ESTABLISHED AND POTENTIAL RISK FACTORS FOR CLOSTRIDUM DIFFICILE INFECTION

Duration from start of antibiotic exposure to onset of Clostridioides difficile infection for different antibiotics in a non-outbreak setting

BACKGROUND

Antibiotic treatment is a well-known risk factor for Clostridioides difficile infection (CDI). The time from start of antibiotic exposure to onset of CDI for different antibiotics is sparsely studied. CDI with onset in the community is often treatable without in-hospital care while CDI patients treated in hospital need isolation, resulting in higher costs and infection control measures.

OBJECTIVES

To determine the time from start of antibiotic exposure to onset of healthcare facility-associated CDI for different antibiotics.

METHODS

Time between antibiotic exposure and disease onset was evaluated retrospectively with chart reading in a two-centre Swedish setting. A case was attributed to an antibiotic group if this represented more than 2/3 of total antibiotic exposure 30 days before onset of CDI.

RESULTS

Cephalosporins caused CDI faster (mean 7.6 days), and more often during ongoing antibiotic therapy (81% of the cases) than any other antibiotic group. All other common agents had between 2-3 times longer period between start of exposure to onset of CDI (quinolones more than 3 times).

CONCLUSIONS

The time gap between antibiotic exposure and onset of CDI is markedly different between different antibiotics. Decreased cephalosporin use could delay onset of healthcare facility-associated CDI and limit infections with onset within the hospital. This might decrease costs for inpatient care, need of infection control measures and shortage of beds in the hospital.

Development of a Prediction Model to Identify the Risk of Clostridioides difficile Infection in Hospitalized Patients Receiving at Least One Dose of Antibiotics

OBJECTIVE

This study's objective was to develop a risk-prediction model to identify hospitalized patients at risk of Clostridioides difficile infection (CDI) who had received at least one dose of systemic antibiotics in a large tertiary hospital.

PATIENTS AND METHODS

This was a retrospective case-control study that included patients hospitalized for more than 2 days who received antibiotic therapy during hospitalization. The study included two groups: patients diagnosed with hospital CDI and controls without hospital CDI. Cases were matched 1:3 with assigned controls by age and sex. Descriptive statistics were used to identify the study population by comparing cases with controls. Continuous variables were stated as the means and standard deviations. A multivariate analysis was built to identify the significantly associated covariates between cases and controls for CDI.

RESULTS

A total of 364 patients were included and distributed between the two groups. The control group included 273 patients, and the case group included 91 patients. The risk factors for CDI were investigated, with only significant risks identified and included in the risk assessment model: age older than 70 years (p = 0.034), chronic kidney disease (p = 0.043), solid organ transplantation (p = 0.021), and lymphoma or leukemia (p = 0.019). A risk score of ≥2 showed the best sensitivity, specificity, and accuracy of 78.02%, 45.42%, and 78.02, respectively, with an area under the curve of 0.6172.

CONCLUSION

We identified four associated risk factors in the risk-prediction model. The tool showed good discrimination that might help predict, identify, and evaluate hospitalized patients at risk of developing CDI.

Impact of the Antimicrobial Stewardship Mandate on Multidrug-Resistant Organisms and Clostridioides difficile Infection Among Long-term Care Facility Residents

Objective To determine whether the long-term care facility (LTCF) Centers for Medicare & Medicaid Services (CMS) Antimicrobial Stewardship (AMS) mandate was associated with a change in the combined rate of LTCF-acquired multidrug-resistant organism infection or colonization (MDRO-I/C) and Clostridioides difficile infection (CDI). Design Retrospective quasi-experimental study. Setting A 233-bed community hospital. Participants LTCF residents 75 years of age and older with MDRO-I/C or CDI admitted to the hospital before the AMS mandate in 2015 through 2016 or after the mandate in 2018 through 2019. Intervention LTCF CMS AMS mandate. Main Outcomes Measures Rates of LTCF-acquired MDRO-I/C and CDI. MDRO-I/C were defined by a culture positive for methicillin-resistant Staphylococcus aureus or extended-spectrum beta-lactamase-producing Enterobacterales. CDI was defined by a positive test for C. difficile using a multistep algorithm of toxin, glutamate dehydrogenase, and nucleic acid amplification tests. These specimens must have been collected within 48 hours of hospital admission. Results There were 33 residents with either LTCF-acquired MDRO-I/C or CDI out of a total of 205 hospitalized residents with MDRO-I/C or CDI in 2015 and 2016, resulting in a rate of 16.10%. In comparison, there were 38 residents with either LTCF-acquired MDRO-I/C or CDI out of a total of 253 hospitalized residents with MDRO-I/C or CDI in 2018 and 2019 resulting in a rate of 15.02%. The difference in the combined rate of LTCF-acquired MDRO-I/C and CDI was -1.08% (P = 0.75). Conclusion The AMS mandate was not associated with a significant change in the combined rate of LTCF-acquired MDRO-I/C and CDI, suggesting a need for more robust AMS programs in LTCFs.

Prevalence and antimicrobial resistance pattern of Clostridium difficile among hospitalized diarrheal patients: A systematic review and meta-analysis

Background

Clostridium difficile is the leading cause of infectious diarrhea that develops in patients after hospitalization during antibiotic administration. It has also become a big issue in community-acquired diarrhea. The emergence of hypervirulent strains of C. difficile poses a major problem in hospital-associated diarrhea outbreaks and it is difficult to treat. The antimicrobial resistance in C. difficile has worsened due to the inappropriate use of broad-spectrum antibiotics including cephalosporins, clindamycin, tetracycline, and fluoroquinolones together with the emergence of hypervirulent strains.

Objective

To estimate the pooled prevalence and antimicrobial resistance pattern of C. difficile derived from hospitalized diarrheal patients, a systematic review and meta-analysis was performed.

Methods

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed to review published studies conducted. We searched bibliographic databases from PubMed, Scopus, Google Scholar, and Cochrane Library for studies on the prevalence and antimicrobial susceptibility testing on C. difficile. The weighted pooled prevalence and resistance for each antimicrobial agent was calculated using a random-effects model. A funnel plot and Egger’s regression test were used to see publication bias.

Results

A total of 15 studies were included. Ten articles for prevalence study and 5 additional studies for antimicrobial susceptibility testing of C. difficile were included. A total of 1967/7852 (25%) C. difficile were isolated from 10 included studies for prevalence study. The overall weighted pooled proportion (WPP) of C. difficile was 30% (95% CI: 10.0–49.0; p<0.001). The analysis showed substantial heterogeneity among studies (Cochran’s test = 7038.73, I2 = 99.87%; p<0.001). The weighed pooled antimicrobial resistance (WPR) were: vancomycin 3%(95% CI: 1.0–4.0, p<0.001); metronidazole 5%(95% CI: 3.0–7.0, p<0.001); clindamycin 61%(95% CI: 52.0–69.0, p<0.001); moxifloxacin 42%(95% CI: 29–54, p<0.001); tetracycline 35%(95% CI: 22–49, p<0.001); erythromycin 61%(95% CI: 48–75, p<0.001) and ciprofloxacin 64%(95% CI: 48–80; p< 0.001) using the random effect model.

Conclusions

A higher weighted pooled prevalence of C. difficile was observed. It needs a great deal of attention to decrease the prevailing prevalence. The resistance of C. difficile to metronidazole and vancomycin was low compared to other drugs used to treat C. difficile infection. Periodic antimicrobial resistance monitoring is vital for appropriate therapy of C. difficile infection.

Immunosuppression and Clostridioides (Clostridium) difficile Infection Risk in Metabolic and Bariatric Surgery Patients

BACKGROUND

Immunosuppressant use increases risk of Clostridioides (Clostridium) difficile infection. To date, no studies have analyzed the relationship between immunosuppressant use and C difficile infections after metabolic and bariatric surgery (MBS).

METHODS

A retrospective analysis of the 2015-2018 MBSAQIP data was conducted. The MBSAQIP data include information from 854 affiliated practices in the US and Canada. Initial sample size was 760,076 MBS patients. After excluding participants due to missing variables (n = 188,106) and the use of surgical procedures other than Roux-en-Y gastric bypass and sleeve gastroplasty (n = 129,712), final analyses were performed on 442,258 participants. Logistic regression models generated the odds of C difficile infection developing post MBS, according to immunosuppressant status (positive or negative).

RESULTS

Unadjusted logistic regression analysis showed that patients using immunosuppressants were 95% more likely to have postoperative C difficile infection (odds ratio 1.945; 95% CI, 1.230 to 3.075; p < 0.001) vs MBS patients not taking immunosuppressants. After adjusting for age, sex, ethnicity, preoperative BMI, diabetes status, and surgical procedure type, the association remained unaffected (adjusted odds ratio 1.956; 95% CI, 1.236 to 3.095; p < 0.01). Patients who completed the laparoscopic Roux-en-Y gastric bypass procedure had more than double the odds of C difficile infection developing compared with those who completed the laparoscopic sleeve gastrectomy procedure (odds ratio 2.183; 95% CI, 1.842 to 2.587; p < 0.0001).

CONCLUSIONS

Our results using a population-based sample of MBS patients showed that those taking immunosuppressants have a significantly higher risk of developing Clostridioides (Clostridium) difficile infection postoperatively. These findings suggest that patients using immunosuppressants should be closely monitored both pre and post procedure.

Use of culture- and ELISA-based toxin assay for detecting Clostridium Difficile, a neglected pathogen: A single-center study from a tertiary care setting

INTRODUCTION:

Clostridium difficile is a Gram-positive spore-bearing anaerobic bacillus increasingly associated with both community- and hospital-acquired colitis and diarrhea. It is the most common identifiable bacterial cause of healthcare-associated diarrhea associated with antibiotic use and one of the most common anaerobic infections. The diagnosis of C. difficile infection includes detection of toxin A/B in stool specimens by direct enzyme immunoassay, culture of pathogen from the stool specimens using a selective agar Cycloserine-Cefoxitin fructose agar (CCFA), tissue culture assay, and detection of glutamate dehydrogenase an enzyme produced by C. difficile. With few reports from India on this disease, the present study was planned to throw more light on the prevalence and utility of laboratory diagnostic methods for C. difficile-associated diarrhea (CDAD).

MATERIAL AND METHODS:

After taking approval from the Ethics Committee, 150 patients with antibiotic-associated diarrhea were taken as a study group and fifty patients with exposure to antibiotics but who did not develop diarrhea were taken as controls. Stool specimen was processed for both culture on CCFA and toxin detection by IVD Tox A + B ELISA.

RESULTS:

Only four specimens were culture positive, whereas 13 were ELISA positive. All culture-positive isolates were toxigenic. C. difficile was neither isolated nor its toxin detected in the control group. Culture- and toxin-based assays may not detect all cases of CDAD.

CONCLUSION:

Based on the results of the present study, culture does not provide any additional yield over toxin assay. Better diagnostic modalities would be required to prove CDAD.

Clostridioides difficile incidence related to in-hospital cephalosporin use: a tale of two highly comparable hospitals

Background

Antibiotic treatment is a well-known risk factor for healthcare facility-associated Clostridioides (Clostridium) difficile infection (HCF-CDI). Antibiotic stewardship programmes (ASPs) targeting high-risk antibiotics have been shown to decrease HCF-CDI incidence. HCF-CDI incidence is high in Nordic countries despite relatively low antibiotic use in hospital.

Objectives

To determine if HCF-CDI incidence was modified by a hospital ASP that restricted cephalosporin use.

Methods

The effects of an ASP on HCF-CDI incidence were evaluated in a two-centre setting using a retrospective design. We exploited a strategy of both individual case ascertainment based on chart reviews and aggregated data from the hospitals. Cases were attributed to the antibiotics given prior to disease onset, in proportion to the number of DDDs used. Three periods were studied: 2007 (before the ASP), 2012 and 2015.

Results

At the ASP hospital, cephalosporin use decreased by 87% and the number of HCF-CDI/1000 hospital admissions decreased significantly from 2.25 (2007) to 1.16 (2015) (P = 0.0014). The corresponding results at the non-ASP hospital showed a non-significant increase from 2.09 to 2.38. A high number of cases could be attributed to cephalosporins at both hospitals. The increased use of other broad-spectrum antibiotics, e.g. piperacillin/tazobactam, at the ASP hospital was not associated with offsetting increases in attributable HCF-CDI cases.

Conclusions

Decreased use of cephalosporins is an effective strategy to decrease HCF-CDI incidence over time in a setting with high incidence and low antibiotic use.

An Unusual Presentation of Pseudomembranous Colitis

Pseudomembranous colitis, also called antibiotic-associated colitis, is caused by the gram-positive anaerobic bacterium Clostridium difficile (C.difficile). The infection is common in elderly patients on chronic antibiotic use and in immunosuppressed patients. We report a rare case of pseudomembranous colitis in a 49-year-old male who presented with cramping abdominal pain, abdominal distension, and loose stools, without any pre-existing immunosuppression or chronic drug intake. The computed tomography (CT) picture was suggestive of fulminant ulcerative colitis and the patient underwent total colectomy in view of severe disease. This patient also had rectal bleeding caused by a bleeding pseudoaneurysm of the right internal pudendal artery, which posed diagnostic and therapeutic challenges. Embolization of the pseudoaneurysm was done in the post-operative period. Though the clinical and radiological pictures were suggestive of ulcerative colitis in our patient, this was disproved in the histopathological examination and by the negative serum anti-Saccharomyces cerevisiae antibodies (ASCA) testing. The presence of extensive pseudomembranous colitis in this patient masked the bleeding pseudoaneurysm of the internal pudendal artery, as bleeding is a common presentation in fulminant colitis, leading to a delay in the management of the pseudoaneurysm. Such a presentation was not reported in the literature to the best of our knowledge. Considering co-existent pathologies, especially in patients who present with an unobvious clinical picture, can prevent delay in the definitive diagnosis of these conditions.

Pancreatic disease patients are at higher risk for Clostridium difficile infection compared to those with other co-morbidities

Background

Surveillance of Clostridium difficile infection (CDI) in patients with underlying diseases is important because use of prophylactic antibiotics makes them prone to CDI. Epidemiology of CDI in this high-risk population is poorly understood. A study was conducted to evaluate the impact of CDI in patients with specific underlying co-morbidities.

Method

A total of 2036 patients, whose fecal samples were processed for C. difficile toxin A and B assay by ELISA formed the basis of study. Patients with underlying diseases were classified based on the organ/kind of disease as pancreatic (n = 340), renal (n = 408), hepatic (n = 245), malignant (n = 517) and miscellaneous disease (n = 526). Laboratory records of clinical and demographic details were reviewed. The association of CDI with age, gender, antibiotic receipt, clinical symptoms and underlying co-morbidities was analyzed. Variation in CDI cases based on age groups was also investigated.

Result

Clostridium difficile toxin positivity was 21.6% in general, whereas it was 30.6% in the pancreatic, 17.9% in the renal, 19.6%, in the hepatic, 21.3% in the malignancy and 20.0% in the miscellaneous disease groups. Toxin positivity was the lowest (14.8%) for female gender under renal disease and the highest (31.8%) for patients aged 40 to < 60 years, under pancreatic disease. Bloody diarrhea was a significant predictor for C. difficile toxin positivity. C. difficile toxin status irrespective to the underlying diseases was neither dependent on gender, age-groups or the number of antibiotics used. Association between patients’ gender, age and antibiotics receipt with underlying disease conditions, respective to C. difficile toxin status showed significance in relation to male gender (p < 0.05), age 40 to < 60 years (p = 0.03) and those receiving single (p = 0.09) or multiple antibiotics (p = 0.07).

Conclusion

Pancreatic disease patients are at a higher risk for developing CDI, and particularly male gender, age 40 to < 60 years and those receiving antibiotics are at significant risk.

Clinico-microbiological analysis of toxigenic clostridium difficile from hospitalised patients in a tertiary care hospital, Mangalore, Karnataka, India

Purpose

Prevalence of Clostridium difficile, an anaerobic, Gram-positive, spore-forming bacillus, is very much underestimated in India. The present study was intended to assess the burden of toxigenic C. difficile in hospitalised patients with clinically significant diarrhoea and analysis of their clinical picture.

Materials and Methods

This cross-sectional study was conducted in a tertiary care teaching hospital, South India, from January 2012 to December 2014. Stool samples were collected consecutively from 563 inpatients from various wards. The prevalence of toxigenic C. difficile was determined by toxigenic culture and a two-step algorithm. The clinical spectrum of these patients was also analysed. Associated pathogens were identified using standard procedures. Statistical analysis was done by frequency, percentage, Chi-square test and z-test.

Results

Out of the 563 stool samples analysed, the prevalence of toxigenic C. difficile was 12.79% and that of non-toxigenic C. difficile was 10.83%. The prevalence of toxigenic C. difficile among oncology patients was highly significant (HS). Antibiotic treatment, prolonged hospital stay and underlying diseases/conditions were the risk factors which were HS, and fever was the significant clinical feature among the patients. Escherichia coli was the predominant associated pathogen isolated (18.47%).

Conclusion

The presence of toxigenic C. difficile in our locality is a matter of concern. Constant supervision, appropriate treatment and preventive measures are crucial in controlling C. difficile infection.

Sensitivity of Single-Molecule Array Assays for Detection of Clostridium difficile Toxins in Comparison to Conventional Laboratory Testing Algorithms

Guidelines recommend the use of an algorithm for the laboratory diagnosis of Clostridium difficile infection (CDI). Enzyme immunoassays (EIAs) detecting C. difficile toxins cannot be used as standalone tests due to suboptimal sensitivity, and molecular tests suffer from nonspecificity by detecting colonization.

Guidelines recommend the use of an algorithm for the laboratory diagnosis of Clostridium difficile infection (CDI). Enzyme immunoassays (EIAs) detecting C. difficile toxins cannot be used as standalone tests due to suboptimal sensitivity, and molecular tests suffer from nonspecificity by detecting colonization. Sensitive immunoassays have recently been developed to improve and simplify CDI diagnosis. Assays detecting CD toxins have been developed using single-molecule array (SIMOA) technology. SIMOA performance was assessed relative to a laboratory case definition of CDI defined by positive glutamate dehydrogenase (GDH) screen and cell cytotoxicity neutralizing assay (CCNA). Samples were tested with SIMOA assays and a commercial toxin EIA to compare performance, with discrepancy resolution using a commercial nucleic acid-based test and a second cell cytotoxicity assay. The SIMOA toxin A and toxin B assays showed limits of detection of 0.6 and 2.9 pg/ml, respectively, and intra-assay coefficients of variation of less than 10%. The optimal clinical thresholds for the toxin A and toxin B assays were determined to be 22.1 and 18.8 pg/ml, respectively, with resultant sensitivities of 84.8 and 95.5%. In contrast, a high-performing EIA toxin test had a sensitivity of 71.2%. Thus, the SIMOA assays detected toxins in 24% more samples with laboratory-defined CDI than the high performing toxin EIA (95% [63/66] versus 71% [47/66]). This study shows that SIMOA C. difficile toxin assays have a higher sensitivity than currently available toxin EIA and have the potential to improve CDI diagnosis.

Toxigenic Clostridium difficile isolates from clinically significant diarrhoea in patients from a tertiary care centre

Background & objectives:

Clostridium difficile is the primary cause of hospital-acquired colitis in patients receiving antibiotics. The pathogenicity of the organism is mainly due to the production of toxins. This study was conducted to investigate the presence of toxigenic C. difficile in the faecal samples of hospitalized patients suspected to have C. difficile infection (CDI) and corroborating the findings with their clinical and demographic data.

Methods:

Diarrhoeic samples obtained from 1110 hospitalized patients were cultured for C. difficile and the isolates confirmed by phenotypic and molecular methods. Toxigenicity of the isolates was determined using enzyme-linked immunosorbent assay for toxins A and B. Details of patients included in the study were noted and analyzed.

Results:

Of the 1110 patients (mean age 39±19.6 yr), 63.9 per cent were males and 36.1 per cent were females. The major antibiotics received by the patients were nitazoxanide (23.9%), penicillins/penicillin combinations (19.0%), quinolones including fluoroquinolones (13.1%), carbapenems (11.5%), glycopeptides (11.0%) and cephalosporins (8.4%). The clinical symptoms predominantly present were watery diarrhoea (56.4%), fever (40.0%) and abdominal pain (35.3%). The underlying diseases were gastrointestinal disorders (52.6%), followed by cancers (13.2%), surgical conditions (8.3%), and hepatic disorders (8.0%). Of the 174 C. difficile isolates, 54.6 per cent were toxigenic. Toxigenic C. difficile was present in all patients with surgical conditions, 65.2 per cent with cancers and 57.1 per cent with gastrointestinal disorders.

Interpretation & conclusions:

C. difficile was found to be an important cause of gastrointestinal infections in hospitalized patients with underlying diseases and on antibiotics. Clinical conditions of the patients correlating with toxigenic culture can be an important tool for establishing CDI diagnosis.

Clostridium difficile colitis: review of the therapeutic approach

Clostridium difficile infection (CDI) is the leading cause of antibiotic-associated and nosocomial infectious diarrhea. Presenting as clostridium difficile colitis, it is a significant cause of morbidity and mortality. Metronidazole is regarded as the agent of choice for CDl therapy and also for the first recurrence in most patients with mild to moderate CDI. Vancomycin is recommended as an initial therapy for patients with severe CDI. With recent Food and Drug Administration-approval fidaxomicin is available for clinical use and is as effective as vancomycin with lower relapse rates. Rifaximin and fecal bacteriotherapy are alternative approaches in patients with severe or refractory CDI, before surgical intervention. Antibiotic research is ongoing to add potential new drugs such as teicoplanin, ramoplanin, fusidic acid, nitazoxanide, rifampin, bacitracin to our armamentarium. Role of toxin-binding agents is still questionable. Monoclonal antibody and intravenous immunoglobulin are still investigational therapies that could be promising options. The ongoing challenges in the treatment of CDI include management of recurrence and presence of resistance strains such as NAP1/BI/027, but early recognition of surgical candidates can potentially decrease mortality in CDI.

Prevalence of clostridium difficile among paediatric patients in a tertiary care hospital, coastal karnataka, South India

INTRODUCTION

The study was intended to analyse the burden of Clostridium difficile (C. difficile) and associated intestinal pathogens from children with diarrhoea who were hospitalized in a tertiary care teaching hospital of South India.

MATERIALS AND METHODS

Stool samples from 138 children with diarrhoea belonging to the age group 0-14 years were analysed by semi quantitative culture, latex agglutination and enzyme immunoassay for C. difficile. The associated intestinal pathogens were also detected from the specimens by standard procedures.

RESULTS

Stool samples of 138 children were tested during the period; 21 (15.22%) samples were culture positive for C. difficile and the isolates were confirmed by biochemical reactions. 9(6.52%) were positive by latex agglutination. EIA for C. difficile toxins A and B was done on all the stool specimens and 15 were found to be positive (10.87 %). According to the reference standard method employed in our study, 4 toxigenic C. difficile isolates (2.90%) were obtained from 138 specimens. Among the other intestinal pathogens, Escherichia coli predominated (22.46%). Rota virus was detected in 7.27% stool samples of children under the age of five years.

CONCLUSION

The study shows the prevalence of C. difficile in hospitalized children in our locality which highlights the importance of judicious use of antibiotics and strict infection control measures.

Ciprofloxacin Affects Host Cells by Suppressing Expression of the Endogenous Antimicrobial Peptides Cathelicidins and Beta-Defensin-3 in Colon Epithelia

Antibiotics exert several effects on host cells including regulation of immune components. Antimicrobial peptides (AMPs), e.g., cathelicidins and defensins display multiple functions in innate immunity. In colonic mucosa, cathelicidins are induced by butyrate, a bacterial fermentation product. Here, we investigated the effect of antibiotics on butyrate-induced expression of cathelicidins and beta-defensins in colon epithelial cells. Real-time PCR analysis revealed that ciprofloxacin and clindamycin reduce butyrate-induced transcription of the human cathelicidin LL-37 in the colonic epithelial cell line HT-29. Suppression of LL-37 peptide/protein by ciprofloxacin was confirmed by Western blot analysis. Immunohistochemical analysis demonstrated that ciprofloxacin suppresses the rabbit cathelicidin CAP-18 in rectal epithelia of healthy and butyrate-treated Shigella-infected rabbits. Ciprofloxacin also down-regulated butyrate-induced transcription of the human beta-defensin-3 in HT-29 cells. Microarray analysis of HT-29 cells revealed upregulation by butyrate with subsequent down-regulation by ciprofloxacin of additional genes encoding immune factors. Dephosphorylation of histone H3, an epigenetic event provided a possible mechanism of the suppressive effect of ciprofloxacin. Furthermore, LL-37 peptide inhibited Clostridium difficile growth in vitro. In conclusion, ciprofloxacin and clindamycin exert immunomodulatory function by down-regulating AMPs and other immune components in colonic epithelial cells. Suppression of AMPs may contribute to the overgrowth of C. difficile, causing antibiotic-associated diarrhea.

Clostridium difficile enteritis: a new role for an old foe

BACKGROUND

Small bowel involvement of Clostridium difficile is increasingly encountered. Data on many management aspects are lacking.

AIM

To synthesis existing reports and assess the frequency, pathophysiology, outcomes, risk factors, diagnosis and management of C. difficle enteritis.

METHODS

A systematic review of the literature was conducted to evaluate evidence regarding frequency, pathophysiology, risk factors, optimal diagnosis, management and outcomes for C. difficle enteritis. Three major databases (PubMed, MEDLINE and the Cochrane Library) were searched. The review included original articles reporting C. difficle enteritis from January 1950 to December 2012.

RESULTS

C. difficle enteritis is rare but increasingly encountered. Presentation is variable and distinct predisposing factors include emergency surgery, white race and increased age. Diagnosis generally involves a sensitive but often non specific screening test for C. difficile antigens. Oral metronidazole represents first line therapy and surgery may be required for complications. Outcomes are inconsistent but may be improving.

CONCLUSIONS

A high index of clinical suspicion, early diagnosis and treatment are vital. Further prospective studies are needed to determine the significance of asymptomatic small bowel C. difficile infections.

Clostridium difficile infection and fecal bacteriotherapy

Clostridium difficile, also called "C. diff," is a gram-positive bacillus associated with nosocomial infections involving diarrhea, most often seen in developing countries. The severity of C. diff-associated diarrhea varies tremendously from mild and self-limiting to fulminant and life-threatening. C. diff has become an extremely important pathogen in community health but can be minimized with attention to proper hygiene. This article presents a case study regarding the treatment and management options of C. diff infection using a recent update of clinical guidelines for patient management.

Clostridium difficile infection in newly diagnosed pediatric patients with inflammatory bowel disease: prevalence and risk factors

BACKGROUND

Epidemiological and microbiological data suggest that Clostridium difficile infection (CDI) plays a substantial role in the clinical initiation of inflammatory bowel disease (IBD). The aim of the present study was to investigate the prevalence and risk factors of CDI in newly diagnosed pediatric patients with IBD.

METHODS

The current investigation was a retrospective study. All patients newly diagnosed with IBD in the pediatric gastroenterology clinic in Warsaw between 2007 and 2010 were included in the present study. The patients were diagnosed according to Porto criteria and microbiology evaluation screening tests for CDI were conducted. Risk factors including prior hospitalization, use of antibiotics within 2 months of CDI detection, colonic involvement, and the duration of symptoms were evaluated. CDI diagnosis was based on a positive stool enzyme immunoassay.

RESULTS

In the present study, 134 patients were evaluated (54 patients with Crohn's disease, and 80 with ulcerative colitis; 87% of the patients had colonic disease). The average age of the patients was 12.3 years, and the prevalence of CDI was 47% (95% confidence interval [CI], 38%-56%). Significant differences in the prevalence of CDI between patients with Crohn's disease and ulcerative colitis (P = 0.72; odds ratio [OR] = 1.187, 95% CI, 0.56-2.52) were not observed. The risk of CDI was associated with an increase in the age of the patient and the severity of the disease.

CONCLUSIONS

The prevalence of CDI in newly diagnosed IBD patients was high and was independent of the type of disease.

Clostridium difficile of the ileum following total abdominal colectomy, with or without proctectomy: who is at risk?

BACKGROUND

Clostridium difficile enteritis is considered a rare entity, although recent data suggest a significant increase in prevalence and incidence. There is paucity of data evaluating risk factors of C difficile enteritis following total colectomy.

OBJECTIVE

The aim of this study was to determine the incidence and risk factors of C difficile enteritis for patients who had undergone total abdominal colectomy with or without proctectomy.

DESIGN

This study involves a retrospective chart review of 310 patients. Univariate analysis was performed on potential risk factors (p ≤ 0.05) with the use of a logistic regression model, and a Fisher exact test was used for variables that had no occurrences of C difficile. These groups of variables were then examined in a multiple variate setting with stepwise logistic regression analysis.

SETTINGS

This study was conducted at a tertiary referral center.

PATIENTS

A data analysis was performed on patients who had undergone total abdominal colectomy with or without proctectomy who were tested for C difficile of the ileum.

RESULTS

Twenty-two of 137 patients that were tested (16%) were positive for C difficile of the ileum. Univariate analysis of known risk factors for C difficile demonstrated that black race was a protective factor against C difficile (p = 0.016). The multivariate analysis demonstrated that emergency surgery (p = 0.035), race (p = 0.003), and increasing age by decade (p = 0.033) were risk factors for C difficile.

LIMITATIONS

This study was limited by the small patient sample, and it was not a randomized trial.

CONCLUSIONS

Black race is protective, and whites are 4 times more likely to acquire C difficile of the ileum after undergoing a total abdominal colectomy with or without proctectomy. The data also demonstrated that an increased age by a decade and emergency surgery are risk factors for C difficile enteritis, whereas the described risk factors of C difficile of the colon and type of colon surgery do not appear to influence the risk of C difficile of the ileum.

Infections, bacterial resistance, and antimicrobial stewardship: the emerging role of hospitalists

The care of patients with serious infections both within and outside healthcare settings is increasingly complicated by the high prevalence of resistant or multidrug-resistant (MDR) pathogens. Moreover, infections caused by MDR versus susceptible bacteria or other pathogens are associated with significantly higher mortality, length of hospital stay, and healthcare costs. Antimicrobial misuse or overuse is the primary driver for development of antimicrobial resistance, suggesting that better use of antimicrobials will translate into improved patient outcomes, more efficient use of hospital resources, and lowered healthcare costs. Antimicrobial stewardship refers to the various practices and procedures utilized to optimize antimicrobial use. The primary goal of antimicrobial stewardship is to improve patient outcomes and lower antimicrobial resistance and other unintended consequences of antimicrobial therapy. Secondary goals are to reduce length of hospital stays and healthcare-related costs. Hospitalists are increasingly involved in the care of hospitalized patients throughout the United States. Expertise in managing conditions requiring hospitalization, and experience in quality improvement across a wide range of clinical conditions, make hospitalists well positioned to participate in the development and implementation of hospital-based antimicrobial stewardship programs designed to improve patient outcomes, reduce antimicrobial resistance, and provide more efficient and lower-cost hospital care.

Hospital-acquired Clostridium difficile infection: determinants for severe disease

Risk factors of severity (need for surgical intervention, intensive care or fatal outcome) were analysed in hospital-acquired Clostridium difficile infection (CDI) in a 777-bed community hospital. In a prospective analytical cross-sectional study, age (≥ 65 years), sex, CDI characteristics, underlying diseases, severity of comorbidity and PCR ribotypes were tested for associations with severe CDI. In total, 133 cases of hospital-acquired CDI (mean age 74.4 years) were identified, resulting in an incidence rate of 5.7/10,000 hospital-days. A recurrent episode of diarrhoea occurred in 25 cases (18.8%) and complications including toxic megacolon, dehydration and septicaemia in 69 cases (51.9%). Four cases (3.0%) required ICU admission, one case (0.8%) surgical intervention and 22 cases (16.5%) died within the 30-day follow-up period. Variables identified to be independently associated with severe CDI were severe diarrhoea (odds ratio [OR] 3.64, 95% confidence interval [CI] 1.19-11.11, p=0.02), chronic pulmonary disease (OR 3.0, 95% CI 1.08-8.40, p=0.04), chronic renal disease (OR 2.9, 95% CI 1.07-7.81, p=0.04) and diabetes mellitus (OR 4.30, 95% CI 1.57-11.76, p=0.004). The case fatality of 16.5% underlines the importance of increased efforts in CDI prevention, in particular for patients with underlying diseases.

Clostridium difficile infection: clinical spectrum and approach to management

Clostridium difficile is recognized globally as an important enteric pathogen associated with considerable morbidity and mortality due to the widespread use of antibiotics. The overall incidence of C. difficile-associated diarrhea (CDAD) is increasing due to the emergence of a hypervirulent strain known as NAP1/BI/027. C. difficile acquisition by a host can result in a varied spectrum of clinical conditions inclusive of both colonic and extracolonic manifestations. Repeated occurrence of CDAD, manifested by the sudden re-appearance of diarrhea and other symptoms usually within a week of stopping treatment, makes it a difficult clinical problem. C. difficile infection has also been reported to be involved in exacerbation of inflammatory bowel diseases. The first step in the management of a suspected CDAD case is the withdrawal of the offending agent and changing the antibiotic regimens. Antimicrobial therapy directed against C. difficile viz. metronidazole for mild cases and vancomycin for severe cases is needed. For patients with ileus, oral vancomycin with simultaneous intravenous (IV) metronidazole and intracolonic vancomycin may be given. Depending on the severity of disease, the further line of management may include surgery, IV immunoglobulin treatment or high dose of vancomycin. Adjunctive measures used for CDAD are probiotics and prebiotics, fecotherapy, adsorbents and immunoglobulin therapy. Among the new therapies fidaxomicin has recently been approved by the American Food and Drugs Administration for treatment of CDAD.

Extended antimicrobial treatment of bacterial vaginosis combined with human lactobacilli to find the best treatment and minimize the risk of relapses

Background

The primary objective of this study was to investigate if extended antibiotic treatment against bacterial vaginosis (BV) together with adjuvant lactobacilli treatment could cure BV and, furthermore, to investigate factors that could cause relapse.

Methods

In all, 63 consecutive women with bacterial vaginosis diagnosed by Amsel criteria were offered a much more aggressive treatment of BV than used in normal clinical practice with repeated antibiotic treatment with clindamycin and metronidazole together with vaginal gelatine capsules containing different strains of lactobacilli both newly characterised and a commercial one (10⁹ freeze-dried bacteria per capsule). Oral clindamycin treatment was also given to the patient's sexual partner.

Results

The cure rate was 74.6% after 6 months. The patients were then followed as long as possible or until a relapse. The cure rate was 65.1% at 12 months and 55.6% after 24 months. There was no significant difference in cure rate depending on which Lactobacillus strains were given to the women or if the women were colonised by lactobacilli. The most striking factor was a new sex partner during the follow up period where the Odds Ratio of having a relapse was 9.3 (2.8-31.2) if the patients had a new sex partner during the observation period.

Conclusions

The study shows that aggressive treatment of the patient with antibiotics combined with specific Lactobacillus strain administration and partner treatment can provide long lasting cure. A striking result of our study is that change of partner is strongly associated with relapse of BV.

Trial registration

ClinicalTrials.gov: NCT01245322

Epidemiology and risk factors for Clostridium difficile infection in children

BACKGROUND

Pediatric Clostridium difficile infection (CDI)-related hospitalizations are increasing. We sought to describe the epidemiology of pediatric CDI at a quaternary care hospital.

METHODS

Nested case-control study within a cohort of children <18 years tested for C. difficile between January and August 2008. The study included patients who were ≥ 1 year with a positive test and diarrhea; those without diarrhea (ie, presumed colonization) were excluded. Two unmatched controls per case were randomly selected from patients ≥ 1 year with a negative test. Potential predictors of CDI included age, gender, comorbidities, prior hospitalization, receipt of C. difficile-active antibiotics in the prior 24 hours, and recent (≤ 4 weeks) exposure to antibiotics or acid-blocking medications. Multivariate logistic regression models were created to identify independent predictors of CDI.

RESULTS

Of 1891 tests performed, 263 (14%) were positive in 181 children. Ninety-five patients ≥ 1 year with CDI were compared with 238 controls. In multivariate analyses, predictors of CDI included solid organ transplant (odds ratio [OR], 8.09; 95% confidence interval [CI], 2.10-31.12), lack of prior hospitalization (OR, 8.43; 95% CI, 4.39-16.20), presence of gastrostomy or jejunostomy (G or J) tube (OR, 3.32; 95% CI 1.71-6.42), and receipt of fluoroquinolones (OR, 17.04; 95% CI, 5.86-49.54) or nonquinolone antibiotics (OR, 2.23; 95% CI, 1.18-4.20) in the past 4 weeks. Receipt of C. difficile-active antibiotics within 24 hours before testing was associated with a lower odds of CDI (OR, 0.22; 95% CI, 0.09-0.58).

CONCLUSIONS

Recent antibiotic exposure and certain comorbid conditions (solid organ transplant, presence of a gastrostomy or jejunostomy tube) were associated with CDI. Diagnostic testing has less utility in patients being treated with C. difficile-active antibiotics.

Clostridium difficile infection: An overview of the disease and its pathogenesis, epidemiology and interventions

Clostridium difficile infection (CDI) is the primary cause of antibiotic-associated diarrhea and is a significant nosocomial disease. In the past ten years, variant toxin-producing strains of C. difficile have emerged, that have been associated with severe disease as well as outbreaks worldwide. This review summarizes current information on C. difficile pathogenesis and disease, and highlights interventions used to combat single and recurrent episodes of CDI.