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Abstract
Clostridioides difficile is the most common cause of nosocomial antibiotic-associated diarrhea, and is responsible for a spectrum of diseases characterized by high levels of recurrence, morbidity, and mortality. Treatment is complex, since antibiotics constitute both the main treatment and the major risk factor for infection. Worryingly, resistance to multiple antibiotics is becoming increasingly widespread, leading to the classification of this pathogen as an urgent threat to global health. As a consummate opportunist, C. difficile is well equipped for promoting disease, owing to its arsenal of virulence factors: transmission of this anaerobe is highly efficient due to the formation of robust endospores, and an array of adhesins promote gut colonization. C. difficile produces multiple toxins acting upon gut epithelia, resulting in manifestations typical of diarrheal disease, and severe inflammation in a subset of patients. This review focuses on such virulence factors, as well as the importance of antimicrobial resistance and genome plasticity in enabling pathogenesis and persistence of this important pathogen.
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Affiliation(s)
- Jessica E Buddle
- Molecular Microbiology, School of Biosciences, University of Sheffield, Sheffield, UK
| | - Robert P Fagan
- Molecular Microbiology, School of Biosciences, University of Sheffield, Sheffield, UK
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Khrais A, Mathew AG, Kahlam A, Le A, Mittal A, Verma S. Investigating the Correlation Between Clostridioides difficile Infection and Vitamin D Deficiency. Cureus 2023; 15:e39970. [PMID: 37416010 PMCID: PMC10320737 DOI: 10.7759/cureus.39970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2023] [Indexed: 07/08/2023] Open
Abstract
INTRODUCTION Clostridioides difficile infection (CDI) is the most common healthcare-associated infection in the US. Symptoms include watery diarrhea, nausea, and anorexia and it can present with leukocytosis on laboratory evaluation. Treatment is based on disease severity and recurrence. Despite antibiotic usage being the highest risk factor for infection, they are also the first-line treatment for initial CDI. Prevention of CDI mostly involves good hand hygiene, antibiotic stewardship, and appropriate precautions when interacting with infected individuals. Vitamin D deficiency (VDD) has been linked to CDI, however, there is limited insight into the correlation between both states. Our aim was to further investigate the potential link between VDD and CDI. METHODS Data were obtained from the National Inpatient Sample (NIS) from 2016 to 2019. Patients with CDI were identified and stratified based on a diagnosis of VDD. Primary outcomes were mortality, CDI recurrence, ileus, toxic megacolon, perforation, and colectomy. Chi-squared and independent t-tests were performed to assess categorical and continuous data, respectively. Multiple logistic regression was used to control for confounders. RESULTS Patients with VDD had higher rates of CDI recurrence (17.4% versus 14.7%, p<0.05), but lower rates of mortality (3.1% versus 6.1%, p<0.05). Differences in rates of ileus, toxic megacolon, perforation, and colectomy were statistically insignificant. Length of stay was higher in the VDD group (10.38 days versus 9.83 days). Total charges were lower in the VDD group ($93,935.85 versus $102,527.9). DISCUSSION CDI patients with comorbid VDD are at higher risk for the recurrence of CDI. This is likely due to the role of vitamin D in the expression of intestinal epithelial antimicrobial peptides, macrophage activation, and maintenance of tight junctions between gut epithelial cells. Furthermore, vitamin D plays a role in maintaining a healthy gut microbiome. Alternatively, deficiency results in poor gut health and detrimental changes to the gut microbiome. In effect, VDD promotes the proliferation of C. difficile within the large colon, resulting in an increased predisposition for CDI.
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Affiliation(s)
- Ayham Khrais
- Department of Medicine, Rutgers University New Jersey Medical School, Newark, USA
| | - Anna G Mathew
- Department of Medicine, Rutgers University New Jersey Medical School, Newark, USA
| | - Aaron Kahlam
- Department of Medicine, Rutgers University New Jersey Medical School, Newark, USA
| | - Alexander Le
- Department of Medicine, Rutgers University New Jersey Medical School, Newark, USA
| | - Anmol Mittal
- Department of Medicine, Rutgers University New Jersey Medical School, Newark, USA
| | - Siddharth Verma
- Department of Gastroenterology and Hepatology, East Orange Veteran's Affairs Medical Center, East Orange, USA
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Majumdar A, Govind R. Regulation of Clostridioides difficile toxin production. Curr Opin Microbiol 2022; 65:95-100. [PMID: 34781095 DOI: 10.1016/j.mib.2021.10.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 10/19/2021] [Accepted: 10/25/2021] [Indexed: 02/03/2023]
Abstract
Clostridioides difficile produces toxins TcdA and TcdB during infection. Since the severity of the illness is directly correlated with the level of toxins produced, researchers have long been interested in the regulation mechanisms of toxin production. The advent of new genetics and mutagenesis technologies in C. difficile has allowed a slew of new investigations in the last decade, which considerably improved our understanding of this crucial regulatory network. The current body of work shows that the toxin regulatory network overlaps with the regulatory networks of sporulation, motility, and key metabolic pathways. This implies that toxin production is a complicated process initiated by bacteria in response to numerous host factors during infection. We summarize the existing knowledge about the toxin gene regulatory network here.
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Heleno CT, Tagintsev A, Lasley K, Summerfield D. Fidaxomicin as a Salvage Therapy for Fulminant Clostridioides difficile Infection. Cureus 2021; 13:e16559. [PMID: 34327111 PMCID: PMC8301726 DOI: 10.7759/cureus.16559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2021] [Indexed: 11/30/2022] Open
Abstract
Few studies have demonstrated the efficacy of fidaxomicin in the treatment of fulminant Clostridioides difficile infection (CDI). Fidaxomicin has been used as part of the standard treatment for nonsevere and severe CDI according to the guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America, but not in severe fulminant CDI due to lack of randomized clinical trials supporting its use. We present the case of a patient who developed severe fulminant colitis initially refractory to treatment with oral vancomycin and intravenous metronidazole that had an impressive improvement within 24-hour of starting fidaxomicin. The patient had a complete resolution of the symptoms at the end of the therapy without requiring a surgical approach. There are few case reports of fulminant CDI treated with fidaxomicin as a salvage therapy for fulminant CDI. In this challenging scenario, information about the use of fidaxomicin is still limited and more clinical trials are needed to support its widespread use.
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Affiliation(s)
- Caio T Heleno
- Internal Medicine, MercyOne North Iowa Medical Center, Mason City, USA
| | - Aleksey Tagintsev
- Internal Medicine, MercyOne North Iowa Medical Center, Mason City, USA
| | - Katharine Lasley
- Internal Medicine, MercyOne North Iowa Medical Center, Mason City, USA
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Aleem A, Firak G, Slenker AK. Multiplex Molecular Stool Testing Rarely Impacts Antimicrobial Treatment Decisions More Than Three Days After Admission. Cureus 2021; 13:e14784. [PMID: 34084686 PMCID: PMC8165332 DOI: 10.7759/cureus.14784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Acute diarrheal illness in the United States is a significant cause of healthcare utilization and hospitalizations. For patients who develop diarrhea while hospitalized, testing for pathogens other than Clostridium difficile (C. difficile) using conventional stool testing is low yield. Newer testing modalities for infectious diarrhea such as the multiplex molecular stool testing provide an improved detection rate and a faster turn-around time compared to conventional stool testing. Methods We retrospectively examined the use of a multiplex molecular stool test at our institution for all hospital encounters over a two-year period to determine which organisms were identified ≤ 3 days and > 3 days after admission. Results A total of 2032 patients underwent multiplex molecular stool testing during the study period, with 1698 (83.6%) performed ≤ 3 days and 334 (16.3%) > 3 days after admission. An enteric non-C. difficile pathogen was identified more frequently when patients were tested ≤ 3 days after admission (350, 20.6%) as compared to > 3 days after admission (38, 11.4%, p<0.0001). Excluding coinfections, C. difficile was identified more frequently when patients were tested > 3 days after admission (64, 20.3%) versus another organism (30, 9.0%) (p<0.0001). Of those patients with a non-C. difficile pathogen identified > 3 days after admission, a bacterial pathogen amenable to treatment was only identified in 6% (21) of patients. Conclusion Multiplex molecular stool testing for patients tested > 3 days after admission is a low yield of information that could guide antimicrobial treatment decisions, and C. difficile testing is more useful in this clinical situation.
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Affiliation(s)
- Abdul Aleem
- Gastroenterology and Hepatology, Lehigh Valley Health Network, Allentown, USA
| | - Gabriela Firak
- Internal Medicine, Tower Health-Reading Hospital, Reading, USA
| | - Amy K Slenker
- Infectious Diseases, Lehigh Valley Health Network, Allentown, USA
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Ramalingam S, Gunasekaran K, Arora H, Muruganandam M, Padmanabhan P. Clostridium Difficile and Noncirrhotic Hyperammonnemia in a Patient With COVID-19 Infection. Cureus 2021; 13:e14533. [PMID: 33880318 PMCID: PMC8052988 DOI: 10.7759/cureus.14533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Clostridium difficile is a bacterial infection that usually presents with diarrhea and is mostly associated with previous antibiotics use. Patients with coronavirus disease 2019 (COVID-19) generally have respiratory symptoms but can also present with diarrhea. Noncirrhotic hyperammonemia is an infrequent presentation and is treated with lactulose. We report the case of a 40-year-old male who was admitted to our hospital with abdominal pain, diarrhea, shortness of breath, and confusion. During hospitalization, the patient tested positive for COVID-19 and C. difficile, and oral vancomycin was administered. His kidney functions improved, but he remained confused. His ammonia levels were elevated, and he was not treated with lactulose due to ongoing diarrhea secondary to C. difficile infection.
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Affiliation(s)
| | | | - Harkesh Arora
- Hospital Medicine, Lovelace Medical Center, Albuquerque, USA
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Siciliano V, Nista EC, Rosà T, Brigida M, Franceschi F. Clinical Management of Infectious Diarrhea. Rev Recent Clin Trials 2020; 15:298-308. [PMID: 32598272 DOI: 10.2174/1574887115666200628144128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/05/2020] [Accepted: 05/11/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Infectious diarrhea is the most common cause of diarrhea worldwide and is responsible for more deaths than other gastrointestinal tract diseases such as gastrointestinal cancers, peptic ulcer disease or inflammatory bowel disease. Diarrheal disease still represents the 8th leading cause of death worldwide, with more than 1,6 million attributed fatalities in 2016 alone. The majority of cases can be divided into three principal clinical presentations: acute watery diarrhea lasting 5-10 days and normally self-limiting, bloody diarrhea (dysentery), and persistent diarrhea with or without intestinal malabsorption. METHODS We performed an electronic search on PUBMED of the scientific literature concerning infectious diarrhea and its clinical management. AIM In this review article, we analyze the most important causes of infectious diarrhea and their constellation of signs and symptoms, providing an update on the diagnostic tools available in today's practice and on the different treatment options. CONCLUSION Even though the majority of intestinal infections are self-limiting in immunocompetent individuals, specific diagnosis and identification of the causative agent remain crucial from public health and epidemiological perspectives. Specific diagnostic investigation can be reserved for patients with severe dehydration, more severe illness, persistent fever, bloody stools, immunosuppression, and for cases of suspected nosocomial infection or outbreak and it includes complete blood count, creatinine and electrolytes evaluation, determination of leukocytes and lactoferrin presence in the stools, stool culture, together with C. difficile testing, PCR, ova and parasites' search, endoscopy and abdominal imaging. Since acute diarrhea is most often self-limited and caused by viruses, routine antibiotic use is not recommended for most adults with mild, watery diarrhea. However, when used appropriately, antibiotics are effective against shigellosis, campylobacteriosis, C. difficile colitis, traveler's diarrhea, and protozoal infections. Furthermore, antibiotics use should be considered in patients who are older than 65 years, immunocompromised, severely ill, or septic.
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Affiliation(s)
| | | | - Tommaso Rosà
- Universita Cattolica del Sacro Cuore - Rome, Italy
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Al Momani LA, Abughanimeh O, Boonpheng B, Gabriel JG, Young M. Fidaxomicin vs Vancomycin for the Treatment of a First Episode of Clostridium Difficile Infection: A Meta-analysis and Systematic Review. Cureus 2018; 10:e2778. [PMID: 30112254 PMCID: PMC6089486 DOI: 10.7759/cureus.2778] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Clostridium difficile infection (CDI) continues to possess a significant disease burden in the United States (US) as well as all over the world. Given the increase in severity and recurrence rate, the decrease in cure rate, and the fact that the virulent ribotype 027 strain remains one of the most commonly identified strains in the US, the Infectious Diseases Society of America (IDSA) published a clinical practice guideline in February 2018 moving away from metronidazole as the first-line treatment for initial CDI and recommending either oral vancomycin or fidaxomicin. The aim of this study is to evaluate the clinical data available comparing the efficacy of primary treatment of CDI between those two antibiotics. We performed a PubMed, PubMed Central, and ScienceDirect database search without restriction to regions, publication types, or languages. A comprehensive literature search was performed from January 1, 1980 up to March 20, 2018. We used the following keywords in different combinations: Clostridium difficile, Clostridium difficile infection, CDI, C. diff, C. difficile, fidaxomicin, vancomycin, pseudomembranous colitis, and antibiotic-associated colitis. The search was limited to human studies. Data were independently extracted by two reviewers with disagreements resolved by a third author. We pooled an odds ratio (OR) on two primary outcomes: Clinical cure rate and rate of recurrence during the follow-up period. The computer search was also supplemented with manual searches by the authors of the retrieved review articles and primary studies. The search phrase “((Clostridium difficile) AND vancomycin) AND fidaxomicin” had the highest yield results. We identified four observational studies with a total of 2,303 patients with CDI that met our inclusion criteria. Compared with vancomycin, fidaxomicin use was associated with a significantly lower recurrence of CDI with a pooled OR of 0.47 (95% confidence interval (CI), 0.37 - 0.60, I2 = 0). On the other hand, there was no significant association of fidaxomicin use with CDI cure rate compared to vancomycin with a pooled OR of 1.22 (95% CI, 0.93 - 1.60, I2 = 0). In light of the recently updated clinical practice guidelines by the IDSA, our review suggests that fidaxomicin has a more sustained clinical response with a statistically significant lower recurrence rate. Although fidaxomicin appears to be the better drug with statistical significance, its cost-effectiveness continues to be an ongoing controversy. More randomized clinical trials are needed to shed light on this matter to assess if there is any clinical significance in fidaxomicin superiority.
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Affiliation(s)
- Laith A Al Momani
- Department of Internal Medicine, East Tennessee State University, Johnson City, USA
| | - Omar Abughanimeh
- Department of Internal Medicine, University of Missouri Kansas City School of Medicine, Kansas City, USA
| | | | | | - Mark Young
- Department of Gastroenterology, East Tennessee State University, Johnson City, USA
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Kassam Z, Fabersunne CC, Smith MB, Alm EJ, Kaplan GG, Nguyen GC, Ananthakrishnan AN. Clostridium difficile associated risk of death score (CARDS): a novel severity score to predict mortality among hospitalised patients with C. difficile infection. Aliment Pharmacol Ther 2016; 43:725-33. [PMID: 26849527 PMCID: PMC5094350 DOI: 10.1111/apt.13546] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 11/14/2015] [Accepted: 01/12/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a public health threat and associated with significant mortality. However, there is a paucity of objectively derived CDI severity scoring systems to predict mortality. AIM To develop a novel CDI risk score to predict mortality entitled: Clostridium difficile associated risk of death score (CARDS). METHODS We obtained data from the United States 2011 Nationwide Inpatient Sample (NIS) database. All CDI-associated hospitalisations were identified using discharge codes (ICD-9-CM, 008.45). Multivariate logistic regression was utilised to identify independent predictors of mortality. Clostridium difficile associated risk of death score was calculated by assigning a numeric weight to each parameter based on their odds ratio in the final logistic model. Predictive properties of model discrimination were assessed using the c-statistic and validated in an independent sample using the 2010 NIS database. RESULTS We identified 77 776 hospitalisations, yielding an estimate of 374 747 cases with an associated diagnosis of CDI in the US, 8% of whom died in the hospital. The eight severity score predictors were identified on multivariate analysis: age, cardiopulmonary disease, malignancy, diabetes, inflammatory bowel disease, acute renal failure, liver disease and ICU admission, with weights ranging from -1 (for diabetes) to 5 (for ICU admission). The overall risk score in the cohort ranged from 0 to 18. Mortality increased significantly as CARDS increased. CDI-associated mortality was 1.2% with a CARDS of 0 compared to 100% with CARDS of 18. The model performed equally well in our validation cohort. CONCLUSION Clostridium difficile associated risk of death score is a promising simple severity score to predict mortality among those hospitalised with C. difficile infection.
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Affiliation(s)
- Zain Kassam
- Massachusetts Institute of Technology, Cambridge, MA, United States,OpenBiome, Medford, MA, United States
| | - Camila Cribb Fabersunne
- Harvard Medical School, Boston, MA, United States,Harvard School of Public Health, Boston, MA, United States
| | - Mark B. Smith
- Massachusetts Institute of Technology, Cambridge, MA, United States,OpenBiome, Medford, MA, United States
| | - Eric J. Alm
- Massachusetts Institute of Technology, Cambridge, MA, United States
| | | | - Geoffrey C. Nguyen
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, University of Toronto, Toronto, ON, Canada
| | - Ashwin N. Ananthakrishnan
- Harvard Medical School, Boston, MA, United States,Massachusetts General Hospital, Boston, MA, United States
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Wiens J, Guttag J, Horvitz E. A study in transfer learning: leveraging data from multiple hospitals to enhance hospital-specific predictions. J Am Med Inform Assoc 2014; 21:699-706. [PMID: 24481703 DOI: 10.1136/amiajnl-2013-002162] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Data-driven risk stratification models built using data from a single hospital often have a paucity of training data. However, leveraging data from other hospitals can be challenging owing to institutional differences with patients and with data coding and capture. OBJECTIVE To investigate three approaches to learning hospital-specific predictions about the risk of hospital-associated infection with Clostridium difficile, and perform a comparative analysis of the value of different ways of using external data to enhance hospital-specific predictions. MATERIALS AND METHODS We evaluated each approach on 132 853 admissions from three hospitals, varying in size and location. The first approach was a single-task approach, in which only training data from the target hospital (ie, the hospital for which the model was intended) were used. The second used only data from the other two hospitals. The third approach jointly incorporated data from all hospitals while seeking a solution in the target space. RESULTS The relative performance of the three different approaches was found to be sensitive to the hospital selected as the target. However, incorporating data from all hospitals consistently had the highest performance. DISCUSSION The results characterize the challenges and opportunities that come with (1) using data or models from collections of hospitals without adapting them to the site at which the model will be used, and (2) using only local data to build models for small institutions or rare events. CONCLUSIONS We show how external data from other hospitals can be successfully and efficiently incorporated into hospital-specific models.
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Affiliation(s)
- Jenna Wiens
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - John Guttag
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
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Torti A, Lossani A, Savi L, Focher F, Wright GE, Brown NC, Xu WC. Clostridium difficile DNA polymerase IIIC: basis for activity of antibacterial compounds. Curr Enzym Inhib 2011; 7:147-153. [PMID: 22844265 PMCID: PMC3404731 DOI: 10.2174/157340811798807597] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Based on the finding that aerobic Gram-positive antibacterials that inhibit DNA polymerase IIIC (pol IIIC) were potent inhibitors of the growth of anaerobic Clostridium difficile (CD) strains, we chose to clone and express the gene for pol IIIC from this organism. The properties of the recombinant enzyme are similar to those of related pol IIICs from Gram-positive aerobes, e.g. B. subtilis. Inhibitors of the CD enzyme also inhibited B. subtilis pol IIIC, and were competitive with respect to the cognate substrate 2'-deoxyguanosine 5'-triphosphate (dGTP). Significantly, several of these inhibitors of the CD pol IIIC had potent activity against the growth of CD clinical isolates in culture.
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Affiliation(s)
- Andrea Torti
- Istituto di Genetica Molecolare, Consiglio Nazionale delle Ricerche, I-27100 Pavia, Italy
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