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Quan M, Zhang X, Fang Q, Lv X, Wang X, Zong Z. Fighting against Clostridioides difficile infection: Current medications. Int J Antimicrob Agents 2024; 64:107198. [PMID: 38734214 DOI: 10.1016/j.ijantimicag.2024.107198] [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: 12/08/2023] [Revised: 04/18/2024] [Accepted: 05/04/2024] [Indexed: 05/13/2024]
Abstract
Clostridioides difficile (formerly Clostridium difficile) has been regarded as an 'urgent threat' and a significant global health problem, as life-threatening diarrhoea and refractory recurrence are common in patients with C. difficile infection (CDI). Unfortunately, the available anti-CDI drugs are limited. Recent guidelines recommend fidaxomicin and vancomycin as first-line drugs to treat CDI, bezlotoxumab to prevent recurrence, and faecal microbiota transplantation for rescue treatment. Currently, researchers are investigating therapeutic antibacterial drugs (e.g. teicoplanin, ridinilazole, ibezapolstat, surotomycin, cadazolid, and LFF571), preventive medications against recurrence (e.g. Rebyota, Vowst, VP20621, VE303, RBX7455, and MET-2), primary prevention strategies (e.g. vaccine, ribaxamase, and DAV132) and other anti-CDI medications in the preclinical stage (e.g. Raja 42, Myxopyronin B, and bacteriophage). This narrative review summarises current medications, including newly marketed drugs and products in development against CDI, to help clinicians treat CDI appropriately and to call for more research on innovation.
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Affiliation(s)
- Min Quan
- Center for Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Xiaoxia Zhang
- Center for Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Qingqing Fang
- Center for Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Xiaoju Lv
- Center for Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China; Division of Infectious Diseases, State Key Laboratory of Biotherapy, West China Hospital of Sichuan University, Chengdu, China
| | - Xiaohui Wang
- Center for Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China; Division of Infectious Diseases, State Key Laboratory of Biotherapy, West China Hospital of Sichuan University, Chengdu, China.
| | - Zhiyong Zong
- Center for Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China; Division of Infectious Diseases, State Key Laboratory of Biotherapy, West China Hospital of Sichuan University, Chengdu, China
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2
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Herbin SR, Crum H, Gens K. Breaking the Cycle of Recurrent Clostridioides difficile Infections: A Narrative Review Exploring Current and Novel Therapeutic Strategies. J Pharm Pract 2024:8971900241248883. [PMID: 38739837 DOI: 10.1177/08971900241248883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Clostridioides difficile is a toxin-producing bacteria that is a main cause of antibiotic-associated diarrhea. Clostridioides difficile infections (CDI) are associated with disruptions within the gastrointestinal (GI) microbiota which can be further exacerbated by CDI-targeted antibiotic treatment thereby causing recurrent CDI (rCDI) and compounding the burden placed on patients and the healthcare system. Treatment of rCDI consists of antibiotics which can be paired with preventative therapeutics, such as bezlotoxumab or fecal microbiota transplants (FMTs), if sustained clinical response is not obtained. Newer preventative strategies have been recently approved to assist in restoring balance within the GI system with the goal of preventing recurrent infections.
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Affiliation(s)
- Shelbye R Herbin
- Antimicrobial Stewardship and Medication Safety, John D. Dingell VA Medical Center, Detroit, MI, USA
| | - Hannah Crum
- Mercy Hospital Southeast, Cape Girardeau, MO, USA
| | - Krista Gens
- Allina Health, Minneapolis, MN, USA
- Abbott Northwestern Hospital, Minneapolis, MN, USA
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Ágreda Fernández M, Origüen J, Rodriguez-Goncer I, San Juan R, López-Medrano F, Parra P, Ruiz-Merlo T, Redondo N, Orellana MÁ, Aguado JM, Fernández-Ruiz M. Predictive value of fecal calprotectin and lactoferrin levels for negative outcomes in Clostridioides difficile infection. Eur J Clin Microbiol Infect Dis 2024; 43:313-324. [PMID: 38072880 DOI: 10.1007/s10096-023-04729-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 11/28/2023] [Indexed: 01/28/2024]
Abstract
PURPOSE We investigated the role of fecal calprotectin (FC) and lactoferrin (FL) as predictive biomarkers in Clostridioides difficile infection (CDI). METHODS We assembled a prospective cohort including all patients with a laboratory-confirmed CDI diagnosis between January and December 2017. FL and FC levels were measured at diagnosis by commercial ELISA and EIA kits. We investigated the diagnostic accuracy of FC and FL to predict CDI recurrence and severity (study outcomes) and explored optimal cut-off values in addition to those proposed by the manufacturers (200 µg/g and 7.2 µg/mL, respectively). RESULTS We included 170 CDI cases (152 first episodes and 18 recurrences). The rates of recurrence (first episodes only) and severity (entire cohort) were 9.2% (14/152) and 46.5% (79/170). Both FL and FC levels were significantly higher in patients who developed study outcomes. Optimal cut-off values for FC and FL to predict CDI recurrence were 1052 µg/g and 6.0 µg/mL. The optimal cut-off value for FC yielded higher specificity (60.9%) and positive predictive value (PPV) (16.9%) than that proposed by the manufacturer. Regarding CDI severity, the optimal cut-off value for FC (439 µg/g) also provided higher specificity (43.9%) and PPV (54.1%) than that of the manufacturer, whereas the optimal cut-off value for FL (4.6 µg/mL) resulted in an improvement of PPV (57.5%). CONCLUSION By modifying the thresholds for assay positivity, the measurement of FC and FL at diagnosis is useful to predict recurrence and severity in CDI. Adding these biomarkers to current clinical scores may help to individualize CDI management.
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Affiliation(s)
- Mario Ágreda Fernández
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital, 12 de Octubre" (imas12), Madrid, Spain.
| | - Julia Origüen
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital, 12 de Octubre" (imas12), Madrid, Spain
| | - Isabel Rodriguez-Goncer
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital, 12 de Octubre" (imas12), Madrid, Spain
| | - Rafael San Juan
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital, 12 de Octubre" (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital, 12 de Octubre" (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Patricia Parra
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital, 12 de Octubre" (imas12), Madrid, Spain
| | - Tamara Ruiz-Merlo
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital, 12 de Octubre" (imas12), Madrid, Spain
| | - Natalia Redondo
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital, 12 de Octubre" (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - María Ángeles Orellana
- Department of Microbiology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital, 12 de Octubre" (imas12), Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital, 12 de Octubre" (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital, 12 de Octubre" (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
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Vuotto C, Donelli G, Buckley A, Chilton C. Clostridioides difficile Biofilm. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1435:249-272. [PMID: 38175479 DOI: 10.1007/978-3-031-42108-2_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Clostridioides difficile infection (CDI), previously Clostridium difficile infection, is a symptomatic infection of the large intestine caused by the spore-forming anaerobic, gram-positive bacterium Clostridioides difficile. CDI is an important healthcare-associated disease worldwide, characterized by high levels of recurrence, morbidity, and mortality. CDI is observed at a higher rate in immunocompromised patients after antimicrobial therapy, with antibiotics disrupting the commensal microbiota and promoting C. difficile colonization of the gastrointestinal tract.A rise in clinical isolates resistant to multiple antibiotics and the reduced susceptibility to the most commonly used antibiotic molecules have made the treatment of CDI more complicated, allowing the persistence of C. difficile in the intestinal environment.Gut colonization and biofilm formation have been suggested to contribute to the pathogenesis and persistence of C. difficile. In fact, biofilm growth is considered as a serious threat because of the related antimicrobial tolerance that makes antibiotic therapy often ineffective. This is the reason why the involvement of C. difficile biofilm in the pathogenesis and recurrence of CDI is attracting more and more interest, and the mechanisms underlying biofilm formation of C. difficile as well as the role of biofilm in CDI are increasingly being studied by researchers in the field.Findings on C. difficile biofilm, possible implications in CDI pathogenesis and treatment, efficacy of currently available antibiotics in treating biofilm-forming C. difficile strains, and some antimicrobial alternatives under investigation will be discussed here.
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Affiliation(s)
- Claudia Vuotto
- Microbial Biofilm Laboratory, IRCCS Fondazione Santa Lucia, Rome, Italy.
| | | | - Anthony Buckley
- Microbiome and Nutritional Sciences Group, School of Food Science & Nutrition, University of Leeds, Leeds, UK
| | - Caroline Chilton
- Healthcare Associated Infection Research Group, Section of Molecular Gastroenterology, Leeds Institute for Medical Research at St James, University of Leeds, Leeds, UK
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Lee P, Nemati K, Silver EJ, Cacace J, Goldman DL. Risk factors for Recurrent Clostridioides Difficile Infection in Children. Hosp Pediatr 2023; 13:1010-1017. [PMID: 37877183 DOI: 10.1542/hpeds.2023-007154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
OBJECTIVE The aims of this study were to determine the epidemiologic and treatment factors associated with recurrent C. difficile infection in children. METHODS We conducted a 13-year retrospective review of pediatric C. difficile infections at our institution focusing on the epidemiologic, clinical, and treatment factors associated with recurrent disease. Repeat episodes occurring between 4 weeks and 2 months after initial infection were defined as early recurrences, whereas repeat episodes between 2 and 12 months after initial infection were defined as late recurrences. RESULTS We identified 303 children with C. difficile infection. Recurrent infections were limited to children with chronic conditions, affecting 27.4% (68 of 248) of this cohort. Early and late recurrences occurred in 36.8 and 63.2% of children, respectively. Among children with a chronic condition, female sex and initial use of metronidazole (as opposed to vancomycin) were associated with recurrent disease in bivariate and multivariate analyses. Overall, there was a high treatment failure rate (34 of 102, 33.3%) once children had developed recurrent disease. CONCLUSIONS Findings from this study demonstrate the importance of underlying chronic conditions in the development of recurrent C. difficile disease and the shortcomings of current treatment options for recurrent cases. Additionally, our findings indicate that initial treatment selection may impact the likelihood of future disease, with metronidazole usage being associated with higher recurrence rates than vancomycin. These findings highlight the need for additional studies to better understand the implications of C. difficile treatment strategies.
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Affiliation(s)
- Philip Lee
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital at Montefiore/Albert Einstein College of Medicine
- Department of Pharmacy
| | - Koorosh Nemati
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital at Montefiore/Albert Einstein College of Medicine
| | | | | | - David L Goldman
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital at Montefiore/Albert Einstein College of Medicine
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York
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Vázquez-Cuesta S, Lozano García N, Fernández AI, Olmedo M, Kestler M, Alcalá L, Marín M, Bermejo J, Díaz FFA, Muñoz P, Bouza E, Reigadas E. Microbiome profile and calprotectin levels as markers of risk of recurrent Clostridioides difficile infection. Front Cell Infect Microbiol 2023; 13:1237500. [PMID: 37780848 PMCID: PMC10534046 DOI: 10.3389/fcimb.2023.1237500] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/23/2023] [Indexed: 10/03/2023] Open
Abstract
Introduction Clostridioides difficile infection (CDI) is the main cause of nosocomial diarrhoea in developed countries. Recurrent CDI (R-CDI), which affects 20%-30% of patients and significantly increases hospital stay and associated costs, is a key challenge. The main objective of this study was to explore the role of the microbiome and calprotectin levels as predictive biomarkers of R-CDI. Methods We prospectively (2019-2021) included patients with a primary episode of CDI. Clinical data and faecal samples were collected. The microbiome was analysed by sequencing the hypervariable V4 region of the 16S rRNA gene on an Illumina Miseq platform. Results We enrolled 200 patients with primary CDI, of whom 54 developed R-CDI and 146 did not. We analysed 200 primary samples and found that Fusobacterium increased in abundance, while Collinsella, Senegalimassilia, Prevotella and Ruminococcus decreased in patients with recurrent versus non-recurrent disease. Elevated calprotectin levels correlated significantly with R-CDI (p=0.01). We built a risk index for R-CDI, including as prognostic factors age, sex, immunosuppression, toxin B amplification cycle, creatinine levels and faecal calprotectin levels (overall accuracy of 79%). Discussion Calprotectin levels and abundance of microbial genera such as Fusobacterium and Prevotella in primary episodes could be useful as early markers of R-CDI. We propose a readily available model for prediction of R-CDI that can be applied at the initial CDI episode. The use of this tool could help to better tailor treatments according to the risk of R-CDI.
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Affiliation(s)
- Silvia Vázquez-Cuesta
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Biochemistry and Molecular Biology Department, Faculty of Biology, Universidad Complutense de Madrid (UCM), Madrid, Spain
| | - Nuria Lozano García
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Ana I. Fernández
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - María Olmedo
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Martha Kestler
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
| | - Luis Alcalá
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en red de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - Mercedes Marín
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
- Centro de Investigación Biomédica en red de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - Javier Bermejo
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
- Centro de Investigación Biomédica en red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Francisco Fernández-Avilés Díaz
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
- Centro de Investigación Biomédica en red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
- Centro de Investigación Biomédica en red de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
- Centro de Investigación Biomédica en red de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - Elena Reigadas
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
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Auria E, Hunault L, England P, Monot M, Pipoli Da Fonseca J, Matondo M, Duchateau M, Tremblay YDN, Dupuy B. The cell wall lipoprotein CD1687 acts as a DNA binding protein during deoxycholate-induced biofilm formation in Clostridioides difficile. NPJ Biofilms Microbiomes 2023; 9:24. [PMID: 37169797 PMCID: PMC10175255 DOI: 10.1038/s41522-023-00393-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 04/27/2023] [Indexed: 05/13/2023] Open
Abstract
The ability of bacterial pathogens to establish recurrent and persistent infections is frequently associated with their ability to form biofilms. Clostridioides difficile infections have a high rate of recurrence and relapses and it is hypothesized that biofilms are involved in its pathogenicity and persistence. Biofilm formation by C. difficile is still poorly understood. It has been shown that specific molecules such as deoxycholate (DCA) or metronidazole induce biofilm formation, but the mechanisms involved remain elusive. In this study, we describe the role of the C. difficile lipoprotein CD1687 during DCA-induced biofilm formation. We showed that the expression of CD1687, which is part of an operon within the CD1685-CD1689 gene cluster, is controlled by multiple transcription starting sites and some are induced in response to DCA. Only CD1687 is required for biofilm formation and the overexpression of CD1687 is sufficient to induce biofilm formation. Using RNAseq analysis, we showed that CD1687 affects the expression of transporters and metabolic pathways and we identified several potential binding partners by pull-down assay, including transport-associated extracellular proteins. We then demonstrated that CD1687 is surface exposed in C. difficile, and that this localization is required for DCA-induced biofilm formation. Given this localization and the fact that C. difficile forms eDNA-rich biofilms, we confirmed that CD1687 binds DNA in a non-specific manner. We thus hypothesize that CD1687 is a component of the downstream response to DCA leading to biofilm formation by promoting interaction between the cells and the biofilm matrix by binding eDNA.
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Affiliation(s)
- Emile Auria
- Institut Pasteur, Université Paris-Cité, UMR-CNRS 6047, Laboratoire Pathogenèse des Bactéries Anaérobies, F-75015, Paris, France
| | - Lise Hunault
- Institut Pasteur, Université Paris-Cité, INSERM UMR1222, Unit of Antibodies in Therapy and Pathology, Paris, France
- Sorbonne Université, INSERM, CNRS, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), F-75013, Paris, France
| | - Patrick England
- Plateforme de Biophysique Moléculaire, Institut Pasteur, CNRS UMR3528, Paris, France
| | - Marc Monot
- Plateforme Technologique Biomics, Institut Pasteur, Paris, France
| | | | | | | | - Yannick D N Tremblay
- Department of Biochemistry, Microbiology and Immunology, University of Saskatchewan, Saskatoon, SK, Canada
| | - Bruno Dupuy
- Institut Pasteur, Université Paris-Cité, UMR-CNRS 6047, Laboratoire Pathogenèse des Bactéries Anaérobies, F-75015, Paris, France.
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8
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Jiang B, Yu D, Zhang Y, Hamza T, Feng H, Hoag SW. Delivery of a therapeutic antibody to the lower gastrointestinal tract for the treatment of Clostridium difficile infection (CDI). Pharm Dev Technol 2023; 28:232-239. [PMID: 36789978 DOI: 10.1080/10837450.2023.2174553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
The colonic delivery system of toxin neutralizing antibody is a promising method for treating Clostridium difficile infection (CDI) and has some advantages over the parental administration of a neutralizing antibody. However, colonic delivery of biologics presents several challenges, including instability of biologics during encapsulation into the delivery system and harsh conditions in the upper GI tract. In this work, we described a multi-particulate delivery system encapsulating a tetra-valent antibody ABAB-IgG1 with the potential to treat CDI. This work first approved that the cecum injection of ABAB-IgG1 into the lower GI tract of mice could relieve the symptoms, enhance the clinical score, and improve the survival rate of mice during CDI. Then, the antibody was spray layered onto mannitol beads and then enteric coated with pH-sensitive polymers to achieve colon-targeting release. The in vitro release of antibody from the multi-particulate system and the pH-sensitive release of antibody was monitored. The in vivo efficacy of this system was further examined and confirmed in mice and hamsters. In summary, the findings of this study should provide practical information and potential treatment options for CDI through colonic delivery of antibody therapeutics to the lower GI tract using a multi-particulate delivery system.
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Affiliation(s)
- Bowen Jiang
- Department of Pharmaceutical Sciences, University of Maryland, Baltimore, MD, USA
| | - Dongyue Yu
- Department of Pharmaceutical Sciences, University of Maryland, Baltimore, MD, USA
| | - Yongrong Zhang
- Department of Microbial Pathogenesis, University of Maryland, Baltimore, MD, USA
| | - Therwa Hamza
- Department of Microbial Pathogenesis, University of Maryland, Baltimore, MD, USA
| | - Hanping Feng
- Department of Microbial Pathogenesis, University of Maryland, Baltimore, MD, USA.,FZata Inc, Baltimore, MD, USA
| | - Stephen W Hoag
- Department of Pharmaceutical Sciences, University of Maryland, Baltimore, MD, USA
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9
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Deshpande A, Chen Y, Boye-Codjoe E, Obi EN. Adoption and Trends in Uptake of Updated ICD-10 Codes for Clostridioides difficile-A Retrospective Observational Study. Open Forum Infect Dis 2022; 9:ofac622. [PMID: 36519119 PMCID: PMC9745779 DOI: 10.1093/ofid/ofac622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 11/12/2022] [Indexed: 08/30/2023] Open
Abstract
BACKGROUND In October 2017, the single International Classification of Diseases, Tenth Revision (ICD-10), code for Clostridioides difficile infection (CDI), A04.7, was replaced with 2 codes delineating "recurrent CDI" (rCDI; A04.71) and "nonrecurrent CDI" (nrCDI; A04.72). METHODS To evaluate and validate use of the updated codes, this retrospective study included inpatient encounters with a CDI-related ICD-10 code from October 2016 to May 2019 in the PINC AITM Healthcare Database (PHD). Encounters after the October 2017 code update were characterized by clinical, facility, and provider variables and whether coding was concordant or discordant to the 8-week recurrence period. Multivariable regression analysis assessed variables associated with concordant coding. RESULTS Widespread adoption of the updated CDI codes across PHD hospitals occurred in October 2017. After October 2017, 21 446 CDI-related encounters met sample selection criteria (concordance in 67% of rCDI and 25% of nrCDI encounters). Higher proportions of rCDI- vs nrCDI-coded encounters (P < .05) had emergency room admission, admission by a gastroenterologist or infectious disease specialist, and were prescribed fidaxomicin, bezlotoxumab, or fecal microbiota transfer (FMT), with no significant difference by coding concordance status. Encounters coded concordantly were significantly more likely to be for rCDI (odds ratio [OR], 5.67; 95% CI, 5.32-6.03), a nonelective admission (OR, 1.35-1.69), or prescribed fidaxomicin (OR, 1.11; 95% CI, 1.01-1.23) or FMT (OR, 1.29; 95% CI, 1.17-1.42). CONCLUSIONS Our study findings suggest no delay in transition to the updated CDI-related codes. Treatment patterns for rCDI vs nrCDI encounters were consistent with Infectious Diseases Society of America guidelines, regardless of concordance status.
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Affiliation(s)
- Abhishek Deshpande
- Center for Value-Based Care Research, Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Infectious Disease, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Yiyun Chen
- Merck & Co., Inc., Rahway, New Jersey, USA
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Mitchell M, Nguyen SV, Macori G, Bolton D, McMullan G, Drudy D, Fanning S. Clostridioides difficile as a Potential Pathogen of Importance to One Health: A Review. Foodborne Pathog Dis 2022; 19:806-816. [PMID: 36516404 DOI: 10.1089/fpd.2022.0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Clostridioides difficile (basonym Clostridium) is a bacterial enteropathogen associated with cases of C. difficile infection that can result in pseudomembranous colitis, rapid fluid loss, and death. For decades following its isolation, C. difficile was thought to be a solely nosocomial pathogen, being isolated from individuals undergoing antimicrobial therapy and largely affecting elderly populations. More recently, C. difficile spores have been identified in the broader environment, including in food-producing animals, soil, and food matrices, in both ready-to-eat foods and meat products. Furthermore, evidence has emerged of hypervirulent ribotypes (RTs), such as RT078, similar to those cultured in asymptomatic carriers, also being identified in these environments. This finding may reflect on adaptations arising in these bacteria following selection pressures encountered in these niches, and which occurs due to an increase in antimicrobial usage in both clinical and veterinary settings. As C. difficile continues to adapt to new ecological niches, the taxonomy of this genus has also been evolving. To help understand the transmission and virulence potential of these bacteria of importance to veterinary public health, strategies applying multi-omics-based technologies may prove useful. These approaches may extend our current understanding of this recognized nosocomial pathogen, perhaps redefining it as a zoonotic bacterium. In this review, a brief background on the epidemiological presentation of C. difficile will be highlighted, followed by a review of C. difficile in food-producing animals and food products. The current state of C. difficile taxonomy will provide evidence of Clade 5 (ST11/RT078) delineation, as well as background on the genomic elements linked to C. difficile virulence and ongoing speciation. Recent studies applying second- and third-generation sequencing technologies will be highlighted, and which will further strengthen the argument made by many throughout the world regarding this pathogen and its consideration within a One Health dimension.
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Affiliation(s)
- Molly Mitchell
- UCD-Centre for Food Safety, University College Dublin, Dublin, Ireland
| | - Scott V Nguyen
- UCD-Centre for Food Safety, University College Dublin, Dublin, Ireland.,District of Columbia Department of Forensic Sciences, Public Health Laboratory, Washington, District of Columbia, USA
| | - Guerrino Macori
- UCD-Centre for Food Safety, University College Dublin, Dublin, Ireland
| | | | - Geoff McMullan
- Institute for Global Food Security, School of Biological Sciences, Queen's University Belfast, Belfast, United Kingdom
| | | | - Séamus Fanning
- UCD-Centre for Food Safety, University College Dublin, Dublin, Ireland.,Institute for Global Food Security, School of Biological Sciences, Queen's University Belfast, Belfast, United Kingdom
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11
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Xu Q, Zhang S, Quan J, Wu Z, Gu S, Chen Y, Zheng B, Lv L, Li L. The evaluation of fecal microbiota transplantation vs vancomycin in a Clostridioides difficile infection model. Appl Microbiol Biotechnol 2022; 106:6689-6700. [DOI: 10.1007/s00253-022-12154-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 11/24/2022]
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12
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Schnizlein MK, Young VB. Capturing the environment of the Clostridioides difficile infection cycle. Nat Rev Gastroenterol Hepatol 2022; 19:508-520. [PMID: 35468953 DOI: 10.1038/s41575-022-00610-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2022] [Indexed: 12/11/2022]
Abstract
Clostridioides difficile (formerly Clostridium difficile) infection is a substantial health and economic burden worldwide. Great strides have been made over the past several years in characterizing the physiology of C. difficile infection, particularly regarding how gut microorganisms and their host work together to provide colonization resistance. As mammalian hosts and their indigenous gut microbiota have co-evolved, they have formed a complex yet stable relationship that prevents invading microorganisms from establishing themselves. In this Review, we discuss the latest advances in our understanding of C. difficile physiology that have contributed to its success as a pathogen, including its versatile survival factors and ability to adapt to unique niches. Using discoveries regarding microorganism-host and microorganism-microorganism interactions that constitute colonization resistance, we place C. difficile within the fiercely competitive gut environment. A comprehensive understanding of these relationships is required to continue the development of precision medicine-based treatments for C. difficile infection.
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Affiliation(s)
- Matthew K Schnizlein
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, MI, USA
| | - Vincent B Young
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, MI, USA.
- Department of Internal Medicine/Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI, USA.
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13
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Kunishima H, Ohge H, Suzuki H, Nakamura A, Matsumoto K, Mikamo H, Mori N, Morinaga Y, Yanagihara K, Yamagishi Y, Yoshizawa S. Japanese Clinical Practice Guidelines for Management of Clostridioides (Clostridium) difficile infection. J Infect Chemother 2022; 28:1045-1083. [PMID: 35618618 DOI: 10.1016/j.jiac.2021.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/16/2021] [Accepted: 12/13/2021] [Indexed: 12/19/2022]
Affiliation(s)
- Hiroyuki Kunishima
- Department of Infectious Diseases, St. Marianna University School of Medicine, Japan.
| | - Hiroki Ohge
- Department of Infectious Diseases, Hiroshima University Hospital, Japan
| | - Hiromichi Suzuki
- Division of Infectious Diseases, Department of Medicine, Tsukuba Medical Center Hospital, Japan
| | - Atsushi Nakamura
- Division of Infection Control and Prevention, Nagoya City University Hospital, Japan
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, Japan
| | - Hiroshige Mikamo
- Clinical Infectious Diseases, Graduate School of Medicine, Aichi Medical University, Japan
| | - Nobuaki Mori
- Division of General Internal Medicine and Infectious Diseases, National Hospital Organization Tokyo Medical Center, Japan
| | - Yoshitomo Morinaga
- Department of Microbiology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
| | - Katsunori Yanagihara
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Yuka Yamagishi
- Clinical Infectious Diseases, Graduate School of Medicine, Aichi Medical University, Japan
| | - Sadako Yoshizawa
- Department of Clinical Laboratory/Department of Microbiology and Infectious Diseases, Toho University School of Medicine, Japan
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Response Regulator CD1688 Is a Negative Modulator of Sporulation in Clostridioides difficile. J Bacteriol 2022; 204:e0013022. [PMID: 35852332 PMCID: PMC9380558 DOI: 10.1128/jb.00130-22] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Two-component signal transduction systems (TCSs), consisting of a sensor histidine kinase (HK) and a response regulator (RR), sense environmental stimuli and then modulate cellular responses, typically through changes in gene expression. Our previous work identified the DNA binding motif of CD1586, an RR implicated in Clostridioides difficile strain R20291 sporulation. To determine the role of this RR in the sporulation pathway in C. difficile, we generated a deletion strain of cd1688 in the historical 630 strain, the homolog of cd1586. The C. difficile Δcd1688 strain exhibited a hypersporulation phenotype, suggesting that CD1688 negatively regulates sporulation. Complementation of the C. difficile Δcd1688 strain restored sporulation. In contrast, a nonphosphorylatable copy of cd1688 did not restore sporulation to wild-type (WT) levels, indicating that CD1688 must be phosphorylated to properly modulate sporulation. Expression of the master regulator spo0A, the sporulation-specific sigma factors sigF, sigE, sigG, and sigK, and a signaling protein encoded by spoIIR was increased in the C. difficile Δcd1688 strain compared to WT. In line with the increased spoIIR expression, we detected an increase in mature SigE at an earlier time point, which arises from SpoIIR-mediated processing of pro-SigE. Taken together, our data suggest that CD1688 is a novel negative modulator of sporulation in C. difficile and contributes to mediating progression through the spore developmental pathway. These results add to our growing understanding of the complex regulatory events involved in C. difficile sporulation, insight that could be exploited for novel therapeutic development. IMPORTANCEClostridioides difficile causes severe gastrointestinal illness and is a leading cause of nosocomial infections in the United States. This pathogen produces metabolically dormant spores that are the major vehicle of transmission between hosts. The sporulation pathway involves an intricate regulatory network that controls a succession of morphological changes necessary to produce spores. The environmental signals inducing the sporulation pathway are not well understood in C. difficile. This work identified a response regulator, CD1688, that, when deleted, led to a hypersporulation phenotype, indicating that it typically acts to repress sporulation. Improving our understanding of the regulatory mechanisms modulating sporulation in C. difficile could provide novel strategies to eliminate or reduce spore production, thus decreasing transmission and disease relapse.
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Wang S, Zhu D, Sun X. Development of an Effective Nontoxigenic Clostridioides difficile-Based Oral Vaccine against C. difficile Infection. Microbiol Spectr 2022; 10:e0026322. [PMID: 35583336 PMCID: PMC9241731 DOI: 10.1128/spectrum.00263-22] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/21/2022] [Indexed: 11/20/2022] Open
Abstract
The symptoms of Clostridioides difficile infection (CDI) are largely attributed to two C. difficile toxins, TcdA and TcdB. Significant efforts have been devoted to developing vaccines targeting both toxins through parenteral immunization routes. Recently, we generated a novel chimeric protein (designated Tcd169), comprised of the glucosyltransferase domain (GT), the cysteine protease domain (CPD), and the receptor binding domain (RBD) of TcdB, and the RBD of TcdA. Parenteral immunizations with Tcd169 provide mice effective protection against infection with a ribotype (RT) 027 C. difficile strain. In this study, we expressed Tcd169 in a nontoxigenic C. difficile CCUG37785 strain (designated NTCD), resulting in strain NTCD_Tcd169 to develop an oral vaccine that can target both C. difficile toxins and colonization/adhesion factors. Oral immunizations with NTCD_Tcd169 spores induced systematic and mucosal antibody responses against, not only both toxins, but also C. difficile flagellins (FliC/FliD). Intriguingly yet importantly, anti-Tcd169 sera raised against Tcd169 protein were significantly cross-reactive with FliC/FliD and two surface layer proteins (SlpA and Cwp2). Oral immunizations with NTCD_Tcd169 spores provided mice effective protection against infection with a hypervirulent RT027 C. difficile strain R20291and significantly reduced R20291spore numbers in feces compared with NTCD or PBS immunized mice. These results imply that the genetically modified, nontoxigenic C. difficile strain expressing Tcd169 may represent a novel mucosal vaccine candidate against CDI. IMPORTANCE Clostridioides difficile is an enteric pathogen, and symptoms of C. difficile infection (CDI) are mainly by two exotoxins TcdA and TcdB. Active vaccination is cost-effective approach to prevent CDI and high rates of recurrence. Ideally, vaccines should target both C. difficile toxins and cell/spore colonization. In this study, we expressed immunodominant fragments of TcdA and TcdB (i.e., Tcd169) in a nontoxigenic C. difficile CCUG37785 strain, generating a promising oral/mucosal vaccine candidate against CDI, by targeting both toxins and colonization of pathogenic C. difficile strains. Importantly, anti-Tcd169 sera raised against Tcd169 protein were significantly cross-reactive with FliC/FliD and two surface layer proteins (SlpA and Cwp2), and all of which are involved in C. difficile adhesion/colonization in vitro and in vivo.
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Affiliation(s)
- Shaohui Wang
- Department of Molecular Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Duolong Zhu
- Department of Molecular Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Xingmin Sun
- Department of Molecular Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
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Towards Development of a Non-Toxigenic Clostridioides difficile Oral Spore Vaccine against Toxigenic C. difficile. Pharmaceutics 2022; 14:pharmaceutics14051086. [PMID: 35631671 PMCID: PMC9146386 DOI: 10.3390/pharmaceutics14051086] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/12/2022] [Accepted: 05/16/2022] [Indexed: 11/24/2022] Open
Abstract
Clostridioides difficile is an opportunistic gut pathogen which causes severe colitis, leading to significant morbidity and mortality due to its toxins, TcdA and TcdB. Two intra-muscular toxoid vaccines entered Phase III trials and strongly induced toxin-neutralising antibodies systemically but failed to provide local protection in the colon from primary C. difficile infection (CDI). Alternatively, by immunising orally, the ileum (main immune inductive site) can be directly targeted to confer protection in the large intestine. The gut commensal, non-toxigenic C. difficile (NTCD) was previously tested in animal models as an oral vaccine for natural delivery of an engineered toxin chimera to the small intestine and successfully induced toxin-neutralising antibodies. We investigated whether NTCD could be further exploited to induce antibodies that block the adherence of C. difficile to epithelial cells to target the first stage of pathogenesis. In NTCD strain T7, the colonisation factor, CD0873, and a domain of TcdB were overexpressed. Following oral immunisation of hamsters with spores of recombinant strain, T7-0873 or T7-TcdB, intestinal and systemic responses were investigated. Vaccination with T7-0873 successfully induced intestinal antibodies that significantly reduced adhesion of toxigenic C. difficile to Caco-2 cells, and these responses were mirrored in sera. Additional engineering of NTCD is now warranted to further develop this vaccine.
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17
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Klezovich-Bénard M, Bouchand F, Rouveix E, Goossens PL, Davido B. Management and characteristics of patients suffering from Clostridiodes difficile infection in primary care. Eur J Gen Pract 2021; 27:320-325. [PMID: 34755587 PMCID: PMC8583832 DOI: 10.1080/13814788.2021.1998447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Clostridioides difficile infection (CDI) is rising and increases patient healthcare costs due to extended hospitalisation, tests and medications. Management of CDI in French primary care is poorly reported. Objectives To characterise patients suffering from CDI, managed in primary care and describe their clinical outcomes. Methods Retrospective observational study based on survey data among 500 randomly selected General Practitioners (GPs) surveyed in France from September 2018 to April 2019. GPs were asked to complete a multiple-choice questionnaire for each reported patient presenting a CDI. Responses were analysed according to clinical characteristics. Treatment strategies were compared according to the outcome: recovery or recurrent infection. Results Participation rate was 8.6% (n = 43/500) with two incomplete questionnaires. Data from 41 patients with an actual diagnosis of CDI were analysed. Recovery was observed in 61% of patients with a confirmed diagnosis of CDI. In the recovery group, this was exclusively a primary episode, most patients (72%) had no comorbidities, were significantly younger (p = 0.02) than the ones who relapsed and 92% were successfully treated with oral metronidazole. Duration of diarrhoea after antimicrobial treatment initiation was significantly shorter in the recovery group (≤ 48 h) (p = 0.03). Cooperation with hospital specialists was reported in 28% of the recovery group versus 87.5% of the recurrent group (p = 0.0003). Overall, GPs managed successfully 82.9% of cases without need of hospital admission. Conclusion GPs provide relevant ambulatory care for mild primary episodes of CDI using oral metronidazole. Persistent diarrhoea despite an appropriate anti-Clostridiodes regimen should be interpreted as an early predictor of relapse.
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Affiliation(s)
- Maria Klezovich-Bénard
- Département de Médecine Générale, l'Université de Versailles Saint Quentin en Yvelines, France
| | - Frédérique Bouchand
- Pharmacie Hospitalière, Centre Hospitalier Universitaire Raymond Poincaré, AP-HP, Garches, France
| | - Elisabeth Rouveix
- Service des Maladies Infectieuses, Centre Hospitalier Universitaire Raymond Poincaré, AP-HP, Garches, France
| | | | - Benjamin Davido
- Service des Maladies Infectieuses, Centre Hospitalier Universitaire Raymond Poincaré, AP-HP, Garches, France
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Meza-Torres J, Auria E, Dupuy B, Tremblay YDN. Wolf in Sheep's Clothing: Clostridioides difficile Biofilm as a Reservoir for Recurrent Infections. Microorganisms 2021; 9:1922. [PMID: 34576818 PMCID: PMC8470499 DOI: 10.3390/microorganisms9091922] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 12/21/2022] Open
Abstract
The microbiota inhabiting the intestinal tract provide several critical functions to its host. Microorganisms found at the mucosal layer form organized three-dimensional structures which are considered to be biofilms. Their development and functions are influenced by host factors, host-microbe interactions, and microbe-microbe interactions. These structures can dictate the health of their host by strengthening the natural defenses of the gut epithelium or cause disease by exacerbating underlying conditions. Biofilm communities can also block the establishment of pathogens and prevent infectious diseases. Although these biofilms are important for colonization resistance, new data provide evidence that gut biofilms can act as a reservoir for pathogens such as Clostridioides difficile. In this review, we will look at the biofilms of the intestinal tract, their contribution to health and disease, and the factors influencing their formation. We will then focus on the factors contributing to biofilm formation in C. difficile, how these biofilms are formed, and their properties. In the last section, we will look at how the gut microbiota and the gut biofilm influence C. difficile biofilm formation, persistence, and transmission.
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Affiliation(s)
- Jazmin Meza-Torres
- Laboratoire Pathogenèse des Bactéries Anaérobies, Institut Pasteur, UMR-CNRS 2001, Université de Paris, 25 rue du Docteur Roux, 75724 Paris, France; (J.M.-T.); (E.A.)
| | - Emile Auria
- Laboratoire Pathogenèse des Bactéries Anaérobies, Institut Pasteur, UMR-CNRS 2001, Université de Paris, 25 rue du Docteur Roux, 75724 Paris, France; (J.M.-T.); (E.A.)
| | - Bruno Dupuy
- Laboratoire Pathogenèse des Bactéries Anaérobies, Institut Pasteur, UMR-CNRS 2001, Université de Paris, 25 rue du Docteur Roux, 75724 Paris, France; (J.M.-T.); (E.A.)
| | - Yannick D. N. Tremblay
- Laboratoire Pathogenèse des Bactéries Anaérobies, Institut Pasteur, UMR-CNRS 2001, Université de Paris, 25 rue du Docteur Roux, 75724 Paris, France; (J.M.-T.); (E.A.)
- Health Sciences Building, Department of Biochemistry, Microbiology and Immunology, University of Saskatchewan, 107 Wiggins Rd, Saskatoon, SK S7N 5E5, Canada
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19
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Bouza E, Cobo J, Rodríguez-Hernández MJ, Salavert M, Horcajada JP, Iribarren JA, Obi E, Lozano V, Maratia S, Cuesta M, Uría E, Limón E. Economic burden of recurrent Clostridioides difficile infection in adults admitted to Spanish hospitals. A multicentre retrospective observational study. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2021; 34:126-135. [PMID: 33618513 PMCID: PMC8019457 DOI: 10.37201/req/135.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/09/2020] [Accepted: 01/07/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Clostridioides difficile infection (CDI) is associated with increased hospital stays and mortality and a high likelihood of rehospitalization, leading to increased health resource use and costs. The objective was to estimate the economic burden of recurrent CDI (rCDI). METHODS Observational, retrospective study carried out in six hospitals. Adults aged ≥18 years with ≥1 confirmed diagnosis (primary or secondary) of rCDI between January 2010 and May 2018 were included. rCDI-related resource use included days of hospital stay (emergency room, ward, isolation and ICU), tests and treatments. For patients with primary diagnosis of rCDI, the complete hospital stay was attributed to rCDI. When diagnosis of rCDI was secondary, hospital stay attributed to rCDI was estimated using 1:1 propensity score matching as the difference in hospital stay compared to controls. Controls were hospitalizations without CDI recorded in the Spanish National Hospital Discharge Database. The cost was calculated by multiplying the natural resource units by the unit cost. Costs (euros) were updated to 2019. RESULTS We included 282 rCDI episodes (188 as primary diagnosis): 66.31% of patients were aged ≥65 years and 57.80% were female. The mean hospital stay (SD) was 17.18 (23.27) days: 86.17% of rCDI episodes were isolated for a mean (SD) of 10.30 (9.97) days. The total mean cost (95%-CI) per episode was €10,877 (9,499-12,777), of which the hospital stay accounted for 92.56. CONCLUSIONS There is high cost and resource use associated with rCDI, highlighting the importance of preventing rCDI to the Spanish National Health System.
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Affiliation(s)
| | | | | | | | | | | | | | - V Lozano
- Virginia Lozano, Merck Sharp-Dohme, Calle de Josefa Valcárcel, 38, 28027, Madrid, Spain.
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Mizusawa M, Carroll KC. Advances and required improvements in methods to diagnosing Clostridioides difficile infections in the healthcare setting. Expert Rev Mol Diagn 2021; 21:311-321. [PMID: 33682564 DOI: 10.1080/14737159.2021.1900737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Clostrididioides difficile is associated with adverse clinical outcomes and increased morbidity, mortality, length of hospital stay, and health-care costs.Areas Covered: We searched relevant papers in PubMed for the last 10 years. In major papers, we scanned the bibliographies to ensure that important articles were included. This review addresses the evolving epidemiology of Clostridioides difficile infection (CDI) and discusses novel methods/approaches for improving the diagnosis of this important disease. EXPERT OPINION No single diagnostic test to date has demonstrated optimum sensitivity and specificity for detection of CDI. Many institutions have developed multi-step algorithms consistent with guidelines established by various professional societies. Some institutions have successfully tried to improve the pretest probability of molecular assays by implementing appropriate sample rejection criteria and establishing best practice alerts at the time of electronic order entry. Others have established PCR cycle threshold cutoffs to attempt to differentiate symptomatic patients from asymptomatic carriers or to make predictions about severity of disease with variable success. As research advances our understanding of C. difficile pathogenesis and pathophysiology, more information on CDI specific biomarkers is emerging. Finally, assessments of the microbiome and metabolome may expand the diagnostic armamentarium with advances in mass spectrometry and sequencing technologies.
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Affiliation(s)
- Masako Mizusawa
- Section of Infectious Diseases, Department of Internal Medicine, University of Missouri, Kansas City, Missouri, Kansas City, MO, USA
| | - Karen C Carroll
- Director Division of Medical Microbiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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21
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van Rossen TM, van Dijk LJ, Heymans MW, Dekkers OM, Vandenbroucke-Grauls CMJE, van Beurden YH. External validation of two prediction tools for patients at risk for recurrent Clostridioides difficile infection. Therap Adv Gastroenterol 2021; 14:1756284820977385. [PMID: 33456500 PMCID: PMC7797589 DOI: 10.1177/1756284820977385] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/03/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND One in four patients with primary Clostridioides difficile infection (CDI) develops recurrent CDI (rCDI). With every recurrence, the chance of a subsequent CDI episode increases. Early identification of patients at risk for rCDI might help doctors to guide treatment. The aim of this study was to externally validate published clinical prediction tools for rCDI. METHODS The validation cohort consisted of 129 patients, diagnosed with CDI between 2018 and 2020. rCDI risk scores were calculated for each individual patient in the validation cohort using the scoring tools described in the derivation studies. Per score value, we compared the average predicted risk of rCDI with the observed number of rCDI cases. Discrimination was assessed by calculating the area under the receiver operating characteristic curve (AUC). RESULTS Two prediction tools were selected for validation (Cobo 2018 and Larrainzar-Coghen 2016). The two derivation studies used different definitions for rCDI. Using Cobo's definition, rCDI occurred in 34 patients (26%) of the validation cohort: using the definition of Larrainzar-Coghen, we observed 19 recurrences (15%). The performance of both prediction tools was poor when applied to our validation cohort. The estimated AUC was 0.43 [95% confidence interval (CI); 0.32-0.54] for Cobo's tool and 0.42 (95% CI; 0.28-0.56) for Larrainzar-Coghen's tool. CONCLUSION Performance of both prediction tools was disappointing in the external validation cohort. Currently identified clinical risk factors may not be sufficient for accurate prediction of rCDI.
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Affiliation(s)
| | - Laura J. van Dijk
- Amsterdam UMC, Vrije Universiteit Amsterdam, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Institute, Amsterdam, The Netherlands
| | - Martijn W. Heymans
- Amsterdam UMC, Vrije Universiteit Amsterdam, Epidemiology and Data Science, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Olaf M. Dekkers
- Leiden University Medical Center, Clinical Epidemiology, Leiden, The Netherlands
| | - Christina M. J. E. Vandenbroucke-Grauls
- Amsterdam UMC, Vrije Universiteit Amsterdam, Medical Microbiology and Infection Control, Amsterdam Infection and Immunity Institute, Amsterdam, The Netherlands
| | - Yvette H. van Beurden
- Amsterdam UMC, Vrije Universiteit Amsterdam, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism Institute, Amsterdam, The Netherlands
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Khanna S, Pardi DS, Jones C, Shannon WD, Gonzalez C, Blount K. RBX7455, a Non-frozen, Orally Administered Investigational Live Biotherapeutic, Is Safe, Effective, and Shifts Patients' Microbiomes in a Phase 1 Study for Recurrent Clostridioides difficile Infections. Clin Infect Dis 2020; 73:e1613-e1620. [PMID: 32966574 PMCID: PMC8492147 DOI: 10.1093/cid/ciaa1430] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Indexed: 12/15/2022] Open
Abstract
Background Recurrent Clostridioides difficile infections (rCDI) are a global public health threat. To reduce rCDI, microbiota-restoring therapies are needed, particularly standardized, easy-to-administer formulations. Methods This phase I open-label trial assessed the safety, efficacy in preventing rCDI recurrence, and intestinal microbiome effects of RBX7455, a room temperature-stable, orally administered investigational live biotherapeutic. Adult participants with 1 or more prior episodes of rCDI received: 4 RBX7455 capsules twice daily for 4 days (group 1); 4 RBX7455 capsules twice daily for 2 days (group 2); or 2 RBX7455 capsules twice daily for 2 days (group 3). For all groups, the first dose was administered in clinic, with remaining doses self-administered at home. Adverse events were monitored during and for 6 months after treatment. Treatment success was defined as rCDI prevention through 8 weeks after treatment. Participants’ microbiome composition was assessed prior to and for 6 months after treatment. Results Nine of 10 group 1 patients (90%), 8 of 10 group 2 patients (80%), and 10 of 10 group 3 patients (100%) were recurrence-free at the 8-week endpoint with durability to 6 months. Seventy-five treatment-emergent adverse events were observed in 27 participants with no serious investigational product-related events. Prior to treatment, participants’ microbiomes were dissimilar from the RBX7455 composition with decreased Bacteroidia- and Clostridia-class bacteria, whereas after treatment, responders’ microbiomes showed increased Bacteroidia and Clostridia. Conclusions Three dosing regimens of RBX7455 were safe and effective at preventing rCDI. Responders’ microbiomes converged toward the composition of RBX7455. These results support its continued clinical evaluation. Clinical Trials Registration NCT02981316.
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Affiliation(s)
- Sahil Khanna
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Courtney Jones
- Rebiotix Inc, a Ferring Company, Roseville, Minnesota, USA
| | | | | | - Ken Blount
- Rebiotix Inc, a Ferring Company, Roseville, Minnesota, USA
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Hernandez BG, Vinithakumari AA, Sponseller B, Tangudu C, Mooyottu S. Prevalence, Colonization, Epidemiology, and Public Health Significance of Clostridioides difficile in Companion Animals. Front Vet Sci 2020; 7:512551. [PMID: 33062657 PMCID: PMC7530174 DOI: 10.3389/fvets.2020.512551] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 08/14/2020] [Indexed: 12/13/2022] Open
Abstract
Clostridioides difficile, previously Clostrdium difficile, is a major cause of antibiotic-associated enteric disease in humans in hospital settings. Increased incidence of C. difficile infection (CDI) in community settings raises concerns over an alternative source of CDI for humans. The detection of genetically similar and toxigenic C. difficile isolates in companion animals, including asymptomatic pets, suggests the potential role of household pets as a source of community-associated CDI. The close association between companion animals and humans, in addition to the use of similar antibiotics in both species, could provide a selective advantage for the emergence of new C. difficile strains and thus increase the incidental transmission of CDI to humans. Therefore, screening household pets for C. difficile is becoming increasingly important from a public health standpoint and may become a part of routine testing in the future, for the benefit of susceptible or infected individuals within a household. In this review, we analyze available information on prevalence, pathophysiology, epidemiology, and molecular genetics of C. difficile infection, focusing on companion animals and evaluate the risk of pet-borne transmission of CDI as an emerging public health concern. Molecular epidemiological characterization of companion animal C. difficile strains could provide further insights into the interspecies transmission of CDI. The mosaic nature of C. difficile genomes and their susceptibility to horizontal gene transfer may facilitate the inter-mixing of genetic material, which could increase the possibility of the emergence of new community-associated CDI strains. However, detailed genome-wide characterization and comparative genome analysis are warranted to confirm this hypothesis.
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Affiliation(s)
- Belen G. Hernandez
- Department of Veterinary Pathology, Iowa State University, Ames, IA, United States
| | | | - Brett Sponseller
- Department of Veterinary Microbiology and Preventive Medicine, Iowa State University, Ames, IA, United States
| | - Chandra Tangudu
- Department of Veterinary Microbiology and Preventive Medicine, Iowa State University, Ames, IA, United States
| | - Shankumar Mooyottu
- Department of Veterinary Pathology, Iowa State University, Ames, IA, United States
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Abstract
Clostridium difficile, the most common cause of hospital-associated diarrhoea in developed countries, presents major public health challenges. The high clinical and economic burden from C. difficile infection (CDI) relates to the high frequency of recurrent infections caused by either the same or different strains of C. difficile. An interval of 8 weeks after index infection is commonly used to classify recurrent CDI episodes. We assessed strains of C. difficile in a sample of patients with recurrent CDI in Western Australia from October 2011 to July 2017. The performance of different intervals between initial and subsequent episodes of CDI was investigated. Of 4612 patients with CDI, 1471 (32%) were identified with recurrence. PCR ribotyping data were available for initial and recurrent episodes for 551 patients. Relapse (recurrence with same ribotype (RT) as index episode) was found in 350 (64%) patients and reinfection (recurrence with new RT) in 201 (36%) patients. Our analysis indicates that 8- and 20-week intervals failed to adequately distinguish reinfection from relapse. In addition, living in a non-metropolitan area modified the effect of age on the risk of relapse. Where molecular epidemiological data are not available, we suggest that applying an 8-week interval to define recurrent CDI requires more consideration.
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Bezlotoxumab for prevention of Clostridium difficile infection recurrence: Distinguishing relapse from reinfection with whole genome sequencing. Anaerobe 2020; 61:102137. [DOI: 10.1016/j.anaerobe.2019.102137] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 08/15/2019] [Accepted: 12/02/2019] [Indexed: 01/05/2023]
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26
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Kachlíková M, Sabaka P, Koščálová A, Bendžala M, Dovalová Z, Stankovič I. Comorbid status and the faecal microbial transplantation failure in treatment of recurrent Clostridioides difficile infection - pilot prospective observational cohort study. BMC Infect Dis 2020; 20:52. [PMID: 31948404 PMCID: PMC6966799 DOI: 10.1186/s12879-020-4773-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 01/07/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Faecal microbial transplantation (FMT) is currently the most effective treatment of recurrent Clostridioides difficile infection (CDI). However, up to 20% of patients experience further recurrences after single FMT. The mechanisms that lead to FMT failure and its risk factors are poorly understood. Comorbidity is one of the risk factors of the failure of standard antibiotic therapy of recurrent CDI. It is not known if comorbidity is also associated with the risk of FMT failure. METHODS We conducted a prospective observational cohort study in order to elucidate if comorbid status is associated with FMT failure. Patients with microbiologically proven recurrent CDI were recruited and underwent FMT via retention enema. Patients were followed up for 12 weeks after FMT for signs and symptoms of CDI recurrence. Single FMT failure was defined as recurrence of diarrhoea and a positive stool test for the presence of C. difficile antigen or toxin at any time point during the 12 weeks of follow-up. We assessed the association of single FMT failure with possible manageable and unmanageable risk factors. As a surrogate of comorbid status, we used Charlson Comorbidity Index (CCI) ≥ 7. RESULTS A total of 60 patients that underwent single FMT (34 women, 26 men) were included in the study. Overall, 15 patients (25%) experienced single FMT failure. 24 patients (40%) had CCI ≥ 7, and 45.0% patients with CCI ≥ 7 experienced failure of single FMT. Patients who experienced single FMT failure had a significantly higher CCI and significantly lower albumin concentration as compared to patients who experienced single FMT success. There was no difference in age, C-reactive protein concentration, leukocyte count and time from FMT to first defecation. In multivariate analysis, CCI ≥ 7 was positively associated with the failure of single FMT. Analysis was controlled for sex, age, time from FMT to first defecation, concomitant PPI therapy, severe CDI, hospital-acquired infection and albumin concentration. CONCLUSIONS Comorbid status surrogated by CCI is positively associated with the failure of single FMT in the treatment of recurrent CDI.
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Affiliation(s)
- M. Kachlíková
- 0000000109409708grid.7634.6Department of Infectology and Geographical Medicine, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovak Republic
| | - P. Sabaka
- 0000000109409708grid.7634.6Department of Infectology and Geographical Medicine, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovak Republic
| | - A. Koščálová
- 0000000095755967grid.9982.aDepartment of Infectology and Geographical Medicine, Faculty of Medicine, Slovak Medical University, Bratislava, Slovak Republic
| | - M. Bendžala
- 0000000109409708grid.7634.6Department of Infectology and Geographical Medicine, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovak Republic
| | - Z. Dovalová
- 0000000109409708grid.7634.6Department of Infectology and Geographical Medicine, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovak Republic
| | - I. Stankovič
- 0000000109409708grid.7634.6Department of Infectology and Geographical Medicine, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovak Republic
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Ho J, Wong SH, Doddangoudar VC, Boost MV, Tse G, Ip M. Regional differences in temporal incidence of Clostridium difficile infection: a systematic review and meta-analysis. Am J Infect Control 2020; 48:89-94. [PMID: 31387772 DOI: 10.1016/j.ajic.2019.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/07/2019] [Accepted: 07/08/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Previous decades have witnessed a change in the epidemiology of Clostridium difficile infections. This study aimed to determine temporal trends in the incidence of C difficile infection across geographic regions. METHODS An initial search of the relevant literature was conducted from date inception to October 2018 without language restriction. We estimated the pooled incidences using logit transformation, weighted by inverse variance. The Joinpoint Regression Analysis Program was used to explore its temporal trend. RESULTS Globally, the estimated incidence of C difficile infection increased from 6.60 per 10,000 patient-days in 1997 to 13.8 per 10,000 patient-days in 2004. Thereafter, a significant downward trend was observed, at -8.75% annually until 2015. From 2005 to 2015, the incidences in most European countries decreased at a rate between 1.97% and 4.11% per annum, except in France, where an increasing incidence was observed (β = 0.16; P < .001). The incidences have stabilized in North America over the same period; however, in Asia, the incidence increased significantly from 2006 to 2014 (annualized percentage change = 14.4%; P < .001). The increase was greatest in Western Asian countries, including Turkey and Israel (β > 0.10; P < .004). CONCLUSIONS This study revealed rapid changes in the incidence of C difficile infection. This meta-analysis should inform the allocation of resources for controlling C difficile infection and future surveillance efforts in countries where epidemiologic information on C difficile infection remains sparse.
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Affiliation(s)
- Jeffery Ho
- Department of Microbiology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong.
| | - Sunny H Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Vijaya C Doddangoudar
- Nitte Gulabi Shetty Memorial Institute of Pharmaceutical Sciences, Nitte University, India
| | - Maureen V Boost
- School of Optometry, The Hong Kong Polytechnic University, Hong Kong
| | - Gary Tse
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Margaret Ip
- Department of Microbiology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
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Gao Y, Li H, Yang H, Su J, Huang L. The current novel therapeutic regimens for Clostridium difficile infection (CDI) and the potentials of Traditional Chinese Medicine in treatment of CDI. Crit Rev Microbiol 2019; 45:729-742. [PMID: 31838936 DOI: 10.1080/1040841x.2019.1700905] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Clostridium difficile infection (CDI) is featured as the dysbiosis of gut microbiota and consequent mild diarrhoea or severe pseudomembranous colitis. However, the frequent recurrence of CDI following treatment course challenged the antibiotic therapy. Currently, to address the relapse of CDI, several novel therapeutic approaches have emerged, including Bezlotoxumab, SYN-004 (Ribaxamase), RBX2660, and faecal microbial transplant. Traditional Chinese Medicine (TCM) is an old medical system accumulated for thousands of years. Orientated by syndrome-based treatment, TCM functions in a multicomponent and multitarget mode. This old medical system showed superiority over conventional medical treatment, particularly in the treatment of complex disorders, including CDI. In the present review, we will elaborate the TCM intervention in the management of CDI and others disorders via restoring the gut microbiota dysbiosis. We hope that this review will deepen our understanding of TCM as an alternative to CDI treatment. However, more rigorously designed basic researches and randomised controlled trials need to conduct to appraise the function mechanisms and effects of TCM. Finally, it is concluded that the combined therapeutic potentials of TCM and western medicine could be harness to resolve the recurrence and improve the outcome of CDI.
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Affiliation(s)
- Yan Gao
- Department of Clinical Laboratory Diagnostics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hui Li
- Institute of Chinese Materia Medica, Chinese Academy of Chinese Medical Sciences, Beijing, China
| | - Hongjun Yang
- Institute of Chinese Materia Medica, Chinese Academy of Chinese Medical Sciences, Beijing, China
| | - Jianrong Su
- Department of Clinical Laboratory Diagnostics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Luqi Huang
- China Academy of Chinese Medical Sciences, Beijing, China
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29
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Ribotype variability of Clostridioides difficile strains in patients with hospital-acquired C. difficile infections, community-acquired C. difficile infections, and colonization with toxigenic and non-toxigenic strains of C. difficile. Anaerobe 2019; 60:102086. [DOI: 10.1016/j.anaerobe.2019.102086] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 07/10/2019] [Accepted: 08/08/2019] [Indexed: 11/19/2022]
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30
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McDonald LC, Gerding DN, Johnson S, Bakken JS, Carroll KC, Coffin SE, Dubberke ER, Garey KW, Gould CV, Kelly C, Loo V, Shaklee Sammons J, Sandora TJ, Wilcox MH. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2019; 66:e1-e48. [PMID: 29462280 DOI: 10.1093/cid/cix1085] [Citation(s) in RCA: 1231] [Impact Index Per Article: 246.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.
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Affiliation(s)
| | | | - Stuart Johnson
- Edward Hines Jr Veterans Administration Hospital, Hines.,Loyola University Medical Center, Maywood, Illinois
| | | | - Karen C Carroll
- Johns Hopkins University School of Medicine, Baltimore, Maryl
| | | | - Erik R Dubberke
- Washington University School of Medicine, St Louis, Missouri
| | | | - Carolyn V Gould
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ciaran Kelly
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Vivian Loo
- McGill University Health Centre, McGill University, Montréal, Québec, Canada
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Connor MC, McGrath JW, McMullan G, Marks N, Guelbenzu M, Fairley DJ. Emergence of a non-sporulating secondary phenotype in Clostridium (Clostridioides) difficile ribotype 078 isolated from humans and animals. Sci Rep 2019; 9:13722. [PMID: 31548637 PMCID: PMC6757067 DOI: 10.1038/s41598-019-50285-y] [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: 03/06/2019] [Accepted: 08/27/2019] [Indexed: 11/09/2022] Open
Abstract
Clostridium (Clostridioides) difficile is a Gram positive, spore forming anaerobic bacterium that is a leading cause of antibiotic associated diarrhoea in the developed world. C. difficile is a genetically diverse species that can be divided into 8 phylogenetically distinct clades with clade 5 found to be genetically distant from all others. Isolates with the PCR ribotype 078 belong to clade 5, and are often associated with C. difficile infection in both humans and animals. Colonisation of animals and humans by ribotype 078 raises questions about possible zoonotic transmission, and also the diversity of reservoirs for ribotype 078 strains within the environment. One of the key factors which enables C. difficile to be a successful, highly transmissible pathogen is its ability to produce oxygen resistant spores capable of surviving harsh conditions. Here we describe the existence of a non-sporulating variant of C. difficile ribotype 078 harbouring mutations leading to premature stop codons within the master regulator, Spo0A. As sporulation is imperative to the successful transmission of C. difficile this study was undertaken to investigate phenotypic characteristics of this asporogenous phenotype with regards to growth rate, antibiotic susceptibility, toxin production and biofilm formation.
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Affiliation(s)
- M C Connor
- School of Biological Sciences and the Institute for Global Food Security, Queen's University Belfast, Belfast, UK.
| | - J W McGrath
- School of Biological Sciences and the Institute for Global Food Security, Queen's University Belfast, Belfast, UK
| | - G McMullan
- School of Biological Sciences and the Institute for Global Food Security, Queen's University Belfast, Belfast, UK
| | - N Marks
- School of Biological Sciences and the Institute for Global Food Security, Queen's University Belfast, Belfast, UK
| | - M Guelbenzu
- Veterinary Science Division, Agri-Food Biosciences Institute, Belfast, UK.,Animal Health Ireland, Carrick on Shannon, Republic of Ireland
| | - D J Fairley
- Department of Microbiology, Belfast Health & Social Care Trust, Belfast, UK
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32
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Boyanova L, Markovska R, Hadzhiyski P, Yordanov D, Yaneva P, Mitov I. Recurrent Clostridioides (Clostridium) difficile infection in a patient suffering from inflammatory bowel disease and benefits of resistotyping. Diagn Microbiol Infect Dis 2019; 94:334-336. [DOI: 10.1016/j.diagmicrobio.2019.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 01/23/2019] [Accepted: 02/11/2019] [Indexed: 11/26/2022]
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Slater RT, Frost LR, Jossi SE, Millard AD, Unnikrishnan M. Clostridioides difficile LuxS mediates inter-bacterial interactions within biofilms. Sci Rep 2019; 9:9903. [PMID: 31289293 PMCID: PMC6616478 DOI: 10.1038/s41598-019-46143-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 06/21/2019] [Indexed: 12/18/2022] Open
Abstract
The anaerobic gut pathogen, Clostridioides difficile, forms adherent biofilms that may play an important role in recurrent C. difficile infections. The mechanisms underlying C. difficile community formation and inter-bacterial interactions are nevertheless poorly understood. C. difficile produces AI-2, a quorum sensing molecule that modulates biofilm formation across many bacterial species. We found that a strain defective in LuxS, the enzyme that mediates AI-2 production, is defective in biofilm development in vitro. Transcriptomic analyses of biofilms formed by wild type (WT) and luxS mutant (luxS) strains revealed a downregulation of prophage loci in the luxS mutant biofilms compared to the WT. Detection of phages and eDNA within biofilms may suggest that DNA release by phage-mediated cell lysis contributes to C. difficile biofilm formation. In order to understand if LuxS mediates C. difficile crosstalk with other gut species, C. difficile interactions with a common gut bacterium, Bacteroides fragilis, were studied. We demonstrate that C. difficile growth is significantly reduced when co-cultured with B. fragilis in mixed biofilms. Interestingly, the absence of C. difficile LuxS alleviates the B. fragilis-mediated growth inhibition. Dual species RNA-sequencing analyses from single and mixed biofilms revealed differential modulation of distinct metabolic pathways for C. difficile WT, luxS and B. fragilis upon co-culture, indicating that AI-2 may be involved in induction of selective metabolic responses in B. fragilis. Overall, our data suggest that C. difficile LuxS/AI-2 utilises different mechanisms to mediate formation of single and mixed species communities.
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Affiliation(s)
- Ross T Slater
- University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, United Kingdom
| | - Lucy R Frost
- University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, United Kingdom
| | - Sian E Jossi
- University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, United Kingdom
| | - Andrew D Millard
- University of Leicester, University Road, Leicester, LE1 7RH, UK
| | - Meera Unnikrishnan
- University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, United Kingdom.
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Simeon R, Jiang M, Chamoun-Emanuelli AM, Yu H, Zhang Y, Meng R, Peng Z, Jakana J, Zhang J, Feng H, Chen Z. Selection and characterization of ultrahigh potency designed ankyrin repeat protein inhibitors of C. difficile toxin B. PLoS Biol 2019; 17:e3000311. [PMID: 31233493 PMCID: PMC6590788 DOI: 10.1371/journal.pbio.3000311] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 05/20/2019] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile infection (CDI) is a major nosocomial disease associated with significant morbidity and mortality. The pathology of CDI stems primarily from the 2 C. difficile-secreted exotoxins-toxin A (TcdA) and toxin B (TcdB)-that disrupt the tight junctions between epithelial cells leading to the loss of colonic epithelial barrier function. Here, we report the engineering of a series of monomeric and dimeric designed ankyrin repeat proteins (DARPins) for the neutralization of TcdB. The best dimeric DARPin, DLD-4, inhibited TcdB with a half maximal effective concentration (EC50) of 4 pM in vitro, representing an approximately 330-fold higher potency than the Food and Drug Administration (FDA)-approved anti-TcdB monoclonal antibody bezlotoxumab in the same assay. DLD-4 also protected mice from a toxin challenge in vivo. Cryo-electron microscopy (cryo-EM) studies revealed that the 2 constituent DARPins of DLD-4-1.4E and U3-bind the central and C-terminal regions of the delivery domain of TcdB. Competitive enzyme-linked immunosorbent assay (ELISA) studies showed that the DARPins 1.4E and U3 interfere with the interaction between TcdB and its receptors chondroitin sulfate proteoglycan 4 (CSPG4) and frizzled class receptor 2 (FZD2), respectively. Our cryo-EM studies revealed a new conformation of TcdB (both apo- and DARPin-bound at pH 7.4) in which the combined repetitive oligopeptides (CROPS) domain points away from the delivery domain. This conformation of the CROPS domain is in stark contrast to that seen in the negative-stain electron microscopy (EM) structure of TcdA and TcdB at the same pH, in which the CROPS domain bends toward and "kisses" the delivery domain. The ultrapotent anti-TcdB molecules from this study serve as candidate starting points for CDI drug development and provide new biological tools for studying the pathogenicity of C. difficile. The structural insights regarding both the "native" conformation of TcdB and the putative sites of TcdB interaction with the FZD2 receptor, in particular, should help accelerate the development of next-generation anti-C. difficile toxin therapeutics.
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Affiliation(s)
- Rudo Simeon
- Department of Microbial Pathogenesis and Immunology, Texas A&M University Health Science Center, College Station, Texas, United States of America
| | - Mengqiu Jiang
- Department of Biochemistry and Biophysics, Texas A&M University, College Station, Texas, United States of America
| | - Ana M. Chamoun-Emanuelli
- Department of Microbial Pathogenesis and Immunology, Texas A&M University Health Science Center, College Station, Texas, United States of America
| | - Hua Yu
- Department of Microbial Pathogenesis, University of Maryland Dental School, Baltimore, Maryland, United Sates of America
| | - Yongrong Zhang
- Department of Microbial Pathogenesis, University of Maryland Dental School, Baltimore, Maryland, United Sates of America
| | - Ran Meng
- Department of Biochemistry and Biophysics, Texas A&M University, College Station, Texas, United States of America
| | - Zeyu Peng
- Department of Microbial Pathogenesis and Immunology, Texas A&M University Health Science Center, College Station, Texas, United States of America
| | - Joanita Jakana
- National Center for Macromolecular Imaging, Verna and Marrs McLean Department of Biochemistry and Molecular Biology, Baylor College of Medicine, Houston, Texas, United States of America
| | - Junjie Zhang
- Department of Biochemistry and Biophysics, Texas A&M University, College Station, Texas, United States of America
| | - Hanping Feng
- Department of Microbial Pathogenesis, University of Maryland Dental School, Baltimore, Maryland, United Sates of America
| | - Zhilei Chen
- Department of Microbial Pathogenesis and Immunology, Texas A&M University Health Science Center, College Station, Texas, United States of America
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Abstract
ABSTRACT
Clostridioides difficile
is a Gram-positive, anaerobic, spore forming pathogen of both humans and animals and is the most common identifiable infectious agent of nosocomial antibiotic-associated diarrhea. Infection can occur following the ingestion and germination of spores, often concurrently with a disruption to the gastrointestinal microbiota, with the resulting disease presenting as a spectrum, ranging from mild and self-limiting diarrhea to severe diarrhea that may progress to life-threating syndromes that include toxic megacolon and pseudomembranous colitis. Disease is induced through the activity of the
C. difficile
toxins TcdA and TcdB, both of which disrupt the Rho family of GTPases in host cells, causing cell rounding and death and leading to fluid loss and diarrhea. These toxins, despite their functional and structural similarity, do not contribute to disease equally.
C. difficile
infection (CDI) is made more complex by a high level of strain diversity and the emergence of epidemic strains, including ribotype 027-strains which induce more severe disease in patients. With the changing epidemiology of CDI, our understanding of
C. difficile
disease, diagnosis, and pathogenesis continues to evolve. This article provides an overview of the current diagnostic tests available for CDI, strain typing, the major toxins
C. difficile
produces and their mode of action, the host immune response to each toxin and during infection, animal models of disease, and the current treatment and prevention strategies for CDI.
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Song JH, Kim YS. Recurrent Clostridium difficile Infection: Risk Factors, Treatment, and Prevention. Gut Liver 2019; 13:16-24. [PMID: 30400734 PMCID: PMC6346998 DOI: 10.5009/gnl18071] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 03/12/2018] [Accepted: 03/22/2018] [Indexed: 12/15/2022] Open
Abstract
The most common cause of antibiotic-associated diarrhea is Clostridium difficile infection (CDI). Recurrent C. difficile infection (rCDI) often occurs after successful treatment of CDI. Due to the increased incidence and the difficulty in treating rCDI, it is becoming an important clinical issue. Identifying risk factors is helpful for early detection, treatment, and prevention of rCDI. Advanced age, use of antibiotics, gastric acid suppression, and infection with a hypervirulent strain are currently regarded as the major risk factors for rCDI. Several treatment modalities, including vancomycin, fidaxomicin, and fecal microbiota transplant (FMT), are suggested for rCDI treatment. However, there is currently no definitive treatment method with sufficient evidence for rCDI. Recent studies have focused on FMT and have shown positive results for rCDI. Prevention of rCDI by measures such as hand washing and isolation of patients is very important. However, these preventive measures are often overlooked in clinical practice. Here, we review the risk factors, treatment, and prevention of rCDI.
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Affiliation(s)
- Jung Hoon Song
- Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, Korea
| | - You Sun Kim
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
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Shoaei P, Shojaei H, Jalali M, Khorvash F, Hosseini SM, Ataei B, Vakili B, Ebrahimi F, Tavakoli H, Esfandiari Z, Weese JS. Clostridium difficile isolated from faecal samples in patients with ulcerative colitis. BMC Infect Dis 2019; 19:361. [PMID: 31039738 PMCID: PMC6492486 DOI: 10.1186/s12879-019-3965-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 04/08/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Ulcerative colitis (UC) is an inflammatory bowel disease (IBD) that is widely identified worldwide. This study aimed to investigate the phenotypic characterization and molecular typing of Clostridium difficile isolates among patients with UC at an inflammatory bowel disease clinic in Iran. METHODS In this cross-sectional study, conducted from April 2015 to December 2015, 85 UC patients were assessed for C.difficile infection (CDI). C. difficile isolates were characterized based on their toxin profile and antimicrobial resistance pattern. Multi-locus sequence typing analysis (MLST) and PCR ribotyping were performed to define the genetic relationships between different lineages of toxigenic strains. RESULTS The prevalence of C. difficile isolates was 31.8% (27/85) in patients, of those 15 patients (17.6%) had CDI. Three different sequence types (STs) identified based on MLST among the toxigenic isolates, that is ST54 (33.3%), ST2 (53.3%), and ST37 (13.6%). C. difficile strains were divided into four different PCR-ribotypes (012, 014, 017 and IR1). The most common ribotype was 014 accounting for 48.3% (7/15) of all strains. The strains isolated during the first episode and recurrence of CDI usually belonged to PCR ribotype 014 (ST2). A high rate of CDI recurrence (14.1%, 12/85) experienced in UC patients. Colonization of the gastrointestinal tract with non-toxigenic C. difficile strains was frequent among patients with mild disease. All C. difficile isolates were susceptible to metronidazole, and vancomycin, 86 and 67% of isolates were resistant to clindamycin and erythromycin respectively. There was no correlation between the toxin type and antibiotic resistance (p > 0.05). CONCLUSION Overall CDI is rather prevalent in UC patients. All patients with CDI experienced moderate to severe disease and exposed to different antimicrobial and anti-inflammatory agents. Close monitoring and appropriate management including early detection and fast treatment of CDI will improve UC outcomes.
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Affiliation(s)
- Parisa Shoaei
- Nosocomial Infection Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hasan Shojaei
- Department of Microbiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Jalali
- School of Food Science and Nutrition, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Farzin Khorvash
- Nosocomial Infection Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Sayed Mohsen Hosseini
- Epidemiology and biostatics department, Isfahan University of Medical sciences, Isfahan, Iran
| | - Behrooz Ataei
- Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Bahareh Vakili
- Department of Microbiology, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Fatemeh Ebrahimi
- Department of Microbiology, Islamic Azad University of Falavarjan, Isfahan, Iran
| | - Hossein Tavakoli
- Department of Physiology and Pathophysiology, University of Manitoba, Winnipeg, MB, Canada
| | - Zahra Esfandiari
- Department of Research and Development, Vice Chancellory for food and drug, Isfahan, Iran
| | - J Scott Weese
- Department of Pathobiology and Centre for Public Health and Zoonoses, Ontario Veterinary College, University of Guelph, Guelph, Canada
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Dayananda P, Wilcox MH. A Review of Mixed Strain Clostridium difficile Colonization and Infection. Front Microbiol 2019; 10:692. [PMID: 31024483 PMCID: PMC6469431 DOI: 10.3389/fmicb.2019.00692] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 03/19/2019] [Indexed: 12/18/2022] Open
Abstract
Given that Clostridium difficile is not part of the normal human microbiota, if multiple strains are to accumulate in the colon implies successive exposure events and/or persistent colonization must occur. Evidence of C. difficile infection (CDI) with more than one strain was first described in 1983. Despite the availability of increasingly discriminatory bacterial fingerprinting methods, the described rate of dual strain recovery in patients with CDI has remained stable at ∼5–10%. More data are needed to determine when dual strain infection may be harmful. Notably, one strain may block the establishment of and infection by another. In humans, patients colonized by non-toxigenic C. difficile strain are at a lower risk of developing CDI. Further studies to elucidate the interaction between co-infecting or colonizing and infecting C. difficile strains may help identify potential exploitable mechanisms to prevent CDI.
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Affiliation(s)
- Pete Dayananda
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom
| | - Mark H Wilcox
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom
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Kaako A, Al-Amer M, Abdeen Y. Bezlotoxumab use as adjunctive therapy with the third fecal microbiota transplant in refractory recurrent Clostridium difficile colitis; a case report and concise literature review. Anaerobe 2018; 55:112-116. [PMID: 30521856 DOI: 10.1016/j.anaerobe.2018.11.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 02/08/2023]
Abstract
Clostridium difficile is the most commonly reported pathogen to cause nosocomial infections in the United States with a high burden affecting morbidity, mortality and healthcare expenditure. The use of Fecal Microbiota Transplantation (FMT) is one of the current standard therapies for recurrent C. difficile infection (CDIr). One emerging promising approach is the use of monoclonal antibodies that bind to and neutralize C. difficile toxins such as Bezlotoxumab. We present the first case report on combining the third FMT with bezlotoxumab after the failure of standard-of-care antibiotics and two trials of FMT alone, with subsequent success in preventing the recurrence of refractory CDI for 12 weeks following treatment. This case highlights the need for further studies and guidelines to recommend the best combination among different treatment options and modalities.
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Affiliation(s)
- Ahmad Kaako
- Mercy Clinic Hospitalist, Physician Building, 7301 Rogers Ave, Fort Smith, AR 72903, United States.
| | - Mohammad Al-Amer
- Internal Medicine Department, Ibn Alhaytham Hospital, Amman, Jordan
| | - Yazan Abdeen
- Pulmonary Department, Physician Building, 7301 Rogers Ave, Fort Smith, AR 72903, United States
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Gupta SB, Dubberke ER. Reprint of: Overview and changing epidemiology of Clostridium difficile infection. SEMINARS IN COLON AND RECTAL SURGERY 2018. [DOI: 10.1053/j.scrs.2018.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Watson RL, Graber CJ. Lack of improvement in antimicrobial prescribing after a diagnosis of Clostridium difficile and impact on recurrence. Am J Infect Control 2018; 46:1370-1374. [PMID: 29779687 DOI: 10.1016/j.ajic.2018.04.213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 04/12/2018] [Accepted: 04/12/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Antimicrobial use is one of the largest modifiable risk factors for development of Clostridium difficile infection (CDI). We sought to determine if a recent diagnosis of CDI affected the appropriateness of subsequent antimicrobial prescribing. METHODS This study is a retrospective electronic chart review of the Greater Los Angeles Veterans Administration. Medication administration records were reviewed for all patients with new CDI from 2015-2016 to determine the appropriateness (drug choice, duration, and dosage) of all non-CDI antimicrobials prescribed within 90 days pre- and post-initial CDI (iCDI) positive testing. RESULTS Of the 210 patients diagnosed with new-onset iCDI, 140 met inclusion criteria. Of antimicrobial courses prescribed, 40.6% of pre-iCDI were inappropriate compared with 43.1% of post-iCDI, demonstrating no difference in prescribing habits (P = .717). Thirty-three patients developed recurrent CDI (rCDI). After adjustment for other known risk factors, inappropriate antimicrobial use was associated with a significant increased risk of recurrence compared with appropriate use alone (odds ratio [OR], 6.19; 95% confidence interval [CI], 1.45-26.42). Antimicrobial use in general was associated with increased recurrence compared with no antimicrobial use post-iCDI (OR, 2.6; 95% CI, 1.16-5.84); however, after adjustment, it was no longer significant (OR, 2.13; 95% CI, 0.90-5.04). CONCLUSIONS The appropriateness of antimicrobial prescribing was not affected by the diagnosis of recent CDI. Inappropriate antimicrobial use after iCDI was associated with higher risk of rCDI.
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Affiliation(s)
- Richard L Watson
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Christopher J Graber
- Infectious Diseases Section, VA Greater Los Angeles Healthcare System, Los Angeles, CA; Infectious Diseases Division, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.
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42
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Li X, Gao X, Hu H, Xiao Y, Li D, Yu G, Yu D, Zhang T, Wang Y. Clinical Efficacy and Microbiome Changes Following Fecal Microbiota Transplantation in Children With Recurrent Clostridium Difficile Infection. Front Microbiol 2018; 9:2622. [PMID: 30450088 PMCID: PMC6224514 DOI: 10.3389/fmicb.2018.02622] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 10/12/2018] [Indexed: 12/14/2022] Open
Abstract
Fecal microbiota transplantation (FMT) has been shown as an effective treatment for recurrent clostridium difficile infection (RCDI) in adults. In this study, we aim to evaluate the clinical efficacy of FMT in treating children with RCDI, and explore fecal microbiota changes during FMT treatment. A total of 11 RCDI subjects with a median age of 3.5 years were enrolled in this single-center prospective pilot study. All patients were cured (11/11, 100%) by FMT either through upper gastrointestinal tract route with a nasointestinal tube (13/16, 81.2%) or lower gastrointestinal tract route with a rectal tube (3/16, 18.8%). The cure rate of single FMT was 63.6% (7/11), and 4 (4/11, 36.4%) cases were performed with 2 or 3 times of FMT. Mild adverse events were reported in 4 children (4/11, 36.4%), including transient diarrhea, mild abdominal pain, transient fever and vomit. Gut microbiota composition analysis of 59 fecal samples collected from 34 participants (9 RCDI children, 9 donors and 16 health controls) showed that the alpha diversity was lower in pediatric RCDI patients before FMT than the healthy controls and donors, and fecal microbial community of pre-FMT samples (beta diversity) was apart from that of healthy controls and donors. No significant differences in alpha diversity, beta diversity or phylogenetic distance were detected between donors and healthy controls. Both the richness and diversity of gut microbiota were improved in the pediatric RCDI patients after FMT, and the bacteria community was shifted closer to the donor and healthy control group. Furthermore, FMT re-directed gut microbiome functions of pediatric RCDI toward a health state. Our results indicate that it is safe and tolerant to use FMT in treating pediatric RCDI. FMT shifted the gut microbiome composition and function in children with RCDI toward a healthy state.
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Affiliation(s)
- Xiaolu Li
- Department of Gastroenterology, Hepatology and Nutrition, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xuefeng Gao
- Shenzhen University General Hospital, Shenzhen, China.,Shenzhen University Clinical Medical Academy, Shenzhen, China
| | - Hui Hu
- Department of Gastroenterology, Hepatology and Nutrition, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yongmei Xiao
- Department of Gastroenterology, Hepatology and Nutrition, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Dan Li
- Department of Gastroenterology, Hepatology and Nutrition, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Guangjun Yu
- Department of Gastroenterology, Hepatology and Nutrition, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Dongbao Yu
- Shenzhen Hoiracle Bio-Tech Co., Ltd., Shenzhen, China
| | - Ting Zhang
- Department of Gastroenterology, Hepatology and Nutrition, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yizhong Wang
- Department of Gastroenterology, Hepatology and Nutrition, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
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Oral Immunization with Nontoxigenic Clostridium difficile Strains Expressing Chimeric Fragments of TcdA and TcdB Elicits Protective Immunity against C. difficile Infection in Both Mice and Hamsters. Infect Immun 2018; 86:IAI.00489-18. [PMID: 30150259 DOI: 10.1128/iai.00489-18] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 08/21/2018] [Indexed: 12/29/2022] Open
Abstract
The symptoms of Clostridium difficile infection (CDI) are attributed largely to two C. difficile toxins, TcdA and TcdB. Significant efforts have been devoted to developing vaccines targeting both toxins through parenteral immunization routes. However, C. difficile is an enteric pathogen, and mucosal/oral immunization would be particularly useful to protect the host against CDI, considering that the gut is the main site of disease onset and progression. Moreover, vaccines directed only against toxins do not target the cells and spores that transmit the disease. Previously, we constructed a chimeric vaccine candidate, mTcd138, comprised of the glucosyltransferase and cysteine proteinase domains of TcdB and the receptor binding domain of TcdA. In this study, to develop an oral vaccine that can target both C. difficile toxins and colonization/adhesion factors, we expressed mTcd138 in a nontoxigenic C. difficile (NTCD) strain, resulting in strain NTCD_mTcd138. Oral immunization with spores of NTCD_mTcd138 provided mice full protection against infection with a hypervirulent C. difficile strain, UK6 (ribotype 027). The protective strength and efficacy of NTCD_mTcd138 were further evaluated in the acute CDI hamster model. Oral immunization with spores of NTCD_mTcd138 also provided hamsters significant protection against infection with 2 × 104 UK6 spores, a dose 200-fold higher than the lethal dose of UK6 in hamsters. These results imply that the genetically modified, nontoxigenic C. difficile strain expressing mTcd138 may represent a novel mucosal vaccine candidate against CDI.
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Teng P, Li C, Peng Z, Anne Marie V, Nimmagadda A, Su M, Li Y, Sun X, Cai J. Facilely accessible quinoline derivatives as potent antibacterial agents. Bioorg Med Chem 2018; 26:3573-3579. [PMID: 29858158 DOI: 10.1016/j.bmc.2018.05.031] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/14/2018] [Accepted: 05/21/2018] [Indexed: 01/22/2023]
Abstract
Quinoline compounds have been extensively explored as anti-malaria and anti-cancer agents for decades and show profound functional bioactivities, however, the studies of these compounds in other medicinal fields have lagged dramatically. In this study, we report the development of a series of facilely accessible quinoline derivatives that display potent antibacterial activity against a panel of multidrug-resistant Gram-positive bacterial strains, especially C. difficile. We also demonstrated that these molecules are effective in vivo against C. difficile. These results revealed that these types of quinoline compounds could serve as prototypes for the development of an appealing class of antibiotic agents used to combat Gram-positive drug-resistant bacterial strains, including C. difficile.
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Affiliation(s)
- Peng Teng
- Department of Chemistry, University of South Florida, 4202 E. Fowler Ave, Tampa, FL 33620, USA
| | - Chunhui Li
- Department of Molecular Medicine, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Down Blvd, Tampa, FL 33612, USA; Department of Infection Control Center of Xiangya Hospital, Central South University, Changsha 410008, China
| | - Zhong Peng
- Department of Molecular Medicine, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Down Blvd, Tampa, FL 33612, USA; State Key Laboratory of Agricultural Microbiology, College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, Hubei 430070, China
| | - Vanderschouw Anne Marie
- Department of Chemistry, University of South Florida, 4202 E. Fowler Ave, Tampa, FL 33620, USA
| | - Alekhya Nimmagadda
- Department of Chemistry, University of South Florida, 4202 E. Fowler Ave, Tampa, FL 33620, USA
| | - Ma Su
- Department of Chemistry, University of South Florida, 4202 E. Fowler Ave, Tampa, FL 33620, USA
| | - Yaqiong Li
- Department of Chemistry, University of South Florida, 4202 E. Fowler Ave, Tampa, FL 33620, USA
| | - Xingmin Sun
- Department of Molecular Medicine, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Down Blvd, Tampa, FL 33612, USA.
| | - Jianfeng Cai
- Department of Chemistry, University of South Florida, 4202 E. Fowler Ave, Tampa, FL 33620, USA.
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Abstract
Each year in the United States, billions of dollars are spent combating almost half a million Clostridium difficile infections (CDIs) and trying to reduce the ∼29,000 patient deaths in which C. difficile has an attributed role. In Europe, disease prevalence varies by country and level of surveillance, though yearly costs are estimated at €3 billion. One factor contributing to the significant health care burden of C. difficile is the relatively high frequency of recurrent CDIs. Recurrent CDI, i.e., a second episode of symptomatic CDI occurring within 8 weeks of successful initial CDI treatment, occurs in ∼25% of patients, with 35 to 65% of these patients experiencing multiple episodes of recurrent disease. Using microbial communities to treat recurrent CDI, either as whole fecal transplants or as defined consortia of bacterial isolates, has shown great success (in the case of fecal transplants) or potential promise (in the case of defined consortia of isolates). This review will briefly summarize the epidemiology and physiology of C. difficile infection, describe our current understanding of how fecal microbiota transplants treat recurrent CDI, and outline potential ways that knowledge can be used to rationally design and test alternative microbe-based therapeutics.
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46
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Chilton C, Pickering D, Freeman J. Microbiologic factors affecting Clostridium difficile recurrence. Clin Microbiol Infect 2018; 24:476-482. [DOI: 10.1016/j.cmi.2017.11.017] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/22/2017] [Accepted: 11/24/2017] [Indexed: 12/17/2022]
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Risk factors for recurrent Clostridium difficile infection in a tertiary hospital in Israel. Eur J Clin Microbiol Infect Dis 2018; 37:1281-1288. [PMID: 29627951 DOI: 10.1007/s10096-018-3247-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 03/28/2018] [Indexed: 02/08/2023]
Abstract
To estimate the rate and identified risk factors for recurrent Clostridium difficile infection (rCDI) in Israel. We conducted a retro-prospective case-control study of all adult (age ≥ 18 years) patients with an initial episode of CDI (iCDI) at Tel Aviv Sourasky Medical Center from January 1, 2012 to December 31, 2014. We collected demographic, clinical, and epidemiological information for patients who were classified as recurrent (cases) and non-recurrent (control) groups. In total, 648 patients with iCDI were identified in the study. During the 36-month study period, 82 (12.7%) patients had at least one rCDI identified. We identified several factors as independent variables significantly associated with recurrent CDI: functional disability, severity of the initial infection, continuous non-Clostridium difficile antibiotic treatment with third-generation cephalosporins or clindamycin, and iCDI treatment with metronidazole and vancomycin; however, neutropenia had high measure of effect as a predictor for rCDI (adjusted odds ratio, 7.9; 95% confidence interval, 1.27-49.58; p = 0.026). The identification of the main modifiable risk factors for recurrent CDI, continuous non-Clostridium difficile antibiotics after diagnosis of the initial infection, and antibiotic treatment with third-generation cephalosporins or clindamycin are critical in reducing the spread of recurrent infection with Clostridium difficile in hospital.
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Sachsenheimer FE, Yang I, Zimmermann O, Wrede C, Müller LV, Gunka K, Groß U, Suerbaum S. Genomic and phenotypic diversity of Clostridium difficile during long-term sequential recurrences of infection. Int J Med Microbiol 2018; 308:364-377. [PMID: 29490877 DOI: 10.1016/j.ijmm.2018.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 01/22/2018] [Accepted: 02/18/2018] [Indexed: 01/26/2023] Open
Abstract
Infection with the emerging pathogen Clostridioides (Clostridium) difficile might lead to colonization of the gastrointestinal tract of humans and mammals eventually resulting in antibiotic-associated diarrhea, which can be mild to possibly life-threatening. Recurrences after antibiotic treatment have been described in 15-30% of the cases and are either caused by the original (relapse) or by new strains (reinfection). In this study, we describe a patient with ongoing recurrent C. difficile infections over 13 months. During this time, ten C. difficile strains of six different ribotypes could be isolated that were further characterized by phenotypic and genomic analyses including motility and sporulation assays, growth fitness and antibiotic susceptibility as well as whole-genome sequencing. PCR ribotyping of the isolates confirmed that the recurrences were a mixture of relapses and reinfections. One recurrence was due to a mixed infection with three different strains of two different ribotypes. Furthermore, genomes were sequenced and multi-locus sequence typing (MLST) was carried out, which identified the strains as members of sequence types (STs) 10, 11, 14 and 76. Comparison of the genomes of isolates of the same ST originating from recurrent CDI (relapses) indicated little within-patient microevolution and some concurrent within-patient diversity of closely related strains. Isolates of ribotype 126 that are binary toxin positive differed from other ribotypes in various phenotypic aspects including motility, sporulation behavior and cell morphology. Ribotype 126 is genetically related to ribotype 078 that has been associated with increased virulence. Isolates of the ribotype 126 exhibited elongated cells and a chaining phenotype, which was confirmed by membrane staining and scanning electron microscopy. Furthermore, this strain exhibits a sinking behavior in liquid medium in stationary growth phase. Taken together, our observation has proven multiple CDI recurrences that were based on a mixture of relapses and reinfections.
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Affiliation(s)
- F E Sachsenheimer
- Institute of Medical Microbiology, University Medical Center Göttingen, Kreuzbergring 57, Göttingen, Germany.
| | - I Yang
- Institute of Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover, Germany; Lower Saxony Centre for Biomedical Engineering, Implant Research and Development, Department of Prosthetic Dentistry and Biomedical Materials Science, Hannover Medical School, Stadtfelddamm 34, Hannover, Germany
| | - O Zimmermann
- Institute of Medical Microbiology, University Medical Center Göttingen, Kreuzbergring 57, Göttingen, Germany
| | - C Wrede
- Institute of Functional and Applied Anatomy, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover, Germany
| | - L V Müller
- National Consulting Laboratory for Clostridium difficile, Germany
| | - K Gunka
- Institute of Medical Microbiology, University Medical Center Göttingen, Kreuzbergring 57, Göttingen, Germany
| | - U Groß
- Institute of Medical Microbiology, University Medical Center Göttingen, Kreuzbergring 57, Göttingen, Germany
| | - S Suerbaum
- Institute of Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover, Germany; Max von Pettenkofer Institute, Ludwig-Maximilians-Universität München, Pettenkoferstr. 9a, 80336 Munich, Germany; DZIF German Center for Infection Research, Hannover-Braunschweig and Munich Partner Sites, Germany
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Brain D, Yakob L, Barnett A, Riley T, Clements A, Halton K, Graves N. Economic evaluation of interventions designed to reduce Clostridium difficile infection. PLoS One 2018; 13:e0190093. [PMID: 29298322 PMCID: PMC5752026 DOI: 10.1371/journal.pone.0190093] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 12/07/2017] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Healthcare decision-makers are increasingly expected to balance increasing demand for health services with a finite budget. The role of economic evaluation in healthcare is increasing and this research provides decision-makers with new information about the management of Clostridium difficile infection, from an economic perspective. METHODS A model-based economic evaluation was undertaken to identify the most cost-effective healthcare intervention relating to the reduction of Clostridium difficile transmission. Efficacy evidence was synthesised from the literature and was used to inform the effectiveness of both bundled approaches and stand-alone interventions, where appropriate intervention combinations were coupled together. Changes in health outcomes were estimated by combining information about intervention effectiveness and its subsequent impact on quality of life. RESULTS A bundled approach of improving hand hygiene and environmental cleaning produces the best combination of increased health benefits and cost-savings. It has the highest mean net monetary benefit when compared to all other interventions. This intervention remains the optimal decision under different clinical circumstances, such as when mortality rate and patient length of stay are increased. Bundled interventions offered the best opportunity for health improvements. CONCLUSION These findings provide healthcare decision-makers with novel information about the allocation of scarce resources relating to Clostridium difficile. If investments are not made in interventions that clearly yield gains in health outcomes, the allocation and use of scarce healthcare resources is inappropriate and improvements in health outcomes will be forgone.
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Affiliation(s)
- David Brain
- Queensland University of Technology, Institute of Health and Biomedical Innovation, Brisbane, Queensland, Australia
- * E-mail:
| | - Laith Yakob
- London School of Hygiene and Tropical Medicine, Faculty of Infectious and Tropical Diseases, London, United Kingdom
| | - Adrian Barnett
- Queensland University of Technology, Institute of Health and Biomedical Innovation, Brisbane, Queensland, Australia
| | - Thomas Riley
- University of Western Australia, Pathology and Laboratory Medicine, Perth, Western Australia, Australia
| | - Archie Clements
- Australian National University, Research School of Population Health, Canberra, Australian Capital Territory, Australia
| | - Kate Halton
- Queensland University of Technology, Institute of Health and Biomedical Innovation, Brisbane, Queensland, Australia
| | - Nicholas Graves
- Queensland University of Technology, Institute of Health and Biomedical Innovation, Brisbane, Queensland, Australia
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