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Bussell C, Vincent J, Brust K. Implementation of a multidisciplinary process to improve diagnostic stewardship of hospital-onset Clostridioides difficile infections. Am J Infect Control 2023; 51:1329-1333. [PMID: 37295677 DOI: 10.1016/j.ajic.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/02/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Testing inappropriate stool samples for Clostridioides (Clostridium) difficile can lead to the identification of the patient colonized with C difficile and erroneous diagnosis of an active infection. We hypothesized that a multidisciplinary process to improve diagnostic stewardship could reduce our numbers of hospital-onset C difficile infection (HO-CDI). METHODS We created an algorithm describing appropriate stool specimens for polymerase chain reaction testing. The algorithm was converted into "ticket to test" checklist cards designed to accompany each specimen. Rejection of a specimen could occur via nursing staff or laboratory staff. RESULTS A baseline period of comparison was established from January 1, 2017 to June 30, 2017. Following implementation of all improvement strategies, a retrospective analysis was done, and the total number of HO-CDI cases in a 6-month period dropped from 57 to 32 cases. During the initial 3 months, the percentage of appropriate samples sent to the lab ranged from 41% to 65%. After the interventions were in place, the percentages improved between 71% and 91%. CONCLUSIONS A multidisciplinary approach led to improved diagnostic stewardship to identify true CDI cases. This, in turn, reduced the number of reported HO-CDIs, and resulted in potentially more than $1,080,000 in patient care savings.
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Affiliation(s)
- Charles Bussell
- Department of Internal Medicine, Baylor Scott & White Medical Center-Temple, Temple, TX; Division of Gastroenterology, Department of Internal Medicine, Baylor Scott & White Medical Center-Temple, Temple, TX.
| | - Jennifer Vincent
- Division of Gastroenterology, Department of Internal Medicine, Baylor Scott & White Medical Center-Temple, Temple, TX
| | - Karen Brust
- Division of Infectious Diseases, Department of Internal Medicine, Baylor Scott & White Medical Center-Temple, Temple, TX
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Bocchetti M, Ferraro MG, Melisi F, Grisolia P, Scrima M, Cossu AM, Yau TO. Overview of current detection methods and microRNA potential in Clostridioides difficile infection screening. World J Gastroenterol 2023; 29:3385-3399. [PMID: 37389232 PMCID: PMC10303512 DOI: 10.3748/wjg.v29.i22.3385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/23/2023] [Accepted: 05/04/2023] [Indexed: 06/06/2023] Open
Abstract
Clostridioides difficile (formerly called Clostridium difficile, C. difficile) infection (CDI) is listed as an urgent threat on the 2019 antibiotic resistance threats report in the United States by the Centers for Disease Control and Prevention. Early detection and appropriate disease management appear to be essential. Meanwhile, although the majority of cases are hospital-acquired CDI, community-acquired CDI cases are also on the rise, and this vulnerability is not limited to immunocompromised patients. Gastrointestinal treatments and/or gastrointestinal tract surgeries may be required for patients diagnosed with digestive diseases. Such treatments could suppress or interfere with the patient’s immune system and disrupt gut flora homeostasis, creating a suitable microecosystem for C. difficile overgrowth. Currently, stool-based non-invasive screening is the first-line approach to CDI diagnosis, but the accuracy is varied due to different clinical microbiology detection methods; therefore, improving reliability is clearly required. In this review, we briefly summarised the life cycle and toxicity of C. difficile, and we examined existing diagnostic approaches with an emphasis on novel biomarkers such as microRNAs. These biomarkers can be easily detected through non-invasive liquid biopsy and can yield crucial information about ongoing pathological phenomena, particularly in CDI.
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Affiliation(s)
- Marco Bocchetti
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli,” Naples 80138, Italy
- Department of Molecular Oncology, Precision Medicine Laboratory and COVID19 Laboratory, Biogem Scarl, Ariano Irpino 83031, Italy
| | - Maria Grazia Ferraro
- School of Infection and Immunity, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow G12 8QQ, United Kingdom
- Department of Pharmacy, School of Medicine and Surgery, University of Naples “Federico II,” Naples 80131, Italy
| | - Federica Melisi
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli,” Naples 80138, Italy
- Department of Molecular Oncology, Precision Medicine Laboratory and COVID19 Laboratory, Biogem Scarl, Ariano Irpino 83031, Italy
| | - Piera Grisolia
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli,” Naples 80138, Italy
- Department of Molecular Oncology, Precision Medicine Laboratory and COVID19 Laboratory, Biogem Scarl, Ariano Irpino 83031, Italy
| | - Marianna Scrima
- Department of Molecular Oncology, Precision Medicine Laboratory and COVID19 Laboratory, Biogem Scarl, Ariano Irpino 83031, Italy
| | - Alessia Maria Cossu
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli,” Naples 80138, Italy
- Department of Molecular Oncology, Precision Medicine Laboratory and COVID19 Laboratory, Biogem Scarl, Ariano Irpino 83031, Italy
| | - Tung On Yau
- School of Science and Technology, Nottingham Trent University, Nottingham NG11 8NS, United Kingdom
- Department of Rural Land Use, Scotland’s Rural College, Aberdeen AB21 9YA, Scotland, United Kingdom
- Department of Health Science, University of the People, Pasadena, CA 9110112, United States
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Impact of Nucleic Acid Amplification Test on Clinical Outcomes in Patients with Clostridioides difficile Infection. Antibiotics (Basel) 2023; 12:antibiotics12030428. [PMID: 36978295 PMCID: PMC10044602 DOI: 10.3390/antibiotics12030428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 02/06/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023] Open
Abstract
A nucleic acid amplification test (NAAT) is recommended to determine whether or not patients have a Clostridioides difficile infection (CDI) when the glutamate dehydrogenase activity assay is positive and the rapid membrane enzyme immunoassays for toxins is negative. In our hospital, a NAAT was introduced to diagnose CDI precisely in April 2020. This study aimed to investigate the impact of a NAAT on the clinical outcomes in patients with CDI at our hospital. Seventy-one patients diagnosed with CDI between April 2017 and March 2022 were included in our study. Patients with CDI were divided into two groups: before (pre-NAAT) and after (post-NAAT) the introduction of NAAT. The clinical outcome was compared between the two groups. Of the 71 patients with CDI, 41 were sorted into the pre-NAAT group and 30 into the post-NAAT group. The clinical cure rate was significantly higher in the post-NAAT group compared to the pre-NAAT group (76.7% vs. 48.8%, p = 0.018). In the multivariable analysis, the clinical cure was significantly associated with the introduction of NAAT (p = 0.022). Our findings suggest that the introduction of NAAT can improve the clinical outcomes in CDI patients.
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Raeisi H, Azimirad M, Asadzadeh Aghdaei H, Yadegar A, Zali MR. Rapid-format recombinant antibody-based methods for the diagnosis of Clostridioides difficile infection: Recent advances and perspectives. Front Microbiol 2022; 13:1043214. [PMID: 36523835 PMCID: PMC9744969 DOI: 10.3389/fmicb.2022.1043214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/13/2022] [Indexed: 08/30/2023] Open
Abstract
Clostridioides difficile, the most common cause of nosocomial diarrhea, has been continuously reported as a worldwide problem in healthcare settings. Additionally, the emergence of hypervirulent strains of C. difficile has always been a critical concern and led to continuous efforts to develop more accurate diagnostic methods for detection of this recalcitrant pathogen. Currently, the diagnosis of C. difficile infection (CDI) is based on clinical manifestations and laboratory tests for detecting the bacterium and/or its toxins, which exhibit varied sensitivity and specificity. In this regard, development of rapid diagnostic techniques based on antibodies has demonstrated promising results in both research and clinical environments. Recently, application of recombinant antibody (rAb) technologies like phage display has provided a faster and more cost-effective approach for antibody production. The application of rAbs for developing ultrasensitive diagnostic tools ranging from immunoassays to immunosensors, has allowed the researchers to introduce new platforms with high sensitivity and specificity. Additionally, DNA encoding antibodies are directly accessible in these approaches, which enables the application of antibody engineering to increase their sensitivity and specificity. Here, we review the latest studies about the antibody-based ultrasensitive diagnostic platforms for detection of C. difficile bacteria, with an emphasis on rAb technologies.
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Affiliation(s)
- Hamideh Raeisi
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoumeh Azimirad
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Asadzadeh Aghdaei
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Abbas Yadegar
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Zali
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Evaluation of Two Rapid Diagnostic Clostridioides difficile Infection Tests in a Chinese Hospital: A Real-world Analysis. Jundishapur J Microbiol 2022. [DOI: 10.5812/jjm-129130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Accurate diagnosis is essential for optimal prevention and treatment of Clostridioides difficile infection (CDI), and various diagnostic methods must be evaluated. Objectives: We aimed to evaluate and compare the performance of VIDAS C. difficile, C. DIFF QUIK CHEK COMPLETE (QCC), and toxigenic culture (TC) tests for diagnosing CDI and further determine the relationships between clinical factors and the toxin status of patients. Methods: Stool samples were randomly selected for VIDAS or QCC testing according to the manufacturer’s instructions between May 2017 and May 2021, and their performance was compared with that of TC. Clinical information was obtained from the hospital’s electronic medical records. Results: Among 10,897 samples tested, 6,435 and 4,462 samples were assigned for VIDAS and QCC tests, respectively. A total of 9.1% (996/10,897) of the samples were positive for TC. The sensitivity, specificity, positive predictive value, and negative predictive value were 36.6%, 98.6%, 72.1%, and 87.6% for VIDAS toxins A and B testing and 31.6%, 98.2%, 64.0%, and 87.8% for QCC toxin testing, respectively. Our results showed that the clinical data of the patients with positive and detectable toxins were not significantly different. Conclusions: The VIDAS and QCC tests provide rapid screening assays for the laboratory diagnosis of CDI. However, a more specific test to detect free toxins is required to confirm the diagnosis for glutamate dehydrogenase (GDH)-positive and toxin-negative samples. The clinical characteristics and outcomes of this cohort were similar, regardless of the results of toxins A and B testing.
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Risk Factors for Recurrence of Clostridioides difficile in Hospitalized Patients. J Infect Public Health 2021; 14:1642-1649. [PMID: 34627059 DOI: 10.1016/j.jiph.2021.09.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 09/02/2021] [Accepted: 09/16/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Diarrhea and pseudomembranous colitis associated with Clostridioides difficile - a spore-forming anaerobic Gram-positive bacillus - is a major infection in hospitalized patients with a profound impact on clinical and economic outcomes. Recurrence (rCDI) is common and predisposes to further episodes with poor outcomes. METHOD We aimed to identify a wide range of risk factors for recurrence to guide stewardship initiatives. After ethical approval, we commenced collecting demographic and clinical data of patients older than 18 years with clinically and microbiologically confirmed C. difficile infection. Data were statistically analyzed using R software. RESULTS Of 204 patients included in the analysis, 36 (18%) suffered 90-day recurrence, rCDI was higher among females (23%) compared to males (13%), overall age median (IQR) was 66 (51-77), and for rCDI cases 81 (69-86) years. Among 26 variables analyzed to evaluate their association with rCDI, prior clindamycin exposure, concurrent use of aztreonam, patients >76 years, total hospital length of stay, and LOS before diagnosis ≤7 days, WBC ≤ 9.85 × 103 at discharge were more likely to experience rCDI. CONCLUSION As identified in this analysis, patients with risk factors for rCDI could be candidates for close monitoring, a high index of suspicion, and risk mitigation interventions to avoid rCDI and improve clinical outcomes.
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Clostridioides difficile Infection. Dis Colon Rectum 2021; 64:650-668. [PMID: 33769319 DOI: 10.1097/dcr.0000000000002047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Chang FC, Liu CP, Sun FJ, Lin CC. Optimizing laboratory workflow for the diagnosis of Clostridiodes difficile infection in a medical center in Northern Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2021; 54:284-289. [DOI: 10.1016/j.jmii.2019.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 08/22/2019] [Accepted: 08/25/2019] [Indexed: 01/24/2023]
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Ghia CJ, Waghela S, Rambhad GS. Systematic Literature Review on Burden of Clostridioides difficile Infection in India. CLINICAL PATHOLOGY (THOUSAND OAKS, VENTURA COUNTY, CALIF.) 2021; 14:2632010X211013816. [PMID: 34104883 PMCID: PMC8170333 DOI: 10.1177/2632010x211013816] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/26/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Owing to limited diagnostic facilities and surveillance protocols, there is a paucity on the prevalence data of Clostridioides difficile infections (CDIs) in developing countries such as India. OBJECTIVE The aims of these studies are (1) to determine the prevalence of CDI in India, (2) to understand the risk factors of CDI, and (3) to determine the impact of different diagnostic methods on reported CDI rates. METHOD A systematic literature search was conducted using PubMed and Google Scholar database to identify Indian studies reporting the prevalence of CDI. A total of 31 studies, published between 1990 and 2020 were included in the final analysis. A chi-square test was used to determine statistically significant association between prevalence rates, accuracy of different diagnosis methods, and antibiotic usage rates of CDI. RESULTS The prevalence of CDI was in the range of 3.4% to 18%, and the difference between regional prevalence of CDI was statistically significant (P < .001). The use of antibiotics, hospital stay, comorbidities, recent surgery, and the use of proton-pump inhibitors was considered as risk factors for the development of CDI. Compared to other regions, the rate of antibiotic usage was significantly higher in North India (P < .001). Among different diagnostic methods, C. difficile detection was significantly higher with enzyme-linked immunosorbent assay (18.02%) versus other multiple testing methods used (P < .001). CONCLUSION There is a significant burden of CDI across the country. Further surveillance studies are required to monitor changes in prevalence of CDI, risk factors, and accuracy of diagnosis methods for a better understanding of the disease burden in India.
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Affiliation(s)
- Canna J Ghia
- Medical and Scientific Affairs, Pfizer Limited,
Mumbai, India
| | - Shaumil Waghela
- Medical and Scientific Affairs, Pfizer Limited,
Mumbai, India
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Zhou H, Xu Q, Liu Y, Guo LT. Risk factors, incidence, and morbidity associated with antibiotic-associated diarrhea in intensive care unit patients receiving antibiotic monotherapy. World J Clin Cases 2020; 8:1908-1915. [PMID: 32518780 PMCID: PMC7262719 DOI: 10.12998/wjcc.v8.i10.1908] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 04/09/2020] [Accepted: 04/28/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND This study aimed to identify factors associated with antibiotic-associated diarrhea (AAD) in patients in the department of intensive care medicine who received antibiotic monotherapy in order to reduce the incidence of AAD and improve rational use of antibiotics in these patients.
AIM To report the incidence of AAD and the factors associated with AAD in patients receiving antibiotic monotherapy.
METHODS The study used a single-center retrospective design. A total of 209 patients were enrolled. Patients were divided into two groups: No-AAD group (without AAD) and AAD group (with AAD). There were 45 cases in the AAD group and 164 cases in the no-AAD group. Clinical data of all patients were collected. Data were analyzed using SPSS (version 18.0), and statistical significance was set at P < 0.05.
RESULTS The overall incidence of AAD was 21.53%. Age [odds ratio (OR) 1.022, 95% confidence interval (CI): 1.001-1.044, P = 0.040], proton pump inhibitor usage time (OR 1.129, 95%CI: 1.020-1.249, P = 0.019), antibiotic usage time (OR 1.163, 95%CI: 1.024-1.320, P = 0.020), and intensive care unit (ICU) stay time (OR 1.133, 95%CI: 1.041-1.234, P = 0.004) were associated with AAD in ICU patients receiving antibiotic monotherapy. mean ± SD ICU stay time was lower in the no-AAD group (8.49 ± 6.31 vs 15.89 ± 10.69, P < 0.001). However, there was no significant difference in ICU-related mortality rates between the two groups (P = 0.729).
CONCLUSION Older age, longer ICU stay time, duration of use of proton pump inhibitors, and duration of antibiotic increase the incidence of AAD in ICU patients receiving antibiotic monotherapy.
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Affiliation(s)
- Hong Zhou
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Qiang Xu
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Yu Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Li-Tao Guo
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
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Martins JP, Felgueiras M, Santos R. The reference method influence on the sensitivity of the Clostridium difficile enzyme immunoassays: A meta analysis. J Microbiol Methods 2020; 173:105912. [PMID: 32278778 DOI: 10.1016/j.mimet.2020.105912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 03/22/2020] [Accepted: 03/31/2020] [Indexed: 11/16/2022]
Abstract
The use of enzyme immunoassays to screen for toxins A and B produced by Clostridium difficile is a common procedure in algorithms designed for its detection. Moreover, the absence of a unique test capable of providing reliable results at low cost motivates a great discussion about which algorithm is the best. Thus, several studies have evaluated the performance of these enzyme immunoassays. However, all fail to provide sufficient explanations for the different behaviours observed in different studies that evaluate the same index test against a common reference method. Our main goal was to find out which factors affect the sensitivity of these assays, since the specificity is very close to 1. In this research, we verified that sensitivity increases with the prevalence rate and with the proportion of reported cases of onset diarrhea. Therefore, its use is advisable for high prevalence rates (e.g. in an epidemic setting). As far as reference methods are concerned, nucleic acid amplification tests can be used as a reference method, with a performance similar to the well-accepted toxigenic culture. The method chosen for toxigenicity screening in a toxigenic culture also seems to affect the evaluation performance of tests and should be better studied in the future.
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Affiliation(s)
- João Paulo Martins
- ESTG, Polytechnic Institute of Leiria, Campus 2, Morro do Lena Alto do Vieiro, Apartado 4163, 2411-901 Leiria, Portugal; CEAUL - Centre of Statistics and its Applications, Faculdade de Ciências da Universidade de Lisboa, Campo Grande, 1749-016 Lisboa, Portugal.
| | - Miguel Felgueiras
- ESTG, Polytechnic Institute of Leiria, Campus 2, Morro do Lena Alto do Vieiro, Apartado 4163, 2411-901 Leiria, Portugal; CARME, Polytechnic Institute of Leiria, Campus 2, Morro do Lena Alto do Vieiro, Apartado 4163, 2411-901 Leiria, Portugal; CEAUL - Centre of Statistics and its Applications, Faculdade de Ciências da Universidade de Lisboa, Campo Grande, 1749-016 Lisboa, Portugal
| | - Rui Santos
- ESTG, Polytechnic Institute of Leiria, Campus 2, Morro do Lena Alto do Vieiro, Apartado 4163, 2411-901 Leiria, Portugal; CEAUL - Centre of Statistics and its Applications, Faculdade de Ciências da Universidade de Lisboa, Campo Grande, 1749-016 Lisboa, Portugal
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Diagnostic stewardship of Clostridioides difficile polymerase chain reaction results from syndromic diarrhea panel and implications for patient outcomes. Diagn Microbiol Infect Dis 2020; 97:115032. [PMID: 32299633 DOI: 10.1016/j.diagmicrobio.2020.115032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 02/27/2020] [Accepted: 02/28/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND A syndromic gastrointestinal pathogen panel (GIP) was implemented in May 2018. All positive (+) GIP and standard-of-care (SOC) C. difficile results were reviewed. METHODS A single-center audit of adult patients with GIP results was conducted May-December 2018. We reviewed GIP(+)/SOC(+/-) and GIP(-)/SOC(-) tests (control group) for clinical outcomes. RESULTS We reviewed 269 GIP(+) patients. Of 119 GIP(+)/SOC(+) patients, 44 (37%) were positive by toxin A/B enzyme immunoassay, and 75 (63%) by PCR only. Thirty-day mortality and re-admission were not significantly different between groups. CDI rates within 6 months were not significantly different between GIP(+)/SOC(-) and controls (p-value = 0.39). Those with initial SOC(+) tests had more true CDI events within 6 months, compared to controls (p-values < 0.001). CONCLUSIONS Forty percent of patients with GIP(+) C. difficile were (-) by SOC test, suggesting that true CDI was not present. Additional PCR-based testing may not impact outcomes.
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Comparative Study of Clostridium difficile Clinical Detection Methods in Patients with Diarrhoea. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2020; 2020:8753284. [PMID: 32064010 PMCID: PMC6996696 DOI: 10.1155/2020/8753284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 11/30/2019] [Indexed: 12/16/2022]
Abstract
Objectives The aim of this study was to evaluate the clinical application of three methods for detecting Clostridium difficile in fecal samples. Methods One hundred and fifty fecal specimens were collected and tested for C. difficile using three methods: (1) the toxigenic culture (TC); (2) the VIDAS enzyme immunoassay (EIA): the VIDAS glutamate dehydrogenase (GDH) assay and toxin A/B assay were used to detect GDH antigen and A/B toxin; and (3) the GeneXpert PCR assay. The toxigenic culture was used as a reference to evaluate the performance of the VIDAS EIA and the GeneXpert PCR assay. Results Of 150 specimens, 26 carried both A and B toxin genes, and none of the samples were positive for the binary toxin gene. Toxin-producing C. difficile using three methods: (1) the toxigenic culture (TC); (2) the VIDAS enzyme immunoassay (EIA): the VIDAS glutamate dehydrogenase (GDH) assay and toxin A/B assay were used to detect GDH antigen and A/B toxin; and (3) the GeneXpert PCR assay. The toxigenic culture was used as a reference to evaluate the performance of the VIDAS EIA and the GeneXpert PCR assay. C. difficile using three methods: (1) the toxigenic culture (TC); (2) the VIDAS enzyme immunoassay (EIA): the VIDAS glutamate dehydrogenase (GDH) assay and toxin A/B assay were used to detect GDH antigen and A/B toxin; and (3) the GeneXpert PCR assay. The toxigenic culture was used as a reference to evaluate the performance of the VIDAS EIA and the GeneXpert PCR assay. Conclusion The VIDAS GDH assay is useful for initial screening of C. difficile using three methods: (1) the toxigenic culture (TC); (2) the VIDAS enzyme immunoassay (EIA): the VIDAS glutamate dehydrogenase (GDH) assay and toxin A/B assay were used to detect GDH antigen and A/B toxin; and (3) the GeneXpert PCR assay. The toxigenic culture was used as a reference to evaluate the performance of the VIDAS EIA and the GeneXpert PCR assay.
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Khodaparast S, Mohabati Mobarez A, Saberifiroozi M. A Two-Step Approach for Diagnosing Glutamate Dehydrogenase Genes by Conventional Polymerase Chain Reaction from Clostridium difficile Isolates. Middle East J Dig Dis 2019; 11:135-140. [PMID: 31687111 PMCID: PMC6819966 DOI: 10.15171/mejdd.2019.139] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 05/10/2019] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Clostridium difficile is the major causative agent of nosocomial antibiotic-associated colitis. The gold standard for C. difficile detection is stool culture followed by cytotoxic assay, although it is laborious and time-consuming. We developed a screening test based on a two-step conventional polymerase chain reaction (PCR) approach to detect gluD, the glutamate dehydrogenase (GDH) enzyme gene, which is a marker for screening of C. difficile. Targeting gluD comparing to the conserved stable genetic element of pathogenicity locus (PaLoc), with an accessory gene of Cdd3, was an effective method for the detection of this pathogen from patients with enterocolitis.
METHODS
Fresh fecal samples of the patients who were clinically suspicious for antibiotic-associated colitis were collected. Stool specimens were cultured on the cycloserine-cefoxitin fructose agar (CCFA) in an anaerobic condition, following alcohol shock treatment and enrichment in Clostridium difficile Brucella broth (CDBB). On confirmed colonies, PCR was carried out for detection of PaLoc subsidiary gene, Cdd3, and toxicogenic genes, tcdA and tcdB. The gluD that is GDH gene detection was performed by conventional PCR on the extracted DNA from 578 fresh stool samples.
RESULTS
57 (9.8%) strains of C. difficile were approved by conventional PCR for gluD and Cdd3 genes, in which 37 (6.4%) colonies had tcdA+/tcdB+ genotype, 2 (0.3%) tcdA+/tcdB-, 4 (0.7%) tcdA-/ tcdB+ and the remaining 14 (2.4%) colonies were tcdA and tcdB negative.
CONCLUSION
These results demonstrate that targeting gluD by PCR is quite promising for rapid detection of C. difficile from fresh fecal samples. Furthermore, the multiple-gene analysis for tcdA and tcdB assay proved a reliable approach for diagnosing of toxigenic strains among clinical samples.
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Affiliation(s)
- Sepideh Khodaparast
- Department of Bacteriology, Faculty of Medical Sciences, Tarbiat Modares University. Tehran, Iran
| | - Ashraf Mohabati Mobarez
- Department of Bacteriology, Faculty of Medical Sciences, Tarbiat Modares University. Tehran, Iran
| | - Mehdi Saberifiroozi
- Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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Ma H, Zhang L, Zhang Y, Liu Y, He Y, Guo L. Combined administration of antibiotics increases the incidence of antibiotic-associated diarrhea in critically ill patients. Infect Drug Resist 2019; 12:1047-1054. [PMID: 31118710 PMCID: PMC6503325 DOI: 10.2147/idr.s194715] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 03/25/2019] [Indexed: 01/12/2023] Open
Abstract
Background: The widespread use of antibiotics has resulted in a high incidence of antibiotic-associated diarrhea (AAD); moreover, the AAD-associated mortality rates have also increased. The effect of combined antibiotic administration on AAD in critically ill patients was analyzed to assist in antibiotic selection for AAD prevention. Methods: Clinical data of patients hospitalized were retrospectively analyzed. Patients were either assigned to the combined-use group (CG) or the monotherapy group (MG). Age, sex, albumin levels, proton pump inhibitors, the type antibiotics, occurrence of AAD were collected. All relevant data were analyzed using SPSS version 18.0 (IBM Inc., Armonk, NY, USA), and significance was set at P<0.05. Measurements and main results: Overall, 277 patients were enrolled (CG, n=143; MG, n=134). The incidence of AAD was significantly different between the groups (44.06% vs 17.16%, P<0.001). Combined use of three or more antibiotics, other antibiotics combined with antifungals antibiotics increases the incidence of AAD (P<0.05). Duration of proton pump inhibitor therapy (odds ratio [OR] 1.142, 95% confidence interval [CI] 1.048–1.244, P=0.002), antifungal antibiotic administration (OR 3.189, 95% CI 1.314–7.740, P=0.010), and beta-lactam plus enzyme inhibitor antibiotic administration (OR 3.072, 95% CI 1.309–7.205, P=0.010) were associated with AAD in critically ill patients receiving combined antibiotics therapy. The mean duration of intensive care unit admission was longer among patients with AAD compared with patients without AAD (19.70±12.16 vs 12.29±8.06 days, P<0.001), with no significant difference in intensive care unit-related mortality rates. Conclusion: Combined administration of antibiotics, especially beta-lactam plus enzyme inhibitors and antifungals, may increase the incidence of AAD in critically ill patients.
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Affiliation(s)
- Hongye Ma
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, People's Republic of China
| | - Lei Zhang
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, People's Republic of China
| | - Yanshu Zhang
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, People's Republic of China
| | - Yu Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, People's Republic of China
| | - Yingli He
- Department of Infectious Diseases, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, People's Republic of China
| | - Litao Guo
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, People's Republic of China
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Jingjing S, Yanshu Z, Yu L, Qindong S, Xue W, Lei Z, Yingli H, Litao G. Factors related to antibiotic-associated diarrhea in patients in the intensive care unit receiving antifungals: a single-center retrospective study. J Int Med Res 2019; 47:2067-2076. [PMID: 30898003 PMCID: PMC6567793 DOI: 10.1177/0300060519836305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective To analyze factors related to antibiotic-associated diarrhea (AAD) in patients in the intensive care unit (ICU) receiving antifungals with the aim of informing rational antibiotic use. Methods Sex, age, medical history, use of proton pump inhibitors, administration of parenteral nutrition, albumin level, occurrence of AAD, type of antibiotics, duration of ICU admission, and prognosis were retrospectively analyzed. The associations of age, sex, medical history, and other factors with AAD were associated by logistic regression. Results In total, 284 patients were enrolled (antifungals, n = 110; no antifungals, n = 174). The total incidence of AAD was 32.39%. The incidence of AAD was significantly different between the groups (52.73% vs. 19.54%). The duration of proton pump inhibitor therapy, duration of antifungal therapy, enzyme inhibitor antibiotic use, and azithromycin use were associated with AAD in ICU patients receiving antifungal therapy. The mean duration of ICU admission was higher in patients receiving antifungal therapy (20.14 ± 11.50 vs. 14.48 ± 8.54 days). There was no significant difference in ICU mortality rates. Conclusion The duration of proton pump inhibitor therapy, duration of antifungal therapy, use of enzyme inhibitor antibiotics, and use of azithromycins were associated with AAD in ICU patients receiving antifungal therapy.
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Affiliation(s)
- Sun Jingjing
- 1 Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zhang Yanshu
- 1 Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Liu Yu
- 1 Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Shi Qindong
- 1 Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Wang Xue
- 1 Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zhang Lei
- 1 Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - He Yingli
- 2 Department of Infectious Diseases, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Guo Litao
- 1 Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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Zhang Y, Sun J, Zhang J, Liu Y, Guo L. Enzyme Inhibitor Antibiotics and Antibiotic-Associated Diarrhea in Critically Ill Patients. Med Sci Monit 2018; 24:8781-8788. [PMID: 30512009 PMCID: PMC6289033 DOI: 10.12659/msm.913739] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND This study aimed to analyze the factors associated with the development of antibiotic-associated diarrhea (AAD) in critically ill patients receiving enzyme inhibitor antibiotics. MATERIAL AND METHODS A retrospective study of patients with and without AAD admitted to the intensive care unit (ICU) of the First Teaching Hospital of Xi'an Jiaotong University from February 1, 2014, to January 31, 2016, was undertaken. Relevant clinical data underwent univariate or multivariate regression analysis. RESULTS Of 184 patients who received enzyme inhibitor antibiotic therapy, 70 patients (38.04%) developed AAD, with a mean duration of onset of 6.97±3.64 days. AAD was associated with the use of enzyme inhibitor antibiotic therapy alone (OR, 1.142; 95% CI, 1.038-1.256; P=0.007), and in combination with antifungal agents (OR, 2.449; 95% CI, 1.116-5.372; P=0.025), quinolones (OR, 5.219; 95% CI, 1.746-15.601; P=0.003), and oxazolidinones (OR 2.895; 95% CI, 1.183-7.083; P=0.020). The mean duration of ICU stay was significantly increased in patients with AAD (19.00±11.49 days vs. 9.60±6.76 days) (P<0.001). Mean duration of antibiotic therapy (14.09±8.82 days vs. 8.10±4.91 days) (P<0.001) and duration of enzyme inhibitor antibiotic therapy (9.26±5.06 days vs. 6.61±3.24 days) (P<0.001) were significantly increased in patients with AAD. CONCLUSIONS Duration of use of enzyme inhibitor antibiotic therapy and the combined use of antifungals, quinolones, and oxazolidinones increased the incidence and duration of AAD and increased the length of stay in ICU.
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Affiliation(s)
- Yanshu Zhang
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Jingjing Sun
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Jing Zhang
- Department of Thoracic Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Yu Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Litao Guo
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
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Abughanimeh O, Qasrawi A, Kaddourah O, Al Momani L, Abu Ghanimeh M. Clostridium difficile infection in oncology patients: epidemiology, pathophysiology, risk factors, diagnosis, and treatment. Hosp Pract (1995) 2018; 46:266-277. [PMID: 30296190 DOI: 10.1080/21548331.2018.1533673] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Clostridium difficile infection (CDI) is one of the most common healthcare-associated infections in the United States. Its incidence has been increasing in the recent years despite preventative measures. CDI increases annual expenses by 1.5 billion dollars. Cancer patients are at higher risk to acquire CDI, as explained by their frequent exposure to risk factors. CDI in cancer patients is associated with higher mortality rates and prolonged hospitalization. Furthermore, CDI affects the course of the disease by delaying treatments such as chemotherapy. Chemotherapeutics drugs are considered independent risk factors for CDI. This review discusses Clostridium difficile infection in cancer patients, including those who are receiving chemotherapy. Herein, we summarize recent data regarding the epidemiology, risk factors, including chemotherapy regimens, pathogenesis, diagnostic techniques and treatment options, including newer agents. Method: A literature search was performed using the PubMed and Google Scholar databases. The MeSH terms utilized in different combinations were 'clostridium difficile', 'neoplasia/cancer/oncology', 'chemotherapy', 'diagnosis', and 'treatment', in addition to looking up each treatment option individually to generate a comprehensive search. The articles were initially screened by title alone, followed by screening through abstracts. Full texts of pertinent articles (including letters to editors, case reports, case series, cohort studies, and clinical trials) were included in this review.
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Affiliation(s)
- Omar Abughanimeh
- a School of Medicine Internal Medicine , University of Missouri , Kansas City , USA
| | - Ayman Qasrawi
- a School of Medicine Internal Medicine , University of Missouri , Kansas City , USA
| | - Osama Kaddourah
- a School of Medicine Internal Medicine , University of Missouri , Kansas City , USA
| | - Laith Al Momani
- b East Tennessee State University James H Quillen College of Medicine - Internal Medicine , USA
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Litao G, Jingjing S, Yu L, Lei Z, Xiaona H, Zhijing Z. Risk Factors for Antibiotic-Associated Diarrhea in Critically Ill Patients. Med Sci Monit 2018; 24:5000-5007. [PMID: 30020891 PMCID: PMC6067053 DOI: 10.12659/msm.911308] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 07/06/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND We analyzed the factors related to AAD to inform the rational use of antibiotics in critically ill patients and to reduce the incidence of AAD by providing a reference for antibiotic use in the clinical setting. MATERIAL AND METHODS This study was a retrospective analysis of the clinical data of patients who were hospitalized in the ICU of the First Teaching Hospital of Xi'an Jiaotong University from January 1, 2015 to December 31, 2016. Patients with AAD were assigned to the case group, and all others were assigned to the control group. Basic data were collected for all the selected patients. All the relevant data were analyzed with univariate or multivariate regression analyses, and P<0.05 was considered statistical significance. RESULTS A total of 293 patients were enrolled. Statistical analyses showed that gender (OR 1.915; 95% [CI] 1.061-3.455; P=0.031), parenteral nutrition (OR 1.877; 95% [CI] 1.043-3.377; P=0.036), preventive use of probiotics (OR 0.497; 95% [CI] 0.285-0.866; P=0.014), APACHE II score upon admission to the ICU (OR 0.961; 95% [CI] 0.927-0.998; P=0.037) and use of enzyme-inhibitor antibiotics (OR 1.899; 95% [CI] 1.044-3.420; P=0.016) were associated with AAD. Further subgroup analysis by gender showed that parenteral nutrition (OR 2.144; 95% [CI] 1.064-4.322; P=0.033), preventive use of probiotics (OR 0.367; 95% [CI] 0.186-0.722; P=0.004), and APACHE II score upon admission to the ICU (OR 1.055; 95% [CI] 1.011-1.101; P=0.014) were associated with AAD in critically ill male patients. Age (OR 0.975; 95% [CI] 0.951-0.999; P=0.041) and use of carbapenem antibiotics (OR 4.826; 95% [CI] 1.011-23.030; P=0.048) were associated with AAD in critically ill female patients. CONCLUSIONS Parenteral nutrition, prophylactic use of probiotics, use of enzyme-inhibitor antibiotics, and use of combinations of antibiotics were associated with AAD in critically ill patients. The prophylactic use of probiotics may be a protective factor in AAD.
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Cohen NA, Miller T, Na'aminh W, Hod K, Adler A, Cohen D, Guzner-Gur H, Santo E, Halpern Z, Carmeli Y, Maharshak N. Clostridium difficile fecal toxin level is associated with disease severity and prognosis. United European Gastroenterol J 2017; 6:773-780. [PMID: 30083340 DOI: 10.1177/2050640617750809] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 11/25/2017] [Indexed: 12/13/2022] Open
Abstract
Background Antibiotic-associated colitis caused by Clostridium difficile (C. difficile) is the most common cause of hospital-acquired diarrhea. The pathogenesis of C. difficile colitis is mediated by bacterial toxins. C. difficile infection (CDI) severity may be determined by the fecal level of these toxins. Objective The objective of this article is to determine whether fecal C. difficile toxin (CDT) levels are associated with disease severity and prognosis. Methods A cross-sectional study of patients admitted with CDI in a tertiary center between 2011 and 2015 was conducted. Fecal CDT levels were determined by quantitative ELISA. Severe CDI was defined as a leukocyte count of > 15 × 103 cells/μl, creatinine levels that deteriorated by > 1.5 times the baseline level, or albumin levels < 3 g/dl. Results Seventy-three patients were recruited for this study. Patients with severe CDI (n = 47) had significantly higher toxin levels compared to patients with mild to moderate CDI (n = 26) (651 ng/ml (IQR 138-3200) versus 164 ng/ml (IQR 55.2-400.1), respectively; p = 0.001). A high toxin level (>2500 ng/ml) was associated with an increased mortality rate (odds ratio 11.8; 95% confidence interval 2.5-56). Conclusions The fecal CDT level is associated with disease severity and mortality rate. Measuring CDT levels may be an objective and accurate way to define the severity of CDI.
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Affiliation(s)
- Nathaniel A Cohen
- Department of Internal Medicine "B," Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Tamar Miller
- Department of Epidemiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Wasef Na'aminh
- Department of Epidemiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Keren Hod
- Research Division, Assuta Medical Center, Tel Aviv, Israel
| | - Amos Adler
- Department of Clinical Microbiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Daniel Cohen
- School of Public Health, Tel Aviv University, Tel Aviv, Israel
| | - Hanan Guzner-Gur
- Department of Internal Medicine "B," Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Erwin Santo
- Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Zamir Halpern
- Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yehuda Carmeli
- Department of Epidemiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Nitsan Maharshak
- Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Bacteriotherapy Clinic, Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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