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Danpanichkul P, Duangsonk K, Uawithya E, Kongarin S, Simadibrata DM, Polpichai N, Suenghataiphorn T, Wattanachayakul P, Pang Y, Sukphutanan B, Kaewdech A, Panpradist N, Chaiyakunapruk N, Pupaibool J, Wijarnpreecha K. Clostridioides difficile Infection in the Elderly: Trend Analysis from 2000 to 2019. J Clin Med 2024; 13:3740. [PMID: 38999306 PMCID: PMC11242796 DOI: 10.3390/jcm13133740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/16/2024] [Accepted: 06/21/2024] [Indexed: 07/14/2024] Open
Abstract
Background/Objective: Clostridioides difficile infection (CDI) is a common healthcare-associated ailment, presenting major health and economic challenges, especially for the elderly. Despite its prevalence, comprehensive data about CDI's impact on the elderly are limited. Methods: This study used the Global Burden of Disease Study 2019 data to analyze CDI trends from 2000 to 2019, considering factors like sex, region, and sociodemographic index (SDI). Results: This study revealed that CDI caused approximately 18,181 deaths and 252,709 disability-adjusted life years (DALYs) among the elderly worldwide. The Americas showed the highest CDI burden, while the Eastern Mediterranean saw the steepest rate increase from 2000 to 2019. Regions with a high SDI also displayed substantial CDI impact. Conclusions: The escalating burden of CDI in the elderly, especially in high-SDI areas and the Americas, emphasizes an urgent need for targeted public health strategies.
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Affiliation(s)
- Pojsakorn Danpanichkul
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
- Immunology Unit, Department of Microbiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Kwanjit Duangsonk
- Department of Microbiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Ekdanai Uawithya
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Siwanart Kongarin
- Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Daniel M Simadibrata
- Faculty of Medicine, Universitas Indonesia, Depok 16424, Indonesia
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
| | - Natchaya Polpichai
- Department of Internal Medicine, Weiss Memorial Hospital, Chicago, IL 60640, USA
| | | | | | - Yanfang Pang
- Affiliated Hospital of Youjiang Medical University for Nationalities, Baise 533000, Guangxi, China
- National Immunological Laboratory for Traditional Chinese Medicine, Baise 533000, Guangxi, China
| | | | - Apichat Kaewdech
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla 90110, Thailand
| | - Nuttada Panpradist
- Global Center for Integrated Health for Women, Adolescents, and Children (Global WACh), Department of Global Health, University of Washington, Seattle, WA 98195, USA
| | - Nathorn Chaiyakunapruk
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT 84112, USA
- IDEAS Center, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT 84148, USA
| | - Jakrapun Pupaibool
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84113, USA
| | - Karn Wijarnpreecha
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Arizona College of Medicine, Phoenix, AZ 85004, USA
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Banner University Medical Center, Phoenix, AZ 85724, USA
- BIO5 Institute, University of Arizona College of Medicine-Phoenix, Phoenix, AZ 85004, USA
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Neri M, Mewes JC, de Almeida FA, Stoychev S, Minarovic N, Charos A, Shea KM, Steuten LMG. Impact of including productivity costs in economic analyses of vaccines for C. difficile infections and infant respiratory syncytial virus, in a UK setting. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2024; 22:34. [PMID: 38689331 PMCID: PMC11059668 DOI: 10.1186/s12962-024-00533-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 03/21/2024] [Indexed: 05/02/2024] Open
Abstract
OBJECTIVES It has been estimated that vaccines can accrue a relatively large part of their value from patient and carer productivity. Yet, productivity value is not commonly or consistently considered in health economic evaluations of vaccines in several high-income countries. To contribute to a better understanding of the potential impact of including productivity value on the expected cost-effectiveness of vaccination, we illustrate the extent to which the incremental costs would change with and without productivity value incorporated. METHODS For two vaccines currently under development, one against Cloistridioides difficile (C. difficile) infection and one against respiratory syncytial disease (RSV), we estimated their incremental costs with and without productivity value included and compared the results. RESULTS In this analysis, reflecting a UK context, a C. difficile vaccination programme would prevent £12.3 in productivity costs for every person vaccinated. An RSV vaccination programme would prevent £49 in productivity costs for every vaccinated person. CONCLUSIONS Considering productivity costs in future cost-effectiveness analyses of vaccines for C. difficile and RSV will contribute to better-informed reimbursement decisions from a societal perspective.
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Sapa D, Brosse A, Coullon H, Péan de Ponfilly G, Candela T, Le Monnier A. A Streamlined Method to Obtain Biologically Active TcdA and TcdB Toxins from Clostridioides difficile. Toxins (Basel) 2024; 16:38. [PMID: 38251254 PMCID: PMC10821508 DOI: 10.3390/toxins16010038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/15/2023] [Accepted: 12/30/2023] [Indexed: 01/23/2024] Open
Abstract
The major virulence factors of Clostridioides difficile (C. difficile) are enterotoxins A (TcdA) and B (TcdB). The study of toxins is a crucial step in exploring the virulence of this pathogen. Currently, the toxin purification process is either laborious and time-consuming in C. difficile or performed in heterologous hosts. Therefore, we propose a streamlined method to obtain functional toxins in C. difficile. Two C. difficile strains were generated, each harboring a sequence encoding a His-tag at the 3' end of C. difficile 630∆erm tcdA or tcdB genes. Each toxin gene is expressed using the Ptet promoter, which is inducible by anhydro-tetracycline. The obtained purification yields were 0.28 mg and 0.1 mg per liter for rTcdA and rTcdB, respectively. In this study, we successfully developed a simple routine method that allows the production and purification of biologically active rTcdA and rTcdB toxins with similar activities compared to native toxins.
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Affiliation(s)
- Diane Sapa
- Micalis Institute, Université Paris-Saclay, INRAE, AgroParisTech, 78350 Jouy-en-Josas, France; (D.S.); (H.C.); (G.P.d.P.); (T.C.); (A.L.M.)
| | - Anaïs Brosse
- Micalis Institute, Université Paris-Saclay, INRAE, AgroParisTech, 78350 Jouy-en-Josas, France; (D.S.); (H.C.); (G.P.d.P.); (T.C.); (A.L.M.)
| | - Héloïse Coullon
- Micalis Institute, Université Paris-Saclay, INRAE, AgroParisTech, 78350 Jouy-en-Josas, France; (D.S.); (H.C.); (G.P.d.P.); (T.C.); (A.L.M.)
| | - Gauthier Péan de Ponfilly
- Micalis Institute, Université Paris-Saclay, INRAE, AgroParisTech, 78350 Jouy-en-Josas, France; (D.S.); (H.C.); (G.P.d.P.); (T.C.); (A.L.M.)
- Service de Microbiologie Clinique, GH Paris Saint-Joseph, 75674 Paris, France
| | - Thomas Candela
- Micalis Institute, Université Paris-Saclay, INRAE, AgroParisTech, 78350 Jouy-en-Josas, France; (D.S.); (H.C.); (G.P.d.P.); (T.C.); (A.L.M.)
| | - Alban Le Monnier
- Micalis Institute, Université Paris-Saclay, INRAE, AgroParisTech, 78350 Jouy-en-Josas, France; (D.S.); (H.C.); (G.P.d.P.); (T.C.); (A.L.M.)
- Service de Microbiologie Clinique, GH Paris Saint-Joseph, 75674 Paris, France
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Reigadas E, Vázquez-Cuesta S, Bouza E. Economic Burden of Clostridioides difficile Infection in European Countries. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1435:1-12. [PMID: 38175468 DOI: 10.1007/978-3-031-42108-2_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Clostridioides difficile infection (CDI) remains a considerable challenge to healthcare systems worldwide. Although CDI represents a significant burden on healthcare systems in Europe, few studies have attempted to estimate the consumption of resources associated with CDI in Europe. The reported extra costs attributable to CDI vary widely according to the definitions, design, and methodologies used, making comparisons difficult to perform. In this chapter, the economic burden of healthcare facility-associated CDI in Europe will be assessed, as will other less explored areas such as the economic burden of recurrent CDI, community-acquired CDI, pediatric CDI, and CDI in outbreaks.
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Affiliation(s)
- Elena Reigadas
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | | | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
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Normington C, Chilton CH, Buckley AM. Clostridioides difficile infections; new treatments and future perspectives. Curr Opin Gastroenterol 2024; 40:7-13. [PMID: 37942659 PMCID: PMC10715702 DOI: 10.1097/mog.0000000000000989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
PURPOSE OF REVIEW As a significant cause of global morbidity and mortality, Clostridioides difficile infections (CDIs) are listed by the Centres for Disease Control and prevention as one of the top 5 urgent threats in the USA. CDI occurs from gut microbiome dysbiosis, typically through antibiotic-mediated disruption; however, antibiotics are the treatment of choice, which can result in recurrent infections. Here, we highlight new treatments available and provide a perspective on different classes of future treatments. RECENT FINDINGS Due to the reduced risk of disease recurrence, the microbiome-sparing antibiotic Fidaxomicin has been recommended as the first-line treatment for C. difficile infection. Based on the success of faecal microbiota transplantations (FMT) in treating CDI recurrence, defined microbiome biotherapeutics offer a safer and more tightly controlled alterative as an adjunct to antibiotic therapy. Given the association between antibiotic-mediated dysbiosis of the intestinal microbiota and the recurrence of CDI, future prospective therapies aim to reduce the dependence on antibiotics for the treatment of CDI. SUMMARY With current first-in-line antibiotic therapy options associated with high levels of recurrent CDI, the availability of new generation targeted therapeutics can really impact treatment success. There are still unknowns about the long-term implications of these new CDI therapeutics, but efforts to expand the CDI treatment toolbox can offer multiple solutions for clinicians to treat this multifaceted infectious disease to reduce patient suffering.
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Affiliation(s)
- Charmaine Normington
- Healthcare Associated Infections Research Group, School of Medicine, Faculty of Health and Medicine, University of Leeds
- Leeds Teaching Hospital Trust, Leeds General Infirmary
| | - Caroline H. Chilton
- Healthcare Associated Infections Research Group, School of Medicine, Faculty of Health and Medicine, University of Leeds
- Leeds Teaching Hospital Trust, Leeds General Infirmary
| | - Anthony M. Buckley
- Microbiome and Nutritional Sciences Group, School of Food Science & Nutrition, Faculty of Environment, University of Leeds, Leeds, UK
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Vehreschild MJGT, Schreiber S, von Müller L, Epple HJ, Weinke T, Manthey C, Oh J, Wahler S, Stallmach A. Trends in the epidemiology of Clostridioides difficile infection in Germany. Infection 2023; 51:1695-1702. [PMID: 37162717 PMCID: PMC10170422 DOI: 10.1007/s15010-023-02044-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 04/25/2023] [Indexed: 05/11/2023]
Abstract
PURPOSES Despite reports of a declining incidence over the last decade, Clostridioides difficile infection (CDI) is still considered the most important healthcare-associated causes of diarrhea worldwide. In Germany, several measures have been taken to observe, report, and influence this development. This report aims to analyze the development of hospital coding for CDI in Germany over the last decade and to use it to estimate the public health burden caused by CDI. METHODS Reports from the Institute for Hospital Remuneration Systems, German Federal Statistical Office (DESTATIS), the Robert-Koch-Institute (RKI), Saxonian authorities and hospital quality reports during 2010-2021 were examined for CDI coding and assessed in a structured expert consultation. Analysis was performed using 2019 versions of Microsoft Excel® and Microsoft Access®. RESULTS Peaks of 32,203 cases with a primary diagnosis (PD) of CDI and 78,648 cases with a secondary diagnosis (SD) of CDI were observed in 2015. The number of cases had decreased to 15,412 PD cases (- 52.1%) and 40,188 SD cases (- 48.9%) by 2021. These results were paralleled by a similar decline in notifiable severe cases. However, average duration of hospitalization of the cases remained constant during this period. CONCLUSIONS Hospital coding of CDI and notification to authorities has approximately halved from 2015 to 2021. Potential influential factors include hospital hygiene campaigns, implementation of antibiotic stewardship programs, social distancing due to the COVID-19 pandemic, and a decrease in more pathogenic subtypes of bacteria. Further research is necessary to validate the multiple possible drivers for this development.
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Affiliation(s)
| | - Stefan Schreiber
- Department Medicine I, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Rosalind-Franklin-Str. 12, 24105 Kiel, Germany
| | - Lutz von Müller
- Christophorus-Kliniken GmbH, Südring 41, 48653 Coesfeld, Germany
| | - Hans-Jörg Epple
- Charité, Universitätsmedizin Berlin, Campus Benjamin Franklin, Antibiotic Stewardship, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Thomas Weinke
- Ernst Von Bergmann Klinikum gGmbH, Charlottenstraße 72, 14467 Potsdam, Germany
| | - Carolin Manthey
- Gemeinschaftspraxis Innere Medizin (GIM), Pferdebachstr. 29, 58455 Witten, Germany
| | - Jun Oh
- Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Steffen Wahler
- St. Bernward GmbH, Friedrich-Kirsten-Str. 40, 22391 Hamburg, Germany
| | - Andreas Stallmach
- Klinik Für Innere Medizin IV, Universitätsklinikum Jena, Am Klinikum 1, 07747 Jena, Germany
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Alhameed AF, Saferuddin N, Alturkistani T, Al Musawa M, Damfu N, Alattas M. Vancomycin vs metronidazole use for the treatment of Clostridioides difficile infection in a tertiary care hospital in Saudi Arabia. Heliyon 2023; 9:e22053. [PMID: 38027991 PMCID: PMC10663888 DOI: 10.1016/j.heliyon.2023.e22053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 11/02/2023] [Accepted: 11/02/2023] [Indexed: 12/01/2023] Open
Abstract
Background The 2017 Infectious Diseases Society of America (IDSA) Clostridioides difficile infection (CDI) guidelines recommendation for oral vancomycin as preferred treatment was based on studies conducted in North America, Australia, and Europe. According to recent published data, metronidazole remains a reasonable option. No studies have been conducted in Saudi Arabia to compare prescribing patterns before and after the release of the guidelines. Due to low CDI burden in Saudi Arabia, the aim is to assess the effectiveness and outcomes of vancomycin vs metronidazole treatment options. Methods This was a retrospective cohort study conducted in a tertiary care hospital in Jeddah which was approved by the Institutional Review Board (IRB 2020-53). Data was collected from January 2017 to April 2020. Eligible patients were adults (>18 years old) diagnosed with CDI who either received oral metronidazole (500 mg 3 times daily) or oral vancomycin (125-500 mg 4 times daily). Patients who received a combination of treatment or who were diagnosed with fulminant CDI were excluded. Demographic data were collected. The primary outcome was to assess treatment response to initial therapy with oral metronidazole versus oral vancomycin. Secondary outcomes included assessing early treatment response, time to discharge after diagnosis, proportion of patients with a positive VRE surveillance culture within 6 months of diagnosis, 30-day recurrence and 30-day all-cause mortality. Chi-square or Fisher's exact test were used to examine differences in categorical variables while student t-test or Mann-Whitney test, were used to examine differences in continuous variables. P value < 0.05 was considered as significant. Results A total of 166 patients were included in the analysis. Demographic characteristics were not significantly different between the two groups. There was no difference in treatment response between vancomycin and metronidazole (96.4 % versus 94.3 %, p = 0.682). However, compared with metronidazole, vancomycin treatment was significantly associated with better early response (94.0 % versus 77.8 %, p = 0.008). Other outcomes were not significantly different between the two drug groups for time to discharge after diagnosis (P = 0.522), 30-day recurrence (P > 0.99) and 30-day all-cause mortality (P = 0.782). Of note, the vancomycin versus metronidazole use before the 2017 IDSA guidelines (26 % versus 74 %) was completely reversed after the release of the guidelines (83.3 % versus 16.7 %), p < 0.001). Conclusion The results of this study demonstrate that vancomycin and metronidazole have comparable outcomes in regards to treatment response for non-fulminant CDI. The study also reveals the high and quick impact of international guidelines on local prescription patterns. Further studies are needed in Saudi Arabia to guide the treatment of CDI.
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Affiliation(s)
- Abrar F. Alhameed
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Centre, Madinah, Saudi Arabia
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Nada Saferuddin
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Tariq Alturkistani
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Mohammed Al Musawa
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Nader Damfu
- Pharmaceutical Care Department, King Abdul Aziz Medical City, Jeddah, Saudi Arabia
| | - Majda Alattas
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
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Berry P, Khanna S. Recurrent Clostridioides difficile Infection: Current Clinical Management and Microbiome-Based Therapies. BioDrugs 2023; 37:757-773. [PMID: 37493938 DOI: 10.1007/s40259-023-00617-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 07/27/2023]
Abstract
Clostridioides difficile is one of the most important causes of healthcare-associated diarrhea. The high incidence and recurrence rates of C. difficile infection, as well as its associated morbidity and mortality, are great concerns. The most common complication of C. difficile infection is recurrence, with rates of 20-30% after a primary infection and 60% after three or more episodes. Medical management of recurrent C. difficile infection involves a choice of therapy that is different from the antibiotic used in the primary episode. Patients with recurrent C. difficile infection also benefit from fecal microbiota transplantation or standardized microbiome restoration therapies (approved or experimental) to restore eubiosis. In contrast to antibiotics, microbiome restoration therapies restore a normal gut flora and eliminate C. difficile colonization and infection. Fecal microbiota transplantation in recurrent C. difficile infection has demonstrated higher success rates than vancomycin, fidaxomicin, or placebo. Fecal microbiota transplantation has traditionally been considered safe, with the most common adverse reactions being abdominal discomfort, and diarrhea, and rare serious adverse events. Significant heterogeneity and a lack of standardization regarding the process of preparation, and administration of fecal microbiota transplantation remain a major pitfall. Standardized microbiome-based therapies provide a promising alternative. In the ECOSPOR III trial of SER-109, an oral formulation of bacterial spores, a significant reduction in the recurrence rate (12%) was observed compared with placebo (40%). In the phase III PUNCH CD3 trial, RBX2660 also demonstrated high efficacy rates of 70.6% versus 57.5%. Both these agents are now US Food and Drug Administration approved for recurrent C. difficile infection. Other standardized microbiome-based therapies currently in the pipeline are VE303, RBX7455, and MET-2. Antibiotic neutralization strategies, vaccines, passive monoclonal antibodies, and drug repurposing are other therapeutic strategies being explored to treat C. difficile infection.
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Affiliation(s)
- Parul Berry
- All India Institute of Medical Sciences, New Delhi, India
| | - Sahil Khanna
- Division of Gastroenterology and Hepatology, C. difficile Clinic and Microbiome Restoration Program, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA.
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Harrison MA, Farthing RJ, Allen N, Ahern LM, Birchall K, Bond M, Kaur H, Wren BW, Bergeron JRC, Dawson LF. Identification of novel p-cresol inhibitors that reduce Clostridioides difficile's ability to compete with species of the gut microbiome. Sci Rep 2023; 13:9492. [PMID: 37303029 PMCID: PMC10258198 DOI: 10.1038/s41598-023-32656-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/30/2023] [Indexed: 06/13/2023] Open
Abstract
Treatment of Clostridioides difficile infection (CDI) is expensive and complex, with a high proportion of patients suffering infection relapse (20-35%), and some having multiple relapses. A healthy, unperturbed gut microbiome provides colonisation resistance against CDI through competition for nutrients and space. However, antibiotic consumption can disturb the gut microbiota (dysbiosis) resulting in the loss of colonisation resistance allowing C. difficile to colonise and establish infection. A unique feature of C. difficile is the production of high concentrations of the antimicrobial compound para-cresol, which provides the bacterium with a competitive advantage over other bacteria found in the gut. p-cresol is produced by the conversion of para-Hydroxyphenylacetic acid (p-HPA) by the HpdBCA enzyme complex. In this study, we have identified several promising inhibitors of HpdBCA decarboxylase, which reduce p-cresol production and render C. difficile less able to compete with a gut dwelling Escherichia coli strain. We demonstrate that the lead compound, 4-Hydroxyphenylacetonitrile, reduced p-cresol production by 99.0 ± 0.4%, whereas 4-Hydroxyphenylacetamide, a previously identified inhibitor of HpdBCA decarboxylase, only reduced p-cresol production by 54.9 ± 13.5%. To interpret efficacy of these first-generation inhibitors, we undertook molecular docking studies that predict the binding mode for these compounds. Notably, the predicted binding energy correlated well with the experimentally determined level of inhibition, providing a molecular basis for the differences in efficacy between the compounds. This study has identified promising p-cresol production inhibitors whose development could lead to beneficial therapeutics that help to restore colonisation resistance and therefore reduce the likelihood of CDI relapse.
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Affiliation(s)
- Mark A Harrison
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Rebecca J Farthing
- Randall Centre for Cell and Molecular Biophysics, King's College London, London, WC2R 2LS, UK
| | - Nyasha Allen
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Lucy M Ahern
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | | | - Michael Bond
- LifeArc, Lynton House, 7-12 Tavistock Square, London, WC1H 9LT, UK
| | - Harparkash Kaur
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Brendan W Wren
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Julien R C Bergeron
- Randall Centre for Cell and Molecular Biophysics, King's College London, London, WC2R 2LS, UK
| | - Lisa F Dawson
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
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Haroun E, Kumar PA, Saba L, Kassab J, Ghimire K, Dutta D, Lim SH. Intestinal barrier functions in hematologic and oncologic diseases. J Transl Med 2023; 21:233. [PMID: 37004099 PMCID: PMC10064590 DOI: 10.1186/s12967-023-04091-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 03/26/2023] [Indexed: 04/03/2023] Open
Abstract
The intestinal barrier is a complex structure that not only regulates the influx of luminal contents into the systemic circulation but is also involved in immune, microbial, and metabolic homeostasis. Evidence implicating disruption in intestinal barrier functions in the development of many systemic diseases, ranging from non-alcoholic steatohepatitis to autism, or systemic complications of intestinal disorders has increased rapidly in recent years, raising the possibility of the intestinal barrier as a potential target for therapeutic intervention to alter the course and mitigate the complications associated with these diseases. In addition to the disease process being associated with a breach in the intestinal barrier functions, patients with hematologic and oncologic diseases are particularly at high risks for the development of increased intestinal permeability, due to the frequent use of broad-spectrum antibiotics and chemoradiation. They also face a distinct challenge of being intermittently severely neutropenic due to treatment of the underlying conditions. In this review, we will discuss how hematologic and oncologic diseases are associated with disruption in the intestinal barrier and highlight the complications associated with an increase in the intestinal permeability. We will explore methods to modulate the complication. To provide a background for our discussion, we will first examine the structure and appraise the methods of evaluation of the intestinal barrier.
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Affiliation(s)
- Elio Haroun
- Division of Hematology and Oncology, State University of New York Upstate Medical University, SUNY Upstate Medical University, 750 E Adams, Syracuse, NY, 13210, USA
| | - Prashanth Ashok Kumar
- Division of Hematology and Oncology, State University of New York Upstate Medical University, SUNY Upstate Medical University, 750 E Adams, Syracuse, NY, 13210, USA
| | - Ludovic Saba
- Department of Medicine, Saint-Joseph University of Beirut, Beirut, Lebanon
| | - Joseph Kassab
- Department of Medicine, Saint-Joseph University of Beirut, Beirut, Lebanon
| | - Krishna Ghimire
- Division of Hematology and Oncology, State University of New York Upstate Medical University, SUNY Upstate Medical University, 750 E Adams, Syracuse, NY, 13210, USA
| | - Dibyendu Dutta
- Division of Hematology and Oncology, State University of New York Upstate Medical University, SUNY Upstate Medical University, 750 E Adams, Syracuse, NY, 13210, USA.
| | - Seah H Lim
- Division of Hematology and Oncology, State University of New York Upstate Medical University, SUNY Upstate Medical University, 750 E Adams, Syracuse, NY, 13210, USA.
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Performance of Clostridioides difficile infection severity scores and risk factors related to 30-day all-cause mortality in patients with cancer. Support Care Cancer 2023; 31:187. [PMID: 36843052 DOI: 10.1007/s00520-023-07651-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 02/20/2023] [Indexed: 02/28/2023]
Abstract
PURPOSE There are currently no standard definitions for assessing the severity of Clostridioides difficile infection (CDI) in cancer patients. We evaluated the performance of scoring systems for severity and analyzed risk factors for mortality in a cancer cohort. METHODS We conducted an observational study in patients with cancer and CDI. We calculated the incidence of hospital-onset (HO-CDI) and community-onset health-care facility associated (CO-HCFA-CDI) episodes. We classified severity using five prognostic scales and calculated sensitivity, specificity, positive (PPV), and negative predictive values (NPV) for mortality and intensive care unit (ICU) admission. In addition, multivariate regression was performed to assess variables associated with mortality. RESULTS The HO-CDI and CO-HCFA-CDI incidence rates were 3.7 cases/10,000 patient-days and 1.9 cases/1,000 admissions, respectively. ESCMID criteria showed the higher sensitivity (97%, 95% CI; 85-100%) and NPV (98%, 95% CI; 85-100%), while ATLAS (≥ 6 points) had the highest specificity (95%, 95% CI; 90-98%) for 30-day all-cause mortality; similar performance was observed for ICU admission. Characteristics associated with fatal outcome were neutropenia (≤ 100 cells/ml) (aOR; 3.03, 95% CI; 1.05-8.74, p = 0.040), male gender (aOR; 2.90, 95% CI; 1.08-7.80, p = 0.034), high serum creatinine (aOR; 1.71, 95% CI; 1.09-2.70, p = 0.020), and albumin (aOR; 0.17, 95% CI; 0.07-0.42, p < 0.001). CONCLUSIONS Some of the current scales may not be appropriate to discriminate severity in patients with cancer. The variables in this study associated with unfavorable outcomes could be evaluated in prospective studies to develop prognostic scores that identify susceptible patients, especially in immunocompromised populations.
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Barbar R, Brazelton JN, Carroll KC, Lewis S, Bourdas D, Tembo A, Gluck L, Hakim H, Hayden RT. Molecular Epidemiology and Genetic Relatedness of Clostridioides difficile Isolates in Pediatric Oncology and Transplant Patients Using Whole Genome Sequencing. Clin Infect Dis 2023; 76:e1071-e1078. [PMID: 35675378 DOI: 10.1093/cid/ciac459] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 05/21/2022] [Accepted: 06/02/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The incidence of Clostridioides difficile infection (CDI) has been rising among hospitalized children, with poor understanding of genomic variability of C. difficile isolates in this population. METHODS This was a retrospective cohort study of CDI in inpatient and outpatient pediatric oncology and cell transplant patients (POTPs) in 2016 and 2017. CDI cases were identified by positive C. difficile toxin polymerase chain reaction tests. Retrieved residual stool specimens were cultured anaerobically and toxin-producing C. difficile isolates underwent whole genome sequencing (WGS) followed by core genome multilocus sequence typing. Plausible time and location epidemiologic links among the closely related strains were evaluated to identify potential transmission events. RESULTS Among 226 CDI episodes in 157 patients, 202 stool samples were cultured and had positive cytotoxicity tests. Sequencing identified 33 different strain types in 162 (80%) isolates. Thirty-nine (28%) patients had multiple episodes of CDI, and 31 clusters of related isolates were identified, 15 (47%) of which involved exclusively multiple specimens from the same patient. For the 16 clusters involving multiple patients, epidemiologic investigation revealed only 2 (12.5%) clusters with potential transmission events. CONCLUSIONS WGS identified a highly diverse group of C. difficile isolates among POTPs with CDI. Although WGS identified clusters of closely related isolates in multiple patients, epidemiologic investigation of shared inpatient exposures identified potential transmission in only 2 clusters. Clostridioides difficile transmission was uncommon in this population. More than 70% of new CDI reinfections in POTPs are actually recurrences caused by a previous CDI strain.
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Affiliation(s)
- Ruba Barbar
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jessica N Brazelton
- Department of Pathology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Karen C Carroll
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Shawna Lewis
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Dimitrios Bourdas
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Anita Tembo
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Linda Gluck
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Hana Hakim
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Randall T Hayden
- Department of Pathology, St Jude Children's Research Hospital, Memphis, Tennessee, USA
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13
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Siraw BB, Reingold AL, Meyahnwi D. Association between epidemiologic case definition categories and adverse clinical outcome in patients with Clostridiodes difficile infection in San Francisco County, California: a five-year retrospective cohort study. BMC Infect Dis 2023; 23:68. [PMID: 36737685 PMCID: PMC9897617 DOI: 10.1186/s12879-023-08030-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 01/24/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Understanding the predictors of adverse clinical outcomes following incident Clostridiodes difficile infection (CDI) can help clinicians identify which patients are at risk of complications and help prioritize the provision of their care. In this study, we assessed the associations between epidemiologic case definition categories and adverse clinical outcomes in patients with CDI in San Francisco County, California. METHODS We conducted a retrospective cohort study using CDI surveillance data (n = 3274) from the California Emerging Infections Program for the time period 2016 to 2020. After independent associations were established, two multivariable logistic and log-binomial regression models were constructed for the final statistical analysis. RESULT The mean cumulative incidence of CDI cases was 78.8 cases per 100,000 population. The overall recurrence rate and the 30-day all-cause mortality rate were 11.1% and 4.5%, respectively. After adjusting for potential confounders, compared to the community associated CDI cases, healthcare facility onset (AOR = 3.1; 95% CI [1.3-7]) and community-onset-healthcare facility associated (AOR = 2.4; 95% CI [1.4-4.3]) CDI cases were found to have higher odds of all-cause 30-day mortality. Community onset-healthcare facility-associated CDI case definition category was found to be significantly associated with an increased risk of recurrence of CDI (ARR = 1.7; 95% CI [1.2-2.4]). CONCLUSION Although the incidence of community-associated CDI cases has been rising, the odds of all-cause 30-day mortality and the risk of recurrent CDI associated with these infections are lower than healthcare facility onset and community-onset healthcare facility-associated CDI cases.
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Affiliation(s)
- Bekure B. Siraw
- grid.47840.3f0000 0001 2181 7878School of Public Health, University of California, 1279 Webster St. San Francisco, Berkeley, CA 94115 USA
| | - Arthur L. Reingold
- grid.47840.3f0000 0001 2181 7878Division of Epidemiology, School of Public Health, University of California, Berkeley, CA USA
| | - Didien Meyahnwi
- grid.47840.3f0000 0001 2181 7878School of Public Health, University of California, 1279 Webster St. San Francisco, Berkeley, CA 94115 USA
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14
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A systematic review of real-world healthcare resource use and costs of Clostridioides difficile infections. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e17. [PMID: 36714290 PMCID: PMC9879868 DOI: 10.1017/ash.2022.369] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 12/08/2022] [Accepted: 12/08/2022] [Indexed: 01/18/2023]
Abstract
Objective To conduct a systematic review of published real-world evidence describing the cost and healthcare resource use for Clostridiodes difficile infection (CDI) in the United States. Methods A systematic literature review was conducted searching for terms for CDI and healthcare costs. Titles of articles and abstracts were reviewed to identify those that met study criteria. Studies were evaluated to examine overall design and comparison groups in terms of healthcare resource use and cost for CDI. Results In total, 28 articles met the inclusion criteria. Moreover, 20 studies evaluated primary CDI or did not specify, and 8 studies1-8 evaluated both primary CDI and recurrent (rCDI). Data from Medicare were used in 6 studies. Nearly all studies used a comparison group, either controls without CDI (N = 20) or comparison between primary CDI and rCDI (N = 7). Two studies examined costs of rCDI by the number of recurrences. Overall, the burden of CDI is significant, with higher aggregate costs for patients with rCDI. Compared with non-CDI controls, hospital length of stay increased in patients with both primary and rCDI compared to patients without CDI. Patients with primary CDI cost healthcare systems $24,000 more than patients without CDI. Additionally, 2 studies that evaluated the impact of recurrence among those patients with an index case of CDI demonstrated significantly higher direct all-cause medical costs among those with rCDI compared to those without. Conclusion CDI, and particularly rCDI, is a costly condition with hospitalizations being the main cost driver.
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15
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Aby ES, Vaughn BP, Enns EA, Rajasingham R. Cost-effectiveness of Fecal Microbiota Transplantation for First Recurrent Clostridioides difficile Infection. Clin Infect Dis 2022; 75:1602-1609. [PMID: 35275989 PMCID: PMC9617579 DOI: 10.1093/cid/ciac207] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Both the American College of Gastroenterology and the Infectious Diseases Society of America (IDSA)/Society for Healthcare Epidemiology of America 2021 Clostridioides difficile infection (CDI) guidelines recommend fecal microbiota transplantation (FMT) for persons with multiple recurrent CDI. Emerging data suggest that FMT may have high cure rates when used for first recurrent CDI. The aim of this study was to assess the cost-effectiveness of FMT for first recurrent CDI. METHODS We developed a Markov model to simulate a cohort of patients presenting with initial CDI infection. The model estimated the costs, effectiveness, and cost-effectiveness of different CDI treatment regimens recommended in the 2021 IDSA guidelines, with the additional option of FMT for first recurrent CDI. The model includes stratification by the severity of initial infection, estimates of cure, recurrence, and mortality. Data sources were taken from IDSA guidelines and published literature on treatment outcomes. Outcome measures were quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs). RESULTS When FMT is available for first recurrent CDI, the optimal cost-effective treatment strategy is fidaxomicin for initial nonsevere CDI, vancomycin for initial severe CDI, and FMT for first and subsequent recurrent CDI, with an ICER of $27 135/QALY. In probabilistic sensitivity analysis at a $100 000 cost-effectiveness threshold, FMT for first and subsequent CDI recurrence was cost-effective 90% of the time given parameter uncertainty. CONCLUSIONS FMT is a cost-effective strategy for first recurrent CDI. Prospective evaluation of FMT for first recurrent CDI is warranted to determine the efficacy and risk of recurrence.
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Affiliation(s)
- Elizabeth S Aby
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Byron P Vaughn
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Eva A Enns
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Radha Rajasingham
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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16
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A Systematic Review and Meta-Analysis of Randomized Controlled Trials of Fecal Microbiota Transplantation for the Treatment of Inflammatory Bowel Disease. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:8266793. [PMID: 35795291 PMCID: PMC9251102 DOI: 10.1155/2022/8266793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/06/2022] [Indexed: 01/30/2023]
Abstract
Objectives Inflammatory bowel disease (IBD) is a chronic recurrent inflammatory disease of the gastrointestinal tract, and its prevalence is increasing worldwide. Fecal microbiota transplantation (FMT) is an emerging therapy that modifies the patient's gut microbiota by transplanting feces from a healthy donor to achieve disease remission. However, its efficacy and safety need to be further investigated. Methods PubMed, the Cochrane Library, Web of Science, Embase, and Google Scholar databases (up to 8th November 2021) were searched and literature was screened by title and abstract as well as full text. The primary outcome was clinical remission, with the clinical response as a secondary outcome. Risk ratios (RR) with 95% confidence intervals (CI) were reported. Results A total of 14 trials were included in this study. In terms of clinical remission, FMT had a significant effect compared to placebo (RR = 1.44, 95 CI%: 1.03 to 2.02, I2 = 38%, P=0.03), with no significant risk of study heterogeneity. Moreover, FMT led to significant results in clinical response compared to placebo with moderate between-study heterogeneity (RR = 1.34, 95 CI%: 0.92 to 1.94, I2 = 51%, P=0.12). Subgroup analysis showed a higher clinical remission for fresh fecal FMT (40.9%) than that for frozen fecal FMT (32.2%); the efficacy of gastrointestinal (GI) pretreatment, the severity of disease, route of administration, and the donor selection remain unclear and require more extensive study. Safety analysis concluded that most adverse events were mild and self-resolving. The microbiological analysis found that the patient's gut microbiota varied in favor of the donor, with increased flora diversity and species richness. Conclusion FMT is a safe, effective, and well-tolerated therapy. Studies have found that fresh fecal microbiota transplant can increase clinical remission rates. However, more randomized controlled trials and long-term follow-ups are needed to assess its long-term effectiveness and safety.
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Fazl Alizadeh R, Li S, Sullivan B, Manasa M, Ruhi-Williams P, Nahmias J, Carmichael J, Nguyen NT, Stamos MJ. Surgical Outcome in Laparoscopic Abdominal Surgical Operations with Clostridium Difficile Infection. Am Surg 2022; 88:2519-2524. [DOI: 10.1177/00031348221103644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Postoperative Clostridium difficile infection (CDI) has associated morbidity, but it is unknown how it impacts different operations. We sought to determine the incidence and postoperative morbidity following abdominal surgery. Method: The National Surgical Quality Improvement Program database (2015-2019) was utilized to evaluate adult (≥18 years-old) patients who developed CDI following laparoscopic abdominal operations. Univariate and multivariate analysis were performed to evaluate outcomes. Results: A total of 973 338 patients were studied and the overall incidence of CDI was .3% within 30 days of operation. Colorectal surgery had the highest incidence of CDI (1601/167 949,1.0%) with significantly longer mean length of stay (LOS) (8.0 days± 9.0, P < .01) compared to other surgical procedures. CDI patients also had a longer mean length of stay (6.6± 8.0 vs 2.1 ± 3.6 days, P < .01) and increased mortality (1.8% vs .2%, AOR: 4.64, CI: 3.45-5.67, P < .01) compared to patients without CDI. Conclusions: This national analysis demonstrates that CDI is a significant complication following abdominal surgery and is associated with increased LOS and mortality. Furthermore, laparoscopic colorectal surgery appears to have the greatest risk of CDI. Future research is needed to determine the exact cause in order to decrease the incidence of CDI by reconsidering the protocol of antibiotic use within the high-risk population.
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Affiliation(s)
- Reza Fazl Alizadeh
- Department of Surgery, School of Medicine, University of California, Irvine, CA, USA
| | - Shiri Li
- Department of Surgery, New York Presbyterian Hospital, Weill Cornell College of Medicine, New York, NY, USA
| | - Brittany Sullivan
- Department of Surgery, School of Medicine, University of California, Irvine, CA, USA
| | - Morgan Manasa
- Department of Surgery, School of Medicine, University of California, Irvine, CA, USA
| | - Perisa Ruhi-Williams
- Department of Surgery, School of Medicine, University of California, Irvine, CA, USA
| | - Jeffery Nahmias
- Department of Surgery, School of Medicine, University of California, Irvine, CA, USA
| | - Joseph Carmichael
- Department of Surgery, School of Medicine, University of California, Irvine, CA, USA
| | - Ninh T. Nguyen
- Department of Surgery, School of Medicine, University of California, Irvine, CA, USA
| | - Michael J. Stamos
- Department of Surgery, School of Medicine, University of California, Irvine, CA, USA
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Chiș AA, Rus LL, Morgovan C, Arseniu AM, Frum A, Vonica-Țincu AL, Gligor FG, Mureșan ML, Dobrea CM. Microbial Resistance to Antibiotics and Effective Antibiotherapy. Biomedicines 2022; 10:biomedicines10051121. [PMID: 35625857 PMCID: PMC9138529 DOI: 10.3390/biomedicines10051121] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/06/2022] [Accepted: 05/10/2022] [Indexed: 12/24/2022] Open
Abstract
Currently, the efficacy of antibiotics is severely affected by the emergence of the antimicrobial resistance phenomenon, leading to increased morbidity and mortality worldwide. Multidrug-resistant pathogens are found not only in hospital settings, but also in the community, and are considered one of the biggest public health concerns. The main mechanisms by which bacteria develop resistance to antibiotics include changes in the drug target, prevention of entering the cell, elimination through efflux pumps or inactivation of drugs. A better understanding and prediction of resistance patterns of a pathogen will lead to a better selection of active antibiotics for the treatment of multidrug-resistant infections.
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19
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Fecal Microbiota Transplant for Hematologic and Oncologic Diseases: Principle and Practice. Cancers (Basel) 2022; 14:cancers14030691. [PMID: 35158960 PMCID: PMC8833574 DOI: 10.3390/cancers14030691] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 01/28/2022] [Accepted: 01/28/2022] [Indexed: 11/28/2022] Open
Abstract
Simple Summary The transfer of a normal intestinal microbial community from healthy donors by way of their fecal material into patients with various diseases is an emerging therapeutic approach, particularly to treat patients with recurrent or refractory C. difficile infections (CDI). This approach, called fecal microbiota transplant (FMT), is increasingly being applied to patients with hematologic and oncologic diseases to treat recurrent CDI, modulate treatment-related complications, and improve cancer treatment outcome. In this review paper, we discussed the principles and methods of FMT. We examined the results obtained thus far from its use in hematologic and oncologic patients. We also propose novel uses for the therapeutic approach and appraised the challenges associated with its use, especially in this group of patients. Abstract Understanding of the importance of the normal intestinal microbial community in regulating microbial homeostasis, host metabolism, adaptive immune responses, and gut barrier functions has opened up the possibility of manipulating the microbial composition to modulate the activity of various intestinal and systemic diseases using fecal microbiota transplant (FMT). It is therefore not surprising that use of FMT, especially for treating relapsed/refractory Clostridioides difficile infections (CDI), has increased over the last decade. Due to the complexity associated with and treatment for these diseases, patients with hematologic and oncologic diseases are particularly susceptible to complications related to altered intestinal microbial composition. Therefore, they are an ideal population for exploring FMT as a therapeutic approach. However, there are inherent factors presenting as obstacles for the use of FMT in these patients. In this review paper, we discussed the principles and biologic effects of FMT, examined the factors rendering patients with hematologic and oncologic conditions to increased risks for relapsed/refractory CDI, explored ongoing FMT studies, and proposed novel uses for FMT in these groups of patients. Finally, we also addressed the challenges of applying FMT to these groups of patients and proposed ways to overcome these challenges.
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20
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Richards SJG, Udayasiri DK, Jones IT, Hastie IA, Chandra R, McCormick JJ, Chittleborough TJ, Read DJ, Hayes IP. Delayed ileostomy closure increases the odds of Clostridium difficile infection. Colorectal Dis 2021; 23:3213-3219. [PMID: 34351046 DOI: 10.1111/codi.15858] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/30/2021] [Accepted: 07/31/2021] [Indexed: 01/06/2023]
Abstract
AIM A diverting ileostomy is typically performed to divert intestinal contents in high-risk colorectal anastomoses. Ileostomy closure is associated with high rates of postoperative Clostridium difficile infection (CDI). Risk factors for the development of CDI are unclear; however, a correlation has been observed with delayed closure. This study aimed to assess the odds of developing CDI in patients who had a delay to reversal of ileostomy, compared to those who had no delay. METHODS A retrospective cohort study was conducted of patients undergoing reversal of ileostomy between 2010 and 2019 at a single tertiary centre. A delay to reversal of ileostomy was defined if the procedure was performed at >365 days following the index procedure. CDI was defined as the presence of Clostridium difficile toxin associated with diarrhoea. Univariable logistic regression analysis was performed to estimate odds of CDI for each covariable, comparing patients who had a delay to reversal of ileostomy with those who did not. Multivariable logistic regression analysis was used to adjust for the potential confounding effects of covariables. RESULTS Of 195 patients, 11 (5.6%), developed postoperative CDI. Multivariable analysis showed that delay to reversal of ileostomy was associated with a nearly 7-fold increase in odds of CDI (OR = 6.95, CI: 1.06-81.6; p-value = 0.03). CONCLUSION A delay to reversal of ileostomy of >365 days was associated with a higher incidence of CDI postoperatively. Careful consideration should be given to the timing of reversal and appropriate preoperative counselling of patients.
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Affiliation(s)
- Simon J G Richards
- Colorectal Surgical Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Dilshan K Udayasiri
- Colorectal Surgical Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Ian T Jones
- Colorectal Surgical Unit, Department of Surgery, The Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Ian A Hastie
- Colorectal Surgical Unit, Department of Surgery, The Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Raaj Chandra
- Colorectal Surgical Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Colorectal Surgical Unit, Department of Surgery, Box Hill Hospital Melbourne, Monash University, Melbourne, Victoria, Australia
| | - Jacob J McCormick
- Colorectal Surgical Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Timothy J Chittleborough
- Colorectal Surgical Unit, Department of Surgery, The Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - David J Read
- Colorectal Surgical Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Ian P Hayes
- Colorectal Surgical Unit, Department of Surgery, The Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
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21
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Son KJ, Kim YA, Park YS. Economic Burden Attributable to Clostridioides difficile Infections in South Korea: A Nationwide Propensity Score-Matched Study. J Hosp Infect 2021; 120:1-8. [PMID: 34774670 DOI: 10.1016/j.jhin.2021.10.016] [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: 07/25/2021] [Revised: 10/11/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Clostridioides (Clostridium) difficile is an important pathogen that causes diarrhoea in patients who take antibacterial drugs. Considering the limited medical resources, it is necessary to prioritize the management of threats caused by antibiotic use and the spread of germs, but there are little available data, especially for C. difficile infections in South Korea. AIMS In this study, we analysed the hospital length of stay (LOS) and the increase in medical costs due to C. difficile infections. METHODS Propensity score-matched experimental (hospitalized patients with C. difficile infection)-control (hospitalized patients without C. difficile infection) studies were conducted to estimate the increase in the LOS and medical costs associated with C. difficile infections. The data were obtained from the National Health Insurance Service-National Sample Cohort from 2006 to 2015. Reliable results were obtained by actively calibrating various confounding variables of demographic characteristics, disease severity, and information on healthcare facilities. FINDINGS The C. difficile-attributable increase in LOS and hospitalization costs were 36.9 days and 8,298 USD, respectively, per infection case. CONCLUSION This study quantified the considerable burden associated with C. difficile infections in South Korea.
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Affiliation(s)
- K J Son
- Department of Biostatistics and Computing, Yonsei University Graduate School, Seoul, Korea; Department of Research and Analysis, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Y A Kim
- Department of Laboratory Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea.
| | - Y S Park
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea; Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea.
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22
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Krishna A, Chopra T. Prevention of Infection due to Clostridium (Clostridioides) difficile. Infect Dis Clin North Am 2021; 35:995-1011. [PMID: 34752229 DOI: 10.1016/j.idc.2021.07.009] [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: 10/20/2022]
Abstract
Clostridium (Clostridioides) difficile infection (CDI) causes significant morbidity and mortality in the United States every year. Prevention of CDI is difficult because of spore durability and requires implementation of multipronged strategies. Two categories of prevention strategies are infection control and prevention and risk factor reduction. Hand hygiene, contact precautions, patient isolation, and environmental decontamination are cornerstones of infection control and prevention. Risk factor reduction should focus on antibiotic stewardship to reduce unnecessary antibiotic use. If CDI incidence remains higher than the institution's goal despite these measures, then special measures should be considered.
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Affiliation(s)
- Amar Krishna
- Internal Medicine, Norther Light AR Gould Hospital, 140 Academy Street, Presque Isle, ME 04769, USA.
| | - Teena Chopra
- Infectious Diseases, Wayne State University/Detroit Medical Center, UHC-2B, 4201 St Antoine, Detroit, MI 48201, USA
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23
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Gupta S, Zhu J, McCarty TR, Pruce J, Kassam Z, Kelly C, Fischer M, Allegretti JR. Cost-effectiveness analysis of sequential fecal microbiota transplantation for fulminant Clostridioides difficile infection. J Gastroenterol Hepatol 2021; 36:2432-2440. [PMID: 33682170 DOI: 10.1111/jgh.15483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 01/28/2021] [Accepted: 02/03/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM Fulminant Clostridioides difficile infections (FCDI) account for 8% of cases and substantial healthcare burden. Fecal microbiota transplantation is recommended for recurrent CDI, but emerging data support use for FCDI. We aimed to assess the cost-effectiveness of a sequential fecal microbiota transplantation (sFMT) protocol for FCDI compared with current standard therapy. METHODS A Markov model simulated patients with FCDI in a 1-year time horizon. The treatment algorithm for up to three sFMTs, clinical probabilities, and direct costs were used from published sources. Outcomes were quality-adjusted life years (QALYs) and costs. The healthcare sector perspective was used with a willingness-to-pay threshold of $100 000 per QALY. RESULTS Sequential fecal microbiota transplantation (FMT) for FCDI was associated with lower overall cost ($28 309 vs $33 980) and higher QALY (0.765 vs 0.686) compared with standard therapy. sFMT is cost-effective in 100% of iterations. sFMT remained cost-effective at cure rates > 44.8% for the first FMT and at stool preparation cost < $6944 per instillation. We find a wide range of efficacies for the first versus second FMT at which sFMT is still preferred. Value of information analysis estimates the expected value of perfect information to be low at $1.89 per person, quantified with net monetary benefit. CONCLUSIONS An sFMT strategy strongly dominates standard therapy, with lower cost and higher QALY. Sensitivity analysis demonstrates benefit even if FMT cure rates are lower than expected and when multiple FMTs are required. FMT material in 2020 was priced at $1695 per treatment but remains cost-effective at a much higher cost.
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Affiliation(s)
- Sanchit Gupta
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Jinyi Zhu
- Center for Health Decision Science, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Thomas R McCarty
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Jordan Pruce
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Zain Kassam
- Finch Therapeutics, Somerville, Massachusetts, USA
| | - Colleen Kelly
- Women's Medicine Collaborative, Lifespan, Providence, Rhode Island, USA.,Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Monika Fischer
- Division of Gastroenterology, Indiana University, Indianapolis, Indiana, USA
| | - Jessica R Allegretti
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Bai Y, Hao Y, Song Z, Chu W, Jin Y, Wang Y. Evaluation of the Cepheid Xpert C. difficile diagnostic assay: an update meta-analysis. Braz J Microbiol 2021; 52:1937-1949. [PMID: 34455573 PMCID: PMC8578272 DOI: 10.1007/s42770-021-00563-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 06/27/2021] [Indexed: 11/28/2022] Open
Abstract
Background Accurate and rapid diagnosis of Clostridium difficile infection (CDI) is critical for effective patient management and implementation of infection control measures to prevent transmission. Objectives We updated our previous meta-analysis to provide a more reliable evidence base for the clinical diagnosis of Xpert C. difficile (Xpert C. difficile) assay. Methods We searched PubMed, EMBASE, Cochrane Library, Chinese National Knowledge Infrastructure (CNKI), and the Chinese Biomedical Literature Database (CBM) databases to identify studies according to predetermined criteria. STATA 13.0 software was used to analyze the tests for sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and area under the summary receiver operating characteristic curves (AUC). QUADAS-2 was used to assess the quality of included studies with RevMan 5.2. Heterogeneity in accuracy measures was tested with Spearman correlation coefficient and chi-square. Meta-regressions and subgroup analyses were performed to figure out the potential sources of heterogeneity. Model diagnostics were used to evaluate the veracity of the data. Results A total of 26 studies were included in the meta-analysis. The pooled sensitivity (95% confidence intervals [CI]) for diagnosis was 0.97(0.95–0.98), and specificity was 0.96(0.95–0.97). The AUC was 0.99 (0.98–1.00). Model diagnostics confirmed the robustness of our meta-analysis’s results. Significant heterogeneity was still observed when we pooled most of the accuracy measures of selected studies. Meta-regression and subgroup analyses showed that the sample size and type, ethnicity, and disease prevalence might be the conspicuous sources of heterogeneity. Conclusions The up-to-date meta-analysis showed the Xpert CD assay had good accuracy for detecting CDI. However, the diagnosis of CDI must combine clinical presentation with diagnostic testing to better answer the question of whether the patient actually has CDI in the future, and inclusion of preanalytical parameters and clinical outcomes in study design would provide a more objective evidence base.
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Affiliation(s)
- Yuanyuan Bai
- Department of Clinical Laboratory, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan, People's Republic of China
| | - Yingying Hao
- Department of Clinical Laboratory, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan, People's Republic of China
| | - Zhen Song
- Department of Clinical Laboratory, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan, People's Republic of China
| | - Wenjun Chu
- Department of Clinical Laboratory, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan, People's Republic of China
| | - Yan Jin
- Department of Clinical Laboratory, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan, People's Republic of China.
| | - Yueling Wang
- Department of Clinical Laboratory, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan, People's Republic of China.
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25
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Mauro J, Kannangara S, Peterson J, Livert D, Tuma RA. Rigorous antibiotic stewardship in the hospitalized elderly population: saving lives and decreasing cost of inpatient care. JAC Antimicrob Resist 2021; 3:dlab118. [PMID: 34396124 PMCID: PMC8360295 DOI: 10.1093/jacamr/dlab118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/07/2021] [Indexed: 11/12/2022] Open
Abstract
Background There is limited literature evaluating the effect of antibiotic stewardship programmes (ASPs) in hospitalized geriatric patients, who are at higher risk for readmissions, developing Clostridioides difficile infection (CDI) or other adverse outcomes secondary to antibiotic treatments. Methods In this cohort study we compare the rates of 30 day hospital readmissions because of reinfection or development of CDI in patients 65 years and older who received ASP interventions between January and June 2017. We also assessed their mortality rates and length of stay. Patients were included if they received antibiotics for pneumonia, urinary tract infection, acute bacterial skin and skin structure infection or complicated intra-abdominal infection. The ASP team reviewed patients on antibiotics daily. ASP interventions included de-escalation of empirical or definitive therapy, change in duration of therapy or discontinuation of therapy. Treatment failure was defined as readmission because of reinfection or a new infection. A control group of patients 65 years and older who received antibiotics between January and June 2015 (pre-ASP) was analysed for comparison. Results We demonstrated that the 30 day hospital readmission rate for all infection types decreased during the ASP intervention period from 24.9% to 9.3%, P < 0.001. The rate of 30 day readmissions because of CDI decreased during the intervention period from 2.4% to 0.30%, P = 0.02. Mortality in the cohort that underwent ASP interventions decreased from 9.6% to 5.4%, P = 0.03. Lastly, antibiotic expenditure decreased after implementation of the ASP from $23.3 to $4.3 per adjusted patient day, in just 6 months. Conclusions Rigorous de-escalation and curtailing of antibiotic therapies were beneficial and without risk for the hospitalized patients 65 years and over.
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Affiliation(s)
- James Mauro
- Department of Pharmacy, Easton Hospital, Easton, PA, USA
| | - Saman Kannangara
- Department of Internal Medicine, Division of Infectious Diseases, Saint Francis Memorial Hospital, San Francisco, CA, USA
| | - Joanne Peterson
- Department of Infection Control, Hackensack Meridian, Bayshore Medical Center, Holmdel, NJ, USA
| | - David Livert
- Department of Medicine, Easton Hospital, Easton, PA, USA.,Penn State University, Center Valley, PA, USA
| | - Roman A Tuma
- Department of Internal Medicine, Hackensack Meridian, Bayshore Medical Center, Holmdel, NJ, USA.,Department of Medicine, Hackensack Meridian School of Medicine, Nutley, NJ, USA
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26
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Costs Associated with the Treatment of Clostridioides Difficile Infections. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18147647. [PMID: 34300098 PMCID: PMC8307892 DOI: 10.3390/ijerph18147647] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/14/2021] [Accepted: 07/17/2021] [Indexed: 12/25/2022]
Abstract
Background: Clostridioides difficile, as the main cause of infectious diarrhoea in hospitalised patients, is a considerable challenge for medical personnel (hospital environment) who have direct contact with the patient, as well as being of interest to public health specialists. Financial issues related to the occurrence of the above-mentioned micro-organism are being increasingly raised. Due to the scale of the phenomenon, we are beginning to pay attention to the significant system costs caused by the diagnosis and treatment of CDI infection and its complications. Studies indicate that the nosocomial infection of C. difficile complicates hospitalisation, by increasing the cost by more than half and extending patient’s stay by an average of 3.6 days. Material and methods: The aim of this study was to attempt to calculate the estimated costs associated with the prolonged hospitalisation of patients with nosocomial CDI infection, using the example of a hospital in Lodz. A total of 53 completed hospitalisations of patients treated in the period of January–August 2018 were analysed, during which hospital Clostridioides difficile infection was identified. For the purposes of this study, statistical data collected in the hospital’s IT system were also analysed, covering 44,868 hospitalisations in the Jan–Aug 2018 period, during which no hospital infection occurred. They was a control group, in which the analysed cases were compared. The obtained data in the study determined how long each patient with Clostridioides difficile infection stayed in the hospital (from the moment infection was diagnosed until the day of hospital discharge), and which diagnosis related groups (DRG) (according to National Health Fund guidelines) were assigned. The average length of patient stay without infection within a given DRG group in each hospital ward was also determined. The collected materials became the initial point for the final analysis of hospital costs and the length of hospital stay caused by Clostridioides difficile infection. Results: Clostridioides difficile infection extended the hospital stay by an average of almost 12 days. The average cost of prolonged hospitalisation due to CDI infection (according to the average cost per person-day) was about PLN 7148 (1664 EUR), which gave a total value of about PLN 378,860.6 (88,240.5 EUR) in the examined period. At the same time, the average expenditure from the National Health Fund for hospitalisation due to CDI infections increased by about PLN 6627 (1542.8 EUR), which in the analysed period translated into over PLN 351,232.0 (81,505.5 EUR) (according to settlements with the National Health Fund). The outcome indicates that there is a clear relation between CDI and the anticipated length of hospitalisation of patients without an infection.
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27
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Brum JM, Gibb RD, Ramsey DL, Balan G, Yacyshyn BR. Systematic Review and Meta-Analyses Assessment of the Clinical Efficacy of Bismuth Subsalicylate for Prevention and Treatment of Infectious Diarrhea. Dig Dis Sci 2021; 66:2323-2335. [PMID: 32772204 PMCID: PMC8236042 DOI: 10.1007/s10620-020-06509-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 07/21/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND A large number of studies have evaluated the pharmacology, safety, and/or efficacy of bismuth subsalicylate for the relief of common gastrointestinal symptoms, diarrhea and vomiting due to acute gastroenteritis. In addition, short-term (48 h) medication with bismuth subsalicylate is known to be effective against infectious gastroenteritis such as travelers' diarrhea. AIMS Previous studies have documented the bacteriostatic/bactericidal effects of bismuth subsalicylate against a variety of pathogenic gastrointestinal bacteria. However, meta-analyses of the clinical efficacy of bismuth subsalicylate for both prevention and treatment of travelers' diarrhea have not yet been published. METHODS A total of 14 clinical studies (from 1970s to 2007) comprised the core data used in this assessment of efficacy of bismuth subsalicylate against infectious (including travelers') diarrhea. These studies allowed for statistical meta-analyses regarding prevention (three travelers' diarrhea studies) and treatment of infectious diarrhea (11 studies [five travelers' diarrhea]). RESULTS The results show that subjects treated with bismuth subsalicylate for up to 21 days have 3.5 times greater odds of preventing travelers' diarrhea compared with placebo (95% CI 2.1, 5.9; p < 0.001). In addition, subjects with infectious diarrhea treated with bismuth subsalicylate had 3.7 times greater odds of diarrhea relief (recorded on diaries as subjective symptomatic improvement) compared to those receiving placebo (95% CI 2.1, 6.3; p < 0.001). CONCLUSIONS This systematic review and meta-analysis suggests that bismuth subsalicylate can be beneficial for those at risk or affected by food and waterborne diarrheal disease such as traveler's (infectious) diarrhea, and may decrease the risk of inappropriate antibiotic utilization.
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Affiliation(s)
- Jose M Brum
- Procter and Gamble Global Clinical Sciences, Health Care and Quantitative Sciences, 8700 Mason Montgomery Road, Mason, OH, 45040, USA
| | - Roger D Gibb
- Procter and Gamble Global Clinical Sciences, Health Care and Quantitative Sciences, 8700 Mason Montgomery Road, Mason, OH, 45040, USA
| | - David L Ramsey
- Procter and Gamble Global Clinical Sciences, Health Care and Quantitative Sciences, 8700 Mason Montgomery Road, Mason, OH, 45040, USA
| | - Guhan Balan
- Procter and Gamble Global Clinical Sciences, Health Care and Quantitative Sciences, 8700 Mason Montgomery Road, Mason, OH, 45040, USA
| | - Bruce R Yacyshyn
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville School of Medicine, Louisville, KY, 40292, USA.
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28
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Finn E, Andersson FL, Madin-Warburton M. Burden of Clostridioides difficile infection (CDI) - a systematic review of the epidemiology of primary and recurrent CDI. BMC Infect Dis 2021; 21:456. [PMID: 34016040 PMCID: PMC8135979 DOI: 10.1186/s12879-021-06147-y] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 05/06/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Clostridioides difficile is a Gram-positive anaerobic bacterium, which causes Clostridioides difficile infection (CDI). It has been recognised as a leading cause of healthcare-associated infections and a considerable threat to public health globally. This systematic literature review (SLR) summarises the current evidence on the epidemiology and clinical burden of CDI. METHODS A SLR was conducted to identify CDI and recurrent CDI (rCDI) epidemiology studies, to evaluate patient and disease characteristics, incidence rates, epidemiological findings and risk factors. Embase, MEDLINE and the Cochrane Library databases were searched for English articles from 2009 to 2019. Included territories were the United Kingdom, France, Germany, Italy, Spain, Poland, US, Canada, Australia, Japan and China. RESULTS Of 11,243 studies identified, 165 fulfilled the selection criteria. An additional 20 studies were identified through targeted review of grey literature. The most widely reported findings were incidence and risk factors for CDI and rCDI. Among key studies reporting both healthcare-associated (HA-CDI) and community-associated CDI (CA-CDI) incidence rates for each country of interest, incidence rates per 10,000 patient days in the US were 8.00 and 2.00 for HA-CDI and CA-CDI, respectively. The highest incidence in Europe was reported in Poland (HA-CDI: 6.18 per 10,000 patient days, CA-CDI: 1.4 per 10,000 patient days), the lowest from the UK, at 1.99 per 10,000 patient days and 0.56 per 10,000 patient days for HA-CDI and CA-CDI, respectively. No clear trend for incidence over time emerged, with most countries reporting stable rates but some either a decrease or increase. Rates of recurrent CDI varied based on geographical setting. The rate of recurrence was lower in community-associated disease compared to healthcare-associated disease. Independent CDI risk factors identified common to both initial CDI and recurrent CDI included increasing age, antibiotic use, recent hospitalisation, and proton pump inhibitor (PPI) use. In addition, leukocyte count, length of hospital stays, and Charlson comorbidity index score featured as statistically significant risk factors for recurrent CDI, but these are not reported among the most common statistically significant risk factors for initial CDI. CONCLUSIONS Despite considerable heterogeneity, evidence suggests substantial incidence of recurrent and primary CDI, even after considerable efforts in the last decade.
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Affiliation(s)
- Elaine Finn
- IQVIA, 210 Pentonville Road, London, N1 9JY, UK.
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29
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Seeberger PH. Discovery of Semi- and Fully-Synthetic Carbohydrate Vaccines Against Bacterial Infections Using a Medicinal Chemistry Approach. Chem Rev 2021; 121:3598-3626. [PMID: 33794090 PMCID: PMC8154330 DOI: 10.1021/acs.chemrev.0c01210] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Indexed: 12/13/2022]
Abstract
The glycocalyx, a thick layer of carbohydrates, surrounds the cell wall of most bacterial and parasitic pathogens. Recognition of these unique glycans by the human immune system results in destruction of the invaders. To elicit a protective immune response, polysaccharides either isolated from the bacterial cell surface or conjugated with a carrier protein, for T-cell help, are administered. Conjugate vaccines based on isolated carbohydrates currently protect millions of people against Streptococcus pneumoniae, Haemophilus influenzae type b, and Neisseria meningitides infections. Active pharmaceutical ingredients (APIs) are increasingly discovered by medicinal chemistry and synthetic in origin, rather than isolated from natural sources. Converting vaccines from biologicals to pharmaceuticals requires a fundamental understanding of how the human immune system recognizes carbohydrates and could now be realized. To illustrate the chemistry-based approach to vaccine discovery, I summarize efforts focusing on synthetic glycan-based medicinal chemistry to understand the mammalian antiglycan immune response and define glycan epitopes for novel synthetic glycoconjugate vaccines against Streptococcus pneumoniae, Clostridium difficile, Klebsiella pneumoniae, and other bacteria. The chemical tools described here help us gain fundamental insights into how the human system recognizes carbohydrates and drive the discovery of carbohydrate vaccines.
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30
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Dutta D, Jafri F, Stuhr D, Knoll BM, Lim SH. A contemporary review of Clostridioides difficile infections in patients with haematologic diseases. J Intern Med 2021; 289:293-308. [PMID: 32910532 DOI: 10.1111/joim.13173] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 08/18/2020] [Indexed: 12/14/2022]
Abstract
Clostridioides (Clostridium) difficile (C. difficile) infection is one of the most common causes of increased morbidity and mortality. Approximately 500 000 C. difficile infections (CDIs) occur each year in the United States, and they result in more than 29 000 deaths. Patients with haematologic diseases are at a higher risk for this infection due to frequent hospitalization and exposure to treatment-associated risk factors. Whilst several currently available antimicrobial agents offer resolution, recurrence of infection remains a major concern. Recent advancement in deciphering C. difficile virulence mechanisms and identification of its allies in contributing to the infection has led to the development of alternative treatment strategies. Here, we will provide a contemporary discussion of how major risk factors in haematologic diseases, such as immunosuppression, chemoradiation, use of antibiotic, proton pump inhibitor and opioid, and deficiency in butyrate and antimicrobial peptides contribute to C. difficile infection. Next, we will highlight different approaches to control and mitigate this infection such as antibiotic stewardship and faecal microbiota transplantation. Finally, we will explore several emerging treatments such as use of pre- and probiotics, immunotherapy and microbiome-sparing agents.
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Affiliation(s)
- D Dutta
- From the, Division of Hematology and Oncology, State University of New York Downstate Health Sciences University, Brooklyn, NY, USA.,Division of Hematology and Oncology, New York Medical College, Valhalla, NY, USA
| | - F Jafri
- Department of Medicine, New York Medical College, Valhalla, NY, USA
| | - D Stuhr
- Division of Hematology and Oncology, New York Medical College, Valhalla, NY, USA.,Lake Erie College of Osteopathic Medicine, Bradenton, FL, USA
| | - B M Knoll
- Department of Medicine, New York Medical College, Valhalla, NY, USA.,Division of Infectious Diseases, New York Medical College, Valhalla, NY, USA
| | - S H Lim
- From the, Division of Hematology and Oncology, State University of New York Downstate Health Sciences University, Brooklyn, NY, USA.,Division of Hematology and Oncology, New York Medical College, Valhalla, NY, USA
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31
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Gupta A, Ananthakrishnan AN. Economic burden and cost-effectiveness of therapies for Clostridiodes difficile infection: a narrative review. Therap Adv Gastroenterol 2021; 14:17562848211018654. [PMID: 34104214 PMCID: PMC8170348 DOI: 10.1177/17562848211018654] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/30/2021] [Indexed: 02/04/2023] Open
Abstract
Clostridioides difficile is the most common cause of healthcare-associated diarrhea. Disease complications as well as recurrent infections contribute significantly to morbidity and mortality. Over the past decades, there has been a rapid increase in the incidence of C. difficile infection (CDI), with a rise in the number of community-acquired cases. CDI has a profound economic impact on both the healthcare system and patients, secondary to recurrences, hospitalization, prolonged length of stay, cost of treatment, and indirect societal costs. With emergence of newer treatment options, the standard of care is shifting from metronidazole and vancomycin towards fidaxomicin and fecal microbiota transplantation (FMT), which despite being more expensive, are more efficacious in preventing recurrences and hence overall are more beneficial forms of therapy per cost-effectiveness analyses. Data regarding preferred route of FMT, timing of FMT, and non-conventional therapies such as bezlotoxumab is scant. There is a need for further studies to elucidate the true attributable costs of CDI as well as continued cost-effectiveness research to reduce the economic burden associated with the disease and improve clinical practice.
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Affiliation(s)
- Akshita Gupta
- Department of Medicine, Massachusetts General
Hospital, Boston, MA, USA
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32
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Madden GR, Smith DC, Poulter MD, Sifri CD. Propensity-Matched Cost of Clostridioides difficile Infection Overdiagnosis. Open Forum Infect Dis 2020; 8:ofaa630. [PMID: 33575420 PMCID: PMC7863872 DOI: 10.1093/ofid/ofaa630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/15/2020] [Indexed: 12/19/2022] Open
Abstract
Background Clostridioides difficile is the leading health care–associated pathogen, but clinicians lack a test that can reliably differentiate colonization from infection. Health care costs attributed to C. difficile are substantial, but the economic burden associated with C. difficile false positives is poorly understood. Methods A propensity score matching model for cost per hospitalization was developed to estimate the costs of both true infection and false positives. Predictors of C. difficile positivity used to estimate the propensity score were age, Charlson comorbidity index, white cell count, and creatinine. We used polymerase chain reaction (PCR) cycle threshold to identify and compare 3 groups: (1) true infection, (2) C. difficile colonization, and (3) C. difficile negative. Results A positive test was associated with $3018 higher unadjusted hospital cost. Among the 3 comparisons made with propensity-matched negative controls (all positives [+$179; P = .934], true positives [–$1892; P = .100], and colonized positives), only colonization was associated with significantly increased (+$3418; P = .012) cost. Differences in lengths of stay (all positives 0 days, P = .126; true 0 days, P = .919; colonized 1 day, P = .019) appeared to underly cost differences. Conclusions In the first C. difficile cost analysis to utilize PCR cycle threshold to differentiate colonization, we found high propensity-matched hospital costs associated with colonized but not true positives. This unexpected finding may be due to misdiagnosis of non–C. difficile diarrhea or unadjusted factors associated with colonization.
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Affiliation(s)
- Gregory R Madden
- Division of Infectious Diseases & International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - David C Smith
- University of Virginia McIntire School of Commerce, Charlottesville, Virginia, USA
| | - Melinda D Poulter
- Clinical Microbiology Laboratory, Department of Pathology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Costi D Sifri
- Division of Infectious Diseases & International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA.,Office of Hospital Epidemiology/Infection Prevention & Control, UVA Health, Charlottesville, Virginia, USA
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Braae UC, Møller FT, Ibsen R, Ethelberg S, Kjellberg J, Mølbak K. The Economic Burden of Clostridioides difficile in Denmark: A Retrospective Cohort Study. Front Public Health 2020; 8:562957. [PMID: 33324595 PMCID: PMC7725905 DOI: 10.3389/fpubh.2020.562957] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 11/02/2020] [Indexed: 01/15/2023] Open
Abstract
Objectives: The aim of this study was to make a comprehensive economic assessment of the costs of hospital-acquired C. difficile infections (CDI). Methods: We carried out a retrospective matched cohort study utilizing Danish registry data with national coverage to identify CDI cases and matched reference patients without CDI (controls) for economic burden assessment in Denmark covering 2011–2014. Health care costs and public transfer costs were obtained from national registries, and calculated for 1 year prior to, and 2 years after index admission using descriptive statistics and regression analysis. Results: The study included 12,768 CDI patients and 23,272 matched controls. The total health care cost was significantly larger for CDI cases than controls throughout all periods. During the index admission period, cost was €12,867 per CDI case compared to €4,522 (p < 0.001) for controls, which increased to an average of €31,388 and €19,512 (p < 0.001) in Year 1 for the two groups, respectively. Excess costs were found both among infections with onset in hospitals and in the community. Diagnosis compatible with complications increased costs to on average >€91,000 per case. The regression analysis showed that CDI adds a substantial economic burden, but only explains about 1/3 of the crude difference observed in the matched analysis. Discussion: The major economic impact of hospital-acquired CDI with complications underlines the importance of preventing complications in these patients. Our study provides an informed estimate of the potential economic gain per patient by successful intervention, which is likely to be relatively comparable across countries.
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Affiliation(s)
- Uffe Christian Braae
- Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark
| | - Frederik Trier Møller
- Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark
| | | | - Steen Ethelberg
- Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark.,Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jakob Kjellberg
- Danish National Institute for Local and Regional Government Research, Copenhagen, Denmark
| | - Kåre Mølbak
- Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark.,Department of Veterinary and Animal Science, University of Copenhagen, Copenhagen, Denmark
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Abstract
INTRODUCTION Clostridioides difficile infection (CDI) is associated with substantial emergency department (ED) and inpatient burden. To date, few studies have evaluated the ED burden of CDI. Using the Nationwide Emergency Department Sample, we evaluated trends in ED use, ED and inpatient charges, admission and mortality rates, length of stay, and independent risk factors for hospital admission and mortality after an ED visit. METHODS Using Nationwide Emergency Department Sample for 2006 through 2014, we identified all patients with the primary diagnosis of CDI (using diagnostic codes). We determined the trends in ED visits and used survey logistic regression analysis to identify factors associated with hospital admission. RESULTS Overall, 909,236 ED visits for CDI resulted in 817,935 admissions (90%) to the hospital. The number of visits increased from 76,709 in 2006 to 106,869 in 2014, and the admission rate decreased from 92.4% to 84.4%. ED charges adjusted for inflation went up from US$1433.0 to 2900, a significant rise even accounting for inflation. The overall length of hospital stay decreased from 7 to 5.8 days. Independent predictors of admission after ED visits included smoking, use of alcohol, and presence of multiple comorbidities. Independent risk factors for mortality in admitted patients include increasing age and presence of comorbidities. CONCLUSIONS Although ED use for CDI increased, rates of hospital admission decreased over 9 years. Identification of predictors of admission and in-hospital mortality will help guide policies and interventions to reduce the burden on health care resources.
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Antibiotic Exposure and Risk for Hospital-Associated Clostridioides difficile Infection. Antimicrob Agents Chemother 2020; 64:AAC.02169-19. [PMID: 31964789 DOI: 10.1128/aac.02169-19] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 01/11/2020] [Indexed: 01/08/2023] Open
Abstract
Clostridioides difficile infection (CDI) is a health care-associated infection associated with significant morbidity and cost, with highly varied risk across populations. More effective, risk-based prevention strategies are needed. Here, we investigate risk factors for hospital-associated CDI in a large integrated health system. In a retrospective cohort of all adult admissions to 21 Intermountain Healthcare hospitals from 2006 to 2012, we identified all symptomatic (i) hospital-onset and (ii) health care-facility-associated, community-onset CDI. We then evaluated the risk associated with antibiotic exposure, including that of specific agents, using multivariable logistic regression. A total of 2,356 cases of CDI among 506,068 admissions were identified (incidence, 46.6 per 10,000). Prior antibiotic use was the dominant risk factor, where for every antibiotic day of therapy prior to the index admission, the odds of subsequent CDI increased by 12.8% (95% confidence interval [CI], 12.2 to 13.4%; P < 0.0001). This was a much stronger association than was inpatient antibiotic exposure (odds ratio [OR], 1.007 [95% CI, 1.005 to 1.009]; P < 0.0001). The highest-risk antibiotics included second-generation and later cephalosporins (especially oral), carbapenems, fluoroquinolones, and clindamycin, while doxycycline and daptomycin were associated with a lower CDI risk. We concluded that cumulative antibiotic exposure prior to admission is the greatest contributor to the risk of subsequent CDI. Most classes of antibiotics carry some risk, which varies by drug and route. This information may be useful for antimicrobial stewardship efforts.
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Rajasingham R, Enns EA, Khoruts A, Vaughn BP. Cost-effectiveness of Treatment Regimens for Clostridioides difficile Infection: An Evaluation of the 2018 Infectious Diseases Society of America Guidelines. Clin Infect Dis 2020; 70:754-762. [PMID: 31001619 PMCID: PMC7319265 DOI: 10.1093/cid/ciz318] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 04/12/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In 2018, the Infectious Diseases Society of America (IDSA) published guidelines for diagnosis and treatment of Clostridioides (formerly Clostridium) difficile infection (CDI). However, there is little guidance regarding which treatments are cost-effective. METHODS We used a Markov model to simulate a cohort of patients presenting with an initial CDI diagnosis. We used the model to estimate the costs, effectiveness, and cost-effectiveness of different CDI treatment regimens recommended in the recently published 2018 IDSA guidelines. The model includes stratification by the severity of the initial infection, and subsequent likelihood of cure, recurrence, mortality, and outcomes of subsequent recurrences. Data sources were taken from IDSA guidelines and published literature on treatment outcomes. Outcome measures were discounted quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs). RESULTS Use of fidaxomicin for nonsevere initial CDI, vancomycin for severe CDI, fidaxomicin for first recurrence, and fecal microbiota transplantation (FMT) for subsequent recurrence (strategy 44) cost an additional $478 for 0.009 QALYs gained per CDI patient, resulting in an ICER of $31 751 per QALY, below the willingness-to-pay threshold of $100 000/QALY. This is the optimal, cost-effective CDI treatment strategy. CONCLUSIONS Metronidazole is suboptimal for nonsevere CDI as it is less beneficial than alternative strategies. The preferred treatment regimen is fidaxomicin for nonsevere CDI, vancomycin for severe CDI, fidaxomicin for first recurrence, and FMT for subsequent recurrence. The most effective treatments, with highest cure rates, are also cost-effective due to averted mortality, utility loss, and costs of rehospitalization and/or further treatments for recurrent CDI.
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Affiliation(s)
- Radha Rajasingham
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota
| | - Eva A Enns
- Division of Health Policy and Management, University of Minnesota School of Public Health
| | - Alexander Khoruts
- Division of Gastroenterology, Department of Medicine, University of Minnesota, Minneapolis
| | - Byron P Vaughn
- Division of Gastroenterology, Department of Medicine, University of Minnesota, Minneapolis
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Bowman JA, Utter GH. Evolving Strategies to Manage Clostridium difficile Colitis. J Gastrointest Surg 2020; 24:484-491. [PMID: 31768834 PMCID: PMC7031036 DOI: 10.1007/s11605-019-04478-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 11/12/2019] [Indexed: 02/06/2023]
Abstract
Clostridium difficile infection remains a common nosocomial illness with a significant impact on health care delivery. As molecular phenotyping of this organism has changed our understanding of its transmission and virulence, so too have diagnostic methods and treatment strategies evolved in recent years. The burden of this infection falls predominantly on elderly patients with comorbidities who have recently received antibiotics. Oral or enteral vancomycin is now preferred for first-line antimicrobial treatment across the disease spectrum, including mild-moderate initial cases. Fidaxomicin (a novel macrolide antibiotic), bezlotoxumab (a monoclonal antibody against toxin TcdB), and fecal microbiota transplantation expand the therapeutic armamentarium, particularly for recurrent infection. Operative treatment should be reserved for patients with fulminant infection, and early identification of patients who would benefit from an operation remains a challenge. Less invasive surgical options-such as laparoscopic diverting ileostomy with colonic irrigation-may improve survival and other outcomes relative to total abdominal colectomy and represent an attractive alternative particularly for frail patients.
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Affiliation(s)
- Jessica A Bowman
- Department of Surgery, University of California, Davis, Medical Center, 2335 Stockton Blvd., Sacramento, CA, 95817, USA
| | - Garth H Utter
- Department of Surgery, University of California, Davis, Medical Center, 2335 Stockton Blvd., Sacramento, CA, 95817, USA.
- Department of Surgery Outcomes Research Group (Utter), University of California, Davis, Medical Center, Sacramento, CA, USA.
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Champredon D, Shoukat A, Moghadas SM. Effectiveness and cost-effectiveness of a Clostridium difficile vaccine candidate in a hospital setting. Vaccine 2020; 38:2585-2591. [PMID: 32014268 DOI: 10.1016/j.vaccine.2020.01.073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 01/18/2020] [Accepted: 01/23/2020] [Indexed: 11/27/2022]
Abstract
Toxoid vaccines against Clostridium difficile infections (CDI) appear promising in reducing the risk of developing toxin-mediated symptoms. We sought to evaluate the effectiveness and cost-effectiveness of a vaccine candidate in a hospital setting. We developed an agent-based simulation model of nosocomial CDI in a 300-bed hospital. Targeting high-risk patients for vaccination, we estimated the reduction of symptomatic CDI. Using the net reduction of CDI-associated isolation days, we evaluated the vaccine's cost-effectiveness from a healthcare provider perspective over a 2-year period with an average monthly incidence of 5 cases per 10,000 patient-days pre-vaccination. Assuming a vaccine efficacy in the range 60-90%, vaccinating 40% of high-risk patients pre-admission reduced symptomatic CDI by 16.6% (95% CI: 15.2, 17.9). When the vaccine coverage increased to 80%, the reduction of symptomatic CDI was 34.6% (95% CI: 33.7, 35.9). For a willingness to pay (WTP) of CDN$1000 (corresponding to the average costs of case isolation per day), vaccine was cost-effective for vaccination costs per individual (VCPI) up to CDN$111 in the scenario of 40% vaccine coverage. With the same WTP, vaccine was cost-effective for VCPI up to CDN$121 when the vaccine coverage increased to 80%. A significant portion (~80%) of hospital colonization is caused by environmental transmission of C. difficile, which markedly reduced the effectiveness of vaccine below its assumed efficacy. However, due to the number of CDI-associated isolation days averted, vaccination of high-risk patients can be cost-effective depending on the WTP and the VCPI.
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Affiliation(s)
- David Champredon
- Department of Pathology and Laboratory Medicine, University of Western Ontario, London, Ontario N6A 3K7, Canada; Agent-Based Modelling Laboratory, York University, Toronto, Ontario M3J 1P3, Canada
| | - Affan Shoukat
- Center for Infectious Disease Modelling and Analysis, Yale University, New Haven, CT 06510, USA; Agent-Based Modelling Laboratory, York University, Toronto, Ontario M3J 1P3, Canada
| | - Seyed M Moghadas
- Agent-Based Modelling Laboratory, York University, Toronto, Ontario M3J 1P3, Canada.
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Cammarota G, Ianiro G, Kelly CR, Mullish BH, Allegretti JR, Kassam Z, Putignani L, Fischer M, Keller JJ, Costello SP, Sokol H, Kump P, Satokari R, Kahn SA, Kao D, Arkkila P, Kuijper EJ, Vehreschild MJG, Pintus C, Lopetuso L, Masucci L, Scaldaferri F, Terveer EM, Nieuwdorp M, López-Sanromán A, Kupcinskas J, Hart A, Tilg H, Gasbarrini A. International consensus conference on stool banking for faecal microbiota transplantation in clinical practice. Gut 2019; 68:2111-2121. [PMID: 31563878 PMCID: PMC6872442 DOI: 10.1136/gutjnl-2019-319548] [Citation(s) in RCA: 259] [Impact Index Per Article: 51.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 09/10/2019] [Accepted: 09/22/2019] [Indexed: 12/13/2022]
Abstract
Although faecal microbiota transplantation (FMT) has a well-established role in the treatment of recurrent Clostridioides difficile infection (CDI), its widespread dissemination is limited by several obstacles, including lack of dedicated centres, difficulties with donor recruitment and complexities related to regulation and safety monitoring. Given the considerable burden of CDI on global healthcare systems, FMT should be widely available to most centres.Stool banks may guarantee reliable, timely and equitable access to FMT for patients and a traceable workflow that ensures safety and quality of procedures. In this consensus project, FMT experts from Europe, North America and Australia gathered and released statements on the following issues related to the stool banking: general principles, objectives and organisation of the stool bank; selection and screening of donors; collection, preparation and storage of faeces; services and clients; registries, monitoring of outcomes and ethical issues; and the evolving role of FMT in clinical practice,Consensus on each statement was achieved through a Delphi process and then in a plenary face-to-face meeting. For each key issue, the best available evidence was assessed, with the aim of providing guidance for the development of stool banks in order to promote accessibility to FMT in clinical practice.
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Affiliation(s)
- Giovanni Cammarota
- Internal Medicine and Gastroenterology, Day Hospital of Gastroenterology and Intestinal Microbiota Transplantation, Fondazione Policlinico A Gemelli IRCCS, Catholic University of Medicine, Roma, Italy
| | - Gianluca Ianiro
- Internal Medicine and Gastroenterology, Day Hospital of Gastroenterology and Intestinal Microbiota Transplantation, Fondazione Policlinico A Gemelli IRCCS, Roma, Italy
| | - Colleen R Kelly
- Division of Gastroenterology, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Benjamin H Mullish
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Jessica R Allegretti
- Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Zain Kassam
- Microbiome Informatics, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
- OpenBiome, Somerville, Massachusetts, United States of America
| | - Lorenza Putignani
- Parasitology Unit and Human Microbiome Unit, Bambino Gesù Pediatric Hospital, Roma, Italy
| | - Monika Fischer
- Department of Medicine, Indiana University, Indianapolis, Indiana, United States of America
| | - Josbert J Keller
- Department of Gastroenterologyand Hepatology, Haaglanden Medical Center, 2597 AX, The Hague, Netherlands
- National Donor Feces Bank, LUMC, Leiden, the Netherlands
| | - Samuel Paul Costello
- Department of Gastroenterology, The Queen Elizabeth Hospital, University of Adelaide, Woodville, South Australia, Australia
| | - Harry Sokol
- Service de Gastroenterologie, Hôpital Saint Antoine, Sorbonne Université, Inserm, Centre de Recherche Saint-Antoine, Paris, France
- French Group of Fecal Microbiota Transplantation, Paris, France
- INRA, UMR1319 Micalis, AgroParisTech, Jouy-en-Josas, France
| | - Patrizia Kump
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Reetta Satokari
- Human Microbiome Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Stacy A Kahn
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, Uunited States of America
| | - Dina Kao
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Perttu Arkkila
- Department of Clinic of Gastroenterology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ed J Kuijper
- Department of Medical Microbiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Maria J Gt Vehreschild
- Department I of Internal Medicine; German Centre for Infection Research, Partner site Bonn-Cologne, University Hospital of Cologne, Cologne, Germany
| | - Cristina Pintus
- Tissues and Cells Area, Italian National Transplant Center, Rome, Italy
| | - Loris Lopetuso
- Internal Medicine and Gastroenterology, Fondazione Policlinico A Gemelli IRCCS, Roma, Italy
| | - Luca Masucci
- Microbiology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University of Medicine, Roma, Italy
| | - Franco Scaldaferri
- Internal Medicine and Gastroenterology, Fondazione Policlinico A Gemelli IRCCS, Roma, Italy
| | - E M Terveer
- National Donor Feces Bank, LUMC, Leiden, the Netherlands
- Department of Medical Microbiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Max Nieuwdorp
- Department of Internal Medicine, Amsterdam University Medical Centers, location AMC and VuMC, Amsterdam, Netherlands
| | - Antonio López-Sanromán
- Gastroenterology and Hepatology Department, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Juozas Kupcinskas
- Department of Gastroenterology, Institute for Digestive Research, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Ailsa Hart
- Department of Gastroenterology, St Mark's Hospital, London, United Kingdom
| | - Herbert Tilg
- Department of Internal Medicine I, Gastroenterology, Endocrinology & Metabolism, Innsbruck Medical University, Innsbruck, Austria
| | - Antonio Gasbarrini
- Internal Medicine and Gastroenterology, Fondazione Policlinico A Gemelli IRCCS, Catholic University of Medicine, Roma, Italy
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Champredon D, Zhang K, Smieja M, Moghadas SM. Clostridium difficile intervention timelines for diagnosis, isolation, and treatment. Am J Infect Control 2019; 47:1370-1374. [PMID: 31182236 DOI: 10.1016/j.ajic.2019.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/30/2019] [Accepted: 05/01/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Developing timelines of nosocomial Clostridium difficile infection (CDI) is critical to improving control and preventive measures. The objective of this study was to provide data-driven estimates of CDI timelines of diagnosis, isolation, and treatment in a hospital setting. METHODS We obtained data for all CDI inpatients with symptoms onset occurring between January 1, 2013, and December 30, 2017, from St Joseph's Healthcare in Hamilton, Canada. We analyzed full empirical distributions of timelines associated with the diagnosis, isolation, and treatment of CDI. RESULTS A total of 683 inpatients with CDI symptoms were recorded, of which 243 cases were identified as health care-associated infection (HAI). The mean time intervals between the onset of CDI symptoms after admission and the release of laboratory results were 1.2 days and 1.9 days for the HAI and community-associated infection (CAI) patient groups, respectively. The mean time intervals from symptoms onset to the start of isolation were 1.5 days and 2.6 days for the corresponding patient groups. The initiation of treatment within 2 days of symptoms onset reduced the duration of first isolation (P value < .0001); however, the type of initial antibiotic used for CDI treatment was not associated with the duration of isolation. CONCLUSIONS Estimated timelines did not differ (P values > .6) between HAI and CAI patient groups with symptoms onset after admission. These estimates are useful for evaluating the effectiveness of CDI interventions.
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Kraft CS, Parrott JS, Cornish NE, Rubinstein ML, Weissfeld AS, McNult P, Nachamkin I, Humphries RM, Kirn TJ, Dien Bard J, Lutgring JD, Gullett JC, Bittencourt CE, Benson S, Bobenchik AM, Sautter RL, Baselski V, Atlas MC, Marlowe EM, Miller NS, Fischer M, Richter SS, Gilligan P, Snyder JW. A Laboratory Medicine Best Practices Systematic Review and Meta-analysis of Nucleic Acid Amplification Tests (NAATs) and Algorithms Including NAATs for the Diagnosis of Clostridioides ( Clostridium) difficile in Adults. Clin Microbiol Rev 2019; 32:32/3/e00032-18. [PMID: 31142497 PMCID: PMC6589859 DOI: 10.1128/cmr.00032-18] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The evidence base for the optimal laboratory diagnosis of Clostridioides (Clostridium) difficile in adults is currently unresolved due to the uncertain performance characteristics and various combinations of tests. This systematic review evaluates the diagnostic accuracy of laboratory testing algorithms that include nucleic acid amplification tests (NAATs) to detect the presence of C. difficile The systematic review and meta-analysis included eligible studies (those that had PICO [population, intervention, comparison, outcome] elements) that assessed the diagnostic accuracy of NAAT alone or following glutamate dehydrogenase (GDH) enzyme immunoassays (EIAs) or GDH EIAs plus C. difficile toxin EIAs (toxin). The diagnostic yield of NAAT for repeat testing after an initial negative result was also assessed. Two hundred thirty-eight studies met inclusion criteria. Seventy-two of these studies had sufficient data for meta-analysis. The strength of evidence ranged from high to insufficient. The uses of NAAT only, GDH-positive EIA followed by NAAT, and GDH-positive/toxin-negative EIA followed by NAAT are all recommended as American Society for Microbiology (ASM) best practices for the detection of the C. difficile toxin gene or organism. Meta-analysis of published evidence supports the use of testing algorithms that use NAAT alone or in combination with GDH or GDH plus toxin EIA to detect the presence of C. difficile in adults. There is insufficient evidence to recommend against repeat testing of the sample using NAAT after an initial negative result due to a lack of evidence of harm (i.e., financial, length of stay, or delay of treatment) as specified by the Laboratory Medicine Best Practices (LMBP) systematic review method in making such an assessment. Findings from this systematic review provide clarity to diagnostic testing strategies and highlight gaps, such as low numbers of GDH/toxin/PCR studies, in existing evidence on diagnostic performance, which can be used to guide future clinical research studies.
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Affiliation(s)
| | - J Scott Parrott
- Department of Interdisciplinary Studies, School of Health Professions, Rutgers University, Newark, New Jersey, USA
- Department of Epidemiology, School of Public Health, Rutgers University, Piscataway, New Jersey, USA
| | - Nancy E Cornish
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | | | - Peggy McNult
- American Society for Microbiology, Washington, DC, USA
| | - Irving Nachamkin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Thomas J Kirn
- Department of Interdisciplinary Studies, School of Health Professions, Rutgers University, Newark, New Jersey, USA
- Department of Epidemiology, School of Public Health, Rutgers University, Piscataway, New Jersey, USA
| | - Jennifer Dien Bard
- Children's Hospital Los Angeles, Los Angeles, California, USA
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | | | - Jonathan C Gullett
- Kaiser Permanente (Southern California Permanente Medical Group) Regional Reference Laboratories, Greater Los Angeles, Los Angeles, California, USA
| | | | - Susan Benson
- PathWest Laboratory Medicine, Perth, Western Australia, Australia
- University of Western Australia, Perth, Western Australia, Australia
| | - April M Bobenchik
- Rhode Island Hospital/Lifespan Academic Medical Center, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | | | - Vickie Baselski
- University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Michel C Atlas
- Kornhauser Health Sciences Library, University of Louisville, Louisville, Kentucky, USA
| | | | - Nancy S Miller
- Boston Medical Center, Boston, Massachusetts, USA
- Boston University School of Medicine, Boston, Massachusetts, USA
| | | | | | - Peter Gilligan
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - James W Snyder
- Kornhauser Health Sciences Library, University of Louisville, Louisville, Kentucky, USA
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Status of vaccine research and development for Clostridium difficile. Vaccine 2019; 37:7300-7306. [PMID: 30902484 DOI: 10.1016/j.vaccine.2019.02.052] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 02/21/2019] [Indexed: 12/15/2022]
Abstract
Clostridium difficile associated disease is fundamentally associated with dysbiosis of the gut microbiome as a consequence of antibiotic use. This is because this sporulating, obligate anaerobe germinates and proliferates rapidly in the dysbiotic gut, which is an indirect consequence of their use. During its growth, C. difficile produces two toxins, toxin A (TcdA) and toxin B (TcdB), which are responsible for the majority of clinical symptoms associated with the disease. Three parenterally delivered vaccines, based on detoxified or recombinant forms of these toxins, have undergone or are undergoing clinical trials. Each offers the opportunity to generate high titres of toxin neutralising antibodies. Whilst these data suggest these vaccines may reduce primary symptomatic disease, they do not in their current form reduce the capacity of the organism to persist and shed from the vaccinated host. The current progress of vaccine development is considered with advantages and limitations of each highlighted. In addition, several alternative approaches are described that seek to limit C. difficile germination, colonisation and persistence. It may yet prove that the most effective treatments to limit infection, disease and spread of the organism will require a combination of therapeutic approaches. The potential use and efficacy of these vaccines in low and middle income countries will be depend on the development of a cost effective vaccine and greater understanding of the distribution and extent of disease in these countries.
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Figueroa Castro CE, Munoz-Price LS. Advances in Infection Control for Clostridioides (Formerly Clostridium) difficile Infection. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2019. [DOI: 10.1007/s40506-019-0179-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Effectiveness of a Two-Step Testing Algorithm for Reliable and Cost-Effective Detection of Clostridium difficile Infection in a Tertiary Care Hospital in Saudi Arabia. Med Sci (Basel) 2019; 7:medsci7010006. [PMID: 30626129 PMCID: PMC6359226 DOI: 10.3390/medsci7010006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 12/21/2018] [Accepted: 12/27/2018] [Indexed: 01/05/2023] Open
Abstract
The aim of this study was to evaluate the effectiveness of a two-step algorithm for the detection of Clostridium difficile infection. Setting and Design: A two-step testing algorithm was evaluated for testing stool samples from patients suspected of Clostridium difficile infection (CDI). A total of 103 stool specimens were tested using the C. diff Quik Chek Complete enzyme immunoassay (EIA) test and the Xpert C. difficile PCR test. A two-step algorithm was implemented, and data from 3518 patient samples tested during a two-year period after implementation were analyzed to evaluate the effectiveness. The sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of the Quik Chek Complete EIA test were calculated using the Xpert C. difficile PCR test as a reference method. The sensitivity, specificity, PPV, and NPV of the Quik Chek Complete EIA test for C. difficile toxin were 46.7%, 100%, 100%, and 91%, respectively. The two-step algorithm, which combined the Quik Chek Complete EIA with Xpert C. difficile PCR, improved the sensitivity and also provided rapid detection. When algorithm-based testing was performed daily, there was a 66% reduction in turnaround time compared to batch testing using a lengthy ELISA procedure. Postimplementation data analysis showed that almost 89% of the samples could be reported immediately by initial screening with Quik Chek Complete EIA. Only 11% of the samples gave discrepant results and required PCR confirmation. According to our results, the two-step algorithm is an effective tool for the rapid and reliable detection of toxigenic C. difficile from stool samples.
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Cost Analysis of Computerized Clinical Decision Support and Trainee Financial Incentive for Clostridioides difficile Testing. Infect Control Hosp Epidemiol 2018; 40:242-244. [PMID: 30466495 DOI: 10.1017/ice.2018.300] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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46
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Murillo T, Ramírez-Vargas G, Riedel T, Overmann J, Andersen JM, Guzmán-Verri C, Chaves-Olarte E, Rodríguez C. Two Groups of Cocirculating, Epidemic Clostridiodes difficile Strains Microdiversify through Different Mechanisms. Genome Biol Evol 2018; 10:982-998. [PMID: 29617810 PMCID: PMC5888409 DOI: 10.1093/gbe/evy059] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2018] [Indexed: 02/04/2023] Open
Abstract
Clostridiodes difficile strains from the NAPCR1/ST54 and NAP1/ST01 types have caused outbreaks despite of their notable differences in genome diversity. By comparing whole genome sequences of 32 NAPCR1/ST54 isolates and 17 NAP1/ST01 recovered from patients infected with C. difficile we assessed whether mutation, homologous recombination (r) or nonhomologous recombination (NHR) through lateral gene transfer (LGT) have differentially shaped the microdiversification of these strains. The average number of single nucleotide polymorphisms (SNPs) in coding sequences (NAPCR1/ST54 = 24; NAP1/ST01 = 19) and SNP densities (NAPCR1/ST54 = 0.54/kb; NAP1/ST01 = 0.46/kb) in the NAPCR1/ST54 and NAP1/ST01 isolates was comparable. However, the NAP1/ST01 isolates showed 3× higher average dN/dS rates (8.35) that the NAPCR1/ST54 isolates (2.62). Regarding r, whereas 31 of the NAPCR1/ST54 isolates showed 1 recombination block (3,301–8,226 bp), the NAP1/ST01 isolates showed no bases in recombination. As to NHR, the pangenome of the NAPCR1/ST54 isolates was larger (4,802 gene clusters, 26% noncore genes) and more heterogeneous (644 ± 33 gene content changes) than that of the NAP1/ST01 isolates (3,829 gene clusters, ca. 6% noncore genes, 129 ± 37 gene content changes). Nearly 55% of the gene content changes seen among the NAPCR1/ST54 isolates (355 ± 31) were traced back to MGEs with putative genes for antimicrobial resistance and virulence factors that were only detected in single isolates or isolate clusters. Congruently, the LGT/SNP rate calculated for the NAPCR1/ST54 isolates (26.8 ± 2.8) was 4× higher than the one obtained for the NAP1/ST1 isolates (6.8 ± 2.0). We conclude that NHR-LGT has had a greater role in the microdiversification of the NAPCR1/ST54 strains, opposite to the NAP1/ST01 strains, where mutation is known to play a more prominent role.
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Affiliation(s)
- Tatiana Murillo
- Facultad de Microbiología and Centro de Investigación en Enfermedades Tropicales (CIET), Universidad de Costa Rica, San José, Costa Rica
| | - Gabriel Ramírez-Vargas
- Facultad de Microbiología and Centro de Investigación en Enfermedades Tropicales (CIET), Universidad de Costa Rica, San José, Costa Rica
| | - Thomas Riedel
- Leibniz Institute DSMZ-German Collection of Microorganisms and Cell Cultures, Braunschweig, Germany.,German Center for Infection Research (DZIF), Partner Site Hannover-Braunschweig, Braunschweig, Germany
| | - Jörg Overmann
- Leibniz Institute DSMZ-German Collection of Microorganisms and Cell Cultures, Braunschweig, Germany.,German Center for Infection Research (DZIF), Partner Site Hannover-Braunschweig, Braunschweig, Germany
| | - Joakim M Andersen
- Department of Food, Processing and Nutritional Sciences, North Carolina State University
| | - Caterina Guzmán-Verri
- Programa de Investigación en Enfermedades Tropicales (PIET), Escuela de Medicina Veterinaria, Universidad Nacional, Heredia, Costa Rica
| | - Esteban Chaves-Olarte
- Facultad de Microbiología and Centro de Investigación en Enfermedades Tropicales (CIET), Universidad de Costa Rica, San José, Costa Rica
| | - César Rodríguez
- Facultad de Microbiología and Centro de Investigación en Enfermedades Tropicales (CIET), Universidad de Costa Rica, San José, Costa Rica
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47
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Abstract
Optimal antimicrobial therapy must take into account the key factors in antibiotic selection, that is, spectrum, tissue penetration, resistance potential, safety profile, and relative cost-effectiveness. The least expensive drug is usually accompanied by other concerns, such as high resistance potential, poor side effect profile, pharmacokinetic properties that limit penetration into target tissue (site of infection), and/or suboptimal activity against the presumed/known pathogen. It is false economy to preferentially select the least expensive antibiotics solely because of its acquisition cost. Therapeutic failure and hidden costs may make an apparently less expensive antibiotic most costly in the end.
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Affiliation(s)
- Cheston B Cunha
- Antibiotic Stewardship Program, Division of Infectious Disease, Rhode Island Hospital, 593 Eddy Street, Physicians Office Building, Suite #328, Providence, RI 02903, USA.
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48
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Clostridium difficile co-infection in inflammatory bowel disease is associated with significantly increased in-hospital mortality. Eur J Gastroenterol Hepatol 2018; 30:1041-1046. [PMID: 29894325 DOI: 10.1097/meg.0000000000001185] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Inflammatory bowel disease (IBD) patients with Clostridium difficile co-infection (CDCI) have an increased risk of morbidity and mortality. We aim to evaluate the impact of CDCI on in-hospital outcomes among adults with IBD hospitalized in the USA. PATIENTS AND METHODS Using the 2007-2013 Nationwide Inpatient Sample, hospitalizations among US adults with Crohn's disease (CD), ulcerative colitis (UC) and CDCI were identified using ICD-9 coding. Hospital charges, hospital length of stay (LOS), and in-hospital mortality was stratified by CD and UC and compared using χ-testing and Student's t-test. Predictors of hospital charges, LOS, and in-hospital mortality were evaluated with multivariate regression models and were adjusted for age, sex, race/ethnicity, year, insurance status, hospital characteristics, and CDCI. RESULTS Among 224 500 IBD hospitalizations (174 629 CD and 49 871 UC), overall prevalence of CDCI was 1.22% in CD and 3.41% in UC. On multivariate linear regression, CDCI was associated with longer LOS among CD [coefficient: 5.30, 95% confidence interval (CI): 4.61-5.99, P<0.001] and UC (coefficient 4.08, 95% CI: 3.54-4.62, P<0.001). Higher hospital charges associated with CDCI were seen among CD (coefficient: $35 720, 95% CI: $30 041-$41 399, P<0.001) and UC (coefficient: $26 009, 95% CI: $20 970-$31 046, P<0.001). On multivariate logistic regression, CDCI was associated with greater risk of in-hospital mortality (CD: odds ratio: 2.74, 95% CI: 1.94-3.87, P<0.001; UC: OR: 5.50, 95% CI: 3.83-7.89, P<0.001). CONCLUSION Among US adults with CD and UC related hospitalizations, CDCI is associated with significantly greater in-hospital mortality and greater healthcare utilization.
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Ford DC, Schroeder MC, Ince D, Ernst EJ. Cost-effectiveness analysis of initial treatment strategies for mild-to-moderate Clostridium difficile infection in hospitalized patients. Am J Health Syst Pharm 2018; 75:1110-1121. [DOI: 10.2146/ajhp170554] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Diana C. Ford
- Department of Pharmaceutical Care, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Mary C. Schroeder
- Division of Health Services Research, University of Iowa College of Pharmacy, Iowa City, IA
| | - Dilek Ince
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Erika J. Ernst
- Division of Health Services Research, University of Iowa College of Pharmacy, Iowa City, IA
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50
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Parthasarathy M, Bowers D, Groot-Wassink T. Do preoperative oral antibiotics increase Clostridium difficile infection rates? An analysis of 13 959 colectomy patients. Colorectal Dis 2018; 20:520-528. [PMID: 29045025 DOI: 10.1111/codi.13926] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 08/14/2017] [Indexed: 02/08/2023]
Abstract
AIM The aim of this study was to determine whether or not preoperative oral antibiotic preparation (POAP) increases the rate of Clostridium difficile colitis (CDC) in patients undergoing colectomy. METHOD In 2015, data for colectomies had been collected prospectively and recorded in the targeted colectomy option of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). This was available for retrospective analysis. Data available for analysis included elective and emergency status, POAP, surgical approach, primary anastomosis and CDC status. The effect of POAP on CDC was analysed and risk adjusted for 14 separate preoperative variables. RESULTS In all, 13 959 adult patients underwent a colectomy in 2015 (POAP group 5311 and non- POAP group 8648). The overall rate of CDC in colectomy patients was 1.6% (227/13 959). On univariate analysis, CDC was significantly less common in the POAP group than in the non-POAP group (1.2% vs 1.9%, P = 0.003). Univariate analysis of a further 41 preoperative variables revealed 14 to be associated with CDC. However, after risk adjustment with these 14 variables, POAP lost its statistical significance (adjusted OR 0.902, 95% CI 0.584-1.486, P = 0.685). Only patients with pre-existing systemic inflammatory response syndrome appeared to be at increased risk of CDC (adjusted OR 2.154, 95% CI 1.139-4.074, P = 0.018). CONCLUSION At the very least this study suggests it is safe to use POAP in colectomy patients without increasing the rate of CDC unless they have pre-existing systemic inflammatory response syndrome.
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Affiliation(s)
- M Parthasarathy
- Department of General Surgery, Ipswich Hospital NHS Trust, Ipswich, UK
| | - D Bowers
- Department of Mathematical Sciences, University of Essex, Colchester, UK
| | - T Groot-Wassink
- Department of General Surgery, Ipswich Hospital NHS Trust, Ipswich, UK
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