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Yamada CH, Ortis GB, Buso GM, Martins TC, Zequinao T, Telles JP, Wollmann LC, Montenegro CDO, Dantas LR, Cruz JW, Tuon FF. Validation of Lyophilized Human Fecal Microbiota for the Treatment of Clostridioides difficile Infection: A Pilot Study with Pharmacoeconomic Analysis of a Middle-Income Country-Promicrobioma Project. Microorganisms 2024; 12:1741. [PMID: 39203583 PMCID: PMC11356882 DOI: 10.3390/microorganisms12081741] [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: 07/30/2024] [Revised: 08/09/2024] [Accepted: 08/21/2024] [Indexed: 09/03/2024] Open
Abstract
BACKGROUND Clostridioides difficile infection (CDI) represents a prevalent and potentially severe health concern linked to the usage of broad-spectrum antibiotics. The aim of this study was to evaluate a new lyophilized product based on human fecal microbiota for transplant, including cost-benefit analysis in the treatment of recurrent or refractory CDI. METHODS The product for fecal microbiota transplant was obtained from two donors. Microbiological, viability, and genomic analysis were evaluated. After validation, a clinical pilot study including recurrent or refractory CDI with 24 patients was performed. Clinical response and 4-week recurrence were the outcome. Cost-benefit analysis compared the fecal microbiota transplant with conventional retreatment with vancomycin or metronidazole. RESULTS The microbiota for transplant presented significant bacterial viability, with and adequate balance of Firmicutes and Bacteroidetes. The clinical response with the microbiota transplant was 92%. In financial terms, estimated expenditure for CDI solely related to recurrence, based on stochastic modeling, totals USD 222.8 million per year in Brazil. CONCLUSIONS The lyophilized human fecal microbiota for transplant is safe and can be an important step for a new product with low cost, even with genomic sequencing. Fecal microbiota transplantation emerges as a more cost-effective alternative compared to antimicrobials in the retreatment of CDI.
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Affiliation(s)
- Carolina Hikari Yamada
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, PR, Brazil; (C.H.Y.); (G.B.O.); (T.C.M.); (T.Z.); (L.R.D.)
| | - Gabriel Burato Ortis
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, PR, Brazil; (C.H.Y.); (G.B.O.); (T.C.M.); (T.Z.); (L.R.D.)
| | - Gustavo Martini Buso
- School of Business, Pontifical Catholic University of Paraná, Rua Imaculada Conceição 1155, Curitiba 80215-901, PR, Brazil; (G.M.B.); (J.W.C.)
| | - Thalissa Colodiano Martins
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, PR, Brazil; (C.H.Y.); (G.B.O.); (T.C.M.); (T.Z.); (L.R.D.)
| | - Tiago Zequinao
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, PR, Brazil; (C.H.Y.); (G.B.O.); (T.C.M.); (T.Z.); (L.R.D.)
| | - Joao Paulo Telles
- Hospital Universitário Evangélico Mackenzie, Curitiba 80730-150, PR, Brazil; (J.P.T.); (L.C.W.)
| | | | - Carolina de Oliveira Montenegro
- School of Business, Pontifical Catholic University of Paraná, Rua Imaculada Conceição 1155, Curitiba 80215-901, PR, Brazil; (G.M.B.); (J.W.C.)
| | - Leticia Ramos Dantas
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, PR, Brazil; (C.H.Y.); (G.B.O.); (T.C.M.); (T.Z.); (L.R.D.)
| | - June Westarb Cruz
- School of Business, Pontifical Catholic University of Paraná, Rua Imaculada Conceição 1155, Curitiba 80215-901, PR, Brazil; (G.M.B.); (J.W.C.)
| | - Felipe Francisco Tuon
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, PR, Brazil; (C.H.Y.); (G.B.O.); (T.C.M.); (T.Z.); (L.R.D.)
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Angulo FJ, Furtado M, Gonzalez E, Zhang P, Kelly PH, Moïsi JC. Incidence of public health surveillance-reported Clostridioides difficile infections in thirteen countries worldwide: A narrative review. Anaerobe 2024; 88:102878. [PMID: 38909713 DOI: 10.1016/j.anaerobe.2024.102878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 06/06/2024] [Accepted: 06/16/2024] [Indexed: 06/25/2024]
Abstract
Clostridioides difficile infection (CDI) is an important cause of morbidity and mortality worldwide. Data from public health surveillance systems are important for estimating country-level CDI burden. CDI surveillance can be population-based or hospital-based. Population-based surveillance results in overall estimates of CDI incidence (cases per 100,000 population-per-year), and hospital-based surveillance results in estimates of hospital-based CDI incidence (cases per 10,000 patient-days) or CDI admission rates (cases per 1,000 admissions). We sought to better understand temporal trends in CDI incidence reported in publicly available surveillance data worldwide and describe varying surveillance methods. We identified 13 countries in Europe, North America, and Oceania with publicly available population-based and/or hospital-based CDI surveillance data in online reports and/or dashboards. Additional countries in Europe, in particular, also conduct hospital-based CDI surveillance. Inconsistent CDI case definitions and surveillance approaches between countries limit the interpretability of multi-country comparisons. Nonetheless, publicly available CDI surveillance data enabled us to compare CDI incidence among countries with population-based and/or hospital-based surveillance systems and to describe trends in CDI incidence within countries over time. The highest CDI incidence is in the United States. While there have been recent declines in CDI incidence in all countries, the CDI burden remains high, and the need persists for CDI prevention strategies in communities and healthcare settings.
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Affiliation(s)
- Frederick J Angulo
- Vaccines & Antivirals, Chief Medical Affairs Office, Pfizer Biopharma, 500 Arcola Road, Collegeville, Pennsylvania 19426, USA.
| | - Melissa Furtado
- Medical Engagement and Impact, Chief Medical Affairs Office, Pfizer Biopharma, The Capital 1802/1901, G Block, Bandra-Kurla Complex, Mumbai 400051, Maharashtra, India
| | - Elisa Gonzalez
- Vaccines & Antivirals, Chief Medical Affairs Office, Pfizer Biopharma, 500 Arcola Road, Collegeville, Pennsylvania 19426, USA
| | - Pingping Zhang
- Medical Affairs Evidence Generation Statistics, Pfizer Research and Development, Collegeville, Pennsylvania, USA
| | - Patrick H Kelly
- Vaccines & Antivirals, Chief Medical Affairs Office, Pfizer Biopharma, 500 Arcola Road, Collegeville, Pennsylvania 19426, USA
| | - Jennifer C Moïsi
- Vaccines & Antivirals, Chief Medical Affairs Office, Pfizer Biopharma, 23-25 Avenue du Docteur Lannelongue, 75014 Paris, France
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3
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Ilic I, Zivanovic Macuzic I, Ilic M. Mortality Attributable to Clostridioides difficile Infection: The Rising Burden of Disease in European Countries. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1222. [PMID: 39202503 PMCID: PMC11355982 DOI: 10.3390/medicina60081222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2024] [Revised: 07/19/2024] [Accepted: 07/26/2024] [Indexed: 09/03/2024]
Abstract
Background and Objectives: Clostridioides difficile infection is a major public health issue, being among the main causes of mortality due to healthcare-associated diarrhea. This study aimed to assess the trends in mortality attributable to Clostridioides difficile infections in European countries over a period of 30 years. Materials and Methods: A descriptive epidemiological study was conducted, with the application of an ecological study design, to evaluate the trends in mortality due to Clostridioides difficile infection in the Central, Eastern, and Western European sub-regions from 1990 to 2019. The Global Burden of Disease study database was used. Trends were evaluated with the joinpoint regression analysis. Results: In both sexes, about 76% of all deaths attributable to Clostridioides difficile infections were recorded in the Western European sub-region in 2019. The age-standardized rates of the burden of Clostridioides difficile infection in 2019 were the highest in the Central European sub-region, followed by the Western European sub-region, while the lowest rates were observed in the Eastern European sub-region. A significantly increasing trend in mortality attributable to Clostridioides difficile infection from 1990 to 2019 was recorded both in males (by +2.1% per year) and females (by +2.8% per year). The burden of Clostridioides difficile infection showed increasing trends in most of the European countries, significantly correlating with the country's development, according to the Human Development Index. Conclusions: The rising burden of Clostridioides difficile infection in European countries in the last few decades suggests a need for improving public health measures, with a focus both on the hospital setting and community.
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Affiliation(s)
- Irena Ilic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Ivana Zivanovic Macuzic
- Department of Anatomy, Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Milena Ilic
- Department of Epidemiology, Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia
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Danpanichkul P, Duangsonk K, Uawithya E, Kongarin S, Simadibrata DM, Polpichai N, Suenghataiphorn T, Wattanachayakul P, Pang Y, Sukphutanan B, Kaewdech A, Panpradist N, Chaiyakunapruk N, Pupaibool J, Wijarnpreecha K. Clostridioides difficile Infection in the Elderly: Trend Analysis from 2000 to 2019. J Clin Med 2024; 13:3740. [PMID: 38999306 PMCID: PMC11242796 DOI: 10.3390/jcm13133740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/16/2024] [Accepted: 06/21/2024] [Indexed: 07/14/2024] Open
Abstract
Background/Objective: Clostridioides difficile infection (CDI) is a common healthcare-associated ailment, presenting major health and economic challenges, especially for the elderly. Despite its prevalence, comprehensive data about CDI's impact on the elderly are limited. Methods: This study used the Global Burden of Disease Study 2019 data to analyze CDI trends from 2000 to 2019, considering factors like sex, region, and sociodemographic index (SDI). Results: This study revealed that CDI caused approximately 18,181 deaths and 252,709 disability-adjusted life years (DALYs) among the elderly worldwide. The Americas showed the highest CDI burden, while the Eastern Mediterranean saw the steepest rate increase from 2000 to 2019. Regions with a high SDI also displayed substantial CDI impact. Conclusions: The escalating burden of CDI in the elderly, especially in high-SDI areas and the Americas, emphasizes an urgent need for targeted public health strategies.
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Affiliation(s)
- Pojsakorn Danpanichkul
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
- Immunology Unit, Department of Microbiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Kwanjit Duangsonk
- Department of Microbiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Ekdanai Uawithya
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Siwanart Kongarin
- Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Daniel M Simadibrata
- Faculty of Medicine, Universitas Indonesia, Depok 16424, Indonesia
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
| | - Natchaya Polpichai
- Department of Internal Medicine, Weiss Memorial Hospital, Chicago, IL 60640, USA
| | | | | | - Yanfang Pang
- Affiliated Hospital of Youjiang Medical University for Nationalities, Baise 533000, Guangxi, China
- National Immunological Laboratory for Traditional Chinese Medicine, Baise 533000, Guangxi, China
| | | | - Apichat Kaewdech
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla 90110, Thailand
| | - Nuttada Panpradist
- Global Center for Integrated Health for Women, Adolescents, and Children (Global WACh), Department of Global Health, University of Washington, Seattle, WA 98195, USA
| | - Nathorn Chaiyakunapruk
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT 84112, USA
- IDEAS Center, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT 84148, USA
| | - Jakrapun Pupaibool
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84113, USA
| | - Karn Wijarnpreecha
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Arizona College of Medicine, Phoenix, AZ 85004, USA
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Banner University Medical Center, Phoenix, AZ 85724, USA
- BIO5 Institute, University of Arizona College of Medicine-Phoenix, Phoenix, AZ 85004, USA
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Mubaraki MA, Hussain M, Hassan FU, Munir S, Fozia F, Ahmad I, Bibi F, Sultan S, Zialluh Z. Antimicrobial Resistance and Associated Risk Factors for Clostridium difficile in Patients Attending Tertiary Care Settings. J Trop Med 2024; 2024:6613120. [PMID: 38784112 PMCID: PMC11115991 DOI: 10.1155/2024/6613120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 03/31/2024] [Accepted: 05/03/2024] [Indexed: 05/25/2024] Open
Abstract
To determine the incidence of antimicrobial-resistant emerging pathogens, Clostridium difficile, and its associated risk factors in tertiary care setups of Pakistan. This cross-sectional prospective study was conducted from January 2019 to December 2020, to determine the prevalence and antimicrobial resistance patterns of C. difficile strains isolated from 450 stool specimens of patients suffering from diarrhea hospitalized in tertiary care hospitals in Peshawar, Pakistan. The stool samples of the patients were processed for culture and detection of toxin A and toxin B by enzyme-linked immunosorbent assay (ELISA) and tpi PCR. The drug sensitivity test was performed for antibiotics including ampicillin, cefixime, cefepime, amoxicillin, nalidixic acid, sulpha/TMP (SXT), chloramphenicol, metronidazole, vancomycin, ciprofloxacin, levofloxacin, and imipenem. Of 450 stool specimens, 108 (24%) were positive for C. difficile by stool culture, whereas 115 (25.5%) were only positive for C. difficile toxins based on ELISA and PCR (128 (28.6%). Of 108, 90.7% (n = 98) isolates were resistant to one antibiotic, and 90 (83.4%) were resistant to three or more antimicrobials. The highest resistance rates were found against penicillin (83.3%) followed by amoxicillin (70%), nalidixic acid (61%), and metronidazole (38%), and the lowest resistance was found against vancomycin (6.4%) and imipenem (3.7%). CDI was statistically significantly correlated with increased age, use of antibiotics, abdominal surgeries, use of proton pump inhibitors and H2a, and presence of comorbidities. The high frequency of C. difficile in Peshawar, Pakistan, indicates that CDI is an important nosocomial infection in different hospitals. The results will be helpful for clinicians to redesign control and therapeutic strategies in hospitals.
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Affiliation(s)
- Murad A. Mubaraki
- Clinical Laboratory Sciences Department, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Mubbashir Hussain
- Department of Microbiology, Kohat University of Science and Technology, Kohat, Pakistan
| | - Faaiz Ul Hassan
- Department of Microbiology, Kohat University of Science and Technology, Kohat, Pakistan
| | | | - Fozia Fozia
- Department of Biochemistry, KMU Institute of Dental Sciences, Kohat 26000, Pakistan
| | - Ijaz Ahmad
- Department of Chemistry, Kohat University of Science and Technology, Kohat, Pakistan
| | - Fatima Bibi
- Department of Microbiology, Kohat University of Science and Technology, Kohat, Pakistan
| | - Samia Sultan
- Department of Zoology, Abdul Wali Khan University, Mardan, Pakistan
| | - Ziaullah Zialluh
- College of Professional Studies, Northeastern University, Boston, MA, USA
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6
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Buddle JE, Fagan RP. Pathogenicity and virulence of Clostridioides difficile. Virulence 2023; 14:2150452. [PMID: 36419222 DOI: 10.1080/21505594.2022.2150452] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 11/02/2022] [Accepted: 11/17/2022] [Indexed: 11/25/2022] Open
Abstract
Clostridioides difficile is the most common cause of nosocomial antibiotic-associated diarrhea, and is responsible for a spectrum of diseases characterized by high levels of recurrence, morbidity, and mortality. Treatment is complex, since antibiotics constitute both the main treatment and the major risk factor for infection. Worryingly, resistance to multiple antibiotics is becoming increasingly widespread, leading to the classification of this pathogen as an urgent threat to global health. As a consummate opportunist, C. difficile is well equipped for promoting disease, owing to its arsenal of virulence factors: transmission of this anaerobe is highly efficient due to the formation of robust endospores, and an array of adhesins promote gut colonization. C. difficile produces multiple toxins acting upon gut epithelia, resulting in manifestations typical of diarrheal disease, and severe inflammation in a subset of patients. This review focuses on such virulence factors, as well as the importance of antimicrobial resistance and genome plasticity in enabling pathogenesis and persistence of this important pathogen.
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Affiliation(s)
- Jessica E Buddle
- Molecular Microbiology, School of Biosciences, University of Sheffield, Sheffield, UK
| | - Robert P Fagan
- Molecular Microbiology, School of Biosciences, University of Sheffield, Sheffield, UK
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Anwar F, Clark M, Lindsey J, Claus-Walker R, Mansoor A, Nguyen E, Billy J, Lainhart W, Shehab K, Viswanathan VK, Vedantam G. Prevalence of diagnostically-discrepant Clostridioides difficile clinical specimens: insights from longitudinal surveillance. Front Med (Lausanne) 2023; 10:1238159. [PMID: 37928470 PMCID: PMC10622765 DOI: 10.3389/fmed.2023.1238159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 10/03/2023] [Indexed: 11/07/2023] Open
Abstract
Background Clostridioides difficile Infection (CDI) is a healthcare-associated diarrheal disease prevalent worldwide. A common diagnostic algorithm relies on a two-step protocol that employs stool enzyme immunoassays (EIAs) to detect the pathogen, and its toxins, respectively. Active CDI is deemed less likely when the Toxin EIA result is negative, even if the pathogen-specific EIA is positive for C. difficile. We recently reported, however, that low-toxin-producing C. difficile strains recovered from Toxin-negative ('discrepant') clinical stool specimens can be fully pathogenic, and cause lethality in a rodent CDI model. To document frequency of discrepant CDI specimens, and evaluate C. difficile strain diversity, we performed longitudinal surveillance at a Southern Arizona tertiary-care hospital. Methods Diarrheic stool specimens from patients with clinical suspicion of CDI were obtained over an eight-year period (2015-2022) from all inpatient and outpatient Units of a > 600-bed Medical Center in Southern Arizona. Clinical laboratory EIA testing identified C. difficile-containing specimens, and classified them as Toxin-positive or Toxin-negative. C. difficile isolates recovered from the stool specimens were DNA fingerprinted using an international phylogenetic lineage assignment system ("ribotyping"). For select isolates, toxin abundance in stationary phase supernatants of pure cultures was quantified via EIA. Results Of 8,910 diarrheic specimens that underwent diagnostic testing, 1733 (19.4%) harbored C. difficile. Our major findings were that: (1) C. difficile prevalence and phylogenetic diversity was stable over the 8-year period; (2) toxigenic C. difficile was recovered from 69% of clinically Tox-neg ('discrepant') specimens; (3) the six most prevalent USA ribotypes were recovered in significant proportions (>60%) from Tox-neg specimens; and (4) toxin-producing C. difficile recovered from discrepant specimens produced less toxin than strains of the same ribotype isolated from non-discrepant specimens. Conclusion Our study highlights the dominance of Toxin EIA-negative CDI specimens in a clinical setting and the high frequency of known virulent ribotypes in these specimens. Therefore, a careful reevaluation of the clinical relevance of diagnostically-discrepant specimens particularly in the context of missed CDI diagnoses and C. difficile persistence, is warranted.
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Affiliation(s)
- Farhan Anwar
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ, United States
| | - Marielle Clark
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ, United States
| | - Jason Lindsey
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ, United States
| | - Rachel Claus-Walker
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ, United States
| | - Asad Mansoor
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ, United States
| | - Evy Nguyen
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ, United States
| | - Justin Billy
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ, United States
| | - William Lainhart
- Department of Pathology, Clinical Microbiology Laboratories, Banner University Medical Center, Tucson, AZ, United States
| | - Kareem Shehab
- Department of Pediatrics, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - V. K. Viswanathan
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ, United States
- Bio5 Institute for Collaborative Research, University of Arizona, Tucson, AZ, United States
| | - Gayatri Vedantam
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ, United States
- Bio5 Institute for Collaborative Research, University of Arizona, Tucson, AZ, United States
- Southern Arizona VA Healthcare System, Tucson, AZ, United States
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Biswas R, Dudani H, Lakhera P, Pal AK, Kurbah P, Bhatia D, Dhok A, Kashyap RS. Challenges and future solutions for detection of Clostridioides difficile in adults. Ann Gastroenterol 2023; 36:369-377. [PMID: 37396008 PMCID: PMC10304531 DOI: 10.20524/aog.2023.0802] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 02/17/2023] [Indexed: 07/04/2023] Open
Abstract
There are no established standards for the diagnosis of Clostridioides difficile infection (CDI), even though the importance of this infection in humans is well known. The effectiveness of the commercially available techniques, which are all standardized for use with human feces, is also limited in terms of the accuracy of the tests. Furthermore, the current approach lacks a point-of-care diagnosis with an acceptable range of sensitivity and specificity. This article reviews the challenges and possible future solutions for the detection of CDI in adults. Existing diagnostic methods, such as enzyme-linked immunoassays and microbial culturing for the detection of toxins A and B, appear to work poorly in samples but exhibit great sensitivity for glutamate dehydrogenase. Real-time polymerase chain reaction and nucleic acid amplification tests have been investigated in a few studies on human samples, but so far have shown poor turnaround times. Thus, developing a multiplex point-of-care test assay with high sensitivity and specificity is required as a bedside approach for diagnosing this emerging infection.
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Affiliation(s)
- Rima Biswas
- Research Laboratory, Dr. G.M. Taori Central India Institute of Medical Sciences, Nagpur (Rima Biswas, Hemanshi Dudani, Rajpal Singh Kashyap)
| | - Hemanshi Dudani
- Research Laboratory, Dr. G.M. Taori Central India Institute of Medical Sciences, Nagpur (Rima Biswas, Hemanshi Dudani, Rajpal Singh Kashyap)
| | - Praveen Lakhera
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, Uttar Pradesh and CSIR-Central Scientific Instruments Organization, Chandigarh (Praveen Lakhera)
| | - Arun Kumar Pal
- Department of Molecular and Cellular Engineering, Sam Higginbottom University of Agriculture, Technology, and Sciences, Prayagraj (Arun Kumar Pal)
| | - Phibalari Kurbah
- Department of Biomedical Engineering, North Eastern Hill University, Shillong, Meghalaya (Phibalari Kurbah, Dinesh Bhatia)
| | - Dinesh Bhatia
- Department of Biomedical Engineering, North Eastern Hill University, Shillong, Meghalaya (Phibalari Kurbah, Dinesh Bhatia)
| | - Archana Dhok
- Department of Biochemistry, Datta Meghe Institute of Medical Sciences, Sawangi (Archana Dhok), India
| | - Rajpal Singh Kashyap
- Research Laboratory, Dr. G.M. Taori Central India Institute of Medical Sciences, Nagpur (Rima Biswas, Hemanshi Dudani, Rajpal Singh Kashyap)
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Liu C, Monaghan T, Yadegar A, Louie T, Kao D. Insights into the Evolving Epidemiology of Clostridioides difficile Infection and Treatment: A Global Perspective. Antibiotics (Basel) 2023; 12:1141. [PMID: 37508237 PMCID: PMC10376792 DOI: 10.3390/antibiotics12071141] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 07/30/2023] Open
Abstract
Clostridioides difficile remains an important public health threat, globally. Since the emergence of the hypervirulent strain, ribotype 027, new strains have been reported to cause C. difficile infection (CDI) with poor health outcomes, including ribotypes 014/020, 017, 056, 106, and 078/126. These strains differ in their geographic distribution, genetic makeup, virulence factors, and antimicrobial susceptibility profiles, which can affect their ability to cause disease and respond to treatment. As such, understanding C. difficile epidemiology is increasingly important to allow for effective prevention measures. Despite the heightened epidemiological surveillance of C. difficile over the past two decades, it remains challenging to accurately estimate the burden and international epidemiological trends given the lack of concerted global effort for surveillance, especially in low- and middle-income countries. This review summarizes the changing epidemiology of C. difficile based on available data within the last decade, highlights the pertinent ribotypes from a global perspective, and discusses evolving treatments for CDI.
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Affiliation(s)
- Crystal Liu
- Department of Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Tanya Monaghan
- National Institute for Health Research, Nottingham Biomedical Research Centre, Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham NG7 2UH, UK
| | - Abbas Yadegar
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran 1985717411, Iran
| | - Thomas Louie
- Medicine and Microbiology, School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Dina Kao
- Division of Gastroenterology, University of Alberta, Edmonton, AB T6G 2P8, Canada
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10
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Villafuerte Gálvez JA, Pollock NR, Alonso CD, Chen X, Xu H, Wang L, White N, Banz A, Miller M, Daugherty K, Gonzalez-Luna AJ, Barrett C, Sprague R, Garey KW, Kelly CP. Stool Interleukin-1β Differentiates Clostridioides difficile Infection (CDI) From Asymptomatic Carriage and Non-CDI Diarrhea. Clin Infect Dis 2023; 76:e1467-e1475. [PMID: 35906836 PMCID: PMC10169396 DOI: 10.1093/cid/ciac624] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/22/2022] [Accepted: 07/27/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Despite advances in the understanding and diagnosis of Clostridioides difficile infection (CDI), clinical distinction within the colonization-infection continuum remains an unmet need. METHODS By measuring stool cytokines and antitoxin antibodies in well-characterized cohorts of CDI (diarrhea, nucleic acid amplification test [NAAT] positive), non-CDI diarrhea (NCD; diarrhea, NAAT negative), asymptomatic carriers (ASC; no diarrhea, NAAT positive) and hospital controls (CON; no diarrhea, NAAT negative), we aim to discover novel biological markers to distinguish between these cohorts. We also explore the relationship of these stool cytokines and antitoxin antibody with stool toxin concentrations and disease severity. RESULTS Stool interleukin (IL) 1β, stool immunoglobulin A (IgA), and immunoglobulin G (IgG) anti-toxin A had higher (P < .0001) concentrations in CDI (n = 120) vs ASC (n = 43), whereas toxins A, B, and fecal calprotectin did not. Areas under the receiver operating characteristic curve (ROC-AUCs) for IL-1β, IgA, and IgG anti-toxin A were 0.88, 0.83, and 0.83, respectively. A multipredictor model including IL-1β and IgA anti-toxin A achieved an ROC-AUC of 0.93. Stool IL-1β concentrations were higher in CDI compared to NCD (n = 75) (P < .0001) and NCD + ASC+ CON (CON, n = 75) (P < .0001), with ROC-AUCs of 0.83 and 0.86, respectively. Stool IL-1β had positive correlations with toxins A (ρA = +0.55) and B (ρB = +0.49) in CDI (P < .0001) but not in ASC (P > .05). CONCLUSIONS Stool concentrations of the inflammasome pathway, proinflammatory cytokine IL-1β, can accurately differentiate CDI from asymptomatic carriage and NCD, making it a promising biomarker for CDI diagnosis. Significant positive correlations exist between stool toxins and stool IL-1β in CDI but not in asymptomatic carriers.
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Affiliation(s)
- Javier A Villafuerte Gálvez
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nira R Pollock
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Infectious Disease, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Department of Laboratory Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Carolyn D Alonso
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Infectious Disease, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Xinhua Chen
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Hua Xu
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Lamei Wang
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nicole White
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Infectious Disease, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | | | - Kaitlyn Daugherty
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Anne J Gonzalez-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Caitlin Barrett
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Rebecca Sprague
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Ciaran P Kelly
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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11
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Adesoji AT, Mgbere O, Darkoh C. Pediatric diarrhea patients living in urban areas have a higher incidence of Clostridioides difficile infection. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0000477. [PMID: 36962940 PMCID: PMC10022077 DOI: 10.1371/journal.pgph.0000477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 12/19/2022] [Indexed: 01/25/2023]
Abstract
Clostridioides difficile infection (CDI) is a major cause of antibiotic-associated diarrhea and an unappreciated contributor to child mortality in low- and middle-income countries where the diagnosis may be difficult. There is little information about the prevalence of CDI among infants, children, and adolescents in Africa. Using a cross-sectional design, seventy-six samples were collected from pediatric patients presenting with diarrhea, including infants (≤ 2 years old), children (2-12 years), and adolescents (13 ≤17 years) from three hospitals between January and December 2019. Demographic data, medical history, and prior antibiotic use were recorded. Toxigenic culture and PCR were used to detect and validate the presence of C. difficile in the samples. Data obtained were analyzed using descriptive and inferential statistics. A total of 29 (38.7%), 39 (52.0%) and 7 (9.3%) samples were from infants, children, and adolescents, respectively. The average age of the patients was 4.4 years. Of these samples, 31 (41%) were positive for C. difficile by culture and were verified by PCR amplification of C. difficile-specific genes (tcdA and tcdB). The most positive cases were children (53.3%) and infants (40.0%) with the majority of them residing in urban areas. Forty-nine (66.2%) of the patients had no known antibiotics exposure, whereas 29.0% and 29.7% reported the use of over-the-counter antibiotics at 14 and 90 days, prior to the hospital visit, respectively. CDI is relatively common among children with diarrhea in Northern Nigeria. Therefore, for effective management and treatment, more attention should be given to testing for C. difficile as one of the causative agents of diarrhea.
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Affiliation(s)
- Ayodele T. Adesoji
- Department of Microbiology, Federal University, Dutsin-Ma, Katsina State, Nigeria
| | - Osaro Mgbere
- Disease Prevention and Control Division, Houston Health Department, Houston, Texas, United States of America
- Institute of Community Health, Texas Medical Center, University of Houston College of Pharmacy, Houston, Texas, United States of America
| | - Charles Darkoh
- Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, Center for Infectious Diseases, University of Texas Health Science Center, Houston, TX, United States of America
- MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Microbiology and Infectious Diseases Program, Houston, Texas, United States of America
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12
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Make It Less difficile: Understanding Genetic Evolution and Global Spread of Clostridioides difficile. Genes (Basel) 2022; 13:genes13122200. [PMID: 36553467 PMCID: PMC9778335 DOI: 10.3390/genes13122200] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/14/2022] [Accepted: 11/22/2022] [Indexed: 11/25/2022] Open
Abstract
Clostridioides difficile is an obligate anaerobic pathogen among the most common causes of healthcare-associated infections. It poses a global threat due to the clinical outcomes of infection and resistance to antibiotics recommended by international guidelines for its eradication. In particular, C. difficile infection can lead to fulminant colitis associated with shock, hypotension, megacolon, and, in severe cases, death. It is therefore of the utmost urgency to fully characterize this pathogen and better understand its spread, in order to reduce infection rates and improve therapy success. This review aims to provide a state-of-the-art overview of the genetic variation of C. difficile, with particular regard to pathogenic genes and the correlation with clinical issues of its infection. We also summarize the current typing techniques and, based on them, the global distribution of the most common ribotypes. Finally, we discuss genomic surveillance actions and new genetic engineering strategies as future perspectives to make it less difficile.
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13
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Differential Overlap in Human and Animal Fecal Microbiomes and Resistomes in Rural versus Urban Bangladesh. Appl Environ Microbiol 2022; 88:e0075922. [DOI: 10.1128/aem.00759-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
While the development of antibiotic resistance in animal gut microbiomes and subsequent transmission to humans has been demonstrated in intensive farming environments and high-income countries, evidence of zoonotic exchange of antibiotic resistance in LMIC communities is lacking. This research provides genomic evidence of overlap of antibiotic resistance genes between humans and animals, especially in urban communities, and highlights chickens as important reservoirs of antibiotic resistance.
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14
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Trunfio M, Scabini S, Rugge W, Bonora S, Di Perri G, Calcagno A. Concurrent and Subsequent Co-Infections of Clostridioides difficile Colitis in the Era of Gut Microbiota and Expanding Treatment Options. Microorganisms 2022; 10:microorganisms10071275. [PMID: 35888994 PMCID: PMC9317215 DOI: 10.3390/microorganisms10071275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 06/19/2022] [Accepted: 06/22/2022] [Indexed: 02/01/2023] Open
Abstract
We narratively reviewed the physiopathology, epidemiology, and management of co-infections in Clostridioides difficile colitis (CDI) by searching the following keywords in Embase, MedLine, and PubMed: “Clostridium/Clostridioides difficile”, “co-infection”, “blood-stream infection” (BSI), “fungemia”, “Candida”, “Cytomegalovirus”, “probiotics”, “microbial translocation” (MT). Bacterial BSIs (mainly by Enterobacteriaceae and Enterococcus) and fungemia (mainly by Candida albicans) may occur in up to 20% and 9% of CDI, increasing mortality and length of hospitalization. Up to 68% of the isolates are multi-drug-resistant bacteria. A pivotal role is played by gut dysbiosis, intestinal barrier leakage, and MT. Specific risk factors are represented by CDI-inducing broad-spectrum antibiotics, oral vancomycin use, and CDI severity. Probiotics administration (mainly Saccharomyces and Lactobacillus) during moderate/severe CDI may favor probiotics superinfection. Other co-infections (such as Cytomegalovirus or protozoa) can complicate limited and specific cases. There is mounting evidence that fidaxomicin, bezlotoxumab, and fecal microbiota transplantation can significantly reduce the rate of co-infections compared to historical therapies by interrupting the vicious circle between CDI, treatments, and MT. Bacterial BSIs and candidemia represent the most common co-infections in CDI. Physicians should be aware of this complication to promptly diagnose and treat it and enforce preventive strategies that include a more comprehensive consideration of newer treatment options.
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Affiliation(s)
- Mattia Trunfio
- Unit of Infectious Diseases, Amedeo di Savoia Hospital, Department of Medical Sciences, University of Turin, 10149 Torino, Italy; (W.R.); (S.B.); (G.D.P.); (A.C.)
- Correspondence: ; Tel.: +39-0114393884
| | - Silvia Scabini
- Unit of Infectious Diseases, AOU “Città della Salute e della Scienza”, Department of Medical Sciences, University of Turin, 10149 Torino, Italy;
| | - Walter Rugge
- Unit of Infectious Diseases, Amedeo di Savoia Hospital, Department of Medical Sciences, University of Turin, 10149 Torino, Italy; (W.R.); (S.B.); (G.D.P.); (A.C.)
| | - Stefano Bonora
- Unit of Infectious Diseases, Amedeo di Savoia Hospital, Department of Medical Sciences, University of Turin, 10149 Torino, Italy; (W.R.); (S.B.); (G.D.P.); (A.C.)
| | - Giovanni Di Perri
- Unit of Infectious Diseases, Amedeo di Savoia Hospital, Department of Medical Sciences, University of Turin, 10149 Torino, Italy; (W.R.); (S.B.); (G.D.P.); (A.C.)
| | - Andrea Calcagno
- Unit of Infectious Diseases, Amedeo di Savoia Hospital, Department of Medical Sciences, University of Turin, 10149 Torino, Italy; (W.R.); (S.B.); (G.D.P.); (A.C.)
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15
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Kullin B, Abratt VR, Reid SJ, Riley TV. Clostridioides difficile infection in Africa: A narrative review. Anaerobe 2022; 74:102549. [PMID: 35337974 DOI: 10.1016/j.anaerobe.2022.102549] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 03/13/2022] [Accepted: 03/17/2022] [Indexed: 12/12/2022]
Abstract
Clostridioides (Clostridium) difficile infection (CDI) places a burden on healthcare facilities worldwide. Most research studies have been concentrated in high-income countries in North America, Europe, Asia and Australia, where C. difficile is the leading cause of diarrhoea associated with antimicrobial use. This narrative review summarises African CDI studies, focussing on reports published in the last 20 years. Although relatively sparse, the data suggest that CDI is an important cause of diarrhoea on the continent. African CDI patient populations are often younger than in European and North American settings, probably due to the high prevalence of co-morbid conditions such as tuberculosis, particularly in sub-Saharan Africa. Strain typing data are rare and where reported generally limited to single sites and institutions. Despite challenges, including a lack of facilities and awareness, there is a need for further investigation to more accurately determine the true burden of disease caused by C. difficile in Africa.
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Affiliation(s)
- Brian Kullin
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Valerie R Abratt
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Sharon J Reid
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Thomas V Riley
- Medical, Molecular and Forensic Sciences, Murdoch University, Murdoch, Western Australia WA, Australia; School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia; Department of Microbiology, PathWest Laboratory Medicine, Nedlands, WA, Australia; School of Biomedical Sciences, The University of Western Australia, Crawley, WA, Australia.
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16
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Enteropathogen spectrum and effect on antimycobacterial pharmacokinetics among children with tuberculosis in rural Tanzania: a prospective cohort study. THE LANCET MICROBE 2022; 3:e408-e416. [PMID: 35659902 PMCID: PMC9174596 DOI: 10.1016/s2666-5247(21)00308-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/02/2021] [Accepted: 11/05/2021] [Indexed: 02/03/2023] Open
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17
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Lanzas C, Jara M, Tucker R, Curtis S. A review of epidemiological models of Clostridioides difficile transmission and control (2009-2021). Anaerobe 2022; 74:102541. [PMID: 35217149 DOI: 10.1016/j.anaerobe.2022.102541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/09/2022] [Accepted: 02/20/2022] [Indexed: 02/08/2023]
Abstract
Clostridioides difficile is the leading cause of infectious diarrhea and one of the most common healthcare-acquired infections worldwide. We performed a systematic search and a bibliometric analysis of mathematical and computational models for Clostridioides difficile transmission. We identified 33 publications from 2009 to 2021. Models have underscored the importance of asymptomatic colonized patients in maintaining transmission in health-care settings. Infection control, antimicrobial stewardship, active testing, and vaccination have often been evaluated in models. Despite active testing and vaccination being not currently implemented, they are the most commonly evaluated interventions. Some aspects of C. difficile transmission, such community transmission and interventions in health-care settings other than in acute-care hospitals, remained less evaluated through modeling.
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Affiliation(s)
- Cristina Lanzas
- Department of Population Health and Pathobiology, North Carolina State University, Raleigh, NC, USA.
| | - Manuel Jara
- Department of Population Health and Pathobiology, North Carolina State University, Raleigh, NC, USA
| | - Rachel Tucker
- Department of Population Health and Pathobiology, North Carolina State University, Raleigh, NC, USA
| | - Savannah Curtis
- Department of Population Health and Pathobiology, North Carolina State University, Raleigh, NC, USA
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- Department of Population Health and Pathobiology, North Carolina State University, Raleigh, NC, USA
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18
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Brennhofer SA, Rogawski McQuade ET, Liu J, Guerrant RL, Platts-Mills JA, Warren CA. Clostridioides difficile colonisation among very young children in resource-limited settings. Clin Microbiol Infect 2022; 28:996-1002. [PMID: 35150876 PMCID: PMC9240321 DOI: 10.1016/j.cmi.2022.01.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 12/01/2022]
Abstract
Objectives To describe the epidemiology and risk factors for Clostridioides difficile (C. difficile) colonization among young children in eight low-resource settings. Methods We tested 41 354 monthly non-diarrhoeal and diarrhoeal stools for C. difficile toxin genes (TcdA and TcdB) using quantitative PCR (qPCR) in 1715 children from birth to age two years in a multisite birth cohort study. We estimated the prevalence, cumulative incidence, and seasonality of C. difficile colonization and investigated the associations of C. difficile detection with risk factors of infection, markers of enteropathy, and growth. Results The prevalence of C. difficile detection was lower in diarrhoeal (2.2%; n = 151/6731) compared to non-diarrhoeal stools (6.1%; n = 2106/34 623). By 24 months of age, the cumulative incidence of C. difficile varied widely by site, with 17.9% (n = 44; Pakistan) to 76.3% (n = 148; Peru) of children having at least one positive stool. Only Bangladesh and Pakistan had seasonal differences in C. difficile detection. Female sex (adjusted risk ratio (aRR): 1.18; 95% CI: 1.02–1.35), cephalosporin use in the past 15 days (aRR: 1.73; 95% CI: 1.39–2.16), and treated water (aRR: 1.24; 95% CI: 1.02–1.50) were risk factors for C. difficile positivity. The presence of C. difficile was significantly associated with elevated faecal myeloperoxidase, neopterin, and α-1-antitrypsin, but no associations were found between C. difficile and child growth at 24 months of age. Discussion C. difficile colonization among children ages 0–2 years was variable across low-resource settings. Significant elevation of intestinal inflammation and barrier disruption markers associated with C. difficile detection suggests a subclinical impact of colonization.
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Affiliation(s)
- Stephanie A Brennhofer
- Division of Infectious Diseases and International Health, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | | | - Jie Liu
- Division of Infectious Diseases and International Health, School of Medicine, University of Virginia, Charlottesville, VA, USA; School of Public Health, Qingdao University, Qingdao, China
| | - Richard L Guerrant
- Division of Infectious Diseases and International Health, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Cirle A Warren
- Division of Infectious Diseases and International Health, School of Medicine, University of Virginia, Charlottesville, VA, USA.
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19
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Monaghan TM, Biswas R, Satav A, Ambalkar S, Kashyap RS. Mini-review: Clostridioides difficile epidemiology in India. Anaerobe 2022; 74:102517. [DOI: 10.1016/j.anaerobe.2022.102517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/20/2021] [Accepted: 01/14/2022] [Indexed: 02/08/2023]
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20
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Perumalsamy S, Riley TV. Molecular Epidemiology of Clostridioides difficile Infections in Children. J Pediatric Infect Dis Soc 2021; 10:S34-S40. [PMID: 34791401 DOI: 10.1093/jpids/piab057] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Clostridioides difficile is a prominent cause of health care-related gastrointestinal illness in adults. C. difficile infection (CDI) has been researched for over 40 years; however, research on pediatric CDI specifically has lagged behind for various reasons. Over the past decade, C. difficile has been increasingly reported as a cause of a broad spectrum of gastrointestinal diseases in children, ranging from mild self-limiting diarrhea to severe conditions such as pseudomembranous colitis and toxic megacolon. Recent publications have shown a rise in CDI incidence in children in different parts of the world, especially in patients with particular comorbidities such as hematological malignancies and inflammatory bowel disease. In addition, rising CDI rates have been reported in children in the community without traditional risk factors for CDI. Due to the extensive use of sensitive molecular detection methods to diagnose CDI in many countries, differentiating children who require treatment from those colonized with toxigenic strains remains a problem. Consequently, the molecular epidemiology of pediatric CDI is poorly understood. Even though well-known C. difficile strains causing CDI in children have been described (including hypervirulent strains such as ribotypes 027 and 078), there is a paucity of information about specific C. difficile strains. This mini-review summarizes the information that is currently available on the molecular epidemiology of CDI in children.
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Affiliation(s)
- Sicilia Perumalsamy
- The University of Western Australia, School of Biomedical Sciences, Queen Elizabeth II Medical Centre, Nedlands, Western Australia, Australia
| | - Thomas V Riley
- The University of Western Australia, School of Biomedical Sciences, Queen Elizabeth II Medical Centre, Nedlands, Western Australia, Australia.,School of Veterinary and Life Sciences, Murdoch University, Murdoch, Western Australia, Australia.,PathWest Laboratory Medicine, Department of Microbiology, Queen Elizabeth II Medical Centre, Nedlands, Western Australia, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
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21
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Cançado GGL, Abreu ESD, Nardelli MJ, Serwa P, Brachmann M. A cost of illness comparison for toxigenic Clostridioides difficile diagnosis algorithms in developing countries. Anaerobe 2021; 70:102390. [PMID: 34058377 DOI: 10.1016/j.anaerobe.2021.102390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 04/16/2021] [Accepted: 05/17/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Availability of several commercial tests with different Clostridioides difficile targets contributes to uncertainty and controversies around the optimal diagnostic algorithm. While numerous studies have estimated the financial impact of C. difficile infection, models to guide testing strategies decisions in developing countries, where economic value significantly impacts clinical practice, are currently not available. AIM To determine the cost of illness of different C. difficile infection (CDI) diagnostic strategies in developing countries. METHODS Cost-comparison analysis was performed to compare eleven different algorithms of CDI diagnosis. The basis of calculation was a hypothetical cohort of 1000 adult inpatients suspected of CDI. We analyzed turnaround time of test results (i.e., time from taking sample to results emission), test performance (i.e., sensitivity and specificity) and testing costs. Patients were divided in true positive, false positive, true negative and false negative in order to integrate test performance and economics effects. Additional medical costs were calculated: costs of hygiene, medication, length of stay and intensive care unit costs, based on a Brazilian University Hospital costs. CDI prevalence was considered 22.64%. FINDINGS From laboratory-assisted tests, simultaneous glutamate dehydrogenase (GDH) and toxin A/B rapid immunoassay arbitrated by nucleic acid amplification test (NAAT) presented the lowest cost of illness (450,038.70 USD), whereas standalone NAAT had the highest (523,709.55 USD). Empirical diagnosis only presented the highest overall cost (809,605.44 USD). CONCLUSION The two-step algorithm with simultaneous GDH and toxin A/B rapid immunoassay arbitrated by NAAT seems to be the best strategy for CDI diagnosis in developing countries.
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Affiliation(s)
- Guilherme Grossi Lopes Cançado
- Hospital Das Clínicas da Universidade Federal de Minas Gerais, Minas Gerais, Brazil; Hospital da Polícia Militar de Minas Gerais, Minas Gerais, Brazil.
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22
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A Review of Clostridioides difficile Infection and Antibiotic-Associated Diarrhea. Gastroenterol Clin North Am 2021; 50:323-340. [PMID: 34024444 DOI: 10.1016/j.gtc.2021.02.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Antibiotic-associated diarrhea and Clostridioides difficile infection (CDI) occur frequently among adults. The pathophysiology of CDI is related to disruption of normal gut flora and risk factors include hospitalization, use of antibiotic therapy, and older age. Clinical manifestations can range from mild disease to toxic megacolon. Diagnosis is challenging and is based on a combination of clinical symptoms and diagnostic tests. Therapy includes cessation of antibiotics, or use of other agents depending on the severity of illness. Many novel agents for the treatment and prevention of CDI show promise and are under investigation.
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23
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Mutai WC, Mureithi MW, Anzala O, Revathi G, Kullin B, Burugu M, Kyany'a C, Odoyo E, Otieno P, Musila L. High Prevalence of Multidrug-Resistant Clostridioides difficile Following Extensive Use of Antimicrobials in Hospitalized Patients in Kenya. Front Cell Infect Microbiol 2021; 10:604986. [PMID: 33628744 PMCID: PMC7897694 DOI: 10.3389/fcimb.2020.604986] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 12/14/2020] [Indexed: 01/02/2023] Open
Abstract
Introduction Clostridioides difficile is a neglected pathogen in many African countries as it is generally not regarded as one of the major contributors toward the diarrheal disease burden in the continent. However, several studies have suggested that C. difficile infection (CDI) may be underreported in many African settings. The aim of this study was to determine the prevalence of CDI in hospitalized patients, evaluate antimicrobial exposure, and detect toxin and antimicrobial resistance profiles of the isolated C. difficile strains. Methods In this cross-sectional study, 333 hospitalized patients with hospital-onset diarrhoea were selected. The stool samples were collected and cultured on cycloserine-cefoxitin egg yolk agar (CCEY). Isolates were presumptively identified by phenotypic characteristics and Gram stain and confirmed by singleplex real-time PCR (qPCR) assays detecting the species-specific tpi gene, toxin A (tcdA) gene, toxin B (tcdB) gene, and the binary toxin (cdtA/cdtB) genes. Confirmed C. difficile isolates were tested against a panel of eight antimicrobials (vancomycin, metronidazole, rifampicin, ciprofloxacin, tetracycline, clindamycin, erythromycin, and ceftriaxone) using E-test strips. Results C. difficile was detected in 57 (25%) of diarrheal patients over the age of two, 56 (98.2%) of whom received antimicrobials before the diarrheal episode. Amongst the 71 confirmed isolates, 69 (97.1%) harbored at least one toxin gene. More than half of the toxigenic isolates harbored a truncated tcdA gene. All isolates were sensitive to vancomycin, while three isolates (2.1%) were resistant to metronidazole (MIC >32 mg/L). High levels of resistance were observed to rifampicin (65/71, 91.5%), erythromycin (63/71, 88.7%), ciprofloxacin (59/71, 83.1%), clindamycin (57/71, 80.3%), and ceftriaxone (36/71, 50.7.8%). Among the resistant isolates, 61 (85.9%) were multidrug-resistant. Conclusion Multidrug-resistant C. difficile strains were a significant cause of healthcare facility-onset C. difficile infections in patients with prior antimicrobial exposure in this Kenyan hospital.
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Affiliation(s)
- Winnie C Mutai
- Department of Medical Microbiology, School of Medicine, University of Nairobi, Nairobi, Kenya
| | - Marianne W Mureithi
- Department of Medical Microbiology, School of Medicine, University of Nairobi, Nairobi, Kenya
| | - Omu Anzala
- Department of Medical Microbiology, School of Medicine, University of Nairobi, Nairobi, Kenya
| | - Gunturu Revathi
- Department of Pathology, Division of Medical Microbiology, Aga Khan University Hospital, Nairobi, Kenya
| | - Brian Kullin
- Department of Molecular and Cell Biology, Faculty of Science, University of Cape Town, Cape Town, South Africa
| | - Magdaline Burugu
- Department of Medical Microbiology, School of Medicine, University of Nairobi, Nairobi, Kenya
| | | | - Erick Odoyo
- US Army Medical Research Directorate-Africa, Nairobi, Kenya
| | - Peter Otieno
- US Army Medical Research Directorate-Africa, Nairobi, Kenya
| | - Lillian Musila
- US Army Medical Research Directorate-Africa, Nairobi, Kenya
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FECAL MICROBIOTES TRANSPLANTATION TECHNOLOGIES: MEDICAL, BIOTECHNOLOGICAL AND REGULATORY ASPECTS. BIOTECHNOLOGIA ACTA 2021. [DOI: 10.15407/biotech14.01.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Fecal microbiota transplantation (FMT) is a treatment method based on donor's fecal solution injection into the patient's gastrointestinal tract. FMT is effectively used in the treatment of recurrent Clostridium difficile infection. There is also growing interest in the therapeutic application of the method to treat metabolic, autoimmune and other disorders that was not previously associated with intestinal microbiota. Despite the promising results of FMT use, the organizational and legal matters and that of the safety FMT application have not yet been resolved in the European and Ukrainian medical community. The purpose of this review was to summarize information on the FMT application and the regulatory aspects of its use. The analysis of the practical instructions provisions of for FMT applying in clinical practice was carried out, and the bioethical problems associated with the FMT use were investigated.
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Interfacility patient sharing and Clostridioides difficile infection incidence in the Ontario hospital system: A 13-year cohort study. Infect Control Hosp Epidemiol 2021; 41:154-160. [PMID: 31762432 DOI: 10.1017/ice.2019.283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Interfacility patient movement plays an important role in the dissemination of antimicrobial-resistant organisms throughout healthcare systems. We evaluated how 3 alternative measures of interfacility patient sharing were associated with C. difficile infection incidence in Ontario acute-care facilities. DESIGN The cohort included adult acute-care facility stays of ≥3 days between April 2003 and March 2016. We measured 3 facility-level metrics of patient sharing: general patient importation, incidence-weighted patient importation, and C. difficile case importation. Each of the 3 patient-sharing metrics were examined against the incidence of C. difficile infection in the facility per 1,000 stays, using Poisson regression models. RESULTS The analyzed cohort included 6.70 million stays at risk of C. difficile infection across 120 facilities. Over the 13-year period, we included 62,189 new cases of healthcare-associated CDI (incidence, 9.3 per 1,000 stays). After adjustment for facility characteristics, general importation was not strongly associated with C. difficile infection incidence (risk ratio [RR] per doubling, 1.10; 95% confidence interval [CI], 0.97-1.24; proportional change in variance [PCV], -2.0%). Incidence-weighted (RR per doubling, 1.18; 95% CI, 1.06-1.30; PCV, -8.4%) and C. difficile case importation (RR per doubling, 1.43; 95% CI, 1.29-1.58; PCV, -30.1%) were strongly associated with C. difficile infection incidence. CONCLUSIONS In this 13-year study of acute-care facilities in Ontario, interfacility variation in C. difficile infection incidence was associated with importation of patients from other high-incidence acute-care facilities or specifically of patients with a recent history of C. difficile infection. Regional infection control strategies should consider the potential impact of importation of patients at high risk of C. difficile shedding from outside facilities.
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Ghia CJ, Waghela S, Rambhad GS. Systematic Literature Review on Burden of Clostridioides difficile Infection in India. CLINICAL PATHOLOGY (THOUSAND OAKS, VENTURA COUNTY, CALIF.) 2021; 14:2632010X211013816. [PMID: 34104883 PMCID: PMC8170333 DOI: 10.1177/2632010x211013816] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/26/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Owing to limited diagnostic facilities and surveillance protocols, there is a paucity on the prevalence data of Clostridioides difficile infections (CDIs) in developing countries such as India. OBJECTIVE The aims of these studies are (1) to determine the prevalence of CDI in India, (2) to understand the risk factors of CDI, and (3) to determine the impact of different diagnostic methods on reported CDI rates. METHOD A systematic literature search was conducted using PubMed and Google Scholar database to identify Indian studies reporting the prevalence of CDI. A total of 31 studies, published between 1990 and 2020 were included in the final analysis. A chi-square test was used to determine statistically significant association between prevalence rates, accuracy of different diagnosis methods, and antibiotic usage rates of CDI. RESULTS The prevalence of CDI was in the range of 3.4% to 18%, and the difference between regional prevalence of CDI was statistically significant (P < .001). The use of antibiotics, hospital stay, comorbidities, recent surgery, and the use of proton-pump inhibitors was considered as risk factors for the development of CDI. Compared to other regions, the rate of antibiotic usage was significantly higher in North India (P < .001). Among different diagnostic methods, C. difficile detection was significantly higher with enzyme-linked immunosorbent assay (18.02%) versus other multiple testing methods used (P < .001). CONCLUSION There is a significant burden of CDI across the country. Further surveillance studies are required to monitor changes in prevalence of CDI, risk factors, and accuracy of diagnosis methods for a better understanding of the disease burden in India.
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Affiliation(s)
- Canna J Ghia
- Medical and Scientific Affairs, Pfizer Limited,
Mumbai, India
| | - Shaumil Waghela
- Medical and Scientific Affairs, Pfizer Limited,
Mumbai, India
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Yu H, Flaster N, Casanello AL, Curcio D. Assessing risk factors, mortality, and healthcare utilization associated with Clostridioides difficile infection in four Latin American countries. Braz J Infect Dis 2020; 25:101040. [PMID: 33290727 PMCID: PMC9392087 DOI: 10.1016/j.bjid.2020.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/27/2020] [Accepted: 11/14/2020] [Indexed: 12/11/2022] Open
Abstract
Background Clostridioides difficile infection (CDI) is the most common cause of healthcare-associated infections in Western countries. Risk factors, mortality, and healthcare utilization for CDI in Latin America are poorly understood. This study assessed risk factors and burden associated with nosocomial CDI in four Latin American countries. Methods This retrospective, case-control study used databases and medical records from 8 hospitals in Argentina, Brazil, Chile, and Mexico to identify nosocomial CDI cases from 2014 − 2017. Cases were patients aged ≥18 years with diarrhea and a positive CDI test ≥72 h after hospital admission. Two controls (without diarrhea; length of hospital stay [LOS] ≥3 days; admitted ±14 days from case patient; shared same ward) were matched to each case. CDI-associated risk factors were assessed by univariate and multivariable analyses. CDI burden (LOS, in-hospital mortality) was compared between cases and controls. Results The study included 481 cases and 962 controls. Mean age and sex were similar between cases and controls, but mean Charlson comorbidity index (4.3 vs 3.6; p < 0.001) and recent hospital admission (35.3% vs 18.8%; p < 0.001) were higher among cases. By multivariable analyses, CDI risk was associated with prior hospital admission within 3 months (odds ratio [OR], 2.08; 95% CI: 1.45, 2.97), recent antibiotic use (ie, carbapenem; OR, 2.85; 95% CI: 1.75, 4.64), acid suppressive therapy use (OR, 1.71; 95% CI: 1.14, 2.58), and medical conditions (ie, renal disease; OR, 1.48; 95% CI: 1.19, 1.85). In-hospital mortality rate (18.7% vs 6.9%; p < 0.001) and mean overall LOS (33.5 vs 18.8 days; p < 0.001) were higher and longer, respectively, in cases versus controls. Conclusion Antibiotic exposure, preexisting medical conditions, and recent hospital admission were major risk factors for CDI in Argentina, Brazil, Chile, and Mexico. CDI was associated with increased in-hospital risk of death and longer LOS. These findings are consistent with published literature in Western countries.
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Affiliation(s)
- Holly Yu
- Pfizer Inc, Collegeville, PA, USA.
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Braae UC, Møller FT, Ibsen R, Ethelberg S, Kjellberg J, Mølbak K. The Economic Burden of Clostridioides difficile in Denmark: A Retrospective Cohort Study. Front Public Health 2020; 8:562957. [PMID: 33324595 PMCID: PMC7725905 DOI: 10.3389/fpubh.2020.562957] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 11/02/2020] [Indexed: 01/15/2023] Open
Abstract
Objectives: The aim of this study was to make a comprehensive economic assessment of the costs of hospital-acquired C. difficile infections (CDI). Methods: We carried out a retrospective matched cohort study utilizing Danish registry data with national coverage to identify CDI cases and matched reference patients without CDI (controls) for economic burden assessment in Denmark covering 2011–2014. Health care costs and public transfer costs were obtained from national registries, and calculated for 1 year prior to, and 2 years after index admission using descriptive statistics and regression analysis. Results: The study included 12,768 CDI patients and 23,272 matched controls. The total health care cost was significantly larger for CDI cases than controls throughout all periods. During the index admission period, cost was €12,867 per CDI case compared to €4,522 (p < 0.001) for controls, which increased to an average of €31,388 and €19,512 (p < 0.001) in Year 1 for the two groups, respectively. Excess costs were found both among infections with onset in hospitals and in the community. Diagnosis compatible with complications increased costs to on average >€91,000 per case. The regression analysis showed that CDI adds a substantial economic burden, but only explains about 1/3 of the crude difference observed in the matched analysis. Discussion: The major economic impact of hospital-acquired CDI with complications underlines the importance of preventing complications in these patients. Our study provides an informed estimate of the potential economic gain per patient by successful intervention, which is likely to be relatively comparable across countries.
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Affiliation(s)
- Uffe Christian Braae
- Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark
| | - Frederik Trier Møller
- Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark
| | | | - Steen Ethelberg
- Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark.,Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jakob Kjellberg
- Danish National Institute for Local and Regional Government Research, Copenhagen, Denmark
| | - Kåre Mølbak
- Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark.,Department of Veterinary and Animal Science, University of Copenhagen, Copenhagen, Denmark
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Monaghan TM, Sloan TJ, Stockdale SR, Blanchard AM, Emes RD, Wilcox M, Biswas R, Nashine R, Manke S, Gandhi J, Jain P, Bhotmange S, Ambalkar S, Satav A, Draper LA, Hill C, Kashyap RS. Metagenomics reveals impact of geography and acute diarrheal disease on the Central Indian human gut microbiome. Gut Microbes 2020; 12:1752605. [PMID: 32459982 PMCID: PMC7781581 DOI: 10.1080/19490976.2020.1752605] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The Central Indian gut microbiome remains grossly understudied. Herein, we sought to investigate the burden of antimicrobial resistance and diarrheal diseases, particularly Clostridioides difficile, in rural-agricultural and urban populations in Central India, where there is widespread unregulated antibiotic use. We utilized shotgun metagenomics to comprehensively characterize the bacterial and viral fractions of the gut microbiome and their encoded functions in 105 participants. RESULTS We observed distinct rural-urban differences in bacterial and viral populations, with geography exhibiting a greater influence than diarrheal status. Clostridioides difficile disease was more commonly observed in urban subjects, and their microbiomes were enriched in metabolic pathways relating to the metabolism of industrial compounds and genes encoding resistance to 3rd generation cephalosporins and carbapenems. By linking phages present in the microbiome to their bacterial hosts through CRISPR spacers, phage variation could be directly related to shifts in bacterial populations, with the auxiliary metabolic potential of rural-associated phages enriched for carbon and amino acid energy metabolism. CONCLUSIONS We report distinct differences in antimicrobial resistance gene profiles, enrichment of metabolic pathways and phage composition between rural and urban populations, as well as a higher burden of Clostridioides difficile disease in the urban population. Our results reveal that geography is the key driver of variation in urban and rural Indian microbiomes, with acute diarrheal disease, including C. difficile disease exerting a lesser impact. Future studies will be required to understand the potential role of dietary, cultural, and genetic factors in contributing to microbiome differences between rural and urban populations.
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Affiliation(s)
- Tanya M. Monaghan
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK,Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK,CONTACT Tanya M. Monaghan NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Tim J. Sloan
- School of Life Sciences, University of Nottingham, Nottingham, UK
| | | | - Adam M. Blanchard
- School of Veterinary Medicine and Science, Sutton Bonington Campus, University of Nottingham, Leicestershire, UK
| | - Richard D. Emes
- School of Veterinary Medicine and Science, Sutton Bonington Campus, University of Nottingham, Leicestershire, UK,Advanced Data Analysis Centre, Sutton Bonington Campus, University of Nottingham, Leicestershire, UK
| | - Mark Wilcox
- Leeds Teaching Hospitals NHS Trust and University of Leeds, UK
| | - Rima Biswas
- Biochemistry Research Centre, Central India Institute of Medical Sciences, Nagpur, India
| | - Rupam Nashine
- Biochemistry Research Centre, Central India Institute of Medical Sciences, Nagpur, India
| | - Sonali Manke
- Biochemistry Research Centre, Central India Institute of Medical Sciences, Nagpur, India
| | - Jinal Gandhi
- Biochemistry Research Centre, Central India Institute of Medical Sciences, Nagpur, India
| | - Pratishtha Jain
- Biochemistry Research Centre, Central India Institute of Medical Sciences, Nagpur, India
| | - Shrejal Bhotmange
- Biochemistry Research Centre, Central India Institute of Medical Sciences, Nagpur, India
| | - Shrikant Ambalkar
- Department of Clinical Microbiology and Infection, King’s Mill Hospital, Sherwood Forest Hospitals NHS Trust, Sutton in Ashfield, UK
| | | | | | - Colin Hill
- APC Microbiome Ireland, University College Cork, Cork, Ireland
| | - Rajpal Singh Kashyap
- Biochemistry Research Centre, Central India Institute of Medical Sciences, Nagpur, India,Rajpal Singh Kashyap Biochemistry Research Centre, Central India Institute of Medical Sciences, 88/2 Bajaj Nagar, Nagpur, Maharashtra, India
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Odoyo E, Kyanya C, Mutai W, Musila L. High levels of toxigenic Clostridioides difficile contamination of hospital environments: a hidden threat in hospital-acquired infections in Kenya. Access Microbiol 2020; 2:acmi000171. [PMID: 33490867 PMCID: PMC7818243 DOI: 10.1099/acmi.0.000171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 09/10/2020] [Indexed: 01/05/2023] Open
Abstract
Introduction The contribution of Clostridioides difficile (formerly Clostridium difficile) to the burden of hospital-associated infections (HAIs) remains undetermined in many African countries. Aim This study aimed to identify a sensitive and readily adaptable C. difficile detection assay and to evaluate the C. difficile HAI risk in Kenya. Methodology Sterile swabs in neutralizing buffer were used to sample equipment or surfaces that patients and clinical staff touched frequently. These swabs were either plated directly on chromogenic agar or cultured in an enrichment broth before plating. The swab suspensions, enrichment broth and plate cultures were screened by quantitative PCR (qPCR) to determine the most efficient detection method. The HAI risk was evaluated by testing the C. difficile-positive samples by qPCR for the A, B and binary toxins. Results C. difficile was detected on 4/57 (7.0 %) equipment and surfaces by direct culture. The additional enrichment step increased the detection rate 10-fold to 43/57 (75.4 %). In total, 51/57 (89.5 %) environmental samples were positive for C. difficile detected through either culture or qPCR. The genes encoding the primary toxins, tcdA and tcdB, were detected on six surfaces, while the genes encoding the binary toxins, cdtA and cdtB, were detected on 2/57 (3.5 %) and 3/57 (5.3 %) surfaces, respectively. Different C. difficile toxin gene profiles were detected: the tcdA+/tcdB− gene profile on 4/10 (40 %) high-touch surfaces, tcdA−/tcdB+ on 3/10 (30 %) surfaces, tcdA+/tcdB+/cdtA+/cdtB+ on 2/10 (20 %) surfaces and tcdA−/tcdB+/cdtB+ on one high-touch surface. Conclusion The widespread contamination of hospital environments by toxigenic C. difficile gives a strong indication of the high risk of C. difficile infections (CDIs). The two-step culture process described can easily be adapted for monitoring hospital environment contamination by C. difficile.
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Affiliation(s)
- Erick Odoyo
- United States Army Medical Research Directorate - Africa, PO Box 606-00621, Nairobi, Kenya
| | - Cecilia Kyanya
- United States Army Medical Research Directorate - Africa, PO Box 606-00621, Nairobi, Kenya
| | - Winnie Mutai
- University of Nairobi, PO Box 30197-00200, Nairobi, Kenya
| | - Lillian Musila
- United States Army Medical Research Directorate - Africa, PO Box 606-00621, Nairobi, Kenya
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Vega L, Herrera G, Muñoz M, Patarroyo MA, Ramírez JD. Occurrence of Blastocystis in Patients with Clostridioides difficile Infection. Pathogens 2020; 9:pathogens9040283. [PMID: 32295242 PMCID: PMC7238161 DOI: 10.3390/pathogens9040283] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/09/2020] [Accepted: 04/09/2020] [Indexed: 12/14/2022] Open
Abstract
Clostridiodes difficile comprises a public-health threat that has been understudied in Colombia. Hypervirulent strains of C. difficile harbor multiple toxins, can be easily spread, and can have their onset of disease within healthcare facilities (HCFO) and the community (CO). Studies have shown that a disrupted microbiota (e.g., dysbiosis) may allow C. difficile infection (CDI). It has been suggested that dysbiosis prevents colonization by the anaerobic eukaryote Blastocystis, possibly due to an increase in luminal oxygen tension. No study has found co-occurrence of CDI and Blastocystis. Therefore, we aimed to determine the frequencies of C. difficile and Blastocystis infection/colonization in 220 diarrheal fecal samples. Molecular detection by PCR for both microorganisms was performed, with descriptive analyses of four variables (CDI detection, determination of C. difficile toxigenic profiles, Blastocystis detection, and patient site of onset). We demonstrate a significant association between the presence of Blastocystis and CDI, with coinfection found in 61 patients, and show a high frequency of CDI among both HCFO and CO groups. Our results of coinfection frequencies could support hypotheses that suggest Blastocystis can adapt to dysbiosis and oxidative stress. Further, the presence of toxigenic C. difficile occurring outside healthcare facilities shown here raises the alarm for community wide spread.
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Affiliation(s)
- Laura Vega
- Grupo de Investigaciones Microbiológicas de la Universidad del Rosario (GIMUR), Departamento de Biología, Facultad de Ciencias Naturales, Universidad del Rosario, Bogotá 110221, Colombia; (L.V.); (G.H.); (M.M.)
| | - Giovanny Herrera
- Grupo de Investigaciones Microbiológicas de la Universidad del Rosario (GIMUR), Departamento de Biología, Facultad de Ciencias Naturales, Universidad del Rosario, Bogotá 110221, Colombia; (L.V.); (G.H.); (M.M.)
| | - Marina Muñoz
- Grupo de Investigaciones Microbiológicas de la Universidad del Rosario (GIMUR), Departamento de Biología, Facultad de Ciencias Naturales, Universidad del Rosario, Bogotá 110221, Colombia; (L.V.); (G.H.); (M.M.)
| | - Manuel Alfonso Patarroyo
- Molecular Biology and Immunology Department, Fundación Instituto de Inmunología de Colombia (FIDIC), Bogotá 110221, Colombia;
- School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 110221, Colombia
| | - Juan David Ramírez
- Grupo de Investigaciones Microbiológicas de la Universidad del Rosario (GIMUR), Departamento de Biología, Facultad de Ciencias Naturales, Universidad del Rosario, Bogotá 110221, Colombia; (L.V.); (G.H.); (M.M.)
- Correspondence:
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Intestinal bile acids directly modulate the structure and function of C. difficile TcdB toxin. Proc Natl Acad Sci U S A 2020; 117:6792-6800. [PMID: 32152097 DOI: 10.1073/pnas.1916965117] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Intestinal bile acids are known to modulate the germination and growth of Clostridioides difficile Here we describe a role for intestinal bile acids in directly binding and neutralizing TcdB toxin, the primary determinant of C. difficile disease. We show that individual primary and secondary bile acids reversibly bind and inhibit TcdB to varying degrees through a mechanism that requires the combined oligopeptide repeats region to which no function has previously been ascribed. We find that bile acids induce TcdB into a compact "balled up" conformation that is no longer able to bind cell surface receptors. Lastly, through a high-throughput screen designed to identify bile acid mimetics we uncovered nonsteroidal small molecule scaffolds that bind and inhibit TcdB through a bile acid-like mechanism. In addition to suggesting a role for bile acids in C. difficile pathogenesis, these findings provide a framework for development of a mechanistic class of C. difficile antitoxins.
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Scheeler A. Where Stool is a Drug: International Approaches to Regulating the use of Fecal Microbiota for Transplantation. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2019; 47:524-540. [PMID: 31957572 DOI: 10.1177/1073110519897729] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Regulatory agencies vary widely in their classification of FMT, with significant impact on patient access. This article conducts a global survey of national regulations and collates existing FMT classification statuses, ultimately suggesting that the human cell and tissue product designation best fits FMT's characteristics and that definitional objectives to that classification may be overcome.
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Affiliation(s)
- Alexandra Scheeler
- Alexandra Scheeler, M.T.S., is a M.B.A. student at the Georgetown McDonough School of Business, and also holds degrees from Princeton University and Harvard Divinity School. She was previously the Regulatory Affairs Manager at OpenBiome, a non-profit stool bank in Cambridge, MA
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Sofjan AK, Islam MA, Halder K, Kabir ND, Saleh AA, Miranda J, Lancaster C, Begum K, Alam MJ, Garey KW. Molecular epidemiology of toxigenic Clostridioides difficile isolates from hospitalized patients and the hospital environment in Dhaka, Bangladesh. Anaerobe 2019; 61:102081. [PMID: 31356958 DOI: 10.1016/j.anaerobe.2019.102081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/23/2019] [Accepted: 07/25/2019] [Indexed: 02/04/2023]
Abstract
Epidemiology of Clostridioides difficile (syn. Clostridium difficile) infection (CDI) in Bangladesh is poorly understood. This study assessed the epidemiology of CDI in hospitalized patients and hospital environmental contamination of toxigenic C. difficile at two large urban Bangladesh hospitals. This 12-month prospective observational cohort study collected stool samples from adults with diarrhea and recent antimicrobial exposure during 2017. Environmental samples were collected by swabbing surfaces of hospital common areas. Samples underwent toxigenic culture. C. difficile isolates were tested for toxins A and B and PCR-ribotyped. Of 208 stool samples, 18 (8.7%) were positive for toxigenic C. difficile. Of 400 environmental samples, 45 (11%) were positive for toxigenic C. difficile. Ribotypes present in ≥10% of stool isolates were 017 (38%), 053-163 (13%), and a novel ribotype (FP435 [13%]). Common ribotypes in environmental isolates were 017 (22%), 053-163 (11%), 106 (24%). This is the first report describing current epidemiology of CDI in at risk hospitalized adult patients in Bangladesh.
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Affiliation(s)
- Amelia K Sofjan
- University of Houston College of Pharmacy, 4849 Calhound Road, Houston, TX, USA.
| | - Mohammad Aminul Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh; Paul G. Allen School for Global Animal Health, Washington State University, Pullman, WA, 99164, USA
| | - Kakali Halder
- Bangabandhu Sheikh Mujib Medical University (BSMMU), Shahbag, Dhaka, 1000, Bangladesh
| | - Nayel D Kabir
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Ahmed Abu Saleh
- Bangabandhu Sheikh Mujib Medical University (BSMMU), Shahbag, Dhaka, 1000, Bangladesh
| | - Julie Miranda
- University of Houston College of Pharmacy, 4849 Calhound Road, Houston, TX, USA
| | - Chris Lancaster
- University of Houston College of Pharmacy, 4849 Calhound Road, Houston, TX, USA
| | - Khurshida Begum
- University of Houston College of Pharmacy, 4849 Calhound Road, Houston, TX, USA
| | - M Jahangir Alam
- University of Houston College of Pharmacy, 4849 Calhound Road, Houston, TX, USA
| | - Kevin W Garey
- University of Houston College of Pharmacy, 4849 Calhound Road, Houston, TX, USA
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Curcio D, Cané A, Fernández FA, Correa J. Clostridium difficile-associated Diarrhea in Developing Countries: A Systematic Review and Meta-Analysis. Infect Dis Ther 2019; 8:87-103. [PMID: 30659481 PMCID: PMC6374231 DOI: 10.1007/s40121-019-0231-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION The prevalence of Clostridium difficile infection is rapidly increasing worldwide, but prevalence is difficult to estimate in developing countries where awareness, diagnostic resources, and surveillance protocols are limited. As diarrhea is the hallmark symptom, we conducted a systematic review and meta-analysis to determine the prevalence and incidence of C. difficile infection in patients in these regions who presented with diarrhea. METHODS We conducted a systematic literature search of MEDLINE/PubMed, Scopus, and Latin-American and Caribbean Health Sciences Literature databases to identify and analyze data from recent studies providing prevalence or incidence rates of C. difficile-associated diarrhea in developing countries within four regions: Africa-Middle East, developing Asia, Latin America, and China. Our objectives were to determine the current prevalence and incidence density rates of first episodes of C. difficile-associated diarrhea in developing countries. RESULTS Within the regions included in our analysis, prevalence of C. difficile infection in patients with diarrhea was 15% (95% CI 13-17%) (including community and hospitalized patients), with no significant difference across regions. The incidence of C. difficile infection in 17 studies including this information was 8.5 per 10,000 patient-days (95% CI 5.83-12.46). Prevalence was significantly higher in hospitalized patients versus community patients (p = 0.0227). CONCLUSION Our prevalence estimate of 15% is concerning; however, low awareness and inconsistent diagnostic and surveillance protocols suggest this is markedly underestimated. Enhanced awareness and management of C. difficile infection in patients with diarrhea, along with improvements in infection control and surveillance practices, should be implemented to reduce prevalence of C. difficile-associated diarrhea in developing countries. FUNDING Pfizer Inc.
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Affiliation(s)
- Daniel Curcio
- Vaccines Emerging Markets, Pfizer Inc, Buenos Aires, Argentina.
| | - Alejandro Cané
- Vaccines Emerging Markets, Pfizer Inc, Buenos Aires, Argentina
| | | | - Jorge Correa
- Buenos Aires University, Buenos Aires, Argentina
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Ramai D, Zakhia K, Ofosu A, Ofori E, Reddy M. Fecal microbiota transplantation: donor relation, fresh or frozen, delivery methods, cost-effectiveness. Ann Gastroenterol 2019; 32:30-38. [PMID: 30598589 PMCID: PMC6302197 DOI: 10.20524/aog.2018.0328] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 10/08/2018] [Indexed: 12/15/2022] Open
Abstract
Fecal microbiota transplantation (FMT) has evolved into a robust and efficient means for treating recurrent Clostridium difficile infection (CDI). Our narrative review looks at the donor selection, preparation, delivery techniques and cost-effectiveness of FMT. We searched electronic databases, including PubMed, MEDLINE, Google Scholar, and Cochrane Databases, for studies that compared the biological effects of donor selection, fresh or frozen fecal preparation, and various delivery techniques. We also evaluated the cost-effectiveness and manually searched references to identify additional relevant studies. Overall, there is a paucity of studies that directly compare outcomes associated with related and non-related stool donors. However, inferences from prior studies indicate that the success of FMT does not depend on the donor-patient relationship. Over time, the use of unrelated donors has increased because of the formation of stool banks and the need to save processing time and capital. However, longitudinal studies are needed to clarify the optimal freezing time before microbial function declines. Several FMT techniques have been developed, such as colonoscopy, enema, nasogastric or nasojejunal tubes, and capsules. The comparable and high efficacy of FMT capsules, combined with their convenience, safety and aesthetically tolerable mode of delivery, makes it an attractive option for many patients. Cost-effective models comparing these various approaches support the use of FMT via colonoscopy as being the best strategy for the treatment of recurrent CDI.
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Affiliation(s)
- Daryl Ramai
- Department of Medicine, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, Brooklyn (Daryl Ramai)
| | - Karl Zakhia
- Department of Medicine, Elmhurst Medical Center, Queens (Karl Zakhia)
| | - Andrew Ofosu
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, Brooklyn (Andrew Ofosu, Emmanuel Ofori, Madhavi Reddy), New York, USA
| | - Emmanuel Ofori
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, Brooklyn (Andrew Ofosu, Emmanuel Ofori, Madhavi Reddy), New York, USA
| | - Madhavi Reddy
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, Brooklyn (Andrew Ofosu, Emmanuel Ofori, Madhavi Reddy), New York, USA
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Kullin BR, Reid S, Abratt V. Clostridium difficile in patients attending tuberculosis hospitals in Cape Town, South Africa, 2014-2015. Afr J Lab Med 2018; 7:846. [PMID: 30568907 PMCID: PMC6295828 DOI: 10.4102/ajlm.v7i2.846] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 09/28/2018] [Indexed: 01/05/2023] Open
Abstract
Background Diarrhoea due to Clostridium difficile infection (CDI) poses a significant burden on healthcare systems around the world. However, there are few reports on the current status of the disease in sub-Saharan Africa. Objectives This study examined the occurrence of CDI in a South African population of tuberculosis patients, as well as the molecular epidemiology and antibiotic susceptibility profiles of C. difficile strains responsible for disease. Methods Toxigenic C. difficile in patients with suspected CDI attending two specialist tuberculosis hospitals in the Cape Town area were detected using a PCR-based diagnostic assay (Xpert® C. difficile). C. difficile strains isolated from PCR-positive specimens were characterised by ribotyping, multilocus variable-number tandem-repeat analysis and antibiotic susceptibility testing. Results The period prevalence of CDI was approximately 70.07 cases per 1000 patient admissions. Strains belonging to ribotype 017 (RT017) made up over 95% of the patient isolates and all of them were multi-drug resistant. Multilocus variable-number tandem-repeat analysis revealed several clusters of highly related C. difficile RT017 strains present in tuberculosis patients in several wards at each hospital. Conclusion Tuberculosis patients represent a population that may be at an increased risk of developing CDI and, in addition, may constitute a multi-drug resistant reservoir of this bacterium. This warrants further investigation and surveillance of the disease in this patient group and other high-risk patient groups in sub-Saharan Africa.
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Affiliation(s)
- Brian R Kullin
- Department of Molecular and Cell Biology, Faculty of Science, University of Cape Town, Cape Town, South Africa
| | - Sharon Reid
- Department of Molecular and Cell Biology, Faculty of Science, University of Cape Town, Cape Town, South Africa
| | - Valerie Abratt
- Department of Molecular and Cell Biology, Faculty of Science, University of Cape Town, Cape Town, South Africa
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Nasiri MJ, Goudarzi M, Hajikhani B, Ghazi M, Goudarzi H, Pouriran R. Clostridioides (Clostridium) difficile infection in hospitalized patients with antibiotic-associated diarrhea: A systematic review and meta-analysis. Anaerobe 2018; 50:32-37. [DOI: 10.1016/j.anaerobe.2018.01.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 01/25/2018] [Accepted: 01/28/2018] [Indexed: 02/08/2023]
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