Clostridium difficile infection in the intensive care unit

Management of Clostridioides difficile colitis: insights for the gastroenterologist

Clostridioides difficile infection (CDI) is a common cause of diarrhea in both inpatient and outpatient settings. The last few years have seen major changes in the treatment spectrum of CDI, most notably, recommendations against using metronidazole for initial CDI, the addition of fidaxomicin and bezlotoxumab, and emergence of microbial replacement therapies. Several other therapies are undergoing clinical trials. This narrative review focuses on the treatment of CDI with a summary of literature on the newer modalities and the treatment guidelines issued by Infectious Diseases Society of America and European Society of Clinical Microbiology and Infectious Diseases.

Diarreia causada por Clostridium difficile: recentes avanços

A infecção causada por Clostridium difficile (C. difficile), um dos agentes causadores de diarréia aguda e recorrente, tem como principal fator de risco o uso de antimicrobianos. Recentemente, houve um aumento da incidência e da mortalidade desta afecção. Clinicamente, a mesma pode manifestar-se desde um quadro de diarreia aquosa leve até a forma grave de colite pseudomembranosa. O objetivo deste artigo é apontar as mudanças epidemiológicas da infecção pelo C. difficile, além de rever fatores de risco, manifestações clínicas, métodos diagnósticos, tratamento e prevenção desta infecção. O aumento na gravidade da infecção causada pelo C. difficile é relacionado a uma nova cepa hipervirulenta, BI/NAPI/Ribotipo 027, que apresenta maior capacidade de produção de toxinas.  Essa nova cepa, mais virulenta, ainda não foi detectada no Brasil, porém como já foi identificada em outros países da América, alerta para a preocupante capacidade de disseminação universal. Essa revisão é baseada em artigos publicados nos últimos 10 anos, utilizando como base de dados o PubMed e o Scielo (Scientific Eletronic Library Online), com as palavras-chave: Epidemiologia, diarreia, Clostridium difficile e cepa hipervirulenta.

Association of Clostridium difficile infection in hospital mortality: A systematic review and meta-analysis

BACKGROUND

The purpose of this study was to evaluate whether Clostridium difficile infection (CDI) contributed to hospital mortality and whether the correlation between intensive care units (ICUs) and surgical wards in hospital CDI risk still remain controversial.

METHODS

By meta-analysis, 12 eligible studies involving 8,509 cases and 247,285 controls were identified via PubMed and Embase.

RESULTS

CDI patients had a higher risk of hospital mortality than non-CDI patients (odds ratio [OR], 1.899; 95% confidence interval [CI], 1.269-2.840), especially in 30-day mortality (OR, 2.521; 95% CI, 1.800-3.531). No correlation was found between hospital CDI and Charlson comorbidity index (OR, 0.830; 95% CI, 0.559-1.231). Patients treated in the ICU have an increased risk of hospital CDI (OR, 1.820; 95% CI, 1.161-2.851). However, the risk of CDI in patients who used to have surgery in surgical wards was not different to patients in the other departments (OR, 1.054; 95% CI, 0.838-1.325). Moreover, CDI patients in studies from the most recent 5 years have a higher risk of hospital mortality (OR, 2.171; 95% CI, 1.426-3.304).

CONCLUSION

Hospital CDI was associated with an increased risk of hospital mortality, especially in 30-day mortality. In addition, when compared with past years, CDI patients have a higher risk of hospital mortality in the most recent 5 years. Given the rapid dissemination of this organism worldwide, there is a need to aggressively develop and evaluate primary preventive strategies targeting CDI among hospitalized patients, especially in ICUs.

Persistent fever in the ICU

Disorders of elevated body temperature may be classified as either fever or hyperthermia. Fever is caused by a pyrogen-mediated upward adjustment of the hypothalamic thermostat; hyperthermia results from a loss of physiologic control of temperature regulation. Fever in the ICU can be due to infectious or noninfectious causes. The initial approach to a febrile, critically ill patient should involve a thoughtful review of the clinical data to elicit the likely source of fever prior to the ordering of cultures, imaging studies, and broad-spectrum antibiotics. Both high fever and prolonged fever have been associated with increased mortality; however, a causal role for fever as a mediator of adverse outcomes during non-neurologic critical illness has not been established. Outside the realm of acute brain injury, the practice of treating fever remains controversial. To generate high-quality, evidence-based guidelines for the management of fever, large, prospective, multicenter trials are needed.

Surgical Management of Clostridium difficile Colitis

Clostridium difficile infection (CDI) will progress to fulminant disease in 3 to 5% of cases. With the emergence of hypervirulent, multidrug-resistant strains, the incidence and severity of disease are continuing to rise. Prompt identification, early resuscitation, and treatment are critical in preventing morbidity and mortality in this increasingly common condition. Discontinuation of antibiotics and treatment with oral vancomycin and intravenous or oral metronidazole are first-line treatments, but complicated cases may require surgery. Subtotal colectomy with ileostomy remains the standard of care when toxic megacolon, perforation, or an acute surgical abdomen is present, but mortality rates are high. Recognition of risk factors for fulminant CDI and earlier surgical intervention may decrease mortality from this highly lethal disease.

Diverticular disease of the colon does not increase risk of repeat C. difficile infection

BACKGROUND

Studies have suggested that colonic diverticulosis might increase the likelihood of repeat Clostridium difficile infection (CDI). Our study was designed to compare rates of repeat infection in patients with and without colon diverticula.

METHODS

Patients who had a positive C. difficile toxin assay and colonoscopic evidence of diverticulosis were classified as CDI and diverticulosis (CDI-D), whereas those with a positive toxin assay but no such colonoscopic evidence were classified as CDI and no diverticulosis (CDI-ND). Various clinical and epidemiologic factors were recorded for each patient. Primary outcomes were "relapse" (repeat CDI within 3 mo of initial infection) and "recurrent" infection (repeat CDI≥3 mo after initial infection). Secondary outcomes 30 days after diagnosis were mortality, intensive care unit transfer, and continuous hospitalization.

RESULTS

A total of 128 patients were classified as CDI-D, whereas 137 had CDI-ND. There were no significant differences between CDI-D and CDI-ND when comparing frequencies of repeat infection and its subclassifications, relapse or recurrence. There were, however, statistical associations seen between diverticulosis of the ascending colon and increased recurrence rates [hazard ratio (HR): 1.4±0.38, P<0.05] and decreased rates of relapse in diverticular disease of the descending (HR: 0.40±0.46, P<0.05), and sigmoid colon (HR: 0.39±0.49, P<0.05). The ascending colon association is limited by a small patient population. There were no significant differences in any of the 30-day outcomes including intensive care unit requirement, hospitalization stay, or mortality.

CONCLUSIONS

Patients with diverticular disease of the colon are not at increased risk of repeat CDI.

Intraabdominal Infections in the Intensive Care Unit

Intraabdominal infections are frequent and dangerous entity in intensive care units. Mortality and morbidity are high, causes are numerous, and treatment options are variable. The intensivist is challenged to recognize and treat intraabdominal infections in a timely fashion to prevent complications and death. Diagnosis of intraabdominal infection is often complicated by confounding underlying disease or masked by overall comorbidity. Current research describes a wide heterogeneity of patient populations, making it difficult to suggest a general treatment regimen and stressing the need of an individualized approach to decision making. Early focus-oriented intervention and antibiotic coverage tailored to the individual patient and hospital is warranted.

Length of stay and mortality due to Clostridium difficile infection acquired in the intensive care unit

PURPOSE

The purpose of this study was to determine the attributable intensive care unit (ICU) and hospital length of stay and mortality of ICU-acquired Clostridium difficile infection (CDI).

MATERIALS AND METHODS

In this retrospective cohort study of 3 tertiary and 3 community ICUs, we screened all patients admitted between April 2006 and December 2011 for ICU-acquired CDI. Using both complete and matched cohort designs and Cox proportional hazards analysis, we determined the association between CDI and ICU and hospital length of stay and mortality. Adjustment or matching variables were site, age, sex, severity of illness, and year of admission; any infection as an ICU admitting or acquired diagnosis before the diagnosis of CDI and diagnosis of CDI were time-dependent exposures.

RESULTS

Of 15314 patients admitted to the ICUs during the study period, 236 developed CDI in the ICU. In the complete cohort analysis, the hazard ratios (95% confidence interval) for CDI related to ICU and hospital discharge were 0.82 (0.72, 0.94) and 0.83 (0.73, 0.95), respectively (0.5 additional ICU days and 3.4 hospital days), and related to death in ICU and hospital, they were 1.00 (0.73, 1.38) and 1.19 (0.93, 1.52), respectively. In the matched analysis, the hazard ratios for CDI related to ICU and hospital discharge were 0.91 (0.81, 1.03) and 0.98 (0.85, 1.13), respectively, and related to death in ICU and hospital, they were 1.18 (0.85, 1.63) and 1.08 (0.82, 1.43), respectively.

CONCLUSIONS

C difficile infection acquired in ICU is associated with an increase in length of ICU and hospital stay but not with any difference in ICU or hospital mortality.

The role of acute care surgery in the treatment of severe, complicated Clostridium difficile-associated disease

Clostridium difficile associated disease (CDAD) is the result of colonic bacterial overgrowth with this gram positive anaerobic organism and the production of toxins that typically induce diarrhea. Most patients with CDAD respond to treatment with oral metronidazole or vancomycin, but a subset of patients will develop a severe systemic illness, multiple organ failure, and death. There are no reliable combinations of clinical or laboratory findings that will distinguish patients who will respond to medical therapy and those who will progress to a more complicated state. Early surgical consultation should be considered in patients with ileus, severe abdominal pain, significant tenderness, immunosuppression, advanced age, high white blood cell or band counts, acute renal failure, mental status changes, or cardiopulmonary compromise. The standard operation for fulminant colitis is subtotal colectomy but the high mortality of the operation, and the long-term morbidity even in survivors combine to act as deterrents to early surgical consultation and operation. Novel operative approaches that preserve the colon and minimize operative morbidity may prove to remove the barriers to earlier surgical treatment for fulminant CDAD and improve outcomes.

Fighting nosocomial infections with biocidal non-intrusive hard and soft surfaces

Approximately 7 million people worldwide acquire a healthcare associated infection each year. Despite aggressive monitoring, hand washing campaigns and other infection control measures, nosocomial infections (NI) rates, especially those caused by antibiotic resistant pathogens, are unacceptably high worldwide. Additional ways to fight these infections need to be developed. A potential overlooked and neglected source of nosocomial pathogens are those found in non-intrusive soft and hard surfaces located in clinical settings. Soft surfaces, such as patient pyjamas and beddings, can be an excellent substrate for bacterial and fungal growth under appropriate temperature and humidity conditions as those present between patients and the bed. Bed making in hospitals releases large quantities of microorganisms into the air, which contaminate the immediate and non-immediate surroundings. Microbes can survive on hard surfaces, such as metal trays, bed rails and door knobs, for very prolonged periods of time. Thus soft and hard surfaces that are in direct or indirect contact with the patients can serve as a source of nosocomial pathogens. Recently it has been demonstrated that copper surfaces and copper oxide containing textiles have potent intrinsic biocidal properties. This manuscript reviews the recent laboratory and clinical studies, which demonstrate that biocidal surfaces made of copper or containing copper can reduce the microbiological burden and the NI rates.

Clostridium difficile: a problem of concern in developed countries and still a mystery in Latin America

Clostridium difficile-associated disease (CDAD) is caused by a spore-forming bacterium and can result in highly variable disease, ranging from mild diarrhoea to severe clinical manifestations. Infections are most commonly seen in hospital settings and are often associated with on-going antibiotic therapy. Incidences of CDAD have shown a sustained increase worldwide over the last ten years and a hypervirulent C. difficile strain, PCR ribotype 027/REA type BI/North American pulsed-field (NAP) type 1 (027/BI/NAP-1), has caused outbreaks in North America and Europe. In contrast, only a few reports of cases in Latin America have been published and the hypervirulent strain 027/BI/NAP-1 has, so far, only been reported in Costa Rica. The potential worldwide spread of this infection calls for epidemiological studies to characterize currently circulating strains and also highlights the need for increased awareness and vigilance among healthcare professionals in currently unaffected areas, such as Latin America. This review attempts to summarize reports of C. difficile infection worldwide, especially in Latin America, and aims to provide an introduction to the problems associated with this pathogen for those countries that might face outbreaks of epidemic strains of C. difficile for the first time in the near future.

Current challenges in the management of the infected patient

PURPOSE OF REVIEW

Management of hospital-associated infections (HAIs) has been made more challenging by the increasing proportion of immunocompromised or otherwise severely ill patients and increasing prevalence of antibiotic-resistant pathogens in this environment. This review examines strategies to optimize clinical outcomes and lower healthcare costs for patients with HAIs by focusing on patient-related, pathogen-related, and drug-related factors.

RECENT FINDINGS

Factors have converged to increase the risk of infection with antibiotic-resistant pathogens in the current hospital environment, including the increasing prevalence of resistant species and number of hospitalized patients with conditions increasingly susceptible to infection with drug-resistant bacteria. Although the list of bacterial pathogens associated with HAIs has been fairly constant over time, the prevalence and resistance profile of these individual species continues to evolve. Periodic antibiograms should be utilized to access local patterns of resistance within the different hospital wards. Outcomes for patients with HAIs are optimized with early empiric treatment with an appropriate regimen, selected on the basis of patient characteristics and local resistance patterns. Dosing strategies should be utilized to ensure that the efficacy of an appropriate antibiotic is optimized, by achieving the pharmacodynamic target predictive of its efficacy. Using these strategies improves quality of care and is associated with lower overall healthcare costs.

SUMMARY

Bacterial resistance is an increasing problem in the hospital environment, and has been associated with poorer clinical outcomes and elevated healthcare costs. By using patient characteristics, local antibiograms, and dosing strategies to achieve an optimal pharmacodynamic profile, early appropriate empiric therapy can be utilized to improve clinical outcomes, minimize the development of resistance, and reduce healthcare costs.