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Moreels N, Boven A, Gressani O, Andersson FL, Vlieghe E, Callens S, Engstrand L, Simin J, Brusselaers N. The combined effect of systemic antibiotics and proton pump inhibitors on Clostridioides difficile infection and recurrence. J Antimicrob Chemother 2024; 79:608-616. [PMID: 38267263 PMCID: PMC10904719 DOI: 10.1093/jac/dkae012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 01/03/2024] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Antibiotics and proton pump inhibitors (PPI) are recognized risk factors for acquisition and recurrence of Clostridioides difficile infection (CDI), yet combined effects remain unclear. OBJECTIVES To assess the short- and long-term effects of antibiotics and PPIs on CDI risk and recurrence. METHODS Population-based study including all 43 152 patients diagnosed with CDI in Sweden (2006-2019), and 355 172 matched population controls without CDI. The impact of antibiotics and PPIs on CDI risk and recurrence was explored for recent (0-30 days) and preceding (31-180 days) use prior to their first CDI diagnosis, using multivariable conditional logistic regression presented as odds ratios (ORs) and 95% confidence interval, adjusted for demographics, comorbidities and other drugs. RESULTS Compared to controls, the combined effect of recent PPIs and antibiotics [ORAB+PPI = 17.51 (17.48-17.53)] on CDI risk was stronger than the individual effects [ORAB = 15.37 (14.83-15.93); ORPPI = 2.65 (2.54-2.76)]. Results were less pronounced for exposure during the preceding months. Dose-response analyses showed increasing exposure correlated with CDI risk [recent use: ORAB = 6.32 (6.15-6.49); ORPPI = 1.65 (1.62-1.68) per prescription increase].Compared to individuals without recurrence (rCDI), recent [ORAB = 1.30 (1.23-1.38)] and preceding [ORAB = 1.23 (1.16-1.31); ORPPI = 1.12 (1.03-1.21)] use also affected the risk of recurrence yet without significant interaction between both. Recent macrolides/lincosamides/streptogramins; other antibacterials including nitroimidazole derivates; non-penicillin beta lactams and quinolones showed the strongest association with CDI risk and recurrence, particularly for recent use. PPI use, both recent and preceding, further increased the CDI risk associated with almost all antibiotic classes. CONCLUSION Recent and less recent use of PPIs and systemic antibiotics was associated with an increased risk of CDI, particularly in combination.
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Affiliation(s)
- Nele Moreels
- Department of Microbiology, Centre for Translational Microbiome Research, Tumour and Cell Biology, Karolinska Institutet, Stockholm, Sweden
- I-BioStat, Data Science Institute, Hasselt University, Hasselt, Belgium
| | - Annelies Boven
- Department of Microbiology, Centre for Translational Microbiome Research, Tumour and Cell Biology, Karolinska Institutet, Stockholm, Sweden
- Department of Family Medicine and Population Health, Global Health Institute, Antwerp University, Antwerp, Belgium
| | - Oswaldo Gressani
- I-BioStat, Data Science Institute, Hasselt University, Hasselt, Belgium
| | | | - Erika Vlieghe
- Department of Family Medicine and Population Health, Global Health Institute, Antwerp University, Antwerp, Belgium
| | - Steven Callens
- Department of Internal Medicine and Pediatrics, General Internal Medicine, Ghent University, Ghent, Belgium
| | - Lars Engstrand
- Department of Microbiology, Centre for Translational Microbiome Research, Tumour and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Johanna Simin
- Department of Microbiology, Centre for Translational Microbiome Research, Tumour and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Nele Brusselaers
- Department of Microbiology, Centre for Translational Microbiome Research, Tumour and Cell Biology, Karolinska Institutet, Stockholm, Sweden
- Department of Family Medicine and Population Health, Global Health Institute, Antwerp University, Antwerp, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
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2
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Kaya G, Usta D, Sag E, Aydin ZG, Buruk CK, Ozkaya E, Aydin F, Cakir M. Incidence and Risk Factors for Antibiotic-associated Diarrhea Among Hospitalized Children. Pediatr Infect Dis J 2023; 42:745-749. [PMID: 37310932 DOI: 10.1097/inf.0000000000003994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND We aimed to evaluate the incidence, clinical findings, and risk factors of antibiotic-associated diarrhea (AAD) in hospitalized children without known comorbid diseases. METHODS All hospitalized children during the 1-year period that fulfilled the inclusion criteria were included in this study (n = 358). AAD was defined as; ≥2 loose or watery stools per day for a minimum of 24 hours during antibiotic treatment caused by Clostridioides difficile or negative stool tests for identifiable infectious agents. RESULTS During hospitalization, diarrhea developed in 32 (8.93%) of the 358 patients. C. difficile toxin B was positive for 1 case. No infectious agents were detected in 21 patients. Overall, AAD was observed in 22 patients (6.14%, 95% CI: 4.09-9.13). Male sex ( P = 0.027, OR: 3.36), age between 1 month and <3 years ( P = 0.01, OR: 4.23), ibuprofen use ( P = 0.044, OR: 2.63) and late administration of antibiotics ( P = 0.001, OR: 9.5) were associated with the development of AAD. CONCLUSIONS The incidence of AAD is low among hospitalized children without comorbid diseases, and most diarrheal episodes are mild and self-limiting. The use of probiotics in this patient group may be limited to certain specific situations.
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Affiliation(s)
- Gülay Kaya
- From the Division of Pediatrics, Karadeniz Technical University, Trabzon, Turkey
| | - Deniz Usta
- From the Division of Pediatrics, Karadeniz Technical University, Trabzon, Turkey
| | - Elif Sag
- Division of Department of Pediatric Gastroenterology, Department of Pediatric Gastroenterology, Istanbul Medical Faculty, Istanbul, Turkey
| | - Zg Gayretli Aydin
- Division of Department of Pediatrics Infectious Diseases, Department of Pediatric Infectious Diseases, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Celal Kurtulus Buruk
- Division of Department of Microbiology, Karadeniz Technical University, Trabzon, Turkey
| | - Esra Ozkaya
- Division of Department of Microbiology, Karadeniz Technical University, Trabzon, Turkey
| | - Faruk Aydin
- Division of Department of Microbiology, Karadeniz Technical University, Trabzon, Turkey
| | - Murat Cakir
- From the Division of Pediatrics, Karadeniz Technical University, Trabzon, Turkey
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3
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Soto Ocaña J, Bayard NU, Hart JL, Thomas AK, Furth EE, Lacy DB, Aronoff DM, Zackular JP. Nonsteroidal anti-inflammatory drugs sensitize epithelial cells to Clostridioides difficile toxin-mediated mitochondrial damage. SCIENCE ADVANCES 2023; 9:eadh5552. [PMID: 37467340 PMCID: PMC10355836 DOI: 10.1126/sciadv.adh5552] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 06/15/2023] [Indexed: 07/21/2023]
Abstract
Clostridioides difficile damages the colonic mucosa through the action of two potent exotoxins. Factors shaping C. difficile pathogenesis are incompletely understood but are likely due to the ecological factors in the gastrointestinal ecosystem, mucosal immune responses, and environmental factors. Little is known about the role of pharmaceutical drugs during C. difficile infection (CDI), but recent studies have demonstrated that nonsteroidal anti-inflammatory drugs (NSAIDs) worsen CDI. The mechanism underlying this phenomenon remains unclear. Here, we show that NSAIDs exacerbate CDI by disrupting colonic epithelial cells (CECs) and sensitizing cells to C. difficile toxin-mediated damage independent of their canonical role of inhibiting cyclooxygenase (COX) enzymes. Notably, we find that NSAIDs and C. difficile toxins target the mitochondria of CECs and enhance C. difficile toxin-mediated damage. Our results demonstrate that NSAIDs exacerbate CDI by synergizing with C. difficile toxins to damage host cell mitochondria. Together, this work highlights a role for NSAIDs in exacerbating microbial infection in the colon.
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Affiliation(s)
- Joshua Soto Ocaña
- Division of Protective Immunity, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Nile U. Bayard
- Division of Protective Immunity, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Jessica L. Hart
- Division of Protective Immunity, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Audrey K. Thomas
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Emma E. Furth
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - D. Borden Lacy
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - David M. Aronoff
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Joseph P. Zackular
- Division of Protective Immunity, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Ok MT, Liu J, Bliton RJ, Hinesley CM, San Pedro EET, Breau KA, Gomez-Martinez I, Burclaff J, Magness ST. A leaky human colon model reveals uncoupled apical/basal cytotoxicity in early Clostridioides difficile toxin exposure. Am J Physiol Gastrointest Liver Physiol 2023; 324:G262-G280. [PMID: 36749911 PMCID: PMC10010926 DOI: 10.1152/ajpgi.00251.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/31/2023] [Accepted: 02/05/2023] [Indexed: 02/09/2023]
Abstract
Clostridioides difficile (C. difficile) toxins A (TcdA) and B (TcdB) cause antibiotic-associated colitis in part by disrupting epithelial barrier function. Accurate in vitro models are necessary to detect early toxicity kinetics, investigate disease etiology, and develop preclinical models for new therapies. Properties of cancer cell lines and organoids inherently limit these efforts. We developed adult stem cell-derived monolayers of differentiated human colonic epithelium (hCE) with barrier function, investigated the impact of toxins on apical/basal aspects of monolayers, and evaluated whether a leaky epithelial barrier enhances toxicity. Single-cell RNA-sequencing (scRNAseq) mapped C. difficile-relevant genes to human lineages. Transcriptomics compared hCE to Caco-2, informed timing of in vitro stem cell differentiation, and revealed transcriptional responses to TcdA. Transepithelial electrical resistance (TEER) and fluorescent permeability assays measured cytotoxicity. Contribution of TcdB toxicity was evaluated in a diclofenac-induced leaky gut model. scRNAseq demonstrated broad and variable toxin receptor expression. Absorptive colonocytes in vivo displayed increased toxin receptor, Rho GTPase, and cell junction gene expression. Advanced TcdA toxicity generally decreased cytokine/chemokine and increased tight junction and death receptor genes. Differentiated Caco-2 cells remained immature whereas hCE monolayers were similar to mature colonocytes in vivo. Basal exposure of TcdA/B caused greater toxicity and apoptosis than apical exposure. Apical exposure to toxins was enhanced by diclofenac. Apical/basal toxicities are uncoupled with more rapid onset and increased magnitude postbasal toxin exposure. Leaky junctions enhance toxicity of apical TcdB exposure. hCE monolayers represent a physiologically relevant and sensitive system to evaluate the impact of microbial toxins on gut epithelium.NEW & NOTEWORTHY Novel human colonocyte monolayer cultures, benchmarked by transcriptomics for physiological relevance, detect early cytopathic impacts of Clostridioides difficile toxins TcdA and TcdB. A fluorescent ZO-1 reporter in primary human colonocytes is used to track epithelial barrier disruption in response to TcdA. Basal TcdA/B exposure generally caused more rapid onset and cytotoxicity than apical exposure. Transcriptomics demonstrate changes in tight junction, chemokine, and cytokine receptor gene expression post-TcdA exposure. Diclofenac-induced leaky epithelium enhanced apical exposure toxicity.
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Affiliation(s)
- Meryem T Ok
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Chapel Hill, North Carolina, United States
| | - Jintong Liu
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill and North Carolina State University, Chapel Hill, North Carolina, United States
| | - R Jarrett Bliton
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Chapel Hill, North Carolina, United States
| | - Caroline M Hinesley
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill and North Carolina State University, Chapel Hill, North Carolina, United States
| | - Ekaterina Ellyce T San Pedro
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill and North Carolina State University, Chapel Hill, North Carolina, United States
| | - Keith A Breau
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Ismael Gomez-Martinez
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Joseph Burclaff
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Chapel Hill, North Carolina, United States
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill and North Carolina State University, Chapel Hill, North Carolina, United States
| | - Scott T Magness
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Chapel Hill, North Carolina, United States
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill and North Carolina State University, Chapel Hill, North Carolina, United States
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
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5
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Kullin B, Abratt VR, Reid SJ, Riley TV. Clostridioides difficile infection in Africa: A narrative review. Anaerobe 2022; 74:102549. [PMID: 35337974 DOI: 10.1016/j.anaerobe.2022.102549] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 03/13/2022] [Accepted: 03/17/2022] [Indexed: 12/12/2022]
Abstract
Clostridioides (Clostridium) difficile infection (CDI) places a burden on healthcare facilities worldwide. Most research studies have been concentrated in high-income countries in North America, Europe, Asia and Australia, where C. difficile is the leading cause of diarrhoea associated with antimicrobial use. This narrative review summarises African CDI studies, focussing on reports published in the last 20 years. Although relatively sparse, the data suggest that CDI is an important cause of diarrhoea on the continent. African CDI patient populations are often younger than in European and North American settings, probably due to the high prevalence of co-morbid conditions such as tuberculosis, particularly in sub-Saharan Africa. Strain typing data are rare and where reported generally limited to single sites and institutions. Despite challenges, including a lack of facilities and awareness, there is a need for further investigation to more accurately determine the true burden of disease caused by C. difficile in Africa.
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Affiliation(s)
- Brian Kullin
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Valerie R Abratt
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Sharon J Reid
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Thomas V Riley
- Medical, Molecular and Forensic Sciences, Murdoch University, Murdoch, Western Australia WA, Australia; School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia; Department of Microbiology, PathWest Laboratory Medicine, Nedlands, WA, Australia; School of Biomedical Sciences, The University of Western Australia, Crawley, WA, Australia.
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6
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Goncuoglu C, Guven GS, Sener B, Demirkan K. Effect of gastric acid suppression on Clostridioides difficile-induced diarrhea and appropriateness of gastric acid suppressors in hospitalized patients: A matched case-control study. Arab J Gastroenterol 2021; 22:292-296. [PMID: 34531136 DOI: 10.1016/j.ajg.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 05/05/2021] [Accepted: 06/30/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND STUDY AIMS The effects of gastric acid suppressors (GASs) on Clostridioides difficile infection remain controversial. Moreover, studies have shown that GASs are overused. This study was designed to evaluate the effects of GAS use on the risk of C. difficile-induced diarrhea (CDID) development and to investigate the appropriate use of GASs. PATIENTS AND METHODS In this observational case-control study, patients hospitalized between January 2010 and December 2016 who had diarrhea after 3 days of hospitalization were included. The study (n = 122) and control (n = 122) groups were matched according to the patients' hospitalization dates and departments. RESULTS No significant difference in CDID development was observed between the study and control groups. However, GAS use was excessive in the study and control groups (usage rates were 90.2% and 91.8%, respectively) (p > 0.05). Most proton pump inhibitors and histamine-2 receptor antagonists were used without an appropriate indication. Surprisingly, the use of nonsteroidal anti-inflammatory drugs for 7 days and longer showed a significant difference between the study and control groups (p < 0.05). Additionally, significant differences in enteral feeding, oral nutritional support products, carbapenem, penicillin, glycopeptide antibiotics, antifungals, hypoalbuminemia, and increased leukocyte levels were observed between the study and control groups (p < 0.05). CONCLUSION A significant difference in CDID development was not detected. The use of non-steroidal anti-inflammatory drugs for 7 days and longer was a risk factor for CDID development. Additionally, an excessive inappropriate use of GASs was observed. Clinicians should be cautious of all these factors, which may increase the risk of CDID development.
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Affiliation(s)
- Cansu Goncuoglu
- Hacettepe University, Faculty of Pharmacy, Department of Clinical Pharmacy, P.O. Box 06100, Sıhhiye, Ankara, Turkey.
| | - Gulay Sain Guven
- Hacettepe University, Faculty of Medicine, Department of Internal Medicine, P.O. Box 06100, Sıhhiye, Ankara, Turkey
| | - Burcin Sener
- Hacettepe University, Faculty of Medicine, Department of Medical Microbiology, P.O. Box 06100, Sıhhiye, Ankara, Turkey
| | - Kutay Demirkan
- Hacettepe University, Faculty of Pharmacy, Department of Clinical Pharmacy, P.O. Box 06100, Sıhhiye, Ankara, Turkey
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7
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Ionescu EM, Curte AM, Olteanu AO, Preda CM, Tieranu I, Klimko A, Tieranu CG. Rare Clinical Association between Clostridioides difficile Infection and Ischemic Colitis: Case Report and Literature Review. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:705. [PMID: 34356986 PMCID: PMC8307989 DOI: 10.3390/medicina57070705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/02/2021] [Accepted: 07/08/2021] [Indexed: 01/14/2023]
Abstract
Background and Objectives: Gut microbiota plays an important role in the wellbeing of the host through different interactions between microflora constituents. In certain instances, Clostridioides difficile may pullulate, causing infection with associated colitis that may vary in terms of severity from mild disease to severe colitis, with increased associated mortality due to its complications. However, there are few literature data regarding the association between Clostridioides difficile and ischemic colitis. Case report: We report the case of a 30-year-old male patient, overweight, with impending dehydration, who presented with hematochezia and colicky abdominal pain, with positive fecal tests for the detection of Clostridioides difficile infection and endoscopic appearance suggesting ischemic colitis in the sigmoid and left colon, confirmed by computed tomography and histology. The patient was treated with oral Vancomycin, with resolution of symptoms, and was reevaluated through colonoscopy eight weeks after discharge, with endoscopic mucosal normalization and histological scarring process on biopsy samples. Conclusion: We report one of the few cases in the literature of ischemic colitis associated with Clostridioides difficile infection, with resolution of clinical, endoscopic, and histologic changes after specific treatment with oral Vancomycin suggesting a possible association between the two diseases. We also review the existing literature data regarding this comorbid association.
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Affiliation(s)
- Elena Mirela Ionescu
- Department of Gastroenterology, “Elias” Emergency University Hospital, 011461 Bucharest, Romania; (A.O.O.); (C.G.T.)
- Department of Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.M.P.); (I.T.); (A.K.)
| | - Ana-Maria Curte
- Department of Pathology, “Elias” Emergency University Hospital, 011461 Bucharest, Romania;
| | - Andrei Ovidiu Olteanu
- Department of Gastroenterology, “Elias” Emergency University Hospital, 011461 Bucharest, Romania; (A.O.O.); (C.G.T.)
| | - Carmen Monica Preda
- Department of Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.M.P.); (I.T.); (A.K.)
- Department of Gastroenterology, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Ioana Tieranu
- Department of Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.M.P.); (I.T.); (A.K.)
| | - Artsiom Klimko
- Department of Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.M.P.); (I.T.); (A.K.)
| | - Cristian George Tieranu
- Department of Gastroenterology, “Elias” Emergency University Hospital, 011461 Bucharest, Romania; (A.O.O.); (C.G.T.)
- Department of Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.M.P.); (I.T.); (A.K.)
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Wang X, Tang Q, Hou H, Zhang W, Li M, Chen D, Gu Y, Wang B, Hou J, Liu Y, Cao H. Gut Microbiota in NSAID Enteropathy: New Insights From Inside. Front Cell Infect Microbiol 2021; 11:679396. [PMID: 34295835 PMCID: PMC8290187 DOI: 10.3389/fcimb.2021.679396] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 06/10/2021] [Indexed: 12/15/2022] Open
Abstract
As a class of the commonly used drugs in clinical practice, non-steroidal anti-inflammatory drugs (NSAIDs) can cause a series of adverse events including gastrointestinal injuries. Besides upper gastrointestinal injuries, NSAID enteropathy also attracts attention with the introduction of capsule endoscopy and double balloon enteroscopy. However, the pathogenesis of NSAID enteropathy remains to be entirely clarified. Growing evidence from basic and clinical studies presents that gut microbiota is a critical factor in NSAID enteropathy progress. We have reviewed the recent data about the interplay between gut microbiota dysbiosis and NSAID enteropathy. The chronic medication of NSAIDs could change the composition of the intestinal bacteria and aggravate bile acids cytotoxicity. Meanwhile, NSAIDs impair the intestinal barrier by inhibiting cyclooxygenase and destroying mitochondria. Subsequently, intestinal bacteria translocate into the mucosa, and then lipopolysaccharide released from gut microbiota combines to Toll-like receptor 4 and induce excessive production of nitric oxide and pro-inflammatory cytokines. Intestinal injuries present in the condition of intestinal inflammation and oxidative stress. In this paper, we also have reviewed the possible strategies of regulating gut microbiota for the management of NSAID enteropathy, including antibiotics, probiotics, prebiotics, mucosal protective agents, and fecal microbiota transplant, and we emphasized the adverse effects of proton pump inhibitors on NSAID enteropathy. Therefore, this review will provide new insights into a better understanding of gut microbiota in NSAID enteropathy.
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Affiliation(s)
- Xianglu Wang
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, Tianjin Institute of Digestive Diseases, Tianjin Key Laboratory of Digestive Diseases, Tianjin, China
| | - Qiang Tang
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, Tianjin Institute of Digestive Diseases, Tianjin Key Laboratory of Digestive Diseases, Tianjin, China
| | - Huiqin Hou
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, Tianjin Institute of Digestive Diseases, Tianjin Key Laboratory of Digestive Diseases, Tianjin, China
| | - Wanru Zhang
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, Tianjin Institute of Digestive Diseases, Tianjin Key Laboratory of Digestive Diseases, Tianjin, China
| | - Mengfan Li
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, Tianjin Institute of Digestive Diseases, Tianjin Key Laboratory of Digestive Diseases, Tianjin, China
| | - Danfeng Chen
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, Tianjin Institute of Digestive Diseases, Tianjin Key Laboratory of Digestive Diseases, Tianjin, China
| | - Yu Gu
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, Tianjin Institute of Digestive Diseases, Tianjin Key Laboratory of Digestive Diseases, Tianjin, China
| | - Bangmao Wang
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, Tianjin Institute of Digestive Diseases, Tianjin Key Laboratory of Digestive Diseases, Tianjin, China
| | - Jingli Hou
- Tianjin Key Laboratory on Technologies Enabling Development of Clinical Therapeutics and Diagnostics, School of Pharmacy, Tianjin Medical University, Tianjin, China
- *Correspondence: Hailong Cao, ; Jingli Hou, ; Yangping Liu,
| | - Yangping Liu
- Tianjin Key Laboratory on Technologies Enabling Development of Clinical Therapeutics and Diagnostics, School of Pharmacy, Tianjin Medical University, Tianjin, China
- *Correspondence: Hailong Cao, ; Jingli Hou, ; Yangping Liu,
| | - Hailong Cao
- Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, Tianjin Institute of Digestive Diseases, Tianjin Key Laboratory of Digestive Diseases, Tianjin, China
- *Correspondence: Hailong Cao, ; Jingli Hou, ; Yangping Liu,
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9
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Smith AB, Soto Ocana J, Zackular JP. From Nursery to Nursing Home: Emerging Concepts in Clostridioides difficile Pathogenesis. Infect Immun 2020; 88:IAI.00934-19. [PMID: 32122939 PMCID: PMC7309631 DOI: 10.1128/iai.00934-19] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Clostridioides difficile is a Gram-positive, spore-forming, anaerobic bacterium that infects the human gastrointestinal tract, causing a wide range of disorders that vary in severity from mild diarrhea to toxic megacolon and/or death. Over the past decade, incidence, severity, and costs associated with C. difficile infection (CDI) have increased dramatically in both the pediatric and adult populations. The factors driving this rapidly evolving epidemiology remain largely unknown but are likely due in part to previously unappreciated host, microbiota, and environmental factors. In this review, we will cover the risks and challenges of CDI in adult and pediatric populations and examine asymptomatic colonization in infants. We will also discuss the emerging role of diet, pharmaceutical drugs, and pathogen-microbiota interactions in C. difficile pathogenesis, as well as the impact of host-microbiota interactions in the manifestation of C. difficile-associated disease. Finally, we highlight new areas of research and novel strategies that may shed light on this complex infection and provide insights into the future of microbiota-based therapeutics for CDI.
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Affiliation(s)
- Alexander B Smith
- Division of Protective Immunity, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua Soto Ocana
- Division of Protective Immunity, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joseph P Zackular
- Division of Protective Immunity, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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10
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Noori M, Yadegar A, Zali MR. A Complex Scenario of Nonsteroidal Anti-inflammatory Drugs Induced Prostaglandin E2 Production and Gut Microbiota Alteration in Clostridium difficile-Infected Mice. mBio 2020; 11:mBio.02596-19. [PMID: 31937640 PMCID: PMC6960283 DOI: 10.1128/mbio.02596-19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Maryam Noori
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Abbas Yadegar
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Zali
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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11
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Puro N, Joseph R, Zengul FD, Cochran KJ, Camins BC, Ray M. Predictors of Hospital-Acquired Clostridioides difficile Infection: A Systematic Review. J Healthc Qual 2020; 42:127-135. [PMID: 31821178 DOI: 10.1097/jhq.0000000000000236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Clostridioides difficile infections (CDIs) have been identified as a major health concern due to the high morbidity, mortality, and cost of treatment. The aim of this study was to review the extant literature and identify the various patient-related, medication-related, and organizational risk factors associated with developing hospital-acquired CDIs in adult patients in the United States. METHODS A systematic review of four (4) online databases, including Scopus, PubMed, CINAHL, and Cochrane Library, was conducted to identify empirical studies published from 2007 to 2017 pertaining to risk factors of developing hospital-acquired CDIs. FINDINGS Thirty-eight studies (38) were included in the review. Various patient-level and medication-related risk factors were identified including advanced patient age, comorbidities, length of hospital stay, previous hospitalizations, use of probiotic medications and proton pump inhibitors. The review also identified organizational factors such as room size, academic affiliation, and geographic location to be significantly associated with hospital-acquired CDIs. CONCLUSION Validation of the factors associated with high risk of developing hospital-acquired CDIs identified in this review can aid in the development of risk prediction models to identify patients who are at a higher risk of developing CDIs and developing quality improvement interventions that might improve patient outcomes by minimizing risk of infection.
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12
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Maseda D, Ricciotti E. NSAID-Gut Microbiota Interactions. Front Pharmacol 2020; 11:1153. [PMID: 32848762 PMCID: PMC7426480 DOI: 10.3389/fphar.2020.01153] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/15/2020] [Indexed: 12/21/2022] Open
Abstract
Nonsteroidal anti-inflammatory drugs (NSAID)s relieve pain, inflammation, and fever by inhibiting the activity of cyclooxygenase isozymes (COX-1 and COX-2). Despite their clinical efficacy, NSAIDs can cause gastrointestinal (GI) and cardiovascular (CV) complications. Moreover, NSAID use is characterized by a remarkable individual variability in the extent of COX isozyme inhibition, therapeutic efficacy, and incidence of adverse effects. The interaction between the gut microbiota and host has emerged as a key player in modulating host physiology, gut microbiota-related disorders, and metabolism of xenobiotics. Indeed, host-gut microbiota dynamic interactions influence NSAID disposition, therapeutic efficacy, and toxicity. The gut microbiota can directly cause chemical modifications of the NSAID or can indirectly influence its absorption or metabolism by regulating host metabolic enzymes or processes, which may have consequences for drug pharmacokinetic and pharmacodynamic properties. NSAID itself can directly impact the composition and function of the gut microbiota or indirectly alter the physiological properties or functions of the host which may, in turn, precipitate in dysbiosis. Thus, the complex interconnectedness between host-gut microbiota and drug may contribute to the variability in NSAID response and ultimately influence the outcome of NSAID therapy. Herein, we review the interplay between host-gut microbiota and NSAID and its consequences for both drug efficacy and toxicity, mainly in the GI tract. In addition, we highlight progress towards microbiota-based intervention to reduce NSAID-induced enteropathy.
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Affiliation(s)
- Damian Maseda
- Department of Microbiology, University of Pennsylvania, Philadelphia, PA, United States
| | - Emanuela Ricciotti
- Department of Systems Pharmacology and Translational Therapeutics, and Institute for Translational Medicine and Therapeutics, University of Pennsylvania, Philadelphia, PA, United States
- *Correspondence: Emanuela Ricciotti,
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13
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Patel H, Makker J, Vakde T, Shaikh D, Badipatla K, Dunne J, Mantri N, Nayudu SK, Glandt M, Balar B, Chilimuri S. Nonsteroidal Anti-Inflammatory Drugs Impact on the Outcomes of Hospitalized Patients with Clostridium difficile Infection. Clin Exp Gastroenterol 2019; 12:449-456. [PMID: 31849510 PMCID: PMC6911331 DOI: 10.2147/ceg.s223886] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 11/21/2019] [Indexed: 12/13/2022] Open
Abstract
Purpose Mouse model experiments have demonstrated an increased Clostridium difficile infection (CDI) severity with Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) use. We aim to evaluate the impact of NSAIDs in humans after a diagnosis of CDI on primary outcomes defined as I) all-cause mortality and II) toxic mega-colon attributable to CDI. Patients and methods All hospitalized patients with a diagnosis of CDI were divided into two groups; those with NSAIDs administered up to 10 days after onset of CDI versus no NSAIDs use. The primary outcomes were analyzed between the groups, while controlling for severity of CDI. A logistic regression analysis was performed to identify the predictors of worse outcomes. Results NSAIDs were administered in 14% (n=80) of the 568 hospitalized visits for an average of 2.5 days after the CDI diagnosis. All-cause mortality was high in patients who did not receive NSAIDs as compared to those who did receive NSAIDs (16.6% vs 12.5%, p 0.354). Patients who were prescribed NSAIDs were more likely to have toxic mega-colon as compared to those who were not prescribed NSAIDs (2.5% vs 0.6%, p 0.094). Results were not statistically significant, even after controlling for CDI severity. Logistic regression analysis did not identify NSAIDs administration as a significant factor for all-cause mortality in CDI patients. Conclusion This retrospective study results, contrary to mouse model, did not show association between NSAID use and CDI related mortality and toxic mega-colon. Shorter duration of NSAIDs use, younger people in study group, and timely CDI treatment may have resulted in contrasting results.
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Affiliation(s)
- Harish Patel
- Department of Medicine, Bronx Care Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY, USA.,Division of Gastroenterology, Bronx Care Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY, USA
| | - Jasbir Makker
- Department of Medicine, Bronx Care Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY, USA.,Division of Gastroenterology, Bronx Care Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY, USA
| | - Trupti Vakde
- Department of Medicine, Bronx Care Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY, USA.,Division of Pulmonary and Critical Care Medicine, Bronx Care Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY, USA
| | - Danial Shaikh
- Department of Medicine, Bronx Care Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY, USA.,Division of Gastroenterology, Bronx Care Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY, USA
| | - Kanthi Badipatla
- Department of Medicine, Bronx Care Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY, USA.,Division of Gastroenterology, Bronx Care Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY, USA
| | - James Dunne
- Support Service and Operation, Bronx Care Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY, USA
| | - Nikhitha Mantri
- Department of Medicine, Bronx Care Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY, USA
| | - Suresh Kumar Nayudu
- Department of Medicine, Bronx Care Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY, USA.,Division of Gastroenterology, Bronx Care Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY, USA
| | - Mariela Glandt
- Department of Medicine, Bronx Care Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY, USA
| | - Bhavna Balar
- Department of Medicine, Bronx Care Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY, USA.,Division of Gastroenterology, Bronx Care Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY, USA
| | - Sridhar Chilimuri
- Department of Medicine, Bronx Care Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY, USA.,Division of Gastroenterology, Bronx Care Health System, Affiliated with Icahn School of Medicine at Mount Sinai, Bronx, NY, USA
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14
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Kamperidis N, Middleton P, Tyrrell T, Stasinos I, Arebi N. Impact of therapeutic drug level monitoring on outcomes of patients with Crohn's disease treated with Infliximab: real world data from a retrospective single centre cohort study. Frontline Gastroenterol 2019; 10:330-336. [PMID: 31682652 PMCID: PMC6788274 DOI: 10.1136/flgastro-2018-101024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 11/24/2018] [Accepted: 12/02/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) by measuring infliximab (IFX) trough levels and antibodies to infliximab (ATI) is used to optimise treatment in inflammatory bowel disease. We aimed to explore the clinical outcomes of TDM for patients with Crohn's disease on IFX in real life setting. METHODS This is a retrospective observational study. Primary outcomes were the clinicians' response to each TDM result and the rate of IFX discontinuation due to secondary loss of response or serious adverse event. Secondary outcomes included the intestinal surgery rate after IFX initiation and remission 6 months after TDM. Multivariate logistic regression was performed to identify factors associated with IFX discontinuation and abdominal surgery. RESULTS 291 patients were included. 238 (81.8%) patients were tested for TDM at least once during their follow-up with 672 TDM results. 95/238 patients (39.9%) had undetectable levels and 76 (31.9%) had positive ATI at least once. The median infliximab trough level was 3.4 µg/mL. IFX was discontinued in 109 patients (37.5%). 526/672 (78.3%) TDMs results were not followed by altered patient management. Treatment was discontinued in 40 (75.5%) patients never tested for TDM compared with 69 (29.0%) of those tested (p<0.01). Fewer TDM tested patients (29; 12.2%) required intestinal surgery post IFX initiation compared with TDM not-tested (15; 28.3%). Not being TDM tested was independently associated with IFX discontinuation and abdominal surgery. CONCLUSIONS IFX discontinuation and intestinal surgery were significantly less frequent with TDM. TDM requested to investigate loss of response resulted in change in patient management.
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Affiliation(s)
| | | | | | | | - Naila Arebi
- IBD Department, St Mark’s Hospital, London, UK
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15
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Zackular JP, Kirk L, Trindade BC, Skaar EP, Aronoff DM. Misoprostol protects mice against severe Clostridium difficile infection and promotes recovery of the gut microbiota after antibiotic perturbation. Anaerobe 2019; 58:89-94. [PMID: 31220605 PMCID: PMC6697607 DOI: 10.1016/j.anaerobe.2019.06.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 06/15/2019] [Indexed: 01/13/2023]
Abstract
Clostridium difficile infection (CDI) is one of the most common nosocomial infections worldwide and an urgent public health threat. Epidemiological and experimental studies have demonstrated an association between nonsteroidal anti-inflammatory drug (NSAID) exposure and enhanced susceptibility to, and severity of, CDI. NSAIDs target cyclooxygenase enzymes and inhibit the production of prostaglandins (PGs), but the therapeutic potential of exogenous introduction of PGs for the treatment of CDI has not been explored. In this study, we report that treatment with the FDA-approved stable PGE1 analogue, misoprostol, protects mice against C. difficile-associated mortality, intestinal pathology, and CDI-mediated intestinal permeability. Furthermore, we report that the effect of misoprostol on the gastrointestinal tract contributes to increased recovery of the gut microbiota following antibiotic perturbation. Together, these data implicate PGs as an important host-factor associated with recovery to C. difficile-associated disease and demonstrate the potential for misoprostol in the treatment of CDI. Further studies to explore the safety and efficacy of misoprostol treatment of CDI in humans is needed.
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Affiliation(s)
- Joseph P Zackular
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA, United States; Division of Protective Immunity, Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States; Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Leslie Kirk
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Bruno C Trindade
- Department of Pathology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Eric P Skaar
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - David M Aronoff
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, United States.
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16
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Lohan C, Diamantopoulos A, LeReun C, Wright E, Bohm N, Sawyer LM. Tofacitinib for the treatment of moderately to severely active ulcerative colitis: a systematic review, network meta-analysis and economic evaluation. BMJ Open Gastroenterol 2019; 6:e000302. [PMID: 31413856 PMCID: PMC6673763 DOI: 10.1136/bmjgast-2019-000302] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/24/2019] [Accepted: 06/07/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND AND AIMS In the UK, treatments for patients with moderately to severely active ulcerative colitis who have an inadequate response to conventional therapies comprise four biological therapies-the tumour necrosis factor inhibitor (TNFi) agents adalimumab, golimumab and infliximab and the anti-integrin vedolizumab-and an orally administered small molecule therapy, tofacitinib. However, there have been few head-to-head studies of these therapies. This study aimed to compare the clinical and cost-effectiveness of tofacitinib with biological therapies. METHODS A systematic literature review was conducted to identify all relevant randomised controlled trial (RCT) evidence. Clinical response, clinical remission and serious infection rates were synthesised using network meta-analysis (NMA). The results were used to compare the cost-effectiveness of tofacitinib and biologics with conventional therapy, using a Markov model, which incorporated lifetime costs and consequences of treatment from a UK National Health Service perspective. Analyses were conducted separately for TNFi-naïve and TNFi-exposed populations. RESULTS Seventeen RCTs were used in the NMAs. There were no statistically significant differences among biological therapies and tofacitinib for either TNFi-naïve or TNFi-exposed patients. In TNFi-naïve patients, all therapies were more efficacious than placebo. In TNFi-exposed patients, only tofacitinib was significantly more efficacious than placebo as induction therapy, and only tofacitinib and vedolizumab were significantly more efficacious than placebo as maintenance therapies. There were no significant differences in serious infection rates among therapies. The incremental cost-effectiveness ratios for tofacitinib versus conventional therapy were £21 338 and £22 816 per quality-adjusted life year (QALY) in the TNFi-naïve and TNFi-exposed populations, respectively. TNFi therapies were dominated or extendedly dominated in both populations. Compared with vedolizumab, tofacitinib was associated with a similar number of QALYs, at a lower cost. CONCLUSION Tofacitinib is an efficacious treatment for moderately to severely active ulcerative colitis and is likely to be a cost-effective use of NHS resources.
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Affiliation(s)
| | | | - Corinne LeReun
- Independent biostatistician, Sainte-Anne, Guadeloupe, France
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17
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Jin Z, Wei Y, Lin H, Huang H, Lv W, Zhang X. Endoscopic ultrasound versus endoscopic retrograde cholangiopancreatography-guided biliary drainage for primary decompression of malignant biliary obstruction: protocol for a systematic review and meta-analysis of randomised controlled trials. BMJ Open 2019; 9:e028156. [PMID: 31203246 PMCID: PMC6588990 DOI: 10.1136/bmjopen-2018-028156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Current evidence supporting the utility of endoscopic ultrasound-guided biliary drainage (EUS-BD) as a first-line treatment option for malignant biliary obstruction (MBO) is limited. We plan to provide a systematic review and meta-analysis to compare the performance of EUS-BD and endoscopic retrograde cholangiopancreatography-guided biliary drainage (ERCP-BD) as primary palliation of MBO. METHODS AND ANALYSIS Randomised controlled trials evaluating EUS-BD versus ERCP-BD in primary drainage of MBO will be searched in MEDLINE, EMBASE, Web of Science, the Cochrane Library, ClinicalTrials.gov and Google Scholar, from database inception to 31 October 2018. Data on study design, participant characteristics, intervention details and outcomes will be extracted. Primary outcomes to be assessed are technical and clinical success. Secondary outcomes include adverse events, stent patency, stent dysfunction, reinterventions, procedure duration and overall survival. Study quality will be assessed using the Cochrane Risk of Bias Tool. Meta-analysis will be performed using RevMan V.5.3 statistical software. Data will be combined with a random effect model. The results will be presented as a risk ratio for dichotomous data, weighted mean difference for continuous data and HR for time-to-event data. Publication bias will be visualised using funnel plots. ETHICS AND DISSEMINATION This study will not use primary data, and therefore, formal ethical approval is not required. The findings will be disseminated through peer-reviewed journals and committee conferences. PROSPERO REGISTRATION NUMBER CRD42018117040.
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Affiliation(s)
- Zheng Jin
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yaping Wei
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Huapeng Lin
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Haitao Huang
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wen Lv
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaofeng Zhang
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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18
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Siau K, Green JT, Hawkes ND, Broughton R, Feeney M, Dunckley P, Barton JR, Stebbing J, Thomas-Gibson S. Impact of the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) on endoscopy services in the UK and beyond. Frontline Gastroenterol 2019; 10:93-106. [PMID: 31210174 PMCID: PMC6540274 DOI: 10.1136/flgastro-2018-100969] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 09/18/2018] [Accepted: 09/24/2018] [Indexed: 02/04/2023] Open
Abstract
The Joint Advisory Group on Gastrointestinal Endoscopy (JAG) was initially established in 1994 to standardise endoscopy training across specialties. Over the last two decades, the position of JAG has evolved to meet its current role of quality assuring all aspects of endoscopy in the UK to provide the highest quality, patient-centred care. Drivers such as changes to healthcare agenda, national audits, advances in research and technology and the advent of population-based cancer screening have underpinned this shift in priority. Over this period, JAG has spearheaded various quality assurance initiatives with support from national stakeholders. These have led to the achievement of notable milestones in endoscopy quality assurance, particularly in the three major areas of: (1) endoscopy training, (2) accreditation of endoscopy services (including the Global Rating Scale), and (3) accreditation of screening endoscopists. These developments have changed the landscape of UK practice, serving as a model to promote excellence in endoscopy. This review provides a summary of JAG initiatives and assesses the impact of JAG on training and endoscopy services within the UK and beyond.
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Affiliation(s)
- Keith Siau
- Endoscopy Unit, Dudley Group NHS Foundation Trust, Dudley, UK
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - John T Green
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Neil D Hawkes
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, Cwm Taf University Health Board, Llantrisant, UK
| | - Raphael Broughton
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
| | - Mark Feeney
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, South Devon Healthcare NHS Foundation Trust, Torquay, UK
| | - Paul Dunckley
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, Gloucestershire Royal Hospital, Gloucester, UK
| | - John Roger Barton
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Newcastle University Medicine Malaysia, Nusajaya, Johor, Malaysia
| | - John Stebbing
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of GI Surgery, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Siwan Thomas-Gibson
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Wolfson Unit for Endoscopy, St Marks Hospital, Harrow, UK
- Imperial College London, London, UK
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19
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Maseda D, Zackular JP, Trindade B, Kirk L, Roxas JL, Rogers LM, Washington MK, Du L, Koyama T, Viswanathan VK, Vedantam G, Schloss PD, Crofford LJ, Skaar EP, Aronoff DM. Nonsteroidal Anti-inflammatory Drugs Alter the Microbiota and Exacerbate Clostridium difficile Colitis while Dysregulating the Inflammatory Response. mBio 2019; 10:mBio.02282-18. [PMID: 30622186 PMCID: PMC6325247 DOI: 10.1128/mbio.02282-18] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Clostridium difficile infection (CDI) is a major public health threat worldwide. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) is associated with enhanced susceptibility to and severity of CDI; however, the mechanisms driving this phenomenon have not been elucidated. NSAIDs alter prostaglandin (PG) metabolism by inhibiting cyclooxygenase (COX) enzymes. Here, we found that treatment with the NSAID indomethacin prior to infection altered the microbiota and dramatically increased mortality and the intestinal pathology associated with CDI in mice. We demonstrated that in C. difficile-infected animals, indomethacin treatment led to PG deregulation, an altered proinflammatory transcriptional and protein profile, and perturbed epithelial cell junctions. These effects were paralleled by increased recruitment of intestinal neutrophils and CD4+ cells and also by a perturbation of the gut microbiota. Together, these data implicate NSAIDs in the disruption of protective COX-mediated PG production during CDI, resulting in altered epithelial integrity and associated immune responses.IMPORTANCEClostridium difficile infection (CDI) is a spore-forming anaerobic bacterium and leading cause of antibiotic-associated colitis. Epidemiological data suggest that use of nonsteroidal anti-inflammatory drugs (NSAIDs) increases the risk for CDI in humans, a potentially important observation given the widespread use of NSAIDs. Prior studies in rodent models of CDI found that NSAID exposure following infection increases the severity of CDI, but mechanisms to explain this are lacking. Here we present new data from a mouse model of antibiotic-associated CDI suggesting that brief NSAID exposure prior to CDI increases the severity of the infectious colitis. These data shed new light on potential mechanisms linking NSAID use to worsened CDI, including drug-induced disturbances to the gut microbiome and colonic epithelial integrity. Studies were limited to a single NSAID (indomethacin), so future studies are needed to assess the generalizability of our findings and to establish a direct link to the human condition.
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Affiliation(s)
- Damian Maseda
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Joseph P Zackular
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Bruno Trindade
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Leslie Kirk
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Jennifer Lising Roxas
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, Arizona, USA
| | - Lisa M Rogers
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Mary K Washington
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Liping Du
- Center for Quantitative Sciences, Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Tatsuki Koyama
- Center for Quantitative Sciences, Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - V K Viswanathan
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, Arizona, USA
| | - Gayatri Vedantam
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, Arizona, USA
| | - Patrick D Schloss
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan, USA
| | - Leslie J Crofford
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Eric P Skaar
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - David M Aronoff
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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20
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Muñoz-Miralles J, Trindade BC, Castro-Córdova P, Bergin IL, Kirk LA, Gil F, Aronoff DM, Paredes-Sabja D. Indomethacin increases severity of Clostridium difficile infection in mouse model. Future Microbiol 2018; 13:1271-1281. [PMID: 30238771 PMCID: PMC6190216 DOI: 10.2217/fmb-2017-0311] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 05/10/2018] [Indexed: 01/05/2023] Open
Abstract
AIM To evaluate the effect on the nonsteroidal anti-inflammatory drug indomethacin on Clostridium difficile infection (CDI) severity. MATERIALS & METHODS Indomethacin was administered in two different mouse models of antibiotic-associated CDI in two different facilities, using a low and high dose of indomethacin. RESULTS Indomethacin administration caused weight loss, increased the signs of severe infection and worsened histopathological damage, leading to 100% mortality during CDI. Indomethacin-treated, antibiotic-exposed mice infected with C. difficile had enhanced intestinal inflammation with increased expression of KC, IL-1β and IL-22 compared with infected mice unexposed to indomethacin. CONCLUSION These results demonstrate a negative impact of nonsteroidal anti-inflammatory drugs on antibiotic-associated CDI in mice and suggest that targeting the synthesis or signaling of prostaglandins might be an approach to ameliorating the severity of CDI.
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Affiliation(s)
- Juan Muñoz-Miralles
- Millennium Nucleus in the Biology of Intestinal Microbiota, Facultad de Ciencias de la Vida, Universidad Andrés Bello, 8370186 Santiago, Chile
- Microbiota-Host Interactions & Clostridia Research Group, Departamento de Ciencias Biológicas, Facultad de Ciencias de la Vida, Universidad Andrés Bello, 8370186 Santiago, Chile
| | - Bruno C Trindade
- Department of Pathology, The University of Massachusetts Medical School, Worcester, 01605 MA, USA
| | - Pablo Castro-Córdova
- Millennium Nucleus in the Biology of Intestinal Microbiota, Facultad de Ciencias de la Vida, Universidad Andrés Bello, 8370186 Santiago, Chile
- Microbiota-Host Interactions & Clostridia Research Group, Departamento de Ciencias Biológicas, Facultad de Ciencias de la Vida, Universidad Andrés Bello, 8370186 Santiago, Chile
| | - Ingrid L Bergin
- The Unit for Laboratory Animal Medicine, The University of Michigan, Ann Arbor, 48109 MI, USA
| | - Leslie A Kirk
- The Unit for Laboratory Animal Medicine, The University of Michigan, Ann Arbor, 48109 MI, USA
| | - Fernando Gil
- Millennium Nucleus in the Biology of Intestinal Microbiota, Facultad de Ciencias de la Vida, Universidad Andrés Bello, 8370186 Santiago, Chile
- Microbiota-Host Interactions & Clostridia Research Group, Departamento de Ciencias Biológicas, Facultad de Ciencias de la Vida, Universidad Andrés Bello, 8370186 Santiago, Chile
| | - David M Aronoff
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, 37232 TN, USA
| | - Daniel Paredes-Sabja
- Millennium Nucleus in the Biology of Intestinal Microbiota, Facultad de Ciencias de la Vida, Universidad Andrés Bello, 8370186 Santiago, Chile
- Microbiota-Host Interactions & Clostridia Research Group, Departamento de Ciencias Biológicas, Facultad de Ciencias de la Vida, Universidad Andrés Bello, 8370186 Santiago, Chile
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Joshi T, Elderd BD, Abbott KC. No appendix necessary: Fecal transplants and antibiotics can resolve Clostridium difficile infection. J Theor Biol 2018; 442:139-148. [PMID: 29355542 DOI: 10.1016/j.jtbi.2018.01.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 12/04/2017] [Accepted: 01/15/2018] [Indexed: 12/18/2022]
Abstract
The appendix has been hypothesized to protect the colon against Clostridium difficile infection (CDI) by providing a continuous source of commensal bacteria that crowd out the potentially unhealthy bacteria and/or by contributing to defensive immune dynamics. Here, a series of deterministic systems comprised of ordinary differential equations, which treat the system as an ecological community of microorganisms, model the dynamics of colon microbiome. The first model includes migration of commensal bacteria from the appendix to the gut, while the second model expands this to also include immune dynamics. Simulations and simple analytic techniques are used to explore dynamics under biologically relevant parameters values. Both models exhibited bistability with steady states of a healthy state and of fulminant CDI. However, we find that the appendix size was much too small for migration to affect the stability of the system. Both models affirm the use of fecal transplants in conjunction with antibiotic use for CDI treatment, while the second model also suggests that anti-inflammatory drugs may protect against CDI. Ultimately, in general neither the appendiceal migration rate of commensal microbiota nor the boost to antibody production could exert an appreciable impact on the stability of the system, thus failing to support the proposed protective role of the appendix against CDI.
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Affiliation(s)
- Tejas Joshi
- Feinberg School of Medicine, Northwestern University, 303. East Chicago Ave., Chicago, IL 60611, USA.
| | - Bret D Elderd
- Department of Biological Sciences, Louisiana State University, Baton Rouge, LA, USA.
| | - Karen C Abbott
- Department of Biology, Case Western Reserve University, Cleveland, OH, USA.
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22
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Schwappach DLB, Häsler L, Pfeiffer Y. Chief physicians’ perceived need for improvement of morbidity and mortality conferences: the role of structural and procedural characteristics. BMJ LEADER 2018. [DOI: 10.1136/leader-2017-000052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundMortality and morbidity conferences (M&MCs) are used to retrospectively discuss adverse events. Recently, the focus of the M&MC shifted from a clinical learning tool to a forum for analysing events using systems-based approaches. The aim of this study was to explore the M&MC characteristics that are associated with perceived improvement needs reported by chief physicians.MethodsA cross-sectional survey among chief physicians assessed characteristics of currently implemented M&MCs in Switzerland (44 items). A summative score was developed covering information on procedural and structural characteristics commonly recommended for design of M&MCs.ResultsOf 223 participants, 145 (65%) indicated that their M&MC could be improved. Regression analysis revealed that the score (ie, the sum of structural and procedural features of the M&MC) was associated with self-perceived need for improvement of M&MCs (OR=0.73, CI 0.62 to 0.85, P<0.001). Chief physicians who explicitly select cases for M&MC discussion which involve problems in cooperation had twice the odds of reporting a need for improvement (OR=1.99, CI 1.05 to 3.74, P=0.034).ConclusionOur study provides important insights into the factors contributing to chief physicians’ evaluation of M&MCs. Offering support for addressing the procedural and structural features of the M&MCs may be a good lever to improve them.
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Bryant AE, Aldape MJ, Bayer CR, Katahira EJ, Bond L, Nicora CD, Fillmore TL, Clauss TRW, Metz TO, Webb-Robertson BJ, Stevens DL. Effects of delayed NSAID administration after experimental eccentric contraction injury - A cellular and proteomics study. PLoS One 2017; 12:e0172486. [PMID: 28245256 PMCID: PMC5330483 DOI: 10.1371/journal.pone.0172486] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 02/06/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Acute muscle injuries are exceedingly common and non-steroidal anti-inflammatory drugs (NSAIDs) are widely consumed to reduce the associated inflammation, swelling and pain that peak 1-2 days post-injury. While prophylactic use or early administration of NSAIDs has been shown to delay muscle regeneration and contribute to loss of muscle strength after healing, little is known about the effects of delayed NSAID use. Further, NSAID use following non-penetrating injury has been associated with increased risk and severity of infection, including that due to group A streptococcus, though the mechanisms remain to be elucidated. The present study investigated the effects of delayed NSAID administration on muscle repair and sought mechanisms supporting an injury/NSAID/infection axis. METHODS A murine model of eccentric contraction (EC)-induced injury of the tibialis anterior muscle was used to profile the cellular and molecular changes induced by ketorolac tromethamine administered 47 hr post injury. RESULTS NSAID administration inhibited several important muscle regeneration processes and down-regulated multiple cytoprotective proteins known to inhibit the intrinsic pathway of programmed cell death. These activities were associated with increased caspase activity in injured muscles but were independent of any NSAID effect on macrophage influx or phenotype switching. CONCLUSIONS These findings provide new molecular evidence supporting the notion that NSAIDs have a direct negative influence on muscle repair after acute strain injury in mice and thus add to renewed concern about the safety and benefits of NSAIDS in both children and adults, in those with progressive loss of muscle mass such as the elderly or patients with cancer or AIDS, and those at risk of secondary infection after trauma or surgery.
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Affiliation(s)
- Amy E. Bryant
- U.S. Department of Veterans Affairs, Office of Research and Development, Boise, ID, United States of America
- University of Washington School of Medicine, Seattle, WA, United States of America
| | - Michael J. Aldape
- U.S. Department of Veterans Affairs, Office of Research and Development, Boise, ID, United States of America
- Northwest Nazarene University, Nampa, ID, United States of America
| | - Clifford R. Bayer
- U.S. Department of Veterans Affairs, Office of Research and Development, Boise, ID, United States of America
| | - Eva J. Katahira
- U.S. Department of Veterans Affairs, Office of Research and Development, Boise, ID, United States of America
| | - Laura Bond
- Boise State University, Boise, ID, United States of America
| | - Carrie D. Nicora
- Pacific Northwest National Laboratory, Richland, WA, United States of America
| | - Thomas L. Fillmore
- Pacific Northwest National Laboratory, Richland, WA, United States of America
| | | | - Thomas O. Metz
- Pacific Northwest National Laboratory, Richland, WA, United States of America
| | | | - Dennis L. Stevens
- U.S. Department of Veterans Affairs, Office of Research and Development, Boise, ID, United States of America
- University of Washington School of Medicine, Seattle, WA, United States of America
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