1
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Kim J, Kim B, Pai H. Diversity of binary toxin positive Clostridioides difficile in Korea. Sci Rep 2023; 13:576. [PMID: 36631661 PMCID: PMC9834304 DOI: 10.1038/s41598-023-27768-0] [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: 08/18/2022] [Accepted: 01/06/2023] [Indexed: 01/13/2023] Open
Abstract
The objective of this study is to determine the trend and diversity of binary toxin-positive Clostridioides difficile over 10 years in Korea. Binary toxin-positive strains were selected from a tertiary hospital in Korea in 2009-2018. The multi-locus sequence typing and antibiotic susceptibility test were performed. Among the 3278 isolates in 2009-2018, 58 possessed binary toxin genes (1.7%). The proportion of CDT- positive isolates was 0.51-4.82% in 2009-2018, which increased over the 10-year period (P = 0.023). Thirteen sequence types (STs) were identified; ST5 (14 [24%]), ST11 (11 [19%]), ST221 (10 [17%]), ST201 (7 [12%]) and ST1 (5 [9%]) were popular. All 58 isolates were susceptible to vancomycin and piperacillin/tazobactam, and clindamycin and moxifloxacin were active in 69.0% and 62% of isolates, respectively. ST1 strains were resistant to several antibiotics, including moxifloxacin (80%), clindamycin (60%) and rifaximin (60%). Moreover, four of five ST1 presented a metronidazole minimum inhibitory concentration of 4 µg/mL. Moxifloxacin resistance was highest (72.3%) for ST11. In conclusion, binary toxin-positive strains are non-prevalent in Korea and involve diverse STs. ST1 strains were resistant to several antibiotics.
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Affiliation(s)
- Jieun Kim
- grid.49606.3d0000 0001 1364 9317Division of Infectious Diseases, Department of Internal Medicine, Hanyang University College of Medicine, 222-1 Wangsimni-Ro, Seongdong-Gu, Seoul, 04763 Korea
| | - Bongyoung Kim
- grid.49606.3d0000 0001 1364 9317Division of Infectious Diseases, Department of Internal Medicine, Hanyang University College of Medicine, 222-1 Wangsimni-Ro, Seongdong-Gu, Seoul, 04763 Korea
| | - Hyunjoo Pai
- Division of Infectious Diseases, Department of Internal Medicine, Hanyang University College of Medicine, 222-1 Wangsimni-Ro, Seongdong-Gu, Seoul, 04763, Korea.
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2
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A nationwide study of molecular epidemiology and antimicrobial susceptibility of Clostridioides difficile in South Korea. Anaerobe 2019; 60:102106. [DOI: 10.1016/j.anaerobe.2019.102106] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 09/09/2019] [Accepted: 10/01/2019] [Indexed: 02/07/2023]
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3
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Metronidazole therapy as initial treatment of Clostridium difficile infection in patients with chronic kidney disease in Korea. Epidemiol Infect 2019; 147:e289. [PMID: 31607272 PMCID: PMC6805788 DOI: 10.1017/s0950268819001742] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The risk of metronidazole treatment failure in Clostridium difficile infection (CDI) patients with chronic kidney disease (CKD) or end-stage renal disease in Korea has not been established. We evaluated 481 patients who had been admitted to two secondary hospitals with a diagnosis of, and treatment for, CDI during 2010–2016. CDI patients were divided into three groups according to CKD status: non-CKD (n = 363), CKD (n = 55) and those requiring dialysis (n = 63). Logistic regression analyses were performed to examine the association of CKD status with treatment failure. CDI patients receiving dialysis tended to have increased odds of metronidazole and overall treatment failure compared to non-CKD patients; adjusted odds ratios and 95% confidence intervals were 2.09 (1.03–4.21) and 2.18 (1.11–4.32) for metronidazole and overall treatment failure, respectively. However, CKD patients did not have increased odds of metronidazole or overall treatment failure compared to non-CKD patients, even where severe CDI was more prevalent in CKD patients. The incidence of symptomatic ileus or toxic megacolon did not differ among groups. Our results suggest that initial metronidazole therapy may be considered in CDI patients with non-dialysis CKD, but should not be considered in CDI patients undergoing dialysis.
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Lee E, Song KH, Bae JY, Yoon D, Hwang JH, Choe PG, Park WB, Bang JH, Kim ES, Park SW, Kim NJ, Oh MD, Kim HB. Risk factors for poor outcome in community-onset Clostridium difficile infection. Antimicrob Resist Infect Control 2018; 7:75. [PMID: 29946450 PMCID: PMC6003152 DOI: 10.1186/s13756-018-0365-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 06/04/2018] [Indexed: 01/19/2023] Open
Abstract
Background A substantial portion of Clostridium difficile infection (CDI) cases occur in communities, and community-onset CDI (CO-CDI) can lead to serious complications including mortality. This study aimed to identify the risk factors for a poor outcome in CO-CDI. Methods We performed a retrospective review of all inpatients with CDI, in a 1300-bed tertiary-care hospital in Korea, from 2008 through 2015. CO-CDI was defined as CDI occurring within 48 h of admission. Poor outcome was defined as follows: 1) all-cause 30-day mortality, 2) in-hospital mortality, or 3) surgery due to CDI. Results Of a total 1256 CDIs occurring over 8 years, 152 (12.1%) cases were classified as CO-CDI and 23 (15.1%) had a poor outcome, including 22 (14.5%) cases of mortality and 2 (1.3%) cases of surgery. Patients with a poor outcome had a higher mean age than those without a poor outcome (75.8 vs. 69.6 years, p = 0.03). The proportion of men and prior proton pump inhibitor (PPI) use were significantly higher in the poor outcome group (65.2% vs. 41.9%, p = 0.04; 39.1% vs. 17.6%, p = 0.02, respectively). Multivariate binary logistic model showed that PPI use and anemia (hemoglobin < 10 g/dL) at presentation were significantly associated with a poor outcome (adjusted odds ratio [aOR], 3.76; 95% confidence interval [95CI], 1.26-11.21, aOR, 4.67; 95CI, 1.52-14.34, respectively). Conclusions Clinicians should not only be aware of the possibility of CDI in the community setting but also pay more attention to PPI-using elderly patients with anemia in consideration of a poor outcome.
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Affiliation(s)
- Eunyoung Lee
- 1Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 463-707 Republic of Korea.,2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyoung-Ho Song
- 1Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 463-707 Republic of Korea.,2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Yun Bae
- 2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Doran Yoon
- 2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Joo-Hee Hwang
- 2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Pyoeng Gyun Choe
- 2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Wan Beom Park
- 2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Hwan Bang
- 2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eu Suk Kim
- 1Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 463-707 Republic of Korea.,2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sang Won Park
- 2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Nam Joong Kim
- 2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Myoung-Don Oh
- 2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hong Bin Kim
- 1Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam, 463-707 Republic of Korea.,2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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5
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Lee JY, Lee DY, Cho YS. Prevalence of Clostridium difficile isolated from various raw meats in Korea. Food Sci Biotechnol 2018; 27:883-889. [PMID: 30263815 PMCID: PMC6049684 DOI: 10.1007/s10068-018-0318-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 01/03/2018] [Accepted: 01/10/2018] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile is an anaerobic, toxin-producing pathogen that causes human infection possibly through the consumption of meat. Clostridium difficile was isolated from 45 of 415 (10.8%) various raw meat samples collected in nationwide markets in Korea between 2013 and 2014. Among the 45 isolated strains, the highest prevalence rate was found in September (28.6%) and detected in chicken (16.4%), pork (8.3%) and beef (6.8%). According to an antibiotic resistance test, resistance was found only for clindamycin (2.2%). The genetic similarity of ribotypes O78 and O27 and strains isolated from raw meats was determined using DiversiLab. Among the isolates studied, four different rep-PCR types were identified, genetically distinct from ribotypes O78 and O27. An ELISA reaction confirmed that the two strains have toxin A and toxin B and showed 89% genetic similarity. This study suggests that food animals could be potential routes of foodborne transmission in C. difficile-associated human infection.
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Affiliation(s)
- Joo Young Lee
- Food Analysis Center, Korea Food Research Institute, 245, Nongsaengmyeong-ro, Iseo-myeon, Wanju-gun, Jeollabuk-do 55365 Republic of Korea
- Department of Food Science and Biotechnology, Sungkyunkwan University, Jangan-gu, Suwon South Korea
| | - Da Yeon Lee
- Food Analysis Center, Korea Food Research Institute, 245, Nongsaengmyeong-ro, Iseo-myeon, Wanju-gun, Jeollabuk-do 55365 Republic of Korea
| | - Yong Sun Cho
- Food Analysis Center, Korea Food Research Institute, 245, Nongsaengmyeong-ro, Iseo-myeon, Wanju-gun, Jeollabuk-do 55365 Republic of Korea
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6
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Kim DB, Lee KM, Park SH, Kim YS, Kim ES, Lee J, Jung SA, Seo GS, Lee JM. Is Clostridium difficile infection a real threat in patients with ulcerative colitis? A prospective, multicenter study in Korea. Intest Res 2018; 16:267-272. [PMID: 29743839 PMCID: PMC5934599 DOI: 10.5217/ir.2018.16.2.267] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 09/25/2017] [Accepted: 10/19/2017] [Indexed: 01/05/2023] Open
Abstract
Background/Aims Clostridium difficile infection (CDI) has been reported to be a cause of flare-ups in patients with ulcerative colitis (UC). We evaluated the prevalence and clinical outcomes of CDI in patients with UC hospitalized for flare-ups. Methods This was a prospective, multicenter study including 7 academic teaching hospitals in Korea. All consecutive patients with UC admitted for disease flare-up were enrolled. We detected the presence of CDI by using enzyme immunoassay, real-time polymerase chain reaction (RT-PCR) for toxin genes, and sigmoidoscopy. Results Eighty-one consecutive patients with UC were enrolled from January 2014 to December 2015. Among 81 patients, 8 (9.9%) were diagnosed with CDI. Most of the cases were identified by RT-PCR. Enzyme immunoassay was positive in 3 of 8 patients, and only 1 had typical endoscopic findings of pseudomembranous colitis. There were no differences in demographic data, length of hospital stay, or colectomy rate between patients with and without CDI. Conclusions CDI was not a rare cause of flare-up in patients with UC in Korea. However, CDI did not appear to affect the course of UC flare-up in Korean patients. RT-PCR was sensitive in detecting CDI and can be considered a diagnostic tool in patients with UC flare-up.
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Affiliation(s)
- Dae Bum Kim
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Kang-Moon Lee
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Sang Hyoung Park
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - You Sun Kim
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Eun Soo Kim
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jun Lee
- Department of Internal Medicine, Chosun University Hospital, Chosun University College of Medicine, Gwangju, Korea
| | - Sung-Ae Jung
- Department of Internal Medicine, Ewha Womans University Medical Center, Ewha Womans University School of Medicine, Seoul, Korea
| | - Geom Seog Seo
- Department of Internal Medicine, Wonkwang University Hospital, Wonkwang University College of Medicine, Iksan, Korea
| | - Ji Min Lee
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
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7
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Song PH, Min JH, Kim YS, Jo SY, Kim EJ, Lee KJ, Lee J, Sung H, Moon JS, Whang DH. Rapid and accurate diagnosis of Clostridium difficile infection by real-time polymerase chain reaction. Intest Res 2018; 16:109-115. [PMID: 29422805 PMCID: PMC5797257 DOI: 10.5217/ir.2018.16.1.109] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 03/28/2017] [Accepted: 04/01/2017] [Indexed: 12/28/2022] Open
Abstract
Background/Aims The incidence and severity of Clostridium difficile infection (CDI) have increased worldwide, resulting in a need for rapid and accurate diagnostic methods. Methods A retrospective study was conducted to compare CDI diagnosis methods between January 2014 and December 2014. The stool samples, which were obtained in presumptive CDI patients, were compared for their diagnostic accuracy and rapidity, including real-time polymerase chain reaction (PCR) of toxin genes, C. difficile toxin assay, and culture for C. difficile. Results A total of 207 cases from 116 patients were enrolled in this study and 117 cases (56.5%) were diagnosed as having CDI. Among the 117 cases, the sensitivities of real-time PCR, C. difficile toxin assay, and culture for C. difficile were 87.2% (102 cases; 95% CI, 80.7%–92.8%), 48.7% (57 cases; 95% CI, 41.0%–59.8%), and 65.0% (76 cases; 95% CI, 60.2%–78.5%), respectively (P<0.005). Notably, 34 cases (29.0%) were diagnosed with CDI by real-time PCR only. The time required to obtain results was 2.27 hours (136.62±82.51 minutes) for real-time PCR, 83.67 hours (5,020.66±3,816.38 minutes) for toxin assay, and 105.79 hours (6,347.68±3,331.46 minutes) for culture (P<0.005), respectively. Conclusions We confirmed that real-time PCR of toxin genes is the most effective diagnostic method for accurate and early diagnosis of CDI. It also helps to diagnose hypervirulent CDI, such as ribotype 027 infection.
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Affiliation(s)
- Pil Hun Song
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jung Hwa Min
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - You Sun Kim
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Soo Yeon Jo
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Eun Jin Kim
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Kyung Jin Lee
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jeonghun Lee
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Hyun Sung
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jeong Seop Moon
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Dong Hee Whang
- Department of Laboratory Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
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8
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Comparative Genome Analysis and Global Phylogeny of the Toxin Variant Clostridium difficile PCR Ribotype 017 Reveals the Evolution of Two Independent Sublineages. J Clin Microbiol 2016; 55:865-876. [PMID: 28031436 PMCID: PMC5328454 DOI: 10.1128/jcm.01296-16] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 11/09/2016] [Indexed: 12/21/2022] Open
Abstract
The diarrheal pathogen Clostridium difficile consists of at least six distinct evolutionary lineages. The RT017 lineage is anomalous, as strains only express toxin B, compared to strains from other lineages that produce toxins A and B and, occasionally, binary toxin. Historically, RT017 initially was reported in Asia but now has been reported worldwide. We used whole-genome sequencing and phylogenetic analysis to investigate the patterns of global spread and population structure of 277 RT017 isolates from animal and human origins from six continents, isolated between 1990 and 2013. We reveal two distinct evenly split sublineages (SL1 and SL2) of C. difficile RT017 that contain multiple independent clonal expansions. All 24 animal isolates were contained within SL1 along with human isolates, suggesting potential transmission between animals and humans. Genetic analyses revealed an overrepresentation of antibiotic resistance genes. Phylogeographic analyses show a North American origin for RT017, as has been found for the recently emerged epidemic RT027 lineage. Despite having only one toxin, RT017 strains have evolved in parallel from at least two independent sources and can readily transmit between continents.
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9
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Characterisation of Clostridium difficile strains isolated from Groote Schuur Hospital, Cape Town, South Africa. Eur J Clin Microbiol Infect Dis 2016; 35:1709-18. [DOI: 10.1007/s10096-016-2717-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 06/23/2016] [Indexed: 10/21/2022]
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10
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Cheng JW, Xiao M, Kudinha T, Xu ZP, Hou X, Sun LY, Zhang L, Fan X, Kong F, Xu YC. The First Two Clostridium difficile Ribotype 027/ST1 Isolates Identified in Beijing, China-an Emerging Problem or a Neglected Threat? Sci Rep 2016; 6:18834. [PMID: 26740150 PMCID: PMC4703979 DOI: 10.1038/srep18834] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 11/27/2015] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile hyper-virulent ribotype 027 strain has become a significant concern globally, but has rarely been reported in Asian countries including China. Recently, a retrospective single-center study in Beijing, China, detected two ribotype 027 C. difficile isolates from two patients coming for outpatient visits in 2012 and 2013. We performed a systematic investigation of the two isolates (and patients). Both C. difficile isolates had the typical PCR ribotype 027 profile; were positive for tcdA, tcdB and binary toxin genes; belonged to multilocus sequence type 1 (ST1); had typical ribotype 027 deletions in the tcdC gene; and were highly-resistant to fluoroquinolones; but had a different MLVA profile and were not genetically related to any previously reported international ribotype 027 clones. A review of the patients' medical records showed that neither received appropriate antimicrobial treatment and were lost to follow-up after outpatient visits. We propose that C. difficile infections caused by ribotype 027 are probably a neglected problem in China, and the subsequent impact of unawareness of this problem is worrying. Appropriate testing assays and multi-center or national level surveillance for C. difficile infections and specifically for ribotype 027 should be introduced to provide essential data and guide future clinical practice.
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Affiliation(s)
- Jing-Wei Cheng
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Meng Xiao
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Timothy Kudinha
- Charles Sturt University, Leeds Parade, Orange, New South Wales 2687, Australia.,Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR - Pathology West, Westmead Hospital, University of Sydney, Darcy Road, Westmead, New South Wales 2145, Australia
| | - Zhi-Peng Xu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xin Hou
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Lin-Ying Sun
- Teaching and Research Section of Clinical Laboratory, School of Public Health, Taishan Medical School, Taian, Shandong 271000, China
| | - Li Zhang
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xin Fan
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Fanrong Kong
- Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR - Pathology West, Westmead Hospital, University of Sydney, Darcy Road, Westmead, New South Wales 2145, Australia
| | - Ying-Chun Xu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
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11
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Liao TL, Lin CF, Chiou CS, Shen GH, Wang J. Clostridium difficile PCR Ribotype 027 Emerges in Taiwan. Jpn J Infect Dis 2014; 68:338-40. [PMID: 25672348 DOI: 10.7883/yoken.jjid.2014.271] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Clostridium difficile PCR ribotype 027 is a hypervirulent strain that has caused significant nosocomial diarrhea in many countries but has not yet been reported or isolated in Taiwan previously. Here, we present the characteristics of a case of C. difficile PCR ribotype 027 identified in Taiwan. Taiwan is located in a key transportation center of Asia. This report is important for alerting hospitals and public health departments in Asia about the emergence of this hypervirulent strain so that close monitoring may be enacted to prevent potential outbreaks.
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Affiliation(s)
- Tsai-Ling Liao
- Department of Medical Research, Taichung Veterans General Hospital
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12
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Doh YS, Kim YS, Jung HJ, Park YI, Mo JW, Sung H, Lee KJ, Seo YK, Moon JS, Hong SW. Long-Term Clinical Outcome of Clostridium difficile Infection in Hospitalized Patients: A Single Center Study. Intest Res 2014; 12:299-305. [PMID: 25374496 PMCID: PMC4214957 DOI: 10.5217/ir.2014.12.4.299] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 05/09/2014] [Accepted: 05/10/2014] [Indexed: 01/25/2023] Open
Abstract
Background/Aims Antibiotic usage and increasingly aging populations have led to increased incidence of Clostridium difficile infection (CDI) in worldwide. Recent studies in Korea have also reported increasing CDI incidence; however, there have been no reports on the long-term outcomes of CDI. We therefore investigated the long-term clinical outcomes of patients with CDI, including delayed recurrence, associated risk factors and mortality. Methods Hospitalized patients diagnosed with CDI at Seoul Paik Hospital between January 2007 and December 2008 were included. Their medical records were retrospectively investigated. 'Delayed recurrence' was defined as a relapse 8 weeks after a successful initial treatment. Multivariate logistic regression analysis was performed to identify risk factors for the delayed recurrence. Kaplan-Meier curves were used to analyze mortality rates. Results A total of 120 patients were enrolled; among them, 87 were followed-up for at least 1 year, with a mean follow-up period of 34.1±25.1 months. Delayed recurrence was observed in 17 patients (19.5%), and significant risk factors were age (over 70 years, P=0.049), nasogastric tube insertion (P=0.008), and proton pump inhibitor or H2-blocker treatments (P=0.028). The 12- and 24-month mortality rates were 24.6% and 32.5%, respectively. No deaths were directly attributed to CDI. Conclusions Delayed recurrence of CDI was not rare, occurring in 19.5% of the study population. Although CDI-related mortality was not reported, 2-year (32.5%) mortality rate of CDI patients implies that a CDI diagnosis may predict severe morbidity and poor prognosis of the underlying disease.
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Affiliation(s)
- Young Seok Doh
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - You Sun Kim
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Hye Jin Jung
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Young Il Park
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jin Won Mo
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Hyun Sung
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Kyung Jin Lee
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Young Ki Seo
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jeong Seop Moon
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Seong Woo Hong
- Department of Surgery, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
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13
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Wang P, Zhou Y, Wang Z, Xie S, Zhang T, Lin M, Li R, Tan J, Chen Y, Jiang B. Identification of Clostridium difficile ribotype 027 for the first time in Mainland China. Infect Control Hosp Epidemiol 2014; 35:95-8. [PMID: 24334809 DOI: 10.1086/674405] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Pu Wang
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
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14
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Han SH, Kim H, Lee K, Jeong SJ, Park KH, Song JY, Seo YB, Choi JY, Woo JH, Kim WJ, Kim JM. Epidemiology and clinical features of toxigenic culture-confirmed hospital-onset Clostridium difficile infection: a multicentre prospective study in tertiary hospitals of South Korea. J Med Microbiol 2014; 63:1542-1551. [PMID: 25187603 DOI: 10.1099/jmm.0.070672-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Hypervirulent Clostridium difficile strains, most notably BI/NAP1/027, have been increasingly emerging in Western countries as local epidemics. We performed a prospective multicentre observational study from December 2011 to May 2012 to identify recent incidences of toxigenic culture-confirmed hospital-onset C. difficile infections (CDI) and their associated clinical characteristics in South Korea. Patients suspected of having been suffering from CDI more than 48 h after admission and aged ≥20 years were prospectively enrolled and provided loose stool specimens. Toxigenic C. difficile culture (anaerobic culture+toxin A/B/binary gene PCR) and PCR ribotyping were performed in one central laboratory. We enrolled 98 toxigenic culture-confirmed CDI-infected patients and 250 toxigenic culture-negative participants from three hospitals. The incidence of toxigenic culture-confirmed hospital-onset CDI cases was 2.7 per 10,000 patient-days. The percentage of severe CDI cases was relatively low at only 3.1%. UK ribotype 018 was the predominant type (48.1%). There were no hypervirulent BI/NAP1/027 isolates identified. The independent risk factors for toxigenic culture-confirmed hospital-onset CDI were invasive procedure (odds ratio (OR) 7.3, P=0.003) and past CDI history within 3 months (OR 28.5, P=0.003). In conclusion, the incidence and severity of CDI in our study were not higher than reported in Western countries.
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Affiliation(s)
- Sang Hoon Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Heejung Kim
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, South Korea
| | - Kyungwon Lee
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, South Korea
| | - Su Jin Jeong
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Ki-Ho Park
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Joon Young Song
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Yu Bin Seo
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Jun Yong Choi
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Jun Hee Woo
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Woo Joo Kim
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - June Myung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
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The first case of severe Clostridium difficile ribotype 027 infection in Taiwan. J Infect 2014; 70:98-101. [PMID: 25150914 DOI: 10.1016/j.jinf.2014.08.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 08/11/2014] [Accepted: 08/15/2014] [Indexed: 11/23/2022]
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Lee JH, Lee Y, Lee K, Riley TV, Kim H. The changes of PCR ribotype and antimicrobial resistance of Clostridium difficile in a tertiary care hospital over 10 years. J Med Microbiol 2014; 63:819-823. [DOI: 10.1099/jmm.0.072082-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The aims of this study were to investigate any change in PCR ribotypes and to determine the antimicrobial resistance of common PCR ribotypes over a 10-year period in a tertiary care hospital. We conducted PCR ribotyping, antimicrobial susceptibility testing and DNA gyrase sequencing to identify changes in 1407 Clostridium difficile non-duplicated isolates obtained between 2000 and 2009. A total of 74 different ribotypes were found. The most prevalent ribotype was ribotype 001 (26.1 %). The prevalence of ribotype 017 was 17 % and that of ribotype 014/020 was 9.6 %. Ribotyping showed that the prevalence of ribotype 001 decreased and the prevalence of ribotypes 017, 014/020 and 018 increased over the 10 years. Antimicrobial resistance rates in prevalent ribotypes were: clindamycin, 81 %; cefotetan, 19 %; moxifloxacin, 42 %; imipenem, 8 %; ciprofloxacin, 100 % and erythromycin, 80 %. Ribotype 018 showed greater antimicrobial resistance than other ribotypes. All ribotype 018 strains showing moxifloxacin resistance had a substitution of a gyrA coding amino acid (Thr82 to Ile). This study will help the understanding of PCR ribotype trends and antimicrobial resistance of C. difficile in Korea.
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Affiliation(s)
- Jong-Han Lee
- Department of Laboratory Medicine, Korea University College of Medicine, Seoul, Korea
| | - Yangsoon Lee
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, Korea
| | - Kyungwon Lee
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, Korea
| | - Thomas V. Riley
- Microbiology and Immunology, University of Western Australia, Perth, Western Australia
| | - Heejung Kim
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, Korea
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Molecular epidemiology of Clostridium difficile infection in a major chinese hospital: an underrecognized problem in Asia? J Clin Microbiol 2013; 51:3308-13. [PMID: 23903542 DOI: 10.1128/jcm.00587-13] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Clostridium difficile infection is almost unrecognized in mainland China. We have undertaken a study in a large Chinese teaching hospital in Changsha, Hunan, China, to identify cases of C. difficile, record patient characteristics, and define the molecular epidemiology with respect to ribotype distribution and cross-infection. Between April 2009 and February 2010, we examined fecal samples from 70 hospitalized patients with diarrhea who were receiving or had received antibiotics within the previous 6 weeks. Clinical information was collected and the samples were cultured for C. difficile retrospectively. Isolates were ribotyped, and multiple-locus variable-number tandem-repeat assay (MLVA) subtyping was performed on clusters of the same ribotype. The mean age of patients from whom C. difficile was cultured was 58 years, with only 4/21 patients aged >65 years. All patients, with a single exception, had received a third-generation cephalosporin and/or a quinolone antibiotic. Twenty-one isolates of C. difficile were recovered, and seven different ribotypes were identified, the dominant types being 017 (48%), 046 (14%), and 012 (14%). We identified two clusters of cross-infection with indistinguishable isolates of ribotype 017, with evidence of spread both within and between wards. We have identified C. difficile as a possibly significant problem, with cross-infection and a distinct ribotype distribution, in a large Chinese hospital. C. difficile may be underrecognized in China, and further epidemiological studies across the country together with the introduction of routine diagnostic testing are needed to ascertain the size of this potentially significant problem.
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Kim J, Seo MR, Kang JO, Choi TY, Pai H. Clinical and Microbiologic Characteristics of Clostridium difficile Infection Caused by Binary Toxin Producing Strain in Korea. Infect Chemother 2013; 45:175-83. [PMID: 24265965 PMCID: PMC3780953 DOI: 10.3947/ic.2013.45.2.175] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 03/29/2013] [Accepted: 03/29/2013] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Binary toxin-producing Clostridium difficile infections (CDI) are known to be more severe and to cause higher case fatality rates than those by binary toxin-negative isolates. There has been few data of binary toxin-producing CDI in Korea. Objective of the study is to characterize clinical and microbiological trait of CDI cause by binary-toxin producing isolates in Korea. MATERIALS AND METHODS From September 2008 through January 2010, clinical characteristics, medication history and treatment outcome of all the CDI patients were collected prospectively. Toxin characterization, PCR ribotyping and antibiotic susceptibility were performed with the stool isolates of C. difficile. RESULTS During the period, CDI caused by 11binary toxin-producing isolates and 105 toxin A & toxin B-positive binary toxin-negative isolates were identified. Comparing the disease severity and clinical findings between two groups, leukocytosis and mucoid stool were more frequently observed in patients with binary toxin-positive isolates (OR: 5.2, 95% CI: 1.1 to 25.4, P = 0.043; OR: 7.6, 95% CI: 1.6 to 35.6, P = 0.010, respectively), but clinical outcome of 2 groups did not show any difference. For the risk factors for acquisition of binary toxin-positive isolates, previous use of glycopeptides was the significant risk factor (OR: 6.2, 95% CI: 1.4 to 28.6, P = 0.019), but use of probiotics worked as an inhibitory factor (OR: 0.1, 95% CI: 0.0 to 0.8; P = 0.026). PCR ribotypes of binary toxinproducing C. difficile showed variable patterns: ribotype 130, 4 isolates; 027, 3 isolates; 267 and 122, 1 each isolate and unidentified C1, 2 isolates. All 11 binary toxin-positive isolates were highly susceptible to clindamycin, moxifloxacin, metronidazole, vancomycin and piperacillin-tazobactam, however, 1 of 11 of the isolates was resistant to rifaximin. CONCLUSIONS Binary toxin-producing C. difficile infection was not common in Korea and those isolates showed diverse PCR ribotypes with high susceptibility to antimicrobial agents. Glycopeptide use was a risk factor for CDI by those isolates.
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Affiliation(s)
- Jieun Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
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Using phenotype microarrays to determine culture conditions that induce or repress toxin production by Clostridium difficile and other microorganisms. PLoS One 2013; 8:e56545. [PMID: 23437164 PMCID: PMC3577869 DOI: 10.1371/journal.pone.0056545] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Accepted: 01/11/2013] [Indexed: 12/18/2022] Open
Abstract
Toxin production is a central issue in the pathogenesis of Clostridium difficile and many other pathogenic microorganisms. Toxin synthesis is influenced by a variety of known and unknown factors of genetics, physiology, and environment. To facilitate the study of toxin production by C. difficile, we have developed a new, reliable, quantitative, and robust cell-based cytotoxicity assay. Then we combined this new assay with Phenotype MicroArrays (PM) technology which provides high throughput testing of culture conditions. This allowed us to quantitatively measure toxin production by C. difficile type strain ATCC 9689 under 768 culture conditions. The culture conditions include different carbon, nitrogen, phosphorus, and sulfur sources. Among these, 89 conditions produced strong toxin induction and 31 produced strong toxin repression. Strong toxin inducers included adenine, guanosine, arginine dipeptides, γ-D-Glu-Gly, methylamine, and others. Some leucine dipeptides and the triple-leucine tripeptide were among the strongest toxin repressors. While some results are consistent with previous observations, others are new observations that provide insights into toxin regulation and pathogenesis of C. difficile. Additionally, we have demonstrated that this combined assay technology can be applied broadly to a wide range of toxin producing microorganisms. This study is the first demonstration of simultaneous assessment of a large number of culture conditions influencing bacterial toxin production. The new functional cytotoxin quantitation method developed provides a valuable tool for studying toxigenic microorganisms and may also find applications in clinical and epidemiological research.
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Clostridium difficile in foods and animals: history and measures to reduce exposure. Anim Health Res Rev 2013; 14:11-29. [PMID: 23324529 DOI: 10.1017/s1466252312000229] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Many articles have summarized the changing epidemiology of Clostridium difficile infections (CDI) in humans, but the emerging presence of C. difficile in foods and animals and possible measures to reduce human exposure to this important pathogen have been infrequently addressed. CDIs have traditionally been assumed to be restricted to health-care settings. However, recent molecular studies indicate that this is no longer the case; animals and foods might be involved in the changing epidemiology of CDIs in humans; and genome sequencing is disproving person-to-person transmission in hospitals. Although zoonotic and foodborne transmission have not been confirmed, it is evident that susceptible people can be inadvertently exposed to C. difficile from foods, animals, or their environment. Strains of epidemic clones present in humans are common in companion and food animals, raw meats, poultry products, vegetables, and ready-to-eat foods, including salads. In order to develop science-based prevention strategies, it is critical to understand how C. difficile reaches foods and humans. This review contextualizes the current understanding of CDIs in humans, animals, and foods. Based on available information, we propose a list of educational measures that could reduce the exposure of susceptible people to C. difficile. Enhanced educational efforts and behavior change targeting medical and non-medical personnel are needed.
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Cairns MD, Stabler RA, Shetty N, Wren BW. The continually evolving Clostridium difficile species. Future Microbiol 2013; 7:945-57. [PMID: 22913354 DOI: 10.2217/fmb.12.73] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Clostridium difficile is a spore-forming Gram-positive bacterium that causes chronic diarrhea and sometimes life-threatening disease mainly in elderly and hospitalized patients. The reported incidence of C. difficile infection has changed dramatically over the last decade and has been related to the emergence of distinct clonal lineages that appear more transmissible and cause more severe infection. These include PCR ribotypes 027, 017 and more recently 078. Population biology studies using multilocus sequence typing and whole-genome comparisons has helped to define the C. difficile species into four clonal complexes that include PCR ribotypes 027, 017, 078 and 023, as well as a general grouping of most other PCR ribotypes. Further analysis of strains from diverse sources and geographical origins reveal significant microdiversity of clonal complexes and confirms that C. difficile is continuing to evolve. The study of C. difficile represents a real-time global evolutionary experiment where the pathogen is responding to a range of selective pressures created by human activity and practices in healthcare settings. The advent of whole-genome sequencing coupled with phylogeny (phylogeography and phylohistory) will provide unprecedented detail on the local and global emergence and disappearance of C. difficile clones, and facilitate more rational approaches to disease control. This review will highlight the emergence of virulent C. difficile clones and our current understanding of molecular epidemiology of the species.
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Affiliation(s)
- Michelle D Cairns
- Department of Pathogen Molecular Biology, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
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22
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Abstract
PURPOSE OF REVIEW This review comprises recent insights on epidemiology, risk factors, diagnostic approaches, pathophysiologic mechanisms, novel treatment options and prevention strategies of Clostridium difficile infection (CDI). RECENT FINDINGS Incidence of Clostridium difficile continues to rise and hypervirulent subtypes such as polymerase chain reaction (PCR) ribotype 027 and 078 have emerged worldwide. Children and postpartum women are increasingly recognized as being at risk for development of CDI and community-associated infection is no longer rare. PCR technology may replace complicated two-step test algorithms in the future, because it is rapid, sensitive and specific. Pathophysiological studies have provided evidence that either one of the two exotoxins A and B is important in conferring virulence - the role of binary toxin requires further investigation. Proton pump inhibitors are now established as important risk factors for acquiring, complicating CDI, and developing recurrences. Fidaxomycin, monoclonal antibodies and intestinal microbiota transplantation are promising new treatment options, especially regarding prevention of recurrent disease. Future prevention strategies involve vaccination and novel insights on reservoirs for ongoing transmission, including the food chain. SUMMARY Important advances in research on CDI include novel diagnostic approaches, better understanding of the underlying pathophysiological mechanisms of disease and the development of new approaches to treatment.
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23
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Incidence and clinical features of Clostridium difficile infection in Korea: a nationwide study. Epidemiol Infect 2012; 141:189-94. [PMID: 22717061 DOI: 10.1017/s0950268812000581] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The incidence and severity of Clostridium difficile infections (CDI) have increased in Western countries. However, there are limited data regarding the epidemiology of CDI in Eastern countries. This nationwide study was conducted in 17 hospitals to determine temporal trends in CDI incidence (from 2004 to 2008) in South Korea. The total incidence of CDI in Korea was 1·7 cases/1000 adult admissions in 2004, and 2·7/1000 cases in 2008 (P = 0·028). When analysing the clinical features of 1367 CDI patients diagnosed in 2008, oral metronidazole was effective as a first-line treatment for CDI (61·9%). Relapse rate was 8·9% and complicated CDI was only observed in 3·6%. The incidence of CDI increased significantly in Korea from 2004 to 2008. Although the clinical features were milder than in Western countries, the increasing burden of CDI needs ongoing surveillance systems.
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Mavros MN, Alexiou VG, Vardakas KZ, Tsokali K, Sardi TA, Falagas ME. Underestimation of Clostridium difficile infection among clinicians: an international survey. Eur J Clin Microbiol Infect Dis 2012; 31:2439-44. [PMID: 22450740 DOI: 10.1007/s10096-012-1587-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 02/09/2012] [Indexed: 12/18/2022]
Abstract
The objective of this investigation was to document clinicians' awareness regarding the incidence and severity of Clostridium difficile-associated diarrhea (CDAD). An international electronic survey was conducted among corresponding authors of articles indexed by PubMed and published during the last 10 years in 'Core Clinical Journals'. A total of 1,163 clinicians answered (response rate 59%); most of the responses were submitted from North America (54.6%), Europe (32.2%), and Asia/Pacific (11.6%). Only 2.2% of the participants answered correctly all four questions, while 14.1% answered all questions incorrectly. Regarding each question, 10.8% of the participants correctly estimated current CDAD treatment failure or recurrence rates to be around 40%, 33.4% correctly estimated the ratio of antibiotic-associated colitis attributed to C. difficile to be around 60%, 72.7% correctly responded that almost all antibiotics are associated with CDAD, and 41.7% correctly responded that any patient is at risk for CDAD. Almost half (44.4%) of the respondents considered CDAD to be underestimated. Participants from North America scored higher than those from Europe or Asia/Pacific (p < 0.001). Participants considering CDAD to be overestimated (3.4%) had the lowest mean score of correct answers. Among a clinically diverse international sample of physicians with academic expertise, there was an inadequate level of awareness of the magnitude and clinical importance of CDAD.
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Affiliation(s)
- M N Mavros
- Alfa Institute of Biomedical Sciences (AIBS), 9 Neapoleos Street, 151 23, Marousi, Athens, Greece
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Abstract
PURPOSE OF REVIEW The incidence and severity of Clostridium difficile infection (CDI) around the world has increased over the past 20 years due to the emergence of hypervirulent strains, increased use and misuse of antibiotics, and the increase of susceptible at-risk populations. Treatments currently available for CDI are inadequate to impede the increasing spread and virulence of the infection, avoid recurrence in chronic patients or prevent infection in at-risk populations. RECENT FINDINGS New and promising evidence has been presented during the past year, focusing on two major points: preservation of gut microflora and optimization of immune response to CDI and toxins. SUMMARY The review aims to summarize the most recent evidence available on the epidemiology, risk factors and treatment of CDI. New antibiotics with selected action on C. difficile and limited effect on microflora (fidaxomicin) and donor fecal transplantation seem to have a relevant efficacy in treating CDI and reducing its recurrence. The use of selected monoclonal antibodies directed against C. difficile toxins in addition to standard therapy is a new, promising approach for the treatment of recurrent cases. Vaccination could be an additional weapon against CDI. New robust data are needed before recommendations can be made to abandon current treatment based on vancomycin and metronidazole and move toward new frontiers.
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27
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Pant C, Sferra TJ, Deshpande A, Minocha A. Clinical approach to severe Clostridium difficile infection: update for the hospital practitioner. Eur J Intern Med 2011; 22:561-8. [PMID: 22075280 DOI: 10.1016/j.ejim.2011.04.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Revised: 04/17/2011] [Accepted: 04/26/2011] [Indexed: 12/18/2022]
Abstract
The rising incidence of Clostridium difficile (C. difficile) infection or CDI is now a problem of pandemic proportions. The NAP1 hypervirulent strain of C. difficile is responsible for a majority of recent epidemics and the widespread use of fluoroquinolone antibiotics may have facilitated the selective proliferation of this strain. The NAP1 strain also is more likely to cause severe and fulminant colitis characterized by marked leukocytosis, renal failure, hemodynamic instability, and toxic megacolon. No single test suffices to diagnose severe CDI, instead; the clinician must rely on a combination of clinical acumen, laboratory testing, and radiologic and endoscopic modalities. Although oral vancomycin and metronidazole are considered standard therapies in the medical management of CDI, recently it has been demonstrated that vancomycin is the more effective antibiotic in cases of severe disease. Moreover, early surgical consultation is necessary in patients who do not respond to medical therapy or who demonstrate rising white blood cell counts or hemodynamic instability indicative of fulminant colitis. Subtotal colectomy with end ileostomy is the procedure of choice for fulminant colitis. When applied to select patients in a judicious and timely fashion, surgery can be a life-saving intervention. In addition to these therapeutic approaches, several investigational treatments including novel antibiotics, fecal bacteriotherapy and immunotherapy have shown promise in the care of patients with severe CDI.
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Affiliation(s)
- Chaitanya Pant
- Department of Pediatrics, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
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28
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Balassiano IT, Yates EA, Domingues RMCP, Ferreira EO. Clostridium difficile: a problem of concern in developed countries and still a mystery in Latin America. J Med Microbiol 2011; 61:169-179. [PMID: 22116982 DOI: 10.1099/jmm.0.037077-0] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Clostridium difficile-associated disease (CDAD) is caused by a spore-forming bacterium and can result in highly variable disease, ranging from mild diarrhoea to severe clinical manifestations. Infections are most commonly seen in hospital settings and are often associated with on-going antibiotic therapy. Incidences of CDAD have shown a sustained increase worldwide over the last ten years and a hypervirulent C. difficile strain, PCR ribotype 027/REA type BI/North American pulsed-field (NAP) type 1 (027/BI/NAP-1), has caused outbreaks in North America and Europe. In contrast, only a few reports of cases in Latin America have been published and the hypervirulent strain 027/BI/NAP-1 has, so far, only been reported in Costa Rica. The potential worldwide spread of this infection calls for epidemiological studies to characterize currently circulating strains and also highlights the need for increased awareness and vigilance among healthcare professionals in currently unaffected areas, such as Latin America. This review attempts to summarize reports of C. difficile infection worldwide, especially in Latin America, and aims to provide an introduction to the problems associated with this pathogen for those countries that might face outbreaks of epidemic strains of C. difficile for the first time in the near future.
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Affiliation(s)
- I T Balassiano
- Leptospira Collection, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil.,WHO Collaborating Center for Leptospirosis, Oswaldo Cruz Foundation, Pavilhão Rocha Lima, 302 Manguinhos, Rio de Janeiro 21040-360, Brazil
| | - E A Yates
- School of Biological Sciences, University of Liverpool, Liverpool L69 7ZB, UK
| | - R M C P Domingues
- Universidade Federal do Rio de Janeiro, CCS, Bloco I, 2° andar, Laboratório de Biologia de Anaeróbios, Rio de Janeiro 20941-901, Brazil
| | - E O Ferreira
- Universidade Federal do Rio de Janeiro, CCS, Bloco I, 2° andar, Laboratório de Biologia de Anaeróbios, Rio de Janeiro 20941-901, Brazil
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Kim J, Pai H, Seo MR, Kang JO. Epidemiology and clinical characteristics of Clostridium difficile infection in a Korean tertiary hospital. J Korean Med Sci 2011; 26:1258-64. [PMID: 22022175 PMCID: PMC3192334 DOI: 10.3346/jkms.2011.26.10.1258] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Accepted: 08/29/2011] [Indexed: 01/05/2023] Open
Abstract
In order to investigate the incidence, clinical and microbiologic characteristics of Clostridium difficile infection (CDI) in Korea, a prospective observational study was performed. From September 2008 through January 2010, all patients whose stool was tested for toxin assay A&B and/or C. difficile culture were studied for clinical characteristics. Toxin types of the isolates from stool were tested. The mean incidence of CDI per 100,000 patient-days was 71.6 by month (range, 52.5-114.0), and the ratio of CDI to antibiotic-associated diarrhea was 0.23. Among 200 CDI patients, 37.5% (75/200) was severe CDI based on severity score. Clinical outcome of 189 CDI was as followed; 25.9% (49/189) improved without treatment, 84.3% (118/140) achieved clinical cure and attributed mortality was 0.7% (1/140) with the treatment. Recurrence rate was 21.4% (30/140) and cure without recurrence was 66.4% (93/140). The most common type of toxin was toxin A-positive/toxin B-positive strain (77.5%), toxin A-negative/toxin B-positive strains or binary toxin-producing strains comprised 15.4% or 7.1%, respectively. In conclusion, the incidence of CDI in Korea is a little higher than other reports during the non-epidemic setting. We expect that the change of epidemiology and clinical severity in CDI can be evaluated based on these results.
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Affiliation(s)
- Jieun Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Guri, Korea
| | - Hyunjoo Pai
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Mi-ran Seo
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Jung Oak Kang
- Department of Clinical Microbiology, Hanyang University College of Medicine, Guri, Korea
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Choi HK, Kim KH, Lee SH, Lee SJ. Risk factors for recurrence of Clostridium difficile infection: effect of vancomycin-resistant enterococci colonization. J Korean Med Sci 2011; 26:859-64. [PMID: 21738336 PMCID: PMC3124713 DOI: 10.3346/jkms.2011.26.7.859] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Accepted: 04/21/2011] [Indexed: 01/20/2023] Open
Abstract
Recurrent Clostridium difficile infection (CDI) is one of the most difficult problems in healthcare infection control. We evaluated the risk factors associated with recurrence in patients with CDI. A retrospective cohort study of 84 patients with CDI from December 2008 through October 2010 was performed at Pusan National University Yangsan Hospital. Recurrence occurred in 13.1% (11/84) of the cases and in-hospital mortality rate was 7.1% (6/84). Stool colonization with vancomycin-resistant enterococci (VRE) (P = 0.006), exposure to more than 3 antibiotics (P = 0.009), low hemoglobin levels (P = 0.025) and continued use of previous antibiotics (P = 0.05) were found to be more frequent in the recurrent group. Multivariate analysis indicated that, stool VRE colonization was independently associated with CDI recurrence (odds ratio, 14.519; 95% confidence interval, 1.157-182.229; P = 0.038). This result suggests that stool VRE colonization is a significant risk factor for CDI recurrence.
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Affiliation(s)
- Hee Kyoung Choi
- Department of Internal Medicine, Division of Infections Disease, Medical Research Institute, Pusan National University School of Medicine, Busan, Korea
| | - Kye Hyung Kim
- Department of Internal Medicine, Division of Infections Disease, Medical Research Institute, Pusan National University School of Medicine, Busan, Korea
| | - Sun Hee Lee
- Department of Internal Medicine, Division of Infections Disease, Medical Research Institute, Pusan National University School of Medicine, Busan, Korea
| | - Su Jin Lee
- Department of Internal Medicine, Division of Infections Disease, Medical Research Institute, Pusan National University School of Medicine, Busan, Korea
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Kim H, Lee Y, Moon HW, Lim CS, Lee K, Chong Y. Emergence of Clostridium difficile ribotype 027 in Korea. Korean J Lab Med 2011; 31:191-6. [PMID: 21779194 PMCID: PMC3129351 DOI: 10.3343/kjlm.2011.31.3.191] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Revised: 04/18/2011] [Accepted: 04/19/2011] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Clostridium difficile infection (CDI) has markedly risen and is associated with hypervirulent ribotype 027 outbreaks in North America and Europe since 2003. The aims of this study were to determine the prevalence of ribotype 027 among C. difficile isolates in Korea, to characterize the ribotype 027 isolates, and to determine the clinical severity of CDI in patients infected with these isolates. METHODS A total of 1,251 isolates of C. difficile recovered from stool specimens of suspected CDI patients at two tertiary-care hospitals and one commercial laboratory between 2002 and 2009. Genes for toxin A (tcdA), toxin B (tcdB), and binary toxin (cdtA and cdtB) were detected by PCR. Mutation in the tcdC gene was detected by sequencing after PCR amplification. For molecular genotyping, we performed PCR-ribotyping, pulsed-field gel electrophoresis (PFGE), and multilocus variable-number tandem-repeat analysis (MLVA). Minimum inhibitory concentrations of moxifloxacin were determined using Etest strips (AB bioMérieux, Sweden). RESULTS We identified 7 isolates as ribotype 027. These isolates had the same tcdC mutation as the epidemic strain, and 6 of them were resistant to moxifloxacin. The isolates were categorized into 3 different PFGE types and 7 different MLVA types. All the 7 cases had occurred sporadically. CONCLUSIONS C. difficile ribotype 027 is uncommon, but it has emerged in Korea. The spread of this ribotype should be closely monitored in order to avoid an outbreak of CDI in Korea.
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Affiliation(s)
- Heejung Kim
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, Korea
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Abstract
PURPOSE OF REVIEW This review summarizes the most recent epidemiological data and advances in research into the pathogenesis, diagnosis and treatment of Clostridium difficile infection (CDI). RECENT FINDINGS The epidemiology of CDI has changed with the emergence of hypervirulent strains. CDI rates have increased in the community, in children and in patients with inflammatory bowel disease. Although the North American pulsed-field gel electrophoresis type 1, restriction endonuclease analysis group BI, PCR ribotype 027 (NAP1/BI/027) strain remains prevalent in North America, surveillance suggests that it is decreasing in Europe. A similar strain, PCR ribotype 078, is emerging which is associated with community-associated CDI and has been isolated in animals and food products. The Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America have published new guidelines on the epidemiology, diagnosis, treatment, infection control and environmental management of C. difficile. Several novel therapies for CDI are at different stages of development. There have been promising trial results with fidaxomicin, a novel antibiotic for the treatment of CDI and monoclonal antibodies against toxins A and B, which have been shown to significantly reduce CDI recurrence rates. SUMMARY Major advances have been made in our understanding of the spread and pathogenesis of C. difficile and new treatment options are becoming available.
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Freeman J, Bauer MP, Baines SD, Corver J, Fawley WN, Goorhuis B, Kuijper EJ, Wilcox MH. The changing epidemiology of Clostridium difficile infections. Clin Microbiol Rev 2010; 33 Suppl 1:S42-5. [PMID: 20610822 DOI: 10.1016/s0924-8579(09)70016-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The epidemiology of Clostridium difficile infection (CDI) has changed dramatically during this millennium. Infection rates have increased markedly in most countries with detailed surveillance data. There have been clear changes in the clinical presentation, response to treatment, and outcome of CDI. These changes have been driven to a major degree by the emergence and epidemic spread of a novel strain, known as PCR ribotype 027 (sometimes referred to as BI/NAP1/027). We review the evidence for the changing epidemiology, clinical virulence and outcome of treatment of CDI, and the similarities and differences between data from various countries and continents. Community-acquired CDI has also emerged, although the evidence for this as a distinct new entity is less clear. There are new data on the etiology of and potential risk factors for CDI; controversial issues include specific antimicrobial agents, gastric acid suppressants, potential animal and food sources of C. difficile, and the effect of the use of alcohol-based hand hygiene agents.
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Affiliation(s)
- J Freeman
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom
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34
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Escher M, Herrlinger K, Stange E. Proktitis – aus gastroenterologischer Sicht. COLOPROCTOLOGY 2010. [DOI: 10.1007/s00053-010-0130-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Freeman J, Bauer MP, Baines SD, Corver J, Fawley WN, Goorhuis B, Kuijper EJ, Wilcox MH. The changing epidemiology of Clostridium difficile infections. Clin Microbiol Rev 2010; 23:529-49. [PMID: 20610822 PMCID: PMC2901659 DOI: 10.1128/cmr.00082-09] [Citation(s) in RCA: 619] [Impact Index Per Article: 44.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The epidemiology of Clostridium difficile infection (CDI) has changed dramatically during this millennium. Infection rates have increased markedly in most countries with detailed surveillance data. There have been clear changes in the clinical presentation, response to treatment, and outcome of CDI. These changes have been driven to a major degree by the emergence and epidemic spread of a novel strain, known as PCR ribotype 027 (sometimes referred to as BI/NAP1/027). We review the evidence for the changing epidemiology, clinical virulence and outcome of treatment of CDI, and the similarities and differences between data from various countries and continents. Community-acquired CDI has also emerged, although the evidence for this as a distinct new entity is less clear. There are new data on the etiology of and potential risk factors for CDI; controversial issues include specific antimicrobial agents, gastric acid suppressants, potential animal and food sources of C. difficile, and the effect of the use of alcohol-based hand hygiene agents.
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Affiliation(s)
- J. Freeman
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - M. P. Bauer
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - S. D. Baines
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - J. Corver
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - W. N. Fawley
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - B. Goorhuis
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - E. J. Kuijper
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - M. H. Wilcox
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
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Clostridium difficile PCR ribotype 027: assessing the risks of further worldwide spread. THE LANCET. INFECTIOUS DISEASES 2010; 10:395-404. [PMID: 20510280 PMCID: PMC7185771 DOI: 10.1016/s1473-3099(10)70080-3] [Citation(s) in RCA: 148] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Highly virulent strains of Clostridium difficile have emerged since 2003, causing large outbreaks of severe, often fatal, colitis in North America and Europe. In 2008–10, virulent strains spread between continents, with the first reported cases of fluoroquinolone-resistant C difficile PCR ribotype 027 in three Asia-Pacific countries and Central America. We present a risk assessment framework for assessing risks of further worldwide spread of this pathogen. This framework first requires identification of potential vehicles of introduction, including international transfers of hospital patients, international tourism and migration, and trade in livestock, associated commodities, and foodstuffs. It then calls for assessment of the risks of pathogen release, of exposure of individuals if release happens, and of resulting outbreaks. Health departments in countries unaffected by outbreaks should assess the risk of introduction or reintroduction of C difficile PCR ribotype 027 using a structured risk-assessment approach.
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Park HS, Han DS. [Is Clostridium difficile infection increasing in Korea?]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2010; 55:208-10. [PMID: 20357534 DOI: 10.4166/kjg.2010.55.3.208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Lee YJ, Choi MG, Lim CH, Jung WR, Cho HS, Sung HY, Nam KW, Chang JH, Cho YK, Park JM, Kim SW, Chung IS. [Change of Clostridium difficile colitis during recent 10 years in Korea]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2010; 55:169-74. [PMID: 20357527 DOI: 10.4166/kjg.2010.55.3.169] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND/AIMS Our clinical experience and recent published literatures suggest that Clostridium difficile colitis (CDC) has become more common and potentially more pathogenic in recent years. The aim of study was to evaluate changes in the epidemiological features of CDC in hospitalized patients in Korea. METHODS We retrospectively reviewed all patients of CDC diagnosed at Kangnam St. Mary Hospital from 1998 to 2007. CDC was defined as having a positive C. difficile cytotoxicity assay, or endoscopic or pathologic evidence of CDC. RESULTS A total of 189 cases (male 73, female 116, mean age 63.3 years) of CDC were diagnosed during the study period. The prevalence of CDC increased from 1.9/10,000 patient admissions in 1998-1999 to 8.82/10,000 patient admissions in 2006-2007. One hundred sixty three indication for cases (86.2%) of patients identified a prior use of antibiotics in the 2 months preceding diagnosis. The most common antibiotic use was prophylactic use during perioperational period (33.3%) followed by pneumonia (23.3%). The overall response rate to initial antibiotics was 82.7%. One hundred seventy two (91%) patients were initially treated with metronidazole. The response rate was 84.3%. All patients with initial failure to metronidazole were successfully treated by vancomycin. The response rate of vancomycin as first treatment was 80%. Three deaths were associated with CDC despite the use of combination of metronidazole and vancomycin. CONCLUSIONS The prevalence of CDC in hospitalized patients in Korea significantly increased from 1998 to 2007.
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Affiliation(s)
- Yune Jeong Lee
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seocho-gu, Seoul, Korea
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Lee JH, Lee SY, Kim YS, Park SW, Park SW, Jo SY, Ryu SH, Lee JH, Moon JS, Whang DH, Shin BM. The Incidence and Clinical Features ofClostridium difficileInfection; Single Center Study. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2010; 55:175-82. [DOI: 10.4166/kjg.2010.55.3.175] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Jin Ho Lee
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Su-Yeon Lee
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - You Sun Kim
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Sun-Wook Park
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Sung Won Park
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - So Young Jo
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Soo Hyung Ryu
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jung Hwan Lee
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jeong Seop Moon
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Dong Hee Whang
- Department of Laboratory Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Bo Moon Shin
- Department of Laboratory Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
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40
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Clinical Guideline for the Diagnosis and Treatment of Gastrointestinal Infections. Infect Chemother 2010. [DOI: 10.3947/ic.2010.42.6.323] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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