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Reflections on the past and perspectives on the future at the Healthcare Infection Society - 40 th Anniversary special celebratory meeting. J Hosp Infect 2022; 130:138-140. [PMID: 36007856 PMCID: PMC9395228 DOI: 10.1016/j.jhin.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Khanpour Ardestani S, Robinson JL, Dieleman LA, Huynh HQ, Jou H, Vohra S. Surveys of parents and clinicians concerning the minimally important difference of probiotic therapy for prevention of paediatric antibiotic-associated diarrhoea. BMJ Open 2019; 9:e024651. [PMID: 30944130 PMCID: PMC6500342 DOI: 10.1136/bmjopen-2018-024651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES To establish the minimally important difference (MID) that would prompt parents and clinicians to use probiotics for prevention of paediatric antibiotic-associated diarrhoea (AAD) and to obtain parent and clinician opinion about the most important outcomes in clinical trials of AAD. METHODS In this survey, parents of children presenting to the emergency department of a Canadian tertiary care children's hospital and paediatricians working in that hospital were approached. A range of potential MIDs were presented and participants selected one that they would require to use probiotics for AAD prevention. In addition, participants were asked to rate a list of outcomes they would consider to be important in clinical trials of AAD. RESULTS In total, 127 parents and 45 paediatricians participated. About 51% (64/125) of parents and 51% (21/41) of clinicians responding to the MID question reported they would use probiotics if it reduced the risk of AAD by 39% (ie, reduce the risk of AAD from 19% to 12%). The most important outcomes to parents, in descending order, were need for hospitalisation, prevention of dehydration, disruption of normal daily activities, diarrhoea duration and physician revisit. Paediatricians considered need for hospitalisation along with physician revisit as the most important outcomes. They rated prevention of dehydration, diarrhoea duration and stool frequency as important outcomes as well. CONCLUSION There is good agreement between parents and clinicians regarding how effective probiotics would need to be in preventing AAD in order to warrant use. This information, along with outcomes perceived to be most important, will help in the design of future clinical trials.
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Affiliation(s)
- Samaneh Khanpour Ardestani
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Joan L Robinson
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Levinus A Dieleman
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Hien Q Huynh
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Hsing Jou
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Sunita Vohra
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Abstract
Clostridioides difficile (formerly Clostridium difficile) infection is the most frequently identified health care-associated infection in the United States. C difficile has also emerged as a cause of community-associated diarrhea, resulting in increased incidence of community-associated infection. Clinical illness ranges in severity from mild diarrhea to fulminant colitis and death. Appropriate management of infection requires understanding of the various diagnostic assays and therapeutic options as well as relevant measures to infection prevention. This article provides updated recommendations regarding the prevention, diagnosis, and treatment of incident and recurrent C difficile infection.
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Affiliation(s)
- Alice Y Guh
- From the Centers for Disease Control and Prevention, Atlanta, Georgia. (A.Y.G., P.K.K.)
| | - Preeta K Kutty
- From the Centers for Disease Control and Prevention, Atlanta, Georgia. (A.Y.G., P.K.K.)
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The effectiveness and safety of two prophylactic antibiotic regimes in hip-fracture surgery. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 26:483-92. [PMID: 27193753 DOI: 10.1007/s00590-016-1794-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 05/03/2016] [Indexed: 10/21/2022]
Abstract
Antibiotic prophylaxis with cefuroxime can reduce the incidence of deep wound infection (DWI) in hip-fracture surgery, but may increase the risk of C. difficile infection (CDI). An alternative is gentamicin with beta-lactam for which a question exists around clinical effectiveness and safety, given the gentamicin-associated nephrotoxicity particularly in the elderly and narrower sensitivity spectrum. We compared 744 consecutive patients (group I-cefuroxime) with 756 in group II (gentamicin + flucloxacillin) who were well matched. There were 4 cases of CDI in the cefuroxime prophylaxis, whereas none in flucloxacillin plus gentamicin (group II). There was a statistically significant (p = 0.036) increased DWI rate in group II (2.5 %) as compared to group I (1.1 %). However, after controlling for age, gender, ASA grade, surgeon grade, implant type and type of anaesthesia, there was no statistically significant difference between the two groups (p = 0.146). 8.5 % of group I and 16.5 % of group II developed AKI post-operatively (p = 0.023); however, 79 % of group I and 80 % of in group II had complete resolution of AKI prior to their discharge. Further, a significant increase in inpatient deaths (p = 0.057) in group II was observed, but not at 30 days (p = 0.378).
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Gillespie D, Hood K, Bayer A, Carter B, Duncan D, Espinasse A, Evans M, Nuttall J, Stanton H, Acharjya A, Allen S, Cohen D, Groves S, Francis N, Howe R, Johansen A, Mantzourani E, Thomas-Jones E, Toghill A, Wood F, Wigglesworth N, Wootton M, Butler CC. Antibiotic prescribing and associated diarrhoea: a prospective cohort study of care home residents. Age Ageing 2015; 44:853-60. [PMID: 26104506 DOI: 10.1093/ageing/afv072] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 03/05/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND the risk factors for and frequency of antibiotic prescription and antibiotic-associated diarrhoea (AAD) among care home residents are unknown. AIM to prospectively study frequency and risks for antibiotic prescribing and AAD for care home residents. DESIGN AND SETTING a 12-month prospective cohort study in care homes across South Wales. METHOD antibiotic prescriptions and the development of AAD were recorded on case report forms. We defined AAD as three or more loose stools in a 24-h period occurring within 8 weeks of exposure to an antibiotic. RESULTS we recruited 279 residents from 10 care homes. The incidence of antibiotic prescriptions was 2.16 prescriptions per resident year (95% CI: 1.90-2.46). Antibiotics were less likely to be prescribed to residents from dual-registered homes (OR compared with nursing homes: 0.38, 95% CI: 0.18-0.79). For those who were prescribed antibiotics, the incidence of AAD was 0.57 episodes per resident year (95% CI: 0.41-0.81 episodes). AAD was more likely in residents who were prescribed co-amoxiclav (hazards ratio, HR = 2.08, 95% confidence interval, CI: 1.18-3.66) or routinely used incontinence pads (HR = 2.54, 95% CI: 1.26-5.13) and less likely in residents from residential homes (HR compared with nursing homes: 0.14, 95% CI: 0.06-0.32). CONCLUSION residents of care homes, particularly of nursing homes, are frequently prescribed antibiotics and often experience diarrhoea following such prescriptions. Co-amoxiclav is associated with greater risk of AAD.
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Affiliation(s)
- David Gillespie
- South East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - Kerenza Hood
- South East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - Antony Bayer
- School of Medicine, Cardiff University, Cardiff, UK
| | - Ben Carter
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Donna Duncan
- Nutrition and Dietetics, Abertawe Bro Morgannwg Health Board, Port Talbot, UK
| | - Aude Espinasse
- South East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - Meirion Evans
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Jacqueline Nuttall
- South East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Arun Acharjya
- Virus Reference Department, Public Health England, London, UK
| | - Stephen Allen
- College of Medicine, Swansea University, Swansea, UK
| | - David Cohen
- Health Economics and Policy Research Unit, University of South Wales, Pontypridd, UK
| | - Sam Groves
- Health Economics and Policy Research Unit, University of South Wales, Pontypridd, UK
| | - Nick Francis
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Robin Howe
- Microbiology Unit, Public Health Wales, Cardiff, UK
| | | | | | - Emma Thomas-Jones
- South East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - Alun Toghill
- South East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - Fiona Wood
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Neil Wigglesworth
- Welsh Healthcare Associated Infection Programme, Public Health Wales, Cardiff, UK
| | - Mandy Wootton
- Specialist Antimicrobial Chemotherapy Unit, Public Health Wales, Cardiff, UK
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Hood K, Nuttall J, Gillespie D, Shepherd V, Wood F, Duncan D, Stanton H, Espinasse A, Wootton M, Acharjya A, Allen S, Bayer A, Carter B, Cohen D, Francis N, Howe R, Mantzourani E, Thomas-Jones E, Toghill A, Butler CC. Probiotics for Antibiotic-Associated Diarrhoea (PAAD): a prospective observational study of antibiotic-associated diarrhoea (including Clostridium difficile-associated diarrhoea) in care homes. Health Technol Assess 2015; 18:1-84. [PMID: 25331573 DOI: 10.3310/hta18630] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Antibiotic prescribing rates in care homes are higher than in the general population. Antibiotics disrupt the normal gut flora, sometimes causing antibiotic-associated diarrhoea (AAD). Clostridium difficile (Hall and O'Toole 1935) Prévot 1938 is the most commonly identified cause of AAD. Little is known either about the frequency or type of antibiotics prescribed in care homes or about the incidence and aetiology of AAD in this setting. OBJECTIVES The Probiotics for Antibiotic-Associated Diarrhoea (PAAD) study was designed as a two-stage study. PAAD stage 1 aimed to (1) prospectively describe antibiotic prescribing in care homes; (2) determine the incidence of C. difficile carriage and AAD (including C. difficile-associated diarrhoea); and (3) to consider implementation challenges and establish the basis for a sample size estimation for a randomised controlled trial (RCT) of probiotic administration with antibiotics to prevent AAD in care homes. If justified by PAAD stage 1, the RCT would be implemented in PAAD stage 2. However, as a result of new evidence regarding the clinical effectiveness of probiotics on the incidence of AAD, a decision was taken not to proceed with PAAD stage 2. DESIGN PAAD stage 1 was a prospective observational cohort study in care homes in South Wales with up to 12 months' follow-up for each resident. SETTING Recruited care homes had management and owner's agreement to participate and three or more staff willing to take responsibility for implementing the study. PARTICIPANTS Eleven care homes were recruited, but one withdrew before any residents were recruited. A total of 279 care home residents were recruited to the observational study and 19 withdrew, 16 (84%) because of moving to a non-participating care home. MAIN OUTCOME MEASURES The primary outcomes were the rate of antibiotic prescribing, incidence of AAD, defined as three or more loose stools (type 5-7 on the Bristol Stool Chart) in a 24-hour period, and C. difficile carriage confirmed on stool culture. RESULTS Stool samples were obtained at study entry from 81% of participating residents. Over half of the samples contained antibiotic-resistant isolates, with Enterobacteriaceae resistant to ciprofloxacin in 47%. Residents were prescribed an average of 2.16 antibiotic prescriptions per year [95% confidence interval (CI) 1.90 to 2.46]. Antibiotics were less likely to be prescribed to residents from dual-registered homes. The incidence of AAD was 0.57 (95% CI 0.41 to 0.81) episodes per year among those residents who were prescribed antibiotics. AAD was more likely in residents who were prescribed co-amoxiclav than other antibiotics and in those residents who routinely used incontinence pads. AAD was less common in residents from residential homes. CONCLUSIONS Care home residents, particularly in nursing homes, are frequently prescribed antibiotics and often experience AAD. Antibiotic resistance, including ciprofloxacin resistance, is common in Enterobacteriaceae isolated from the stool of care home residents. Co-amoxiclav is associated with greater risk of AAD than other commonly prescribed antibiotics. TRIAL REGISTRATION Current Controlled Trials ISRCTN 7954844. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 63. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Kerenza Hood
- South East Wales Trials Unit, Cardiff University, Cardiff, UK
| | - Jacqui Nuttall
- South East Wales Trials Unit, Cardiff University, Cardiff, UK
| | - David Gillespie
- South East Wales Trials Unit, Cardiff University, Cardiff, UK
| | | | - Fiona Wood
- Institute of Primary Care and Public Health, Cardiff University, Cardiff, UK
| | - Donna Duncan
- Abertawe Bro Morang University Health Board, Swansea, UK
| | - Helen Stanton
- South East Wales Trials Unit, Cardiff University, Cardiff, UK
| | - Aude Espinasse
- South East Wales Trials Unit, Cardiff University, Cardiff, UK
| | | | | | - Stephen Allen
- College of Medicine, Swansea University, Swansea, UK
| | - Antony Bayer
- Institute of Primary Care and Public Health, Cardiff University, Cardiff, UK
| | - Ben Carter
- Institute of Primary Care and Public Health, Cardiff University, Cardiff, UK
| | - David Cohen
- Health Economics and Policy Research Unit, University of South Wales, Pontypridd, UK
| | - Nick Francis
- Institute of Primary Care and Public Health, Cardiff University, Cardiff, UK
| | - Robin Howe
- Public Health Wales Microbiology, Cardiff, UK
| | - Efi Mantzourani
- UK School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, UK
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Newham R, Thomson AH, Semple Y, Dewar S, Steedman T, Bennie M. Barriers to the safe and effective use of intravenous gentamicin and vancomycin in Scottish hospitals, and strategies for quality improvement. Eur J Hosp Pharm 2014. [DOI: 10.1136/ejhpharm-2014-000483] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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Lenoir-Wijnkoop I, Nuijten MJC, Craig J, Butler CC. Nutrition economic evaluation of a probiotic in the prevention of antibiotic-associated diarrhea. Front Pharmacol 2014; 5:13. [PMID: 24596556 PMCID: PMC3926519 DOI: 10.3389/fphar.2014.00013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 01/23/2014] [Indexed: 12/26/2022] Open
Abstract
Introduction: Antibiotic-associated diarrhea (AAD) is common and frequently more severe in hospitalized elderly adults. It can lead to increased use of healthcare resources. We estimated the cost-effectiveness of a fermented milk (FM) with probiotic in preventing AAD and in particular Clostridium difficile-associated diarrhea (CDAD). Methods: Clinical effectiveness data and cost information were incorporated in a model to estimate the cost impact of administering a FM containing the probiotic Lactobacillus paracasei ssp paracasei CNCM I-1518 in a hospital setting. Preventing AAD by the consumption of the probiotic was compared to no preventive strategy. Results: The probiotic intervention to prevent AAD generated estimated mean cost savings of £339 per hospitalized patient over the age of 65 years and treated with antibiotics, compared to no preventive probiotic. Estimated cost savings were sensitive to variation in the incidence of AAD, and to the proportion of patients who develop non-severe/severe AAD. However, probiotics remained cost saving in all sensitivity analyses. Conclusion: Use of the fermented dairy drink containing the probiotic L. paracasei CNCM I-1518 to prevent AAD in older hospitalized patients treated with antibiotics could lead to substantial cost savings.
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Affiliation(s)
- Irene Lenoir-Wijnkoop
- Department of Pharmaceutical Sciences, University of Utrecht Utrecht, Netherlands ; Scientific Affairs, Danone Research Palaiseau, France
| | | | - Joyce Craig
- York Health Economics Consortium Limited, University of York York, UK
| | - Christopher C Butler
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University Cardiff, UK
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Goldenberg S, French G. Diagnostic testing for Clostridium difficile: a comprehensive survey of laboratories in England. J Hosp Infect 2011; 79:4-7. [DOI: 10.1016/j.jhin.2011.03.030] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Accepted: 03/11/2011] [Indexed: 02/04/2023]
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Allard R, Dascal A, Camara B, Létourneau J, Valiquette L. Community-acquired Clostridium difficile-associated diarrhea, Montréal, 2005-2006: frequency estimates and their validity. Infect Control Hosp Epidemiol 2011; 32:1032-4. [PMID: 21931255 DOI: 10.1086/661911] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A retrospective search for community-acquired Clostridium difficile-associated diarrhea in 15 hospitals revealed important discrepancies with numbers for the same period reported in real time to the surveillance system. Several of the observed problems could be solved by implementing case-by-case notification with subsequent investigation by local public health, as for other reportable diseases.
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Affiliation(s)
- Robert Allard
- Public Health Department, Montréal Health and Social Services Agency, Montréal, Québec, Canada.
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Navaneethan U, Venkatesh PGK, Shen B. Clostridium difficile infection and inflammatory bowel disease: Understanding the evolving relationship. World J Gastroenterol 2010; 16:4892-904. [PMID: 20954275 PMCID: PMC2957597 DOI: 10.3748/wjg.v16.i39.4892] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Clostridium difficile (C. difficile) infection (CDI) is the leading identifiable cause of antibiotic-associated diarrhea. While there is an alarming trend of increasing incidence and severity of CDI in the United States and Europe, superimposed CDI in patients with inflammatory bowel disease (IBD) has drawn considerable attention in the gastrointestinal community. The majority of IBD patients appear to contract CDI as outpatients. C. difficile affects disease course of IBD in several ways, including triggering disease flares, sustaining activity, and in some cases, acting as an “innocent” bystander. Despite its wide spectrum of presentations, CDI has been reported to be associated with a longer duration of hospitalization and a higher mortality in IBD patients. IBD patients with restorative proctocolectomy or with diverting ileostomy are not immune to CDI of the small bowel or ileal pouch. Whether immunomodulator or corticosteroid therapy for IBD should be continued in patients with superimposed CDI is controversial. It appears that more adverse outcomes was observed among patients treated by a combination of immunomodulators and antibiotics than those treated by antibiotics alone. The use of biologic agents does not appear to increase the risk of acquisition of CDI. For CDI in the setting of underlying IBD, vancomycin appears to be more efficacious than metronidazole. Randomized controlled trials are required to clearly define the appropriate management for CDI in patients with IBD.
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Fellmeth G, Yarlagadda S, Iyer S. Epidemiology of community-onset Clostridium difficile infection in a community in the South of England. J Infect Public Health 2010; 3:118-23. [PMID: 20869672 DOI: 10.1016/j.jiph.2010.07.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Revised: 06/22/2010] [Accepted: 07/02/2010] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND AND AIMS Clostridium difficile infection (CDI) has traditionally been considered a hospital acquired infection but there are a rising number of infections in the community. This study estimates the prevalence of community-onset CDI (CO-CDI), defined as onset of symptoms in a community setting and outside the hospital, and examines the risk factors for CO-CDI in 2-64 year-olds. METHODS A standard questionnaire was used to retrospectively obtain information on the CDI risk factors of 58 cases of CO-CDI diagnosed between 1st April 2008 and 31st March 2009 in a community in the South of England. Each case was reviewed for the presence of 'established' risk factors for CDI, i.e., age ≥65 years, in-patient hospital stay, and recent (within ≤4 weeks) receipt of broad spectrum antibiotics, and other, 'non-established' risk factors for CDI, such as exposure to antibiotics more than 4 weeks preceding symptom onset, out-patient and day-surgery hospital exposure, contact with a hospitalised patient, and travel outside of the UK. RESULTS Fifty-eight cases of CO-CDI were diagnosed among a total community population of 418,000, representing an estimated prevalence of CO-CDI of 1.29 per 10,000. All 58 cases were successfully contacted, representing a 100% response rate. Four cases were excluded from further analysis due to co-infection with Salmonella spp. and Campylobacter spp. Cases were more likely to be female, aged between 31 and 40 years, and present in the spring season (March-May), 2009. 46.3% (25/54) of cases had established risk factors for CDI, 20.4% (11/54) had non-established risk factors, 16.7% (9/54) had no risk factors and in the remaining 16.7% (9/54), available information was insufficient to classify by risk factor category. CONCLUSIONS This study suggests that CDI should be included in the differential diagnosis of community-onset diarrhea in patients with or without established risk factors for CDI.
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Affiliation(s)
- Gracia Fellmeth
- Public Health Directorate, NHS Berkshire West, Reading, United Kingdom.
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Recognition and prevention of hospital-associated enteric infections in the intensive care unit. Crit Care Med 2010; 38:S324-34. [PMID: 20647790 DOI: 10.1097/ccm.0b013e3181e69f05] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The objectives of this article were to review the causes and extent of hospital-associated infectious diarrhea and associated risks in the general hospital ward and intensive care unit (ICU), to compare microorganisms with similar symptoms to aid in recognition that will lead to timely and appropriate treatment and control measures, and to propose infection prevention protocols that could decrease human process errors in the ICU. This literature review describes epidemiology, comparison of microbial characteristics for potential hospital-associated enteric pathogens, diagnosis, and prevention, especially if important in the ICU, and particularly in regard to Clostridium difficile. Enteric organisms that most commonly cause hospital-associated infectious diarrhea in acute care settings and the ICU are C. difficile, rotavirus, and norovirus, although others may also be important, particularly in developing countries. To recognize and control infectious diarrhea successfully in the ICU, intensivists should be aware that epidemiology, risks, and prevention measures may differ between these microorganisms. In addition, intensivists should be ready to implement systems changes related to notification, isolation precautions and prevention, and environmental cleaning in the ICU.
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Clostridium difficile PCR ribotype 027: assessing the risks of further worldwide spread. THE LANCET. INFECTIOUS DISEASES 2010; 10:395-404. [PMID: 20510280 PMCID: PMC7185771 DOI: 10.1016/s1473-3099(10)70080-3] [Citation(s) in RCA: 149] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Highly virulent strains of Clostridium difficile have emerged since 2003, causing large outbreaks of severe, often fatal, colitis in North America and Europe. In 2008–10, virulent strains spread between continents, with the first reported cases of fluoroquinolone-resistant C difficile PCR ribotype 027 in three Asia-Pacific countries and Central America. We present a risk assessment framework for assessing risks of further worldwide spread of this pathogen. This framework first requires identification of potential vehicles of introduction, including international transfers of hospital patients, international tourism and migration, and trade in livestock, associated commodities, and foodstuffs. It then calls for assessment of the risks of pathogen release, of exposure of individuals if release happens, and of resulting outbreaks. Health departments in countries unaffected by outbreaks should assess the risk of introduction or reintroduction of C difficile PCR ribotype 027 using a structured risk-assessment approach.
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Kaczmarzyk T. Abuse of Antibiotic Prophylaxis in Third Molar Surgeries. J Oral Maxillofac Surg 2009; 67:2551-2. [DOI: 10.1016/j.joms.2009.06.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Accepted: 06/26/2009] [Indexed: 10/20/2022]
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Dubberke ER, Gerding DN, Classen D, Arias KM, Podgorny K, Anderson DJ, Burstin H, Calfee DP, Coffin SE, Fraser V, Griffin FA, Gross P, Kaye KS, Klompas M, Lo E, Marschall J, Mermel LA, Nicolle L, Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R, Yokoe DS. Strategies to prevent clostridium difficile infections in acute care hospitals. Infect Control Hosp Epidemiol 2009; 29 Suppl 1:S81-92. [PMID: 18840091 DOI: 10.1086/591065] [Citation(s) in RCA: 153] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Erik R Dubberke
- Washington University School of Medicine, St. Louis, Missouri, USA
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Schulze T, Lüdtke A, Rahlff I, Tunn PU, Hohenberger P. Salmonella osteomyelitis in an immunocompromized patient presenting as a primary lymphoma of the bone. Int J Infect Dis 2008; 13:e67-70. [PMID: 18845462 DOI: 10.1016/j.ijid.2008.06.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2008] [Accepted: 06/05/2008] [Indexed: 11/25/2022] Open
Abstract
During the past few decades, an increasing number of immunosuppressive drugs have been developed to treat autoimmune and rheumatic diseases, as well as post-transplant patients. In parallel, the incidence of immunocompromized patients in the general population has risen, for example, patients who are HIV positive, undergoing hemodialysis or suffering from diabetes mellitus. In such predisposed patients, infections with organisms of even reduced invasive potential can result in atypical invasive manifestations. In industrialized countries, an increase in the number of human non-typhoid Salmonella infections was observed in the 1980-1990s [Shimoni Z, Pitlik S, Leibovici L, Samra Z, Konigsberger H, Drucker M, et al. Nontyphoid Salmonella bacteremia: age-related differences in clinical presentation, bacteriology, and outcome. Clin Infect Dis 1999;28:822-7]. Beyond the main clinical manifestation of gastroenteritis, there is an increasing prevalence of extra-intestinal infections by this pathogen. We report a patient with acute osteomyelitis due to Salmonella typhimurium without any previous signs of gastroenteritis.
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Affiliation(s)
- Tobias Schulze
- Division of Surgery and Surgical Oncology, Charité, Campus Berlin-Buch, Berlin, Germany.
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Van Gessel H. Measuring the incidence of Clostridium difficile-associated diarrhoea in a group of Western Australian hospitals. ACTA ACUST UNITED AC 2008. [DOI: 10.1071/hi08010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Tolevamer, an anionic polymer, neutralizes toxins produced by the BI/027 strains of Clostridium difficile. Antimicrob Agents Chemother 2008; 52:2190-5. [PMID: 18391047 DOI: 10.1128/aac.00041-08] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile-associated diarrhea (CDAD) is caused by the toxins the organism produces when it overgrows in the colon as a consequence of antibiotic depletion of normal flora. Conventional antibiotic treatment of CDAD increases the likelihood of recurrent disease by again suppressing normal bacterial flora. Tolevamer, a novel toxin-binding polymer, was developed to ameliorate the disease without adversely affecting normal flora. In the current study, tolevamer was tested for its ability to neutralize clostridial toxins produced by the epidemic BI/027 strains, thereby preventing toxin-mediated tissue culture cell rounding. The titers of toxin-containing C. difficile culture supernatants were determined using confluent cell monolayers, and then the supernatants were used in assays containing dilutions of tolevamer to determine the lowest concentration of tolevamer that prevented > or =90% cytotoxicity. Tolevamer neutralized toxins in the supernatants of all C. difficile strains tested. Specific antibodies against the large clostridial toxins TcdA and TcdB also neutralized the cytopathic effect, suggesting that tolevamer is specifically neutralizing these toxins and that the binary toxin (whose genes are carried by the BI/027 strains) is not a significant source of cytopathology against tissue culture cells in vitro.
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Freeman J, Baines SD, Saxton K, Wilcox MH. Effect of metronidazole on growth and toxin production by epidemic Clostridium difficile PCR ribotypes 001 and 027 in a human gut model. J Antimicrob Chemother 2007; 60:83-91. [PMID: 17483547 DOI: 10.1093/jac/dkm113] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES We compared the behaviour of Clostridium difficile PCR ribotypes 001 and 027 in a human gut model, and compared the responses to metronidazole exposure. METHODS Using a human gut model primed with pooled human faeces, gut flora bacterial counts, C. difficile total viable counts, spore counts and cytotoxin titres were determined, following exposure to clindamycin, in the absence or presence of metronidazole. RESULTS Duration of cytotoxin production by C. difficile ribotype 027 was markedly longer than that of ribotype 001 (23 versus 13 days, respectively), but peak toxin titres were similar. During toxin production, total C. difficile ribotype 027 populations had higher proportions of vegetative cells than did ribotype 001 (median 56.33 versus 23.54%). Similarly, total C. difficile ribotype 027 populations remained predominantly as vegetative cells for longer than did ribotype 001 (20 versus 9 days). The effects of metronidazole on C. difficile were markedly less than expected. Titres of C. difficile ribotype 001 cytotoxin were reduced but recurred following metronidazole administration. C. difficile ribotype 027 cytotoxin titres in the distal section of the gut model were unaffected by metronidazole. These observations correlated with poor metronidazole concentrations. CONCLUSIONS Duration of cytotoxin production by C. difficile ribotype 027 markedly exceeds that of ribotype 001. Sub-optimal gut concentrations of metronidazole, possibly due to inactivation by components of normal gut flora, are associated with continued toxin production. These findings may help to explain the increased severity of symptoms and higher case-fatality ratio associated with infections due to C. difficile ribotype 027.
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Affiliation(s)
- Jane Freeman
- Department of Microbiology, Leeds Teaching Hospital and University of Leeds, Leeds LS1 3EX, UK
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Kuijper EJ, Coignard B, Tüll P. Emergence of Clostridium difficile-associated disease in North America and Europe. Clin Microbiol Infect 2007; 12 Suppl 6:2-18. [PMID: 16965399 DOI: 10.1111/j.1469-0691.2006.01580.x] [Citation(s) in RCA: 639] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The clinical spectrum of Clostridium difficile-associated disease (CDAD) ranges from diarrhoea to severe life-threatening pseudomembranous colitis. Although not always associated with previous antibiotic exposure, it is in the majority of cases. CDAD is recognised increasingly in a variety of animal species and in individuals previously not considered to be predisposed. C. difficile can be transmitted via personal contact or environmentally. The role of patients and healthcare workers who are symptom-free but colonised with C. difficile in the intestinal tract is unclear. C. difficile, with more than 150 PCR ribotypes and 24 toxinotypes, has a pathogenicity locus (PaLoc) with genes encoding enterotoxin A (tcdA) and cytotoxin B (tcdB). Genes for the binary toxin are located outside the PaLoc, but the role of this toxin is unclear. The recently completed genome sequence of C. difficile 630 revealed a large proportion of 11% of mobile genetic elements, mainly in the form of conjugative transposons. Diagnostic assays include tests for the detection of C. difficile products or genes and culture methods for isolation of a toxin-producing bacterium. Enzyme immunoassays to detect toxin in faeces are widely available, with varying sensitivities and specificities. Despite practical drawbacks and sensitivity less than 100%, the cell cytototoxicity assay is still considered to be the standard. Rapid diagnostic assays are available on a limited scale and require much improvement. Molecular tests enable the detection of carriers of toxigenic and non-toxigenic strains, as does culture. It is highly recommended to culture C. difficile from toxin-positive faeces samples and to store isolates for future characterisation and typing. The financial impact of CDAD on the healthcare system is substantial (5-15,000 euro/case in England and $1.1 billion/year in the USA). Assuming a European Union population of 457 million, the potential cost of CDAD can be estimated to be 3000 million euro/year, and is expected to almost double over the next four decades. In North America, increasing rates of CDAD have been reported in Canada and the USA since March 2003, involving a more severe course, higher mortality, increased risk of relapse and more complications. This increased virulence is presumably associated with higher levels of toxin production by fluoroquinolone-resistant strains belonging to PCR ribotype 027, pulsed-field gel electrophoresis (PFGE) type NAP1, REA (restriction endonuclease analysis) type BI and toxinotype III. In Europe, outbreaks of CDAD due to the new, highly virulent strain of C. difficile PCR ribotype 027, toxinotype III have been recognised in 75 hospitals in England, 16 hospitals in The Netherlands, 13 healthcare facilities in Belgium and nine healthcare facilities in France. These outbreaks are very difficult to control, and preliminary results from case-control studies indicate a correlation with fluoroquinolones and cephalosporins. Information concerning community-acquired cases of ribotype 027 is lacking, and data concerning its incidence in nursing homes are limited. European countries should first develop early-warning and response capabilities at a national level. Depending on the nature of the notifications received, countries should implement laboratory-based or patient-based surveillance systems in specific, targeted populations.
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Tan ET, Robertson CA, Brynildsen S, Bresnitz E, Tan C, McDonald C. Clostridium difficile-associated disease in New Jersey hospitals, 2000-2004. Emerg Infect Dis 2007; 13:498-500. [PMID: 17552112 PMCID: PMC2725912 DOI: 10.3201/eid1303.060294] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Recent emergence of a virulent strain of Clostridium difficile demonstrates the importance of tracking C. difficile incidence locally. Our survey of New Jersey hospitals documented increases in the rates of C. difficile disease (by 2-fold), C. difficile-associated complications (by 7-fold), and C. difficile outbreaks (by 12-fold) during 2000-2004.
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Affiliation(s)
- Esther T Tan
- New Jersey Department of Health and Senior Services, Trenton, New Jersey, USA.
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Fordtran JS. Colitis due to Clostridium difficile toxins: underdiagnosed, highly virulent, and nosocomial. Proc (Bayl Univ Med Cent) 2006; 19:3-12. [PMID: 16424922 PMCID: PMC1325276 DOI: 10.1080/08998280.2006.11928114] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Clostridium difficile colitis is a major complication of antibiotic therapy. Antibiotics cause a reduction in bacteria that normally reside in the colon. If an antibiotic-treated patient ingests C. difficile bacteria, this organism may proliferate in the colon because it is resistant to most antibiotics and because it does not have to compete with the normal bacteria for nutrients. If the C. difficile organism has the gene for toxin production, the toxin can produce a colitis. In addition to antibiotics, other proposed risk factors for development of C. difficile colitis include advanced age, contact with infected patients and with their health care providers, impaired immune function, suppression of gastric acid secretion by a proton pump inhibitor, and postpyloric tube feeding. Many of the risk factors become simultaneously focused on patients admitted to the hospital. The incidence of C. difficile disease has been rising, and strains have become more virulent. In some forms of the disease, the patient doesn't have diarrhea, and in such patients C. difficile can be deadly but difficult to diagnose. The standard treatment, with metronidazole or vancomycin, fails to work in up to 25% of patients with the fulminant form of colitis. Since C. difficile causes only 20% of cases of antibiotic-associated diarrhea, a specific test is needed to diagnose this organism. Toxigenic cultureis highly specific but not available at most institutions. The tests that are available--enzyme-linked immunosorbent assay and fecal cytotoxicity assay--have high false-negative rates, even in patients with severe clinical disease, creating a diagnostic dilemma. The only proven way to reduce the risk of C. difficile disease is implementation of an antibiotic management program in conjunction with enhanced infection control procedures.
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Affiliation(s)
- John S Fordtran
- Division of Gastroenterology, Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas 75246, USA.
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Valiquette L, Low DE, Pépin J, McGeer A. Clostridium difficile infection in hospitals: a brewing storm. CMAJ 2004; 171:27-9. [PMID: 15238490 PMCID: PMC437677 DOI: 10.1503/cmaj.1040957] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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