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Campidelli C, Bruxelle JF, Collignon A, Péchiné S. Immunization Strategies Against Clostridioides difficile. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1435:117-150. [PMID: 38175474 DOI: 10.1007/978-3-031-42108-2_7] [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 (C. difficile) infection (CDI) is an important healthcare but also a community-associated disease. CDI is considered a public health threat and an economic burden. A major problem is the high rate of recurrences. Besides classical antibiotic treatments, new therapeutic strategies are needed to prevent infection, to treat patients, and to prevent recurrences. If fecal transplantation has been recommended to treat recurrences, another key approach is to elicit immunity against C. difficile and its virulence factors. Here, after a summary concerning the virulence factors, the host immune response against C. difficile, and its role in the outcome of disease, we review the different approaches of passive immunotherapies and vaccines developed against CDI. Passive immunization strategies are designed in function of the target antigen, the antibody-based product, and its administration route. Similarly, for active immunization strategies, vaccine antigens can target toxins or surface proteins, and immunization can be performed by parenteral or mucosal routes. For passive immunization and vaccination as well, we first present immunization assays performed in animal models and second in humans and associated clinical trials. The different studies are presented according to the mode of administration either parenteral or mucosal and the target antigens and either toxins or colonization factors.
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Affiliation(s)
- Camille Campidelli
- Université Paris-Saclay, INRAE, AgroParisTech, Micalis Institute, Jouy-en-Josas, France
| | - Jean-François Bruxelle
- CIRI-Centre International de Recherche en Infectiologie, Université de Lyon, Université Claude Bernard Lyon 1, Inserm U1111, CNRS UMR5308, ENS Lyon, Lyon, France
| | - Anne Collignon
- Université Paris-Saclay, INRAE, AgroParisTech, Micalis Institute, Jouy-en-Josas, France
| | - Severine Péchiné
- Université Paris-Saclay, INRAE, AgroParisTech, Micalis Institute, Jouy-en-Josas, France.
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Fitzpatrick F, Brennan R, van Prehn J, Skally M, Brady M, Burns K, Rooney C, Wilcox MH. European Practice for CDI Treatment. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1435:57-84. [PMID: 38175471 DOI: 10.1007/978-3-031-42108-2_4] [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 significant cause of morbidity and mortality worldwide. Historically, two antibiotics (metronidazole and vancomycin) and a recent third (fidaxomicin) have been used for CDI treatment; convincing data are now available showing that metronidazole is the least efficacious agent. The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) management guidance for CDI were updated in 2021. This guidance document outlines the treatment options for a variety of CDI clinical scenarios and for non-antimicrobial management (e.g., faecal microbiota transplantation, FMT). One of the main changes is that metronidazole is no longer recommended as first-line CDI treatment. Rather, fidaxomicin is preferred on the basis of reduced recurrence rates with vancomycin as an acceptable alternative. Recommended options for recurrent CDI now include bezlotoxumab as well as FMT.A 2017 survey of 20 European countries highlighted variation internationally in CDI management strategies. A variety of restrictions were in place in 65% countries prior to use of new anti-CDI treatments, including committee/infection specialist approval or economic review/restrictions. This survey was repeated in November 2022 to assess the current landscape of CDI management practices in Europe. Of 64 respondents from 17 countries, national CDI guidelines existed in 14 countries, and 11 have already/plan to incorporate the ESCMID 2021 CDI guidance, though implementation has not been surveyed in 6. Vancomycin is the most commonly used first-line agent for the treatment of CDI (n = 42, 66%), followed by fidaxomicin (n = 30, 47%). Six (9%) respondents use metronidazole as first-line agent for CDI treatment, whereas 22 (34%) only in selected low-risk patient groups. Fidaxomicin is more likely to be used in high-risk patient groups. Availability of anti-CDI therapy influenced prescribing in six respondents (9%). Approval pre-prescription was required before vancomycin (n = 3, 5%), fidaxomicin (n = 10, 6%), bezlotoxumab (n = 11, 17%) and FMT (n = 10, 6%). Implementation of CDI guidelines is rarely audited.Novel anti-CDI agents are being evaluated; it is not yet clear what will be the roles of these agents. The treatment of recurrent CDI is particularly troublesome, and several different live biotherapeutics are being developed, in addition to FMT.
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Affiliation(s)
- Fidelma Fitzpatrick
- Department of Clinical Microbiology, The Royal College of Surgeons in Ireland, Dublin, Ireland.
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland.
| | - Robert Brennan
- Department of Clinical Microbiology, The Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Joffrey van Prehn
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Mairead Skally
- Department of Clinical Microbiology, The Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
| | - Melissa Brady
- Health Protection Surveillance Centre (HPSC), Dublin, Ireland
| | - Karen Burns
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
| | - Christopher Rooney
- Microbiology, Leeds Teaching Hospitals, Leeds, UK
- University of Leeds, Leeds, UK
| | - Mark H Wilcox
- University of Leeds, Leeds, UK.
- Leeds Teaching Hospitals and Leeds Regional Public Health Laboratory, UK Health Security Agency (UKHSA), Leeds, UK.
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Heuler J, Chandra H, Sun X. Mucosal Vaccination Strategies against Clostridioides difficile Infection. Vaccines (Basel) 2023; 11:vaccines11050887. [PMID: 37242991 DOI: 10.3390/vaccines11050887] [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: 02/01/2023] [Revised: 04/16/2023] [Accepted: 04/18/2023] [Indexed: 05/28/2023] Open
Abstract
Clostridioides difficile infection (CDI) presents a major public health threat by causing frequently recurrent, life-threatening cases of diarrhea and intestinal inflammation. The ability of C. difficile to express antibiotic resistance and to form long-lasting spores makes the pathogen particularly challenging to eradicate from healthcare settings, raising the need for preventative measures to curb the spread of CDI. Since C. difficile utilizes the fecal-oral route of transmission, a mucosal vaccine could be a particularly promising strategy by generating strong IgA and IgG responses that prevent colonization and disease. This mini-review summarizes the progress toward mucosal vaccines against C. difficile toxins, cell-surface components, and spore proteins. By assessing the strengths and weaknesses of particular antigens, as well as methods for delivering these antigens to mucosal sites, we hope to guide future research toward an effective mucosal vaccine against CDI.
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Affiliation(s)
- Joshua Heuler
- Department of Molecular Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA
| | - Harish Chandra
- Department of Molecular Genetics, Biochemistry and Microbiology, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Xingmin Sun
- Department of Molecular Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA
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Serum IgM antibody response to Clostridioides difficile polysaccharide PS-II vaccination in pony foals. Anaerobe 2022; 77:102635. [PMID: 36064161 DOI: 10.1016/j.anaerobe.2022.102635] [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: 06/26/2022] [Revised: 08/16/2022] [Accepted: 08/28/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Clostridioides difficile (formerly Clostridium difficile) is associated with colitis in foals and mature horses. C. difficile exposes specific phosphorylated polysaccharides (PSs), named PS-I, PS-II and PS-III. These cell-surface PSs are potential vaccine targets, especially the hexasaccharide phosphate PS-II, that has been found in all C. difficile ribotypes examined. Since we previously identified anti-PS-II circulating antibodies in horses, we postulated that vaccinating foals with PS-II may prevent colonization by C. difficile. In this study, we aim to evaluate the IgM antibody responses in foals to PS-II. METHODS To evaluate the reactogenicity and immunogenicity of C. difficile PS-II in foals, three-to four-month-old foals were vaccinated intramuscularly three times at intervals of three weeks with 100 μg/dose (3 foals) or 500 μg/dose (3 foals) of purified PS-II antigen with aluminum hydroxide adjuvant, or with a placebo preparation (2 foals) containing adjuvant alone. RESULTS No injection site swelling, pain or fever was observed after vaccination. Two of the three foals receiving 100 μg/dose, and three out of three foals receiving 500 μg/dose of PS-II responded with increases in serum IgM antibodies. No control foals that received the placebo had IgM responses to PS-II. There was a trend towards a higher response rate in foals receiving 500 μg PS-II one week after second vaccination when compared to control foals and towards higher concentrations of serum IgM antibodies in foals receiving 500 μg PS-II. CONCLUSIONS No adverse reactions were observed following vaccination with PS-II in foals; Serum IgM immune responses were induced by vaccination. A polysaccharide-based vaccine for C. difficile in horses deserves further investigation.
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Abdolmohammadi Khiav L, Zahmatkesh A. Major pathogenic Clostridia in human and progress toward the clostridial vaccines. IRANIAN JOURNAL OF BASIC MEDICAL SCIENCES 2022; 25:1059-1068. [PMID: 36246067 PMCID: PMC9526890 DOI: 10.22038/ijbms.2022.65518.14417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/20/2022] [Indexed: 12/02/2022]
Abstract
The Clostridium genus is composed of a large spectrum of heterogeneous bacteria. They are Gram-positive, mostly mesophilic, and anaerobic spore-forming strains. Clostridia are widely distributed in oxygen-free habitats. They are found principally in the soil and intestines of ruminants as normal flora, but also are the cause of several infections in humans. The infections produced by important species in humans include botulism, tetanus, pseudomembranous colitis, antibiotics-associated diarrhea, and gas gangrene. Immunization with toxoid or bacterin-toxoid or genetically modified or other vaccines is a protective way against clostridial infection. Several experimental or commercial vaccines have been developed worldwide. Although conventional vaccines including toxoid vaccines are very important, the new generation of vaccines is an effective alternative to conventional vaccines. Recent advances have made it possible for new vaccines to increase immunogenicity. This review discusses briefly the important species of clostridia in humans, their toxins structure, and vaccine development and usage throughout the world.
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Affiliation(s)
- Lida Abdolmohammadi Khiav
- Department of Anaerobic Vaccine Research and Production, Specialized Clostridia Research Laboratory, Razi Vaccine and Serum Research Institute, Agricultural Research, Education and Extension Organization, Karaj, Iran,Corresponding author: Lida Abdolmohammadi Khiav. Department of Anaerobic Vaccine Research and Production, Specialized Clostridia Research Laboratory, Razi Vaccine and Serum Research Institute, Agricultural Research, Education and Extension Organization, Karaj, Iran. Tel: +98-2634570038; Fax: +98-2634552194;
| | - Azadeh Zahmatkesh
- Department of Anaerobic Vaccine Research and Production, Specialized Clostridia Research Laboratory, Razi Vaccine and Serum Research Institute, Agricultural Research, Education and Extension Organization, Karaj, Iran
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Krauss SR, Barbateskovic M, Klingenberg SL, Djurisic S, Petersen SB, Kenfelt M, Kong DZ, Jakobsen JC, Gluud C. Aluminium adjuvants versus placebo or no intervention in vaccine randomised clinical trials: a systematic review with meta-analysis and Trial Sequential Analysis. BMJ Open 2022; 12:e058795. [PMID: 35738649 PMCID: PMC9226993 DOI: 10.1136/bmjopen-2021-058795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES To assess the benefits and harms of aluminium adjuvants versus placebo or no intervention in randomised clinical trials in relation to human vaccine development. DESIGN Systematic review with meta-analysis and trial sequential analysis assessing the certainty of evidence with Grading of Recommendations Assessment, Development and Evaluation (GRADE). DATA SOURCES We searched CENTRAL, MEDLINE, Embase, LILACS, BIOSIS, Science Citation Index Expanded and Conference Proceedings Citation Index-Science until 29 June 2021, and Chinese databases until September 2021. ELIGIBILITY CRITERIA Randomised clinical trials irrespective of type, status and language of publication, with trial participants of any sex, age, ethnicity, diagnosis, comorbidity and country of residence. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted data and assessed risk of bias with Cochrane's RoB tool 1. Dichotomous data were analysed as risk ratios (RRs) and continuous data as mean differences. We explored both fixed-effect and random-effects models, with 95% CI. Heterogeneity was quantified with I2 statistic. We GRADE assessed the certainty of the evidence. RESULTS We included 102 randomised clinical trials (26 457 participants). Aluminium adjuvants versus placebo or no intervention may have no effect on serious adverse events (RR 1.18, 95% CI 0.97 to 1.43; very low certainty) and on all-cause mortality (RR 1.02, 95% CI 0.74 to 1.41; very low certainty). No trial reported on quality of life. Aluminium adjuvants versus placebo or no intervention may increase adverse events (RR 1.13, 95% CI 1.07 to 1.20; very low certainty). We found no or little evidence of a difference between aluminium adjuvants versus placebo or no intervention when assessing serology with geometric mean titres or concentrations or participants' seroprotection. CONCLUSIONS Based on evidence at very low certainty, we were unable to identify benefits of aluminium adjuvants, which may be associated with adverse events considered non-serious.
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Affiliation(s)
- Sara Russo Krauss
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Marija Barbateskovic
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Sarah Louise Klingenberg
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Snezana Djurisic
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Sesilje Bondo Petersen
- Department of Occupational and Environmental Medicine, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | | | - De Zhao Kong
- The Evidence-Based Medicine Research Center of Traditional Chinese Medicine, Liaoning University of Traditional Chinese Medicine, Shenyang, Liaoning, China
- Department of Evidence-based Chinese Medicine Research Centre, The Affiliated Hospital of Liaoning University of Traditional Chinese Medicine, Shenyang, Liaoning, China
| | - Janus C Jakobsen
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Christian Gluud
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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7
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Islam MI, Seo H, Redwan A, Kim S, Lee S, Siddiquee M, Song HY. In Vitro and In Vivo Anti- Clostridioides difficile Effect of a Probiotic Bacillus amyloliquefaciens Strain. J Microbiol Biotechnol 2022; 32:46-55. [PMID: 34675143 PMCID: PMC9628829 DOI: 10.4014/jmb.2107.07057] [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: 07/30/2021] [Revised: 10/05/2021] [Accepted: 10/12/2021] [Indexed: 12/15/2022]
Abstract
Clostridioides difficile infection (CDI) is a significant cause of hospital-acquired and antibiotic-mediated intestinal diseases and is a growing global public health concern. Overuse of antibiotics and their effect on normal intestinal flora has increased the incidence and severity of infections. Thus, the development of new, effective, and safe treatment options is a high priority. Here, we report a new probiotic strain, Bacillus amyloliquefaciens (BA PMC-80), and its in vitro/in vivo anti-C. difficile effect as a prospective novel candidate for replacing conventional antibiotics. BA PMC-80 showed a significant anti-C. difficile effect in coculture assay, and its cell-free supernatant (CFS) also exhibited a considerable anti-C. difficile effect with an 89.06 μg/ml 50% minimal inhibitory concentration (MIC) in broth microdilution assay. The CFS was stable and equally functional under different pHs, heat, and proteinase treatments. It also exhibited a high sensitivity against current antibiotics and no toxicity in subchronic toxicity testing in hamsters. Finally, BA PMC-80 showed a moderate effect in a hamster CDI model with reduced infection severity and delayed death. However, further studies are required to optimize the treatment condition of the hamster CDI model for better efficacy and identify the antimicrobial compound produced by BA PMC-80.
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Affiliation(s)
- Md Imtiazul Islam
- Department of Microbiology and Immunology, School of Medicine, Soonchunhyang University, Cheonan 31151, Republic of Korea,Probiotics Microbiome Convergence Center, Soonchunhyang University, Asan 31538, Republic of Korea
| | - Hoonhee Seo
- Department of Microbiology and Immunology, School of Medicine, Soonchunhyang University, Cheonan 31151, Republic of Korea,Probiotics Microbiome Convergence Center, Soonchunhyang University, Asan 31538, Republic of Korea
| | - Asma Redwan
- Department of Microbiology and Immunology, School of Medicine, Soonchunhyang University, Cheonan 31151, Republic of Korea
| | - Sukyung Kim
- Department of Microbiology and Immunology, School of Medicine, Soonchunhyang University, Cheonan 31151, Republic of Korea,Probiotics Microbiome Convergence Center, Soonchunhyang University, Asan 31538, Republic of Korea
| | - Saebim Lee
- Department of Microbiology and Immunology, School of Medicine, Soonchunhyang University, Cheonan 31151, Republic of Korea,Probiotics Microbiome Convergence Center, Soonchunhyang University, Asan 31538, Republic of Korea
| | - Mashuk Siddiquee
- Department of Microbiology and Immunology, School of Medicine, Soonchunhyang University, Cheonan 31151, Republic of Korea
| | - Ho-Yeon Song
- Department of Microbiology and Immunology, School of Medicine, Soonchunhyang University, Cheonan 31151, Republic of Korea,Probiotics Microbiome Convergence Center, Soonchunhyang University, Asan 31538, Republic of Korea,Corresponding author Phone: +82-41-570-2412 Fax: +82-41-577-2415 E-mail:
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Chen K, Zhu Y, Zhang Y, Hamza T, Yu H, Saint Fleur A, Galen J, Yang Z, Feng H. A probiotic yeast-based immunotherapy against Clostridioides difficile infection. Sci Transl Med 2021; 12:12/567/eaax4905. [PMID: 33115949 DOI: 10.1126/scitranslmed.aax4905] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 02/12/2020] [Accepted: 10/07/2020] [Indexed: 12/12/2022]
Abstract
Antibiotic-resistant Clostridioides difficile is an anaerobic Gram-positive bacterium that colonizes the colon and is responsible for more than 29,000 deaths in the United States each year. Hence, C. difficile infection (CDI) poses an urgent threat to public health. Antibody-mediated neutralization of TcdA and TcdB toxins, the major virulence factors of CDI, represents an effective strategy to combat the disease without invoking antibiotic resistance. However, current antitoxin approaches are mostly based on parenteral infusion of monoclonal antibodies that are costly, narrow spectrum, and not optimized against the intestinal disease. Here, we engineered probiotic Saccharomyces boulardii to constitutively secrete a single tetra-specific antibody that potently and broadly neutralized both toxins and demonstrated protection against primary and recurrent CDI in both prophylactic and therapeutic mouse models of disease. This yeast immunotherapy is orally administered, can be used concurrently with antibiotics, and may have potential as a prophylactic against CDI risk and as a therapeutic for patients with CDI.
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Affiliation(s)
- Kevin Chen
- Department of Microbial Pathogenesis, University of Maryland School of Dentistry, Baltimore, MD 21201, USA
| | - Yixuan Zhu
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Yongrong Zhang
- Department of Microbial Pathogenesis, University of Maryland School of Dentistry, Baltimore, MD 21201, USA
| | - Therwa Hamza
- Department of Microbial Pathogenesis, University of Maryland School of Dentistry, Baltimore, MD 21201, USA
| | - Hua Yu
- FZata Inc., Halethorpe, MD 21227, USA
| | - Ashley Saint Fleur
- Department of Microbial Pathogenesis, University of Maryland School of Dentistry, Baltimore, MD 21201, USA
| | - James Galen
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | | | - Hanping Feng
- Department of Microbial Pathogenesis, University of Maryland School of Dentistry, Baltimore, MD 21201, USA.
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Trzewikoswki de Lima G, Rodrigues TS, Portilho AI, Correa VA, Gaspar EB, De Gaspari E. Immune responses of meningococcal B outer membrane vesicles in middle-aged mice. Pathog Dis 2021; 78:5868766. [PMID: 32639524 DOI: 10.1093/femspd/ftaa028] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/07/2020] [Indexed: 01/18/2023] Open
Abstract
The elderly are more likely to die when infected with Neisseria meningitidis. Aging is associated with immune system dysfunctions that impair responses to vaccines and infections. Therefore, immunization of middle-aged individuals could be beneficial. This study aims to evaluate the immunogenicity of N. meningitidis B outer membrane vesicles (OMVs) complexed to two different adjuvants. Middle-aged BALB/c and A/Sn mice were immunized and subsequent immune response was assessed by ELISA, immunoblotting and ELISpot. IgG levels were similar between the animals immunized with OMVs complexed to adjuvants. A total of 235 days after the last immunization only A/Sn mice presented higher IgG levels than those observed in the baseline, especially the group immunized with OMVs and aluminum hydroxide. The predominant IgG subclasses were IgG2a and IgG2b. Immunization with the three-dose regimen generated IgG antibodies that recognized a variety of antigens present in the homologous and heterologous meningococcal OMVs evaluated. There was an increase in the frequency of antigen-specific IFN-γ secreting splenocytes, after in vitro stimulation, in mice immunized with OMVs and adjuvants compared to the control group, almost 1 year after the last immunization. Both adjuvants showed similar performance. Immunization of middle-aged mice has generated a robust immune response and it appears to be advantageous.
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Affiliation(s)
- Gabriela Trzewikoswki de Lima
- Department of Immunology, Adolfo Lutz Institute, Av. Dr. Arnaldo 355, 11 floor, Sao Paulo, SP, Brazil.,Interunits Post-Graduate Program in Biotechnology, University of Sao Paulo, Sao Paulo, SP, Brazil
| | - Thais Sousa Rodrigues
- Department of Immunology, Adolfo Lutz Institute, Av. Dr. Arnaldo 355, 11 floor, Sao Paulo, SP, Brazil
| | - Amanda Izeli Portilho
- Department of Immunology, Adolfo Lutz Institute, Av. Dr. Arnaldo 355, 11 floor, Sao Paulo, SP, Brazil.,Interunits Post-Graduate Program in Biotechnology, University of Sao Paulo, Sao Paulo, SP, Brazil
| | - Victor Araujo Correa
- Department of Immunology, Adolfo Lutz Institute, Av. Dr. Arnaldo 355, 11 floor, Sao Paulo, SP, Brazil.,Interunits Post-Graduate Program in Biotechnology, University of Sao Paulo, Sao Paulo, SP, Brazil
| | | | - Elizabeth De Gaspari
- Department of Immunology, Adolfo Lutz Institute, Av. Dr. Arnaldo 355, 11 floor, Sao Paulo, SP, Brazil.,Interunits Post-Graduate Program in Biotechnology, University of Sao Paulo, Sao Paulo, SP, Brazil
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10
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Diagnostic and therapy of severe Clostridioides difficile infections in the ICU. Curr Opin Crit Care 2021; 26:450-458. [PMID: 32739967 DOI: 10.1097/mcc.0000000000000753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of the review is to provide all the recent data focusing on the diagnostic and treatment of Clostridioides difficile infection in patients admitted in the ICU. RECENT FINDINGS In the ICU, diagnosis remains complicated with a large number of alternative diagnosis. The treatment classically relies on vancomycin but fidaxomicin and fecal microbiota transplantation are now potential solutions in selected indications. SUMMARY Data on ICU-related CDI remain limited and conflicting. To date, there is no unique and simple way to obtain a diagnosis for CDI, the combination of clinical signs and a two-step testing algorithm remains the recommended gold-standard. Two molecules can be proposed for first line treatment: vancomycin and fidaxomicin. Although metronidazole may still be discussed as a treatment option for mild CDI in low-risk patients, its use for ICU-patients does not seem reasonable. Several reports suggest that fecal microbiota transplantation could be discussed, as it is well tolerated and associated with a high rate of clinical cure. CDI is a dynamic and active area of research with new diagnostic techniques, molecules, and management concepts likely changing our approach to this old disease in the near future.
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Quazi S. Vaccine in response to COVID-19: Recent developments, challenges, and a way out. BIOMEDICAL AND BIOTECHNOLOGY RESEARCH JOURNAL (BBRJ) 2021. [DOI: 10.4103/bbrj.bbrj_166_20] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Sehgal K, Khanna S. Immune response against Clostridioides difficile and translation to therapy. Therap Adv Gastroenterol 2021; 14:17562848211014817. [PMID: 33995585 PMCID: PMC8111532 DOI: 10.1177/17562848211014817] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 04/12/2021] [Indexed: 02/04/2023] Open
Abstract
The pathogenesis of Clostridioides difficile infection (CDI) has largely been attributed to the action of two major toxins - A and B. An enhanced systemic humoral immune response against these toxins has been shown to be protective against recurrent CDI. Over the years, fully human monoclonal antibodies against both of these toxins have been developed in an attempt to counter the increasing incidence of recurrent CDI. Clinical trials conducted to evaluate the efficacy of anti-toxin A monoclonal antibody, actoxumab, and anti-toxin B monoclonal antibody, bezlotoxumab, demonstrated that bezlotoxumab substantially lowered the rate of recurrent infection, while actoxumab did not. A significant therapeutic benefit was appreciated in patients with at least one high-risk factor for recurrence, including, age ⩾65 years, immunocompromised state, prior CDI and severe CDI. In light of toxins A and B being immunogenic, vaccine trials are underway with the aim to prevent primary infection.
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Affiliation(s)
- Kanika Sehgal
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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13
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Development and verification of an enzyme-linked immunosorbent assay for the quantification of toxoid A and toxoid B from Clostridioides difficile. J Immunol Methods 2020; 488:112917. [PMID: 33221460 DOI: 10.1016/j.jim.2020.112917] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/14/2020] [Accepted: 11/15/2020] [Indexed: 11/23/2022]
Abstract
Clostridioides difficile (C. difficile) is the most common cause of nosocomial antibiotic associated diarrhoea. The incidence of C. difficile infection (CDI) has been rising worldwide over the last 20 years with consequent rises in morbidity, mortality and healthcare costs, although the incidence has fallen in the UK over the last few years. Confirmation of diagnosis and early intervention are critical to the management of CDI. The standard treatment for CDI is the administration of antibiotics. However, vaccination has been recognized as the most cost-effective treatment for the prevention and possible long-term protection against CDI episode. There are several promising vaccine candidates in various stages of development. Many of these vaccines have displayed good efficacy for CDI under laboratory conditions or in clinical trials. With the emergence of vaccines against C. difficile, here we describe the development and verification of an Enzyme Linked Immunosorbent Assay (ELISA) that can be used for the quality control testing of candidate vaccines against C. difficile through the measurement of vaccine antigen content. Verification of the assay was performed by assessment of specificity, sensitivity, intermediate precision and relative accuracy. The ELISAs were specific for the toxoids being detected and the detection limit of the assay for toxoid A was 4.88 ng/mL and 3.91 ng/mL for toxoid B. The geometric coefficients of variation for intermediate precision did not exceed 25% and relative accuracy was within 77-130%. We therefore conclude that the ELISA described here is sufficiently sensitive, specific, precise and accurate for use for the quality control testing of candidate C. difficile vaccines.
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Abstract
Clostridioides difficile (formerly Clostridium) is a major cause of healthcare associated diarrhea, and is increasingly present in the community. Historically, C difficile infection was considered easy to diagnose and treat. Over the past two decades, however, diagnostic techniques have changed in line with a greater understanding of the physiopathology of C difficile infection and the use of new therapeutic molecules. The evolution of diagnosis showed there was an important under- and misdiagnosis of C difficile infection, emphasizing the importance of algorithms recommended by European and North American infectious diseases societies to obtain a reliable diagnosis. Previously, metronidazole was considered the reference drug to treat C difficile infection, but more recently vancomycin and other newer drugs are shown to have higher cure rates. Recurrence of infection represents a key parameter in the evaluation of new drugs, and the challenge is to target the right population with the adapted therapeutic molecule. In multiple recurrences, fecal microbiota transplantation is recommended. New approaches, including antibodies, vaccines, and new molecules are already available or in the pipeline, but more data are needed to support the inclusion of these in practice guidelines. This review aims to provide a baseline for clinicians to understand and stratify their choice in the diagnosis and treatment of C difficile infection based on the most recent data available.
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Affiliation(s)
- Benoit Guery
- Infectious Diseases Service, Department of Medicine, University Hospital and University of Lausanne, Lausanne, Switzerland
- French Group of Faecal Microbiota Transplantation
- European Study Group on Host and Microbiota Interactions
- European Study Group on Clostridium difficile
| | - Tatiana Galperine
- Infectious Diseases Service, Department of Medicine, University Hospital and University of Lausanne, Lausanne, Switzerland
- French Group of Faecal Microbiota Transplantation
| | - Frédéric Barbut
- National Reference Laboratory for Clostridium difficile, Paris, France
- INSERM, Faculté de Pharmacie de Paris, Université Paris Descartes, Paris, France
- European Study Group on Clostridium difficile
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15
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Wang C, Rosner GL, Roden RB. A Bayesian design for phase I cancer therapeutic vaccine trials. Stat Med 2019; 38:1170-1189. [PMID: 30368868 PMCID: PMC6399043 DOI: 10.1002/sim.8021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 08/24/2018] [Accepted: 10/06/2018] [Indexed: 12/30/2022]
Abstract
Phase I clinical trials are the first step in drug development to test a new drug or drug combination on humans. Typical designs of Phase I trials use toxicity as the primary endpoint and aim to find the maximum tolerable dosage. However, these designs are poorly applicable for the development of cancer therapeutic vaccines because the expected safety concerns for these vaccines are not as much as cytotoxic agents. The primary objectives of a cancer therapeutic vaccine phase I trial thus often include determining whether the vaccine shows biologic activity and the minimum dose necessary to achieve a full immune or even clinical response. In this paper, we propose a new Bayesian phase I trial design that allows simultaneous evaluation of safety and immunogenicity outcomes. We demonstrate the proposed clinical trial design by both a numeric study and a therapeutic human papillomavirus vaccine trial.
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Affiliation(s)
- Chenguang Wang
- Oncology Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Gary L. Rosner
- Oncology Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
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Management of adult Clostridium difficile digestive contaminations: a literature review. Eur J Clin Microbiol Infect Dis 2018; 38:209-231. [PMID: 30498879 DOI: 10.1007/s10096-018-3419-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 10/30/2018] [Indexed: 02/08/2023]
Abstract
Clostridium difficile infections (CDI) dramatically increased during the last decade and cause a major public health problem. Current treatments are limited by the high disease recurrence rate, severity of clinical forms, disruption of the gut microbiota, and colonization by vancomycin-resistant enterococci (VRE). In this review, we resumed current treatment options from official recommendation to promising alternatives available in the management of adult CDI, with regard to severity and recurring or non-recurring character of the infection. Vancomycin remains the first-line antibiotic in the management of mild to severe CDI. The use of metronidazole is discussed following the latest US recommendations that replaced it by fidaxomicin as first-line treatment of an initial episode of non-severe CDI. Fidaxomicin, the most recent antibiotic approved for CDI in adults, has several advantages compared to vancomycin and metronidazole, but its efficacy seems limited in cases of multiple recurrences. Innovative therapies such as fecal microbiota transplantation (FMT) and antitoxin antibodies were developed to limit the occurrence of recurrence of CDI. Research is therefore very active, and new antibiotics are being studied as surotomycin, cadazolid, and rinidazole.
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Therapie akuter und rekurrenter Clostridium-difficile-Infektionen. Internist (Berl) 2018. [DOI: 10.1007/s00108-018-0401-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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18
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Immunization Strategies Against Clostridium difficile. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1050:197-225. [PMID: 29383671 DOI: 10.1007/978-3-319-72799-8_12] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
C. difficile infection (CDI) is an important healthcare- but also community-associated disease. CDI is considered a public health threat and an economic burden. A major problem is the high rate of recurrences. Besides classical antibiotic treatments, new therapeutic strategies are needed to prevent infection, to treat patients and prevent recurrences. If fecal transplantation has been recommended to treat recurrences, another key approach is to restore immunity against C. difficile and its virulence factors. Here, after a summary concerning the virulence factors, the host immune response against C. difficile and its role in the outcome of disease, we review the different approaches of passive immunotherapies and vaccines developed against CDI. Passive immunization strategies are designed in function of the target antigen, the antibody-based product and its administration route. Similarly, for active immunization strategies, vaccine antigens can target toxins or surface proteins and immunization can be performed by parenteral or mucosal routes. For passive immunization and vaccination as well, we first present immunization assays performed in animal models and second in humans and associated clinical trials. The different studies are presented according to the mode of administration either parenteral or mucosal and the target antigens, either toxins or colonization factors.
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Fitzpatrick F, Skally M, Brady M, Burns K, Rooney C, Wilcox MH. European Practice for CDI Treatment. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1050:117-135. [PMID: 29383667 DOI: 10.1007/978-3-319-72799-8_8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Clostridium difficile infection (CDI) remains a significant cause of morbidity and mortality worldwide. Historically, two antibiotics (metronidazole and vancomycin) and a recent third (fidaxomicin) have been used routinely for CDI treatment; convincing data are now available showing that metronidazole is the least efficacious agent. The European Society of Clinical Microbiology and Infectious Diseases CDI treatment guidelines outline the treatment options for a variety of CDI clinical scenarios, including use of the more traditional anti-CDI therapies (e.g., metronidazole, vancomycin), the role of newer anti-CDI agents (e.g., fidaxomicin), indications for surgical intervention and for non-antimicrobial management (e.g., faecal microbiota transplantation, FMT). A 2017 survey of 20 European countries found that while the majority (n = 14) have national CDI guidelines that provide a variety of recommendations for CDI treatment, only five have audited guideline implementation. A variety of restrictions are in place in 13 (65%) countries prior to use of new anti-CDI treatments, including committee/infection specialist approval or economic review/restrictions. Novel anti-CDI agents are being evaluated in Phase III trials; it is not yet clear what will be the roles of these agents. Prophylaxis is an optimum approach to reduce the impact of CDI especially in high-risk populations; monoclonal antibodies, antibiotic blocking approaches and multiple vaccines are currently in advanced clinical trials. The treatment of recurrent CDI is particularly troublesome, and several different live bio therapeutics are being developed, in addition to FMT.
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Affiliation(s)
- Fidelma Fitzpatrick
- Department of Clinical Microbiology, The Royal College of Surgeons in Ireland, Dublin, Ireland.
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland.
| | - Mairead Skally
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
| | - Melissa Brady
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
| | - Karen Burns
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
- Health Protection Surveillance Centre, Dublin, Ireland
| | - Christopher Rooney
- Microbiology, Leeds Teaching Hospitals and University of Leeds, Leeds, UK
| | - Mark H Wilcox
- Microbiology, Leeds Teaching Hospitals and University of Leeds, Leeds, UK.
- Leeds Teaching Hospitals and University of Leeds, Leeds, UK.
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Couture-Cossette A, Carignan A, Ilangumaran S, Valiquette L. Bezlotoxumab for the prevention of Clostridium difficile recurrence. Expert Opin Biol Ther 2017; 17:1439-1445. [PMID: 28805081 DOI: 10.1080/14712598.2017.1363886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Clostridium difficile infection is a major economic and clinical burden, due to its high frequency of recurrence. Currently recommended treatments are not efficient for prevention and may contribute to the risk of recurrent infection. In recent years, research has focused on strategies to lessen this risk. Bezlotoxumab is a monoclonal antibody that prevents recurrences of C. difficile infection through the antagonism of toxin B. Areas covered: In this review, the authors discuss the burden of C. difficile infection and its recurrences, the mechanisms underlying the recurrences, and current C. difficile treatments. They subsequently analyze the strategic therapeutic rationale for bezlotoxumab use, as well as the supporting clinical evidence. Expert opinion: Bezlotoxumab is an attractive solution for reducing the unacceptable level of recurrence that occurs with the currently recommended C. difficile treatments and other alternative therapies under consideration. Even though bezlotoxumab has not been tested in large-scale trials exclusively in cases of already established recurrent C.difficile infection (rCDI), it has an advantage over current treatments in that it does not interfere with the patient's gut flora while directly neutralizing the key virulence factor. Although cost remains an important factor against its widespread use, simpler administration, fewer side-effects, and better social acceptability justify its consideration for treating rCDI.
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Affiliation(s)
- Antoine Couture-Cossette
- a Department of Microbiology and Infectious Diseases , Université de Sherbrooke , Québec , Canada
| | - Alex Carignan
- a Department of Microbiology and Infectious Diseases , Université de Sherbrooke , Québec , Canada
| | - Subburaj Ilangumaran
- b Department of Pediatrics, Immunology Division , Université de Sherbrooke , Québec , Canada
| | - Louis Valiquette
- a Department of Microbiology and Infectious Diseases , Université de Sherbrooke , Québec , Canada
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21
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Henderson M, Bragg A, Fahim G, Shah M, Hermes-DeSantis ER. A Review of the Safety and Efficacy of Vaccines as Prophylaxis for Clostridium difficile Infections. Vaccines (Basel) 2017; 5:E25. [PMID: 28869502 PMCID: PMC5620556 DOI: 10.3390/vaccines5030025] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 08/24/2017] [Accepted: 08/29/2017] [Indexed: 01/03/2023] Open
Abstract
This review aims to evaluate the literature on the safety and efficacy of novel toxoid vaccines for the prophylaxis of Clostridium difficile infections (CDI) in healthy adults. Literature searches for clinical trials were performed through MEDLINE, ClinicalTrials.gov, and Web of Science using the keywords bacterial vaccines, Clostridium difficile, and vaccine. English-language clinical trials evaluating the efficacy and/or safety of Clostridium difficile toxoid vaccines that were completed and had results posted on ClinicalTrials.gov or in a published journal article were included. Six clinical trials were included. The vaccines were associated with mild self-reported adverse reactions, most commonly injection site reactions and flu-like symptoms, and minimal serious adverse events. Five clinical trials found marked increases in antibody production in vaccinated participants following each dose of the vaccine. Clinical trials evaluating C. difficile toxoid vaccines have shown them to be well tolerated and relatively safe. Surrogate markers of efficacy (seroconversion and geometric mean antibody levels) have shown significant immune responses to a vaccination series in healthy adults, indicating that they have the potential to be used as prophylaxis for CDI. However, more research is needed to determine the clinical benefits of the vaccines.
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Affiliation(s)
- Mackenzie Henderson
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ 08854, USA.
| | - Amanda Bragg
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ 08854, USA.
| | - Germin Fahim
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ 08854, USA.
- Pharmacy Department, Monmouth Medical Center, Long Branch, NJ 07740, USA.
| | - Monica Shah
- Pharmacy Department, Monmouth Medical Center, Long Branch, NJ 07740, USA.
| | - Evelyn R Hermes-DeSantis
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ 08854, USA.
- Pharmacy Department, Robert Wood Johnson University Hospital, New Brunswick, NJ 08901, USA.
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22
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Villafuerte Gálvez JA, Kelly CP. Bezlotoxumab: anti-toxin B monoclonal antibody to prevent recurrence of Clostridium difficile infection. Expert Rev Gastroenterol Hepatol 2017. [PMID: 28636484 DOI: 10.1080/17474124.2017.1344551] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Clostridium difficile infection (CDI) is the most common nosocomial infection in the U.S. 25% of CDI patients go on to develop recurrent CDI (rCDI) following current standard of care (SOC) therapy, leading to morbidity, mortality and economic loss. The first passive immunotherapy drug targeting C.difficile toxin B (bezlotoxumab) has been approved recently by the FDA and EMA for prevention of rCDI. Areas covered: A body of key studies was selected and reviewed by the authors. The unmet needs in CDI care were ascertained with emphasis in rCDI, including the epidemiology, pathophysiology and current management. The current knowledge about the immune response to C. difficile toxins and how this knowledge led to the development and the clinical use of bezlotoxumab is described. Current and potential future competitors to the drug were examined. Expert commentary: A single 10 mg/kg intravenous infusion of bezlotoxumab has been shown to decrease rCDI by ~40% (absolute reduction ~10%) in patients being treated for primary CDI or rCDI with SOC antibiotics. Targeting C.difficile toxins by passive immunotherapy is a novel mechanism for prevention of C.difficile infection. Bezlotoxumab will be a valuable adjunctive therapy to reduce the burden of CDI.
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Affiliation(s)
- Javier A Villafuerte Gálvez
- a Department of Medicine , Harvard Medical School , Boston , MA
- b Department of Medicine - Division of Hematology and Oncology , Beth Israel Deaconess Medical Center , Boston , MA , USA
| | - Ciarán P Kelly
- a Department of Medicine , Harvard Medical School , Boston , MA
- c Department of Medicine - Division of Gastroenterology , Beth Israel Deaconess Medical Center , Boston , MA , USA
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23
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Abstract
Clostridium difficile is an anaerobic, Gram-positive, spore-forming, toxin-secreting bacillus that has long been recognized to be the most common etiologic pathogen of antibiotic-associated diarrhea. C. difficile infection (CDI) is now the most common cause of health care-associated infections in the United States and accounts for 12% of these infections (Magill SS et al., N Engl J Med370:1198-1208, 2014). Among emerging pathogens of public health importance in the United States, CDI has the highest population-based incidence, estimated at 147 per 100,000 (Lessa FC et al., N Engl J Med372:825-834, 2015). In a report on antimicrobial resistance, C. difficile has been categorized by the Centers for Disease Control and Prevention as one of three "urgent" threats (http://www.cdc.gov/drugresistance/threat-report-2013/). Although C. difficile was first described in the late 1970s, the past decade has seen the emergence of hypertoxigenic strains that have caused increased morbidity and mortality worldwide. Pathogenic strains, host susceptibility, and other regional factors vary and may influence the clinical manifestation and approach to intervention. In this article, we describe the global epidemiology of CDI featuring the different strains in circulation outside of North America and Europe where strain NAP1/027/BI/III had originally gained prominence. The elderly population in health care settings has been disproportionately affected, but emergence of CDI in children and healthy young adults in community settings has, likewise, been reported. New approaches in management, including fecal microbiota transplantation, are discussed.
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24
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Yoshikawa TT, Norman DC. Geriatric Infectious Diseases: Current Concepts on Diagnosis and Management. J Am Geriatr Soc 2017; 65:631-641. [PMID: 28140454 DOI: 10.1111/jgs.14731] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
New information on infectious diseases in older adults has become available in the past 20 years. In this review, in-depth discussions on the general problem of geriatric infectious diseases (epidemiology, pathogenesis, age-related host defenses, clinical manifestations, diagnostic approach); diagnosis and management of bacterial pneumonia, urinary tract infection, and Clostridium difficile infection; and the unique challenges of diagnosing and managing infections in a long-term care setting are presented.
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Affiliation(s)
- Thomas T Yoshikawa
- Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.,David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Dean C Norman
- Department of Veterans Affairs San Diego Healthcare System, San Diego, California.,University of California at Los Angeles, Los Angeles, California
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25
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Secore S, Wang S, Doughtry J, Xie J, Miezeiewski M, Rustandi RR, Horton M, Xoconostle R, Wang B, Lancaster C, Kristopeit A, Wang SC, Christanti S, Vitelli S, Gentile MP, Goerke A, Skinner J, Strable E, Thiriot DS, Bodmer JL, Heinrichs JH. Development of a Novel Vaccine Containing Binary Toxin for the Prevention of Clostridium difficile Disease with Enhanced Efficacy against NAP1 Strains. PLoS One 2017; 12:e0170640. [PMID: 28125650 PMCID: PMC5268477 DOI: 10.1371/journal.pone.0170640] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 01/06/2017] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile infections (CDI) are a leading cause of nosocomial diarrhea in the developed world. The main virulence factors of the bacterium are the large clostridial toxins (LCTs), TcdA and TcdB, which are largely responsible for the symptoms of the disease. Recent outbreaks of CDI have been associated with the emergence of hypervirulent strains, such as NAP1/BI/027, many strains of which also produce a third toxin, binary toxin (CDTa and CDTb). These hypervirulent strains have been associated with increased morbidity and higher mortality. Here we present pre-clinical data describing a novel tetravalent vaccine composed of attenuated forms of TcdA, TcdB and binary toxin components CDTa and CDTb. We demonstrate, using the Syrian golden hamster model of CDI, that the inclusion of binary toxin components CDTa and CDTb significantly improves the efficacy of the vaccine against challenge with NAP1 strains in comparison to vaccines containing only TcdA and TcdB antigens, while providing comparable efficacy against challenge with the prototypic, non-epidemic strain VPI10463. This combination vaccine elicits high neutralizing antibody titers against TcdA, TcdB and binary toxin in both hamsters and rhesus macaques. Finally we present data that binary toxin alone can act as a virulence factor in animal models. Taken together, these data strongly support the inclusion of binary toxin in a vaccine against CDI to provide enhanced protection from epidemic strains of C. difficile.
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Affiliation(s)
- Susan Secore
- Vaccine Basic Research, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Su Wang
- Vaccine Basic Research, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Julie Doughtry
- Vaccine Basic Research, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Jinfu Xie
- Vaccine Basic Research, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Matt Miezeiewski
- Eurofins Laboratories, Lancaster, Pennsylvania, United States of America
| | - Richard R. Rustandi
- Vaccine Analytical Development, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Melanie Horton
- Vaccine Basic Research, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Rachel Xoconostle
- Vaccine Basic Research, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Bei Wang
- Vaccine Drug Product Development, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Catherine Lancaster
- Vaccine Analytical Development, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Adam Kristopeit
- Vaccine Process Development, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Sheng-Ching Wang
- Vaccine Process Development, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Sianny Christanti
- Vaccine Process Development, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Salvatore Vitelli
- Vaccine Analytical Development, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Marie-Pierre Gentile
- Vaccine Process Development, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Aaron Goerke
- Vaccine Process Development, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Julie Skinner
- Vaccine Basic Research, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Erica Strable
- Vaccine Drug Product Development, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - David S. Thiriot
- Vaccine Drug Product Development, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Jean-Luc Bodmer
- Vaccine Basic Research, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Jon H. Heinrichs
- Vaccine Basic Research, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
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Abstract
PURPOSE OF REVIEW Clostridium difficile infection has attained high prominence given its prevalence and impacts on patients and healthcare institutions. Multiple new approaches to the prevention and treatment of C. difficile infection (CDI) are undergoing clinical trials. RECENT FINDINGS Bezlotoxumab is a monoclonal antibody against toxin B that has successfully completed phase III studies, demonstrating a significant reduction in recurrent CDI when given with standard of care antibiotics. Antibiotics under development include cadazolid and ridinilazole, whereas surotomycin has had disappointing phase III results. Multiple live biotherapeutics are being developed, including freeze thawed and encapsulated versions of faecal microbiota transplantation to improve the practicality of treating patients with recurrent CDI. Alternatives to faecal microbiota transplantation, that aim to improve safety, including a microbial suspension, RBX2660, and a complex spore formulation, SER-109, have progressed to phase II studies. A nontoxigenic C. difficile strain has also shown promise to prevent recurrent CDI. In addition, three C. difficile vaccines have progressed to phase II/III clinical trials. SUMMARY The diverse approaches to treating and preventing CDI offer substantial promise that new treatment options will soon emerge, particular ones that reduce the risk of recurrences.
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Affiliation(s)
- Jessica Martin
- aLeeds Teaching Hospitals NHS Trust/University of Leeds, Microbiology, Old Medical School, Leeds General Infirmary bLeeds Teaching Hospitals NHS Trust cUniversity of Leeds, Leeds dPublic Health England, UK
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27
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Jodlowski TZ, Oehler R, Kam LW, Melnychuk I. Emerging Therapies in the Treatment of Clostridium difficile–Associated Disease. Ann Pharmacother 2016; 40:2164-9. [PMID: 17119105 DOI: 10.1345/aph.1h340] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objective: To describe emergent therapies, such as rifaximin, nitazoxanide, intravenous immunoglobulin (IVIG), tinidazole, tolevamer, and the possible use of a vaccine, in Clostridium difficile–associated disease (CDAD), one of the most common causes of diarrhea in hospitalized adults in North America. Data Sources: A literature search was performed using MEDLINE (1996-October 2006), PubMed (1996–October 2006), abstracts from Infectious Diseases Society of America (September 2006) and International Conference on Antimicrobial Agents and Chemotherapy (September 2006), Internet (October 2006), Genzyme product Web site (October 2006), and Romark Laboratories Web site (October 2006) using the terms Clostridium difficile, rifaximin, nitazoxanide, intravenous immunoglobulin, tolevamer, vaccine, and tinidazole. Study Selection and Data Extraction: Data presented in this article were selected based on clinical relevance and power of the studies. In vivo and in vitro studies supporting the use of drugs available for treatment of refractory CDAD were reviewed. Some of the information on new and emerging modalities was also included, although there were limited published data available. Data Synthesis: Clinical trials evaluating the use of nitazoxanide and tolevamer for the treatment of CDAD have been published. Tinidazole use is based on structural similarities to metronidazole; however, clinical trials have not been conducted and the cost of this agent may be a limiting factor. The use of rifaximin and IVIG will require randomized clinical trials to establish their place in therapy. Limited information in the literature suggests that a vaccine may be effective for CDAD prevention. Conclusions: CDAD is a debilitating disease with increasing treatment failure rates and recurrences using standard therapies. Clinicians need to look at other options to expand the available treatment arsenal in addition to placing a greater emphasis on prevention.
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28
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van Kleef E, Deeny SR, Jit M, Cookson B, Goldenberg SD, Edmunds WJ, Robotham JV. The projected effectiveness of Clostridium difficile vaccination as part of an integrated infection control strategy. Vaccine 2016; 34:5562-5570. [DOI: 10.1016/j.vaccine.2016.09.046] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 08/19/2016] [Accepted: 09/22/2016] [Indexed: 12/14/2022]
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Yang Z, Shi L, Yu H, Zhang Y, Chen K, Saint Fleur A, Bai G, Feng H. Intravenous adenovirus expressing a multi-specific, single-domain antibody neutralizing TcdA and TcdB protects mice from Clostridium difficile infection. Pathog Dis 2016; 74:ftw078. [PMID: 27502696 DOI: 10.1093/femspd/ftw078] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2016] [Indexed: 01/09/2023] Open
Abstract
Clostridium difficile infection (CDI) is the most common cause of antibiotic-associated diarrhea and colitis in developed countries. The disease is mainly mediated via two major exotoxins TcdA and TcdB secreted by the bacterium. We have previously developed a novel, potently neutralizing, tetravalent and bispecific heavy-chain-only single domain (VHH) antibody to both TcdA and TcdB (designated as ABA) that reverses fulminant CDI in mice. Since ABA has a short serum half-life, in this study a replication-deficient recombinant adenovirus expressing ABA was generated and the long-lasting expression of functional ABA was demonstrated in vitro and in vivo Mice transduced with one dose of the adenovirus displayed high levels of serum ABA for more than1 month and were fully protected against systemic toxin challenges. More importantly, the ABA delivered by the adenovirus protected mice from both primary and recurrent CDI. Thus, replication-deficient adenoviral vector may be used to deliver neutralizing antibodies against the toxins in order to prevent CDI and recurrence.
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Affiliation(s)
- Zhiyong Yang
- Department of Microbial Pathogenesis, University of Maryland School of Dentistry, Baltimore, MD 21201, USA
| | - Lianfa Shi
- Department of Microbial Pathogenesis, University of Maryland School of Dentistry, Baltimore, MD 21201, USA
| | - Hua Yu
- Department of Microbial Pathogenesis, University of Maryland School of Dentistry, Baltimore, MD 21201, USA
| | - Yongrong Zhang
- Department of Microbial Pathogenesis, University of Maryland School of Dentistry, Baltimore, MD 21201, USA
| | - Kevin Chen
- Department of Microbial Pathogenesis, University of Maryland School of Dentistry, Baltimore, MD 21201, USA
| | - Ashley Saint Fleur
- Department of Microbial Pathogenesis, University of Maryland School of Dentistry, Baltimore, MD 21201, USA
| | - Guang Bai
- Department of Neural and Pain Sciences, University of Maryland School of Dentistry, Baltimore, MD 21201, USA
| | - Hanping Feng
- Department of Microbial Pathogenesis, University of Maryland School of Dentistry, Baltimore, MD 21201, USA
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Knisely JM, Liu B, Ranallo RT, Zou L. Vaccines for Healthcare-associated Infections: Promise and Challenge. Clin Infect Dis 2016; 63:657-62. [PMID: 27208045 DOI: 10.1093/cid/ciw333] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 05/11/2016] [Indexed: 01/09/2023] Open
Abstract
As antibiotic resistance increases and the rate of antibiotic development slows, it is becoming more urgent to develop novel approaches to prevent and mitigate serious bacterial and fungal infections. Healthcare-associated infections (HAIs), including those caused by Clostridium difficile, Staphylococcus aureus, Pseudomonas aeruginosa, Acinetobacter baumannii, carbapenem-resistant Enterobacteriaceae, and Candida species, are a major cause of morbidity, mortality, and healthcare costs. HAIs are also a key driver of antibiotic use. Vaccines directed toward these pathogens could help prevent a large number of HAIs and associated antibiotic use if administered to targeted populations. Despite numerous scientific and operational challenges, there are vaccine candidates in late-stage clinical development for C. difficile, S. aureus, and P. aeruginosa Basic, preclinical, and early clinical research to develop vaccines for other types of HAIs is also under way. In addition, other prophylactic immune interventions, such as monoclonal antibodies, for several of these pathogens are in advanced development. Here we describe the promise, challenges, and current pipeline of vaccines to prevent HAIs.
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Affiliation(s)
- Jane M Knisely
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland
| | - Baoying Liu
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland
| | - Ryan T Ranallo
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland
| | - Lanling Zou
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland
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Sheldon E, Kitchin N, Peng Y, Eiden J, Gruber W, Johnson E, Jansen KU, Pride MW, Pedneault L. A phase 1, placebo-controlled, randomized study of the safety, tolerability, and immunogenicity of a Clostridium difficile vaccine administered with or without aluminum hydroxide in healthy adults. Vaccine 2016; 34:2082-91. [DOI: 10.1016/j.vaccine.2016.03.010] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 03/01/2016] [Accepted: 03/04/2016] [Indexed: 12/21/2022]
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Ünal CM, Steinert M. Novel therapeutic strategies for Clostridium difficile infections. Expert Opin Ther Targets 2015; 20:269-85. [PMID: 26565670 DOI: 10.1517/14728222.2016.1090428] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION In recent years, Clostridium difficile has become the primary cause of antibiotic-associated diarrhea and pseudomembranous colitis, resulting in long and complicated hospital stays that represent a serious burden for patients as well as health care systems. Currently, conservative treatment of C. difficile infection (CDI) relies on the antibiotics vancomycin, metronidazole or fidaxomicin, or in case of multiple recurrences, fecal microbiota transplantation (FMT). AREAS COVERED The fast-spreading, epidemic nature of this pathogen urgently necessitates the search for alternative treatment strategies as well as antibiotic targets. Accordingly, in this review, we highlight the recent findings regarding virulence associated traits of C. difficile, evaluate their potential as alternative drug targets, and present current efforts in designing inhibitory compounds, with the aim of pointing out possibilities for future treatment strategies. EXPERT OPINION Increased attention on systematic analysis of the virulence mechanisms of C. difficile has already led to the identification of several alternative drug targets. In the future, applying state of the art 'omics' and the development of novel infection models that mimic the human gut, a highly complex ecological niche, will unveil the genomic and metabolic plasticity of this pathogen and will certainly help dealing with future challenges.
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Affiliation(s)
- Can M Ünal
- a 1 Technische Universität Braunschweig, Institut für Mikrobiologie , Spielmannstr. 7, D-38106, Braunschweig, Germany ; .,b 2 Türk-Alman Üniversitesi, Fen Fakültesi , Şahinkaya Cad. 86, 34820, Istanbul, Turkey
| | - Michael Steinert
- a 1 Technische Universität Braunschweig, Institut für Mikrobiologie , Spielmannstr. 7, D-38106, Braunschweig, Germany ; .,c 3 Helmholtz Centre for Infection Research , Mascheroder Weg 1, 38124, Braunschweig, Germany
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Zhao S, Ghose-Paul C, Zhang K, Tzipori S, Sun X. Immune-based treatment and prevention of Clostridium difficile infection. Hum Vaccin Immunother 2015; 10:3522-30. [PMID: 25668664 DOI: 10.4161/21645515.2014.980193] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Clostridium difficile (C. difficile) causes over 500,000 infections per year in the US, with an estimated 15,000 deaths and an estimated cost of $1-3 billion. Moreover, a continual rise in the incidence of severe C. difficile infection (CDI) has been observed worldwide. Currently, standard treatment for CDI is the administration of antibiotics. While effective, these treatments do not prevent and may contribute to a disease recurrence rate of 15-35%. Prevention of recurrence is one of the most challenging aspects in the field. A better knowledge of the molecular mechanisms of the disease, the host immune response and identification of key virulence factors of C. difficilenow permits the development of immune-based therapies. Antibodies specific for C. difficile toxins have been shown to effectively treat CDI and prevent disease relapse in animal models and in humans. Vaccination has been recognized as the most cost-effective treatment/prevention for CDI. This review will summarize CDI transmission, epidemiology, major virulent factors and highlights the rational and the development of immune-based approaches against this remerging threat.
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Key Words
- AAD, antibiotic-associated diarrhea
- CDI, Clostridium difficile infection
- CPD, cysteine proteinase domain
- GTD, glucosyltransferase domain
- HuMabs, human monoclonal antibodies
- IVIG, intravenous immunoglobulin
- RBD, receptor binding domain
- SLP, surface-layer protein
- TMD, transmembrane domain
- bacterial toxins
- clostridium difficile infection (CDI)
- immunotherapy
- mAb, monoclonal antibody
- monoclonal antibody
- vaccine
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Affiliation(s)
- Song Zhao
- a Department of Infectious Diseases and Global Health ; Tufts University Cummings School of Veterinary Medicine ; North Grafton , MA USA
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Shields K, Araujo-Castillo RV, Theethira TG, Alonso CD, Kelly CP. Recurrent Clostridium difficile infection: From colonization to cure. Anaerobe 2015; 34:59-73. [PMID: 25930686 PMCID: PMC4492812 DOI: 10.1016/j.anaerobe.2015.04.012] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 04/22/2015] [Accepted: 04/23/2015] [Indexed: 12/16/2022]
Abstract
Clostridium difficile infection (CDI) is increasingly prevalent, dangerous and challenging to prevent and manage. Despite intense national and international attention the incidence of primary and of recurrent CDI (PCDI and RCDI, respectively) have risen rapidly throughout the past decade. Of major concern is the increase in cases of RCDI resulting in substantial morbidity, morality and economic burden. RCDI management remains challenging as there is no uniformly effective therapy, no firm consensus on optimal treatment, and reliable data regarding RCDI-specific treatment options is scant. Novel therapeutic strategies are critically needed to rapidly, accurately, and effectively identify and treat patients with, or at-risk for, RCDI. In this review we consider the factors implicated in the epidemiology, pathogenesis and clinical presentation of RCDI, evaluate current management options for RCDI and explore novel and emerging therapies.
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Affiliation(s)
- Kelsey Shields
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave., Boston, MA 02215, United States.
| | - Roger V Araujo-Castillo
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Lowry Medical Office Building, Suite GB 110 Francis Street, Boston, MA 02215, United States.
| | - Thimmaiah G Theethira
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave., Boston, MA 02215, United States.
| | - Carolyn D Alonso
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Lowry Medical Office Building, Suite GB 110 Francis Street, Boston, MA 02215, United States.
| | - Ciaran P Kelly
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave., Boston, MA 02215, United States.
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To KB, Napolitano LM. Clostridium difficile infection: update on diagnosis, epidemiology, and treatment strategies. Surg Infect (Larchmt) 2015; 15:490-502. [PMID: 25314344 DOI: 10.1089/sur.2013.186] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Clostridium difficile infection (CDI) has increased in incidence and severity over the past quarter century, and is now considered a major cause of healthcare-associated infections. METHODS Review of the pertinent English-language medical literature. RESULTS There has been a substantial change in the management of CDI. The emergence of the NAP1/BI/O27 strain in the early to mid-2000s has been associated with more severe forms of CDI. The pathophysiology, epidemiology, clinical manifestations and diagnosis, as well as new strategies for medical and surgical management are discussed in this review. CONCLUSIONS Clostridium difficile infection can range from benign diarrhea to severe disease associated with substantial morbidity and mortality. Treatment modalities vary based on disease severity and timing of onset. The mainstay of medical treatment remains metronidazole and oral/rectal vancomycin. New management strategies are evolving, including adjunctive treatments such as monoclonal antibodies, vaccination, and fecal transplant. In patients with severe disease or clinical deterioration, early surgical consultation for total colectomy or loop ileostomy may be life-saving. Infection control measures are vital to mitigating the spread of CDI.
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Affiliation(s)
- Kathleen B To
- Department of Surgery, University of Michigan , Ann Arbor, Michigan
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36
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Drekonja DM. Clostridium difficile infection: current, forgotten and emerging treatment options. J Comp Eff Res 2015; 3:547-57. [PMID: 25350805 DOI: 10.2217/cer.14.36] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Clostridium difficile infection (CDI) has increased in incidence and severity, and is now among the most common nosocomial infections. Several agents are available for the initial treatment of CDI, some of which are rarely used, and none of which is clearly superior for initial clinical cure. Fidaxomicin appears to offer a benefit in terms of preventing recurrent disease, although the cost-benefit ratio is debated. Recurrent CDI is a major challenge, occurring after 15-30% of initial episodes. The treatment of recurrent CDI is difficult, with sparse evidence available to support any particular agent. Fecal microbiota therapy, also known as 'stool transplantation', appears to be highly effective, although availability is currently limited, and the regulatory environment is in flux. Synthetic stool products and an orally available fecal microbiota therapy product are both under investigation, which may address the problem of availability. As with most infectious diseases, an effective vaccine would be a welcome addition to our armamentarium, but none is currently available.
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Affiliation(s)
- Dimitri M Drekonja
- Minneapolis Veterans Affairs Health Care System, Infectious Diseases Section, Minneapolis, MN 55417, USA
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37
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Wang YK, Yan YX, Kim HB, Ju X, Zhao S, Zhang K, Tzipori S, Sun X. A chimeric protein comprising the glucosyltransferase and cysteine proteinase domains of toxin B and the receptor binding domain of toxin A induces protective immunity against Clostridium difficile infection in mice and hamsters. Hum Vaccin Immunother 2015; 11:2215-22. [PMID: 26036797 PMCID: PMC4635733 DOI: 10.1080/21645515.2015.1052352] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Clostridium difficile is the major cause of hospital-acquired infectious diarrhea and colitis in developed countries. The pathogenicity of C. difficile is mainly mediated by the release of 2 large potent exotoxins, toxin A (TcdA) and toxin B (TcdB), both of which require neutralization to prevent disease occurrence. We have generated a novel chimeric protein, designated mTcd138, comprised of the glucosyltransferase and cysteine proteinase domains of TcdB and the receptor binding domain of TcdA and expressed it in Bacillus megaterium. To ensure that mTcd138 is atoxic, 2 point mutations were introduced to the glucosyltransferase domain of TcdB, which essentially eliminates toxicity of mTcd138. Parenteral immunizations of mice and hamsters with mTcd138 induced protective antibodies to both toxins and provided protection against infection with the hyper-virulent C. difficile strain UK6.
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Affiliation(s)
- Yuan-Kai Wang
- a Department of Infectious Diseases and Global Health ; Tufts University Cummings School of Veterinary Medicine ; North Grafton , MA USA
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Kachrimanidou M, Sarmourli T, Skoura L, Metallidis S, Malisiovas N. Clostridium difficile infection: New insights into therapeutic options. Crit Rev Microbiol 2015; 42:773-9. [PMID: 25955884 DOI: 10.3109/1040841x.2015.1027171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Clostridium difficile infection (CDI) is an important cause of mortality and morbidity in healthcare settings and represents a major social and economic burden. The major virulence determinants are large clostridial toxins, toxin A (TcdA) and toxin B (TcdB), encoded within the pathogenicity locus. Traditional therapies, such as metronidazole and vancomycin, frequently lead to a vicious circle of recurrences due to their action against normal human microbiome. New disease management strategies together with the development of novel therapeutic and containment approaches are needed in order to better control outbreaks and treat patients. This article provides an overview of currently available CDI treatment options and discusses the most promising therapies under development.
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Affiliation(s)
- Melina Kachrimanidou
- a Department of Microbiology , Medical School, Aristotle University of Thessaloniki , Greece , Thessaloniki , Greece and
| | - Theopisti Sarmourli
- a Department of Microbiology , Medical School, Aristotle University of Thessaloniki , Greece , Thessaloniki , Greece and
| | - Lemonia Skoura
- a Department of Microbiology , Medical School, Aristotle University of Thessaloniki , Greece , Thessaloniki , Greece and
| | - Symeon Metallidis
- b Infectious Diseases Division, Department of Internal Medicine , Medical School, Aristotle University of Thessaloniki , Thessaloniki , Greece
| | - Nikolaos Malisiovas
- a Department of Microbiology , Medical School, Aristotle University of Thessaloniki , Greece , Thessaloniki , Greece and
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39
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Yu H, Chen K, Wu J, Yang Z, Shi L, Barlow LL, Aronoff DM, Garey KW, Savidge TC, von Rosenvinge EC, Kelly CP, Feng H. Identification of toxemia in patients with Clostridium difficile infection. PLoS One 2015; 10:e0124235. [PMID: 25885671 PMCID: PMC4401762 DOI: 10.1371/journal.pone.0124235] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 02/27/2015] [Indexed: 01/05/2023] Open
Abstract
Toxemia can develop in Clostridium difficile-infected animals, and correlates with severe and fulminant disease outcomes. Circumstantial evidence suggests that toxemia may occur in patients with C. difficile infection (CDI), but positive diagnosis is extremely rare. We analyzed the potential for C. difficile toxemia in patients, determined its characteristics, and assessed challenges. C. difficile toxins in serum from patients were tested using an ultrasensitive cell-based assay and further confirmed by Rac1 glucosylation assay. The factors that hinder a diagnosis of toxemia were assessed, including investigation of toxin stability, the level of toxins-specific neutralizing antibodies in sera and its effect on diagnosis limits. CDI patients develop detectable toxemia in some cases (2.3%). Toxins were relatively stable in stored sera. Neutralizing anti-toxin antibodies were present during infection and positively correlated with the diagnosis limits. Thus, the masking effect of toxin-specific neutralizing antibodies is the major obstacle in diagnosing C. difficile toxemia using cell-based bioassays.
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Affiliation(s)
- Hua Yu
- Department of Microbial Pathogenesis, University of Maryland Dental School, Baltimore, Maryland, United States of America
| | - Kevin Chen
- Department of Microbial Pathogenesis, University of Maryland Dental School, Baltimore, Maryland, United States of America
| | - Jianguo Wu
- Department of Microbial Pathogenesis, University of Maryland Dental School, Baltimore, Maryland, United States of America
| | - Zhiyong Yang
- Department of Microbial Pathogenesis, University of Maryland Dental School, Baltimore, Maryland, United States of America
| | - Lianfa Shi
- Department of Microbial Pathogenesis, University of Maryland Dental School, Baltimore, Maryland, United States of America
| | - Lydia L. Barlow
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - David M. Aronoff
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America; Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Kevin W. Garey
- University of Houston College of Pharmacy, Houston, Texas, United States of America; Baylor St. Luke's Medical Center, Houston, Texas, United States of America; University of Texas School of Public Health, Houston, Texas, United States of America
| | - Tor C. Savidge
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas, United States of America; Texas Children's Microbiome Center, Texas Children's Hospital, Houston, Texas, United States of America
| | - Erik C. von Rosenvinge
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Maryland, Baltimore, Maryland, United States of America; VA Maryland Health Care System, Baltimore, Maryland, United States of America
| | - Ciaran P. Kelly
- Department of Medicine, Harvard Medical School and Celiac Center, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America; Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Hanping Feng
- Department of Microbial Pathogenesis, University of Maryland Dental School, Baltimore, Maryland, United States of America
- * E-mail:
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41
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Abstract
Clostridium difficile is a spore-forming anaerobic gram-positive organism that is the leading cause of antibiotic-associated nosocomial infectious diarrhea in the Western world. This article describes the evolving epidemiology of C difficile infection (CDI) in the twenty-first century, evaluates the importance of vaccines against the disease, and defines the roles of both innate and adaptive host immune responses in CDI. The effects of passive immunotherapy and active vaccination against CDI in both humans and animals are also discussed.
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Affiliation(s)
- Chandrabali Ghose
- Aaron Diamond AIDS Research Center, 455 First Avenue, 7th Floor, New York, NY 10016, USA.
| | - Ciarán P Kelly
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
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42
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Mizrahi A, Collignon A, Péchiné S. Passive and active immunization strategies against Clostridium difficile infections: State of the art. Anaerobe 2014; 30:210-9. [DOI: 10.1016/j.anaerobe.2014.07.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 07/07/2014] [Accepted: 07/18/2014] [Indexed: 02/04/2023]
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Abstract
Vaccination of children has had a major impact on the morbidity and mortality of many infectious diseases globally. However, with age, immune responses to vaccines can be less robust, which can be further enhanced by underlying diseases that are common in the older adult. In many countries around the globe booster vaccinations against diphtheria, tetanus, and pertussis are recommended for adults. For the older adult, vaccination against pneumococcal diseases, influenza and herpes zoster are also recommended. Despite these recommendations, the widespread use of these vaccines in the adult population clearly lags behind the vaccine uptake and successes documented for pediatric vaccination programs. Furthermore, extensive and sometimes inappropriate use of antibiotics have fostered the emergence of antibiotic-resistant bacteria (e.g., methicillin resistant Staphylococcus aureus (MRSA)) as well as increased susceptibility in the elderly to bacterial species such as Clostridium difficile. Infectious diseases remain an important unmet medical need and new concepts to successfully implement vaccination of adults are urgently needed.
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Affiliation(s)
- Kena A Swanson
- a Pfizer Vaccine Research and Early Development; Pearl River, NY USA
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44
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Heinrichs JH, Therien AG. Prevention of Clostridium difficile infections—The role of vaccines and therapeutic immunoglobulins. SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2014.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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45
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Abstract
Clostridium difficile infection (CDI) is the most common infectious cause of healthcare-acquired diarrhoea. Outcomes of C. difficile colonization are varied, from asymptomatic carriage to fulminant colitis and death, due in part to the interplay between the pathogenic virulence factors of the bacterium and the counteractive immune responses of the host. Secreted toxins A and B are the major virulence factors of C. difficile and induce a profound inflammatory response by intoxicating intestinal epithelial cells causing proinflammatory cytokine release. Host cell necrosis, vascular permeability and neutrophil infiltration lead to an elevated white cell count, profuse diarrhoea and in severe cases, dehydration, hypoalbuminaemia and toxic megacolon. Other bacterial virulence factors, including surface layer proteins and flagella proteins, are detected by host cell surface signal molecules that trigger downstream cell-mediated immune pathways. Human studies have identified a role for serum and faecal immunoglobulin levels in protection from disease, but the recent development of a mouse model of CDI has enabled studies into the precise molecular interactions that trigger the immune response during infection. Key effector molecules have been identified that can drive towards a protective anti-inflammatory response or a damaging proinflammatory response. The limitations of current antimicrobial therapies for CDI have led to the development of both active and passive immunotherapies, none of which have, as yet been formally approved for CDI. However, recent advances in our understanding of the molecular basis of host immune protection against CDI may provide an exciting opportunity for novel therapeutic developments in the future.
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Affiliation(s)
- Katie Solomon
- School of Medicine and Medical Science, University College Dublin, Belfield, Dublin 4, Republic of Ireland
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46
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Vassallo A, Tran MCN, Goldstein EJC. Clostridium difficile: improving the prevention paradigm in healthcare settings. Expert Rev Anti Infect Ther 2014; 12:1087-102. [DOI: 10.1586/14787210.2014.942284] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Angela Vassallo
- Department of Infection Prevention, Providence Saint John’s Health Center,
2121 Santa Monica Blvd, Santa Monica, CA 90404, USA
| | - Mai-Chi N Tran
- Department of Pharmacy, Providence Saint John’s Health Center,
2121 Santa Monica Blvd, Santa Monica, CA 90404, USA
| | - Ellie JC Goldstein
- Department of Infectious Diseases, Providence Saint John’s Health Center,
2121 Santa Monica Blvd, Santa Monica, CA 90404, USA
- The UCLA School of Medicine,
Los Angeles, CA 90073, USA
- The R M Alden Research Laboratory,
Santa Monica CA, 90404, USA
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47
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Abstract
Clostridium difficile-associated illness is an increasingly prevalent and morbid condition. The elderly population is at a disproportionate risk of developing symptomatic disease and associated complications, including progression to severe or fulminant disease, and development of recurrent infections. This article analyzes the factors that influence C difficile disease propensity and severity, with particular attention directed toward features relevant to the rapidly aging population.
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Affiliation(s)
- Jonathan M Keller
- Department of Medicine, University of Washington Medical Center, 1959 Northeast Pacific Street, Box 356421, Seattle, WA 98195, USA
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48
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Böhles N, Böhles N, Busch K, Busch K, Hensel M, Hensel M. Vaccines against human diarrheal pathogens: current status and perspectives. Hum Vaccin Immunother 2014; 10:1522-35. [PMID: 24861668 PMCID: PMC5396248 DOI: 10.4161/hv.29241] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 05/08/2014] [Accepted: 05/15/2014] [Indexed: 12/16/2022] Open
Abstract
Worldwide, nearly 1.7 billion people per year contract diarrheal infectious diseases (DID) and almost 760 000 of infections are fatal. DID are a major problem in developing countries where poor sanitation prevails and food and water may become contaminated by fecal shedding. Diarrhea is caused by pathogens such as bacteria, protozoans and viruses. Important diarrheal pathogens are Vibrio cholerae, Shigella spp. and rotavirus, which can be prevented with vaccines for several years. The focus of this review is on currently available vaccines against these three pathogens, and on development of new vaccines. Currently, various types of vaccines based on traditional (killed, live attenuated, toxoid or conjugate vaccines) and reverse vaccinology (DNA/mRNA, vector, recombinant subunit, plant vaccines) are in development or already available. Development of new vaccines demands high levels of knowledge, experience, budget, and time, yet promising new vaccines often fail in preclinical and clinical studies. Efficacy of vaccination also depends on the route of delivery, and mucosal immunization in particular is of special interest for preventing DID. Furthermore, adjuvants, delivery systems and other vaccine components are essential for an adequate immune response. These aspects will be discussed in relation to the improvement of existing and development of new vaccines against DID.
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Affiliation(s)
| | | | | | | | - Michael Hensel
- Abt. Mikrobiologie; Universität Osnabrück; Osnabrück, Germany
| | - Michael Hensel
- Abt. Mikrobiologie; Universität Osnabrück; Osnabrück, Germany
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Recombinant Clostridium difficile toxin fragments as carrier protein for PSII surface polysaccharide preserve their neutralizing activity. Toxins (Basel) 2014; 6:1385-96. [PMID: 24759173 PMCID: PMC4014741 DOI: 10.3390/toxins6041385] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 03/06/2014] [Accepted: 04/09/2014] [Indexed: 11/29/2022] Open
Abstract
Clostridium difficile is a Gram-positive bacterium and is the most commonly diagnosed cause of hospital-associated and antimicrobial-associated diarrhea. Despite the emergence of epidemic C. difficile strains having led to an increase in the incidence of the disease, a vaccine against this pathogen is not currently available. C. difficile strains produce two main toxins (TcdA and TcdB) and express three highly complex cell-surface polysaccharides (PSI, PSII and PSIII). PSII is the more abundantly expressed by most C. difficile ribotypes offering the opportunity of the development of a carbohydrate-based vaccine. In this paper, we evaluate the efficacy, in naive mice model, of PSII glycoconjugates where recombinant toxins A and B fragments (TcdA_B2 and TcdB_GT respectively) have been used as carriers. Both glycoconjugates elicited IgG titers anti-PSII although only the TcdB_GT conjugate induced a response comparable to that obtained with CRM197. Moreover, TcdA_B2 and TcdB_GT conjugated to PSII retained the ability to elicit IgG with neutralizing activity against the respective toxins. These results are a crucial proof of concept for the development of glycoconjugate vaccines against C. difficile infection (CDI) that combine different C. difficile antigens to potentially prevent bacterial colonization of the gut and neutralize toxin activity.
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