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Schwartz O, Rohana H, Azrad M, Shor A, Rainy N, Maor Y, Nesher L, Sagi O, Ken-Dror S, Kechker P, Peretz A. Characterization of community-acquired Clostridioides difficile strains in Israel, 2020-2022. Front Microbiol 2023; 14:1323257. [PMID: 38169783 PMCID: PMC10758451 DOI: 10.3389/fmicb.2023.1323257] [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: 10/17/2023] [Accepted: 11/29/2023] [Indexed: 01/05/2024] Open
Abstract
Background The prevalence of community-acquired Clostridioides difficile infection (CA-CDI) has been rising, due to changes in antibiotics prescribing practices, emergence of hypervirulent strains and improved diagnostics. This study explored CA-CDI epidemiology by examining strain diversity and virulence factors of CA-CDI isolates collected across several geographical regions in Israel. Methods Stool samples of 126 CA-CDI patients were subjected to PCR and an immunoassay to identify toxin genes and proteins, respectively. Toxin loci PaLoc and PaCdt were detected by whole-genome sequencing (WGS). Biofilm production was assessed by crystal violet-based assay. Minimum inhibitory concentration was determined using the Etest technique or agar dilution. WGS and multi-locus sequence typing (MLST) were used to classify strains and investigate genetic diversity. Results Sequence types (ST) 2 (17, 13.5%), ST42 (13, 10.3%), ST104 (10, 8%) and ST11 (9, 7.1%) were the most common. All (117, 92.8%) but ST11 belonged to Clade 1. No associations were found between ST and gender, geographic area or antibiotic susceptibility. Although all strains harbored toxins genes, 34 (27%) produced toxin A only, and 54 (42.9%) strains produced toxin B only; 38 (30.2%) produced both toxins. Most isolates were biofilm-producers (118, 93.6%), primarily weak producers (83/118, 70.3%). ST was significantly associated with both biofilm and toxin production. Conclusion C. difficile isolates in Israel community exhibit high ST diversity, with no dominant strain. Other factors may influence the clinical outcomes of CDI such as toxin production, antibiotic resistance and biofilm production. Further studies are needed to better understand the dynamics and influence of these factors on CA-CDI.
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Affiliation(s)
- Orna Schwartz
- Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
- Clinical Microbiology Laboratory, The Edith Wolfson Medical Center, Holon, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hanan Rohana
- Clinical Microbiology Laboratory, Tzafon Medical Center, Poriya, Israel
| | - Maya Azrad
- Clinical Microbiology Laboratory, Tzafon Medical Center, Poriya, Israel
| | - Anna Shor
- Shamir Medical Center, Be’er Ya’akov, Israel
| | - Nir Rainy
- Shamir Medical Center, Be’er Ya’akov, Israel
| | - Yasmin Maor
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Infectious Diseases Unit, The Edith Wolfson Medical Center, Holon, Israel
| | - Lior Nesher
- Infectious Diseases Institute, Soroka University Medical Center, Be’er Sheba, Israel
- Faculty of Health Sciences Ben-Gurion University of the Negev, Be’er Sheba, Israel
| | - Orli Sagi
- Microbiology Laboratory, Soroka University Medical Center, Be’er Sheba, Israel
| | - Shifra Ken-Dror
- W. Hirsch Regional Microbiology Laboratory, Clalit Health Services, Haifa, Israel
| | - Peter Kechker
- W. Hirsch Regional Microbiology Laboratory, Clalit Health Services, Haifa, Israel
| | - Avi Peretz
- Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
- Clinical Microbiology Laboratory, Tzafon Medical Center, Poriya, Israel
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Stojanovic P, Harmanus C, Kuijper EJ. Community-onset Clostridioides difficile infection in south Serbia. Anaerobe 2023; 79:102669. [PMID: 36455757 DOI: 10.1016/j.anaerobe.2022.102669] [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: 09/01/2022] [Revised: 11/15/2022] [Accepted: 11/20/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Data from the past decade indicates that Clostridioides difficile infection (CDI) is not only a nosocomial infection but is also increasingly recognized as a disease in the community. OBJECTIVE We aimed to study community-onset (CO) CDI in the various age groups in south Serbia with its clinical characteristics, risk factors and microbiological characterization. METHODS The study group included 93 patients with CO-CDI (median age 62). The control group consisted of 186 patients with community-onset diarrhea and stool samples negative tested for CDI. RESULTS Of all CDI cases diagnosed with a community onset, 74.19% had a previous contact with a healthcare facility in the previous 12 weeks, but 34.40% have no record on hospitalization in the previous 12 months. Using a multivariate statistical regression model, the following risk factors for CO-CDI development were found; antacid usage (OR = 0.267, 95%C.I.:0.10-0.291, p < 0.01), chronic kidney disease (OR = 0.234, 95%C.I.:0.10-0.51, p < 0.01) and antibiotic use during the prior 2 months (OR = 0.061, 95%C.I.:0.02-0.17, p < 0.01), especially tetracycline's (OR = 0.146, 95% C.I.:0.07-0.22, p < 0.01) and cephalosporin's (OR = 0.110, 95%C.I.:0.14-0.42, p < 0.01). The most common ribotypes (RTs) detected in patients with CO-CDI were RT001 (32.3%) and RT027 (24.7%). All tested toxin producing C. difficile isolates were sensitive to metronidazole, vancomycin and tigecycline. A high rate of resistance to moxifloxacin (73.11%) and rifampicin (23.65%) was found. CONCLUSION Patients with CO-CDI had frequently contact with healthcare facility in the previous 12 weeks. Restriction of antacid usage and of high-risk antibiotics in the community may help reduce the incidence of CO-CDI.
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Affiliation(s)
- Predrag Stojanovic
- Faculty of Medicine, University of Niš, Zorana Đinđića 50, 18000, Niš, Serbia; Institute for Public Health Nis, Center of Microbiology, 18000, Niš, Serbia(1).
| | - Celine Harmanus
- Department of Medical Microbiology, Center for Infectious Diseases, National Expertise Center for Clostridioides difficile infections, National Institute of Public Health and the Environment, Leiden University Medical Center, PO Box 9600, 2300RC, Leiden, the Netherlands
| | - Ed J Kuijper
- Department of Medical Microbiology, Center for Infectious Diseases, National Expertise Center for Clostridioides difficile infections, National Institute of Public Health and the Environment, Leiden University Medical Center, PO Box 9600, 2300RC, Leiden, the Netherlands
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3
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Albuquerque C, Pagnossin D, Landsgaard K, Simpson J, Brown D, Irvine J, Candlish D, Ridyard AE, Douce G, Millins C. The duration of antibiotic treatment is associated with carriage of toxigenic and non-toxigenic strains of Clostridioides difficile in dogs. PLoS One 2021; 16:e0245949. [PMID: 33979349 PMCID: PMC8115768 DOI: 10.1371/journal.pone.0245949] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 04/29/2021] [Indexed: 02/04/2023] Open
Abstract
Clostridioides difficile is a leading cause of human antibiotic-associated diarrhoeal disease globally. Zoonotic reservoirs of infection are increasingly suspected to play a role in the emergence of this disease in the community and dogs are considered as one potential source. Here we use a canine case-control study at a referral veterinary hospital in Scotland to assess: i) the risk factors associated with carriage of C. difficile by dogs, ii) whether carriage of C. difficile is associated with clinical disease in dogs and iii) the similarity of strains isolated from dogs with local human clinical surveillance. The overall prevalence of C. difficile carriage in dogs was 18.7% (95% CI 14.8–23.2%, n = 61/327) of which 34% (n = 21/61) were toxigenic strains. We found risk factors related to prior antibiotic treatment were significantly associated with C. difficile carriage by dogs. However, the presence of toxigenic strains of C. difficile in a canine faecal sample was not associated with diarrhoeal disease in dogs. Active toxin was infrequently detected in canine faecal samples carrying toxigenic strains (2/11 samples). Both dogs in which active toxin was detected had no clinical evidence of gastrointestinal disease. Among the ten toxigenic ribotypes of C. difficile detected in dogs in this study, six of these (012, 014, 020, 026, 078, 106) were ribotypes commonly associated with human clinical disease in Scotland, while nontoxigenic isolates largely belonged to 010 and 039 ribotypes. Whilst C. difficile does not appear commonly associated with diarrhoeal disease in dogs, antibiotic treatment increases carriage of this bacteria including toxigenic strains commonly found in human clinical disease.
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Affiliation(s)
- Carolina Albuquerque
- Small Animal Hospital, School of Veterinary Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Davide Pagnossin
- Veterinary Pathology, Public Health and Disease Investigation, School of Veterinary Medicine, University of Glasgow, Glasgow, United Kingdom
- Institute of Infection, Immunity and Inflammation, Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Kirsten Landsgaard
- Veterinary Pathology, Public Health and Disease Investigation, School of Veterinary Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Jessica Simpson
- Institute of Infection, Immunity and Inflammation, Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Derek Brown
- Scottish Microbiology Reference Laboratories, Glasgow, United Kingdom
| | - June Irvine
- Institute of Infection, Immunity and Inflammation, Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Denise Candlish
- Institute of Infection, Immunity and Inflammation, Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Alison E. Ridyard
- Small Animal Hospital, School of Veterinary Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Gillian Douce
- Institute of Infection, Immunity and Inflammation, Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
- * E-mail: (CM); (GD)
| | - Caroline Millins
- Veterinary Pathology, Public Health and Disease Investigation, School of Veterinary Medicine, University of Glasgow, Glasgow, United Kingdom
- Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
- * E-mail: (CM); (GD)
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Khader K, Munoz-Price LS, Hanson R, Stevens V, Keegan LT, Thomas A, Pezzin LE, Nattinger A, Singh S, Samore MH. Transmission Dynamics of Clostridioides difficile in 2 High-Acuity Hospital Units. Clin Infect Dis 2021; 72:S1-S7. [PMID: 33512524 DOI: 10.1093/cid/ciaa1580] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/14/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The key epidemiological drivers of Clostridioides difficile transmission are not well understood. We estimated epidemiological parameters to characterize variation in C. difficile transmission, while accounting for the imperfect nature of surveillance tests. METHODS We conducted a retrospective analysis of C. difficile surveillance tests for patients admitted to a bone marrow transplant (BMT) unit or a solid tumor unit (STU) in a 565-bed tertiary hospital. We constructed a transmission model for estimating key parameters, including admission prevalence, transmission rate, and duration of colonization to understand the potential variation in C. difficile dynamics between these 2 units. RESULTS A combined 2425 patients had 5491 admissions into 1 of the 2 units. A total of 3559 surveillance tests were collected from 1394 patients, with 11% of the surveillance tests being positive for C. difficile. We estimate that the transmission rate in the BMT unit was nearly 3-fold higher at 0.29 acquisitions per percentage colonized per 1000 days, compared to our estimate in the STU (0.10). Our model suggests that 20% of individuals admitted into either the STU or BMT unit were colonized with C. difficile at the time of admission. In contrast, the percentage of surveillance tests that were positive within 1 day of admission to either unit for C. difficile was 13.4%, with 15.4% in the STU and 11.6% in the BMT unit. CONCLUSIONS Although prevalence was similar between the units, there were important differences in the rates of transmission and clearance. Influential factors may include antimicrobial exposure or other patient-care factors.
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Affiliation(s)
- Karim Khader
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | | | - Ryan Hanson
- Collaborative for Healthcare Delivery Science, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Vanessa Stevens
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Lindsay T Keegan
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Alun Thomas
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Liliana E Pezzin
- Collaborative for Healthcare Delivery Science, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Ann Nattinger
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Collaborative for Healthcare Delivery Science, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Siddhartha Singh
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Collaborative for Healthcare Delivery Science, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Matthew H Samore
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
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5
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Ghia CJ, Waghela S, Rambhad GS. Systematic Literature Review on Burden of Clostridioides difficile Infection in India. CLINICAL PATHOLOGY (THOUSAND OAKS, VENTURA COUNTY, CALIF.) 2021; 14:2632010X211013816. [PMID: 34104883 PMCID: PMC8170333 DOI: 10.1177/2632010x211013816] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/26/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Owing to limited diagnostic facilities and surveillance protocols, there is a paucity on the prevalence data of Clostridioides difficile infections (CDIs) in developing countries such as India. OBJECTIVE The aims of these studies are (1) to determine the prevalence of CDI in India, (2) to understand the risk factors of CDI, and (3) to determine the impact of different diagnostic methods on reported CDI rates. METHOD A systematic literature search was conducted using PubMed and Google Scholar database to identify Indian studies reporting the prevalence of CDI. A total of 31 studies, published between 1990 and 2020 were included in the final analysis. A chi-square test was used to determine statistically significant association between prevalence rates, accuracy of different diagnosis methods, and antibiotic usage rates of CDI. RESULTS The prevalence of CDI was in the range of 3.4% to 18%, and the difference between regional prevalence of CDI was statistically significant (P < .001). The use of antibiotics, hospital stay, comorbidities, recent surgery, and the use of proton-pump inhibitors was considered as risk factors for the development of CDI. Compared to other regions, the rate of antibiotic usage was significantly higher in North India (P < .001). Among different diagnostic methods, C. difficile detection was significantly higher with enzyme-linked immunosorbent assay (18.02%) versus other multiple testing methods used (P < .001). CONCLUSION There is a significant burden of CDI across the country. Further surveillance studies are required to monitor changes in prevalence of CDI, risk factors, and accuracy of diagnosis methods for a better understanding of the disease burden in India.
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Affiliation(s)
- Canna J Ghia
- Medical and Scientific Affairs, Pfizer Limited,
Mumbai, India
| | - Shaumil Waghela
- Medical and Scientific Affairs, Pfizer Limited,
Mumbai, India
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6
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Hostler CJ, Bertumen JB, Park LP, Wilkins SB, Woods CW. Differences in time-to-testing and time-to-isolation between community-onset and hospital-onset Clostridioides difficile cases at a tertiary care VA medical center. Am J Infect Control 2020; 48:1148-1151. [PMID: 31911067 DOI: 10.1016/j.ajic.2019.12.008] [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: 08/16/2019] [Revised: 12/06/2019] [Accepted: 12/07/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Delayed identification and isolation of patients with Clostridiodies difficile infection (CDI) may contribute to in-hospital transmission and delay appropriate therapy. To assess potential points for intervention, we conducted a retrospective cohort study to determine differences in time-to-testing and time-to-isolation among community-onset (CO), community-onset healthcare facility-associated (CO-HCFA), and hospital-onset (HO) CDI. METHODS We compared clinical and demographic data of all CO, CO-HCFA, and HO CDI patients at our institution between October 2011 and September 2015. We then performed bivariable analysis on our cohorts to identify differences in time-to-testing and time-to-isolation for CO versus CO-HCFA versus HO CDI patients. RESULTS 355 patients with CDI were hospitalized during the study; 138 (38.9%) with CO CDI, 52 (14.6%) with CO-HCFA CDI, and 165 (46.5%) with HO CDI. 117 (84.8%) CO CDI patients were tested within 1 day of diarrhea onset compared to 41 (78.8%) of CO-HCFA and 113 (68.5%) of HO CDI patients (P < .01). 51 CO CDI patients (36.7%) were placed on empirical isolation precautions at the time of diarrhea onset compared to 22 (43.1%) of CO-HCFA CDI patients and 32 (19.4%) of HO CDI patients (P < .01). CONCLUSIONS CO CDI patients are more likely to be isolated empirically and tested earlier than HO CDI patients. Further attention should be paid to isolating hospitalized patients who develop diarrhea as an inpatient.
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7
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Turner NA, Grambow SC, Woods CW, Fowler VG, Moehring RW, Anderson DJ, Lewis SS. Epidemiologic Trends in Clostridioides difficile Infections in a Regional Community Hospital Network. JAMA Netw Open 2019; 2:e1914149. [PMID: 31664443 PMCID: PMC6824221 DOI: 10.1001/jamanetworkopen.2019.14149] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Clostridioides difficile infection (CDI) remains a leading cause of health care facility-associated infection. A greater understanding of the regional epidemiologic profile of CDI could inform targeted prevention strategies. OBJECTIVES To assess trends in incidence of health care facility-associated and community-acquired CDI among hospitalized patients over time and to conduct a subanalysis of trends in the NAP1 strain of CDI over time. DESIGN, SETTING, AND PARTICIPANTS This long-term multicenter cohort study reviewed records of patients (N = 2 025 678) admitted to a network of 43 regional community hospitals primarily in the southeastern United States from January 1, 2013, through December 31, 2017. Generalized linear mixed-effects models were used to adjust for potential clustering within facilities and changing test method (nucleic acid amplification testing or toxin enzyme immunoassay) over time. MAIN OUTCOMES AND MEASURES Clostridioides difficile infection incidence rates were counted as cases per 1000 admissions for community-acquired and total CDI cases or cases per 10 000 patient-days for health care facility-associated CDI. Long-term trends in the proportion of cases acquired in the community and in NAP1 strain incidence were also evaluated. RESULTS A total of 2 025 678 admissions and 21 254 CDI cases were included (12 678 [59.6%] female; median [interquartile range] age, 69 [55-80] years). Median (interquartile range) total CDI incidence increased slightly from 7.9 (3.5-12.4) cases per 1000 admissions in 2013 to 9.3 (4.9-13.7) cases per 1000 admissions in 2017. After adjustment, the overall incidence of health care facility-associated CDI declined (incidence rate ratio [IRR], 0.995; 95% CI, 0.990-0.999; P = .03), whereas insufficient evidence was found for either an increase or a decrease in community-acquired CDI (IRR, 1.004; 95% CI, 0.999-1.009; P = .14). The proportion of cases classified as community acquired increased over time from a mean (SD) of 0.49 (0.28) in 2013 to 0.61 (0.26) in 2017 (odds ratio, 1.010 per month; 95% CI, 1.006-1.015; P < .001). Rates of the NAP1 strain of CDI varied widely between facilities, with no statistically significant change in NAP1 strain incidence over time in the community setting (IRR, 1.007; 95% CI, 0.994-1.021) or health care facility setting (IRR, 1.011; 95% CI, 0.990-1.032). CONCLUSIONS AND RELEVANCE The findings suggest that, despite the modest improvement in health care facility-associated CDI rates, a better understanding of community-acquired CDI incidence is needed for future infection prevention efforts.
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Affiliation(s)
- Nicholas A. Turner
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | - Steven C. Grambow
- Duke University, Department of Biostatistics and Bioinformatics, Durham, North Carolina
| | - Christopher W. Woods
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
- Durham Veterans Affairs Health System, Durham, North Carolina
| | - Vance G. Fowler
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Rebekah W. Moehring
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | - Deverick J. Anderson
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | - Sarah S. Lewis
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
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Knight DR, Riley TV. Genomic Delineation of Zoonotic Origins of Clostridium difficile. Front Public Health 2019; 7:164. [PMID: 31281807 PMCID: PMC6595230 DOI: 10.3389/fpubh.2019.00164] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 06/03/2019] [Indexed: 01/27/2023] Open
Abstract
Clostridium difficile is toxin-producing antimicrobial resistant (AMR) enteropathogen historically associated with diarrhea and pseudomembranous colitis in hospitalized patients. In recent years, there have been dramatic increases in the incidence and severity of C. difficile infection (CDI), and associated morbidity and mortality, in both healthcare and community settings. C. difficile is an ancient and diverse species that displays a sympatric lifestyle, establishing itself in a range of ecological niches external to the healthcare system. These sources/reservoirs include food, water, soil, and over a dozen animal species, in particular, livestock such as pigs and cattle. In a manner analogous to human infection, excessive antimicrobial exposure, particularly to cephalosporins, is driving the expansion of C. difficile in livestock populations worldwide. Subsequent spore contamination of meat, vegetables grown in soil containing animal feces, agricultural by-products such as compost and manure, and the environment in general (households, lawns, and public spaces) is contributing to a persistent community source/reservoir of C. difficile and the insidious rise of CDI in the community. The whole-genome sequencing era continues to redefine our view of this complex pathogen. The application of high-resolution microbial genomics in a One Health framework (encompassing clinical, veterinary, and environment derived datasets) is the optimal paradigm for advancing our understanding of CDI in humans and animals. This approach has begun to yield critical insights into the genetic diversity, evolution, AMR, and zoonotic potential of C. difficile. In Europe, North America, and Australia, microevolutionary analysis of the C. difficile core genome shows strains common to humans and animals (livestock or companion animals) do not form distinct populations but share a recent evolutionary history. Moreover, for C. difficile sequence type 11 and PCR ribotypes 078 and 014, major lineages of One Health importance, this approach has substantiated inter-species clonal transmission between animals and humans. These findings indicate either a zoonosis or anthroponosis. Moreover, they challenge the existing paradigm and the long-held misconception that CDI is primarily a healthcare-associated infection. In this article, evolutionary, and zoonotic aspects of CDI are discussed, including the anthropomorphic factors that contribute to the spread of C. difficile from the farm to the community.
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Affiliation(s)
- Daniel R Knight
- Medical, Molecular, and Forensic Sciences, Murdoch University, Perth, WA, Australia
| | - Thomas V Riley
- Medical, Molecular, and Forensic Sciences, Murdoch University, Perth, WA, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia.,School of Biomedical Sciences, The University of Western Australia, Nedlands, WA, Australia.,PathWest Laboratory Medicine, Department of Microbiology, Nedlands, WA, Australia
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9
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Jiménez A, Araya R, Paniagua D, Camacho-Mora Z, Du T, Golding G, Leandro-Astorga G, Rodríguez C, Quesada-Gómez C. Molecular epidemiology and antimicrobial resistance of Clostridium difficile in a national geriatric hospital in Costa Rica. J Hosp Infect 2018; 99:475-480. [DOI: 10.1016/j.jhin.2018.03.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 03/22/2018] [Indexed: 12/19/2022]
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10
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Ofori E, Ramai D, Dhawan M, Mustafa F, Gasperino J, Reddy M. Community-acquired Clostridium difficile: epidemiology, ribotype, risk factors, hospital and intensive care unit outcomes, and current and emerging therapies. J Hosp Infect 2018; 99:436-442. [DOI: 10.1016/j.jhin.2018.01.015] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 01/23/2018] [Indexed: 02/06/2023]
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11
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Ge IY, Fevrier HB, Conell C, Kheraj MN, Flint AC, Smith DS, Herrinton LJ. Reducing risk of Clostridium difficile infection and overall use of antibiotic in the outpatient treatment of urinary tract infection. Ther Adv Urol 2018; 10:283-293. [PMID: 30186366 DOI: 10.1177/1756287218783871] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 05/29/2018] [Indexed: 11/17/2022] Open
Abstract
Background Risk of community-acquired Clostridium difficile infection (CA-CDI) following antibiotic treatment specifically for urinary tract infection (UTI) has not been evaluated. Methods We conducted a nested case-control study at Kaiser Permanente Northern California, 2007-2010, to assess antibiotic prescribing and other factors in relation to risk of CA-CDI in outpatients with uncomplicated UTI. Cases were diagnosed with CA-CDI within 90 days of antibiotic use. We used matched controls and confirmed case-control eligibility through chart review. Antibiotics were classified as ciprofloxacin (most common), or low risk (nitrofurantoin, sulfamethoxazole/trimethoprim), moderate risk, or high risk (e.g. cefpodoxime, ceftriaxone, clindamycin) for CDI. We computed the adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the relationship of antibiotic treatment for uncomplicated UTI and history of relevant gastrointestinal comorbidity (including gastrointestinal diagnoses, procedures, and gastric acid suppression treatment) with risk of CA-CDI using logistic regression analysis. Results Despite the large population, only 68 cases were confirmed with CA-CDI for comparison with 112 controls. Female sex [81% of controls, adjusted odds ratio (OR) 6.3, CI 1.7-24), past gastrointestinal comorbidity (prevalence 39%, OR 2.3, CI 1.1-4.8), and nongastrointestinal comorbidity (prevalence 6%, OR 2.8, CI 1.4-5.6) were associated with increased CA-CDI risk. Compared with low-risk antibiotic, the adjusted ORs for antibiotic groups were as follows: ciprofloxacin, 2.7 (CI 1.0-7.2); moderate-risk antibiotics, 3.6 (CI 1.2-11); and high-risk antibiotics, 11.2 (CI 2.4-52). Conclusions Lower-risk antibiotics should be used for UTI whenever possible, particularly in patients with a gastrointestinal comorbidity. However, UTI can be managed through alternative approaches. Research into the primary prevention of UTI is urgently needed.
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Affiliation(s)
- Ivy Y Ge
- Inpatient Pharmacy, Kaiser Permanente Northern California South San Francisco Medical Center, 1200 El Camino Real, 3rd Floor, South San Francisco, CA 94080, USA
| | | | - Carol Conell
- Division of Research, Kaiser Permanente, Oakland, CA, USA
| | - Malika N Kheraj
- Department of Infectious Disease, Kaiser Permanente Redwood City Medical Center, Redwood City, CA, USA
| | - Alexander C Flint
- Department of Neurology, Kaiser Permanente Redwood City Medical Center, Redwood City, CA, USA
| | - Darvin S Smith
- Department of Infectious Disease, Kaiser Permanente Redwood City Medical Center, Redwood City, CA, USA
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12
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González-Abad MJ, Alonso Sanz M. Recuperación de episodios de infección por Clostridium difficile tras la aplicación de un documento de consenso. An Pediatr (Barc) 2018; 88:226-227. [DOI: 10.1016/j.anpedi.2017.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 05/23/2017] [Accepted: 05/25/2017] [Indexed: 11/27/2022] Open
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13
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González-Abad MJ, Alonso Sanz M. Recovery from episodes of Clostridium difficile infection following the implementation of a consensus document. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.anpede.2017.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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14
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Marsh JW, Curry SR. Therapeutic Approaches for
Clostridium difficile
Infections. ACTA ACUST UNITED AC 2018; 30:9A.3.1-9A.3.9. [DOI: 10.1002/9780471729259.mc09a03s30] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Jane W. Marsh
- Epidemiology Research Unit, University of Pittsburgh Pittsburgh Pennsylvania
| | - Scott R. Curry
- Epidemiology Research Unit, University of Pittsburgh Pittsburgh Pennsylvania
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15
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Guh AY, Adkins SH, Li Q, Bulens SN, Farley MM, Smith Z, Holzbauer SM, Whitten T, Phipps EC, Hancock EB, Dumyati G, Concannon C, Kainer MA, Rue B, Lyons C, Olson DM, Wilson L, Perlmutter R, Winston LG, Parker E, Bamberg W, Beldavs ZG, Ocampo V, Karlsson M, Gerding DN, McDonald LC. Risk Factors for Community-Associated Clostridium difficile Infection in Adults: A Case-Control Study. Open Forum Infect Dis 2017; 4:ofx171. [PMID: 29732377 DOI: 10.1093/ofid/ofx171] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 08/08/2017] [Indexed: 12/26/2022] Open
Abstract
Background An increasing proportion of Clostridium difficile infections (CDI) in the United States are community-associated (CA). We conducted a case-control study to identify CA-CDI risk factors. Methods We enrolled participants from 10 US sites during October 2014-March 2015. Case patients were defined as persons age ≥18 years with a positive C. difficile specimen collected as an outpatient or within 3 days of hospitalization who had no admission to a health care facility in the prior 12 weeks and no prior CDI diagnosis. Each case patient was matched to one control (persons without CDI). Participants were interviewed about relevant exposures; multivariate conditional logistic regression was performed. Results Of 226 pairs, 70.4% were female and 52.2% were ≥60 years old. More case patients than controls had prior outpatient health care (82.1% vs 57.9%; P < .0001) and antibiotic (62.2% vs 10.3%; P < .0001) exposures. In multivariate analysis, antibiotic exposure-that is, cephalosporin (adjusted matched odds ratio [AmOR], 19.02; 95% CI, 1.13-321.39), clindamycin (AmOR, 35.31; 95% CI, 4.01-311.14), fluoroquinolone (AmOR, 30.71; 95% CI, 2.77-340.05) and beta-lactam and/or beta-lactamase inhibitor combination (AmOR, 9.87; 95% CI, 2.76-340.05),-emergency department visit (AmOR, 17.37; 95% CI, 1.99-151.22), white race (AmOR 7.67; 95% CI, 2.34-25.20), cardiac disease (AmOR, 4.87; 95% CI, 1.20-19.80), chronic kidney disease (AmOR, 12.12; 95% CI, 1.24-118.89), and inflammatory bowel disease (AmOR, 5.13; 95% CI, 1.27-20.79) were associated with CA-CDI. Conclusions Antibiotics remain an important risk factor for CA-CDI, underscoring the importance of appropriate outpatient prescribing. Emergency departments might be an environmental source of CDI; further investigation of their contribution to CDI transmission is needed.
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Affiliation(s)
- Alice Y Guh
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Susan Hocevar Adkins
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Qunna Li
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sandra N Bulens
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Monica M Farley
- Emory University Department of Medicine, Atlanta, Georgia.,Georgia Emerging Infections Program, Decatur, Georgia.,Atlanta Veterans Affairs Medical Center, Atlanta, Georgia
| | - Zirka Smith
- Georgia Emerging Infections Program, Decatur, Georgia.,Atlanta Veterans Affairs Medical Center, Atlanta, Georgia.,Atlanta Research and Education Foundation, Decatur, Georgia
| | - Stacy M Holzbauer
- Minnesota Department of Health, St Paul, Minnesota.,Career Epidemiology Field Officer Program, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Tory Whitten
- Minnesota Department of Health, St Paul, Minnesota
| | - Erin C Phipps
- University of New Mexico, New Mexico Emerging Infections Program, Albuquerque, New Mexico
| | - Emily B Hancock
- University of New Mexico, New Mexico Emerging Infections Program, Albuquerque, New Mexico
| | - Ghinwa Dumyati
- New York Emerging Infections Program and University of Rochester Medical Center, Rochester, New York
| | - Cathleen Concannon
- New York Emerging Infections Program and University of Rochester Medical Center, Rochester, New York
| | | | - Brenda Rue
- Tennessee Department of Health, Nashville, Tennessee
| | - Carol Lyons
- Yale School of Public Health, Connecticut Emerging Infections Program, New Haven, Connecticut
| | - Danyel M Olson
- Yale School of Public Health, Connecticut Emerging Infections Program, New Haven, Connecticut
| | - Lucy Wilson
- Maryland Department of Health and Mental Hygiene, Baltimore, Maryland
| | | | - Lisa G Winston
- University of California, San Francisco, School of Medicine, San Francisco, California
| | - Erin Parker
- California Emerging Infections Program, Oakland, California
| | - Wendy Bamberg
- Colorado Department of Public Health and Environment, Denver, Colorado
| | | | | | - Maria Karlsson
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Dale N Gerding
- Loyola University Chicago Stritch School of Medicine, Maywood, Illinois.,Edward Hines, Jr. Veterans Affairs Hospital, Hines, Illinois
| | - L Clifford McDonald
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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16
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Nosocomial-acquired and community-onset Clostridium difficile infection at an academic hospital in Italy: Epidemiology, recurrences and toxin genes distribution. J Infect Chemother 2017; 23:763-768. [PMID: 28899610 DOI: 10.1016/j.jiac.2017.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 07/03/2017] [Accepted: 08/04/2017] [Indexed: 01/27/2023]
Abstract
Toxinogenic Clostridium difficile infection (CDI) is a leading cause of infectious diarrhea. In this retrospective cohort study the molecular epidemiology of hospital-acquired and community-associated CDI was investigated in patients admitted to a tertiary care hospital. CD in stools samples was revealed by a two steps diagnostic algorithm, firstly screening for positivity to GDH antigen and thereafter RT-PCR analysis. Increased CDI incidence was observed ranging from 1.70episodes/10000patient-days in the 1st year, to 2.62 in the 2nd year, mostly hospitalized in the medicine wards, followed by outpatients (5.74 and 5.12episodes/10.000patient-days respectively). CDI positive were older than CDI negative patients and presented increased trend of diarrhea episodes as the patients' age increased. RT-PCR positive patients (n° = 314) were classified according to the CD toxin producing genes in three groups (1-3, carrying tcdB, both tcdB and cdt, and the two genes plus the deletion Δ117 of tcdC, respectively). The incidence of the group 2 and 3 increased statistically with the age of the patients showing correlation with the gender. Higher frequency of patients belonging to group 1 and group 3 was observed in the medical wards. Of note was the high incidence of group 3 in outpatients. Interestingly, patients with previous health care contacts had higher risk (RR = 1.88) of being infected by CD strains with higher toxicity than community patients. Recurrence rate was 15.9%. In conclusion the knowledge of the toxigenic profiles and of their relationships to gender, age and wards distribution may help the clinicians in the clinical management of the disease.
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17
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Abstract
Clostridium difficile is an anaerobic, Gram-positive, spore-forming, toxin-secreting bacillus that has long been recognized to be the most common etiologic pathogen of antibiotic-associated diarrhea. C. difficile infection (CDI) is now the most common cause of health care-associated infections in the United States and accounts for 12% of these infections (Magill SS et al., N Engl J Med370:1198-1208, 2014). Among emerging pathogens of public health importance in the United States, CDI has the highest population-based incidence, estimated at 147 per 100,000 (Lessa FC et al., N Engl J Med372:825-834, 2015). In a report on antimicrobial resistance, C. difficile has been categorized by the Centers for Disease Control and Prevention as one of three "urgent" threats (http://www.cdc.gov/drugresistance/threat-report-2013/). Although C. difficile was first described in the late 1970s, the past decade has seen the emergence of hypertoxigenic strains that have caused increased morbidity and mortality worldwide. Pathogenic strains, host susceptibility, and other regional factors vary and may influence the clinical manifestation and approach to intervention. In this article, we describe the global epidemiology of CDI featuring the different strains in circulation outside of North America and Europe where strain NAP1/027/BI/III had originally gained prominence. The elderly population in health care settings has been disproportionately affected, but emergence of CDI in children and healthy young adults in community settings has, likewise, been reported. New approaches in management, including fecal microbiota transplantation, are discussed.
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18
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Kavanagh K, Pan J, Marwick C, Davey P, Wiuff C, Bryson S, Robertson C, Bennie M. Cumulative and temporal associations between antimicrobial prescribing and community-associated Clostridium difficile infection: population-based case-control study using administrative data. J Antimicrob Chemother 2017; 72:1193-1201. [PMID: 27999064 DOI: 10.1093/jac/dkw528] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 11/10/2016] [Indexed: 12/11/2022] Open
Abstract
Background Community-associated Clostridium difficile infection (CA-CDI; defined as cases without prior hospitalization in the previous 12 weeks who were either tested outside of hospital or tested within 2 days of admission to hospital) is a major public health problem. This study estimates the magnitude of the association between temporal and cumulative prescribing of antimicrobials in primary care and CA-CDI. Methods Three national patient-level datasets, covering CDI cases, community prescriptions and hospitalizations, were linked by the NHS Scotland unique patient identifier, the Community Health Index (CHI). All validated cases of CDI from August 2010 to July 2013 were extracted and up to six population-based controls were matched to each case from the CHI register for Scotland. Statistical analysis used conditional logistic regression. Results The 1446 unique cases of CA-CDI were linked with 7964 age-, sex- and location-matched controls. Cumulative exposure to any antimicrobial in the previous 6 months has a monotonic dose-response association with CA-CDI. Individuals with more than 28 DDDs to any antimicrobial (19.9% of cases) had an OR of 4.4 (95% CI 3.4-5.6) compared with those unexposed. Individuals exposed to 29+ DDDs of high-risk antimicrobials (cephalosporins, clindamycin, co-amoxiclav or fluoroquinolones) had an OR of 17.9 (95% CI 7.6-42.2). Elevated CA-CDI risk following high-risk antimicrobial exposure was greatest in the first month (OR = 12.5, 95% CI 8.9-17.4), but was still present 4-6 months later (OR = 2.6, 95% CI 1.7-3.9). Cases exposed to 29+ DDDs had prescription patterns more consistent with repeated therapeutic courses, using different antimicrobials, than long-term prophylactic use. Conclusions This analysis demonstrated temporal and dose-response associations between CA-CDI risk and antimicrobials, with an impact of exposure to high-risk antimicrobials remaining 4-6 months later.
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Affiliation(s)
- Kimberley Kavanagh
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK
- Information Services Division, NHS National Services Scotland, Edinburgh, UK
| | - Jiafeng Pan
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK
| | - Charis Marwick
- Population Health Sciences, School of Medicine, University of Dundee, Dundee, UK
| | - Peter Davey
- Population Health Sciences, School of Medicine, University of Dundee, Dundee, UK
| | - Camilla Wiuff
- Health Protection Scotland, NHS National Services Scotland, Glasgow, UK
| | - Scott Bryson
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Chris Robertson
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK
- Health Protection Scotland, NHS National Services Scotland, Glasgow, UK
- International Prevention Research Institute, Lyon, France
| | - Marion Bennie
- Information Services Division, NHS National Services Scotland, Edinburgh, UK
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
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19
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Tsai CS, Hung YP, Lee JC, Lee NY, Chen PL, Syue LS, Li MC, Li CW, Ko WC. Community-onset Clostridium difficile infection at a tertiary medical center in southern Taiwan, 2007-2015. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2016; 51:243-250. [PMID: 28089100 DOI: 10.1016/j.jmii.2016.08.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 08/22/2016] [Accepted: 08/23/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is well-known as the major cause of infectious diarrhea in hospitalized patients. Community-onset CDI (CO-CDI) is an emerging threat. However, clinical information of CO-CDI in Taiwan remains scarce. METHODS A retrospective study was conducted at a medical center in southern Taiwan. Symptomatic patients between 2007 and 2015 with C. difficile toxin or tcdB detected in stool were identified as CDI, and were classified as CO-CDI [including community-associated CDI (CA-CDI) and community-onset health care facility-associated CDI (CO-HCFA-CDI)] and health care facility-onset CDI (HCFO-CDI). RESULTS Of 427 patients, 15 (3.5%) were CA-CDI, 49 (11.5%) CO-HCFA-CDI, and 363 (85.0%) HCFO-CDI. Despite major involvement of the elderly (mean age: 66.1 years vs. 69.9 years, p = 0.46), no significant differences were noted between CA-CDI and CO-HCFA-CDI groups, except that solid organ cancer was more common in the CO-HCFA-CDI group. The CO-CDI group more often presented with abdominal pain but had shorter hospital stays and less exposure of proton-pump inhibitors or broad-spectrum antibiotics than the HCFO-CDI group did. The mortality rate related to CDI was 4.7% (3 patients) in the CO-CDI group. Despite a lower in-hospital mortality rate in the CO-CDI group (10.9% vs. 22.0%; p = 0.04), the recurrence rate was similar (10.9% vs. 7.2%; p = 0.3). CONCLUSIONS CO-CDI is not common but associated with substantial morbidity and mortality. Physicians should put CDI into consideration among patients who present community-onset fever, diarrhea, or abdominal pain alone or in combination.
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Affiliation(s)
- Chin-Shiang Tsai
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yuan-Pin Hung
- Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan; Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Executive Yuan, Tainan, Taiwan
| | - Jen-Chieh Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Nan-Yao Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan
| | - Po-Lin Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan
| | - Ling-Shan Syue
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ming-Chi Li
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chia-Wen Li
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan.
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20
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Community-acquired Clostridium difficile infections in emergency departments. Med Mal Infect 2016; 46:372-379. [DOI: 10.1016/j.medmal.2016.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 03/27/2016] [Accepted: 06/07/2016] [Indexed: 12/15/2022]
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21
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Miller-Roll T, Na'amnih W, Cohen D, Carmeli Y, Adler A. Molecular types and antimicrobial susceptibility patterns of Clostridium difficile isolates in different epidemiological settings in a tertiary care center in Israel. Diagn Microbiol Infect Dis 2016; 86:450-454. [PMID: 27638350 DOI: 10.1016/j.diagmicrobio.2016.08.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 08/17/2016] [Accepted: 08/22/2016] [Indexed: 01/11/2023]
Abstract
The aims of this prospective study were to examine the correlation between the molecular types and the antimicrobial susceptibility patterns of Clostridium difficile isolates with the source of acquisition and the occurrence of C. difficile infections (CDI) in a tertiary center in Israel. All available isolates from community-acquired (CA) CDI episodes (n=43) and matching numbers of isolates from community-onset, hospital acquired (CO-HA, n=67) and HA-CDI (n=56) and 32 cases of recurrent CDI were typed and tested for susceptibility to vancomycin and metronidazole. The most common types were SlpA hr-02 (21%), SlpA hr-05/PCR-ribotype-014 (12%), PCR-ribotype-027 (10%) and SlpA cr-02 (10%). The PCR-ribotype-027 was most common in the CO-HA group and the hr-05 type was more common in the CA group. Non-susceptibility to metronidazole and/or vancomycin was found in 4/7 of re-infection isolates. Our study shows that CA-CDI is uncommon and is caused by similar strains as HA-CDI, albeit with different rates.
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Affiliation(s)
- Tamar Miller-Roll
- Section of Epidemiology, Tel-Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Wasef Na'amnih
- Section of Epidemiology, Tel-Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dani Cohen
- School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Yehuda Carmeli
- Section of Epidemiology, Tel-Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Amos Adler
- Section of Epidemiology, Tel-Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel.
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22
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Vickers RJ, Tillotson G, Goldstein EJC, Citron DM, Garey KW, Wilcox MH. Ridinilazole: a novel therapy for Clostridium difficile infection. Int J Antimicrob Agents 2016; 48:137-43. [PMID: 27283730 DOI: 10.1016/j.ijantimicag.2016.04.026] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 04/22/2016] [Accepted: 04/23/2016] [Indexed: 12/15/2022]
Abstract
Clostridium difficile infection (CDI) is the leading cause of infectious healthcare-associated diarrhoea. Recurrent CDI increases disease morbidity and mortality, posing a high burden to patients and a growing economic burden to the healthcare system. Thus, there exists a significant unmet and increasing medical need for new therapies for CDI. This review aims to provide a concise summary of CDI in general and a specific update on ridinilazole (formerly SMT19969), a novel antibacterial currently under development for the treatment of CDI. Owing to its highly targeted spectrum of activity and ability to spare the normal gut microbiota, ridinilazole provides significant advantages over metronidazole and vancomycin, the mainstay antibiotics for CDI. Ridinilazole is bactericidal against C. difficile and exhibits a prolonged post-antibiotic effect. Furthermore, treatment with ridinilazole results in decreased toxin production. A phase 1 trial demonstrated that oral ridinilazole is well tolerated and specifically targets clostridia whilst sparing other faecal bacteria. Phase 2 and 3 trials will hopefully further our understanding of the clinical utility of ridinilazole for the treatment of CDI.
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Affiliation(s)
- Richard J Vickers
- Summit Therapeutics plc, 85b Park Drive, Milton Park, Abingdon, Oxford OX14 4RY, UK.
| | | | - Ellie J C Goldstein
- R.M. Alden Research Laboratory, Culver City, CA, USA; David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Kevin W Garey
- University of Houston College of Pharmacy, Houston, TX, USA
| | - Mark H Wilcox
- Microbiology, Leeds Teaching Hospitals and University of Leeds, Old Medical School, Leeds General Infirmary, Leeds, UK
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23
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Fawley WN, Davies KA, Morris T, Parnell P, Howe R, Wilcox MH. Enhanced surveillance of Clostridium difficile infection occurring outside hospital, England, 2011 to 2013. Euro Surveill 2016; 21:30295. [DOI: 10.2807/1560-7917.es.2016.21.29.30295] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 03/18/2016] [Indexed: 12/20/2022] Open
Abstract
There are limited national epidemiological data for community-associated (CA)-Clostridium difficile infections (CDIs). Between March 2011 and March 2013, laboratories in England submitted to the Clostridium difficile Ribotyping Network (CDRN) up to 10 diarrhoeal faecal samples from successive patients with CA-CDI, defined here as C. difficile toxin-positive diarrhoea commencing outside hospital (or less than 48 hours after hospital admission), including those cases associated with community-based residential care, with no discharge from hospital within the previous 12 weeks. Patient demographics and C. difficile PCR ribotypes were compared for CA-CDIs in our study and presumed healthcare-associated (HA) CDIs via CDRN. Ribotype diversity indices, ranking and relative prevalences were very similar in CA- vs HA-CDIs, although ribotypes 002 (p ≤ 0.0001),020 (p = 0.009) and 056 (p < 0.0001) predominated in CA-CDIs; ribotype 027 (p = 0.01) predominated in HA-CDIs. Epidemic ribotypes 027 and 078 predominated in institutional residents with CDI (including care/nursing homes) compared with people with CDI living at home. Ribotype diversity decreased with increasing age in HA-CDIs, but not in CA-CDIs. Ribotype 078 CA-CDIs were significantly more common in elderly people (3.4% (6/174) vs 8.7% (45/519) in those aged < 65 and ≥ 65 years, respectively; p = 0.019). No antibiotics were prescribed in the previous four weeks in about twofold more CA-CDI vs HAs (38.6% (129/334) vs 20.3% (1,226/6,028); p < 0.0001). We found very similar ribotype distributions in CA- and HA-CDIs, although a few ribotypes significantly predominated in one setting. These national data emphasise the close interplay between, and likely common reservoirs for, CDIs, particularly when epidemic strains are not dominant.
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Affiliation(s)
- Warren N Fawley
- Public Health Laboratory Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Kerrie A Davies
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Trefor Morris
- UK Anaerobe Reference Unit (UKARU), Public Health Wales, Cardiff, United Kingdom
| | - Peter Parnell
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Robin Howe
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom
| | - Mark H Wilcox
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
- Public Health Laboratory Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
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24
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Tsai BY, Ko WC, Chen TH, Wu YC, Lan PH, Chen YH, Hung YP, Tsai PJ. Zoonotic potential of the Clostridium difficile RT078 family in Taiwan. Anaerobe 2016; 41:125-130. [PMID: 27292030 DOI: 10.1016/j.anaerobe.2016.06.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 06/06/2016] [Accepted: 06/07/2016] [Indexed: 02/08/2023]
Abstract
Clostridium difficile is the major cause of nosocomial diarrhea. We have previously demonstrated that in southern Taiwan, severe C. difficile-associated diarrhea (CDAD) cases were due to the C. difficile RT 126 strain infection, indicating the arrival of an epidemic C. difficile clone in southern Taiwan. RT126 has a close genetic relationship with RT078. However, the RT078 family is the predominant strain of C. difficile in animals worldwide, particularly in swine. In this study, we surveyed C. difficile strains isolated from swine at several farms in Taiwan from August 2011 to March 2015. We found that all swine strains, namely RT078 (32.5%, 37 of 114), RT126 (28.9%, 33 of 114) and RT127 (37.7%, 43 of 114), belonged to the toxigenic RT078 family. All strains had high gyrA mutation rate (57.9%, 66/114), which was linked to quinolone resistance. Notably, Rep-PCR revealed that 3 RT078 animal strains had the same fingerprint as human RT078 clinical isolates; their phylogenic relationship was closely related to the whole gene sequences of tcdB, thus suggesting zoonotic potential for C. difficile infection in Taiwan.
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Affiliation(s)
- Bo-Yang Tsai
- Department of Microbiology and Immunology, National Cheng Kung University, Medical College, Tainan, Taiwan.
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan.
| | - Ter-Hsin Chen
- Graduate Institute of Veterinary Pathobiology, College of Veterinary Medicine, National Chung Hsing University, Taichung, Taiwan.
| | - Ying-Chen Wu
- Graduate Institute of Veterinary Pathobiology, College of Veterinary Medicine, National Chung Hsing University, Taichung, Taiwan.
| | - Po-Han Lan
- Kaohsiung American School, Kaohsiung, Taiwan.
| | - Yi-Hsuan Chen
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Medical College, Tainan, Taiwan.
| | - Yuan-Pin Hung
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan.
| | - Pei-Jane Tsai
- Department of Microbiology and Immunology, National Cheng Kung University, Medical College, Tainan, Taiwan; Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Medical College, Tainan, Taiwan; Center of Infectious Disease and Signaling Research, National Cheng Kung University, Tainan, Taiwan.
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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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Sentinel community Clostridium difficile infection (CDI) surveillance in Scotland, April 2013 to March 2014. Anaerobe 2016; 37:49-53. [DOI: 10.1016/j.anaerobe.2015.12.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 12/04/2015] [Accepted: 12/15/2015] [Indexed: 02/04/2023]
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Jamal W, Pauline E, Rotimi V. A prospective study of community-associated Clostridium difficile infection in Kuwait: Epidemiology and ribotypes. Anaerobe 2015; 35:28-32. [DOI: 10.1016/j.anaerobe.2015.06.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 06/24/2015] [Accepted: 06/26/2015] [Indexed: 12/16/2022]
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Dantes R, Mu Y, Hicks LA, Cohen J, Bamberg W, Beldavs ZG, Dumyati G, Farley MM, Holzbauer S, Meek J, Phipps E, Wilson L, Winston LG, McDonald LC, Lessa FC. Association Between Outpatient Antibiotic Prescribing Practices and Community-Associated Clostridium difficile Infection. Open Forum Infect Dis 2015; 2:ofv113. [PMID: 26509182 PMCID: PMC4551478 DOI: 10.1093/ofid/ofv113] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 08/03/2015] [Indexed: 01/21/2023] Open
Abstract
A modest, 10% reduction in outpatient antibiotic prescribing among U.S. adults
could result in a substantial 17% reduction in Clostridium
difficile infections that originate in the community. Background. Antibiotic use predisposes patients to
Clostridium difficile infections (CDI), and approximately
32% of these infections are community-associated (CA) CDI. The
population-level impact of antibiotic use on adult CA-CDI rates is not well
described. Methods. We used 2011 active population- and
laboratory-based surveillance data from 9 US geographic locations to identify adult
CA-CDI cases, defined as C difficile-positive stool specimens (by
toxin or molecular assay) collected from outpatients or from patients ≤3 days
after hospital admission. All patients were surveillance area residents and aged
≥20 years with no positive test ≤8 weeks prior and no overnight stay in a
healthcare facility ≤12 weeks prior. Outpatient oral antibiotic prescriptions
dispensed in 2010 were obtained from the IMS Health Xponent database. Regression
models examined the association between outpatient antibiotic prescribing and adult
CA-CDI rates. Methods. Healthcare providers prescribed 5.2
million courses of antibiotics among adults in the surveillance population in 2010,
for an average of 0.73 per person. Across surveillance sites, antibiotic prescription
rates (0.50–0.88 prescriptions per capita) and unadjusted CA-CDI rates
(40.7–139.3 cases per 100 000 persons) varied. In regression modeling, reducing
antibiotic prescribing rates by 10% among persons ≥20 years old was
associated with a 17% (95% confidence interval,
6.0%–26.3%; P = .032) decrease in CA-CDI
rates after adjusting for age, gender, race, and type of diagnostic assay. Reductions
in prescribing penicillins and amoxicillin/clavulanic acid were associated with the
greatest decreases in CA-CDI rates. Conclusions and Relevance. Community-associated
CDI prevention should include reducing unnecessary outpatient antibiotic use. A
modest reduction of 10% in outpatient antibiotic prescribing can have a
disproportionate impact on reducing CA-CDI rates.
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Affiliation(s)
| | - Yi Mu
- Centers for Disease Control and Prevention , Atlanta
| | - Lauri A Hicks
- Centers for Disease Control and Prevention , Atlanta
| | - Jessica Cohen
- Centers for Disease Control and Prevention , Atlanta ; Atlanta Research and Education Foundation, Georgia
| | - Wendy Bamberg
- Colorado Department of Public Health and Environment, Denver
| | | | | | - Monica M Farley
- Emory University , Atlanta ; Atlanta Veterans Affairs Medical Center , Georgia
| | | | - James Meek
- Connecticut Emerging Infections Program , New Haven
| | | | - Lucy Wilson
- Maryland Emerging Infections Program Baltimore ; Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland
| | - Lisa G Winston
- University of California , San Francisco ; San Francisco General Hospital , California
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Ogielska M, Lanotte P, Le Brun C, Valentin AS, Garot D, Tellier AC, Halimi JM, Colombat P, Guilleminault L, Lioger B, Vegas H, De Toffol B, Constans T, Bernard L. Emergence of community-acquired Clostridium difficile infection: the experience of a French hospital and review of the literature. Int J Infect Dis 2015; 37:36-41. [PMID: 26092300 DOI: 10.1016/j.ijid.2015.06.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 06/10/2015] [Accepted: 06/11/2015] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a common cause of nosocomial diarrhoea. People in the general community are not usually considered to be at risk of CDI. CDI is associated with a high risk of morbidity and mortality. The risk of severity is defined by the Clostridium Severity Index (CSI). METHODS The cases of 136 adult patients with CDI treated at the University Hospital of Tours, France between 2008 and 2012 are described. This was a retrospective study. RESULTS Among the 136 patients included, 62 were men and 74 were women. Their median age was 64.4 years (range 18-97 years). Twenty-six of the 136 (19%) cases were community-acquired (CA) and 110 (81%) were healthcare-acquired (HCA). The major risk factors for both groups were long-term treatment with proton pump inhibitors (54% of CA, 53% of HCA patients) and antibiotic treatment within the 2.5 months preceding the CDI (50% of CA, 91% of HCA). The CSI was higher in the CA-CDI group (1.56) than in the HCA-CDI group (1.39). Intensive care was required for 8% of CA-CDI and 16.5% of HCA-CDI patients. CONCLUSIONS CDI can cause community-acquired diarrhoea, and CA-CDI may be more severe than HCA-CDI. Prospective studies of CDI involving people from the general community without risk factors are required to confirm this observation.
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Affiliation(s)
- Maja Ogielska
- Infectious Diseases Department, University Hospital of Tours, 2 boulevard Tonnellé, 37000 Tours, France.
| | | | | | - Anne Sophie Valentin
- Bacteriology and Virology Department of Bretonneau, University Hospital of Tours, France(c)Bacteriology Department of Trousseau, University Hospital of Tours, Tours, France
| | - Denis Garot
- Medical Intensive Care Unit, University Hospital of Tours, Tours, France
| | | | - Jean Michel Halimi
- Kidney Transplant Department, University Hospital of Tours, Tours, France
| | | | | | - Bertrand Lioger
- Internal Medicine Department, University Hospital of Tours, Tours, France
| | - Hélène Vegas
- Oncology Department, University Hospital of Tours, Tours, France
| | | | - Thierry Constans
- Geriatric Medicine Department, University Hospital of Tours, Tours, France
| | - Louis Bernard
- Infectious Diseases Department, University Hospital of Tours, 2 boulevard Tonnellé, 37000 Tours, France
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Levy AR, Szabo SM, Lozano-Ortega G, Lloyd-Smith E, Leung V, Lawrence R, Romney MG. Incidence and Costs of Clostridium difficile Infections in Canada. Open Forum Infect Dis 2015; 2:ofv076. [PMID: 26191534 PMCID: PMC4503917 DOI: 10.1093/ofid/ofv076] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 06/01/2015] [Indexed: 12/18/2022] Open
Abstract
Background. Limited data are available on direct medical costs and lost productivity due to Clostridium difficile infection (CDI) in Canada. Methods. We developed an economic model to estimate the costs of managing hospitalized and community-dwelling patients with CDI in Canada. The number of episodes was projected based on publicly available national rates of hospital-associated CDI and the estimate that 64% of all CDI is hospital-associated. Clostridium difficile infection recurrences were classified as relapses or reinfections. Resource utilization data came from published literature, clinician interviews, and Canadian CDI surveillance programs, and this included the following: hospital length of stay, contact with healthcare providers, pharmacotherapy, laboratory testing, and in-hospital procedures. Lost productivity was considered for those under 65 years of age, and the economic impact was quantified using publicly available labor statistics. Unit costs were obtained from published sources and presented in 2012 Canadian dollars. Results. There were an estimated 37 900 CDI episodes in Canada in 2012; 7980 (21%) of these were relapses, out of a total of 10 900 (27%) episodes of recurrence. The total cost to society of CDI was estimated at $281 million; 92% ($260 million) was in-hospital costs, 4% ($12 million) was direct medical costs in the community, and 4% ($10 million) was due to lost productivity. Management of CDI relapses alone accounted for $65.1 million (23%). Conclusions. The largest proportion of costs due to CDI in Canada arise from extra days of hospitalization. Interventions reducing the severity of infection and/or relapses leading to rehospitalizations are likely to have the largest absolute effect on direct medical costs.
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Affiliation(s)
- Adrian R Levy
- Department of Community Health and Epidemiology , Dalhousie University , Halifax, Nova Scotia , Canada ; Oxford Outcomes Ltd , Vancouver , Canada
| | - Shelagh M Szabo
- Department of Community Health and Epidemiology , Dalhousie University , Halifax, Nova Scotia , Canada
| | - Greta Lozano-Ortega
- Department of Community Health and Epidemiology , Dalhousie University , Halifax, Nova Scotia , Canada
| | - Elisa Lloyd-Smith
- St Paul's Hospital, Providence Health Care , Vancouver, British Columbia , Canada
| | - Victor Leung
- St Paul's Hospital, Providence Health Care , Vancouver, British Columbia , Canada ; University of British Columbia , Vancouver , Canada
| | | | - Marc G Romney
- St Paul's Hospital, Providence Health Care , Vancouver, British Columbia , Canada ; University of British Columbia , Vancouver , Canada
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Wozniak TM, Rubin G, Raina MacIntyre C. The emergence of community-acquired Clostridium difficile in an Australian hospital. ACTA ACUST UNITED AC 2015. [DOI: 10.1071/hi15003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Excess Length of Stay Attributable to Clostridium difficile Infection (CDI) in the Acute Care Setting: A Multistate Model. Infect Control Hosp Epidemiol 2015; 36:1024-30. [PMID: 26006153 DOI: 10.1017/ice.2015.132] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Standard estimates of the impact of Clostridium difficile infections (CDI) on inpatient lengths of stay (LOS) may overstate inpatient care costs attributable to CDI. In this study, we used multistate modeling (MSM) of CDI timing to reduce bias in estimates of excess LOS. METHODS A retrospective cohort study of all hospitalizations at any of 120 acute care facilities within the US Department of Veterans Affairs (VA) between 2005 and 2012 was conducted. We estimated the excess LOS attributable to CDI using an MSM to address time-dependent bias. Bootstrapping was used to generate 95% confidence intervals (CI). These estimates were compared to unadjusted differences in mean LOS for hospitalizations with and without CDI. RESULTS During the study period, there were 3.96 million hospitalizations and 43,540 CDIs. A comparison of unadjusted means suggested an excess LOS of 14.0 days (19.4 vs 5.4 days). In contrast, the MSM estimated an attributable LOS of only 2.27 days (95% CI, 2.14-2.40). The excess LOS for mild-to-moderate CDI was 0.75 days (95% CI, 0.59-0.89), and for severe CDI, it was 4.11 days (95% CI, 3.90-4.32). Substantial variation across the Veteran Integrated Services Networks (VISN) was observed. CONCLUSIONS CDI significantly contributes to LOS, but the magnitude of its estimated impact is smaller when methods are used that account for the time-varying nature of infection. The greatest impact on LOS occurred among patients with severe CDI. Significant geographic variability was observed. MSM is a useful tool for obtaining more accurate estimates of the inpatient care costs of CDI.
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Impact of clinical awareness and diagnostic tests on the underdiagnosis of Clostridium difficile infection. Eur J Clin Microbiol Infect Dis 2015; 34:1515-25. [PMID: 25904126 DOI: 10.1007/s10096-015-2380-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 03/31/2015] [Indexed: 12/18/2022]
Abstract
A multicenter study of Clostridium difficile infection (CDI) performed during 2008 in Spain revealed that two of every three episodes went undiagnosed or were misdiagnosed owing to nonsensitive diagnostic tests or lack of clinical suspicion and request. Since then, efforts have been made to improve the diagnostic tests used by laboratories and to increase the awareness of this disease among both clinicians and microbiologists. Our objective was to evaluate the impact of these efforts by assessing the current magnitude of underdiagnosis of CDI in Spain using two point-prevalence studies performed on one day each in January and July of 2013. A total of 111 Spanish laboratories selected all unformed stool specimens received for microbiological diagnosis on these days, and toxigenic culture was performed at a central reference laboratory. Toxigenic isolates were characterized both pheno- and genotypically. The reference laboratory detected 103 episodes of CDI in patients aged 2 years or more. Half (50.5 %) of the episodes were not diagnosed in the participating laboratories, owing to insensitive diagnostic tests (15.5 %) or the lack of clinical suspicion and request (35.0 %). The main ribotypes were 014, 078/126, 001/072, and 106. Ribotype 027 caused 2.9 % of all cases. Despite all the interventions undertaken, CDI remains a highly neglected disease because of the lack of sensitive diagnostic tests in some institutions and, especially, the absence of clinical suspicion, mainly in patients with community-associated CDI. Toxigenic C. difficile should be routinely sought in unformed stools sent for microbiological diagnosis, regardless of their origin.
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Kociolek LK, Gerding DN. Is pediatric Clostridium difficile infection associated with prior antibiotic exposure? Future Microbiol 2015; 9:825-8. [PMID: 25156370 DOI: 10.2217/fmb.14.51] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Larry K Kociolek
- Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Gerding DN, Lessa FC. The epidemiology of Clostridium difficile infection inside and outside health care institutions. Infect Dis Clin North Am 2015; 29:37-50. [PMID: 25582647 PMCID: PMC10924674 DOI: 10.1016/j.idc.2014.11.004] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
This article describes the global changes in Clostridium difficile epidemiology since the late twentieth century and into the twenty-first century when the new epidemic strain BI/NAP1/027 emerged. The article provides an overview of how understanding of C difficile epidemiology has rapidly evolved since its initial association with colitis in 1974. It also discusses how C difficile has spread across the globe, the role of asymptomatic carriers in disease transmission, the increased recognition of C difficile outside health care settings, the changes in epidemiology of C difficile infection in children, and the risk factors for disease.
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Affiliation(s)
- Dale N Gerding
- Department of Medicine, Loyola University Chicago Stritch School of Medicine, 2160 S 1st Avenue, Maywood, IL 60153, USA; Research Service, Edward Hines, Jr. Veterans Affairs Hospital, 5000 South Fifth Avenue, Building 1, Room 347, Hines, IL 60141, USA.
| | - Fernanda C Lessa
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329, USA
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Pitz AM, Park GW, Lee D, Boissy YL, Vinjé J. Antimicrobial activity of bismuth subsalicylate on Clostridium difficile, Escherichia coli O157:H7, norovirus, and other common enteric pathogens. Gut Microbes 2015; 6:93-100. [PMID: 25901890 PMCID: PMC4615802 DOI: 10.1080/19490976.2015.1008336] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 10/30/2014] [Accepted: 01/08/2015] [Indexed: 02/03/2023] Open
Abstract
Previous studies have shown bismuth subsalicylate (BSS) has antimicrobial properties, but few studies have addressed the mechanism of action. Furthermore, following BSS ingestion other bismuth salts form throughout the gastrointestinal tract including bismuth oxychloride (BiOCl) that also act upon enteric pathogens. To further understand the antimicrobial activity of bismuth in infectious diarrhea, the antimicrobial effect of BSS and BiOCl on Clostridium difficile, Salmonella, Shigella, Shiga toxin-producing Escherichia coli strains and norovirus (NoV) were measured. Bacterial enteric pathogens in pure culture or in human fecal material were exposed to 35mg/ml BSS or BiOCl with or without a vehicle suspension. BSS and BiOCl treated samples were quantified and visualized by transmission electron microscopy. To measure the effect on NoV, reduction of infectious murine NoV (MNV), a surrogate for human NoV, and Norwalk virus RNA levels were measured by viral plaque assay and RT-qPCR, respectively. BSS and BiOCl reduced bacterial growth by 3-9 logs in all strains with majority resulting in populations of <10 cfu/ml within 24 h. Similar results were found when fecal material was included. Microscopy images detected bismuth on bacterial membranes and within the bacterial organisms at 30 min post-treatment. At 8.8mg/ml BSS and BiOCl reduced infectivity of MNV significantly by 2.7 and 2.0 log after 24 h of exposure. In addition, both BSS and BiOCl slightly reduced the level of Norwalk replicon-bearing cells suggesting that bismuth may inhibit NoV in vivo. Collectively, our results confirm and build on existing data that BSS has antimicrobial properties against a wide-range of diarrhea-causing pathogens.
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Key Words
- BSS, bismuth subsalicylate
- BiOCl, bismuth oxychloride
- Clostridium difficile
- ETEC, enterotoxigenic Eschericia coli
- Escherichia coli
- GI, gastrointestinal
- MIC, minimum inhibitory concentration
- MNV, murine norovirus
- NoV, norovirus
- SS, sodium salicylate
- Salmonella
- Shigella
- TD, traveler's diarrhea
- TEM, transmission electron microscopy
- bismuth oxychloride
- bismuth subsalicylate
- diarrhea
- enteric pathogens
- norovirus
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Affiliation(s)
| | - Geun Woo Park
- Division of Viral Diseases; Centers for Disease Control and Prevention; Atlanta, GA USA
| | - David Lee
- Division of Viral Diseases; Centers for Disease Control and Prevention; Atlanta, GA USA
- Atlanta Research & Education Foundation (AREF); Atlanta, GA USA
| | | | - Jan Vinjé
- Division of Viral Diseases; Centers for Disease Control and Prevention; Atlanta, GA USA
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Smith AM, Wuerth BA, Wiemken TL, Arnold FW. Prevalence of Clostridium difficile infection presenting to US EDs. Am J Emerg Med 2014; 33:238-43. [PMID: 25488337 DOI: 10.1016/j.ajem.2014.11.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 11/07/2014] [Accepted: 11/20/2014] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE The objective of the study is to determine the prevalence of Clostridium difficile infection (CDI) presenting to emergency departments (EDs) in the United States. Secondary objectives included defining the burden of CDI. METHODS This is a retrospective, observational cohort study of 2006-2010 Nationwide Emergency Department Sample database of 980 US hospital EDs in 29 states. Prevalence, mortality rate, length of stay, hospital charges, and endemicity were measured. RESULTS A total of 474513 patients with CDI-related ED visits were identified. From 2006 to 2010, the prevalence of CDI increased from 26.2 to 33.1 per 100,000 population (P<.001). The number of CDI-related ED cases increased 26.1% (P<.001) over the study period: 18.6% from 2006 to 2007 (P<.001), 4.3% from 2007 to 2008 (P=.46), 1.8% from 2008 to 2009 (P=.73), and 0.13% from 2009 to 2010 (P=.95). Emergency department visits occurred more frequently with individuals 85 years or older (relative risk [RR], 13.74; P<.001), females (RR, 1.77; P<.001) and in the northeast United States (RR, 1.42; P<.001). From 2009 to 2010, the mortality rate decreased 17.9% (P=.01). CONCLUSIONS The prevalence of CDI presenting to EDs increased each year from 2006 to 2010; however, the rate of increase slowed from each year to the next. The mortality rate increased from 2006 to 2009 and decreased significantly from 2009 to 2010. C difficile infection visits presenting to EDs occurred more frequently with older individuals, females, and in the northeast.
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Affiliation(s)
- Aaron M Smith
- School of Medicine, University of Louisville, Louisville, KY, USA
| | - Brandon A Wuerth
- School of Medicine, University of Louisville, Louisville, KY, USA
| | - Timothy L Wiemken
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Forest W Arnold
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of Louisville, Louisville, KY, USA.
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Increasing hospitalizations in inflammatory bowel disease among children in the United States, 1988-2011. Inflamm Bowel Dis 2014. [PMID: 25185689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND Our objective was to characterize national trends in inflammatory bowel disease (IBD)-related hospitalizations for children. We hypothesized that over time, improvements in care would be associated with a decrease in hospitalization rates, similar to what has been observed in Canadian children with IBD. METHODS Retrospective, serial, cross-sectional analysis of annual, nationally representative samples of children with IBD. RESULTS Overall, discharges for all children irrespective of diagnosis decreased from 1988 to 2011 (P for trend <0.001). In contrast, discharges for children with IBD rose over the same time period from 6.1 (95% confidence interval [CI], 4.0-8.2) to 8.2 (95% CI, 5.5-10.9) per 100,000 individuals per year (P for trend <0.001). More of this rise occurred in hospitalizations that did not have IBD-related endoscopy or surgery performed (P for trend <0.001). Although mean length of stay decreased over the study period (P for trend <0.001), total hospital days increased over the latter half of the study with a significant increase over the entire study period (P for trend <0.001). CONCLUSIONS Contrary to clinically informed hypotheses, nationally representative rates of hospitalization for pediatric patients with IBD have increased since the mid-1990s. This directly contrasts with stable rates over the preceding years. Most of the expansion in hospital care seems to be related to hospitalizations that do not include procedures. Several lines of future research may greatly facilitate a better understanding of the epidemiologic, therapeutic, and health care resource issues at play.
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Abstract
BACKGROUND Our objective was to characterize national trends in inflammatory bowel disease (IBD)-related hospitalizations for children. We hypothesized that over time, improvements in care would be associated with a decrease in hospitalization rates, similar to what has been observed in Canadian children with IBD. METHODS Retrospective, serial, cross-sectional analysis of annual, nationally representative samples of children with IBD. RESULTS Overall, discharges for all children irrespective of diagnosis decreased from 1988 to 2011 (P for trend <0.001). In contrast, discharges for children with IBD rose over the same time period from 6.1 (95% confidence interval [CI], 4.0-8.2) to 8.2 (95% CI, 5.5-10.9) per 100,000 individuals per year (P for trend <0.001). More of this rise occurred in hospitalizations that did not have IBD-related endoscopy or surgery performed (P for trend <0.001). Although mean length of stay decreased over the study period (P for trend <0.001), total hospital days increased over the latter half of the study with a significant increase over the entire study period (P for trend <0.001). CONCLUSIONS Contrary to clinically informed hypotheses, nationally representative rates of hospitalization for pediatric patients with IBD have increased since the mid-1990s. This directly contrasts with stable rates over the preceding years. Most of the expansion in hospital care seems to be related to hospitalizations that do not include procedures. Several lines of future research may greatly facilitate a better understanding of the epidemiologic, therapeutic, and health care resource issues at play.
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Clostridium difficile-induced colitis in mice is independent of leukotrienes. Anaerobe 2014; 30:90-8. [PMID: 25230329 DOI: 10.1016/j.anaerobe.2014.09.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 09/04/2014] [Accepted: 09/07/2014] [Indexed: 02/03/2023]
Abstract
Clostridium difficile is the major cause of antibiotic-associated diarrhea and pseudomembranous colitis in healthcare settings. However, the host factors involved in the intestinal inflammatory response and pathogenesis of C. difficile infection (CDI) are largely unknown. Here we investigated the role of leukotrienes (LTs), a group of pro-inflammatory lipid mediators, in CDI. Notably, the neutrophil chemoattractant LTB4, but not cysteinyl (cys) LTs, was induced in the intestine of C57BL/6 mice infected with either C. difficile strain VPI 10463 or strain 630. Genetic or pharmacological ablation of LT production did not ameliorate C. difficile colitis or clinical signs of disease in infected mice. Histological analysis demonstrated that intestinal neutrophilic inflammation, edema and tissue damage in mice during acute and severe CDI were not modulated in the absence of LTs. In addition, CDI induced a burst of cytokines in the intestine of infected mice in a LT-independent manner. Serum levels of anti-toxin A immunoglobulin (Ig) G levels were also not modulated by endogenous LTs. Collectively, our results do not support a role for LTs in modulating host susceptibility to CDI in mice.
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Abstract
There has been dramatic change in the epidemiology of Clostridium difficile infection (CDI) since the turn of the 21st century noted by a marked increase in incidence and severity, occurring at a disproportionately higher frequency in older patients. Historically considered a nosocomial infection associated with antibiotic exposure, CDI has now also emerged in the community in populations previously considered low risk. Emerging risk factors and disease recurrence represent continued challenges in the management of CDI. The increased incidence and severity associated with CDI has coincided with the emergence and rapid spread of a previously rare strain, ribotype 027. Recent data from the United States and Europe suggest that the incidence of CDI may have reached a crescendo in the recent years and is perhaps beginning to plateau. The acute care direct costs of CDI were estimated to be US$4.8 billion in 2008. However, nearly all the published studies have focused on CDI diagnosed and treated in the acute care hospital setting and fail to measure the burden outside the hospital, including recently discharged patients, outpatients, and those in long-term care facilities. Enhanced surveillance methods are needed to monitor the incidence, to identify populations at risk, and to characterize the molecular epidemiology of strains causing CDI.
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42
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Gupta A, Khanna S. Community-acquired Clostridium difficile infection: an increasing public health threat. Infect Drug Resist 2014; 7:63-72. [PMID: 24669194 PMCID: PMC3962320 DOI: 10.2147/idr.s46780] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
There has been a startling shift in the epidemiology of Clostridium difficile infection over the last decade worldwide, and it is now increasingly recognized as a cause of diarrhea in the community. Classically considered a hospital-acquired infection, it has now emerged in populations previously considered to be low-risk and lacking the traditional risk factors for C. difficile infection, such as increased age, hospitalization, and antibiotic exposure. Recent studies have demonstrated great genetic diversity for C. difficile, pointing toward diverse sources and a fluid genome. Environmental sources like food, water, and animals may play an important role in these infections, apart from the role symptomatic patients and asymptomatic carriers play in spore dispersal. Prospective strain typing using highly discriminatory techniques is a possible way to explore the suspected diverse sources of C. difficile infection in the community. Patients with community-acquired C. difficile infection do not necessarily have a good outcome and clinicians should be aware of factors that predict worse outcomes in order to prevent them. This article summarizes the emerging epidemiology, risk factors, and outcomes for community-acquired C. difficile infection.
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Affiliation(s)
- Arjun Gupta
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Sahil Khanna
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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43
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Le Guern R, Herwegh S, Courcol R, Wallet F. Molecular methods in the diagnosis ofClostridium difficileinfections: an update. Expert Rev Mol Diagn 2014; 13:681-92. [DOI: 10.1586/14737159.2013.829705] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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44
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Tan X, Verrall A, Jureen R, Riley T, Collins D, Lin R, Balm M, Chan D, Tambyah P. The emergence of community-onset Clostridium difficile infection in a tertiary hospital in Singapore: A cause for concern. Int J Antimicrob Agents 2014; 43:47-51. [DOI: 10.1016/j.ijantimicag.2013.09.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 09/15/2013] [Accepted: 09/17/2013] [Indexed: 01/05/2023]
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45
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Abstract
There has been dramatic change in the epidemiology of Clostridium difficile infection (CDI) since the turn of the 21st century noted by a marked increase in incidence and severity, occurring at a disproportionately higher frequency in older patients. Historically considered a nosocomial infection associated with antibiotic exposure, CDI has now also emerged in the community in populations previously considered low risk. Emerging risk factors and disease recurrence represent continued challenges in the management of CDI. The increased incidence and severity associated with CDI has coincided with the emergence and rapid spread of a previously rare strain, ribotype 027. Recent data from the United States and Europe suggest that the incidence of CDI may have reached a crescendo in the recent years and is perhaps beginning to plateau. The acute care direct costs of CDI were estimated to be US$4.8 billion in 2008. However, nearly all the published studies have focused on CDI diagnosed and treated in the acute care hospital setting and fail to measure the burden outside the hospital, including recently discharged patients, outpatients, and those in long-term care facilities. Enhanced surveillance methods are needed to monitor the incidence, to identify populations at risk, and to characterize the molecular epidemiology of strains causing CDI.
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Affiliation(s)
- Daryl D. DePestel
- Clinical Scientific Director, Medical Affairs, Cubist Pharmaceuticals, Inc., 65 Hayden Ave, Lexington, MA 02421
| | - David M. Aronoff
- Division of Infectious Diseases, Department of Internal Medicine, Department of Microbiology & Immunology, University of Michigan Medical School, Ann Arbor, MI, 48109
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46
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Abstract
Clostridium difficile infection, the most frequent cause of nosocomial diarrhea, disproportionately affects older adults. The two most important risk factors for developing C. difficile infection are antimicrobial exposure and age >65 years old. Risk factors specific to older adults are frequent interactions with healthcare systems and age-related changes in physiology, including immune senescence and changes to the gut microbiome. Metronidazole and oral vancomcyin are the mainstays of conventional treatment for C. difficile infection. Alternative therapies include fidaxomicin, a narrow-spectrum macrocyclic antibiotic, and fectal bacteriotherapy, which offers an excellent therapeutic outcome. Strategies to prevent C. difficile infections include enhanced infection control measures and reducing inappropriate antimicrobial use through stewardship.
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Affiliation(s)
- Robin LP Jump
- Geriatric Research Education & Clinical Center & Infectious Diseases Section, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, 10701 East Blvd, Cleveland, OH 44106, USA
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Jury LA, Sitzlar B, Kundrapu S, Cadnum JL, Summers KM, Muganda CP, Deshpande A, Sethi AK, Donskey CJ. Outpatient healthcare settings and transmission of Clostridium difficile. PLoS One 2013; 8:e70175. [PMID: 23894609 PMCID: PMC3722238 DOI: 10.1371/journal.pone.0070175] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 06/15/2013] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Recent reports suggest that community-associated Clostridium difficile infection (CDI) (i.e., no healthcare facility admission within 90 days) may be increasing in frequency. We hypothesized that outpatient clinics could be an important source for acquisition of community-associated CDI. METHODS We performed a 6-month prospective study of CDI patients to determine frequency of and risk factors for skin and environmental shedding during outpatient visits and to derive a prediction rule for positive cultures. We performed a point-prevalence culture survey to assess the frequency of C. difficile contamination in outpatient settings and evaluated the frequency of prior outpatient visits in patients with community-associated CDI. RESULTS Of 67 CDI patients studied, 54 (81%) had 1 or more outpatient visits within 12 weeks after diagnosis. Of 44 patients cultured during outpatient visits, 14 (32%) had skin contamination and 12 (27%) contaminated environmental surfaces. Decreased mobility, fecal incontinence, and treatment with non-CDI antibiotics were associated with positive cultures, whereas vancomycin taper therapy was protective. In patients not on CDI therapy, a prediction rule including incontinence or decreased mobility was 90% sensitive and 79% specific for detection of spore shedding. Of 84 clinic and emergency department rooms cultured, 12 (14%) had 1 or more contaminated environmental sites. For 33 community-associated CDI cases, 31 (94%) had an outpatient visit during the 12 weeks prior to onset of diarrhea. CONCLUSIONS Patients with recent CDI present a significant risk for transmission of spores during outpatient visits. The outpatient setting may be an underappreciated source of community-associated CDI cases.
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Affiliation(s)
- Lucy A. Jury
- Geriatric Research Education and Clinical Center, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, United States of America
| | - Brett Sitzlar
- Geriatric Research Education and Clinical Center, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, United States of America
| | - Sirisha Kundrapu
- Division of Infectious Diseases, Department of Medicine, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Jennifer L. Cadnum
- Division of Infectious Diseases, Department of Medicine, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Kim M. Summers
- Research Service, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, United States of America
| | - Christine P. Muganda
- Department of Population Health Sciences, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Abhishek Deshpande
- Division of Infectious Diseases, Department of Medicine, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Ajay K. Sethi
- Department of Population Health Sciences, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Curtis J. Donskey
- Geriatric Research Education and Clinical Center, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, United States of America
- Division of Infectious Diseases, Department of Medicine, Case Western Reserve University, Cleveland, Ohio, United States of America
- * E-mail:
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Are there reasons to prefer tetracyclines to macrolides in older patients with community-acquired pneumonia? Antimicrob Agents Chemother 2013; 57:4093. [PMID: 23858063 DOI: 10.1128/aac.00828-13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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49
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Marwick CA, Yu N, Lockhart MC, McGuigan CC, Wiuff C, Davey PG, Donnan PT. Community-associated Clostridium difficile infection among older people in Tayside, Scotland, is associated with antibiotic exposure and care home residence: cohort study with nested case-control. J Antimicrob Chemother 2013; 68:2927-33. [PMID: 23825381 DOI: 10.1093/jac/dkt257] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES To estimate the risks of community-associated Clostridium difficile infection (CA-CDI) among the population aged ≥ 65 years associated with antibiotic exposure and care home residence. POPULATION AND METHODS We linked cases from a prospective study in Tayside, Scotland from 1 November 2008 to 31 October 2009 to population datasets to conduct a cohort study and a nested, matched (1 : 10 by age and gender) case-control study. RESULTS There were 79,039 eligible residents. CA-CDI incidence was 20.3/10,000 person years. In the cohort study, after adjustment, we found a significantly increasing risk of CA-CDI with increasing age and comorbidity, prior hospital admission, care home residence [hazard ratio (HR) 1.96, 95% CI 1.14-3.34] and baseline antibiotic exposure (1.94, 1.35-2.77). In separate adjusted models, '4C' antibiotics (clindamycin, co-amoxiclav, cephalosporins, ciprofloxacin; 2.75, 1.78-4.26) and fluoroquinolones (3.33, 1.95-5.67) had higher associated risks. We matched 62 CA-CDI cases without recent (prior 3 months) hospital admission to 620 controls. In adjusted logistic regression models, exposure to any antibiotics increased the risk of CA-CDI (OR 6.04, 95% CI 3.19-11.43). Exposure to 4C antibiotics or fluoroquinolones had higher associated risks: adjusted OR 11.60 (95% CI 5.57-24.15) and 13.04 (4.91-34.64), respectively. Risk of CA-CDI increased with cumulative antibiotic exposure. Subgroup analysis of 42 cases with C. difficile cultured and 420 controls amplified all associations between antibiotic exposure and CA-CDI. Care home residence independently increased the risk of CA-CDI in all models. CONCLUSIONS Our results have two important implications. First, they validate the classification of 4C antibiotics and fluoroquinolones in primary care as high risk for CA-CDI. Second, they demonstrate the importance of prior antibiotic exposure and place of residence for risk assessment by primary care prescribers.
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Affiliation(s)
- Charis A Marwick
- Population Health Sciences Division, Medical Research Institute, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK
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50
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Lamps L. PCR vs "PCAren't": limitations of PCR-based assays performed on formalin-fixed, paraffin-embedded mucosal biopsy specimens. Am J Clin Pathol 2013; 139:705-7. [PMID: 23690111 DOI: 10.1309/ajcpwfn9d0egdeuk] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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