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Kunishima H, Ohge H, Suzuki H, Nakamura A, Matsumoto K, Mikamo H, Mori N, Morinaga Y, Yanagihara K, Yamagishi Y, Yoshizawa S. Japanese Clinical Practice Guidelines for Management of Clostridioides (Clostridium) difficile infection. J Infect Chemother 2022; 28:1045-1083. [PMID: 35618618 DOI: 10.1016/j.jiac.2021.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/16/2021] [Accepted: 12/13/2021] [Indexed: 12/19/2022]
Affiliation(s)
- Hiroyuki Kunishima
- Department of Infectious Diseases, St. Marianna University School of Medicine, Japan.
| | - Hiroki Ohge
- Department of Infectious Diseases, Hiroshima University Hospital, Japan
| | - Hiromichi Suzuki
- Division of Infectious Diseases, Department of Medicine, Tsukuba Medical Center Hospital, Japan
| | - Atsushi Nakamura
- Division of Infection Control and Prevention, Nagoya City University Hospital, Japan
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, Japan
| | - Hiroshige Mikamo
- Clinical Infectious Diseases, Graduate School of Medicine, Aichi Medical University, Japan
| | - Nobuaki Mori
- Division of General Internal Medicine and Infectious Diseases, National Hospital Organization Tokyo Medical Center, Japan
| | - Yoshitomo Morinaga
- Department of Microbiology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
| | - Katsunori Yanagihara
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Yuka Yamagishi
- Clinical Infectious Diseases, Graduate School of Medicine, Aichi Medical University, Japan
| | - Sadako Yoshizawa
- Department of Clinical Laboratory/Department of Microbiology and Infectious Diseases, Toho University School of Medicine, Japan
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Lephart P, LeBar W, Newton D. Behind Every Great Infection Prevention Program is a Great Microbiology Laboratory: Key Components and Strategies for an Effective Partnership. Infect Dis Clin North Am 2021; 35:789-802. [PMID: 34362544 DOI: 10.1016/j.idc.2021.04.012] [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] [Indexed: 11/18/2022]
Abstract
A great clinical microbiology laboratory supporting a great infection prevention program requires focusing on the following services: rapid and accurate identification of pathogens associated with health care-associated infections; asymptomatic surveillance for health care-acquired pathogens before infections arise; routine use of broad and flexible antimicrobial susceptibility testing to direct optimal therapy; implementation of epidemiologic tracking tools to identify outbreaks; development of clear result communication with interpretative comments for clinicians. These goals are best realized in a collaborative relationship with the infection prevention program so that both can benefit from the shared priorities of providing the best patient care.
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Affiliation(s)
- Paul Lephart
- Clinical Microbiology Laboratory, Department of Pathology, University of Michigan Medical School, 2800 Plymouth Road Building 36-1221-52, Ann Arbor, MI 48109-2800, USA.
| | - William LeBar
- Clinical Microbiology Laboratory, Department of Pathology, University of Michigan Medical School, 2800 Plymouth Road Building 36-1221-52, Ann Arbor, MI 48109-2800, USA
| | - Duane Newton
- NaviDx Consulting, Department of Pathology, University of Michigan Medical School, 2800 Plymouth Road Building 36-1221-52, Ann Arbor, MI 48109-2800, USA
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Temporal change of risk factors in hospital-acquired Clostridioides difficile infection using time-trend analysis. Infect Control Hosp Epidemiol 2020; 41:1048-1057. [PMID: 32468975 DOI: 10.1017/ice.2020.206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Given recent changes in the epidemiology of Clostridioides difficile infection (CDI) and prevention efforts, we investigated temporal changes over a period of 11 years (2006-2016) in incidence and risk factors for CDI. DESIGN Retrospective matched case-control study. SETTING/PATIENTS Pediatric and adult inpatients (n = 694,849) discharged from 3 hospitals (tertiary and quaternary care, community, and pediatric) in a large, academic health center in New York City. METHODS Risk factors were identified in cases and controls matched by length of stay at a ratio of 1:4. A Cochran-Armitage or Mann-Kendall test was used to investigate trends of incidence and risk factors. RESULTS Of 694,849 inpatients, 6,038 (0.87%) had CDI: 44% of these cases were hospital acquired (HA-CDI) and 56% were community acquired (CA-CDI). We observed temporal downward trends in HA-CDI (-0.03% per year) and upward trends in CA-CDI (+0.04% per year). Over time, antibiotics were administered to more patients (+3% per year); the use of high-risk antibiotics declined (-1.2% per year); and antibiotic duration increased in patients with HA-CDI (+4.4% per year). Fewer proton-pump inhibitors and more histamine-2 blockers were used (-3.8% and +7.3% per year, respectively; all Ptrend <.05). CONCLUSIONS Although the incidence of HA-CDI decreased over time, CA-CDI simultaneously increased. Continued efforts to assure judicious use of antibiotics in inpatient and community settings is clearly vital. Measuring the actual the level of exposure of an antibiotic (incidence density) should be used for ongoing surveillance and assessment.
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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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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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Munson E, Rodriguez S, Riederer N, Munson KL, Block D, Land G, Stone R, Villalobos A, Dewey E, Block TK. Outcome of Electronic Order Alert Intervention Relative to Toxigenic Clostridium difficile PCR Analysis and Hospital-Onset C difficile Infection in a Multihospital Health Care System. Am J Clin Pathol 2019; 151:622-627. [PMID: 30989227 DOI: 10.1093/ajcp/aqz022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 12/23/2018] [Accepted: 02/21/2019] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Concern exists regarding overdiagnosis of Clostridium difficile infection (CDI) via molecular modalities. We determined effects of a preanalytic order intervention on laboratory and CDI prevention measures in a multihospital system. METHODS Intervals before and following implementation of a CDI electronic order alert (relative to appropriate testing scenario) were assessed for C difficile test volume and positivity rate, hospital-onset CDI frequency, and hospital-onset C difficile standardized infection ratio (SIR). C difficile detection occurred by PCR throughout the study. RESULTS During the first half of 2015, testing volume was 1,578, with 88 hospital-onset CDIs. Following implementation, 18.9% and 56.8% reductions in volume and hospital-onset CDIs were realized, respectively, in the first half of 2017. Regression analysis revealed decreasing trends in PCR volume, positivity rate, hospital-onset CDI frequency, and SIR in larger facilities. CONCLUSIONS Preanalytic considerations affect not only the microbiology laboratory but also hospital infection prevention in the context of CDI.
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Affiliation(s)
- Erik Munson
- College of Health Sciences, Marquette University, Milwaukee, WI
- Wisconsin Clinical Laboratory Network Technical Advisory Group, Madison
| | | | - Nancy Riederer
- Wheaton Franciscan Healthcare, Ascension Wisconsin, Milwaukee
| | | | - Denise Block
- Wheaton Franciscan Healthcare, Ascension Wisconsin, Milwaukee
| | - Gayle Land
- Wheaton Franciscan Healthcare, Ascension Wisconsin, Milwaukee
| | - Rosalyn Stone
- Wheaton Franciscan Healthcare, Ascension Wisconsin, Milwaukee
| | | | - Erin Dewey
- College of Health Sciences, Marquette University, Milwaukee, WI
| | - Timothy K Block
- Wisconsin Clinical Laboratory Network Technical Advisory Group, Madison
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Dávila LP, Garza-González E, Rodríguez-Zulueta P, Morfín-Otero R, Rodríguez-Noriega E, Vilar-Compte D, Rodríguez-Aldama JC, Camacho-Ortiz A. Increasing rates of Clostridium difficile infection in Mexican hospitals. Braz J Infect Dis 2017. [PMID: 28641091 PMCID: PMC9425492 DOI: 10.1016/j.bjid.2017.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Introduction The epidemiology of Clostridium difficile infection (CDI) has changed in the last two decades. There is a lack of information regarding incidence and severity of CDI, especially in the developing world. Methods This was a retrospective and observational study from four hospitals of three Mexican cities. Patients were diagnosed with CDI when presented with loose stools and had at least one of the following tests positive: toxins assay, real-time PCR, or an endoscopic image compatible with pseudomembranous colitis. CDI was classified according to international guidelines. Demographic and clinical data as well as information regarding total hospital admissions, total length-of-hospital stay, and other variables related to hospitalization were gathered from the epidemiology and administration departments of each hospital. Results A total of 2050 hospital beds were analyzed with 288,171 patients hospitalized accumulating 1,576,446 days of hospitalization during the study period. The average rate of CDI per 1000 hospital-days was lower than the rates reported in the US and Europe, although in 2015 CDI rates were almost persistently above the mean rate for the study period. More than half of PCR positive patients were ribotype 027. Conclusion Hospital rates of CDI are increasing in Mexican hospitals with a predominance of infections caused by ribotype 027.
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Murad YM, Perez J, Ybazeta G, Mavin S, Lefebvre S, Weese JS, Rousseau J, Diaz-Mitoma F, Nokhbeh R. False Negative Results in Clostridium difficile Testing. BMC Infect Dis 2016; 16:430. [PMID: 27543102 PMCID: PMC4992222 DOI: 10.1186/s12879-016-1741-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 07/29/2016] [Indexed: 01/05/2023] Open
Abstract
Background Accurate diagnosis of Clostridium difficile infection (CDI) is paramount for patient management. The wrong diagnosis places patients at risk, delays treatment, and/ or contributes to transmission of infection in the healthcare setting. Although amplification of the toxin B gene by polymerase chain reaction (PCR) is a sensitive method for detecting toxigenic C. difficile, false negative results still occur and could impact the diagnosis and treatment of this infection. Methods This study investigated 48 patients that tested negative for toxigenic C. difficile via GeneXpert C. difficile epi test, while simultaneously testing positive for toxigenic C. difficile via stool culture. Fifty discrepant samples were collected over a 15-month period and all C. difficile isolates were characterized by ribotype. Patient charts were reviewed to assess whether discrepant results impacted the treatment course or clinical outcome of affected patients. Results Fifty samples of a total of 2308 samples tested in an acute healthcare facility over a 15-month period had negative PCR and positive stool culture for toxigenic C. difficile. C. difficile isolated from the discrepant samples resulted in diverse ribotyping patterns suggesting they were derived from different strains. The samples belonged to patients who were distributed evenly between age groups and wards in the hospital. In the majority of cases, the false negative C. difficile test results did not seem to impact the clinical outcome in these patients. Conclusions The PCR limit of detection may impact the results of molecular methods for C. difficile detection. Both clinical and analytical sensitivity of C. difficile tests should be considered when deciding which diagnostic assay to use, and clinical correlates should be examined carefully before excluding CDI as a cause of disease.
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Affiliation(s)
- Yanal M Murad
- Current Address: Advanced Medical Research Institute of Canada, 41 Ramsey Lake Road, Sudbury, ON, P3E 5J1, Canada. .,Northern Ontario School of Medicine, 935 Ramsey Lake Road, Sudbury, ON P3E 2C6, Canada.
| | - Justo Perez
- Current Address: Advanced Medical Research Institute of Canada, 41 Ramsey Lake Road, Sudbury, ON, P3E 5J1, Canada
| | - Gustavo Ybazeta
- Current Address: Advanced Medical Research Institute of Canada, 41 Ramsey Lake Road, Sudbury, ON, P3E 5J1, Canada
| | - Sarah Mavin
- Northern Ontario School of Medicine, 935 Ramsey Lake Road, Sudbury, ON P3E 2C6, Canada
| | - Sebastien Lefebvre
- Current Address: Advanced Medical Research Institute of Canada, 41 Ramsey Lake Road, Sudbury, ON, P3E 5J1, Canada
| | - J Scott Weese
- Centre for Public Health and Zoonoses, University of Guelph, Guelph, ON, N1G 2W1, Canada
| | - Joyce Rousseau
- Centre for Public Health and Zoonoses, University of Guelph, Guelph, ON, N1G 2W1, Canada
| | - Francisco Diaz-Mitoma
- Current Address: Advanced Medical Research Institute of Canada, 41 Ramsey Lake Road, Sudbury, ON, P3E 5J1, Canada.,Northern Ontario School of Medicine, 935 Ramsey Lake Road, Sudbury, ON P3E 2C6, Canada.,Health Sciences North, 41 Ramsey Lake Road, Sudbury, ON P3E 5J1, Canada
| | - Reza Nokhbeh
- Current Address: Advanced Medical Research Institute of Canada, 41 Ramsey Lake Road, Sudbury, ON, P3E 5J1, Canada. .,Northern Ontario School of Medicine, 935 Ramsey Lake Road, Sudbury, ON P3E 2C6, Canada.
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Ross CL, Spinler JK, Savidge TC. Structural and functional changes within the gut microbiota and susceptibility to Clostridium difficile infection. Anaerobe 2016; 41:37-43. [PMID: 27180006 DOI: 10.1016/j.anaerobe.2016.05.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 05/05/2016] [Accepted: 05/10/2016] [Indexed: 02/06/2023]
Abstract
Alteration of the gut microbial community structure and function through antibiotic use increases susceptibility to colonization by Clostridium difficile and other enteric pathogens. However, the mechanisms that mediate colonization resistance remain elusive. As the leading definable cause of infectious diarrhea, toxigenic C. difficile represents a burden for patients and health care systems, underscoring the need for better diagnostics and treatment strategies. Next-generation sequence data has increased our understanding of how the gut microbiota is influenced by many factors including diet, disease, aging and drugs. However, a microbial-based biomarker differentiating C. difficile infection from antibiotic-associated diarrhea has not been identified. Metabolomics profiling, which is highly responsive to changes in physiological conditions, have shown promise in differentiating subtle disease phenotypes that exhibit a nearly identical microbiome community structure, suggesting metabolite-based biomarkers may be an ideal diagnostic for identifying patients with CDI. This review focuses on the current understanding of structural and functional changes to the gut microbiota during C. difficile infection obtained from studies assessing the microbiome and metabolome of samples from patients and murine models.
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Affiliation(s)
- Caná L Ross
- Texas Children's Microbiome Center, Department of Pathology, Texas Children's Hospital, 1102 Bates Ave., Houston, TX, USA; Department of Pathology & Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA
| | - Jennifer K Spinler
- Texas Children's Microbiome Center, Department of Pathology, Texas Children's Hospital, 1102 Bates Ave., Houston, TX, USA; Department of Pathology & Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA
| | - Tor C Savidge
- Texas Children's Microbiome Center, Department of Pathology, Texas Children's Hospital, 1102 Bates Ave., Houston, TX, USA; Department of Pathology & Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA.
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Abstract
Clostridium difficile (C. difficile) infection (CDI) is the most common cause of healthcare-associated infections in US hospitals. The epidemic strain NAP1/BI/ribotype 027 accounts for outbreaks worldwide, with increasing mortality and severity. CDI is acquired from an endogenous source or from spores in the environment, most easily acquired during the hospital stay. The use of antimicrobials disrupts the intestinal microflora enabling C. difficile to proliferate in the colon and produce toxins. Clinical diagnosis in symptomatic patients requires toxin detection from stool specimens and rarely in combination with stool culture to increase sensitivity. However, stool culture is essential for epidemiological studies. Oral metronidazole is the recommended therapy for milder cases of CDI and oral vancomycin or fidaxomicin for more severe cases. Treatment of first recurrence involves the use of the same therapy used in the initial CDI. In the event of a second recurrence oral vancomycin often given in a tapered dose or intermittently, or fidaxomicin may be used. Fecal transplantation is playing an immense role in therapy of recurrent CDI with remarkable results. Fulminant colitis and toxic megacolon warrant surgical intervention. Novel approaches including new antibiotics and immunotherapy against CDI or its toxins appear to be of potential value.
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Affiliation(s)
- Andrew Ofosu
- Department of Medicine, Jefferson Medical College, Philadelphia, USA
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Wenzler E, Mulugeta SG, Danziger LH. The Antimicrobial Stewardship Approach to Combating Clostridium Difficile. Antibiotics (Basel) 2015; 4:198-215. [PMID: 27025621 PMCID: PMC4790327 DOI: 10.3390/antibiotics4020198] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 06/10/2015] [Accepted: 06/15/2015] [Indexed: 12/14/2022] Open
Abstract
Clostridium difficile remains a major public health threat and continues to contribute to excess morbidity, mortality and healthcare costs. Antimicrobial stewardship programs have demonstrated success in combating C. difficile, primarily through antibiotic restrictive strategies. As the incidence and prevalence of C. difficile associate disease continues to increase both in the hospital and community setting, additional stewardship approaches are needed. This manuscript reviews stewardship interventions that have been successful against C. difficile associated disease and proposes future tactics that antimicrobial stewardship programs may employ to develop a more global approach to combat this difficult pathogen.
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Affiliation(s)
- Eric Wenzler
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL 60612, USA.
| | - Surafel G Mulugeta
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL 60612, USA.
| | - Larry H Danziger
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL 60612, USA.
- College of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA.
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