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An Osmotic Laxative Renders Mice Susceptible to Prolonged Clostridioides difficile Colonization and Hinders Clearance. mSphere 2021; 6:e0062921. [PMID: 34585964 PMCID: PMC8550136 DOI: 10.1128/msphere.00629-21] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Antibiotics are a major risk factor for Clostridioides difficile infections (CDIs) because of their impact on the microbiota. However, nonantibiotic medications such as the ubiquitous osmotic laxative polyethylene glycol 3350 (PEG 3350) also alter the microbiota. Clinicians also hypothesize that PEG helps clear C. difficile. But whether PEG impacts CDI susceptibility and clearance is unclear. To examine how PEG impacts susceptibility, we treated C57BL/6 mice with 5-day and 1-day doses of 15% PEG in the drinking water and then challenged the mice with C. difficile 630. We used clindamycin-treated mice as a control because they consistently clear C. difficile within 10 days postchallenge. PEG treatment alone was sufficient to render mice susceptible, and 5-day PEG-treated mice remained colonized for up to 30 days postchallenge. In contrast, 1-day PEG-treated mice were transiently colonized, clearing C. difficile within 7 days postchallenge. To examine how PEG treatment impacts clearance, we administered a 1-day PEG treatment to clindamycin-treated, C. difficile-challenged mice. Administering PEG to mice after C. difficile challenge prolonged colonization up to 30 days postchallenge. When we trained a random forest model with community data from 5 days postchallenge, we were able to predict which mice would exhibit prolonged colonization (area under the receiver operating characteristic curve [AUROC] = 0.90). Examining the dynamics of these bacterial populations during the postchallenge period revealed patterns in the relative abundances of Bacteroides, Enterobacteriaceae, Porphyromonadaceae, Lachnospiraceae, and Akkermansia that were associated with prolonged C. difficile colonization in PEG-treated mice. Thus, the osmotic laxative PEG rendered mice susceptible to C. difficile colonization and hindered clearance. IMPORTANCE Diarrheal samples from patients taking laxatives are typically rejected for Clostridioides difficile testing. However, there are similarities between the bacterial communities from people with diarrhea and those with C. difficile infections (CDIs), including lower diversity than the communities from healthy patients. This observation led us to hypothesize that diarrhea may be an indicator of C. difficile susceptibility. We explored how osmotic laxatives disrupt the microbiota’s colonization resistance to C. difficile by administering a laxative to mice either before or after C. difficile challenge. Our findings suggest that osmotic laxatives disrupt colonization resistance to C. difficile and prevent clearance among mice already colonized with C. difficile. Considering that most hospitals recommend not performing C. difficile testing on patients taking laxatives, and laxatives are prescribed prior to administering fecal microbiota transplants via colonoscopy to patients with recurrent CDIs, further studies are needed to evaluate if laxatives impact microbiota colonization resistance in humans.
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Kuon C, Wannier R, Sterken D, Fang MC, Wolf J, Prasad PA. Are Antimotility Agents Safe for Use in Clostridioides difficile Infections? Results From an Observational Study in Malignant Hematology Patients. Mayo Clin Proc Innov Qual Outcomes 2020; 4:792-800. [PMID: 33367215 PMCID: PMC7749233 DOI: 10.1016/j.mayocpiqo.2020.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objectives To evaluate the safety of antimotility agents (AAs) in a population of patients with hematologic malignancies and concurrent Clostridioides difficile infection (CDI) and to describe the outcomes of AA use in a hospital setting. Patients and Methods We used the electronic health record to identify patients who were hospitalized in the adult malignant hematology service who had 1 or more toxin-positive C difficile stool assay between April 1, 2012, and September 21, 2017. We reviewed medical charts to obtain information on the use of AAs and any subsequent gastrointestinal complications. Results There were 339 patients who were stool toxin positive for CDI during the study period. Of those, 94 patients (27%) were prescribed AAs within 14 days of CDI diagnosis. All patients received CDI antimicrobial therapy within the first 24 hours. There were 2 adverse gastrointestinal events in the group that received AAs and 6 in the group that did not receive AAs. The risk of adverse events did not differ between patients who received AAs and those who did not (adjusted odds ratio, 0.36; 95% CI, 0.06 to 2.10). The mean age of the full cohort was 52.7±15.5 years, and the mean length of stay was 26.7±22.6 days. Early AA use (<48 hours of diagnosis) was not associated with increased adverse effects. Conclusion There was no increase in the incidence of gastrointestinal events in the arm that used AAs compared with the control arm. The evidence suggests that for patients with hematologic malignancies and CDI, the addition of AAs to appropriate antimicrobial therapy poses no additional risk.
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Key Words
- AA, antimotility agent
- CDI, Clostridioides difficile infection
- EHR, electronic health record
- HSCT, hematopoietic stem cell transplant
- ICD-10, International Statistical Classification of Diseases, Tenth Revision
- ICD-9, International Classification of Diseases, Ninth Revision
- IDSA, Infectious Disease Society of America
- RR, relative risk
- UCSF, University of California, San Francisco
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Affiliation(s)
- Carla Kuon
- Division of Hospital Medicine, University of California, San Francisco, San Francisco
| | - Rae Wannier
- Division of Hospital Medicine, University of California, San Francisco, San Francisco
| | - David Sterken
- Division of Hospital Medicine, University of California, San Francisco, San Francisco
| | - Margaret C Fang
- Division of Hospital Medicine, University of California, San Francisco, San Francisco
| | - Jeffrey Wolf
- Division of Hospital Medicine, University of California, San Francisco, San Francisco
| | - Priya A Prasad
- Division of Hospital Medicine, University of California, San Francisco, San Francisco
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A Single-Center Experience and Literature Review of Management Strategies for Clostridium difficile Infection in Hematopoietic Stem Cell Transplant Patients. ACTA ACUST UNITED AC 2019; 28:10-15. [PMID: 33424210 DOI: 10.1097/ipc.0000000000000798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Introduction The aim of our study is to evaluate risk factors associated with the development of C. difficile infection (CDI) in hematopoietic stem cell transplant (HSCT) patients, determine its incidence and report outcomes of CDI in our patient population. Methods We performed a retrospective review of medical records of adult HSCT recipients diagnosed between 2013 and 2016 at our center. Logistic regression models were used to determine the relationship between risk factors and the odds of CDI. Results The overall incidence of CDI in HSCT patients was 9.4%. The incidence of CDI was higher in allogeneic HSCT (20%) versus autologous HSCT (4.8%). No statistically significant differences in age, gender, cancer type, transplant type were found between those who developed CDI and those who did not. However, patients with CDI had a longer length of stay (25 days) and used more antibiotics (30 days prior to and during admission for HSCT) than non-CDI patients (19 days). Only two of 17 patients (11.8%) with CDI experienced recurrence among 180 patients after HSCT. No patient suffered from toxic megacolon or ileus and no patient underwent colectomy. There was no mortality associated with CDI at our center. Conclusion CDI has an incidence rate of 9.4% in HSCT recipients. Established risk factors including age, gender, cancer type, and transplant type were not identified as risk factors in our population. However, longer LOS and use of greater than four lines of antibiotics were observed among those with CDI compared to those without CDI.
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Ran-Castillo D, Oluwole A, Abuaisha M, Banks Paulino AR, Alkhatatneh A, Jang J, Donaldson S, Shammash J, Williams K. Risk, Outcomes, and Trends of Clostridium Difficile Infection in Multiple Myeloma Patients from a Nationwide Analysis. Cureus 2019; 11:e4391. [PMID: 31205828 PMCID: PMC6561517 DOI: 10.7759/cureus.4391] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background: Patients hospitalized with hematologic malignancy are particularly vulnerable to infection. We sought to determine the risk of Clostridium difficile infection (CDI) in hospitalization with multiple myeloma (MM), as well as its outcomes and trends, using a nationally representative database. Methods: The Nationwide Inpatient Sample (NIS) from January 2010 to September 2015 was used for this study. We identified all patients aged 18 years or older with a diagnosis of MM using the International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes. We identified trends in the annual rates of CDI in MM using negative binomial regressions with robust error variance. We conducted multivariate logistic regression to determine the incidence and the associated risk factors of CDI in MM and compared the outcomes between those with and without CDI using the propensity score method inverse probability weighting to adjust for baseline covariates. Results: In our cohort study of 114,249 MM patients, 45.96% were females and 54.04% were males. CDI was present in 3.1% of the MM patients. The number of CDI cases increased over the study period with an average rate of 3.27% per year. The mortality rate decreased over the same period with an average rate of 10% decrease per year. Hematopoietic stem cell transplantation (HSCT), neutropenia, inflammatory disease, atrial fibrillation (AF), and chronic kidney disease (CKD) were significant associated risk factors of CDI in MM patients. After adjusting for covariates, patients with CDI had a prolonged hospital stay, inpatient mortality, and significantly increased odds of acute kidney injury (AKI) and AKI requiring hemodialysis, along with higher healthcare resources utilization with significantly higher hospital costs. Conclusion: MM patients with CDI have significantly increased odds of inpatient mortality, AKI, and AKI requiring hemodialysis. They also have increased healthcare resource utilization compared with those without CDI. Despite the increased rate of the CDI over the years, the mortality rate is going down.
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Affiliation(s)
| | | | | | | | | | - Jeehoon Jang
- Internal Medicine, Englewood Hospital, Englewood, USA
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Apewokin S, Lee JY, Goodwin JA, McKelvey KD, Stephens OW, Zhou D, Coleman EA. Host genetic susceptibility to Clostridium difficile infections in patients undergoing autologous stem cell transplantation: a genome-wide association study. Support Care Cancer 2018; 26:3127-3134. [PMID: 29594489 DOI: 10.1007/s00520-018-4173-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 03/20/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is the most common hospital-acquired infection. Unfortunately, genes that identify CDI-susceptible patients have not been well described. We performed a genome-wide association study (GWAS) to determine genetic variants associated with the development of CDI. METHODS A cohort study of Caucasian patients undergoing autologous stem cell transplantation for multiple myeloma was performed. Patients were genotyped using Illumina® Whole Genome Genotyping Infinium chemistry. We then compared CDI-positive to CDI-negative patients using logistic regression for baseline clinical factors and false discovery rate (FDR) for genetic factors [single nucleotide polymorphisms (SNPs)]. SNPs associated with CDI at FDR of p < 0.01 were then incorporated into a logistic regression model combining clinical and genetic factors. RESULTS Of the 646 patients analyzed (59.7% male), 57 patients were tested CDI positive (cases) and were compared to 589 patients who were tested negative (controls). Hemoglobin, albumin, and hematocrit were lower for cases (p < 0.05). Eight SNPs on five genes (FLJ16171, GORASP2, RLBP1L1, ASPH, ATP7B) were associated with CDI at FDR p < 0.01. In the combined clinical and genetic model, low albumin and three genes RLBP1L1, ASPH, and ATP7B were associated with CDI. CONCLUSION Low serum albumin and genes RLBP1L1 and ASPH located on chromosome 8 and ATP7B on chromosome 13 were associated with CDI. Of particular interest is ATP7B given its copper modulatory role and the sporicidal properties of copper against Clostridium difficile.
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Affiliation(s)
- Senu Apewokin
- Division of Infectious Diseases, University of Cincinnati, 231 Albert Sabin Way, MSB 6153B, Cincinnati, OH, USA.
| | - Jeannette Y Lee
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Julia A Goodwin
- Medical Center, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Kent D McKelvey
- Department of Genetics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Owen W Stephens
- Genomics Core Laboratory, Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Daohong Zhou
- Pharmaceutical Sciences, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Vargas E, Apewokin S, Madan R. Role of the leukocyte response in normal and immunocompromised host after Clostridium difficile infection. Anaerobe 2017; 45:101-105. [PMID: 28223256 DOI: 10.1016/j.anaerobe.2017.02.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 02/09/2017] [Accepted: 02/15/2017] [Indexed: 02/07/2023]
Abstract
Clostridium difficile is the leading cause of healthcare-associated infections in the United States. Clinically, C. difficile-associated disease can present as asymptomatic colonization, self-limited diarrheal illness or severe colitis (that may result in death). This variability in disease course and outcomes suggests that host factors play an important role as key determinants of disease severity. Currently, there are several scoring indices to estimate severity of C. difficile-associated disease. Leukocytosis and renal failure are considered to be the most important predictors of C. difficile disease severity in hosts with a normal immune system. The degree of leukocytosis which is considered significant for severe disease and how it is scored vary amongst scoring indices. None of the scores have been prospectively validated, and while total WBC count is useful to estimate the magnitude of the host response in most patient populations, in immune-compromised patients like those receiving chemotherapy, solid organ transplant patients or hematopoietic stem cell transplants the WBC response can be variable or even absent making this marker of severity difficult to interpret. Other cellular subsets like neutrophils, eosinophils and lymphocytes provide important information about the host immune status and play an important role in the immune response against C. difficile infection. However, under the current scoring systems the role of these cellular subsets have been underestimated and only total white blood cell counts are taken into account. In this review we highlight the role of host leukocyte response to C. difficile challenge in the normal and immunocompromised host, and propose possible ways that would allow for a better representation of the different immune cell subsets (neutrophils, lymphocytes and eosinophils) in the current scoring indices.
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Affiliation(s)
- Edwin Vargas
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati, 231 Albert Sabin Way, MSB 6109, ML 0560, Cincinnati, OH 45267, USA.
| | - Senu Apewokin
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati, 231 Albert Sabin Way, MSB 6109, ML 0560, Cincinnati, OH 45267, USA
| | - Rajat Madan
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati, 231 Albert Sabin Way, MSB 6109, ML 0560, Cincinnati, OH 45267, USA
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Hebbard AIT, Slavin MA, Reed C, Trubiano JA, Teh BW, Haeusler GM, Thursky KA, Worth LJ. Risks factors and outcomes of Clostridium difficile infection in patients with cancer: a matched case-control study. Support Care Cancer 2017; 25:1923-1930. [PMID: 28155020 DOI: 10.1007/s00520-017-3606-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 01/23/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE Clostridium difficile infection (CDI) is the leading cause of diarrhoea in hospitalised patients. Cancer populations are at high-risk for infection, but comprehensive evaluation in the current era of cancer care has not been performed. The objective of this study was to describe characteristics, risk factors, and outcomes of CDI in cancer patients. METHODS Fifty consecutive patients with CDI at a large Australian cancer centre (2013-2015) were identified from the hospital pathology database. Each case was matched by ward and hospital admission date to three controls without toxigenic CDI. Treatment and outcomes of infection were evaluated and potential risk factors were analysed using conditional logistic regression. RESULTS Patients with CDI had a mean age of 59.7 years and 74% had an underlying solid tumour. Healthcare-associated infection comprised 80% of cases. Recurrence occurred in 10, and 12% of cases were admitted to ICU within 30 days. Severe or severe-complicated infection was observed in 32%. Independent risk factors for infection included chemotherapy (odds ratio (OR) 3.82, 95% CI 1.67-8.75; p = 0.002), gastro-intestinal/abdominal surgery (OR 4.64, 95% CI 1.20-17.91; p = 0.03), proton pump inhibitor (PPI) therapy (OR 2.47, 95% CI 1.05-5.80; p = 0.04), and days of antibiotic therapy (OR 1.04, 95% CI 1.01-1.08; p = 0.02). CONCLUSIONS Severe or complicated infections are frequent in patients with cancer who develop CDI. Receipt of chemotherapy, gastro-intestinal/abdominal surgery, PPI therapy, and antibiotic exposure contribute to infection risk. More effective CDI therapy for cancer patients is required and dedicated antibiotic stewardship programs in high-risk cancer populations are needed to ameliorate infection risk.
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Affiliation(s)
- Andrew I T Hebbard
- Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Locked Bag 1 A'Beckett Street, Melbourne, VIC, 8006, Australia
| | - Monica A Slavin
- Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Locked Bag 1 A'Beckett Street, Melbourne, VIC, 8006, Australia.,Centre for Improving Cancer Outcomes through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Caroline Reed
- Microbiology Department, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Locked Bag 1 A'Beckett Street, Melbourne, VIC, 8006, Australia
| | - Benjamin W Teh
- Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Locked Bag 1 A'Beckett Street, Melbourne, VIC, 8006, Australia
| | - Gabrielle M Haeusler
- Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Locked Bag 1 A'Beckett Street, Melbourne, VIC, 8006, Australia
| | - Karin A Thursky
- Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Locked Bag 1 A'Beckett Street, Melbourne, VIC, 8006, Australia.,Centre for Improving Cancer Outcomes through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Leon J Worth
- Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Locked Bag 1 A'Beckett Street, Melbourne, VIC, 8006, Australia. .,Centre for Improving Cancer Outcomes through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia. .,Victorian Healthcare Associated Infection Surveillance System (VICNISS), Doherty Institute, Melbourne, VIC, Australia.
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Chung MS, Kim J, Kang JO, Pai H. Impact of malignancy on Clostridium difficile infection. Eur J Clin Microbiol Infect Dis 2016; 35:1771-1776. [DOI: 10.1007/s10096-016-2725-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 07/05/2016] [Indexed: 12/22/2022]
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