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Dionne JC, Johnstone J, Heels-Ansdell D, Duan E, Lauzier F, Arabi YM, Adhikari NKJ, Sligl W, Dodek P, Rochwerg B, Marshall JC, Niven DJ, Williamson DR, Reynolds S, Zytaruk N, Cook D. Clostridioides difficile infection in mechanically ventilated critically ill patients: A nested cohort study. J Crit Care 2023; 75:154254. [PMID: 36682909 DOI: 10.1016/j.jcrc.2023.154254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/02/2023] [Accepted: 01/05/2023] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Clostridioides difficile infection (CDI) is a serious complication of critical illness. The objective of the study was to determine its incidence, prevalence, timing, severity, predictors, and outcomes. METHODS We performed a prospective nested cohort study of CDI within a randomized trial comparing Lactobacillus rhamnosus GG to placebo. We adjudicated cases of CDI using standardized definitions, assessed timing (pre-ICU, in ICU, post-ICU) and severity. We analyzed risk factors and outcomes. RESULTS Of 2650 patients, 86 were diagnosed with CDI during 90,833 hospital-days (0.95/1000 hospital-days); CDI prevalence was 3.2%. CDI incidence varied in timing; 0.3% patients had CDI pre-ICU, 2.2% in the ICU; an 0.8% developed CDI post-ICU. Relapse or recurrence of CDI was documented in 9.3% patients. Infections were mild/moderate in severity. Complications included septic shock (26.7%), organ failure (16.3%), and toxic megacolon requiring colectomy (1.2%). No risk factors for CDI were identified. CDI was not associated with hospital mortality. The duration of hospital stay was longer for those who had CDI compared those who did not, CONCLUSION: CDI was uncommon, severity was mild to moderate and not associated with mortality however CDI was associated with a longer hospital stay.
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Affiliation(s)
- Joanna C Dionne
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Farncombe Family Digestive Health Research Institute, McMaster University Hamilton, Ontario, Canada; Department of Health Research Methods, Evaluation and Impact, McMaster University, Canada.
| | - Jennie Johnstone
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evaluation and Impact, McMaster University, Canada
| | - Erick Duan
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Francois Lauzier
- Department of Critical Care Medicine, Universite Laval, Quebec City, Quebec, Canada
| | - Yaseen M Arabi
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Neill K J Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada
| | - Wendy Sligl
- Departments of Critical Care Medicine and Infectious Diseases, University of Alberta, Edmonton, Alberta, Canada
| | - Peter Dodek
- Division of Critical Care Medicine and Center for Health Evaluation and Outcome Sciences, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evaluation and Impact, McMaster University, Canada
| | - John C Marshall
- Department of Surgery, Keenan Research Centre for Biomedical Research, University of Toronto, Toronto, Ontario, Canada
| | - Daniel J Niven
- Departments of Critical Care Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - David R Williamson
- Pharmacy Department, Hôpital du Sacré-Cœur de Montréal, Montréal, Quebec, Canada; Research Centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal, Faculté de Pharmacie, Université de Montréal, Canada
| | - Steven Reynolds
- Division of Critical Care Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicole Zytaruk
- Department of Health Research Methods, Evaluation and Impact, McMaster University, Canada
| | - Deborah Cook
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evaluation and Impact, McMaster University, Canada
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Comparison between Symptomatic and Asymptomatic Mice after Clostridioides difficile Infection Reveals Novel Inflammatory Pathways and Contributing Microbiota. Microorganisms 2022; 10:microorganisms10122380. [PMID: 36557633 PMCID: PMC9782979 DOI: 10.3390/microorganisms10122380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/23/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022] Open
Abstract
Clostridioides difficile causes the highest number of nosocomial infections. Currently, treatment options for C. difficile infection (CDI) are very limited, resulting in poor treatment outcomes and high recurrence rates. Although the disease caused by CDI is inflammatory in nature, the role of inflammation in the development of CDI symptoms is contradictory and not completely understood. Hence, the use of anti-inflammatory medication is debatable in CDI. In the current study, we evaluated the genetic and microbiome profiles of mice after infection with C. difficile. These mice were categorized based on the severity of CDI and the results were viewed accordingly. Our results indicate that certain genes are upregulated in severe CDI more than in the moderate case. These include oncostatin-M (OSM), matrix metalloprotease 8 (MMP8), triggering receptor expressed on myeloid cells 1 (Trem-1), and dual oxidase 2 (Duox2). We also investigated the microbiome composition of CDI mice before and after infecting with C. difficile. The results show that C. difficile abundance is not indicative of diseases severity. Certain bacterial species (e.g., Citrobacter) were enriched while others (e.g., Turicibacter) were absent in severe CDI. This study identifies novel inflammatory pathways and bacterial species with a potential role in determining the severity of CDI.
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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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4
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Masaki M, Matsuo T, Kobayashi D, Mori N. SEASON GAP score: A predictor of Clostridioides difficile infection among patients with tube feeding. J Infect Chemother 2022; 28:1131-1137. [DOI: 10.1016/j.jiac.2022.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/25/2022] [Accepted: 04/08/2022] [Indexed: 10/18/2022]
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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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Sahra S, Abureesh M, Amarnath S, Alkhayyat M, Badran R, Jahangir A, Gumaste V. Clostridioides difficile infection in liver cirrhosis patients: A population-based study in United States. World J Hepatol 2021; 13:926-938. [PMID: 34552699 PMCID: PMC8422922 DOI: 10.4254/wjh.v13.i8.926] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/11/2021] [Accepted: 07/22/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Clostridioides (formerly Clostridium) difficile infection (CDI) is an increasingly frequent cause of morbidity and mortality in hospitalized patients. Multiple risk factors are documented in the literature that includes, but are not limited to, antibiotics use, advanced age, and gastric acid suppression. Several epidemiological studies have reported an increased incidence of CDI in advanced liver disease patients. Some have also demonstrated a higher prevalence of nosocomial infections in cirrhotic patients.
AIM To use a large nationwide database, we sought to determine CDI’s risk among liver cirrhosis patients in the United States.
METHODS We queried a commercial database (Explorys IncTM, Cleveland, OH, United States), and obtained an aggregate of electronic health record data from 26 major integrated United States healthcare systems comprising 360 hospitals in the United States from 2018 to 2021. Diagnoses were organized into the Systematized Nomenclature of Medicine Clinical Terms (SNOMED–CT) hierarchy. Statistical analysis for the multivariable model was performed using Statistical Package for Social Sciences (SPSS version 25, IBM CorpTM). For all analyses, a two-sided P value of < 0.05 was considered statistically significant.
RESULTS There were a total of 19387760 patients in the database who were above 20 years of age between the years 2018-2021. Of those, 133400 were diagnosed with liver cirrhosis. The prevalence of CDI amongst the liver cirrhosis population was 134.93 per 100.000 vs 19.06 per 100.000 in non-cirrhotic patients (P < 0.0001). The multivariate analysis model uncovered that cirrhotic patients were more likely to develop CDI (OR: 1.857; 95%CI: 1.665-2.113, P < 0.0001) compared to those without any prior history of liver cirrhosis.
CONCLUSION In this large database study, we uncovered that cirrhotic patients have a significantly higher CDI prevalence than those without cirrhosis. Liver cirrhosis may be an independent risk factor for CDI. Further prospective studies are needed to clarify this possible risk association that may lead to the implementation of screening methods in this high-risk population.
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Affiliation(s)
- Syeda Sahra
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Mohammad Abureesh
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Shivantha Amarnath
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Motasem Alkhayyat
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Rawan Badran
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Abdullah Jahangir
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Vivek Gumaste
- Department of Gastroenterology, Staten Island University Hospital, Staten Island, NY 10305, United States
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Takedani Y, Nakamura T, Fukiwake N, Imada T, Mashino J, Morimoto T. Clinical characteristics and factors related to antibiotic-associated diarrhea in elderly patients with pneumonia: a retrospective cohort study. BMC Geriatr 2021; 21:317. [PMID: 34001039 PMCID: PMC8130363 DOI: 10.1186/s12877-021-02267-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 04/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antibiotic-associated diarrhea (AAD) is a common problem among elderly inpatients because many elderly patients are admitted for pneumonia or other conditions that necessitate antibiotic treatment. In the super aging population, more patients are suffering from pneumonia than before, but the incidence or risk factors for AAD among many elderly patients have not been well scrutinized. METHODS We conducted a retrospective cohort study of elderly patients diagnosed with pneumonia from April 2014 to March 2019 who were admitted to the Department of General Medicine of a Tertiary Care Hospital in Japan. Patients (≥ 65 years of age) who were diagnosed with bacterial pneumonia or aspiration pneumonia and treated with antibiotics were included. We defined AAD by diarrhea with more than three loose or watery stools per day and included patients who had these symptoms for either one day or two or more consecutive days. We also assessed the length of hospital stay and in-hospital mortality. The potential risk factors for AAD included age, sex, body weight, body mass index, smoking, alcohol, activities of daily living (ADL), comorbidities, vital signs, laboratories, the severity of pneumonia, antibiotic and other medication use. RESULTS There were 1,067 patients, the mean age was 83 years, and men accounted for 59 %. β-Lactamase inhibitors were frequently prescribed antibiotics in 703 patients (66 %), and proton pump inhibitors (PPIs) were also commonly administered (48 %). AAD developed in 322 patients (30 %). The multivariate logistic regression model showed that β-lactamase inhibitors (OR 1.43, 95 % CI 1.05-1.95) and PPIs (OR 1.37, 95 % CI 1.03-1.83) were associated with AAD as well as age (OR 1.03 per year, 95 % CI 1.01-1.05). CONCLUSIONS AAD was common among elderly inpatients with pneumonia, and β-lactamase inhibitors and PPIs were associated with AAD. Strict use of such medication should be considered to decrease the risk of AAD.
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Affiliation(s)
- Yoko Takedani
- Department of General Medicine, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Tsukasa Nakamura
- Department of Infectious Diseases, Shimane Prefectural Central Hospital, Izumo, Japan.,Clinical Education and Research Center, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Noriko Fukiwake
- Department of General Medicine, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Toshihiro Imada
- Department of General Medicine, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Junji Mashino
- Department of General Medicine, Shimane Prefectural Central Hospital, Izumo, Japan.,Clinical Education and Research Center, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Takeshi Morimoto
- Clinical Education and Research Center, Shimane Prefectural Central Hospital, Izumo, Japan. .,Department of Clinical Epidemiology, Hyogo College of Medicine, 1-1 Mukogawa, Hyogo, 663-8501, Nishinomiya, Japan.
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8
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Davies K, Lawrence J, Berry C, Davis G, Yu H, Cai B, Gonzalez E, Prantner I, Kurcz A, Macovei I, Pituch H, Nováková E, Nyč O, Gärtner B, Berger FK, Oleastro M, Cornely OA, Vehreschild MJGT, Pedneault L, Wilcox M. Risk Factors for Primary Clostridium difficile Infection; Results From the Observational Study of Risk Factors for Clostridium difficile Infection in Hospitalized Patients With Infective Diarrhea (ORCHID). Front Public Health 2020; 8:293. [PMID: 32766196 PMCID: PMC7379483 DOI: 10.3389/fpubh.2020.00293] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/03/2020] [Indexed: 01/05/2023] Open
Abstract
Background: There are inconsistent data on the risk factors for Clostridium difficile infection (CDI) in the literature. Aims: To use two C. difficile infection (CDI) case-control study groups to compare risk factors in hospitalized patients with diarrhea across different countries. Methods: A multi-center group of CDI cases/controls were identified by standardized testing from seven countries from the prior EUropean, multi-center, prospective bi-annual point prevalence study of CLostridium difficile Infection in hospitalized patients with Diarrhea (EUCLID). A second group of CDI cases/controls was identified from a single center in Germany [parallel study site (PSS)]. Data were extracted from the medical notes to assess CDI risk factors. Univariate analyses and multivariate logistic regression models were used to identify and compare risk factors between the two groups. Results: There were 253 and 158 cases and 921 and 584 controls in the PSS and EUCLID groups, respectively. Significant variables from univariate analyses in both groups were age ≥65, number of antibiotics (OR 1.2 for each additional antibiotic) and prior hospital admission (all p < 0.001). Congestive heart failure, diabetes, admission from assisted living or Emergency Department, proton pump inhibitors, and chronic renal disease were significant in PSS (all p < 0.05) but not EUCLID. Dementia and admitted with other bacterial diseases were significant in EUCLID (p < 0.05) but not PSS. Following multivariate analyses, age ≥ 65, number of antibiotics and prior hospital admission were consistently identified as CDI risk factors in each individual group and combined datasets. Conclusion: Our results show that the same CDI risk factors were identified across datasets. These were age ≥ 65 years, antibiotic use and prior hospital admission. Importantly, the odds of developing CDI increases with each extra antibiotic prescribed.
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Affiliation(s)
- Kerrie Davies
- Healthcare Associated Infections Research Group, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, United Kingdom
| | - Jody Lawrence
- Vaccine Research and Development, Pfizer Inc., Pearl River, NY, United States
| | - Claire Berry
- Healthcare Associated Infections Research Group, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, United Kingdom
| | - Georgina Davis
- Healthcare Associated Infections Research Group, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, United Kingdom
| | - Holly Yu
- Vaccine Research and Development, Pfizer Inc., Pearl River, NY, United States
| | - Bing Cai
- Vaccine Research and Development, Pfizer Inc., Pearl River, NY, United States
| | - Elisa Gonzalez
- Vaccine Research and Development, Pfizer Inc., Pearl River, NY, United States
| | - Ida Prantner
- Department of Hospital Epidemiology and Hygiene, National Center for Epidemiology, Budapest, Hungary
| | - Andrea Kurcz
- Department of Hospital Epidemiology and Hygiene, National Center for Epidemiology, Budapest, Hungary
| | - Ioana Macovei
- Cantacuzino National Medico-Military Institute for Research and Development, Bucharest, Romania
| | - Hanna Pituch
- Department of Medical Microbiology, Medical University of Warsaw, Warsaw, Poland
| | - Elena Nováková
- Department of Microbiology and Immunology in Jessenius Faculty of Medicine Martin, Comenius University Bratislava, Martin, Slovakia
| | - Otakar Nyč
- Department of Medical Microbiology, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Barbara Gärtner
- Germany National Reference Centre for Clostridiodies Clostridium difficile, Institute of Medical Microbiology and Hygiene, Saarland University of Medical Center, Homburg, Germany
| | - Fabian K Berger
- German National Reference Center for Clostridioides (Clostridium) Difficile, Institute of Medical Microbiology and Hygiene, Saarland University, Saarbrücken, Germany
| | - Monica Oleastro
- Department of Infectious Diseases, National Institute of Health Dr. Ricardo Jorge, Lisbon, Portugal
| | - Oliver A Cornely
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Department I of Internal Medicine, Clinical Trials Center Cologne (ZKS Köln), University of Cologne, Cologne, Germany
| | - Maria J G T Vehreschild
- Department I of Internal Medicine, Germany and German Centre for Infection Research (DZIF), University Hospital of Cologne, Partner Site Bonn-Cologne, Cologne, Germany
| | - Louise Pedneault
- Vaccine Research and Development, Pfizer Inc., Pearl River, NY, United States
| | - Mark Wilcox
- Healthcare Associated Infections Research Group, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, United Kingdom
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9
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Abstract
Clostridium (reclassified as " Clostridioides ") difficile infection (CDI) is a healthcare-associated infection and significant source of potentially preventable morbidity, recurrence, and death, particularly among hospitalized older adults. Additional risk factors include antibiotic use and severe underlying illness. The increasing prevalence of community-associated CDI is gaining recognition as a novel source of morbidity in previously healthy patients. Even after recovery from initial infection, patients remain at risk for recurrence or reinfection with a new strain. Some pharmaco-epidemiologic studies have suggested an increased risk associated with proton pump inhibitors and protective effect from statins, but these findings have not been uniformly reproduced in all studies. Certain ribotypes of C. difficile , including the BI/NAP1/027, 106, and 018, are associated with increased antibiotic resistance and potential for higher morbidity and mortality. CDI remains a high-morbidity healthcare-associated infection, and better understanding of ribotypes and medication risk factors could help to target treatment, particularly for patients with high recurrence risk.
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Affiliation(s)
- Ana C. De Roo
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Scott E. Regenbogen
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
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10
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Bowman JA, Utter GH. Evolving Strategies to Manage Clostridium difficile Colitis. J Gastrointest Surg 2020; 24:484-491. [PMID: 31768834 PMCID: PMC7031036 DOI: 10.1007/s11605-019-04478-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 11/12/2019] [Indexed: 02/06/2023]
Abstract
Clostridium difficile infection remains a common nosocomial illness with a significant impact on health care delivery. As molecular phenotyping of this organism has changed our understanding of its transmission and virulence, so too have diagnostic methods and treatment strategies evolved in recent years. The burden of this infection falls predominantly on elderly patients with comorbidities who have recently received antibiotics. Oral or enteral vancomycin is now preferred for first-line antimicrobial treatment across the disease spectrum, including mild-moderate initial cases. Fidaxomicin (a novel macrolide antibiotic), bezlotoxumab (a monoclonal antibody against toxin TcdB), and fecal microbiota transplantation expand the therapeutic armamentarium, particularly for recurrent infection. Operative treatment should be reserved for patients with fulminant infection, and early identification of patients who would benefit from an operation remains a challenge. Less invasive surgical options-such as laparoscopic diverting ileostomy with colonic irrigation-may improve survival and other outcomes relative to total abdominal colectomy and represent an attractive alternative particularly for frail patients.
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Affiliation(s)
- Jessica A Bowman
- Department of Surgery, University of California, Davis, Medical Center, 2335 Stockton Blvd., Sacramento, CA, 95817, USA
| | - Garth H Utter
- Department of Surgery, University of California, Davis, Medical Center, 2335 Stockton Blvd., Sacramento, CA, 95817, USA.
- Department of Surgery Outcomes Research Group (Utter), University of California, Davis, Medical Center, Sacramento, CA, USA.
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11
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Nana T, Moore C, Boyles T, Brink AJ, Cleghorn J, Devenish LM, du Toit B, Fredericks ES, Lekalakala-Mokaba MR, Maluleka C, Rajabally MN, Reubenson G, Shuping L, Swart K, Swe Han KS, Wadula J, Wojno J, Lowman W. South African Society of Clinical Microbiology Clostridioides difficile infection diagnosis, management and infection prevention and control guideline. S Afr J Infect Dis 2020; 35:219. [PMID: 34485483 PMCID: PMC8378053 DOI: 10.4102/sajid.v35i1.219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/24/2020] [Indexed: 12/17/2022] Open
Abstract
Clostridioides difficile infection (CDI) is a problem in both developed and developing countries and is a common hospital-acquired infection. This guideline provides evidence-based practical recommendations for South Africa and other developing countries. The scope of the guideline includes CDI diagnostic approaches; adult, paediatric and special populations treatment options; and surveillance and infection prevention and control recommendations.
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Affiliation(s)
- Trusha Nana
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Charlotte Maxeke Johannesburg Academic Hospital Microbiology Laboratory, National Health Laboratory Services, Johannesburg, South Africa
| | | | - Tom Boyles
- Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Adrian J. Brink
- Department of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Joy Cleghorn
- Life Healthcare Group, Johannesburg, South Africa
| | - Lesley M. Devenish
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Infection Control Services Laboratory, National Health Laboratory Services, Johannesburg, South Africa
| | | | - Ernst S. Fredericks
- Department of Physiology, Faculty of Science, Nelson Mandela University, Port Elizabeth, South Africa
| | - Molebogeng R. Lekalakala-Mokaba
- Department of Microbiology, Faculty of Health Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
- Dr George Mukhari Academic Hospital Microbiology Laboratory, National Health Laboratory Services, Pretoria, South Africa
| | - Caroline Maluleka
- Department of Microbiology, Faculty of Health Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
- Dr George Mukhari Academic Hospital Microbiology Laboratory, National Health Laboratory Services, Pretoria, South Africa
| | | | - Gary Reubenson
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Liliwe Shuping
- Centre for Healthcare-Associated Infections, National Institute for Communicable Diseases, a division of National Health Laboratory Service, Johannesburg, South Africa
| | - Karin Swart
- Netcare Hospitals Limited, Johannesburg, South Africa
| | - Khine Swe Swe Han
- Medical Microbiology Department, Inkosi Albert Luthuli Central Hospital Academic Complex, National Health Laboratory Services, Durban, South Africa
- Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Jeannette Wadula
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Chris Hani Baragwanath Hospital Microbiology Laboratory, National Health Laboratory Services, Johannesburg, South Africa
| | | | - Warren Lowman
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Clinical Microbiology, PathCare/Vermaak Pathologists, Johannesburg, South Africa
- Department of Clinical Microbiology and Infection Prevention and Control, WITS Donald Gordon Medical Centre, Johannesburg, South Africa
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12
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Chu Y, Lee C, Chen H, Hung C. Predictors of mortality in patients with
Clostridium difficile
infection. ADVANCES IN DIGESTIVE MEDICINE 2019. [DOI: 10.1002/aid2.13159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Yu‐Ming Chu
- Division of Digestive Medicine, Department of Internal MedicineCathay General Hospital Taipei City Taiwan
| | - Chia‐Long Lee
- Division of Digestive Medicine, Department of Internal MedicineCathay General Hospital Taipei City Taiwan
| | - Hsin‐Yu Chen
- Division of Digestive Medicine, Department of Internal MedicineCathay General Hospital Taipei City Taiwan
| | - Chih‐Sheng Hung
- Division of Digestive Medicine, Department of Internal MedicineCathay General Hospital Taipei City Taiwan
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13
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McDonald LC, Gerding DN, Johnson S, Bakken JS, Carroll KC, Coffin SE, Dubberke ER, Garey KW, Gould CV, Kelly C, Loo V, Shaklee Sammons J, Sandora TJ, Wilcox MH. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2019; 66:e1-e48. [PMID: 29462280 DOI: 10.1093/cid/cix1085] [Citation(s) in RCA: 1233] [Impact Index Per Article: 246.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.
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Affiliation(s)
| | | | - Stuart Johnson
- Edward Hines Jr Veterans Administration Hospital, Hines.,Loyola University Medical Center, Maywood, Illinois
| | | | - Karen C Carroll
- Johns Hopkins University School of Medicine, Baltimore, Maryl
| | | | - Erik R Dubberke
- Washington University School of Medicine, St Louis, Missouri
| | | | - Carolyn V Gould
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ciaran Kelly
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Vivian Loo
- McGill University Health Centre, McGill University, Montréal, Québec, Canada
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14
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Lanas-Gimeno A, Hijos G, Lanas Á. Proton pump inhibitors, adverse events and increased risk of mortality. Expert Opin Drug Saf 2019; 18:1043-1053. [DOI: 10.1080/14740338.2019.1664470] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
| | - Gonzalo Hijos
- Servicio de Aparato Digestivo, Hospital Clínico Universitario, Zaragoza, Spain
- Instituto de Investigación Sanitaria Aragón, Zaragoza, Spain
| | - Ángel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico Universitario, Zaragoza, Spain
- Instituto de Investigación Sanitaria Aragón, Zaragoza, Spain
- CIBERehd, Madrid, Spain
- Department of Medicine, Universidad de Zaragoza, Zaragoza, Spain
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15
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Bradley ES, Howe E, Wu X, Haran JP. Proton pump inhibitors and 180-day mortality in the elderly after Clostridium difficile treatment. Gut Pathog 2019; 11:29. [PMID: 31210787 PMCID: PMC6563367 DOI: 10.1186/s13099-019-0309-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 05/29/2019] [Indexed: 02/08/2023] Open
Abstract
Background There is a reported association between proton pump inhibitor (PPI) exposure and increased risk of Clostridium difficile infection (CDI), but less is known about how this class of medications taken during treatment might influence mortality after CDI. Here we examine 180-day mortality rates in a cohort of CDI elders and its association with exposure to PPIs. We conducted a retrospective cohort study of elderly patients (> 65 years of age) diagnosed and treated for CDI in the years 2014–2016 (n = 874) in the Umass Memorial Health Care system, which represents both academic and community healthcare. Patient characteristics and medication use was extracted from the electronic medical record (EMR) and 6 month mortality data was obtained via the Center for Disease Control National Death Index. A Cox proportional hazards model was used to estimate hazard ratios associated with medication exposures and other relevant variables. Results Of the 874 elderly adults treated for CDI, 180-day all-cause mortality was 12.4%. Exposure to a PPI was associated with a 55% reduced risk of mortality (adjusted hazard ratio (aHR) 0.45; 95% confidence interval (CI) 0.28–0.72). In our Cox model, increasing age (aHR 1.45; 95% CI 1.14–1.84), those with severe CDI infections (aHR 1.87; 95% CI 1.22–2.88), and those with hospital acquired CDI (aHR 3.01; 95% CI 1.81–4.99) also had increased 180 day mortality risk. There were similar associations noted with both 90 day and 1-year mortality. Conclusion Use of PPIs during CDI treatment in elderly patients is associated with decreased 180-day mortality. Although use of PPIs has been associated with an increased risk of CDI, it appears to be protective against mortality when used during the treatment phase.
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Affiliation(s)
- Evan Stuart Bradley
- Department of Emergency Medicine, University of Massachusetts Medical School and Umass Memorial Medical Center, 55 North Lake Avenue, Worcester, MA 01605 USA
| | - Emily Howe
- 2University of Massachusetts Medical School, 55 North Lake Avenue, Worcester, MA 01605 USA
| | - Xun Wu
- 2University of Massachusetts Medical School, 55 North Lake Avenue, Worcester, MA 01605 USA
| | - John P Haran
- Department of Emergency Medicine, University of Massachusetts Medical School and Umass Memorial Medical Center, 55 North Lake Avenue, Worcester, MA 01605 USA
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16
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Abstract
Clostridium difficile (C. difficile) is a Gram-positive, spore-forming, anaerobic bacillus, which is widely distributed in the intestinal tract of humans and animals and in the environment. In the last decade, the frequency and severity of C. difficile infection has been increasing worldwide to become one of the most common hospital-acquired infections. Transmission of this pathogen occurs by the fecal-oral route and the most important risk factors include antibiotic therapy, old age, and hospital or nursing home stay. The clinical picture is diverse and ranges from asymptomatic carrier status, through various degrees of diarrhea, to the most severe, life threatening colitis resulting with death. Diagnosis is based on direct detection of C. difficile toxins in feces, most commonly with the use of EIA assay, but no single test is suitable as a stand-alone test confirming CDI. Antibiotics of choice are vancomycin, fidaxomicin, and metronidazole, though metronidazole is considered as inferior. The goal of this review is to update physicians on current scientific knowledge of C. difficile infection, focusing also on fecal microbiota transplantation which is a promising therapy.
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17
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Lee HY, Hsiao HL, Chia CY, Cheng CW, Tsai TC, Deng ST, Chen CL, Chiu CH. Risk factors and outcomes of Clostridium difficile infection in hospitalized patients. Biomed J 2019; 42:99-106. [PMID: 31130254 PMCID: PMC6541878 DOI: 10.1016/j.bj.2018.12.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 08/22/2018] [Accepted: 12/12/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The aim of this study was to identify risk factors for Clostridium difficile infection (CDI) and its attributable mortality and to propose methods to prevent CDI and improve patients' outcomes. METHODS CDI was defined as diarrheal patients with stool samples that were positive for C. difficile toxin. Clinical presentations of all patients with CDI and two times as many age- and sex-matched culture-negative controls at the Chang Gung Memorial Hospital in 2014 were identified and compared by multivariate, nonparametric, and Kaplan-Meier survival analysis. RESULTS There were no significant differences in ages, sex, or Charlson comorbidity indexes between the CDI group (n = 42) and the control group (n = 86). The multivariate analysis indicated that underlying peptic ulcer disease and previous use of gastric acid inhibitors or third-generation cephalosporins for at least 3 days were significantly more common in patients with CDI than in the controls. Charlson scores were associated with mortality due to CDI. Recommended treatment using oral vancomycin to treat patients with Charlson score ≥ 5 and oral metronidazole or vancomycin to treat those with moderate underlying disease (Charlson score ≥ 2 and ≤ 5) significantly increased survival in these patients (p = 0.001). CONCLUSIONS Oral vancomycin given to patients with high Charlson scores and oral metronidazole or vancomycin to patients with moderate Charlson scores decreased mortality due to CDI. Restricting the use of third-generation cephalosporins and gastric acid inhibitors is recommended to prevent CDI in hospitalized patients.
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Affiliation(s)
- Hao-Yuan Lee
- Department of Nursing, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli, Taiwan; Department of Pediatrics, Wei Gong Memorial Hospital, Miaoli, Taiwan; Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsuan-Ling Hsiao
- Department of Pharmacy, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chin-Yuan Chia
- Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Department of Pediatrics, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Wen Cheng
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tzu-Cheng Tsai
- Department of Pharmacy, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shin-Tarng Deng
- Department of Pharmacy, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chyi-Liang Chen
- Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Hsun Chiu
- Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Department of Pediatrics, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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18
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Kullin BR, Reid S, Abratt V. Clostridium difficile in patients attending tuberculosis hospitals in Cape Town, South Africa, 2014-2015. Afr J Lab Med 2018; 7:846. [PMID: 30568907 PMCID: PMC6295828 DOI: 10.4102/ajlm.v7i2.846] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 09/28/2018] [Indexed: 01/05/2023] Open
Abstract
Background Diarrhoea due to Clostridium difficile infection (CDI) poses a significant burden on healthcare systems around the world. However, there are few reports on the current status of the disease in sub-Saharan Africa. Objectives This study examined the occurrence of CDI in a South African population of tuberculosis patients, as well as the molecular epidemiology and antibiotic susceptibility profiles of C. difficile strains responsible for disease. Methods Toxigenic C. difficile in patients with suspected CDI attending two specialist tuberculosis hospitals in the Cape Town area were detected using a PCR-based diagnostic assay (Xpert® C. difficile). C. difficile strains isolated from PCR-positive specimens were characterised by ribotyping, multilocus variable-number tandem-repeat analysis and antibiotic susceptibility testing. Results The period prevalence of CDI was approximately 70.07 cases per 1000 patient admissions. Strains belonging to ribotype 017 (RT017) made up over 95% of the patient isolates and all of them were multi-drug resistant. Multilocus variable-number tandem-repeat analysis revealed several clusters of highly related C. difficile RT017 strains present in tuberculosis patients in several wards at each hospital. Conclusion Tuberculosis patients represent a population that may be at an increased risk of developing CDI and, in addition, may constitute a multi-drug resistant reservoir of this bacterium. This warrants further investigation and surveillance of the disease in this patient group and other high-risk patient groups in sub-Saharan Africa.
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Affiliation(s)
- Brian R Kullin
- Department of Molecular and Cell Biology, Faculty of Science, University of Cape Town, Cape Town, South Africa
| | - Sharon Reid
- Department of Molecular and Cell Biology, Faculty of Science, University of Cape Town, Cape Town, South Africa
| | - Valerie Abratt
- Department of Molecular and Cell Biology, Faculty of Science, University of Cape Town, Cape Town, South Africa
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19
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Schäffler H, Breitrück A. Clostridium difficile - From Colonization to Infection. Front Microbiol 2018; 9:646. [PMID: 29692762 PMCID: PMC5902504 DOI: 10.3389/fmicb.2018.00646] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 03/19/2018] [Indexed: 12/19/2022] Open
Abstract
Clostridium difficile is the most frequent cause of nosocomial antibiotic-associated diarrhea. The incidence of C. difficile infection (CDI) has been rising worldwide with subsequent increases in morbidity, mortality, and health care costs. Asymptomatic colonization with C. difficile is common and a high prevalence has been found in specific cohorts, e.g., hospitalized patients, adults in nursing homes and in infants. However, the risk of infection with C. difficile differs significantly between these cohorts. While CDI is a clear indication for therapy, colonization with C. difficile is not believed to be a direct precursor for CDI and therefore does not require treatment. Antibiotic therapy causes alterations of the intestinal microbial composition, enabling C. difficile colonization and consecutive toxin production leading to disruption of the colonic epithelial cells. Clinical symptoms of CDI range from mild diarrhea to potentially life-threatening conditions like pseudomembranous colitis or toxic megacolon. While antibiotics are still the treatment of choice for CDI, new therapies have emerged in recent years such as antibodies against C. difficile toxin B and fecal microbial transfer (FMT). This specific therapy for CDI underscores the role of the indigenous bacterial composition in the prevention of the disease in healthy individuals and its role in the pathogenesis after alteration by antibiotic treatment. In addition to the pathogenesis of CDI, this review focuses on the colonization of C. difficile in the human gut and factors promoting CDI.
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Affiliation(s)
- Holger Schäffler
- Division of Gastroenterology, Department of Medicine II, University of Rostock, Rostock, Germany
| | - Anne Breitrück
- Extracorporeal Immunomodulation Unit, Fraunhofer Institute for Cell Therapy and Immunology, Rostock, Germany.,Institute of Medical Microbiology, Virology and Hygiene, University of Rostock, Rostock, Germany
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20
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Hopkins RJ, Wilson RB. Treatment of recurrent Clostridium difficile colitis: a narrative review. Gastroenterol Rep (Oxf) 2018; 6:21-28. [PMID: 29479439 PMCID: PMC5806400 DOI: 10.1093/gastro/gox041] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 10/17/2017] [Accepted: 10/31/2017] [Indexed: 12/11/2022] Open
Abstract
Clostridium difficile is a gram-positive, spore-forming, obligate anaerobic bacillus that was originally isolated from the stool of a healthy neonate in 1935. In high-income countries, C. difficile is the most common cause of infectious diarrhoea in hospitalized patients. The incidence of C. difficile infection in the USA has increased markedly since 2000, with hospitalizations for C. difficile infections in non-pregnant adults doubling between 2000 and 2010. Between 20% and 35% of patients with C. difficile infection will fail initial antibiotic treatment and, of these, 40-60% will have a second recurrence. Recurrence of C. difficile infection after initial treatment causes substantial morbidity and is a major burden on health care systems. In this article, current treatments for recurrent C. difficile infection are reviewed and future directions explored. These include the use of antibiotics, probiotics, donor faecal transplants, anion resins, secondary bile acids or anti-toxin antibodies.
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Affiliation(s)
- Roy J Hopkins
- Department of Upper GI Surgery, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Robert B Wilson
- Department of Upper GI Surgery, Liverpool Hospital, Sydney, New South Wales, Australia
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21
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Abstract
This narrative review summarises the benefits, risks and appropriate use of acid-suppressing drugs (ASDs), proton pump inhibitors and histamine-2 receptor antagonists, advocating a rationale balanced and individualised approach aimed to minimise any serious adverse consequences. It focuses on current controversies on the potential of ASDs to contribute to infections-bacterial, parasitic, fungal, protozoan and viral, particularly in the elderly, comprehensively and critically discusses the growing body of observational literature linking ASD use to a variety of enteric, respiratory, skin and systemic infectious diseases and complications (Clostridium difficile diarrhoea, pneumonia, spontaneous bacterial peritonitis, septicaemia and other). The proposed pathogenic mechanisms of ASD-associated infections (related and unrelated to the inhibition of gastric acid secretion, alterations of the gut microbiome and immunity), and drug-drug interactions are also described. Both probiotics use and correcting vitamin D status may have a significant protective effect decreasing the incidence of ASD-associated infections, especially in the elderly. Despite the limitations of the existing data, the importance of individualised therapy and caution in long-term ASD use considering the balance of benefits and potential harms, factors that may predispose to and actions that may prevent/attenuate adverse effects is evident. A six-step practical algorithm for ASD therapy based on the best available evidence is presented.
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22
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Oshima T, Wu L, Li M, Fukui H, Watari J, Miwa H. Magnitude and direction of the association between Clostridium difficile infection and proton pump inhibitors in adults and pediatric patients: a systematic review and meta-analysis. J Gastroenterol 2018; 53:84-94. [PMID: 28744822 DOI: 10.1007/s00535-017-1369-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 07/10/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a cause of increased morbidity and health care costs among hospitalized patients. Proton pump inhibitors (PPIs) are mainly used for the treatment of acid-related upper gastrointestinal diseases. The aim of the study was to assess the risks associated with initial and recurrent CDI in adult and pediatric patients treated with PPIs. METHODS A systematic search was performed using PubMed (Medline), Embase, and Web of Science with the following search terms: ("proton pump inhibitor," "PPI," or "acid suppression") AND ("infection," "diarrhea," "diarrhoea," "colitis," or "disease") AND ("Clostridium difficile"). Meta-analysis was performed using Revman5.3 software. Pooled odds ratios (ORs) presented as standard plots with 95% confidence intervals (CIs) were determined. RESULTS Sixty-seven eligible studies were selected. PPI use was significantly associated with risk of CDI (OR 2.34, 95% CI 1.94-2.82; P < 0.00001). Pooled data from twelve studies demonstrated a significant association between PPI use and recurrent CDI (OR 1.73, 95% CI 1.39-2.15; P = 0.02). Subgroup analysis revealed significant associations between PPI use and an increased incidence of CDI among adult (OR 2.30, 95% CI 1.89-2.80; P < 0.00001) and pediatric (OR 3.00, 95% CI 1.44-6.23; P < 0.00001) patients. CONCLUSIONS PPI use was associated with CDI in adult and pediatric patients, and with recurrent CDI. Although many risk factors are associated with the occurrence and recurrence of CDI, consideration should be given to not administering PPIs at any age if they are unnecessary.
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Affiliation(s)
- Tadayuki Oshima
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan.
| | - Liping Wu
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan.,Department of Gastroenterology, The Third People's Hospital of Chengdu, Chengdu, China
| | - Min Li
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan.,Department of Gastroenterology, The Third People's Hospital of Chengdu, Chengdu, China
| | - Hirokazu Fukui
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Jiro Watari
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Hiroto Miwa
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
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23
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Abstract
PURPOSE OF REVIEW The rising burden of Clostridium difficile infection (CDI) requires urgent identification of preventable risk factors. Observational studies suggest an association between proton-pump inhibitor (PPI) use and CDI risk. RECENT FINDINGS Key historical literature on PPI and CDI associations is reviewed as a prelude to evaluating the plausibility of a causative association. Impactful literature from the past 18 months is examined in detail and critically appraised through the lens of the Bradford Hill Criteria for determination of causality. The PPI and CDI association has been studied extensively and is valid. Nonetheless, causality is not proven due to extensive and difficult to control confounding in observational studies of CDI patient populations with complex comorbidities. SUMMARY In the authors' opinion, systematic discontinuation of PPIs in patients at risk for CDI is not warranted based on current evidence. Well controlled prospective human studies are needed. Careful and repeated consideration should be given to all PPI prescriptions to avoid potential adverse effects.
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24
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Abstract
Clostridium difficile is the most frequent cause of nosocomial antibiotic-associated diarrhea. The incidence of C. difficile infection (CDI) has been rising worldwide with subsequent increases in morbidity, mortality, and health care costs. Asymptomatic colonization with C. difficile is common and a high prevalence has been found in specific cohorts, e.g., hospitalized patients, adults in nursing homes and in infants. However, the risk of infection with C. difficile differs significantly between these cohorts. While CDI is a clear indication for therapy, colonization with C. difficile is not believed to be a direct precursor for CDI and therefore does not require treatment. Antibiotic therapy causes alterations of the intestinal microbial composition, enabling C. difficile colonization and consecutive toxin production leading to disruption of the colonic epithelial cells. Clinical symptoms of CDI range from mild diarrhea to potentially life-threatening conditions like pseudomembranous colitis or toxic megacolon. While antibiotics are still the treatment of choice for CDI, new therapies have emerged in recent years such as antibodies against C. difficile toxin B and fecal microbial transfer (FMT). This specific therapy for CDI underscores the role of the indigenous bacterial composition in the prevention of the disease in healthy individuals and its role in the pathogenesis after alteration by antibiotic treatment. In addition to the pathogenesis of CDI, this review focuses on the colonization of C. difficile in the human gut and factors promoting CDI.
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Affiliation(s)
- Holger Schäffler
- Division of Gastroenterology, Department of Medicine II, University of Rostock, Rostock, Germany
| | - Anne Breitrück
- Extracorporeal Immunomodulation Unit, Fraunhofer Institute for Cell Therapy and Immunology, Rostock, Germany
- Institute of Medical Microbiology, Virology and Hygiene, University of Rostock, Rostock, Germany
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25
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Updated meta-analysis of controlled observational studies: proton-pump inhibitors and risk of Clostridium difficile infection. J Hosp Infect 2017; 98:4-13. [PMID: 28842261 DOI: 10.1016/j.jhin.2017.08.017] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 08/18/2017] [Indexed: 12/18/2022]
Abstract
Attention has recently been directed toward a plausible link between Clostridium difficile infection (CDI) and proton-pump inhibitors (PPIs). However, the results of studies on the association between CDI and PPI remain controversial. We searched the literature databases from their inception to December 2016, without restriction of language, including all controlled observational studies examining the association between acid-suppressive therapy and CDI. Pooled analysis of 50 studies showed a significant association between PPI use and risk of developing CDI (odds ratio: 1.26; 95% confidence interval: 1.12-1.39) as compared with non-users. When stratified by study patients, the relative risk of hospital-acquired CDI and community-associated CDI were 1.29 (1.14-1.44) and 1.17 (0.74-1.59). After restricting the studies according to hospital department, the relative risks of hospital-acquired CDI in ICUs and general wards were 1.43 (0.74-2.11) and 1.29 (1.13-1.45). By implementing cumulative meta-analysis, it was clear that earlier trials of CDI conducted in the early 2000s demonstrated a high degree of heterogeneity and a high percentage of negative results. Since 2011, the overall association between PPI use and risk of developing CDI has remained relatively stable within an effect size between OR 1.20 and 1.26. Our findings indicate a significant associated risk of incident CDI among PPI users, especially in general ward patients. The totality of evidence, when using cumulative meta-analysis, showed that further trials are unlikely to overturn this positive result. Therefore establishing a guideline for the use of PPIs may help in future with the control of CDI.
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26
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Khanafer N, Vanhems P, Barbut F, Luxemburger C, Demont C, Hulin M, Dauwalder O, Vandenesch F, Argaud L, Badet L, Barth X, Bertrand M, Burillon C, Chapurlat R, Chuzeville M, Comte B, Disant F, Fessy MH, Gouillat C, Juillard L, Lermusiaux P, Monneuse O, Morelon E, Ninet J, Ponchon T, Poulet E, Rimmele T, Tazarourte K. Factors associated with Clostridium difficile infection: A nested case-control study in a three year prospective cohort. Anaerobe 2017; 44:117-123. [PMID: 28279859 DOI: 10.1016/j.anaerobe.2017.03.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 02/27/2017] [Accepted: 03/03/2017] [Indexed: 02/09/2023]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a serious medical condition that is associated with substantial morbidity and mortality. Identification of risk factors associated with CDI and prompt recognition of patients at risk is key to successfully preventing CDI. METHODS A 3-year prospective, observational, cohort study was conducted in a French university hospital and a nested case-control study was performed to identify risk factors for CDI. Inpatients aged 18 years or older, suffering from diarrhea suspected to be related to CDI, were asked to participate. RESULTS A total of 945 patients were included, of which 233 cases had a confirmed CDI. CDI infection was more common in men (58.4%) (P = 0.04) compared with patients with diarrhea not related to C. difficile. Previous hospitalization (P < 0.001), prior treatment with antibiotics (P = 0.001) or antiperistaltics (P = 0.002), liver disease (P = 0.003), malnutrition (P < 0.001), and previous CDI (P < 0.001) were significantly more common in patients with CDI. Multivariate logistic regression analysis showed that exposure to antibiotics in the last 60 days (especially third generation cephalosporins and penicillins with β-lactamase inhibitor), chronic renal or liver disease, malnutrition or previous CDI, were associated with an independent high risk of CDI. Age was not related with CDI. CONCLUSIONS This study showed that antibiotics and some comorbid conditions were predictors of CDI. Patients at high risk of acquiring CDI at the time of admission may benefit from careful monitoring of antibiotic prescriptions and early attention to infection control issues. In future, these "high-risk" patients may benefit from novel agents being developed to prevent CDI.
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Affiliation(s)
- Nagham Khanafer
- Epidemiology and Infection Control Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France; University of Lyon, Lyon, France.
| | - Philippe Vanhems
- Epidemiology and Infection Control Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France; University of Lyon, Lyon, France
| | - Frédéric Barbut
- Pierre and Marie Curie University, Paris, France; National Reference Laboratory for C. difficile, Saint Antoine Hospital, Paris, France
| | - Christine Luxemburger
- Epidemiology and Infection Control Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France; University of Lyon, Lyon, France.
| | | | | | - Monique Hulin
- Epidemiology and Infection Control Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France; University of Lyon, Lyon, France.
| | - Olivier Dauwalder
- Laboratory of Micro-biology Est, Hospices Civils de Lyon, Bron, France
| | | | | | - Laurent Argaud
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Lionel Badet
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Xavier Barth
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Malik Bertrand
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Carole Burillon
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Roland Chapurlat
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Michel Chuzeville
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Brigitte Comte
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - François Disant
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Michel Henry Fessy
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Christian Gouillat
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Laurent Juillard
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Patrick Lermusiaux
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Olivier Monneuse
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Emmanuel Morelon
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Jacques Ninet
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Thierry Ponchon
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Emmanuel Poulet
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Thomas Rimmele
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
| | - Karim Tazarourte
- Groupement Hospitalier Edouard Herriot, Hos-
pices Civils de Lyon, Lyon, France
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Arriola V, Tischendorf J, Musuuza J, Barker A, Rozelle JW, Safdar N. Assessing the Risk of Hospital-Acquired Clostridium Difficile Infection With Proton Pump Inhibitor Use: A Meta-Analysis. Infect Control Hosp Epidemiol 2016; 37:1408-1417. [PMID: 27677811 PMCID: PMC5657489 DOI: 10.1017/ice.2016.194] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Clostridium difficile is the principal infectious cause of antibiotic-associated diarrhea and accounts for 12% of hospital-acquired infections. Recent literature has shown an increased risk of C. difficile infection (CDI) with proton pump inhibitor (PPI) use. OBJECTIVE To conduct a systematic assessment of the risk of hospital-acquired CDI following exposure to PPI. METHODS We searched multiple databases for studies examining the relationship between PPI and hospital-acquired CDI. Pooled odds ratios were generated and assessment for heterogeneity performed. RESULTS We found 23 observational studies involving 186,033 cases that met eligibility criteria. Across studies, 10,307 cases of hospital-acquired CDI were reported. Significant heterogeneity was present; therefore, a random effects model was used. The pooled odds ratio was 1.81 (95% CI, 1.52-2.14), favoring higher risk of CDI with PPI use. Significant heterogeneity was present, likely due to differences in assessment of exposure, study population, and definition of CDI. DISCUSSION This meta-analysis suggests PPIs significantly increase the risk of hospital-acquired CDI. Given the significant health and economic burden of CDI and the risks of PPI, optimization of PPI use should be included in a multifaceted approach to CDI prevention. Infect Control Hosp Epidemiol 2016;1408-1417.
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Affiliation(s)
- Vanessa Arriola
- Tulane University School of Public Health and Tropical Medicine, Department of Epidemiology, New Orleans, LA, USA
| | - Jessica Tischendorf
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jackson Musuuza
- Institute of Clinical and Translational Research, University of Wisconsin, Madison, WI, USA
| | - Anna Barker
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jeffrey W. Rozelle
- Tulane University School of Public Health and Tropical Medicine, Department of Epidemiology, New Orleans, LA, USA
| | - Nasia Safdar
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Infectious Disease, University of Wisconsin Hospital and Clinics, Madison, WI, USA; William S. Middleton Memorial Veterans Affairs Hospital, Madison, WI, USA
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Hebbard AIT, Slavin MA, Reed C, Teh BW, Thursky KA, Trubiano JA, Worth LJ. The epidemiology of Clostridium difficile infection in patients with cancer. Expert Rev Anti Infect Ther 2016; 14:1077-1085. [PMID: 27606976 DOI: 10.1080/14787210.2016.1234376] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Clostridium difficile infection (CDI) is a significant cause of healthcare-associated diarrhoea, and the emergence of endemic strains resulting in poorer outcomes is recognised worldwide. Patients with cancer are a specific high-risk group for development of infection. Areas covered: In this review, modifiable and non-modifiable risk factors for CDI in adult patients with haematological malignancy or solid tumours are evaluated. In particular, the contribution of antimicrobial exposure, hospitalisation and gastric acid suppression to risk of CDI are discussed. Recent advances in CDI treatment are outlined, namely faecal microbiota transplantation and fidaxomicin therapy for severe/refractory infection in cancer populations. Outcomes of CDI, including mortality are presented, together with the need for valid severity rating tools customised for cancer populations. Expert commentary: Future areas for research include the prognostic value of C. difficile colonisation in cancer patients and the potential impact of dedicated antimicrobial stewardship programs in reducing the burden of CDI in cancer units.
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Affiliation(s)
- Andrew I T Hebbard
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Monica A Slavin
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Australia.,b Department of Medicine , University of Melbourne , Melbourne , Australia
| | - Caroline Reed
- c Microbiology Department , Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Benjamin W Teh
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Karin A Thursky
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Jason A Trubiano
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Leon J Worth
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Australia.,b Department of Medicine , University of Melbourne , Melbourne , Australia.,d Victorian Healthcare Associated Infection Surveillance System (VICNISS) , Doherty Institute , Melbourne , Australia
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Cooper CC, Jump RLP, Chopra T. Prevention of Infection Due to Clostridium difficile. Infect Dis Clin North Am 2016; 30:999-1012. [PMID: 27660089 DOI: 10.1016/j.idc.2016.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Clostridium difficile is one of the foremost nosocomial pathogens. Preventing infection is particularly challenging. Effective prevention efforts typically require a multifaceted bundled approach. A variety of infection control procedures may be advantageous, including strict hand decontamination with soap and water, contact precautions, and using chlorine-containing decontamination agents. Additionally, risk factor reduction can help reduce the burden of disease. The risk factor modification is principally accomplished though antibiotic stewardship programs. Unfortunately, most of the current evidence for prevention is in acute care settings. This review focuses on preventative approaches to reduce the incidence of Clostridium difficile infection in healthcare settings.
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Affiliation(s)
- Christopher C Cooper
- Division of Infectious Diseases, Wayne State University, 3990 John R. Street, 5 Hudson, Detroit, MI 48201, USA
| | - Robin L P Jump
- Infectious Disease Section, Medical Division, Geriatric Research Education and Clinical Center (GRECC), Louis Stokes Cleveland Veterans Affairs Medical Center, 10701 East Boulevard, Cleveland, OH 44106, USA; Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106, USA
| | - Teena Chopra
- Division of Infectious Diseases, Wayne State University, 3990 John R. Street, 5 Hudson, Detroit, MI 48201, USA.
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Fehér C, Mensa J. A Comparison of Current Guidelines of Five International Societies on Clostridium difficile Infection Management. Infect Dis Ther 2016; 5:207-30. [PMID: 27470257 PMCID: PMC5019978 DOI: 10.1007/s40121-016-0122-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Indexed: 12/31/2022] Open
Abstract
Clostridium difficile infection (CDI) is increasingly recognized as an emerging healthcare problem of elevated importance. Prevention and treatment strategies are constantly evolving along with the apperance of new scientific evidence and novel treatment methods, which is well-reflected in the differences among consecutive international guidelines. In this article, we summarize and compare current guidelines of five international medical societies on CDI management, and discuss some of the controversial and currently unresolved aspects which should be addressed by future research.
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Affiliation(s)
- Csaba Fehér
- Department of Infectious Diseases, Hospital Clínic of Barcelona, C/Villarroel 170, 08036, Barcelona, Spain.
| | - Josep Mensa
- Department of Infectious Diseases, Hospital Clínic of Barcelona, C/Villarroel 170, 08036, Barcelona, Spain
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Khanafer N, Oltra L, Hulin M, Dauwalder O, Vandenesch F, Vanhems P. Clostridium difficile infection in a French university hospital: Eight years of prospective surveillance study. Medicine (Baltimore) 2016; 95:e3874. [PMID: 27281101 PMCID: PMC4907679 DOI: 10.1097/md.0000000000003874] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
The epidemiology of Clostridium difficile infection (CDI) has changed with an increase in incidence and severity. Prospective surveillance was therefore implemented in a French university hospital to monitor the characteristics of patients at risk and to recognize local trends. Between 2007 and 2014, all hospitalized patients (≥18 years) with CDI were included. During the survey, the mean incidence rate of CDI was 2.9 per 10,000 hospital-days. In all, 590 patients were included. Most of the episodes were healthcare-associated (76.1%). The remaining cases were community-acquired (18.1%) and unknown (5.9%). The comparison with healthcare-associated cases showed that the community-acquired group had a lower rate of antimicrobial exposure (P < 0.001), proton pump inhibitor (P < 0.001), and immunosuppressive drugs (P = 0.02). Over the study period, death occurred in 61 patients (10.3%), with 18 (29.5%) being related to CDI according to the physician in charge of the patient. Active surveillance of CDI is required to obtain an accurate picture of the real dimensions of CDI.
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Affiliation(s)
- Nagham Khanafer
- University of Lyon 1, University of Lyon
- Infection Control Unit, Edouard Herriot hospital, Hospices Civils de Lyon
- ∗Correspondence: Nagham Khanafer, Groupement Hospitalier Edouard Herriot Service d’Hygiène, Épidémiologie et Prévention Place d’Arsonval, 69437 Lyon cedex 03, France (e-mail: /)
| | - Luc Oltra
- Infection Control Unit, Edouard Herriot hospital, Hospices Civils de Lyon
| | - Monique Hulin
- Infection Control Unit, Edouard Herriot hospital, Hospices Civils de Lyon
| | - Olivier Dauwalder
- Laboratory of microbiology, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron
| | - Francois Vandenesch
- Laboratory of microbiology, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron
| | - Philippe Vanhems
- University of Lyon 1, University of Lyon
- Infection Control Unit, Edouard Herriot hospital, Hospices Civils de Lyon
- Laboratoire des Pathogènes Emergents-Fondation Mérieux, Centre International de Recherche en Infectiologie, INSERM U1111, CNRS UMR5308, ENS de LYON, UCBL1, Lyon, France
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Abstract
Infection of the colon with the Gram-positive bacterium Clostridium difficile is potentially life threatening, especially in elderly people and in patients who have dysbiosis of the gut microbiota following antimicrobial drug exposure. C. difficile is the leading cause of health-care-associated infective diarrhoea. The life cycle of C. difficile is influenced by antimicrobial agents, the host immune system, and the host microbiota and its associated metabolites. The primary mediators of inflammation in C. difficile infection (CDI) are large clostridial toxins, toxin A (TcdA) and toxin B (TcdB), and, in some bacterial strains, the binary toxin CDT. The toxins trigger a complex cascade of host cellular responses to cause diarrhoea, inflammation and tissue necrosis - the major symptoms of CDI. The factors responsible for the epidemic of some C. difficile strains are poorly understood. Recurrent infections are common and can be debilitating. Toxin detection for diagnosis is important for accurate epidemiological study, and for optimal management and prevention strategies. Infections are commonly treated with specific antimicrobial agents, but faecal microbiota transplants have shown promise for recurrent infections. Future biotherapies for C. difficile infections are likely to involve defined combinations of key gut microbiota.
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Affiliation(s)
- Wiep Klaas Smits
- Section Experimental Bacteriology, Department of Medical Microbiology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Dena Lyras
- Infection and Immunity Program, Monash Biomedicine Discovery Institute, and Department of Microbiology, Monash University, Victoria, Australia
| | - D. Borden Lacy
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, and The Veterans Affairs Tennessee Valley Healthcare System, Nashville Tennessee, USA
| | - Mark H. Wilcox
- Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Ed J. Kuijper
- Section Experimental Bacteriology, Department of Medical Microbiology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
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Depoorter L, Verhaegen J, Joosten E. Use of Proton Pump Inhibitors and Risk of Nosocomial Clostridium Difficile
Infection in Hospitalized Elderly Adults. J Am Geriatr Soc 2016; 64:667-9. [DOI: 10.1111/jgs.13985] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
| | - Jan Verhaegen
- Department of Microbiology; University Hospitals of Leuven; Leuven Belgium
| | - Etienne Joosten
- Geriatric Department; University Hospitals of Leuven; Leuven Belgium
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O'Donoghue C, Solomon K, Fenelon L, Fitzpatrick F, Kyne L. Effect of proton pump inhibitors and antibiotics on the gut microbiome of hospitalised older persons. J Infect 2016; 72:498-500. [PMID: 26855324 DOI: 10.1016/j.jinf.2016.01.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 01/29/2016] [Indexed: 01/17/2023]
Affiliation(s)
- Caoilfhionn O'Donoghue
- Department of Medicine for the Older Person, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland.
| | - Katie Solomon
- University of Exeter, College of Life and Environmental Science, Geoffrey Pope Building, Exeter EX44QD, United Kingdom.
| | - Lynda Fenelon
- Department of Microbiology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
| | - Fidelma Fitzpatrick
- Health Protection Surveillance Centre, 25-27 Middle Gardiner Street, Dublin 1, Ireland.
| | - Lorraine Kyne
- Department of Medicine for the Older Person, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland.
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Abstract
Clostridium difficile infection (CDI) is a potentially deadly cause of diarrhea that is virtually always connected to healthcare system exposures, both inpatient and outpatient. Once a disease mainly of hospitals, 75% of CDI cases are now diagnosed outside of hospitals. However, the diagnosis location may not reflect where C. difficile spores were acquired or antibiotic exposure occurred. Changing epidemiology and increasing awareness about the role of every segment of the healthcare system in mediating this disease makes it clear that reducing its burden will also require active participation from all US healthcare professionals.
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Ticinesi A, Nouvenne A, Folesani G, Prati B, Morelli I, Guida L, Turroni F, Ventura M, Lauretani F, Maggio M, Meschi T. Multimorbidity in elderly hospitalised patients and risk of Clostridium difficile infection: a retrospective study with the Cumulative Illness Rating Scale (CIRS). BMJ Open 2015; 5:e009316. [PMID: 26503394 PMCID: PMC4636642 DOI: 10.1136/bmjopen-2015-009316] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To identify the role of chronic comorbidities, considered together in a literature-validated index (Cumulative Illness Rating Scale, CIRS), and antibiotic or proton-pump inhibitor (PPI) treatments as risk factors for hospital-acquired Clostridium difficile infection (CDI) in elderly multimorbid hospitalised patients. DESIGN Retrospective cohort study. SETTING Subacute hospital geriatric care ward in Italy. PARTICIPANTS 505 (238 male (M), 268 female (F)) elderly (age≥65) multimorbid patients. MAIN OUTCOME MEASURES The relationship between CDI and CIRS Comorbidity Score, number of comorbidities, antibiotic, antifungal and PPI treatments, and length of hospital stay was assessed through age-adjusted and sex-adjusted and multivariate logistic regression models. The CIRS Comorbidity Score was handled after categorisation in quartiles. RESULTS Mean age was 80.7±11.3 years. 43 patients (22 M, 21 F) developed CDI. The prevalence of CDI increased among quartiles of CIRS Comorbidity Score (3.9% first quartile vs 11.1% fourth quartile, age-adjusted and sex-adjusted p=0.03). In the multivariate logistic regression analysis, patients in the highest quartile of CIRS Comorbidity Score (≥17) carried a significantly higher risk of CDI (OR 5.07, 95% CI 1.28 to 20.14, p=0.02) than patients in the lowest quartile (<9). The only other variable significantly associated with CDI was antibiotic therapy (OR 2.62, 95% CI 1.21 to 5.66, p=0.01). PPI treatment was not associated with CDI. CONCLUSIONS Multimorbidity, measured through CIRS Comorbidity Score, is independently associated with the risk of CDI in a population of elderly patients with prolonged hospital stay.
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Affiliation(s)
- Andrea Ticinesi
- Internal Medicine and Critical Subacute Care Unit, Parma University Hospital, Parma, Italy
- Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
| | - Antonio Nouvenne
- Internal Medicine and Critical Subacute Care Unit, Parma University Hospital, Parma, Italy
- Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
| | | | - Beatrice Prati
- Internal Medicine and Critical Subacute Care Unit, Parma University Hospital, Parma, Italy
- Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
| | - Ilaria Morelli
- Internal Medicine and Critical Subacute Care Unit, Parma University Hospital, Parma, Italy
| | - Loredana Guida
- Internal Medicine and Critical Subacute Care Unit, Parma University Hospital, Parma, Italy
| | - Francesca Turroni
- Laboratory of Probiogenomics, Department of Life Sciences, University of Parma, Parma, Italy
| | - Marco Ventura
- Laboratory of Probiogenomics, Department of Life Sciences, University of Parma, Parma, Italy
| | | | - Marcello Maggio
- Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
| | - Tiziana Meschi
- Internal Medicine and Critical Subacute Care Unit, Parma University Hospital, Parma, Italy
- Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
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