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Boeriu A, Roman A, Fofiu C, Dobru D. The Current Knowledge on Clostridioides difficile Infection in Patients with Inflammatory Bowel Diseases. Pathogens 2022; 11:pathogens11070819. [PMID: 35890064 PMCID: PMC9323231 DOI: 10.3390/pathogens11070819] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/17/2022] [Accepted: 07/18/2022] [Indexed: 11/17/2022] Open
Abstract
Clostridioides difficile (C. difficile) represents a major health burden with substantial economic and clinical impact. Patients with inflammatory bowel diseases (IBD) were identified as a risk category for Clostridioides difficile infection (CDI). In addition to traditional risk factors for C. difficile acquisition, IBD-specific risk factors such as immunosuppression, severity and extension of the inflammatory disease were identified. C. difficile virulence factors, represented by both toxins A and B, induce the damage of the intestinal mucosa and vascular changes, and promote the inflammatory host response. Given the potential life-threatening complications, early diagnostic and therapeutic interventions are required. The screening for CDI is recommended in IBD exacerbations, and the diagnostic algorithm consists of clinical evaluation, enzyme immunoassays (EIAs) or nucleic acid amplification tests (NAATs). An increased length of hospitalization, increased colectomy rate and mortality are the consequences of concurrent CDI in IBD patients. Selection of CD strains of higher virulence, antibiotic resistance, and the increasing rate of recurrent infections make the management of CDI in IBD more challenging. An individualized therapeutic approach is recommended to control CDI as well as IBD flare. Novel therapeutic strategies have been developed in recent years in order to manage severe, refractory or recurrent CDI. In this article, we aim to review the current evidence in the field of CDI in patients with underlying IBD, pointing to pathogenic mechanisms, risk factors for infection, diagnostic steps, clinical impact and outcomes, and specific management.
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Affiliation(s)
- Alina Boeriu
- Gastroenterology Department, University of Medicine Pharmacy, Sciences, and Technology “George Emil Palade” Targu Mures, 540142 Targu Mures, Romania; (A.B.); (C.F.); (D.D.)
- Gastroenterology Department, Mures County Clinical Hospital, 540103 Targu Mures, Romania
| | - Adina Roman
- Gastroenterology Department, University of Medicine Pharmacy, Sciences, and Technology “George Emil Palade” Targu Mures, 540142 Targu Mures, Romania; (A.B.); (C.F.); (D.D.)
- Gastroenterology Department, Mures County Clinical Hospital, 540103 Targu Mures, Romania
- Correspondence: ; Tel.: +40-752934465
| | - Crina Fofiu
- Gastroenterology Department, University of Medicine Pharmacy, Sciences, and Technology “George Emil Palade” Targu Mures, 540142 Targu Mures, Romania; (A.B.); (C.F.); (D.D.)
| | - Daniela Dobru
- Gastroenterology Department, University of Medicine Pharmacy, Sciences, and Technology “George Emil Palade” Targu Mures, 540142 Targu Mures, Romania; (A.B.); (C.F.); (D.D.)
- Gastroenterology Department, Mures County Clinical Hospital, 540103 Targu Mures, Romania
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Klimko A, Tieranu CG, Curte AM, Preda CM, Tieranu I, Olteanu AO, Ionescu EM. Clostridioides Difficile Enteritis: Case Report and Literature Review. Antibiotics (Basel) 2022; 11:antibiotics11020206. [PMID: 35203809 PMCID: PMC8868300 DOI: 10.3390/antibiotics11020206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 01/28/2022] [Accepted: 02/02/2022] [Indexed: 12/10/2022] Open
Abstract
Background: Clostridioides Difficile is a well-known pathogen causing diarrhea of various degrees of severity through associated infectious colitis. However, there have been reports of infectious enteritis mainly in patients with ileostomy, causing dehydration through high-output volume; Case presentation: We report the case of a 46-year-old male patient, malnourished, who presented with high-output ileostomy following a recent hospitalization where he had suffered an ileo-colic resection with ileal and transverse colon double ostomy, for stricturing Crohn’s disease. Clostridioides Difficile toxin A was identified in the ileal output confirming the diagnosis of acute enteritis. Treatment with oral Vancomycin was initiated with rapid reduction of the ileostomy output volume; Conclusion: We report a case of Clostridioides Difficile enteral infection as a cause for high-output ileostomy, successfully treated with oral Vancomycin. We also review the existing literature data regarding this specific localized infection.
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Affiliation(s)
- Artsiom Klimko
- Division of Physiology and Neuroscience, “Carol Davila” University of Medicine and Pharmacy, 050747 Bucharest, Romania;
| | - Cristian George Tieranu
- Department of Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.M.P.); (A.O.O.); (E.M.I.)
- Department of Gastroenterology, “Elias” Emergency University Hospital, 011461 Bucharest, Romania
- Correspondence: ; Tel.: +40-765-490-005
| | - Ana-Maria Curte
- Department of Pathology, “Elias” Emergency University Hospital, 011461 Bucharest, Romania;
| | - Carmen Monica Preda
- Department of Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.M.P.); (A.O.O.); (E.M.I.)
- Department of Gastroenterology, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Ioana Tieranu
- Department of Pediatrics, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Andrei Ovidiu Olteanu
- Department of Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.M.P.); (A.O.O.); (E.M.I.)
- Department of Gastroenterology, “Elias” Emergency University Hospital, 011461 Bucharest, Romania
| | - Elena Mirela Ionescu
- Department of Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.M.P.); (A.O.O.); (E.M.I.)
- Department of Gastroenterology, “Elias” Emergency University Hospital, 011461 Bucharest, Romania
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Engevik MA, Danhof HA, Chang-Graham AL, Spinler JK, Engevik KA, Herrmann B, Endres BT, Garey KW, Hyser JM, Britton RA, Versalovic J. Human intestinal enteroids as a model of Clostridioides difficile-induced enteritis. Am J Physiol Gastrointest Liver Physiol 2020; 318:G870-G888. [PMID: 32223302 PMCID: PMC7272722 DOI: 10.1152/ajpgi.00045.2020] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Clostridioides difficile is an important nosocomial pathogen that produces toxins to cause life-threatening diarrhea and colitis. Toxins bind to epithelial receptors and promote the collapse of the actin cytoskeleton. C. difficile toxin activity is commonly studied in cancer-derived and immortalized cell lines. However, the biological relevance of these models is limited. Moreover, no model is available for examining C. difficile-induced enteritis, an understudied health problem. We hypothesized that human intestinal enteroids (HIEs) express toxin receptors and provide a new model to dissect C. difficile cytotoxicity in the small intestine. We generated biopsy-derived jejunal HIE and Vero cells, which stably express LifeAct-Ruby, a fluorescent label of F-actin, to monitor actin cytoskeleton rearrangement by live-cell microscopy. Imaging analysis revealed that toxins from pathogenic C. difficile strains elicited cell rounding in a strain-dependent manner, and HIEs were tenfold more sensitive to toxin A (TcdA) than toxin B (TcdB). By quantitative PCR, we paradoxically found that HIEs expressed greater quantities of toxin receptor mRNA and yet exhibited decreased sensitivity to toxins when compared with traditionally used cell lines. We reasoned that these differences may be explained by components, such as mucins, that are present in HIEs cultures, that are absent in immortalized cell lines. Addition of human-derived mucin 2 (MUC2) to Vero cells delayed cell rounding, indicating that mucus serves as a barrier to toxin-receptor binding. This work highlights that investigation of C. difficile infection in that HIEs can provide important insights into the intricate interactions between toxins and the human intestinal epithelium.NEW & NOTEWORTHY In this article, we developed a novel model of Clostridioides difficile-induced enteritis using jejunal-derived human intestinal enteroids (HIEs) transduced with fluorescently tagged F-actin. Using live-imaging, we identified that jejunal HIEs express high levels of TcdA and CDT receptors, are more sensitive to TcdA than TcdB, and secrete mucus, which delays toxin-epithelial interactions. This work also optimizes optically clear C. difficile-conditioned media suitable for live-cell imaging.
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Affiliation(s)
- Melinda A. Engevik
- 1Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas,2Department of Pathology, Texas Children’s Hospital, Houston, Texas
| | - Heather A. Danhof
- 3Alkek Center for Metagenomic and Microbiome Research, Baylor College of Medicine, Houston, Texas,4Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas
| | | | - Jennifer K. Spinler
- 1Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas,2Department of Pathology, Texas Children’s Hospital, Houston, Texas
| | - Kristen A. Engevik
- 3Alkek Center for Metagenomic and Microbiome Research, Baylor College of Medicine, Houston, Texas,4Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas
| | - Beatrice Herrmann
- 1Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas,2Department of Pathology, Texas Children’s Hospital, Houston, Texas
| | - Bradley T. Endres
- 5Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas
| | - Kevin W. Garey
- 5Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas
| | - Joseph M. Hyser
- 1Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas,2Department of Pathology, Texas Children’s Hospital, Houston, Texas
| | - Robert A. Britton
- 3Alkek Center for Metagenomic and Microbiome Research, Baylor College of Medicine, Houston, Texas,4Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas
| | - James Versalovic
- 1Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas,2Department of Pathology, Texas Children’s Hospital, Houston, Texas
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Abstract
We report an atypical case of Clostridium difficile (C.difficile) infection in a 35-year male who presented to the hospital because of diffuse abdominal pain associated with nausea and vomiting. Patient denied diarrhea or hematochezia. On physical examination, he was afebrile, but tachycardic and hypotensive. Abdominal examination revealed mild diffuse tenderness without signs of peritonitis. Lab work up was significant for leucocytosis and elevated serum lactate. Computed tomography (CT) of the abdomen and pelvis with intravenous (IV) contrast was done with findings suggestive of enteritis. Initial work up did not reveal any source of infection, so he was treated with broad-spectrum antibiotics for severe sepsis of unknown origin. Broad-spectrum antibiotics were continued for two days without significant improvement in signs and symptoms; stool studies were obtained which showed positive C.difficile on polymerase chain reaction (PCR) after which oral vancomycin was started and IV antibiotics were stopped. The patient's signs and symptoms improved after a couple of days of oral vancomycin and he was discharged home to complete a 14-day course of oral vancomycin.
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Affiliation(s)
- Haisam Abid
- Internal Medicine, Bassett Medical Center, Cooperstown, USA
| | - Edward Bischof
- Internal Medicine, Bassett Medical Center, Cooperstown, USA
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Clostridium difficile Enteritis after Total Abdominal Colectomy for Ulcerative Colitis. Case Rep Crit Care 2019; 2019:2987682. [PMID: 30863646 PMCID: PMC6378043 DOI: 10.1155/2019/2987682] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 01/03/2019] [Accepted: 01/17/2019] [Indexed: 01/29/2023] Open
Abstract
Introduction Isolated Clostridium difficile small bowel enteritis is a rare condition with significant morbidity and mortality. Presentation of Case An 83-year-old female with refractory ulcerative colitis underwent a total proctocolectomy and end ileostomy. Her postoperative course was complicated with return to the operating room for repair of an incarcerated port site hernia. Subsequently, she developed septic shock and multiorgan failure requiring intubation and mechanical ventilation, renal replacement therapy, and high dose vasopressors. Diagnostic workup revealed diffuse small bowel wall thickening on computed tomography scan as well as positive nucleic acid amplification test for C. difficile toxin B gene. Despite treatment with antibiotics and maximum attempts at resuscitation, the patient expired. Discussion. C. difficile infection most commonly affects the colon but rarely can involve the small bowel. The pathogenesis of C. difficile enteritis is unclear but is believed to mirror that of colitis. Surgical patients are susceptible for C. difficile infection, as they tend to be relatively immunosuppressed in the postoperative period. Radiologic findings of enteritis may mimic those of colitis and this includes small bowel dilation and thickening. Treatment for this condition has not been well established but it is approached similar to colitis. Conclusion Despite an increase in the number of case reports of C. difficile enteritis, it continues to be a rare but potentially fatal infection. Clinicians should maintain a high index of suspicion especially in patients with inflammatory bowel disease who undergo colon resections.
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