 0.73 to 1.33) or 28-day mortality (RR, 0.93; 95% CI, 0.46 to 1.89). However, observational studies indicated that statins were associated with a significant decrease in mortality with adjusted data (RR, 0.65; 95% CI, 0.57 to 0.75) or unadjusted data (RR, 0.74; 95% CI, 0.59 to 0.94). CONCLUSIONS Limited evidence suggests that statins may not be associated with a significant reduction in mortality from infection and sepsis. Although meta-analysis from observational studies showed that the use of statins was associated with a survival advantage, these outcomes were limited by high heterogeneity and possible bias in the data. Therefore, we should be cautious about the use of statins in infection and sepsis.
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