Clostridium difficile-associated diarrhea and colitis

Guideline for the management of Clostridioides difficile infection in pediatric patients with cancer and hematopoietic cell transplantation recipients: 2024 update

Our objective was to update a clinical practice guideline for the prevention and treatment of Clostridioides difficile infection (CDI) in pediatric patients with cancer and hematopoietic cell transplantation recipients. We reconvened an international multi-disciplinary panel. A systematic review of randomized controlled trials (RCTs) for the prevention or treatment of CDI in any population was updated and identified 31 new RCTs. Strong recommendations were made to use either oral metronidazole or oral vancomycin for non-severe CDI treatment, and to use either oral vancomycin or oral fidaxomicin for severe CDI. A strong recommendation that fecal microbiota transplantation should not be routinely used to treat CDI was also made. The panel made two new good practice statements to follow infection control practices including isolation in patients experiencing CDI, and to minimize systemic antibacterial administration where feasible, especially in patients who have experienced CDI.

Clostridioides difficile toxin B subverts germinal center and antibody recall responses by stimulating a drug-treatable CXCR4-dependent mechanism

Recurrent Clostridioides difficile infection (CDI) results in significant morbidity and mortality. We previously established that CDI in mice does not protect against reinfection and is associated with poor pathogen-specific B cell memory (Bmem), recapitulating our observations with human Bmem. Here, we demonstrate that the secreted toxin TcdB2 is responsible for subversion of Bmem responses. TcdB2 from an endemic C. difficile strain delayed immunoglobulin G (IgG) class switch following vaccination, attenuated IgG recall to a vaccine booster, and prevented germinal center formation. The mechanism of TcdB2 action included increased B cell CXCR4 expression and responsiveness to its ligand CXCL12, accounting for altered cell migration and a failure of germinal center-dependent Bmem. These results were reproduced in a C. difficile infection model, and a US Food and Drug Administration (FDA)-approved CXCR4-blocking drug rescued germinal center formation. We therefore provide mechanistic insights into C. difficile-associated pathogenesis and illuminate a target for clinical intervention to limit recurrent disease.

Primary clostridium difficile infection in patients with ulcerative colitis: Case report and literature review

RATIONALE

Inflammatory bowel disease (IBD), including Crohn disease (CD) and ulcerative colitis (UC), is a chronic immune-mediated disorder characterized by inflammation of the gastrointestinal tract. Patients with IBD are susceptible to various complications, including the coexistence of Clostridioides difficile infection (CDI). The incidence of IBD combined with difficile infection is higher in patients with compromised immune function, which can lead to increased mortality.

PATIENT CONCERNS

A 43-year-old male presented with recurrent episodes of mucus and bloody stools persisting for more than a month without any identifiable triggering factors. Initially, the stool consistency was normal, but it progressively shifted to a loose and watery texture, with up to 8 occurrences daily.

DIAGNOSES

This case underscores the diagnosis of severe UC through colonoscopy and colonic biopsy, along with the supplementary identification of a positive result for Clostridioides difficile in the fecal sample.

INTERVENTIONS

The patient initiated infliximab therapy alongside a full vancomycin course, demonstrating the potential effectiveness of this intervention in managing early-stage ulcerative colitis with concurrent Clostridioides difficile infection.

OUTCOMES

Following the completion of a full vancomycin course, the patient initiated infliximab therapy. The patient was free from significant discomfort, exhibited no fever, and had no mucopurulent bloody stools. A follow-up blood test indicated reduced inflammatory markers compared to the preoperative period, and the stools were normal.

LESSONS

We illustrate the potential effectiveness of this medication by presenting an in-depth case report of a patient with early-stage UC. The report outlines the patient inclusion of infliximab to better manage UC inflammation alongside an adjunct vancomycin regimen, given the ineffectiveness of mesalazine therapy and the concurrent presence of Clostridium difficile infection. This case prompts consideration of therapeutic approaches for complex UC and contributes to advancing both research and clinical practice. Nonetheless, we should remain attentive to the variations and potential risks unique to each patient in order to formulate personalized treatment strategies.

Comparison of fidaxomicin, thuricin CD, vancomycin and nisin highlights the narrow spectrum nature of thuricin CD

Vancomycin and metronidazole are commonly used treatments for Clostridioides difficile infection (CDI). However, these antibiotics have been associated with high levels of relapse in patients. Fidaxomicin is a new treatment for CDI that is described as a narrow spectrum antibiotic that is minimally active on the commensal bacteria of the gut microbiome. The aim of this study was to compare the effect of fidaxomicin on the human gut microbiome with a number of narrow (thuricin CD) and broad spectrum (vancomycin and nisin) antimicrobials. The spectrum of activity of each antimicrobial was tested against 47 bacterial strains by well-diffusion assay. Minimum inhibitory concentrations (MICs) were calculated against a select number of these strains. Further, a pooled fecal slurry of 6 donors was prepared and incubated for 24 h with 100 µM of each antimicrobial in a mini-fermentation system together with a no-treatment control. Fidaxomicin, vancomycin, and nisin were active against most gram positive bacteria tested in vitro, although fidaxomicin and vancomycin produced larger zones of inhibition compared to nisin. In contrast, the antimicrobial activity of thuricin CD was specific to C. difficile and some Bacillus spp. The MICs showed similar results. Thuricin CD exhibited low MICs (<3.1 µg/mL) for C. difficile and Bacillus firmus, whereas fidaxomicin, vancomycin, and nisin demonstrated lower MICs for all other strains tested when compared to thuricin CD. The narrow spectrum of thuricin CD was also observed in the gut model system. We conclude that the spectrum of activity of fidaxomicin is comparable to that of the broad-spectrum antibiotic vancomycin in vitro and the broad spectrum bacteriocin nisin in a complex community.

Clostridioides difficile infection in the allogeneic hematopoietic cell transplant recipient

Clostridioides difficile (CD) is one of the most important causes of diarrhea in hospitalized patients, in particular those who undergo an allogeneic hematopoietic cell transplant (allo-HCT) and who are more at risk of developing a CD infection (CDI) due to frequent hospitalizations, iatrogenic immunosuppression, and prolonged antibiotic cycles. CDI may represent a severe condition in allo-HCT patients, increasing the length of hospitalization, influencing the intestinal microbiome with a bidirectional association with graft-versus-host disease, and leading to unfavorable outcomes, including death. The diagnosis of CDI requires the exclusion of other probable causes of diarrhea in HCT patients and is based on highly sensitive and highly specific tests to distinguish colonization from infection. In adult patients, fidaxomicin is recommended as first-line, with oral vancomycin as an alternative agent. Bezlotoxumab may be used to reduce the risk of recurrence. In pediatric patients, vancomycin and metronidazole are still suggested as first-line therapy, but fidaxomicin will probably become standard in pediatrics in the near future. Because of insufficient safety data, fecal microbiota transplantation is not routinely recommended in HCT in spite of promising results for the management of recurrences in other populations.

Comparison of Different Antibiotics and the Risk for Community-Associated Clostridioides difficile Infection: A Case-Control Study

Background

Antibiotics are the greatest risk factor for Clostridioides difficile infection (CDI). Risk for CDI varies across antibiotic types and classes. Optimal prescribing and stewardship recommendations require comparisons of risk across antibiotics. However, many prior studies rely on aggregated antibiotic categories or are underpowered to detect significant differences across antibiotic types. Using a large database of real-world data, we evaluate community-associated CDI risk across individual antibiotic types.

Methods

We conducted a matched case-control study using a large database of insurance claims capturing longitudinal health care encounters and medications. Case patients with community-associated CDI were matched to 5 control patients by age, sex, and enrollment period. Antibiotics prescribed within 30 days before the CDI diagnosis along with other risk factors, including comorbidities, health care exposures, and gastric acid suppression were considered. Conditional logistic regression and a Bayesian analysis were used to compare risk across individual antibiotics. A sensitivity analysis of antibiotic exposure windows between 30 and 180 days was conducted.

Results

We identified 159 404 cases and 797 020 controls. Antibiotics with the greatest risk for CDI included clindamycin and later-generation cephalosporins, and those with the lowest risk included minocycline and doxycycline. We were able to differentiate and order individual antibiotics in terms of their relative level of associated risk for CDI. Risk estimates varied considerably with different exposure windows considered.

Conclusions

We found wide variation in CDI risk within and between classes of antibiotics. These findings ordering the level of associated risk across antibiotics can help inform tradeoffs in antibiotic prescribing decisions and stewardship efforts.

Emerging Options for the Prevention and Management of Clostridioides difficile Infection

Agents in development for the prevention or treatment of Clostridioides difficile infection can be split into three broad categories: antibiotics, microbiome restoration, and vaccines. Given the extensive list of agents currently in development, this narrative review will focus on agents that have progressed into late-stage clinical trials, defined as having a Phase III clinical trial registered on ClinicalTrials.gov. These agents include one antibiotic (ridinilazole), three live biotherapeutic products (LBPs) (CP101, RBX2660, and SER109), and two toxoid vaccines (PF06425090 and a second toxoid vaccine). As new prevention and treatment strategies enter the market, clinicians and administrators will need knowledge of these products to make rational decisions on how best to adopt them into clinical practice.

Gut microbiota changes associated with Clostridioides difficile infection and its various treatment strategies

Human gut microbiota are critical to both the development of and recovery from Clostridioides difficile infection (CDI). Antibiotics are the mainstay of CDI treatment, yet inherently cause further imbalances in the gut microbiota, termed dysbiosis, complicating recovery. A variety of microbiota-based therapeutic approaches are in use or in development to limit disease- and treatment-associated dysbiosis and improve rates of sustained cure. These include the recently FDA-approved fecal microbiota, live-jslm (formerly RBX2660) and fecal microbiota spores, live-brpk (formerly SER-109), which represent a new class of live biotherapeutic products (LBPs), traditional fecal microbiota transplantation (FMT), and ultra-narrow-spectrum antibiotics. Here, we aim to review the microbiome changes associated with CDI as well as a variety of microbiota-based treatment approaches.

Evidence of within-facility patient-patient Clostridiodes difficile infection spread across diverse settings

Previous studies have suggested that a hospital patient's risk of developing healthcare facility-onset (HCFO) Clostridioides difficile infections (CDIs) increases with the number of concurrent spatially proximate patients with CDI, termed CDI pressure. However, these studies were performed either in a single institution or in a single state with a very coarse measure of concurrence. We conducted a retrospective case-control study involving over 17.5 million inpatient visits across 700 hospitals in eight US states. We built a weighted, directed network connecting overlapping inpatient visits to measure facility-level CDI pressure. We then matched HCFO-CDIs with non-CDI controls on facility, comorbidities and demographics and performed a conditional logistic regression to determine the odds of developing HCFO-CDI given the number of coincident patient visits with CDI. On average, cases' visits coincided with 9.2 CDI cases, which for an individual with an average length of stay corresponded to an estimated 17.7% (95% CI 12.9-22.7%) increase in the odds of acquiring HCFO-CDI compared to an inpatient visit without concurrent CDI cases or fully isolated from both direct and indirect risks from concurrent CDI cases. These results suggest that, either directly or indirectly, hospital patients with CDI lead to CDIs in non-infected patients with temporally overlapping visits.

Prevalence of and factors associated with inappropriate Clostridioides difficile testing in a teaching hospital in Korea

Background

Given the increasing incidence of Clostridioides difficile infections in Korea, there has been an increase in inappropriate testing for C. difficile, which has rendered overdiagnosis of asymptomatic colonisers common. We aimed to investigate the appropriateness of C. difficile testing and the related factors.

Methods

We retrospectively reviewed the medical records of patients who were admitted to a 1300-bed tertiary-care teaching hospital in Korea and were tested for C. difficile infection from September 2019 to November 2019. We performed logistic regression analysis to investigate factors related to inappropriate testing. Further, a survey was conducted on physicians to assess the knowledge and ordering patterns of C. difficile testing.

Results

We included 715 tests from 520 patients in the analysis. Testing was classified as hospital-onset and community-onset and subclassified as appropriate and inappropriate following an algorithmic method. Among the 715 tests, 576 (80.6%) and 139 (19.6%) tests were classified as hospital-onset and community-onset, respectively. Among the hospital-onset tests, 297 (52%) were considered inappropriate. The risk of inappropriate testing increased when C. difficile tests were conducted in the emergency room (OR 24.96; 95% CI 3.12–199.98) but decreased in intensive care units (OR 0.36, 95% CI 0.19–0.67). The survey was conducted on 61 physicians. Internal medicine physicians had significantly higher scores than non-internal medicine physicians (7.1 vs. 5.7, p = 0.001). The most frequently ordered combination of tests was toxin + glutamate dehydrogenase (47.5%), which was consistent with the ordered tests.

Conclusion

Almost half of the C. difficile tests were performed inappropriately. The patient being located in the emergency room and intensive care unit increased and decreased the risk of inappropriate testing, respectively. In a questionnaire survey, we showed that internal medicine physicians were more knowledgeable about C. difficile testing than non-internal medicine physicians. There is a need to implement the diagnostic stewardship for C. difficile, especially through educational interventions for emergency room and non-internal medicine physicians.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01111-0.

Clostridioides difficile infection in paediatric patients with cancer and haematopoietic stem cell transplant recipients

BACKGROUND

Epidemiology of Clostridioides difficile infection (CDI) in paediatric cancer patients is uncertain. The primary objective was to describe the prevalence of CDI outcomes among paediatric patients receiving cancer treatments. Secondary objectives were to describe clinical features of CDI, propose a definition of severe CDI and to determine risk factors for CDI clinical outcomes.

METHODS

A multi-centre retrospective cohort study that included paediatric patients (1-18 years of age) receiving cancer treatments with CDI. Severe CDI definition was achieved by consensus. Univariable and multivariable regression was conducted to evaluate risk factors for CDI outcomes.

RESULTS

There were 627 eligible patients who experienced 721 CDI episodes. The prevalence of clinical cure was 82.9%, recurrence was 9.6%, global cure was 75.0% and repeated new CDI episode was 12.8%. The proposed definition of severe CDI was the presence of colitis, pneumatosis intestinalis, pseudomembranous colitis, ileus or surgery for CDI, occurring in 70 (9.7%) episodes. In univariable regression, initial oral metronidazole or initial oral vancomycin were not significantly associated with failure to achieve clinical cure or CDI recurrence. In multiple regression, oral metronidazole was significantly associated with higher odds (odds ratio (OR) 1.7, 95% confidence interval (CI) 1.0-2.7) and oral vancomycin was significantly associated with lower odds (OR 0.4, 95% CI 0.2-0.8) of repeated new episodes.

CONCLUSION

The prevalence of clinical cure was 82.9% and recurrence was 9.6% in pediatric patients receiving cancer treatments. Severe CDI, as per our proposed definition, occurred in 9.7% episodes. Initial oral vancomycin was significantly associated with a reduction in repeated new CDI episodes.

Risk for Clostridioides difficile Infection Among Hospitalized Patients Associated With Multiple Healthcare Exposures Prior to Admission

BACKGROUND

Clostridioides difficile infection (CDI) is a common healthcare-associated infection and is often used as an indicator of hospital safety or quality. However, healthcare exposures occurring prior to hospitalization may increase risk for CDI. We conducted a case-control study comparing hospitalized patients with and without CDI to determine if healthcare exposures prior to hospitalization (ie, clinic visits, antibiotics, family members with CDI) were associated with increased risk for hospital-onset CDI, and how risk varied with time between exposure and hospitalization.

METHODS

Records were collected from a large insurance-claims database from 2001 to 2017 for hospitalized adult patients. Prior healthcare exposures were identified using inpatient, outpatient, emergency department, and prescription drug claims; results were compared between various CDI case definitions.

RESULTS

Hospitalized patients with CDI had significantly more frequent healthcare exposures prior to admission. Healthcare visits, antibiotic use, and family exposures were associated with greater likelihood of CDI during hospitalization. The degree of association diminished with time between exposure and hospitalization. Results were consistent across CDI case definitions.

CONCLUSIONS

Many different prior healthcare exposures appear to increase risk for CDI presenting during hospitalization. Moreover, patients with CDI typically have multiple exposures prior to admission, confounding the ability to attribute cases to a particular stay.

Correlation between antibiotic consumption and the incidence of healthcare facility-onset Clostridioides difficile infection: a retrospective chart review and analysis

Background

Healthcare facility-onset Clostridioides difficile infection is the leading cause of antibiotic-associated diarrhea, and is associated with morbidity and mortality. The use of antibiotics is an important risk factor for healthcare facility-onset C. difficile infection. We evaluated the correlation between the incidence of healthcare facility-onset C. difficile infection and antibiotic consumption, according to antibiotic class.

Methods

Patients with healthcare facility-onset C. difficile infection from January 2017 to December 2018 at Konkuk University Medical Center (a tertiary medical center) were included. We evaluated changes in the incidence of healthcare facility-onset C. difficile infection and antibiotic consumption. The correlation between the incidence of healthcare facility-onset C. difficile infection and antibiotic consumption was evaluated two ways: without a time interval and with 1-month interval matching.

Results

A total of 446 episodes of healthcare facility-onset C. difficile infection occurred during the study period. The incidence of healthcare facility-onset C. difficile infection was 9.3 episodes per 10,000 patient-days, and increased significantly. We observed an increase in the consumption of β-lactam/β-lactamase inhibitors, and a decrease in the consumption of other classes of antibiotics, with a significant decrease in the consumption of fluoroquinolones, glycopeptides, and clindamycin (P = 0.01, P < 0.001, and P = 0.001, respectively). The consumption of β-lactam/β-lactamase inhibitors was independently correlated with the incidence of healthcare facility-onset C. difficile infection in the analysis without a time interval. When the analysis was conducted with 1-month interval matching, glycopeptide consumption was independently associated with the incidence of healthcare facility-onset C. difficile infection.

Conclusions

Despite the reduction in fluoroquinolone and clindamycin consumption, the incidence of healthcare facility-onset C. difficile infection increased during the study period, and was correlated with increased consumption of β-lactam/β-lactamase inhibitors. Reduced consumption of specific antibiotics may be insufficient to reduce the incidence of healthcare facility-onset C. difficile infection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-021-00986-9.

Mathematically modeling the effect of touch frequency on the environmental transmission of Clostridioides difficile in healthcare settings

Clostridioides difficile, formerly Clostridium difficile, is the leading cause of infectious diarrhea and one of the most common healthcare acquired infections in United States hospitals. C. difficile persists well in healthcare environments because it forms spores that can survive for long periods of time and can be transmitted to susceptible patients through contact with contaminated hands and fomites, objects or surfaces that can harbor infectious agents. Fomites can be classified as high-touch or low-touch based on the frequency they are contacted. The mathematical model in this study investigates the relative contribution of high-touch and low-touch fomites on new cases of C. difficile colonization among patients of a hospital ward. The dynamics of transmission are described by a system of ordinary differential equations representing four patient population classes and two pathogen environmental reservoirs. Parameters that have a significant effect on incidence, as determined by a global sensitivity analysis, are varied in stochastic simulations of the system to identify feasible strategies to prevent disease transmission. Results indicate that on average, under one-quarter of asymptomatically colonized patients are exposed to C. difficile via low-touch fomites. In comparison, over three-quarters of colonized patients are colonized through high-touch fomites, despite additional cleaning of high-touch fomites. Increased contacts with high-touch fomites increases the contribution of these fomites to the incidence of colonized individuals and decreasing the duration of a hospital visit reduces the amount of pathogen in the environment. Thus, enhanced efficacy of disinfection upon discharge and extra cleaning of high-touch fomites, reduced contact with high-touch fomites, and higher discharge rates, among other control measures, could lead to a decrease in the incidence of colonized individuals.

Evolution of clinical guidelines for antimicrobial management of Clostridioides difficile infection

Clostridioides difficile infection (CDI) has been an epidemic for many years. Our biggest challenge in treating CDI is preventing recurrence, which is seen in approximately 25% of patients with initial infection and in 40-60% of those with subsequent episodes. Given the major disease burden of this infection, appropriate data-driven treatment remains essential. Clinical treatment guidelines provide an unbiased critical analysis of the literature, integrating the quality of the available data to make recommendations. As CDI has been evolving and more research has become available, the frequency of guideline issue from various global societies has increased, as has the detail of the recommendations to fit more relevant clinical scenarios. In this review, we will discuss clinical guideline recommendations over three time periods: The Initial Guidelines 1995-1997, The Second Wave 2009-2013, and The Modern Era 2014-present. We see the changing recommendations from metronidazole or vancomycin for initial infection during earlier times to preferential treatment with fidaxomicin within the Infectious Diseases Society of America (IDSA) and Society of Healthcare Epidemiology of America (SHEA) joint guidelines provisional update in late 2020. The recommended treatments for first recurrence were initially with the same antimicrobial as the first episode but have since changed to having multiple options for one or more recurrences. We have also seen the addition of immune boosting treatments, including fecal microbiota transplantation (FMT)/microbiota restoration therapy (MRT) and bezlotoxumab in the more modern recommendations. As the guidelines are evolving with the times, it remains important to understand the differences among them so we can apply this information clinically and optimize patient outcomes.

Outcomes associated with recent guideline recommendations removing metronidazole for treatment of non-severe Clostridioides difficile infection: a retrospective, observational, nationwide cohort study

OBJECTIVES

The 2017 Society for Healthcare Epidemiology of America (SHEA) and Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for Clostridioides difficile (C. difficile) infection (CDI) removed metronidazole as a preferred option for initial episodes of non-severe CDI. This study aimed to determine if the shift away from metronidazole improved clinical outcomes of initial episodes of non-severe CDI.

METHODS

The study was a retrospective, observational, nationwide cohort study using a Veterans Health Administration national clinical administrative database. Adult patients treated for non-severe CDI before and after the February 2018 publication of the 2017 IDSA/SHEA C. difficile Clinical Practice Guidelines were included. The primary outcome was the composite of treatment failure or probable recurrence.

RESULTS

A total of 3608 patients were included, with 1809 in the pre-guideline cohort (mean [SD] age, 65.5 [14.2] years; 1602 [88.6%] male) and 1799 in the post-guideline cohort (mean [SD] age, 64 [14.6] years; 1584 [88%] male). Overall composite of treatment failure or probable recurrence was similar between both cohorts (318 of 1809 [17.6%] pre-guideline cohort vs. 317 of 1799 [17.6%] post-guideline cohort [P = 0.97]).

CONCLUSION

The shift away from metronidazole as a preferred option in initial non-severe Clostridioides difficile infection did not improve the composite of treatment failure or recurrence.

Economic burden and cost-effectiveness of therapies for Clostridiodes difficile infection: a narrative review

Clostridioides difficile is the most common cause of healthcare-associated diarrhea. Disease complications as well as recurrent infections contribute significantly to morbidity and mortality. Over the past decades, there has been a rapid increase in the incidence of C. difficile infection (CDI), with a rise in the number of community-acquired cases. CDI has a profound economic impact on both the healthcare system and patients, secondary to recurrences, hospitalization, prolonged length of stay, cost of treatment, and indirect societal costs. With emergence of newer treatment options, the standard of care is shifting from metronidazole and vancomycin towards fidaxomicin and fecal microbiota transplantation (FMT), which despite being more expensive, are more efficacious in preventing recurrences and hence overall are more beneficial forms of therapy per cost-effectiveness analyses. Data regarding preferred route of FMT, timing of FMT, and non-conventional therapies such as bezlotoxumab is scant. There is a need for further studies to elucidate the true attributable costs of CDI as well as continued cost-effectiveness research to reduce the economic burden associated with the disease and improve clinical practice.

Lemon Exosome-like Nanoparticles-Manipulated Probiotics Protect Mice from C. d iff Infection

Clostridioides difficile (C. diff) is the leading cause of antibiotic-associated colitis. Here, we report that lemon exosome-like nanoparticles (LELNs) manipulated probiotics to inhibit C. diff infection (CDI). LELN-manipulated Lactobacillus rhamnosus GG (LGG) and Streptococcus thermophilus ST-21 (STH) (LELN-LS) decrease CDI mortality via an LELN-mediated increase in bile resistance and gut survivability. LELN-LS treatment increases the AhR ligands indole-3-lactic acid (I3LA) and indole-3-carboxaldehyde (I3Ald), leading to induction of IL-22, and increases lactic acid leading to a decrease of C. diff fecal shedding by inhibiting C. diff growth and indole biosynthesis. A synergistic effect between STH and LGG was identified. The STH metabolites inhibit gluconeogenesis of LGG and allow fructose-1,6-bisphosphate (FBP) to accumulate in LGG; accumulated FBP then activates lactate dehydrogenase of LGG (LGG-LDH) and enhances production of lactic acid and the AhR ligand. Our findings provide a new strategy for CDI prevention and treatment with a new type of prebiotics.

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LELNs-manipulated probiotics protect mice from C. diff infection

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LELNs manipulation modulates gut metabolomics composition

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Cross talk between LGG and STH enhances production of lactic acid and AhR ligands

Healthcare facility-onset, healthcare facility-associated Clostridioides difficile infection in Veterans with spinal cord injury and disorder

Objective: To describe the burden and risk of healthcare facility-onset, healthcare facility-associated (HO-HCFA) Clostridioides difficile infection (CDI) in Veterans with spinal cord injury and disorder (SCI/D). Design: Retrospective, longitudinal cohort study from October 1, 2001-September 30, 2010. Setting: Ninety-four acute care Veterans Affairs facilities. Participants: Patients with SCI/D. Outcomes: Incidence rate of HO-HCFA CDI. Methods: Rates of CDI were determined, and crude unadjusted incidence rate ratios (IRRs) and 95% confidence intervals (CIs) were calculated. Multivariable Poisson random-effects regression analyses were used to assess factors independently associated with the rate of CDI. Results: 1,409 cases of HO-HCFA CDI were identified. CDI rates in 2002 were 13.9/10,000 person-days and decreased to 5.5/10,000 person-days by 2010. Multivariable regression analyses found that antibiotic (IRR = 18.79, 95% CI 14.09-25.07) and proton-pump inhibitor (PPI) or H2 blocker use (IRR = 7.71, 95% CI 5.47-10.86) were both independently associated with HO-HCFA CDI. Exposure to both medications demonstrated a synergistic risk (IRR = 37.55, 95% CI 28.39-49.67). Older age, Northeast region, and invasive respiratory procedure in the prior 30 days were also independent risk factors, while longer SCI duration and care at a SCI center were protective. Conclusion: Although decreasing, CDI rates in patients with SCI/D remain high. Targeted antimicrobial stewardship and pharmacy interventions that reduce antibiotic and PPI/H2 blocker use could have profound benefits in decreasing HO-HCFA CDI in this high-risk population.

Modest Clostridiodes difficile infection prediction using machine learning models in a tertiary care hospital

Previous studies have shown promising results of machine learning (ML) models for predicting health outcomes. We develop and test ML models for predicting Clostridioides difficile infection (CDI) in hospitalized patients. This is a retrospective cohort study conducted during 2015-2017. All inpatients tested for C. difficile were included. CDI was defined as having a positive glutamate dehydrogenase and toxin results. We restricted analyses to the first record of C. difficile testing per patient. Of 3514 patients tested, 136 (4%) had CDI. Age and antibiotic use within 90 days before C. difficile testing were associated with CDI (P < 0.01). We tested 10 ML methods with and without resampling. Logistic regression, random forest and naïve Bayes models yielded the highest AUC ROC performance: 0.6. Predicting CDI was difficult in our cohort of patients tested for CDI. Multiple ML models yielded only modest results in a real-world population of hospitalized patients tested for CDI.

Association of Household Exposure to Primary Clostridioides difficile Infection With Secondary Infection in Family Members

Importance

Clostridioides difficile infection (CDI) is a common hospital-acquired infection. Whether family members are more likely to experience a CDI following CDI in another separate family member remains to be studied.

Objective

To determine the incidence of potential family transmission of CDI.

Design, Setting, and Participants

In this case-control study comparing the incidence of CDI among individuals with prior exposure to a family member with CDI to those without prior family exposure, individuals were binned into monthly enrollment strata based on exposure status (eg, family exposure) and confounding factors (eg, age, prior antibiotic use). Data were derived from population-based, longitudinal commercial insurance claims from the Truven Marketscan Commercial Claims and Encounters and Medicare Supplemental databases from 2001 to 2017. Households with at least 2 family members continuously enrolled for at least 1 month were eligible. CDI incidence was computed within each stratum. A regression model was used to compare incidence of CDI while controlling for possible confounding characteristics.

Exposures

Index CDI cases were identified using inpatient and outpatient diagnosis codes. Exposure risks 60 days prior to infection included CDI diagnosed in another family member, prior hospitalization, and antibiotic use.

Main Outcomes and Measures

The primary outcome was the incidence of CDI in a given monthly enrollment stratum. Separate analyses were considered for CDI diagnosed in outpatient or hospital settings.

Results

A total of 224 818 cases of CDI, representing 194 424 enrollees (55.9% female; mean [SD] age, 52.8 [22.2] years) occurred in families with at least 2 enrollees. Of these, 1074 CDI events (4.8%) occurred following CDI diagnosis in a separate family member. Prior family exposure was significantly associated with increased incidence of CDI, with an incidence rate ratio (IRR) of 12.47 (95% CI, 8.86-16.97); this prior family exposure represented the factor with the second highest IRR behind hospital exposure (IRR, 16.18 [95% CI, 15.31-17.10]). For community-onset CDI cases without prior hospitalization, the IRR for family exposure was 21.74 (95% CI, 15.12-30.01). Age (IRR, 9.90 [95% CI, 8.92-10.98] for ages ≥65 years compared with ages 0-17 years), antibiotic use (IRR, 3.73 [95% CI, 3.41-4.08] for low-risk and 14.26 [95% CI, 13.27-15.31] for high-risk antibiotics compared with no antibiotics), and female sex (IRR, 1.44 [95% CI, 1.36-1.53]) were also positively associated with incidence.

Conclusions and Relevance

This study found that individuals with family exposure may be at significantly greater risk for acquiring CDI, which highlights the importance of the shared environment in the transmission and acquisition of C difficile.

Clindamycin, Gentamicin, and Risk of Clostridium difficile Infection and Acute Kidney Injury During Delivery Hospitalizations

OBJECTIVE

To describe risk of Clostridium difficile infection associated with clindamycin and acute kidney injury associated with gentamicin during delivery hospitalizations.

METHODS

Women admitted for delivery from January 2006 to March 2015 were analyzed using an inpatient administrative database. Primary outcomes were C difficile infection and acute kidney injury. C difficile infection was compared between women receiving clindamycin (with or without other antibiotics) and women receiving antibiotics other than clindamycin. Acute kidney injury was compared between women receiving gentamicin (with or without other antibiotics), women receiving antibiotics other than gentamicin, and women receiving no antibiotics. Unadjusted and adjusted log linear models analyzing the role of patient demographics, mode of delivery, and hospital-level characteristics were created evaluating risk of C difficile infection and acute kidney injury with risk ratios (RRs) and adjusted risk ratios with 99% CIs as measures of association. A sensitivity analysis for gentamicin and acute kidney injury was performed restricted to women with preeclampsia.

RESULTS

Of 5,657,523 women admitted for delivery hospitalization, 266,402 (4.7%) received clindamycin and 165,726 (2.9%) received gentamicin. C difficile infection was diagnosed in 0.04% of women receiving clindamycin. Compared with women receiving other antibiotics, clindamycin was associated with a nearly threefold increased risk of C difficile infection (RR 2.93, 99% CI 2.21-3.90). Acute kidney injury was diagnosed in 0.24% of women receiving gentamicin. Gentamicin was associated with a threefold increased risk of acute kidney injury (RR 3.01, 99% CI 2.62-3.45) compared with women receiving other antibiotics, whereas receipt of no antibiotics was associated with significantly lower risk (RR 0.18, 99% CI 0.15-0.20). In adjusted analyses, these associations retained significance. Significantly increased risk of acute kidney injury was noted for women with preeclampsia receiving gentamicin (RR 2.04, 99% CI 1.64-2.53).

CONCLUSION

Receipt of clindamycin was associated with significantly increased likelihood for C difficile infection and receipt of gentamicin with significantly increased likelihood of acute kidney injury, although the absolute risk of these complications was low.

Effect of antibiotic to induce Clostridioides difficile-susceptibility and infectious strain in a mouse model of Clostridioides difficile infection and recurrence

The anaerobic bacterium Clostridioides difficile is the leading cause of antibiotic-associated diarrhea that can culminate in life-threating colitis. During the C. difficile infection (CDI), C. difficile produces toxins that generate the clinical symptoms of the disease, and produce spores, which persist in the host during antibiotic treatment and can cause recurrent CDI (R-CDI). In this work, we aimed to compare three antibiotic regimens in the susceptibility of mice to CDI and R-CDI (i.e., antibiotic cocktail followed by clindamycin, 5 days of cefoperazone and 10 days of cefoperazone) with three different C. difficile isolates (i.e., strains 630; R20291, and VPI 10463). We observed that the severity of the clinical symptoms of CDI and R-CDI was dependent on the antibiotic treatment used to induce C. difficile-susceptibility, and that the three strains generated a different onset to diarrhea and weight loss in mice that were administrated with the same antibiotic treatment and which differed in comparison to the effect previously reported by other research groups. Our results suggest that, in our experimental conditions, in those animals treated with antibiotic cocktail followed by clindamycin, infection with strain R20291 had the highest diarrhea manifestation in comparison to strains 630 and VPI 10463. In animals treated with cefoperazone for 5 days, infection with strains R20291 or 630 had the highest diarrhea manifestation in comparison to VPI 10463, while in animals treated with cefoperazone for 10 days, infection with strain R20291 or VPI 10463, but not 630, had the highest diarrhea manifestation.

Spatiotemporal clustering of in-hospital Clostridioides difficile infection

OBJECTIVE

To determine whether Clostridioides difficile infection (CDI) exhibits spatiotemporal interaction and clustering.

DESIGN

Retrospective observational study.

SETTING

The University of Iowa Hospitals and Clinics.

PATIENTS

This study included 1,963 CDI cases, January 2005 through December 2011.

METHODS

We extracted location and time information for each case and ran the Knox, Mantel, and mean and maximum component size tests for time thresholds (T = 7, 14, and 21 days) and distance thresholds (D = 2, 3, 4, and 5 units; 1 unit = 5-6 m). All tests were implemented using Monte Carlo simulations, and random CDI cases were constructed by randomly permuting times of CDI cases 20,000 times. As a counterfactual, we repeated all tests on 790 aspiration pneumonia cases because aspiration pneumonia is a complication without environmental factors.

RESULTS

Results from the Knox test and mean component size test rejected the null hypothesis of no spatiotemporal interaction (P < .0001), for all values of T and D. Results from the Mantel test also rejected the hypothesis of no spatiotemporal interaction (P < .0003). The same tests showed no such effects for aspiration pneumonia. Our results from the maximum component size tests showed similar trends, but they were not consistently significant, possibly because CDI outbreaks attributable to the environment were relatively small.

CONCLUSION

Our results clearly show spatiotemporal interaction and clustering among CDI cases and none whatsoever for aspiration pneumonia cases. These results strongly suggest that environmental factors play a role in the onset of some CDI cases. However, our results are not inconsistent with the possibility that many genetically unrelated CDI cases occurred during the study period.

Successful perioperative infection control measures after gastroenterological surgery reduced the number of cases of methicillin-resistant Staphylococcus aureus or Clostridioides (Clostridium) difficile infection to almost zero over a 30-year period: a single-department experience

PURPOSE

To investigate changes in the incidence of postoperative infections in the surgical department of a teaching hospital.

METHODS

During the 30-year period from September 1987 to August 2017, 11,568 gastroenterological surgical procedures were performed in our surgical department. This 30-year period was divided into seven periods (A-G), ranging from 2 to 7 years each and based on the infection control methods used in each period. We then compared the rates of incisional surgical site infection (SSI) and organ/space SSI; remote infection (RI) including respiratory tract infection (RTI), intravascular catheter-related infection, and urinary tract infection (UTI); and antibiotic-associated colitis caused by methicillin-resistant Staphylococcus aureus (MRSA) enteritis or Clostridioides (Clostridium) difficile-associated disease (CDAD) among the seven periods.

RESULTS

In periods B (September 1990-August 1997) and E (November 2004-July 2007), when a unique antibiotic therapy devised in our department was in use, MRSA was isolated from only 0.3% and 0.4% of surgical patients, respectively, and these rates were significantly lower than those in the other periods (p < 0.05). The rate of CDAD increased during period F (August 2007-July 2014), but in period G (August 2014-August 2017), restrictions were placed on the use of antibiotics with a strong anti-anaerobic action and, in this period, the rate of CDAD was only 0.04%, which was significantly lower than that in period F (p < 0.05).

CONCLUSIONS

Limiting the use of antibiotics that tend to disrupt the intestinal flora may reduce the rates of MRSA infection and CDAD after gastroenterological surgery.

The rise of Clostridioides difficile infections and fall of associated mortality in hospitalized advanced cirrhotics

BACKGROUND & AIMS

Cirrhotics are at increased risk of Clostridioides difficile infection (CDI) and its associated high morbidity and mortality. However, the impact of CDI in cirrhotics over time remains unclear. This study analyses prevalence and mortality in CDI in hospitalized patients with advanced cirrhosis over 15 years and identifies trends.

METHODS

Using the Nationwide Inpatient Sample (NIS) from 1998 to 2014, 3 049 696 weighted patients with advanced cirrhosis (defined as evidence of decompensation or oesophageal varices) were identified using a validated algorithm of ICD-9-CM codes and included in the study. Trends were analysed using Cochran Armitage test and joinpoint regression and compared to the general population. Multivariable logistic regression was performed controlling for risk factors that affect mortality in cirrhotics.

RESULTS

CDI prevalence in advanced cirrhotics increased from 0.8% to 2.6%, annual percent change (APC) 8.8% (compared to 7.6% for the general population), while CDI-related mortality decreased from 20.7% to 11.3%, APC -3.4% (compared to -2.0% for the general population), from 1998 to 2014. CDI independently increased mortality in advanced cirrhotics (OR 1.47, P < 0.001) and was associated with acute kidney injury (AKI) (OR 2.09, P < 0.001), which itself significantly increased mortality (OR 4.54, P < 0.001). Hepatic encephalopathy and Hispanic ethnicity were interestingly associated with a lower prevalence of CDI.

CONCLUSIONS

CDI is increasingly common in advanced cirrhotics, but on the contrary, its associated mortality is decreasing. Despite improvements in outcomes in patients with advanced cirrhosis, CDI is associated with an increased mortality, driven by AKI, and therefore, requires aggressive identification and therapy.

Dual role of the colonization factor CD2831 in Clostridium difficile pathogenesis

Clostridium difficile is a Gram-positive, anaerobic bacterium and the leading cause of antibiotic-associated diarrhea and pseudomembranous colitis. C. difficile modulates its transition from a motile to a sessile lifestyle through a mechanism of riboswitches regulated by cyclic diguanosine monophosphate (c-di-GMP). Previously described as a sortase substrate positively regulated by c-di-GMP, CD2831 was predicted to be a collagen-binding protein and thus potentially involved in sessility. By overexpressing CD2831 in C. difficile and heterologously expressing it on the surface of Lactococcus lactis, here we further demonstrated that CD2831 is a collagen-binding protein, able to bind to immobilized collagen types I, III and V as well as native collagen produced by human fibroblasts. We also observed that the overexpression of CD2831 raises the ability to form biofilm on abiotic surface in both C. difficile and L. lactis. Notably, we showed that CD2831 binds to the collagen-like domain of the human complement component C1q, suggesting a role in preventing complement cascade activation via the classical pathway. This functional characterization places CD2831 in the Microbial Surface Components Recognizing Adhesive Matrix Molecule (MSCRAMMs) family, a class of virulence factors with a dual role in adhesion to collagen-rich tissues and in host immune evasion by binding to human complement components.

Rapid, label-free genetic detection of enteropathogens in stool without genetic isolation or amplification

Current genetic detection methods require gene isolation, gene amplification and detection with a fluorescent-tagged probe. They typically require sophisticated equipment and expensive fluorescent probes, rendering them not widely available for rapid acute infection diagnoses at the point of care to ensure timely treatment of the diseases. Here we report a rapid genetic detection method that can detect the bacterial gene directly from patient stools using a piezoelectric plate sensor (PEPS) in conjunction with a continuous flow system with two temperature zones. With stools spiked with sodium dodecyl sulfate (SDS) in situ bacteria lysing and DNA denaturation occurred in the high-temperature zone whereas in situ specific detection of the denatured DNA by the PEPS occurred in the lower-temperature zone. The outcome was a rapid genetic detection method that directly detected bacterial genes from stool in < 40 min without the need of gene isolation, gene amplification, or expensive fluorescent tag but with polymerase chain reaction (PCR) sensitivity. In 40 blinded patient stools, it detected the toxin B gene of Clostridium difficile with 95% sensitivity and 95% specificity. The all-electrical, label-free nature of the detection further supports its potential as a low-cost genetic test that can be used at the point of care.

Guideline for the Management of Clostridium Difficile Infection in Children and Adolescents With Cancer and Pediatric Hematopoietic Stem-Cell Transplantation Recipients

PURPOSE

The aim of this work was to develop a clinical practice guideline for the prevention and treatment of Clostridium difficile infection (CDI) in children and adolescents with cancer and pediatric hematopoietic stem-cell transplantation (HSCT) patients.

METHODS

An international multidisciplinary panel of experts in pediatric oncology and infectious diseases with patient advocate representation was convened. We performed systematic reviews of randomized controlled trials for the prevention or treatment of CDI in any population and considered the directness of the evidence to children with cancer and pediatric HSCT patients. We used the Grading of Recommendations Assessment, Development, and Evaluation approach to generate recommendations.

RESULTS

The panel made strong recommendations to administer either oral metronidazole or oral vancomycin for the initial treatment of nonsevere CDI and oral vancomycin for the initial treatment of severe CDI. Fidaxomicin may be considered in the setting of recurrent CDI. The panel suggested that probiotics not be routinely used for the prevention of CDI, and that monoclonal antibodies and probiotics not be routinely used for the treatment of CDI. A strong recommendation to not use fecal microbiota transplantation was made in this population. We identified key knowledge gaps and suggested directions for future research.

CONCLUSION

We present a guideline for the prevention and treatment of CDI in children and adolescents with cancer and pediatric HSCT patients. Future research should include randomized controlled trials that involve children with cancer and pediatric HSCT patients to improve the management of CDI in this population.

Antibiotics as both friends and foes of the human gut microbiome: The microbial community approach

The exposure of the human gut to antibiotics can have a great impact on human health. Antibiotics pertain to the preservation of human health and are useful tools for fighting bacterial infections. They can be used for curing infections and can play a critical role in immunocompromised or chronic patients, or in fighting childhood severe malnutrition. Yet, the genomic and phylogenetic diversity of the human gut changes under antibiotic exposure. Antibiotics can also have severe side effects on human gut health, due to the spreading of potential antibiotic resistance genetic traits and to their correlation with virulence of some bacterial pathogens. They can shape, and even disrupt, the composition and functioning diversity of the human gut microbiome. Traditionally bacterial antibiotic resistances have been evaluated at clone or population level. However, the understanding of these two apparently disparate perspectives as both friends and foes may come from the study of microbiomes as a whole and from the evaluation of both positive and negative effects of antibiotics on microbial community dynamics and diversity. In this review we present some metagenomic tools and databases that enable the studying of antibiotic resistance in human gut metagenomes, promoting the development of personalized medicine strategies, new antimicrobial therapy protocols and patient follow-up.

Indomethacin increases severity of Clostridium difficile infection in mouse model

AIM

To evaluate the effect on the nonsteroidal anti-inflammatory drug indomethacin on Clostridium difficile infection (CDI) severity.

MATERIALS & METHODS

Indomethacin was administered in two different mouse models of antibiotic-associated CDI in two different facilities, using a low and high dose of indomethacin.

RESULTS

Indomethacin administration caused weight loss, increased the signs of severe infection and worsened histopathological damage, leading to 100% mortality during CDI. Indomethacin-treated, antibiotic-exposed mice infected with C. difficile had enhanced intestinal inflammation with increased expression of KC, IL-1β and IL-22 compared with infected mice unexposed to indomethacin.

CONCLUSION

These results demonstrate a negative impact of nonsteroidal anti-inflammatory drugs on antibiotic-associated CDI in mice and suggest that targeting the synthesis or signaling of prostaglandins might be an approach to ameliorating the severity of CDI.

Clostridium difficile, the Difficult "Kloster" Fuelled by Antibiotics

Clostridium difficile is normally present in low numbers in a healthy adult gastro-intestinal tract (GIT). Drastic changes in the microbial population, e.g., dysbiosis caused by extensive treatment with antibiotics, stimulates the growth of resistant strains and the onset of C. difficile infection (CDI). Symptoms of infection varies from mild diarrhea to colitis (associated with dehydration and bleeding), pseudomembranous colitis with yellow ulcerations in the mucosa of the colon, to fulminant colitis (perforation of the gut membrane), and multiple organ failure. Inflamed epithelial cells and damaged mucosal tissue predisposes the colon to other opportunistic pathogens such as Clostridium perfringens, Staphylococcus aureus, Klebsiella oxytoca, Candida spp., and Salmonella spp. This may lead to small intestinal bacterial overgrowth (SIBO), sepsis, toxic megacolon, and even colorectal cancer. Many stains of C. difficile are resistant to metronidazole and vancomycin. Vaccination may be an answer to CDI, but requires more research. Success in treatment with probiotics depends on the strains used. Oral or rectal fecal transplants are partly effective, as spores in the small intestine may germinate and colonize the colon. The effect of antibiotics on C. difficile and commensal gut microbiota is summarized and changes in gut physiology are discussed. The need to search for non-antibiotic methods in the treatment of CDI and C. difficile-associated disease (CDAD) is emphasized.

Diagnosis of Clostridium difficile infection using an UPLC-MS based metabolomics method

INTRODUCTION

The fecal metabolome of Clostridium difficile (CD) infection is far from being understood, particularly its non-volatile organic compounds. The drawbacks of current tests used to diagnose CD infection hinder their application.

OBJECTIVE

The aims of this study were to find new characteristic fecal metabolites of CD infection and develop a metabolomics model for the diagnosis of CD infection.

METHODS

Ultra-performance liquid chromatography-mass spectrometry (UPLC-MS) was used to characterize the fecal metabolome of CD positive and negative diarrhea and healthy control stool samples.

RESULTS

Diarrhea and healthy control samples showed distinct clusters in the principal components analysis score plot, and CD positive group and CD negative group demonstrated clearer separation in a partial least squares discriminate analysis model. The relative abundance of sphingosine, chenodeoxycholic acid, phenylalanine, lysophosphatidylcholine (C16:0), and propylene glycol stearate was higher, and the relative abundance of fatty amide, glycochenodeoxycholic acid, tyrosine, linoleyl carnitine, and sphingomyelin was lower in CD positive diarrhea groups, than in the CD negative group. A linear discriminant analysis model based on capsiamide, dihydrosphingosine, and glycochenodeoxycholic acid was further constructed to identify CD infection in diarrhea. The leave-one-out cross-validation accuracy and area under receiver operating characteristic curve for the training set/external validation set were 90.00/78.57%, and 0.900/0.7917 respectively.

CONCLUSIONS

Compared with other hospital-onset diarrhea, CD diarrhea has distinct fecal metabolome characteristics. Our UPLC-MS metabolomics model might be useful tool for diagnosing CD diarrhea.

Clostridium difficile - From Colonization to Infection

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.

The effect of concomitant use of systemic antibiotics in patients with Clostridium difficile infection receiving metronidazole therapy

Management of Clostridium difficile infection (CDI) involves discontinuation of the offending antibiotic agent as soon as possible. However, the ongoing infection does not allow discontinuation of the offending antibiotic. We aimed to retrospectively investigate the predictors of treatment failure and impact of the concomitant use of systemic antibiotics in patients receiving metronidazole therapy. This study was conducted among patients hospitalised at a second care academic hospital from January 2013 to December 2014. Eligible patients were identified by reviewing stool toxin enzyme immunoassay results for C. difficile. Diarrhoea was defined as the passage of at least three loose or watery stools within 24 h. Among 314 patients with CDI receiving metronidazole therapy, 62 (19.7%) showed treatment failure and 105 (33.4%) received concomitant antibiotics. Underlying dialysis, fever >38.3 °C, low median serum albumin levels and concomitant use of antibiotics were independent predictors of treatment failure in patients with CDI receiving metronidazole therapy. The concomitant use of antibiotics increased the rates of treatment failure and 30-day mortality in patients receiving metronidazole therapy. These results suggest that metronidazole should be used in mild cases of CDI only after discontinuation of the offending antibiotics.

Institutional review of the implementation and use of a Clostridium difficile infection bundle and probiotics in adult trauma patients

BACKGROUND

Clostridium difficile infection (CDI) is a common cause of healthcare associated infections contributing to morbidity and mortality. Our objective was to evaluate the impact of the implementation of a CDI bundle along with probiotic utilization.

METHODS

A retrospective review of trauma admissions from 2008 to 2014 was performed. The CDI bundle was implemented in stages from 2009 through 2014 with probiotics initiated in 2010. The bundle included changes in cleaning practices, education, screening, and contact precautions.

RESULTS

4632 (49%) patients received antibiotics with 21% receiving probiotics. Probiotic use was associated with increased age, male sex, more severely injured, and antibiotic use. CDI incidence decreased from 11.2 to 4.8 per 1000 admissions, p = .03. Among patients who received antibiotics CDI incidence decreased from 2.2% to 0.7%, p = .01.

CONCLUSIONS

We report the largest series of a CDI bundle implementation including probiotics. During the period of adoption of these interventions, the incidence of CDI decreased significantly.

The Rise and Fall of Metronidazole for Clostridium difficile Infection

Clostridium difficile is posing urgent health threats. Older studies have shown that metronidazole and vancomycin are equally effective in the treatment of Clostridium difficile infection (CDI). Given its inexpensive cost and low propensity to select antimicrobial resistant organisms, metronidazole became rapidly the drug of choice despite its pharmacokinetic limitations in the treatment of CDI. However, newer studies demonstrated that metronidazole is inferior to vancomycin, prompting clinicians to change their long-standing position on using metronidazole for mild to moderate infections and on reserving vancomycin for severe infections. Moving forward, metronidazole will fall out of favor in the treatment of CDI.

Clostridium difficile - From Colonization to Infection

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.

Prevalence of Clostridium Difficile Infection in Patients After Radical Cystectomy and Neoadjuvant Chemotherapy

Background and Objectives:

Clostridium Difficile is the most common cause of nosocomial infectious diarrhea. This study evaluates the prevalence and predictors of Clostridium Difficile infections in patients undergoing radical cystectomy with or without neoadjuvant chemotherapy.

Methods:

Retrospective chart review was performed of all patients undergoing cystectomy and urinary diversion at a single institution from 2011–2017. Infection was documented in all cases with testing for Clostridium Difficile polymerase chain reaction toxin B. Patient and disease related factors were compared for those who received neoadjuvant chemotherapy vs. those who did not in order to identify potential risk factors associated with C. Difficile infections. Chi squared test and logistic regression analysis were used to determine statistical significance.

Results:

Of 350 patients who underwent cystectomy, 41 (11.7%) developed Clostridium Difficile in the 30 day post-operative period. The prevalence of C. Difficile infection was higher amongst the patients undergoing cystectomy compared to the non-cystectomy admissions at our hospital (11.7 vs. 2.9%). Incidence was not significantly different among those who underwent cystectomy for bladder cancer versus those who underwent the procedure for other reasons. Median time to diagnosis was 6 days (range 3–28 days). The prevalence of C. Diff infections was not significantly different among those who received neoadjuvant chemotherapy vs. those who did not (11% vs. 10.4% p = 0.72). A significant association between C. Difficile infection was not seen with proton pump inhibitor use (p = 0.48), patient BMI (p = 0.67), chemotherapeutic regimen (p = 0.94), individual surgeon (p = 0.54), type of urinary diversion (0.41), or peri-operative antibiotic redosing (p = 0.26).

Conclusions:

Clostridium Difficile infection has a higher prevalence in patients undergoing cystectomy. No significant association between prevalence and exposure to neoadjuvant chemotherapy was seen.

Characterization of Chicken IgY Specific to Clostridium difficile R20291 Spores and the Effect of Oral Administration in Mouse Models of Initiation and Recurrent Disease

Clostridium difficile infection (CDI) are the leading cause of world-wide nosocomial acquired diarrhea. The current main clinical challenge in CDI is the elevated rate of infection recurrence that may reach up to 30% of the patients, which has been associated to the formation of dormant spores during the infection. We sought to characterize the effects of oral administration of specific anti-spore IgY in mouse models of CDI and recurrent CDI. The specificity of anti-spore IgY was evaluated in vitro. In both, initiation mouse model and recurrence mouse model, we evaluated the prophylactic and therapeutic effect of anti-spore IgY, respectively. Our results demonstrate that anti-spore IgY exhibited high specificity and titers against C. difficile spores and reduced spore adherence to intestinal cells in vitro. Administration of anti-spore IgY to C57BL/6 mice prior and during CDI delayed the appearance of the diarrhea by 1.5 day, and spore adherence to the colonic mucosa by 90%. Notably, in the recurrence model, co-administration of anti-spore IgY coupled with vancomycin delayed the appearance of recurrent diarrhea by a median of 2 days. Collectively, these observations suggest that anti-spore IgY antibodies may be used as a novel prophylactic treatment for CDI, or in combination with antibiotics to treat CDI and prevent recurrence of the infection.

Reducing Clostridium difficile in the Inpatient Setting: A Systematic Review of the Adherence to and Effectiveness of C. difficile Prevention Bundles

BACKGROUND Clostridium difficile infection (CDI) is the most common infectious cause of nosocomial diarrhea, and its prevention is an urgent public health priority. However, reduction of CDI is challenging because of its complex pathogenesis, large reservoirs of colonized patients, and the persistence of infectious spores. The literature lacks high-quality evidence for evaluating interventions, and many hospitals have implemented bundled interventions to reduce CDI with variable results. Thus, we conducted a systematic review to examine the components of CDI bundles, their implementation processes, and their impact on CDI rates. METHODS We conducted a comprehensive literature search of multiple computerized databases from their date of inception through April 30, 2016. The protocol was registered in PROSPERO, an international prospective register of systematic reviews. Bundle effectiveness, adherence, and study quality were assessed for each study meeting our criteria for inclusion. RESULTS In the 26 studies that met the inclusion criteria for this review, implementation and adherence factors to interventions were variably and incompletely reported, making study reproducibility and replicability challenging. Despite contextual differences and the variety of bundle components utilized, all 26 studies reported an improvement in CDI rates. However, given the lack of randomized controlled trials in the literature, assessing a causal relationship between bundled interventions and CDI rates is currently impossible. CONCLUSION Cluster randomized trials that include a rigorous assessment of the implementation of bundled interventions are urgently needed to causally test the effect of intervention bundles on CDI rates. Infect Control Hosp Epidemiol 2017;38:639-650.

Antibiotic treatment for Clostridium difficile-associated diarrhoea in adults

BACKGROUND

Clostridium difficile (C. difficile) is recognized as a frequent cause of antibiotic-associated diarrhoea and colitis. This review is an update of a previously published Cochrane review.

OBJECTIVES

The aim of this review is to investigate the efficacy and safety of antibiotic therapy for C. difficile-associated diarrhoea (CDAD), or C. difficile infection (CDI), being synonymous terms.

SEARCH METHODS

We searched MEDLINE, EMBASE, CENTRAL and the Cochrane IBD Group Specialized Trials Register from inception to 26 January 2017. We also searched clinicaltrials.gov and clinicaltrialsregister.eu for ongoing trials.

SELECTION CRITERIA

Only randomised controlled trials assessing antibiotic treatment for CDI were included in the review.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed abstracts and full text articles for inclusion and extracted data. The risk of bias was independently rated by two authors. For dichotomous outcomes, we calculated the risk ratio (RR) and corresponding 95% confidence interval (95% CI). We pooled data using a fixed-effect model, except where significant heterogeneity was detected, at which time a random-effects model was used. The following outcomes were sought: sustained symptomatic cure (defined as initial symptomatic response and no recurrence of CDI), sustained bacteriologic cure, adverse reactions to the intervention, death and cost.

MAIN RESULTS

Twenty-two studies (3215 participants) were included. The majority of studies enrolled patients with mild to moderate CDI who could tolerate oral antibiotics. Sixteen of the included studies excluded patients with severe CDI and few patients with severe CDI were included in the other six studies. Twelve different antibiotics were investigated: vancomycin, metronidazole, fusidic acid, nitazoxanide, teicoplanin, rifampin, rifaximin, bacitracin, cadazolid, LFF517, surotomycin and fidaxomicin. Most of the studies were active comparator studies comparing vancomycin with other antibiotics. One small study compared vancomycin to placebo. There were no other studies that compared antibiotic treatment to a placebo or a 'no treatment' control group. The risk of bias was rated as high for 17 of 22 included studies. Vancomycin was found to be more effective than metronidazole for achieving symptomatic cure. Seventy-two per cent (318/444) of metronidazole patients achieved symptomatic cure compared to 79% (339/428) of vancomycin patients (RR 0.90, 95% CI 0.84 to 0.97; moderate quality evidence). Fidaxomicin was found to be more effective than vancomycin for achieving symptomatic cure. Seventy-one per cent (407/572) of fidaxomicin patients achieved symptomatic cure compared to 61% (361/592) of vancomycin patients (RR 1.17, 95% CI 1.04 to 1.31; moderate quality evidence). Teicoplanin may be more effective than vancomycin for achieving a symptomatic cure. Eightly-seven per cent (48/55) of teicoplanin patients achieved symptomatic cure compared to 73% (40/55) of vancomycin patients (RR 1.21, 95% CI 1.00 to 1.46; very low quality evidence). For other comparisons including the one placebo-controlled study the quality of evidence was low or very low due to imprecision and in many cases high risk of bias because of attrition and lack of blinding. One hundred and forty deaths were reported in the studies, all of which were attributed by study authors to the co-morbidities of the participants that lead to acquiring CDI. Although many other adverse events were reported during therapy, these were attributed to the participants' co-morbidities. The only adverse events directly attributed to study medication were rare nausea and transient elevation of liver enzymes. Recent cost data (July 2016) for a 10 day course of treatment shows that metronidazole 500 mg is the least expensive antibiotic with a cost of USD 13 (Health Warehouse). Vancomycin 125 mg costs USD 1779 (Walgreens for 56 tablets) compared to fidaxomicin 200 mg at USD 3453.83 or more (Optimer Pharmaceuticals) and teicoplanin at approximately USD 83.67 (GBP 71.40, British National Formulary).

AUTHORS' CONCLUSIONS

No firm conclusions can be drawn regarding the efficacy of antibiotic treatment in severe CDI as most studies excluded patients with severe disease. The lack of any 'no treatment' control studies does not allow for any conclusions regarding the need for antibiotic treatment in patients with mild CDI beyond withdrawal of the initiating antibiotic. Nonetheless, moderate quality evidence suggests that vancomycin is superior to metronidazole and fidaxomicin is superior to vancomycin. The differences in effectiveness between these antibiotics were not too large and the advantage of metronidazole is its far lower cost compared to the other two antibiotics. The quality of evidence for teicoplanin is very low. Adequately powered studies are needed to determine if teicoplanin performs as well as the other antibiotics. A trial comparing the two cheapest antibiotics, metronidazole and teicoplanin, would be of interest.

Evolutionary clade affects resistance of Clostridium difficile spores to Cold Atmospheric Plasma

Clostridium difficile is a spore forming bacterium and the leading cause of colitis and antibiotic associated diarrhoea in the developed world. Spores produced by C. difficile are robust and can remain viable for months, leading to prolonged healthcare-associated outbreaks with high mortality. Exposure of C. difficile spores to a novel, non-thermal atmospheric pressure gas plasma was assessed. Factors affecting sporicidal efficacy, including percentage of oxygen in the helium carrier gas admixture, and the effect on spores from different strains representing the five evolutionary C. difficile clades was investigated. Strains from different clades displayed varying resistance to cold plasma. Strain R20291, representing the globally epidemic ribotype 027 type, was the most resistant. However all tested strains displayed a ~3 log reduction in viable spore counts after plasma treatment for 5 minutes. Inactivation of a ribotype 078 strain, the most prevalent clinical type seen in Northern Ireland, was further assessed with respect to surface decontamination, pH, and hydrogen peroxide concentration. Environmental factors affected plasma activity, with dry spores without the presence of organic matter being most susceptible. This study demonstrates that cold atmospheric plasma can effectively inactivate C. difficile spores, and highlights factors that can affect sporicidal activity.

Lincosamides, Streptogramins, Phenicols, and Pleuromutilins: Mode of Action and Mechanisms of Resistance

Lincosamides, streptogramins, phenicols, and pleuromutilins (LSPPs) represent four structurally different classes of antimicrobial agents that inhibit bacterial protein synthesis by binding to particular sites on the 50S ribosomal subunit of the ribosomes. Members of all four classes are used for different purposes in human and veterinary medicine in various countries worldwide. Bacteria have developed ways and means to escape the inhibitory effects of LSPP antimicrobial agents by enzymatic inactivation, active export, or modification of the target sites of the agents. This review provides a comprehensive overview of the mode of action of LSPP antimicrobial agents as well as of the mutations and resistance genes known to confer resistance to these agents in various bacteria of human and animal origin.