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Tsai CS, Lu PL, Lu MC, Hsieh TC, Chen WT, Wang JT, Ko WC. Ribotypes and antimicrobial susceptibility profiles of clinical Clostridioides difficile isolates: A multicenter, laboratory-based surveillance in Taiwan, 2019-2021. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2024; 57:320-327. [PMID: 38135646 DOI: 10.1016/j.jmii.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 11/30/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND The clinical burden of Clostridioides difficile infections (CDIs) remains substantial globally. This study aimed to investigate the ribotypes (RTs) and antimicrobial susceptibility of C. difficile isolates collected in Taiwan. METHODS C. difficile isolates were prospectively collected from four medical centers in Taiwan from 2019 to 2021. In a reference laboratory, in vitro susceptibility to clindamycin, moxifloxacin, metronidazole, vancomycin, fidaxomicin, and rifaximin were tested, and ribotyping was conducted to determine their genetic diversity. RESULTS A total of 568 C. difficile isolates were included. Metronidazole resistance was not observed, and the susceptibility rate of vancomycin was 99.5 %. Clindamycin showed poor activity against these isolates, with a resistance rate of 74.8 %. Fidaxomicin exhibited potent activity and 97.4 % of isolates were inhibited at 0.25 μg/mL. Rifaximin MIC90 increased from 0.015 μg/mL in 2019 to 0.03 μg/mL in 2020 and 2021. Of 40 RTs identified, two predominant RTs were RT 078/126 (78, 14 %) and 014/020 (76, 13 %). RT 017, traditional harboring truncated tcdA, accounted for 3 % (20 isolates) and there was no isolate belonging to RT 027. The proportions of RT 078 increased from 11.2 % in 2019 to 17.1 % in 2021, and the predominance of RT 078/126 was more evident in central Taiwan. CONCLUSIONS Vancomycin, fidaxomicin, and metronidazole remain in vitro effective against clinical C. difficile isolates in Taiwan. The reservoirs and genetic relatedness of two major RTs with zoonotic potentials, RT 078/126 and 014/020, warrant further investigations.
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Affiliation(s)
- Chin-Shiang Tsai
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po-Liang Lu
- Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Center for Liquid Biopsy and Cohort Research, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Min-Chi Lu
- Department of Internal Medicine, China Medical University Hospital, School of Medicine, China Medical University, Taichung, Taiwan
| | - Tai-Chin Hsieh
- Global Medical and Scientific Affairs, MSD Taiwan, Taipei, Taiwan
| | - Wei-Ting Chen
- Global Medical and Scientific Affairs, MSD Taiwan, Taipei, Taiwan
| | - Jann-Tay Wang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Newcomer EP, Fishbein SRS, Zhang K, Hink T, Reske KA, Cass C, Iqbal ZH, Struttmann EL, Burnham CAD, Dubberke ER, Dantas G. Genomic surveillance of Clostridioides difficile transmission and virulence in a healthcare setting. mBio 2024; 15:e0330023. [PMID: 38329369 PMCID: PMC10936198 DOI: 10.1128/mbio.03300-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/16/2024] [Indexed: 02/09/2024] Open
Abstract
Clostridioides difficile infection (CDI) is a major cause of healthcare-associated diarrhea, despite the widespread implementation of contact precautions for patients with CDI. Here, we investigate strain contamination in a hospital setting and the genomic determinants of disease outcomes. Across two wards over 6 months, we selectively cultured C. difficile from patients (n = 384) and their environments. Whole-genome sequencing (WGS) of 146 isolates revealed that most C. difficile isolates were from clade 1 (131/146, 89.7%), while only one isolate of the hypervirulent ST1 was recovered. Of culture-positive admissions (n = 79), 19 (24%) patients were colonized with toxigenic C. difficile on admission to the hospital. We defined 25 strain networks at ≤2 core gene single nucleotide polymorphisms; two of these networks contain strains from different patients. Strain networks were temporally linked (P < 0.0001). To understand the genomic correlates of the disease, we conducted WGS on an additional cohort of C. difficile (n = 102 isolates) from the same hospital and confirmed that clade 1 isolates are responsible for most CDI cases. We found that while toxigenic C. difficile isolates are associated with the presence of cdtR, nontoxigenic isolates have an increased abundance of prophages. Our pangenomic analysis of clade 1 isolates suggests that while toxin genes (tcdABER and cdtR) were associated with CDI symptoms, they are dispensable for patient colonization. These data indicate that toxigenic and nontoxigenic C. difficile contamination persist in a hospital setting and highlight further investigation into how accessory genomic repertoires contribute to C. difficile colonization and disease. IMPORTANCE Clostridioides difficile infection remains a leading cause of hospital-associated diarrhea, despite increased antibiotic stewardship and transmission prevention strategies. This suggests a changing genomic landscape of C. difficile. Our study provides insight into the nature of prevalent C. difficile strains in a hospital setting and transmission patterns among carriers. Longitudinal sampling of surfaces and patient stool revealed that both toxigenic and nontoxigenic strains of C. difficile clade 1 dominate these two wards. Moreover, quantification of transmission in carriers of these clade 1 isolates underscores the need to revisit infection prevention measures in this patient group. We identified unique genetic signatures associated with virulence in this clade. Our data highlight the complexities of preventing transmission of this pathogen in a hospital setting and the need to investigate the mechanisms of in vivo persistence and virulence of prevalent lineages in the host gut microbiome.
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Affiliation(s)
- Erin P. Newcomer
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Skye R. S. Fishbein
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, Missouri, USA
- Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Kailun Zhang
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, Missouri, USA
- Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Tiffany Hink
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Kimberly A. Reske
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Candice Cass
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Zainab H. Iqbal
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Emily L. Struttmann
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Carey-Ann D. Burnham
- Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Erik R. Dubberke
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Gautam Dantas
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
- Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
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3
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Newcomer EP, Fishbein SRS, Zhang K, Hink T, Reske KA, Cass C, Iqbal ZH, Struttmann EL, Dubberke ER, Dantas G. Genomic surveillance of Clostridioides difficile transmission and virulence in a healthcare setting. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.26.23295023. [PMID: 38105952 PMCID: PMC10723495 DOI: 10.1101/2023.09.26.23295023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Clostridioides difficile infection (CDI) is a major cause of healthcare-associated diarrhea, despite the widespread implementation of contact precautions for patients with CDI. Here, we investigate strain contamination in a hospital setting and genomic determinants of disease outcomes. Across two wards over six months, we selectively cultured C. difficile from patients (n=384) and their environments. Whole-genome sequencing (WGS) of 146 isolates revealed that most C. difficile isolates were from clade 1 (131/146, 89.7%), while only one isolate of the hypervirulent ST1 was recovered. Of culture-positive admissions (n=79), 19 (24%) of patients were colonized with toxigenic C. difficile on admission to the hospital. We defined 25 strain networks at ≤ 2 core gene SNPs; 2 of these networks contain strains from different patients. Strain networks were temporally linked (p<0.0001). To understand genomic correlates of disease, we conducted WGS on an additional cohort of C. difficile (n=102 isolates) from the same hospital and confirmed that clade 1 isolates are responsible for most CDI cases. We found that while toxigenic C. difficile isolates are associated with the presence of cdtR , nontoxigenic isolates have an increased abundance of prophages. Our pangenomic analysis of clade 1 isolates suggests that while toxin genes ( tcdABER and cdtR ) were associated with CDI symptoms, they are dispensable for patient colonization. These data indicate toxigenic and nontoxigenic C. difficile contamination persists in a hospital setting and highlight further investigation into how accessory genomic repertoires contribute to C. difficile colonization and disease.
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Li Z, Lee K, Rajyaguru U, Jones CH, Janezic S, Rupnik M, Anderson AS, Liberator P. Ribotype Classification of Clostridioides difficile Isolates Is Not Predictive of the Amino Acid Sequence Diversity of the Toxin Virulence Factors TcdA and TcdB. Front Microbiol 2020; 11:1310. [PMID: 32636819 PMCID: PMC7318873 DOI: 10.3389/fmicb.2020.01310] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 05/25/2020] [Indexed: 12/18/2022] Open
Abstract
Clostridioides (Clostridium) difficile is the most commonly recognized cause of infectious diarrhea in healthcare settings. Currently there is no vaccine to prevent initial or recurrent C. difficile infection (CDI). Two large clostridial toxins, TcdA and TcdB, are the primary virulence factors for CDI. Immunological approaches to prevent CDI include antibody-mediated neutralization of the cytotoxicity of these toxins. An understanding of the sequence diversity of the two toxins expressed by disease causing isolates is critical for the interpretation of the immune response to the toxins. In this study, we determined the whole genome sequence (WGS) of 478 C. difficile isolates collected in 12 countries between 2004 and 2018 to probe toxin variant diversity. A total of 44 unique TcdA variants and 37 unique TcdB variants were identified. The amino acid sequence conservation among the TcdA variants (≥98%) is considerably greater than among the TcdB variants (as low as 86.1%), suggesting that different selection pressures may have contributed to the evolution of the two toxins. Phylogenomic analysis of the WGS data demonstrate that isolates grouped together based on ribotype or MLST code for multiple different toxin variants. These findings illustrate the importance of determining not only the ribotype but also the toxin sequence when evaluating strain coverage using vaccine strategies that target these virulence factors. We recommend that toxin variant type and sequence type (ST), be used together with ribotype data to provide a more comprehensive strain classification scheme for C. difficile surveillance during vaccine development objectives.
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Affiliation(s)
- Zhenghui Li
- Vaccine Research and Development, Pfizer Inc., Pearl River, NY, United States
| | - Kwok Lee
- Vaccine Research and Development, Pfizer Inc., Pearl River, NY, United States
| | - Urvi Rajyaguru
- Vaccine Research and Development, Pfizer Inc., Pearl River, NY, United States
| | - C Hal Jones
- Vaccine Research and Development, Pfizer Inc., Pearl River, NY, United States
| | - Sandra Janezic
- National Laboratory for Health, Environment and Food, Maribor, Slovenia.,Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Maja Rupnik
- National Laboratory for Health, Environment and Food, Maribor, Slovenia.,Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | | | - Paul Liberator
- Vaccine Research and Development, Pfizer Inc., Pearl River, NY, United States
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Emberger J, Hitchcock MM, Markley JD. Diagnostic Stewardship Approaches to Clostridioides difficile Infection in the Era of Two-Step Testing: a Shifting Landscape. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2020. [DOI: 10.1007/s40506-020-00223-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Rizzardi K, Åkerlund T, Norén T, Matussek A. Impact of ribotype on Clostridioides difficile diagnostics. Eur J Clin Microbiol Infect Dis 2020; 39:847-853. [PMID: 31884555 PMCID: PMC7182543 DOI: 10.1007/s10096-019-03772-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/20/2019] [Indexed: 12/18/2022]
Abstract
This study investigates the performance of diagnostic methods for detection of Clostridioides difficile infection in Sweden, including impact of PCR ribotype on diagnostic performance. Between 2011 and 2016, a total of 17,878 stool samples from 26 laboratories were tested by either well-type enzyme immunoassays (EIAs), membrane bound EIAs, cell cytotoxicity neutralization assay (CTA), or nucleic acid amplification tests (NAATs) and subsequently cultured for C. difficile. Roughly half of the samples (9454/17878) were subjected to diagnostic testing both on the fecal sample and on the 1323 isolated C. difficile strains. All C. difficile isolates were typed by PCR ribotyping, and the isolates were classified as toxigenic or non-toxigenic based on the empirical knowledge of the association between toxin-positivity and ribotype. The overall sensitivity, specificity, and positive and negative predictive values were highest for NAATs and membrane EIAs. Ribotype-specific sensitivity varied greatly between methods and ribotypes. All methods had 100% sensitivity against ribotype 027 and 013. For other types, the sensitivity ranged from 33 to 85% in fecal samples and from 78 to 100% on isolates. For the most prevalent ribotypes (014, 020, and 001), the sensitivity varied between 38 and 100% in the fecal samples, with the lowest sensitivity observed for well-type EIAs and CTA. The large variation in diagnostic sensitivity implies that type distribution significantly affects the outcome when evaluating diagnostic performance. Furthermore, performing comparative studies of diagnostic tests in settings with high prevalence of ribotype 027 will overestimate the general performance of diagnostic tests.
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Affiliation(s)
- Kristina Rizzardi
- Department of Microbiology, Public Health Agency of Sweden, Solna, Sweden.
| | - Thomas Åkerlund
- Department of Microbiology, Public Health Agency of Sweden, Solna, Sweden
| | - Torbjörn Norén
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Andreas Matussek
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska University Hospital, Huddinge, Sweden
- Karolinska University Laboratory, Solna, Stockholm, Sweden
- Department of Laboratory Medicine, Jönköping, Jönköping County, Sweden
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Clostridium difficile Infection in Children: Epidemiology and Trend in a Swedish Tertiary Care Hospital. Pediatr Infect Dis J 2019; 38:1208-1213. [PMID: 31738336 DOI: 10.1097/inf.0000000000002480] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Several studies have shown an increasing trend in pediatric Clostridium difficile infection (CDI). However, the Public Health Agency in Sweden reports a decreasing incidence of CDI in the Swedish population since 2007. The main aim of this study is to analyze the epidemiology of CDI in children. METHODS Retrospective chart-review of patients 1 to <19 years old, positive for Clostridium difficile toxin B, tested at Karolinska University Hospital Units, over the time period from July 1, 2010 to June 30, 2018. Episodes were classified as recurrences (≥2 weeks, ≤8 weeks from previous episode) or new episodes (>8 weeks from previous episode). New episodes were classified as hospital- (HA-CDI) or community-associated (CA-CDI). Annual infection rates/100,000 children in the catchment area were calculated. RESULTS Three hundred twenty-eight positive tests in 206 patients were included of which 259 (79.0%) tests were new episodes and 69 (21.0%) recurrences. In 63/206 (30.6%) children, >1 episode of CDI was recorded. The mean infection rate was 8.5/100,000 children. There was an overall increasing trend in CDI-rate July 2010-June 2018, however not statistically significant (P = 0.061) nor for the incidence in HA-CDI (P = 0.720) or CA-CDI (P = 0.179). Underlying medical conditions were present in 226/259 (87.3%) new episodes of which the most common was malignancy. Of the new episodes, 188/259 (72.6%) were HA-CDI and 46/259 (17.8%) were CA-CDI. CONCLUSIONS There was an increasing trend in CDI in children in Sweden from 2010 to 2018, although not statistically significant. CDI was associated with comorbid conditions and repeated episodes were common.
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Tickler IA, Obradovich AE, Goering RV, Fang FC, Tenover FC. Changes in molecular epidemiology and antimicrobial resistance profiles of Clostridioides (Clostridium) difficile strains in the United States between 2011 and 2017. Anaerobe 2019; 60:102050. [PMID: 31173889 DOI: 10.1016/j.anaerobe.2019.06.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 05/13/2019] [Accepted: 06/03/2019] [Indexed: 12/20/2022]
Abstract
PCR ribotyping and antimicrobial susceptibility testing were used to characterize 940 Clostridioides (Clostridium) difficile isolates collected from 26 U S. hospitals over three time periods from 2011 to 2017. The proportion of ribotype (RT) 027 isolated during the three surveys decreased significantly over time from 31% in 2011-2012, to 22% in 2013-2014, and to 14% in 2015-2017 (p < 0.001 and p = 0.010, respectively), while we observed an increase in prevalence of RT106, that rose from 7% in our first survey to 19% of isolates in our last survey (p < 0.001). In addition, both RT056 and RT002 rose from 3% to 10% (p < 0.001). The proportions of all other ribotypes remained steady over time, and RT014/020 was the third most common strain type in our convenience sample in the final survey. Overall, resistance to moxifloxacin, rifampin, and vancomycin decreased during our studies, mainly due to the decline in RT027 isolates. A decrease in moxifloxacin resistance and an increase in tetracycline resistance were found among RT027 strains isolated in the last survey. Although the proportion of RT027 isolates declined, multidrug resistance among this ribotype continues to be common.
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Affiliation(s)
| | | | | | - Ferric C Fang
- University of Washington School of Medicine, Seattle, WA, United States
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Halstead F, Ravi A, Thomson N, Nuur M, Hughes K, Brailey M, Oppenheim B. Whole genome sequencing of toxigenic Clostridium difficile in asymptomatic carriers: insights into possible role in transmission. J Hosp Infect 2019; 102:125-134. [DOI: 10.1016/j.jhin.2018.10.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 10/15/2018] [Indexed: 01/05/2023]
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Rizzardi K, Norén T, Aspevall O, Mäkitalo B, Toepfer M, Johansson Å, Åkerlund T. National Surveillance for Clostridioides difficile Infection, Sweden, 2009-2016. Emerg Infect Dis 2019; 24:1617-1625. [PMID: 30124193 PMCID: PMC6106436 DOI: 10.3201/eid2409.171658] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
We report results from a national surveillance program for Clostridioides difficile infection (CDI) in Sweden, where CDI incidence decreased by 22% and the proportion of multidrug-resistant isolates decreased by 80% during 2012-2016. Variation in incidence between counties also diminished during this period, which might be attributable to implementation of nucleic acid amplification testing as the primary diagnostic tool for most laboratories. In contrast to other studies, our study did not indicate increased CDI incidence attributable the introduction of nucleic acid amplification testing. Our results also suggest that successful implementation of hygiene measures is the major cause of the observed incidence decrease. Despite substantial reductions in CDI incidence and prevalence of multidrug-resistant isolates, Sweden still has one of the highest CDI incidence levels in Europe. This finding is unexpected and warrants further investigation, given that Sweden has among the lowest levels of antimicrobial drug use.
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Management of adult Clostridium difficile digestive contaminations: a literature review. Eur J Clin Microbiol Infect Dis 2018; 38:209-231. [PMID: 30498879 DOI: 10.1007/s10096-018-3419-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 10/30/2018] [Indexed: 02/08/2023]
Abstract
Clostridium difficile infections (CDI) dramatically increased during the last decade and cause a major public health problem. Current treatments are limited by the high disease recurrence rate, severity of clinical forms, disruption of the gut microbiota, and colonization by vancomycin-resistant enterococci (VRE). In this review, we resumed current treatment options from official recommendation to promising alternatives available in the management of adult CDI, with regard to severity and recurring or non-recurring character of the infection. Vancomycin remains the first-line antibiotic in the management of mild to severe CDI. The use of metronidazole is discussed following the latest US recommendations that replaced it by fidaxomicin as first-line treatment of an initial episode of non-severe CDI. Fidaxomicin, the most recent antibiotic approved for CDI in adults, has several advantages compared to vancomycin and metronidazole, but its efficacy seems limited in cases of multiple recurrences. Innovative therapies such as fecal microbiota transplantation (FMT) and antitoxin antibodies were developed to limit the occurrence of recurrence of CDI. Research is therefore very active, and new antibiotics are being studied as surotomycin, cadazolid, and rinidazole.
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Abrahamian FM, Talan DA, Krishnadasan A, Citron DM, Paulick AL, Anderson LJ, Goldstein EJ, Moran GJ, Abrahamian F, Moore J, Femling J, Chiang W, LoVecchio F, Jui J, Garg M, Steele M, Sullivan D, Rothman R. Clostridium difficile Infection Among US Emergency Department Patients With Diarrhea and No Vomiting. Ann Emerg Med 2017; 70:19-27.e4. [DOI: 10.1016/j.annemergmed.2016.12.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 12/04/2016] [Accepted: 12/08/2016] [Indexed: 12/24/2022]
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Incidence and Risk Factors for Community and Hospital Acquisition of Clostridium difficile Infection in the Tel Aviv Sourasky Medical Center. Infect Control Hosp Epidemiol 2017; 38:912-920. [DOI: 10.1017/ice.2017.82] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVESTo estimate the incidence and identified risk factors for community-acquired (CA) and hospital-acquired (HA) Clostridium difficile infection (CDI)METHODSWe conducted 2 parallel case-control studies at Tel Aviv Sourasky Medical Center from January 1, 2011, to December 31, 2014. We identified persons with CDI, determined whether infection was community or hospital acquired, and calculated incidence rates from 2007 to 2014. We collected demographic, clinical, and epidemiological information for CDI cases and hospitalized control cases and estimated the odds ratio with 95% confidence interval using conditional logistic regression.RESULTSIn total, 1,563 CDI cases were identified in the study. The incidence rate of CA-CDI and HA-CDI increased by 1.6-fold and 1.2-fold, respectively, during 2012–2014. However, the incidence rate of CA-CDI was 0.84 per 100,000 (95% CI, 0.52–1.30), the rate for HA-CDI was 4.7 per 10,000 patient days (95% CI, 4.08–5.38), respectively, in 2014. We identified several factors as independent variables significantly associated with HA-CDI: functional disability, presence of nasogastric tube, antibiotic use, chemotherapy, infection by extended-spectrum β-lactamases, and mean of albumin values. Risk factors independently associated with CA-CDI were close contact with a family member who had been hospitalized in the previous 6 months, inflammatory bowel disease, and home density index (adjusted odds ratio, 25.7; 95% confidence interval, 3.99–165.54; P=.001).CONCLUSIONSThe identification of the main modifiable risk factors for HA-CDI (antibiotic exposure and hypoalbuminemia) and for CA-CDI (close contact with a family member who had been hospitalized in the previous 6 months) is likely to optimize prevention efforts; these factors are critical in preventing the spread of CDI.Infect Control Hosp Epidemiol 2017;38:912–920
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Caroff DA, Yokoe DS, Klompas M. Evolving Insights Into the Epidemiology and Control of Clostridium difficile in Hospitals. Clin Infect Dis 2017; 65:1232-1238. [DOI: 10.1093/cid/cix456] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 05/12/2017] [Indexed: 12/13/2022] Open
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Durham DP, Olsen MA, Dubberke ER, Galvani AP, Townsend JP. Quantifying Transmission of Clostridium difficile within and outside Healthcare Settings. Emerg Infect Dis 2016; 22:608-16. [PMID: 26982504 PMCID: PMC4806959 DOI: 10.3201/eid2204.150455] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
To quantify the effect of hospital and community-based transmission and control measures on Clostridium difficile infection (CDI), we constructed a transmission model within and between hospital, community, and long-term care-facility settings. By parameterizing the model from national databases and calibrating it to C. difficile prevalence and CDI incidence, we found that hospitalized patients with CDI transmit C. difficile at a rate 15 (95% CI 7.2-32) times that of asymptomatic patients. Long-term care facility residents transmit at a rate of 27% (95% CI 13%-51%) that of hospitalized patients, and persons in the community at a rate of 0.1% (95% CI 0.062%-0.2%) that of hospitalized patients. Despite lower transmission rates for asymptomatic carriers and community sources, these transmission routes have a substantial effect on hospital-onset CDI because of the larger reservoir of hospitalized carriers and persons in the community. Asymptomatic carriers and community sources should be accounted for when designing and evaluating control interventions.
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Harvala H, Alm E, Åkerlund T, Rizzardi K. Emergence and spread of moxifloxacin-resistant Clostridium difficile ribotype 231 in Sweden between 2006 and 2015. New Microbes New Infect 2016; 14:58-66. [PMID: 27752322 PMCID: PMC5061077 DOI: 10.1016/j.nmni.2016.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 08/03/2016] [Accepted: 09/06/2016] [Indexed: 01/05/2023] Open
Abstract
An aggregation of moxifloxacin-resistant Clostridium difficile ribotype 231 (RT231) isolates was first identified in the county of Stockholm in 2008, and by the end of 2015 isolates of RT231 had spread to 13 of 21 Swedish counties. We investigated the epidemiology of C. difficile RT231 in Sweden between 2006 and 2015 using whole genome sequencing (WGS) and evaluated whether its emergence could be associated with extended moxifloxacin use. We performed WGS and phylogenetic analysis of 51 C. difficile RT231 strains isolated in Sweden over a 10-year period. We also calculated the county-specific prescription rates for moxifloxacin between 2005 and 2015. Using WGS and detailed single nucleotide polymorphism analysis, we demonstrated three divergent sublineages of moxifloxacin-resistant C. difficile RT231 in Sweden from 2008 to 2015. A set of closely related RT231 was identified in hospitals located in the counties of Stockholm and Uppsala in 2008. Another set of RT231 isolates was found in four different counties in the Uppsala-Örebro Health Care Region. A gradual drop in moxifloxacin use in the county of Stockholm coincided with a reduction of RT231 in the area. However, RT231 continued to be frequent in surrounding counties including Uppsala, a county that also had the highest moxifloxacin prescription rates. We demonstrated frequent transmission of C. difficile RT231 within and between counties, indicating the importance of careful monitoring of hospitalized individuals infected with moxifloxacin-resistant C. difficile as well as the need for a strict moxifloxacin prescription policy.
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Affiliation(s)
- H. Harvala
- Public Health Agency of Sweden, Solna, Sweden
- European Programme for Public Health Microbiology Training (EUPHEM), European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | - E. Alm
- Public Health Agency of Sweden, Solna, Sweden
| | - T. Åkerlund
- Public Health Agency of Sweden, Solna, Sweden
| | - K. Rizzardi
- Public Health Agency of Sweden, Solna, Sweden
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17
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Abstract
Clostridium difficile is one of the many aetiological agents of antibiotic associated diarrhoea and is implicated in 15-25 per cent of the cases. The organism is also involved in the exacearbation of inflammatory bowel disease and extracolonic manifestations. Due to increase in the incidence of C. difficile infection (CDI), emergence of hypervirulent strains, and increased frequency of recurrence, the clinical management of the disease has become important. The management of CDI is based on disease severity, and current antibiotic treatment options are limited to vancomycin or metronidazole in the developing countries. this review article briefly describes important aspects of CDI, and the new drug, fidaxomicin, for its treatment. Fidaxomicin is particularly active against C. difficile and acts by inhibition of RNA synthesis. Clinical trials done to compare the efficacy and safety of fidaxomicin with that of vancomycin in treating CDI concluded that fidaxomicin was non-inferior to vancomycin for treatment of CDI and that there was a significant reduction in recurrences. The bactericidal properties of fidaxomicin make it an ideal alternative for CDI treatment. However, fidaxomicin use should be considered taking into account the potential benefits of the drug, along with the medical requirements of the patient, the risks of treatment and the high cost of fidaxomicin compared to other treatment regimens.
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Affiliation(s)
- Chetana Vaishnavi
- Department of Gastroenterology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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18
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Sentinel community Clostridium difficile infection (CDI) surveillance in Scotland, April 2013 to March 2014. Anaerobe 2016; 37:49-53. [DOI: 10.1016/j.anaerobe.2015.12.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 12/04/2015] [Accepted: 12/15/2015] [Indexed: 02/04/2023]
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19
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Burd EM, Hinrichs BH. Gastrointestinal Infections. MOLECULAR PATHOLOGY IN CLINICAL PRACTICE 2016. [PMCID: PMC7123654 DOI: 10.1007/978-3-319-19674-9_50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Establishing a specific etiology for gastrointestinal infections can be challenging because of the common clinical features and wide variety of causative microorganisms. In many cases, the etiologic agent cannot be determined using traditional diagnostic methods and may result in unnecessary antibiotic use or prolonged periods of illness. Molecular tests provide many advantages over traditional laboratory methods but, with the exception of a few analytes, are still largely in the developmental phase for gastrointestinal pathogens and are not widely used. The main advantages of molecular tests include increased sensitivity and the ability to detect agents which will not grow in culture. To test for all possible gastrointestinal pathogens at one time would require a large panel that would include a variety of bacterial, viral and parasitic agents. Challenges inherent in developing diagnostic molecular panels include ensuring that all variants of a particular microorganism can be detected as well as the rapid evolution of pathogens. In this chapter, the diagnostic merit of molecular tests as well as available tests will be presented for the major groups of gastrointestinal pathogens.
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20
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Wetterwik KJ, Trowald-Wigh G, Fernström LL, Krovacek K. Clostridium difficile in faeces from healthy dogs and dogs with diarrhea. Acta Vet Scand 2013; 55:23. [PMID: 23497714 PMCID: PMC3606456 DOI: 10.1186/1751-0147-55-23] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 02/28/2013] [Indexed: 02/04/2023] Open
Abstract
Background This study was conducted to evaluate the faecal occurrence and characterization of Clostridium difficile in clinically healthy dogs (N = 50) and in dogs with diarrhea (N = 20) in the Stockholm-Uppsala region of Sweden. Findings Clostridium difficile was isolated from 2/50 healthy dogs and from 2/20 diarrheic dogs. Isolates from healthy dogs were negative for toxin A and B and for the tcdA and tcdB genes. Both isolates from diarrheic dogs were positive for toxin B and for the tcdA and tcdB genes. The C. difficile isolates from healthy dogs had PCR ribotype 009 (SE-type 6) and 010 (SE-type 3) whereas both isolates from dogs with diarrhoea had the toxigenic ribotype 014 (SE-type 21). One of the isolates from healthy dogs was initially resistant to metronidazole. Conclusions This study revealed presence of toxigenic C. difficile in faecal samples of diarrheic dogs and low number of non- toxigenic isolates in healthy dogs from Uppsala-Stockholm region in Sweden. However, more comprehensive studies are warranted to investigate the role of C. difficile in gastrointestinal disease in dogs.
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21
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Epidemiología de la infección por Clostridium difficile en España. Enferm Infecc Microbiol Clin 2012; 30:333-7. [DOI: 10.1016/j.eimc.2011.09.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Accepted: 09/22/2011] [Indexed: 11/23/2022]
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22
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Vesteinsdottir I, Gudlaugsdottir S, Einarsdottir R, Kalaitzakis E, Sigurdardottir O, Bjornsson ES. Risk factors for Clostridium difficile toxin-positive diarrhea: a population-based prospective case-control study. Eur J Clin Microbiol Infect Dis 2012; 31:2601-10. [PMID: 22441775 DOI: 10.1007/s10096-012-1603-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Accepted: 03/05/2012] [Indexed: 12/22/2022]
Abstract
Increased incidence and severity of Clostridium difficile infections (CDIs) is of major concern. However, by minimizing known risk factors, the incidence can be decreased. The aim of this investigation was to calculate the incidence and assess risk factors for CDI in our population. A 1-year prospective population-based nationwide study in Iceland of CDIs was carried out. For risk factor evaluation, each case was matched with two age- and sex-matched controls that tested negative for C. difficile toxin. A total of 128 CDIs were identified. The crude incidence was 54 cases annually per 100,000 population >18 years of age. Incidence increased exponentially with older age (319 per 100,000 population >86 years of age). Community-acquired origin was 27 %. Independent risk factors included: dicloxacillin (odds ratio [OR]: 7.55, 95 % confidence interval [CI]: 1.89-30.1), clindamycin (OR: 6.09, 95 % CI: 2.23-16.61), ceftriaxone (OR: 4.28, 95 % CI: 1.59-11.49), living in a retirement home (OR: 3.9, 95 % CI: 1.69-9.16), recent hospital stay (OR: 2.3, 95 % CI: 1.37-3.87). Proton pump inhibitors (PPIs) were used by 60/111 (54 %) versus 91/222 (41 %) (p = 0.026) and ciprofloxacin 19/111 (17 %) versus 19/222 (9 %) (p = 0.027) for cases and controls, respectively. In all, 75 % of primary CDIs treated with metronidazole recovered from one course of treatment. CDI was mostly found among elderly patients. The most commonly identified risk factors were broad-spectrum antibiotics and recent contact with health care institutions. PPI use was significantly more prevalent among CDI patients.
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Collini PJ, Bauer M, Kuijper E, Dockrell DH. Clostridium difficile infection in HIV-seropositive individuals and transplant recipients. J Infect 2012; 64:131-47. [PMID: 22178989 DOI: 10.1016/j.jinf.2011.12.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Revised: 12/03/2011] [Accepted: 12/06/2011] [Indexed: 12/16/2022]
Abstract
Immunocompromise is a commonly cited risk factor for Clostridium difficile infection (CDI). We reviewed the experimental and epidemiological literature on CDI in three immunocompromised groups, HIV-seropositive individuals, haematopoietic stem cell or bone marrow transplant recipients and solid organ transplant recipients. All three groups have varying degrees of impairment of humoral immunity, a major factor influencing the outcome of CDI. Soluble HIV proteins such as nef and immunosuppressive agents such as cyclosporin, azathioprine and mycophenalate mofetil modify signalling from the key cellular pathways triggered by C. difficile toxin A, although there is a paucity of data on how these factors may interact with pathways activated by toxin B. Despite this, there has been little direct investigation into the effect of immunosuppression on the pathogenesis of CDI. Epidemiological studies consistently show increased rates of CDI in these populations, which are higher in those with greater degrees of immunocompromise such as individuals with advanced AIDS not receiving combination antiretroviral therapy or allogeneic haematopoietic stem cell transplant recipients. Less consistently data suggests immunocompromise in each group also impacts rates of severe, recurrent or complicated CDI. However all these conditions are characterised by high levels of antibiotic use and prolonged hospital stay, both powerful drivers of CDI risk.
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Affiliation(s)
- Paul J Collini
- Department of Infection and Immunity, University of Sheffield Medical School and Sheffield Teaching Hospitals, Beech Hill Rd, Sheffield S10 2RX, UK.
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24
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Comparison of strain typing results for Clostridium difficile isolates from North America. J Clin Microbiol 2011; 49:1831-7. [PMID: 21389155 DOI: 10.1128/jcm.02446-10] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Accurate strain typing is critical for understanding the changing epidemiology of Clostridium difficile infections. We typed 350 isolates of toxigenic C. difficile from 2008 to 2009 from seven laboratories in the United States and Canada. Typing was performed by PCR-ribotyping, pulsed-field gel electrophoresis (PFGE), and restriction endonuclease analysis (REA) of whole-cell DNA. The Cepheid Xpert C. difficile test for presumptive identification of 027/NAP1/BI isolates was also tested directly on original stool samples. Of 350 isolates, 244 (70%) were known PCR ribotypes, 224 (68%) were 1 of 8 common REA groups, and 187 (54%) were known PFGE types. Eighty-four isolates typed as 027, NAP1, and BI, and 83 of these were identified as presumptive 027/NAP1/BI by Xpert C. difficile. Eight additional isolates were called presumptive 027/NAP1/BI by Xpert C. difficile, of which three were ribotype 027. Five PCR ribotypes contained multiple REA groups, and three North American pulsed-field (NAP) profiles contained both multiple REA groups and PCR ribotypes. There was modest concordance of results among the three methods for C. difficile strains, including the J strain (ribotype 001 and PFGE NAP2), the toxin A-negative 017 strain (PFGE NAP9 and REA type CF), the 078 animal strain (PFGE NAP7 and REA type BK), and type 106 (PFGE NAP11 and REA type DH). PCR-ribotyping, REA, and PFGE provide different but overlapping patterns of strain clustering. Unlike the other methods, the Xpert C. difficile 027/NAP1/BI assay gave results directly from stool specimens, required only 45 min to complete, but was limited to detection of a single strain type.
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25
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Apostolopoulou E, Raftopoulos V, Terzis K, Elefsiniotis I. Infection Probability Score: a predictor of Clostridium difficile-associated disease onset in patients with haematological malignancy. Eur J Oncol Nurs 2010; 15:404-9. [PMID: 21130685 DOI: 10.1016/j.ejon.2010.11.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Revised: 11/07/2010] [Accepted: 11/09/2010] [Indexed: 11/26/2022]
Abstract
PURPOSE to assess the predictive power of three systems: Infection Probability Score, APACHE II and KARNOFSKY score for the onset of Clostridium difficile-associated disease (CDAD) in hematology-oncology patients. METHODS AND SAMPLE A retrospective pilot surveillance survey was conducted in the hematology unit of a general hospital in Greece. Data were collected by using an anonymous standardised case-record form. The sample consisted of 102 hospitalized patients. RESULTS The majority of the patients (33.3%) suffered from acute myeloid leukemia. The cumulative incidence of CDAD was 10.8% and the incidence rate of C difficile associated diarrhea was 5 per 1000 patient-days (14.2 per 1000 patient-days at risk). Patients with CDAD had twofold higher time of mean length of hospital stay compared with patients without CDAD (38.82 ± 23.88 vs 19.45 ± 14.56 days). Additionally patients with CDAD had received a greater number of different antibiotics compared to those without CDAD (5.18 ± 1.99 vs 2.54 ± 2.13), suffered from diabetes, from non Hodgkin's lymphoma, had a statistically significant higher duration of neutropenia ≥3 days and had received antifungal treatment. The best cutoff value of IPS for the prediction of CDAD was 13 with a sensitivity of 45.5% and a specificity of 82.4%. CONCLUSIONS IPS is an early diagnostic test for CDAD detection.
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26
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Freeman J, Bauer MP, Baines SD, Corver J, Fawley WN, Goorhuis B, Kuijper EJ, Wilcox MH. The changing epidemiology of Clostridium difficile infections. Clin Microbiol Rev 2010; 33 Suppl 1:S42-5. [PMID: 20610822 DOI: 10.1016/s0924-8579(09)70016-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The epidemiology of Clostridium difficile infection (CDI) has changed dramatically during this millennium. Infection rates have increased markedly in most countries with detailed surveillance data. There have been clear changes in the clinical presentation, response to treatment, and outcome of CDI. These changes have been driven to a major degree by the emergence and epidemic spread of a novel strain, known as PCR ribotype 027 (sometimes referred to as BI/NAP1/027). We review the evidence for the changing epidemiology, clinical virulence and outcome of treatment of CDI, and the similarities and differences between data from various countries and continents. Community-acquired CDI has also emerged, although the evidence for this as a distinct new entity is less clear. There are new data on the etiology of and potential risk factors for CDI; controversial issues include specific antimicrobial agents, gastric acid suppressants, potential animal and food sources of C. difficile, and the effect of the use of alcohol-based hand hygiene agents.
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Affiliation(s)
- J Freeman
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom
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27
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Impact of strain type on detection of toxigenic Clostridium difficile: comparison of molecular diagnostic and enzyme immunoassay approaches. J Clin Microbiol 2010; 48:3719-24. [PMID: 20702676 DOI: 10.1128/jcm.00427-10] [Citation(s) in RCA: 169] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
A multicenter clinical trial assessed the performance of the Cepheid Xpert C. difficile assay on stool specimens collected from patients suspected of having Clostridium difficile infection (CDI). A total of 2,296 unformed stool specimens, collected from seven study sites, were tested by Xpert C. difficile enrichment culture followed by cell culture cytotoxicity testing of the isolates (i.e., toxigenic culture with enrichment) and the study sites' standard C. difficile test methods. The methods included enzyme immunoassay (EIA), direct cytotoxin testing, and two- and three-step algorithms using glutamate dehydrogenase (GDH) screening followed by either EIA or EIA and an in-house PCR assay. All C. difficile strains were typed by PCR-ribotyping. Compared to results for toxigenic culture with enrichment, the sensitivity, specificity, and positive and negative predictive values of the Xpert assay were 93.5, 94.0, 73.0, and 98.8%, respectively. The overall sensitivity of the EIAs compared to that of enrichment culture was 60.0%, and the sensitivity of combined GDH algorithms was 72.9%; both were significantly lower than that of Xpert C. difficile (P < 0.001 and P = 0.03, respectively). The sensitivity of the EIA was significantly lower than that of the Xpert C. difficile assay for detection of ribotypes 002, 027, and 106 (P < 0.0001, P < 0.0001, and P = 0.004, respectively, Fisher's exact test), and the sensitivity of GDH algorithms for ribotypes other than 027 was lower than that for Xpert C. difficile (P < 0.001). The Xpert C. difficile assay is a simple, rapid, and accurate method for detection of toxigenic C. difficile in unformed stool specimens and is minimally affected by strain type compared to EIA and GDH-based methods.
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28
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Freeman J, Bauer MP, Baines SD, Corver J, Fawley WN, Goorhuis B, Kuijper EJ, Wilcox MH. The changing epidemiology of Clostridium difficile infections. Clin Microbiol Rev 2010; 23:529-49. [PMID: 20610822 PMCID: PMC2901659 DOI: 10.1128/cmr.00082-09] [Citation(s) in RCA: 619] [Impact Index Per Article: 44.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The epidemiology of Clostridium difficile infection (CDI) has changed dramatically during this millennium. Infection rates have increased markedly in most countries with detailed surveillance data. There have been clear changes in the clinical presentation, response to treatment, and outcome of CDI. These changes have been driven to a major degree by the emergence and epidemic spread of a novel strain, known as PCR ribotype 027 (sometimes referred to as BI/NAP1/027). We review the evidence for the changing epidemiology, clinical virulence and outcome of treatment of CDI, and the similarities and differences between data from various countries and continents. Community-acquired CDI has also emerged, although the evidence for this as a distinct new entity is less clear. There are new data on the etiology of and potential risk factors for CDI; controversial issues include specific antimicrobial agents, gastric acid suppressants, potential animal and food sources of C. difficile, and the effect of the use of alcohol-based hand hygiene agents.
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Affiliation(s)
- J. Freeman
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - M. P. Bauer
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - S. D. Baines
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - J. Corver
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - W. N. Fawley
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - B. Goorhuis
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - E. J. Kuijper
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - M. H. Wilcox
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
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Zidaric V, Beigot S, Lapajne S, Rupnik M. The occurrence and high diversity of Clostridium difficile genotypes in rivers. Anaerobe 2010; 16:371-5. [PMID: 20541023 DOI: 10.1016/j.anaerobe.2010.06.001] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2009] [Revised: 05/29/2010] [Accepted: 06/01/2010] [Indexed: 02/08/2023]
Abstract
Clostridium difficile is mainly associated with nosocomial infections but can be present also in other environments. In this study we compared three methods (culturing with and without ethanol shock and real-time PCR) for detection of C. difficile in water and have used them on a series of river water samples. C. difficile was present in 17 of 25 rivers tested (68.0%) and in 42 of 69 water samples tested (60.9%). Positive sampling sites correlated with increased population densities. Isolates were distributed into 34 PCR ribotypes, of which more than half are present also in humans and animals. PCR ribotype 014 was the predominate type (16.2% of all isolates).
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Affiliation(s)
- Valerija Zidaric
- Institute of Public Health Maribor, Prvomajska 1, Maribor, Slovenia
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30
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Hospital-based epidemiology: a strategy for ‘dealing with Clostridium difficile’. J Hosp Infect 2010; 74:319-25. [DOI: 10.1016/j.jhin.2009.07.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Accepted: 07/11/2009] [Indexed: 11/24/2022]
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31
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Southern WN, Rahmani R, Aroniadis O, Khorshidi I, Thanjan A, Ibrahim C, Brandt LJ. Postoperative Clostridium difficile-associated diarrhea. Surgery 2010; 148:24-30. [PMID: 20116817 DOI: 10.1016/j.surg.2009.11.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Accepted: 11/25/2009] [Indexed: 12/15/2022]
Abstract
BACKGROUND Abdominal surgery is thought to be a risk factor for Clostridium difficile-associated diarrhea (CDAD). The aims of this study were to discern pre-operative factors associated with postoperative CDAD, examine outcomes after postoperative CDAD, and compare outcomes of postoperative versus medical CDAD. METHODS Data from 3904 patients who had abdominal operations at Montefiore Medical Center were extracted from Montefiore's clinical information system. Cases of 30-day postoperative CDAD were identified. Pre-operative factors associated with developing postoperative CDAD were identified using logistic regression. Medical patients and surgical patients with postoperative CDAD were compared for demographic and clinical characteristics, CDAD recurrence, and 90-day postinfection mortality. RESULTS The rate of 30-day postoperative CDAD was 1.2%. After adjustment for age and comorbidities, factors significantly associated with postoperative CDAD were: antibiotic use (OR: 1.94), proton pump inhibitor (PPI) use (OR: 2.32), prior hospitalization (OR: 2.27), and low serum albumin (OR: 2.05). In comparison with medical patients with CDAD, postoperative patients with CDAD were significantly more likely to have received antibiotics (98% vs 85%), less likely to have received a PPI (39% vs 58%), or to have had a prior hospitalization (43% vs 67%). Postoperative patients with CDAD had decreased risk of mortality when compared with medical patients with CDAD (HR 0.36). CONCLUSION CDAD is an infrequent complication after abdominal operations. Several avoidable pre-operative exposures (eg, antibiotic and PPI use) were identified that increase the risk of postoperative CDAD. Postoperative CDAD is associated with decreased risk of mortality when compared with CDAD on the medical service.
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Affiliation(s)
- William N Southern
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA.
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Lipp MJ, Pagovich OE, Rabin D, Min AD, Bernstein BB. Prevalence of diverticulosis in recurrent Clostridium difficile infection. World J Gastroenterol 2010; 16:345-7. [PMID: 20082480 PMCID: PMC2807955 DOI: 10.3748/wjg.v16.i3.345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To re-evaluate the theory that colonic diverticulosis is associated with relapse of Clostridium difficile associated disease (CDAD) in light of data suggesting increasing rates of CDAD infection and relapse.
METHODS: Charts were reviewed for patients with recurrent CDAD who had also had a prior colonoscopy or flexible sigmoidoscopy. An age and gender matched control group was used to compare the prevalence of diverticulosis.
RESULTS: Twenty-two patients met the study criteria, and the prevalence of diverticulosis in patients with CDAD relapse was 23% compared to 32% in age and sex matched controls (P = 0.44). A significant proportion of patients with CDAD relapse had co-morbidities associated with immune suppression.
CONCLUSION: Diverticulosis does not appear to be associated with CDAD relapse.
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Evaluation of tcdB real-time PCR in a three-step diagnostic algorithm for detection of toxigenic Clostridium difficile. J Clin Microbiol 2009; 48:124-30. [PMID: 19923482 DOI: 10.1128/jcm.00734-09] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile is the most common infectious cause of diarrhea in hospitalized patients. The optimal approach for the detection of toxigenic C. difficile remains controversial because no single test is sensitive, specific, and affordable. We have developed a real-time PCR method (direct stool PCR [DPCR]) to detect the tcdB gene encoding toxin B directly from stool specimens and have combined it with enzyme immunoassays (EIAs) in a three-step protocol. DPCR was performed on 699 specimens that were positive for C. difficile glutamate dehydrogenase (GDH) by Wampole C Diff Quik Chek EIA (GDH-Q) and negative for toxins A and B by Wampole Tox A/B Quik Chek EIA (AB-Q), performed sequentially. The performance of this three-step algorithm was compared with a modified "gold standard" that combined tissue culture cytotoxicity (CYT) and DPCR. A separate investigation was performed to evaluate the sensitivity of the GDH-Q as a screening test, and toxigenic C. difficile was found in 1.9% of 211 GDH-Q-negative specimens. The overall sensitivity, specificity, and positive and negative predictive values, respectively, were as follows for an algorithm combining GDH-Q, AB-Q, and DPCR: 83.8%, 99.7%, 97.1%, and 97.9%. Those for CYT alone were 58.8%, 100%, 100%, and 94.9%, respectively. In comparison, the sensitivity and specificity of DPCR were estimated to be 97.5% and 99.7%, respectively, using the same modified gold standard. Neither CYT nor toxin EIA was sufficiently sensitive to exclude toxigenic C. difficile, and combining EIAs with CYT in a three-step algorithm failed to substantially improve sensitivity. DPCR is a sensitive and specific method for the detection of toxigenic C. difficile that can provide same-day results at a cost-per-positive test comparable to those of other methods. A three-step algorithm in which DPCR is used to analyze GDH EIA-positive, toxin EIA-negative specimens provides a convenient and specific alternative with rapid results for 87.7% of specimens, although this approach is less sensitive than performing DPCR on all specimens.
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Kolli S, Mallipedhi A, Thomas R, Reddy MK. Injudicious antibiotic use leading to fulminating Clostridium difficile infection: a case report. CASES JOURNAL 2009; 2:7978. [PMID: 20181200 PMCID: PMC2827121 DOI: 10.1186/1757-1626-0002-0000007978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 05/27/2009] [Accepted: 08/25/2009] [Indexed: 05/28/2023]
Abstract
The case illustrates the myriad of fulminating complications due to Clostridium difficile infection in a previously healthy individual without any risk factors. Community acquired Clostridium difficile infection can occur even many weeks after the course of broad spectrum antibiotics. There is no definitive pattern or guidelines to predict who would develop the fulminating complications.
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Affiliation(s)
- Sreedhar Kolli
- Department of Rehabilitation Medicine, Rookwood Hospital, Fairwater Road, Cardiff, CF5 2YN, UK
| | - Akhila Mallipedhi
- Department of Endocrinology, Singleton Hospital, Sketty lane, Sketty, Swansea, SA2 8QA, UK
| | - Rhys Thomas
- Department of Neurology, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
| | - Male Kishore Reddy
- Department of Accident and Emergency Medicine, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
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Pawlowski SW, Warren CA, Guerrant R. Diagnosis and treatment of acute or persistent diarrhea. Gastroenterology 2009; 136:1874-86. [PMID: 19457416 PMCID: PMC2723735 DOI: 10.1053/j.gastro.2009.02.072] [Citation(s) in RCA: 132] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Revised: 02/03/2009] [Accepted: 02/25/2009] [Indexed: 01/10/2023]
Abstract
Studies of microbial pathogens and the toxins they produce are important for determining the mechanisms by which they cause disease and spread throughout a population. Some bacteria produce secretory enterotoxins (such as cholera toxin or the heat-labile or stable enterotoxins produced by Escherichia coli) that invade cells directly. Others invade cells or produce cytotoxins (such as those produced by Shigella, enteroinvasive E coli, or Clostridium difficile) that damage cells or trigger host responses that cause small or large bowel diseases (such as enteroaggregative or enteropathogenic E coli or Salmonella). Viruses (such as noroviruses and rotaviruses) and protozoa (such as Cryptosporidium, Giardia, or Entamoeba histolytica) disrupt cell functions and cause short- or long-term disease. Much epidemiologic data about these pathogens have been collected from community- and hospital-acquired settings, as well as from patients with traveler's or persistent diarrhea. These studies have led to practical approaches for prevention, diagnosis, and treatment.
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Key Words
- camp, cyclic adenosine 3′,5′ monophosphate
- cdi, clostridium difficile infection
- eaec, enteroaggregative escherichia coli
- ehec, enterohemorrhagic escherichia coli
- eiec, enteroinvasive escherichia coli
- elisa, enzyme-linked immunoabsorbent assay
- epec, enteropathogenic escherichia coli
- etec, enterotoxigenic escherichia coli
- gi, gastrointestinal
- pcr, polymerase chain reaction
- pi-ibs, postinfectious irritable bowel syndrome
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Affiliation(s)
| | | | - Richard Guerrant
- Reprint requests Address requests for reprints to: Richard Guerrant, Center for Global Health, Division of Infectious Disease and International Health, University of Virginia School of Medicine, Charlottesville, Virginia 22908. fax: (434) 982-0591
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Perencevich EN, Thom KA. Commentary: preventing Clostridium difficile-associated disease: is it time to pay the piper? Infect Control Hosp Epidemiol 2008; 29:829-31. [PMID: 18643747 DOI: 10.1086/591058] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Eli N Perencevich
- Veterans Affairs Maryland Health Care System, Baltimore, Maryland, USA.
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Bignardi G, Settle C. Different ribotypes in community-acquired Clostridium difficile. J Hosp Infect 2008; 70:96-8. [DOI: 10.1016/j.jhin.2008.04.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2008] [Accepted: 04/04/2008] [Indexed: 11/16/2022]
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Abstract
The main purpose of this article is to review recent developments in the management of acute and recurrent Clostridium difficile-associated disease, with consideration of existing and new antibiotic and non-antibiotic agents for treatment. Details of the current developmental stage of new agents are provided and the role of surgery in the management of severe disease is discussed. Infection control measures considered comprise prudent use of antimicrobials, prevention of cross-infection and surveillance. Other topics that are covered include the recent emergence of an epidemic hypervirulent strain, pathogenesis, clinical presentation and approaches to rapid diagnosis and assessment of the colonic disease.
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Affiliation(s)
- T Monaghan
- Institute of Infection, Immunity & Inflammation, University of Nottingham and Nottingham University Hospitals NHS Trust, UK
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Johansen K, Mannerqvist K, Allard A, Andersson Y, Burman LG, Dillner L, Hedlund KO, Jönsson K, Kumlin U, Leitner T, Lysén M, Thorhagen M, Tiveljung-Lindell A, Wahlström C, Zweygberg-Wirgart B, Widell A. Norovirus strains belonging to the GII.4 genotype dominate as a cause of nosocomial outbreaks of viral gastroenteritis in Sweden 1997--2005. Arrival of new variants is associated with large nation-wide epidemics. J Clin Virol 2008; 42:129-34. [PMID: 18304864 DOI: 10.1016/j.jcv.2007.12.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2007] [Revised: 11/23/2007] [Accepted: 12/27/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND In recent years an increase of the incidence of nosocomial outbreaks caused by noroviruses has been observed throughout Sweden, with high peaks noted in the winter seasons 2002/2003 and 2004/2005, respectively. OBJECTIVES To phylogenetically characterize norovirus strains causing nosocomial outbreaks from 1997 to 2005 and estimate the impact of norovirus-like disease on the Swedish health care system during the peak season 2002/2003 when a new variant of norovirus occurred. STUDY DESIGN Stool samples from 115 randomly selected nosocomial outbreaks occurring during 1997--2005 throughout Sweden were studied by RT-PCR and sequencing. In addition, to investigate the impact on the health-care system, a questionnaire was distributed to infection control units (n=90) serving all Swedish hospitals, nursing homes and other health-care institutions during the largest epidemic of nosocomial outbreaks. RESULTS Sequencing of 279 nucleotides of the norovirus RNA polymerase gene in stools containing norovirus RNA showed that strains belonging to the GII.4 genotype dominated. Each of the two large epidemics was due to a new variant within this cluster. The questionnaire revealed that 30,000-35,000 episodes of nosocomial norovirus-like infections occurred in 80 of 82 major Swedish hospitals affected in 2002/2003. CONCLUSION New norovirus variants within the cluster GGII.4 may have a major impact on the health-care system.
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Affiliation(s)
- Kari Johansen
- Department of Virology, Immunology and Vaccinology, Swedish Institute for Infectious Disease Control, 171 82 Solna, Sweden.
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Abstract
Clostridium difficile PCR ribotype 027 comprised 0.2% of a collection of Swedish isolates in 1997-2001 (3 of 1,325 isolates). These isolates had lower moxifloxacin MICs than the epidemic type 027 isolates, but they had the same tcdC sequence and toxin yield. Type 027 produced 3- to 13-fold more toxin than did major Swedish types. One epidemic strain (027/NAP1a) sporulated more than did other type 027 isolates, a feature that should contribute to its survival and spread.
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Barbut F. [Clostridium difficile infections: an unexpected re-emergence]. PATHOLOGIE-BIOLOGIE 2008; 56:6-9. [PMID: 18178330 DOI: 10.1016/j.patbio.2007.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2007] [Accepted: 09/19/2007] [Indexed: 05/25/2023]
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Koh TH, Tan AL, Tan ML, Wang G, Song KP. Epidemiology of Clostridium difficile infection in a large teaching hospital in Singapore. Pathology 2007; 39:438-42. [PMID: 17676487 PMCID: PMC7130798 DOI: 10.1080/00313020701444507] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
AIMS We undertook this study to define the incidence of toxigenic Clostridium difficile in our hospital and to characterise the isolates. METHODS All unformed stool was tested for the presence of Toxin A (TcdA) and Toxin B (TcdB), and cultured for C. difficile. Culture filtrates were also tested for TcdA and TcdB. Detection of tcdA and tcdB genes was carried out for A(-)B(+) strains by polymerase chain reaction (PCR).The minimum inhibitory concentrations (MICs) of metronidazole, vancomycin and clindamycin for all isolates were tested using the Etest. PCR ribotyping was carried out on all isolates. RESULTS The incidence of Clostridium difficile associated disease (CDAD) was 3.2 cases per 1000 admissions or discharges and 53.8 cases per 100 000 patient days. Most cases occurred in renal and haematology patients. CDAD was more common in patients aged over 50 years and of male gender. The Indian population was under-represented. Fourteen (11.8%) isolates were A(-)B(+). All strains were susceptible to metronidazole but one strain showed intermediate resistance to vancomycin. Only 12.8% of the isolates were susceptible to clindamycin. Thirty-five isolates had PCR ribotype A, of which 29 (83%) had a clindamycin MIC >256 mg/L. Thirty-three had PCR ribotype B, of which only one (3%) had a clindamycin MIC >256 mg/L. The 14 A(-)B(+) strains were all PCR ribotype C, and had a range of MICs for clindamycin from 2 to >256 mg/L. CONCLUSIONS The incidence of CDAD in our hospital is relatively low. Isolates remain susceptible to metronidazole and vancomycin.
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Affiliation(s)
- Tse Hsien Koh
- Department of Pathology, Singapore General Hospital, University of Singapore, Singapore.
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Barbut F, Gariazzo B, Bonné L, Lalande V, Burghoffer B, Luiuz R, Petit JC. Clinical features of Clostridium difficile-associated infections and molecular characterization of strains: results of a retrospective study, 2000-2004. Infect Control Hosp Epidemiol 2007; 28:131-9. [PMID: 17265393 DOI: 10.1086/511794] [Citation(s) in RCA: 138] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2006] [Accepted: 07/18/2006] [Indexed: 01/05/2023]
Abstract
BACKGROUND Recent outbreaks of severe cases of Clostridium difficile-associated diarrhea (CDAD) reported in North America, the United Kingdom, and The Netherlands have emphasized the importance of an ongoing epidemiological surveillance of CDAD. OBJECTIVE To determine the epidemiology of CDAD over the years 2000-2004 and the rate of nosocomial transmission of C. difficile. DESIGN Retrospective survey of inpatients with CDAD and molecular characterization of the strains isolated. SETTING A 760-bed teaching hospital. METHODS All CDAD cases diagnosed from January 1, 2000, to December 31, 2004, were reviewed. A CDAD case was defined as diarrhea in a hospitalized patient who had a stool specimen that tested positive for C. difficile cytotoxin or had a positive toxigenic culture result. CDAD was considered to be severe if a patient fulfilled at least 1 of the following 3 criteria: (1) presence of a fever (defined as temperature higher than 38.5 degrees C), abdominal pain, and leukocyte count greater than 10,000 cells/mm(3); (2) endoscopically or histologically proven pseudomembranous colitis; or (3) complications (defined as death with C. difficile infection as the primary or a contributing cause, toxic megacolon, perforation, toxic shock, and/or colectomy). CDAD was considered community-acquired if the diarrhea occurred in the patient within 72 hours after admission and if the patient had no history of hospitalization in the previous month; otherwise, CDAD was considered healthcare-associated. All the strains isolated were serogrouped and were characterized by toxinotyping and PCR ribotyping. Detection of toxin A, toxin B, and binary toxin was performed by PCR. RESULTS One hundred fifty-one cases of CDAD were diagnosed; 147 clinical records could be reviewed, and 131 strains were studied. The overall incidence of CDAD was 1.1 cases per 1,000 patients admitted, but incidence rates were higher in 2003-2004, compared with 2000-2002 (P=.017). Diarrhea was community acquired in 28 patients (19%). For patients with healthcare-associated CDAD, transmission of the strain from patient to patient (ie, infection with a strain of the same serogroup and PCR ribotype as the strain isolated from another patient hospitalized in the same ward or in a linked ward in the previous 2 months) was demonstrated in 12 cases (10.1%). Eleven percent of strains were positive for binary toxin. Binary toxin-positive strains were associated with more-severe diarrhea (P=.01) and with a higher case-fatality rate (P=.03). A specific clone of C. difficile (serogroup H, PCR ribotype sa026) accounted for 35 (26.7%) of all the strains isolated, but this clone was found both in healthcare-associated and community-acquired cases. Three strains belonged to toxinotype III, but only 1 was related to the hypervirulent clone involved in recent outbreaks. CONCLUSION The incidence of CDAD is low in our hospital, and cross-infection is limited. These results also suggest that strains with binary toxin might be more virulent.
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Affiliation(s)
- Frédéric Barbut
- Service de Microbiologie, Hopital Saint-Antoine, Paris, 75012, France.
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Sadeghifard N, Gürtler V, Beer M, Seviour RJ. The mosaic nature of intergenic 16S-23S rRNA spacer regions suggests rRNA operon copy number variation in Clostridium difficile strains. Appl Environ Microbiol 2006; 72:7311-23. [PMID: 16980415 PMCID: PMC1636144 DOI: 10.1128/aem.01179-06] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2006] [Accepted: 09/07/2006] [Indexed: 11/20/2022] Open
Abstract
Clostridium difficile is a major spore-forming environmental pathogen that causes serious health problems in patients undergoing antibiotic therapy. Consequently, reliable and sensitive methods for typing individual strains are required for epidemiological and environmental studies. Ribotyping is generally considered the best method, but it fails to account for sequence diversity which might exist in intergenic 16S-23S rRNA spacer regions (ISRs) within and among strains of this organism. Therefore, this study was undertaken to compare the sequence of each individual ISR in five strains of C. difficile to explore the extent of this diversity and see whether such information might provide the basis for more sensitive and discriminatory strain typing methods. After targeted PCR amplification, cloning, and sequencing, the diversity of the ISRs was used as a measure of rRNA operon copy number. In C. difficile strains 630, ATCC 43593, A, and B, 11, 11, 7, and 8 ISR length variants, respectively, were found (containing different combinations of sequence groups [i to xiii]), suggesting 11, 11, 7, and 8 rrn copies in the respective strains. Many ISRs of the same length differed markedly in their sequences, and some of these were restricted in occurrence to a single strain. Most of these ISRs did not contain any tRNA genes, and only single copies of the tRNA(Ala) gene were found in those that did. The presence of ISR sequence groups (i to xiii) varied between strains, with some found in one, two, three, four, or all five strains. We conclude that the intergenic 16S-23S rRNA spacer regions showed a high degree of diversity, not only among the rrn operons in different strains and different rrn copies in a single strain but also among ISRs of the same length. It appears that C. difficile ISRs vary more at the inter- and intragenic levels than those of other species as determined by empirical comparison of sequences. The precise characterization of these sequences has demonstrated a high level of mosaic sequence block rearrangements that are present or absent in multiple strain-variable rrn copies within and between five different strains of C. difficile.
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Affiliation(s)
- Nourkhoda Sadeghifard
- Biotechnology Research Centre, La Trobe University, Bendigo, Victoria 3552, Australia
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Aspevall O, Lundberg A, Burman LG, Akerlund T, Svenungsson B. Antimicrobial susceptibility pattern of Clostridium difficile and its relation to PCR ribotypes in a Swedish university hospital. Antimicrob Agents Chemother 2006; 50:1890-2. [PMID: 16641471 PMCID: PMC1472208 DOI: 10.1128/aac.50.5.1890-1892.2006] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
All 238 Clostridium difficile isolates were susceptible to metronidazole and vancomycin, whereas 84% and 1% were resistant to clindamycin and fusidic acid. Etest MICs for metronidazole were lower than agar dilution MICs (P < 0.01) but without difference in susceptible-intermediate-resistant categorization. No particular PCR ribotype was associated with clindamycin or fusidic acid resistance.
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Affiliation(s)
- Olle Aspevall
- Department of Clinical Microbiology, Akademiska University Hospital, SE-751 85 Uppsala, Sweden.
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46
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Akerlund T, Svenungsson B, Lagergren A, Burman LG. Correlation of disease severity with fecal toxin levels in patients with Clostridium difficile-associated diarrhea and distribution of PCR ribotypes and toxin yields in vitro of corresponding isolates. J Clin Microbiol 2006; 44:353-8. [PMID: 16455883 PMCID: PMC1392646 DOI: 10.1128/jcm.44.2.353-358.2006] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We investigated in vivo and in vitro yields of toxins A and B from and PCR ribotypes of Clostridium difficile isolates from 164 patients with differing severities of C. difficile-associated diarrhea (CDAD) (patients were grouped as follows: <3 loose stools per day, n = 45; 3 to 10 per day, n = 97; >10 per day, n = 22). The median fecal toxin levels in each group were 0.5, 6.8, and 149 U/g feces (P < 0.001), respectively. Patients with severe diarrhea also had more-frequent occurrence of blood in stool and vomiting, but there was no association with fecal toxin levels per se. There was no correlation between fecal toxin level and toxin yield in vitro for the corresponding C. difficile isolate or between its PCR ribotype and disease severity. A broad range of toxin yields among isolates belonging to major PCR ribotypes indicated a presence of many subtypes. We hypothesize that bacterial and host factors that affect C. difficile toxin levels in feces are important determinants of symptoms in CDAD patients. An inverse correlation between toxin yield and spore count (r = 0.66) in stationary-phase cultures supported the notion that toxin production and sporulation represent opposite alternative survival strategies for C. difficile cells facing nutrient shortage.
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Affiliation(s)
- Thomas Akerlund
- Department of Bacteriology, Swedish Institute for Infectious Disease Control, S-17182, Solna, Sweden.
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Arroyo LG, Kruth SA, Willey BM, Staempfli HR, Low DE, Weese JS. PCR ribotyping of Clostridium difficile isolates originating from human and animal sources. J Med Microbiol 2005; 54:163-166. [PMID: 15673511 DOI: 10.1099/jmm.0.45805-0] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Molecular typing of Clostridium difficile isolates from animals and humans may be useful for evaluation of the possibility for interspecies transmission. The objective of this study was to evaluate C. difficile isolates from domestic animals and humans using PCR ribotyping. Isolates were also tested using PCR for the presence of genes encoding toxins A and B. One hundred and thirty-three isolates of C. difficile from dogs (n = 92), horses (n = 21) and humans (n = 20), plus one each from a cat and a calf, were evaluated. Overall, 23 ribotypes were identified. Of these, nine were identified from dogs, 12 from horses, seven from humans and one each from the cat and calf. In dogs, humans and horses, one or two different ribotypes predominated. Overall, 25 % of isolates from humans were indistinguishable from isolates from one or more animal species. Genes encoding C. difficile toxins A and B were detected in all human, equine and bovine isolates, and in 69 % of canine isolates. While different ribotypes appear to predominate in different mammalian species, several indistinguishable strains may be found in multiple species. This suggests that there is a potential for interspecies transmission of C. difficile and epidemiological studies are warranted.
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Affiliation(s)
- Luis G Arroyo
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada N1G 2W1 2Department of Microbiology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Stephen A Kruth
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada N1G 2W1 2Department of Microbiology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Barbara M Willey
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada N1G 2W1 2Department of Microbiology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Henry R Staempfli
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada N1G 2W1 2Department of Microbiology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Don E Low
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada N1G 2W1 2Department of Microbiology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - J Scott Weese
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada N1G 2W1 2Department of Microbiology, Mount Sinai Hospital, Toronto, Ontario, Canada
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Schaier M, Wendt C, Zeier M, Ritz E. Clostridium difficile diarrhoea in the immunosuppressed patient--update on prevention and management. Nephrol Dial Transplant 2004; 19:2432-6. [PMID: 15280518 DOI: 10.1093/ndt/gfh428] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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