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Rubak T, Baunwall SMD, Gregersen M, Hansen TK, Rosenbæk JB, Erikstrup LT, Hvas CL, Damsgaard EMS. Frailty level at discharge predicts mortality in older patients with Clostridioides difficile more accurately than age or disease severity. Eur Geriatr Med 2023:10.1007/s41999-023-00772-3. [PMID: 37046032 PMCID: PMC10097521 DOI: 10.1007/s41999-023-00772-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 03/22/2023] [Indexed: 04/14/2023]
Abstract
PURPOSE Clostridioides difficile infection (CDI) has a high mortality among older patients. Identification of older patients with CDI in increased mortality risk is important to target treatment and thereby reduce mortality. The aim of this study was to investigate mortality rates and compare frailty levels at discharge, measured by the record-based Multidimensional Prognostic Index (MPI), with age and severity of CDI as mortality predictors in patients with CDI diagnosed during hospitalisation. METHODS This was a population-based cohort study from Central Denmark Region, Denmark, including all patients ≥ 60 years with a positive CD toxin test without prior infection and diagnosed from 1 January to 31 December 2018. Frailty level, estimated from the electronic medical record, was defined as low, moderate, or severe frailty. CDI severity was graded according to international guidelines. Primary outcome was 90-day mortality. RESULTS We included 457 patients with median age 77 years (interquartile range 69-84) and females (49%). Overall, 90-day mortality was 28%, and this was associated with age (hazard ratio (HR): 2.71 (95% confidence interval 1.64-4.47)), CDI severity (HR 4.58 (3.04-6.88)) and frailty (HR 10.15 (4.06-25.36)). Frailty was a better predictor of 90-day mortality than both age (p < 0.001) and CDI severity (p = 0.04) with a receiver operating characteristic curve area of 77%. CONCLUSION The 90-day mortality among older patients with CDI in a Danish region is 28%. Frailty measured by record-based MPI at discharge outperforms age and disease severity markers in predicting mortality in older patients with CDI.
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Affiliation(s)
- Tone Rubak
- Department of Geriatrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Simon Mark Dahl Baunwall
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Merete Gregersen
- Department of Geriatrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Troels Kjærskov Hansen
- Department of Geriatrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | | | | | - Christian Lodberg Hvas
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Else Marie Skjøde Damsgaard
- Department of Geriatrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Covino M, Gallo A, Pero E, Simeoni B, Macerola N, Murace CA, Ibba F, Landi F, Franceschi F, Montalto M. Early Prognostic Stratification of Clostridioides difficile Infection in the Emergency Department: The Role of Age and Comorbidities. J Pers Med 2022; 12:jpm12101573. [PMID: 36294712 PMCID: PMC9604882 DOI: 10.3390/jpm12101573] [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: 08/10/2022] [Revised: 09/07/2022] [Accepted: 09/20/2022] [Indexed: 11/16/2022] Open
Abstract
Clostridioides difficile infection (CDI) represents a significant cause of morbidity and mortality, mainly in older and frail subjects. Early identification of outcome predictors, starting from emergency department (ED) admission, could help to improve their management. In a retrospective single-center study on patients accessing the ED for diarrhea and hospitalized with a diagnosis of CDI infection, the patients’ clinical history, presenting symptoms, vital signs, and laboratory exams at ED admission were recorded. Quick sequential organ failure assessments (qSOFA) were conducted and Charlson’s comorbidity indices (CCI) were calculated. The primary outcomes were represented by all-cause in-hospital death and the occurrence of major cumulative complications. Univariate and multivariate Cox regression analyses were performed to establish predictive risk factors for poor outcomes. Out of 450 patients, aged > 81 years, dyspnea at ED admission, creatinine > 2.5 mg/dL, white blood cell count > 13.31 × 109/L, and albumin < 30 µmol/L were independently associated with in-hospital death and major complications (except for low albumin). Both in-hospital death and major complications were not associated with multimorbidity. In patients with CDI, the risk of in-hospital death and major complications could be effectively predicted upon ED admission. Patients in their 8th decade have an increased risk independent of comorbidities.
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Affiliation(s)
- Marcello Covino
- Department of Emergency Medicine, Fondazione Policlinico Universitario “A. Gemelli”, IRCCS, Largo A. Gemelli, 8, 00168 Rome, Italy
| | - Antonella Gallo
- Department of Geriatrics and Orthopedics, Fondazione Policlinico Universitario “A. Gemelli”, IRCCS, Largo A. Gemelli, 8, 00168 Rome, Italy
- Correspondence:
| | - Erika Pero
- Department of Geriatrics and Orthopedics, Fondazione Policlinico Universitario “A. Gemelli”, IRCCS, Largo A. Gemelli, 8, 00168 Rome, Italy
| | - Benedetta Simeoni
- Department of Emergency Medicine, Fondazione Policlinico Universitario “A. Gemelli”, IRCCS, Largo A. Gemelli, 8, 00168 Rome, Italy
| | - Noemi Macerola
- Department of Geriatrics and Orthopedics, Fondazione Policlinico Universitario “A. Gemelli”, IRCCS, Largo A. Gemelli, 8, 00168 Rome, Italy
| | - Celeste Ambra Murace
- Department of Geriatrics and Orthopedics, Fondazione Policlinico Universitario “A. Gemelli”, IRCCS, Largo A. Gemelli, 8, 00168 Rome, Italy
| | - Francesca Ibba
- Department of Geriatrics and Orthopedics, Fondazione Policlinico Universitario “A. Gemelli”, IRCCS, Largo A. Gemelli, 8, 00168 Rome, Italy
| | - Francesco Landi
- Department of Geriatrics and Orthopedics, Fondazione Policlinico Universitario “A. Gemelli”, IRCCS, Largo A. Gemelli, 8, 00168 Rome, Italy
- Department of Geriatrics and Orthopedics, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168 Rome, Italy
| | - Francesco Franceschi
- Department of Emergency Medicine, Fondazione Policlinico Universitario “A. Gemelli”, IRCCS, Largo A. Gemelli, 8, 00168 Rome, Italy
- Department of Emergency Medicine, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168 Rome, Italy
| | - Massimo Montalto
- Department of Geriatrics and Orthopedics, Fondazione Policlinico Universitario “A. Gemelli”, IRCCS, Largo A. Gemelli, 8, 00168 Rome, Italy
- Department of Geriatrics and Orthopedics, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168 Rome, Italy
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3
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Skinner AM, Scardina T, Kociolek LK. Fidaxomicin for the treatment of Clostridioides difficile in children. Future Microbiol 2020; 15:967-979. [PMID: 32715754 DOI: 10.2217/fmb-2020-0104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Fidaxomicin is an oral narrow-spectrum novel 18-membered macrocyclic antibiotic that was initially approved in 2011 by the US FDA for the treatment of Clostridioides difficile infections (CDI) in adults. In February 2020, the FDA approved fidaxomicin for the treatment of CDI in children age >6 months. In adults, fidaxomicin is as efficacious as vancomycin in treating CDI and reduces the risk of recurrent CDI. An investigator-blinded, randomized, multicenter, multinational clinical trial comparing the efficacy and safety of fidaxomicin with vancomycin in children was recently published confirming similar findings as previously reported in adults. Fidaxomicin is the first FDA-approved treatment for CDI in children and offers a promising option for reducing recurrent CDI in this population.
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Affiliation(s)
- Andrew M Skinner
- Department of Medicine, Division of Infectious Diseases, Loyola University Medical Center, Maywood, IL, USA
| | - Tonya Scardina
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Larry K Kociolek
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Department of Pediatrics, Division of Pediatric Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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4
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Pereira JA, McGeer A, Tomovici A, Selmani A, Chit A. The Clinical Burden of Clostridioides difficile in Ontario, Canada. Open Forum Infect Dis 2020; 7:ofz523. [PMID: 32025524 PMCID: PMC6993863 DOI: 10.1093/ofid/ofz523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/12/2019] [Indexed: 02/04/2023] Open
Abstract
Background To understand the clinical burden of Clostridioides difficile infection (CDI), we analyzed health outcome data from Ontario, Canada for CDI associated with and manifested in acute care hospitals (ACH), long-term care facilities (LTCF), the community, or ACH-associated with community-onset. Methods We performed a retrospective analysis using individual-level data from Ontario databases (April 1, 2005 to March 31, 2015), identifying CDI cases ≥18 years requiring hospitalization, and stratifying into cohorts based on association and onset location. Cohort members were matched to controls on demographics and medical conditions at onset, for outcomes including 30- and 180-day all-cause mortality and rehospitalization. Results We stratified 22 617 individuals hospitalized with CDI during the study period: 13 152 (58.1%) ACH-associated/ACH-onset, 7116 (31.5%) community-associated/community-onset, 1847 (8.2%) ACH-associated/community-onset, and 502 (2.2%) LTCF-associated/LTCF-onset. Compared with controls, unadjusted 30-day rehospitalization rates were significantly higher (P < .0001) for ACH-associated/ACH-onset CDI (9.5% vs 0.4%), LTCF-associated/LTCF-onset (7.2% vs 1.1%), community-associated/community-onset (7.8% vs 0.8%), and ACH-associated/community-onset (10.9% vs 0.7%). One hundred eighty-day mortality rates were higher in the community-associated/community-onset and the LTCF-associated/LTCF-onset cohorts than controls: 66.3% vs 12.3% (P < .0001) and 30.9% vs 3.1% (P < .0001), respectively. All differences remained significant after adjusting for patient factors. Conclusions Clostridioides difficile infection is associated with higher rates of 30-day rehospitalization compared with controls. In addition, mortality rates within 180-days of hospital discharge are significantly higher for community-associated/community-onset and LTCF-associated/LTCF-onset CDI cohorts than controls. Clostridioides difficile infection warrants increased prevention and monitoring efforts.
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Affiliation(s)
| | - Allison McGeer
- Department of Microbiology, Mount Sinai Hospital, Toronto, Canada
| | | | | | - Ayman Chit
- Sanofi Pasteur, Swiftwater, Pennsylvania, USA
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Acute Clostridioides difficile Infection in Hospitalized Persons Aged 75 and Older: 30-Day Prognosis and Risk Factors for Mortality. J Am Med Dir Assoc 2019; 21:110-114. [PMID: 31537480 DOI: 10.1016/j.jamda.2019.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 07/01/2019] [Accepted: 07/02/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To assess the 30-day mortality predictive markers in the oldest patients with Clostridioides difficile infection (CDI) and to analyze the accuracy of the European severity risk markers in this population. DESIGN Observational prospective multicenter cohort study conducted by the French Infectious Diseases Society and Geriatrics Society networks. An electronic questionnaire was sent to members of both societies regarding their participation. Each investigator used an online survey to gather the data. SETTING AND PARTICIPANTS Patients aged ≥75 years hospitalized in French geriatric or infectious wards with confirmed diagnosis of CDI between March 1, 2016 and May 1, 2017. METHODS Clinical and laboratory parameters included medical history and comorbidities with the Cumulative Illness Rating Scale (CIRS). Criteria increasing the risk of severe disease were recorded as listed in the European guidelines. Therapeutic management, recurrence, and mortality rates were assessed at day 30 after diagnosis. RESULTS Included patients numbered 247; mean age was 87.2 years (SD 5.4). Most of the CDI incidences (66.4%) were health care-associated infections, with 81% diagnosed within 30 days of hospitalization; CIRS mean score was 16.6 (SD 6.6). Markers of severity ≥3 included 97 patients (39.3%). Metronidazole was the main initial treatment (51.0%). C difficile infection in the older adult was associated with a 30-day mortality of 12.6%. Multivariate analysis showed that baseline CIRS score [hazard ratio (HR) 1.06 per 1-point increase, 95% confidence interval (CI) 1.00-1.12] and evidence of cardiac, respiratory, or renal decompensation (HR 3.04, 95% CI 1.40-6.59) were significantly associated with mortality. CONCLUSIONS AND IMPLICATIONS European severity markers are adequate in the oldest old. Organ failure and comorbidities appeared to be the main markers of prognosis, and these should raise the awareness of practitioners. Although antibiotic treatment was not predictive of mortality, our results point out the lack of adherence to current guidelines in this population.
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Dingle KE, Didelot X, Quan TP, Eyre DW, Stoesser N, Marwick CA, Coia J, Brown D, Buchanan S, Ijaz UZ, Goswami C, Douce G, Fawley WN, Wilcox MH, Peto TEA, Walker AS, Crook DW. A Role for Tetracycline Selection in Recent Evolution of Agriculture-Associated Clostridium difficile PCR Ribotype 078. mBio 2019; 10:e02790-18. [PMID: 30862754 PMCID: PMC6414706 DOI: 10.1128/mbio.02790-18] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 01/31/2019] [Indexed: 02/04/2023] Open
Abstract
The increasing clinical importance of human infections (frequently severe) caused by Clostridium difficile PCR ribotype 078 (RT078) was first reported in 2008. The severity of symptoms (mortality of ≤30%) and the higher proportion of infections among community and younger patients raised concerns. Farm animals, especially pigs, have been identified as RT078 reservoirs. We aimed to understand the recent changes in RT078 epidemiology by investigating a possible role for antimicrobial selection in its recent evolutionary history. Phylogenetic analysis of international RT078 genomes (isolates from 2006 to 2014, n = 400), using time-scaled, recombination-corrected, maximum likelihood phylogenies, revealed several recent clonal expansions. A common ancestor of each expansion had independently acquired a different allele of the tetracycline resistance gene tetM Consequently, an unusually high proportion (76.5%) of RT078 genomes were tetM positive. Multiple additional tetracycline resistance determinants were also identified (including efflux pump tet40), frequently sharing a high level of nucleotide sequence identity (up to 100%) with sequences found in the pig pathogen Streptococcus suis and in other zoonotic pathogens such as Campylobacter jejuni and Campylobacter coli Each RT078 tetM clonal expansion lacked geographic structure, indicating rapid, recent international spread. Resistance determinants for C. difficile infection-triggering antimicrobials, including fluoroquinolones and clindamycin, were comparatively rare in RT078. Tetracyclines are used intensively in agriculture; this selective pressure, plus rapid, international spread via the food chain, may explain the increased RT078 prevalence in humans. Our work indicates that the use of antimicrobials outside the health care environment has selected for resistant organisms, and in the case of RT078, has contributed to the emergence of a human pathogen.IMPORTANCEClostridium difficile PCR ribotype 078 (RT078) has multiple reservoirs; many are agricultural. Since 2005, this genotype has been increasingly associated with human infections in both clinical settings and the community. Investigations of RT078 whole-genome sequences revealed that tetracycline resistance had been acquired on multiple independent occasions. Phylogenetic analysis revealed a rapid, recent increase in numbers of closely related tetracycline-resistant RT078 (clonal expansions), suggesting that tetracycline selection has strongly influenced its recent evolutionary history. We demonstrate recent international spread of emergent, tetracycline-resistant RT078. A similar tetracycline-positive clonal expansion was also identified in unrelated nontoxigenic C. difficile, suggesting that this process may be widespread and may be independent of disease-causing ability. Resistance to typical C. difficile infection-associated antimicrobials (e.g., fluoroquinolones, clindamycin) occurred only sporadically within RT078. Selective pressure from tetracycline appears to be a key factor in the emergence of this human pathogen and the rapid international dissemination that followed, plausibly via the food chain.
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Affiliation(s)
- Kate E Dingle
- Nuffield Department of Clinical Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, United Kingdom
- NIHR Oxford Health Protection Research Unit on Healthcare Associated Infection and Antimicrobial Resistance, John Radcliffe Hospital, Oxford University, Oxford, United Kingdom
| | - Xavier Didelot
- School of Life Sciences and Department of Statistics, University of Warwick, Coventry, United Kingdom
| | - T Phuong Quan
- Nuffield Department of Clinical Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, United Kingdom
- NIHR Oxford Health Protection Research Unit on Healthcare Associated Infection and Antimicrobial Resistance, John Radcliffe Hospital, Oxford University, Oxford, United Kingdom
| | - David W Eyre
- Nuffield Department of Clinical Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Nicole Stoesser
- Nuffield Department of Clinical Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - Charis A Marwick
- Population Health Sciences, School of Medicine, University of Dundee, Scotland, United Kingdom
| | - John Coia
- Scottish Microbiology Reference Laboratories, Glasgow, United Kingdom
| | - Derek Brown
- Scottish Microbiology Reference Laboratories, Glasgow, United Kingdom
| | | | - Umer Z Ijaz
- University of Glasgow, Scotland, United Kingdom
| | | | - Gill Douce
- University of Glasgow, Scotland, United Kingdom
| | - Warren N Fawley
- Department of Microbiology, Leeds General Infirmary, Leeds Teaching Hospitals, University of Leeds, Leeds, United Kingdom
| | - Mark H Wilcox
- Department of Microbiology, Leeds General Infirmary, Leeds Teaching Hospitals, University of Leeds, Leeds, United Kingdom
| | - Timothy E A Peto
- Nuffield Department of Clinical Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, United Kingdom
- NIHR Oxford Health Protection Research Unit on Healthcare Associated Infection and Antimicrobial Resistance, John Radcliffe Hospital, Oxford University, Oxford, United Kingdom
| | - A Sarah Walker
- Nuffield Department of Clinical Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, United Kingdom
- NIHR Oxford Health Protection Research Unit on Healthcare Associated Infection and Antimicrobial Resistance, John Radcliffe Hospital, Oxford University, Oxford, United Kingdom
| | - Derrick W Crook
- Nuffield Department of Clinical Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, United Kingdom
- NIHR Oxford Health Protection Research Unit on Healthcare Associated Infection and Antimicrobial Resistance, John Radcliffe Hospital, Oxford University, Oxford, United Kingdom
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Esteban-Vasallo MD, de Miguel-Díez J, López-de-Andrés A, Hernández-Barrera V, Jiménez-García R. Clostridium difficile-related hospitalizations and risk factors for in-hospital mortality in Spain between 2001 and 2015. J Hosp Infect 2018; 102:148-156. [PMID: 30240814 DOI: 10.1016/j.jhin.2018.09.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 09/11/2018] [Indexed: 01/05/2023]
Abstract
AIMS To examine trends in the incidence, characteristics and in-hospital outcomes of Clostridium difficile infection (CDI) hospitalizations from 2001 to 2015, to compare clinical variables among patients according to the diagnosis position (primary or secondary) of CDI, and to identify factors associated with in-hospital mortality (IHM). METHODS A retrospective study was performed using the Spanish National Hospital Discharge Database, 2001-2015. The study population included patients who had CDI as the primary or secondary diagnosis in their discharge report. Annual hospitalization rates were calculated and trends were assessed using Poisson regression models and Jointpoint analysis. Multi-variate logistic regression models were performed to identify variables associated with IHM. FINDINGS In total, 49,347 hospital discharges were identified (52.31% females, 33.69% with CDI as the primary diagnosis). The rate of hospitalization increased from 3.9 cases per 100,000 inhabitants in 2001-2003 to 12.97 cases per 100,000 inhabitants in 2013-2015. Severity of CDI and mean cost per patient increased from 6.36% and 3750.11€ to 11.19% and 4340.91€, respectively, while IHM decreased from 12.66% to 10.66%. Age, Charlson Comorbidity Index, severity, length of hospital stay and mean cost were significantly higher in patients with a primary diagnosis of CDI. Irrespective of the CDI diagnosis position, IHM was associated with male sex, older age, comorbidities, readmission and severity of CDI. Primary diagnosis of CDI was associated with lower IHM (odds ratio 0.60; 95% confidence interval 0.56-0.65). CONCLUSION CDI-related hospitalization rates are increasing, leading to a high cost burden, although IHM has decreased in recent years. Factors associated with IHM should be considered in strategies for the prevention and management of CDI.
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Affiliation(s)
| | - J de Miguel-Díez
- Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - A López-de-Andrés
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Madrid, Spain
| | - V Hernández-Barrera
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Madrid, Spain
| | - R Jiménez-García
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Madrid, Spain
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Gray J, Oppenheim B, Mahida N. The Journal of Hospital Infection - a history of infection prevention and control in 100 volumes. J Hosp Infect 2018; 100:1-8. [PMID: 30173875 DOI: 10.1016/j.jhin.2018.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 07/04/2018] [Indexed: 02/04/2023]
Affiliation(s)
- J Gray
- Journal of Hospital Infection, London, UK.
| | | | - N Mahida
- Journal of Hospital Infection, London, UK
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Bradshaw WJ, Roberts AK, Shone CC, Acharya KR. The structure of the S-layer of Clostridium difficile. J Cell Commun Signal 2018; 12:319-331. [PMID: 29170885 PMCID: PMC5842191 DOI: 10.1007/s12079-017-0429-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 10/25/2017] [Indexed: 12/28/2022] Open
Abstract
The nosocomially acquired pathogen Clostridium difficile is the primary causative agent of antibiotic associated diarrhoea and causes tens of thousands of deaths globally each year. C. difficile presents a paracrystalline protein array on the surface of the cell known as an S-layer. S-layers have been demonstrated to possess a wide range of important functions, which, combined with their inherent accessibility, makes them a promising drug target. The unusually complex S-layer of C. difficile is primarily comprised of the high- and low- molecular weight S-layer proteins, HMW SLP and LMW SLP, formed from the cleavage of the S-layer precursor protein, SlpA, but may also contain up to 28 SlpA paralogues. A model of how the S-layer functions as a whole is required if it is to be exploited in fighting the bacterium. Here, we provide a summary of what is known about the S-layer of C. difficile and each of the paralogues and, considering some of the domains present, suggest potential roles for them.
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Affiliation(s)
- William J Bradshaw
- Department of Biology and Biochemistry, University of Bath, Claverton Down, Bath, BA2 7AY, UK
- Public Health England, Porton Down, Salisbury, SP4 0JG, UK
| | | | | | - K Ravi Acharya
- Department of Biology and Biochemistry, University of Bath, Claverton Down, Bath, BA2 7AY, UK.
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10
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Rees CA, Shen A, Hill JE. Characterization of the Clostridium difficile volatile metabolome using comprehensive two-dimensional gas chromatography time-of-flight mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 2016; 1039:8-16. [DOI: 10.1016/j.jchromb.2016.11.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 09/05/2016] [Accepted: 11/05/2016] [Indexed: 10/20/2022]
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Chopra T, Awali RA, Biedron C, Vallin E, Bheemreddy S, Saddler CM, Mullins K, Echaiz JF, Bernabela L, Severson R, Marchaim D, Lephart P, Johnson L, Thyagarajan R, Kaye KS, Alangaden G. Predictors of Clostridium difficile infection-related mortality among older adults. Am J Infect Control 2016; 44:1219-1223. [PMID: 27424303 DOI: 10.1016/j.ajic.2016.04.231] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/01/2016] [Accepted: 04/01/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Over 90% of annual deaths caused by Clostridium difficile infection (CDI) occur in persons aged ≥65 years. However, no large-scale studies have been conducted to investigate predictors of CDI-related mortality among older adults. METHODS This case-control study included 540 CDI patients aged ≥60 years admitted to a tertiary care hospital in Detroit, Michigan, between January 2005 and December 2012. Cases were CDI patients who died within 30 days of CDI date. Controls were CDI patients who survived >30 days after CDI date. Cases were matched to controls on a 1:3 ratio based on age and hospital acquisition of CDI. RESULTS One-hundred and thirty cases (25%) were compared with 405 controls (75%). Independent predictors of CDI-related mortality included admission from another acute hospital (odds ratio [OR], 8.25; P = .001) or a long-term care facility (OR, 13.12; P = .012), McCabe score ≥2 (OR, 12.19; P < .001), and high serum creatinine (≥1.7 mg/dL) (OR, 3.43; P = .021). The regression model was adjusted for the confounding effect of limited activity of daily living score, total number of antibiotic days prior to CDI, ileus on abdominal radiograph, low albumin (≤2.5 g/dL), elevated white blood cell count (>15 × 1,000/mm3), and admission to intensive care unit because of CDI. CONCLUSIONS Predictors of CDI-related mortality reported in this study could be applied to the development of a bedside scoring system for older adults with CDI.
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Leibovici-Weissman Y, Atamna A, Schlesinger A, Eliakim-Raz N, Bishara J, Yahav D. Risk factors for short- and long-term mortality in very old patients with Clostridium difficile infection: A retrospective study. Geriatr Gerontol Int 2016; 17:1378-1383. [PMID: 27647625 DOI: 10.1111/ggi.12866] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 06/01/2016] [Accepted: 06/14/2016] [Indexed: 11/30/2022]
Abstract
AIM Most cases of Clostridium difficile infections (CDI) occur in patients aged 65 years and older. Older age is associated with increased mortality. Risk factors for mortality in patients aged 80 years and older are not well recognized. METHODS We analyzed retrospective data including 184 patients aged 80 years and older hospitalized with CDI during 2009-2014. We aimed to delineate risk factors for short- and long-term mortality. RESULTS The 30-day mortality was 33.2%; 1-year mortality was 64.7%. Median survival was 110 days (interquartile range 24-655 days). All four patients who underwent colectomy died. Risk factors for 30-day mortality in multivariate analysis were diabetes mellitus, low albumin and therapy other than metronidazole monotherapy, the latter probably reflecting higher severity of disease rather than a true predictor of mortality. Risk factors for long-term mortality analyzed in Cox regression were albumin ≤2.5 g/dL (HR 0.58, 95% CI 0.395-0.850), presentation with sepsis (HR 0.597, 95% CI 0.408-0.873), a non-independent activities of daily living baseline status (HR 0.460, 95% CI 0.236--0.897) and Charlson score (HR 0.867, 95% CI 0.801-0.938). None of the traditional severity indices for CDI (such as leukocytosis or creatinine increase) proved to be predictors of mortality over the age of 80 years. CONCLUSIONS The prognosis of old patients with CDI is dismal. Considering the high mortality, efforts to prevent CDI should be first priority in patients aged 80 years and older. Assessment of albumin levels should be part of the evaluation at presentation and considered when choosing treatment, rather than standard severity indexes for CDI. Geriatr Gerontol Int 2017; 17: 1378-1383.
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Affiliation(s)
- Yaara Leibovici-Weissman
- Internal Medicine D, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel
| | - Alaa Atamna
- Internal Medicine C, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Agata Schlesinger
- Department of Acute Geriatrics, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel
| | - Noa Eliakim-Raz
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel.,Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Jihad Bishara
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel.,Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Dafna Yahav
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel.,Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
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Epidemiological and economic burden of Clostridium difficile in the United States: estimates from a modeling approach. BMC Infect Dis 2016; 16:303. [PMID: 27316794 PMCID: PMC4912810 DOI: 10.1186/s12879-016-1610-3] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 06/01/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Despite a large increase in Clostridium difficile infection (CDI) severity, morbidity and mortality in the US since the early 2000s, CDI burden estimates have had limited generalizability and comparability due to widely varying clinical settings, populations, or study designs. METHODS A decision-analytic model incorporating key input parameters important in CDI epidemiology was developed to estimate the annual number of initial and recurrent CDI cases, attributable and all-cause deaths, economic burden in the general population, and specific number of high-risk patients in different healthcare settings and the community in the US. Economic burden was calculated adopting a societal perspective using a bottom-up approach that identified healthcare resources consumed in the management of CDI. RESULTS Annually, a total of 606,058 (439,237 initial and 166,821 recurrent) episodes of CDI were predicted in 2014: 34.3 % arose from community exposure. Over 44,500 CDI-attributable deaths in 2014 were estimated to occur. High-risk susceptible individuals representing 5 % of the total hospital population accounted for 23 % of hospitalized CDI patients. The economic cost of CDI was $5.4 billion ($4.7 billion (86.7 %) in healthcare settings; $725 million (13.3 %) in the community), mostly due to hospitalization. CONCLUSIONS A modeling framework provides more comprehensive and detailed national-level estimates of CDI cases, recurrences, deaths and cost in different patient groups than currently available from separate individual studies. As new treatments for CDI are developed, this model can provide reliable estimates to better focus healthcare resources to those specific age-groups, risk-groups, and care settings in the US where they are most needed. (Trial Identifier ClinicaTrials.gov: NCT01241552).
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Kirk JA, Banerji O, Fagan RP. Characteristics of the Clostridium difficile cell envelope and its importance in therapeutics. Microb Biotechnol 2016; 10:76-90. [PMID: 27311697 PMCID: PMC5270738 DOI: 10.1111/1751-7915.12372] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 05/26/2016] [Accepted: 05/30/2016] [Indexed: 01/08/2023] Open
Abstract
Clostridium difficile infection (CDI) is a challenging threat to human health. Infections occur after disruption of the normal microbiota, most commonly through the use of antibiotics. Current treatment for CDI largely relies on the broad‐spectrum antibiotics vancomycin and metronidazole that further disrupt the microbiota resulting in frequent recurrence, highlighting the need for C. difficile‐specific antimicrobials. The cell surface of C. difficile represents a promising target for the development of new drugs. C. difficile possesses a highly deacetylated peptidoglycan cell wall containing unique secondary cell wall polymers. Bound to the cell wall is an essential S‐layer, formed of SlpA and decorated with an additional 28 related proteins. In addition to the S‐layer, many other cell surface proteins have been identified, including several with roles in host colonization. This review aims to summarize our current understanding of these different C. difficile cell surface components and their viability as therapeutic targets.
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Affiliation(s)
- Joseph A Kirk
- Krebs Institute, Department of Molecular Biology and Biotechnology, University of Sheffield, Sheffield, S10 2TN, UK
| | - Oishik Banerji
- Krebs Institute, Department of Molecular Biology and Biotechnology, University of Sheffield, Sheffield, S10 2TN, UK
| | - Robert P Fagan
- Krebs Institute, Department of Molecular Biology and Biotechnology, University of Sheffield, Sheffield, S10 2TN, UK
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Adverse events in faecal microbiota transplant: a review of the literature. J Hosp Infect 2015; 92:117-27. [PMID: 26803556 DOI: 10.1016/j.jhin.2015.10.024] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 10/08/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Faecal microbiota transplant (FMT) is the infusion of donor faeces into the gut with the aim of improving microbial diversity. The procedure has gained significant interest recently in the treatment of recurrent Clostridium difficile infection (CDI). The literature is currently dominated by small case series and isolated case reports. There is no standardization of methods and recording of outcomes. AIM To present the adverse events that have been associated with the use of FMT, as reported in the English literature to date. METHODS A database search of Medline and Embase identified publications where FMT has been administered. Review articles were excluded. In total, 109 publications were identified that described the use of FMT in 1555 individuals. FINDINGS Other than three small randomized controlled studies, the data consisted of small series and case reports. CDI was the most common indication for FMT (N = 1190), with the majority of the remaining cases receiving FMT for inflammatory bowel disease. FMT had also been applied for irritable bowel syndrome, metabolic syndrome and constipation in small numbers. Adverse events appear to be uncommon, often mild and self-limiting; however, serious adverse events including bacteraemia, perforations and death have been reported. CONCLUSION The vast majority of adverse events of FMT appear to be mild, self-limiting and gastrointestinal in nature. In some cases, a credible association was not established due to the lack of controlled data. There is a need for standardized, randomized controlled trials to qualify and quantify the risks associated with FMT.
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16
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Steindl G, Fiedler A, Huhulescu S, Wewalka G, Allerberger F. Effect of airborne hydrogen peroxide on spores of Clostridium difficile. Wien Klin Wochenschr 2014; 127:421-6. [PMID: 25527140 DOI: 10.1007/s00508-014-0682-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 11/20/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Contamination of surfaces by spores of Clostridium difficile is a major factor influencing the spread of healthcare-associated C. difficile infection. The aim of this study was to test the effect of an automated room disinfection system that provides an aerosol of 7.5 % hydrogen peroxide (H2O2) disinfectant, on spores of two different strains of C. difficile, and to evaluate the impact of biological soiling on the efficacy of H2O2 disinfection. MATERIAL AND METHOD The strains used were a C. difficile PCR ribotype 027 and a C. difficile ATCC 9689. Spore suspensions of each strain were applied to ceramic tiles and exposed to aerosolized H2O2 at different locations in a test room. Biological soiling was simulated by bovine serum albumin and sheep erythrocytes. At set time points spores were recovered, plated onto Columbia 5 % sheep blood agar, and surviving bacteria were counted as colony-forming units (cfu). RESULTS No viable spores of either strain were recovered after a 3 h exposure to gaseous H2O2. Spores located inside a drawer showed recovery of approximately 1E5 cfu/ml for C. difficile ribotype 027 after 1 h. In the presence of organic matter, a more than fivefold log reduction compared with not exposed controls could be observed for spores of either strain tested. CONCLUSION Appropriate decontamination of surfaces exposed to spores of C. difficile is challenging for conventional cleaning methods. Aerosolized H2O2 delivered by automated room disinfection systems could possibly improve surface decontamination and thereby reduce transmission of healthcare-associated C. difficile infection. Also in the presence of organic matter H2O2 disinfection appears to be an effective adjunct for decontamination of environmental surfaces.
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Affiliation(s)
- Georg Steindl
- Institute of Medical Microbiology and Hygiene, Austrian Agency for Health and Food Safety, Beethovenstraße 6, 8010, Graz, Austria,
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17
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The evolution of urban C. difficile infection (CDI): CDI in 2009-2011 is less severe and has better outcomes than CDI in 2006-2008. Am J Gastroenterol 2014; 109:1265-76. [PMID: 25001255 DOI: 10.1038/ajg.2014.167] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Accepted: 05/14/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Over the past decade, the epidemiology of Clostridium difficile infection (CDI) has shown a remarkable increase in incidence with an associated increase in severity. This study was designed to compare the demographics, medication exposure, evaluation, treatment patterns, and outcomes of patients with CDI in two different time periods: 2006-2008 and 2009-2011. We hypothesized that mortality is decreasing with increasing appropriateness of medical management. METHODS We retrospectively identified consecutive patients admitted to Montefiore Medical Center between 1/1/2006 and 12/31/2011 with symptomatic diarrhea and a positive C. difficile toxin assay. The cohort was subdivided into those diagnosed in 2006-2008 (CDI 06-08) and 2009-2011 (CDI 09-11). We obtained key parameters at the time of diagnosis including demographics, medication exposure, medical comorbidities, laboratory data, CDI evaluation, and various outcome measures. We created a subcohort for each time frame of patients diagnosed with severe CDI defined by white blood cell count (WBC) >15,000 cells/μl and albumin <3.0 g/dl and made the same comparisons as for the overall cohort. The two cohorts were compared using SPSS (16.0). RESULTS Cohorts and the number of patients who met criteria for inclusion were as follows: CDI 06-08 (n=1189), CDI 09-11 (n=1,907), severe CDI 06-08 (n=243), and severe CDI 09-11 (n=382). CDI 09-11 patients were older (P=0.01) and had higher Charlson comorbidity scores (P=0.02) than did those in the CDI 06-08 cohort. There were no significant demographic differences in the severe cohort. For both the overall and severe cohorts, there was more macrolide exposure before diagnosis with CDI and lower rates of quinolone exposure in the more recent era. The disease process also appeared less severe in the CDI 09-11 cohort with lower peak WBC during admission and at diagnosis. Treatment patterns appeared more aggressive during the more recent time frame, with shorter durations of oral metronidazole (P<0.001), longer durations of IV metronidazole (P=0.04), more frequent use of vancomycin as the sole therapy (P<0.001), more frequent switching from metronidazole to vancomycin (P<0.001), and less frequent exposure to any metronidazole throughout treatment (P<0.001) in the overall cohort. The 30-day mortality decreased significantly in both the overall (17.1 vs. 13.1%, P<0.01) and the severe (31.3 vs. 23.3%, P<0.05) cohorts from CDI 06-08 to CDI 09-11, with mortality decreasing significantly in the 8th and 9th decades of life in the overall cohort and in the 8th, 9th, and 10th decades in the severe cohort. CONCLUSIONS In an urban United States population, CDI 09-11 showed changes in medication exposures, less severe disease, and more aggressive management with better outcomes and decreased mortality compared with CDI 06-08. The most important factors associated with 30-day mortality in both an overall and severe CDI population include age, WBC, and albumin level at the time of diagnosis.
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18
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Decreasing Clostridium difficile infections by an antimicrobial stewardship program that reduces moxifloxacin use. Antimicrob Agents Chemother 2014; 58:5079-83. [PMID: 24936597 DOI: 10.1128/aac.03006-14] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile infections (CDI) in hospitalized patients are known to be closely related to antibiotic exposure. Although several substances can cause CDI, the risk differs between individual agents. In Vienna and other eastern parts of Austria, CDI ribotype 027 is currently highly prevalent. This ribotype has the characteristic of intrinsic moxifloxacin resistance. Therefore, we hypothesized that moxifloxacin restriction can decrease the number of CDI cases in hospitalized patients. Our antibiotic stewardship (ABS) group applied an information campaign on CDI and formal restriction of moxifloxacin in Wilhelminenspital (Vienna, Austria), a 1,000- bed tertiary care hospital. The preintervention period (period 1) was January through May 2013, and the intervention period (period 2) was June through December 2013. We recorded the defined daily doses (DDD) of moxifloxacin and the number of CDI patients/month. Moxifloxacin use was reduced from a mean (±standard error of the mean [SEM]) of 1,038±109 DDD per month (period 1) to 42±10 DDD per month (period 2) (P=0.0045). Total antibiotic use was not affected. The mean (±SEM) numbers of CDI cases in period 1 were 59±3 per month and in period 2 were 32±3 per month (46% reduction; P=0.0044). Reducing moxifloxacin use in combination with providing structured information on CDI was associated with an immediate decrease in CDI rates in this large community teaching hospital.
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19
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Valiente E, Cairns M, Wren B. The Clostridium difficile PCR ribotype 027 lineage: a pathogen on the move. Clin Microbiol Infect 2014; 20:396-404. [DOI: 10.1111/1469-0691.12619] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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20
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Schmid D, Kuo H, Simons E, Kanitz E, Wenisch J, Allerberger F, Wenisch C. All-cause mortality in hospitalized patients with infectious diarrhea: Clostridium difficile versus other enteric pathogens in Austria from 2008 to 2010. J Infect Public Health 2014; 7:133-44. [DOI: 10.1016/j.jiph.2013.07.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 07/11/2013] [Accepted: 07/17/2013] [Indexed: 12/19/2022] Open
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22
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Stewart DB, Hollenbeak CS, Wilson MZ. Is colectomy for fulminant Clostridium difficile colitis life saving? A systematic review. Colorectal Dis 2013; 15:798-804. [PMID: 23350898 DOI: 10.1111/codi.12134] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 11/15/2012] [Indexed: 12/31/2022]
Abstract
AIM It is unclear whether colectomy for fulminant Clostridium difficile colitis (FCDC) leads to a improvement in survival compared with continued medical therapy for this moribund population. METHOD Selected studies from 1994-2010 were identified through a comprehensive search theme applied to MEDLINE (OvidSP and PubMed), EMBASE and by hand searching. Data regarding mortality rates between medically and surgically treated patients were extracted. Risk of bias was assessed using a Newcastle-Ottawa Scale score. A meta-analysis of the odds ratios for mortality between surgical and medical treatment for FCDC was conducted using the Mantel-Haenszel method and fixed-effects modelling. RESULTS Five hundred and ten patients with FCDC were identified in six studies. The pooled adjusted odds ratio of mortality comparing surgery with medical therapy was 0.70 (0.49-0.99), suggesting that surgery provided a survival benefit. CONCLUSION Emergent colectomy for patients with FCDC provides a survival advantage compared with continuing antibiotics. Though there is selection bias of patients having surgery, the results of this systematic review suggest that colectomy has a therapeutic role in treating severe forms of C. difficile colitis.
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Affiliation(s)
- D B Stewart
- Department of Surgery, Division of Colon and Rectal Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania 17033, USA.
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23
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Norén T, Unemo M, Magnusson C, Eiserman M, Matussek A. Evaluation of the rapid loop-mediated isothermal amplification assay Illumigene for diagnosis of Clostridium difficile in an outbreak situation. APMIS 2013; 122:155-60. [PMID: 23758095 DOI: 10.1111/apm.12121] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 04/08/2013] [Indexed: 02/04/2023]
Abstract
An outbreak of Clostridium difficile infection (CDI) at Höglandet Hospital Eksjö in southern Sweden in 2011 was mainly due to a multidrug-resistant PCR ribotype 046 (30% of all samples). Diagnostics used routinely was the Vidas CDAB assay, but to control the outbreak the rapid loop-mediated isothermal amplification (LAMP) assay Illumigene was introduced and both techniques were compared to Toxigenic culture (TC) prospectively. The LAMP assay had a superior sensitivity, that is, 98% compared to 79% for the Vidas CDAB assay. Most importantly, the mean turn-around-time from collecting sample to result was reduced from 59 h to 2 h enabling early isolation of patients and effective hygiene precautions. This may potentially decrease the morbidity and nosocomial transmissions of C. difficile.
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Affiliation(s)
- Torbjörn Norén
- Department of Laboratory Medicine, Microbiology, Örebro University Hospital, Örebro, Sweden
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24
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Inns T, Gorton R, Berrington A, Sails A, Lamagni T, Collins J, Perry J, Hill K, Magee J, Gould K. Effect of ribotype on all-cause mortality following Clostridium difficile infection. J Hosp Infect 2013; 84:235-41. [PMID: 23759667 DOI: 10.1016/j.jhin.2013.04.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 04/15/2013] [Indexed: 01/08/2023]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is significantly associated with subsequent all-cause mortality. Although a number of studies have investigated mortality associated with CDI, few have compared all-cause mortality between ribotypes. AIM We aimed to estimate all-cause mortality following CDI and to investigate the relationship between mortality, ribotype and other available variables. METHODS We undertook a retrospective cohort study. All patients with toxin-positive CDI in North East England between July 2009 and June 2011 were matched to death registration data. Differences in all-cause 30-day case fatality were explored using Poisson regression with robust error variances. For survival analysis, an accelerated failure time model with generalized gamma distribution was chosen. FINDINGS In total, 1426 patients were included. All-cause case fatality was 10.2%, 16.4%, 25.7% and 38.1% at 7, 14, 30 and 90 days respectively. In multivariate analysis, ribotype 027 (risk ratio: 1.34; 95% confidence interval: 1.02-1.75) and ribotype 015 (0.46; 0.26-0.82) were significantly associated with higher and lower all-cause 30-day case fatality rates, respectively. In survival analysis, only ribotype 015 had significantly lower predicted mortality (P = 0.008). Patients whose infection was hospital-acquired had significantly higher predicted mortality (P < 0.001). CONCLUSION This is the first population-based study of comparative mortality between multiple ribotypes. Our study identified a high rate of all-cause mortality following CDI. We found evidence of variability in mortality between ribotypes in this cohort with mortality significantly higher for ribotype 027 at 30 days following diagnosis and significantly lower for ribotype 015.
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Affiliation(s)
- T Inns
- Regional Epidemiology Unit, Health Protection Agency North East, UK.
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Venugopal AA, Szpunar S, Sanchez K, Sessions R, Johnson LB. Assessment of 30-day all-cause mortality in metronidazole-treated patients with Clostridium difficile infection. ACTA ACUST UNITED AC 2013; 45:786-90. [PMID: 23746336 DOI: 10.3109/00365548.2013.796087] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The Society for Healthcare Epidemiology (SHEA) and the Infectious Diseases Society of America (IDSA) clinical practice guidelines for Clostridium difficile infection (CDI) help to define and make recommendations for the treatment of mild to moderate disease with metronidazole and severe disease with vancomycin. We retrospectively evaluated 285 patients who were initially treated with metronidazole and stratified them by severity of illness using the guideline criteria. We compared the outcomes in the 2 groups including the need to change therapy, recurrences, and 30-day all-cause mortality. There were no differences in recurrence rates based on severity of disease. From the multivariate analysis, severe CDI was predictive of 30-day all-cause mortality (odds ratio (OR) 1.98, 95% confidence interval (CI) 1.07-3.67, p = 0.03), after controlling for ICU stay prior to diagnosis (OR 2.94, 95% CI 1.60-5.41. p = 0.001), age (OR 1.02, 95% CI 1.004-1.05, p = 0.02), and the modified Charlson score (OR 1.31, 95% CI 1.14-1.49, p < 0.0001).
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Affiliation(s)
- Anilrudh A Venugopal
- From the Division of Infectious Diseases and Department of Medicine, St. John Hospital and Medical Center , Detroit
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Dingle KE, Didelot X, Ansari MA, Eyre DW, Vaughan A, Griffiths D, Ip CLC, Batty EM, Golubchik T, Bowden R, Jolley KA, Hood DW, Fawley WN, Walker AS, Peto TE, Wilcox MH, Crook DW. Recombinational switching of the Clostridium difficile S-layer and a novel glycosylation gene cluster revealed by large-scale whole-genome sequencing. J Infect Dis 2012. [PMID: 23204167 DOI: 10.1093/infdis/jis734] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Clostridium difficile is a major cause of nosocomial diarrhea, with 30-day mortality reaching 30%. The cell surface comprises a paracrystalline proteinaceous S-layer encoded by the slpA gene within the cell wall protein (cwp) gene cluster. Our purpose was to understand the diversity and evolution of slpA and nearby genes also encoding immunodominant cell surface antigens. METHODS Whole-genome sequences were determined for 57 C. difficile isolates representative of the population structure and different clinical phenotypes. Phylogenetic analyses were performed on their genomic region (>63 kb) spanning the cwp cluster. RESULTS Genetic diversity across the cwp cluster peaked within slpA, cwp66 (adhesin), and secA2 (secretory translocase). These genes formed a 10-kb cassette, of which 12 divergent variants were found. Homologous recombination involving this cassette caused it to associate randomly with genotype. One cassette contained a novel insertion (length, approximately 24 kb) that resembled S-layer glycosylation gene clusters. CONCLUSIONS Genetic exchange of S-layer cassettes parallels polysaccharide capsular switching in other species. Both cause major antigenic shifts, while the remainder of the genome is unchanged. C. difficile genotype is therefore not predictive of antigenic type. S-layer switching and immune escape could help explain temporal and geographic variation in C. difficile epidemiology and may inform genotyping and vaccination strategies.
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Affiliation(s)
- Kate E Dingle
- Nuffield Department of Clinical Medicine, Oxford Biomedical Research Centre, John Radcliffe Hospital, UK.
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Hung YP, Tsai PJ, Hung KH, Liu HC, Lee CI, Lin HJ, Wu YH, Wu JJ, Ko WC. Impact of toxigenic Clostridium difficile colonization and infection among hospitalized adults at a district hospital in southern Taiwan. PLoS One 2012; 7:e42415. [PMID: 22876321 PMCID: PMC3411658 DOI: 10.1371/journal.pone.0042415] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 07/05/2012] [Indexed: 01/05/2023] Open
Abstract
Background The impact of toxigenic Clostridium difficile colonization (tCDC) in hospitalized patients is not clear. Aim To study the significance of tCDC in hospitalized patients. Methods A prospective study in the medical wards of a regional hospital was performed from January to June 2011. Fecal samples collected from patients at the time of admission were tested for tcdB by real-time polymerase chain reaction (PCR) and cultured for C. difficile. The patients were followed up weekly or when they developed diarrhea during hospitalization. If C. difficile was isolated, tcdA and tcdB would be tested by multiplex PCR. The primary outcome was the development of C. difficile-associated diarrhea (CDAD). Findings Of 168 patients enrolled, females predominated (87, 51.8%), and the mean patient age was 75.4 years old. Approximately 70% of the patients were nursing home residents, and one third had a recent hospitalization within the prior three months. Twenty-eight (16.7%) patients had tCDC, including 16 (9.5%) patients with tCDC at the time of admission and 12 (7.2%) with tCDC during the follow-up period. With regard to the medications taken during hospitalization, the patients were more likely to have tCDC if they had received more than one class of antibiotics than if they had received monotherapy (odds ratio [OR] 6.67, 95% confidence interval [CI] 1.41–31.56, P = 0.01), particularly if they received a glycopeptide in combination with a cephalosporin or penicillin or a cephalosporin and a carbapenem. More patients with tCDC developed CDAD than those without tCDC (17.9%, 5/28 vs. 1.4%, 2/140, P = 0.002). Overall 7 (4.2%) of the 168 patients developed CDAD, and crude mortality rate of those with and without tCDC was similar (21.4%, 6/28 vs. 19.4%, 27/140, P = 0.79). Conclusion Recent use of glycopeptides and β-lactam antibiotics is associated with toxigenic C. difficile colonization, which is a risk factor for developing C. difficile-associated diarrhea.
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Affiliation(s)
- Yuan-Pin Hung
- Department of Internal Medicine, Tainan Hospital, Department of Health, Executive Yuan, Tainan, Taiwan
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
- Graduate Institute of Clinical Medicine, National Health Research Institutes, Tainan, Taiwan
| | - Pei-Jane Tsai
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Medical College, Tainan, Taiwan
| | - Kuei-Hsiang Hung
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Medical College, Tainan, Taiwan
| | - Hsiu-Chuan Liu
- Department of Experiment and Diagnosis, Tainan Hospital, Department of Health, Executive Yuan, Tainan, Taiwan
| | - Chih-I Lee
- Department of Internal Medicine, Tainan Hospital, Department of Health, Executive Yuan, Tainan, Taiwan
| | - Hsiao-Ju Lin
- Department of Internal Medicine, Tainan Hospital, Department of Health, Executive Yuan, Tainan, Taiwan
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yi-Hui Wu
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Jiunn-Jong Wu
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Medical College, Tainan, Taiwan
- * E-mail: (J-JW); (W-CK)
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
- Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan
- Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan
- * E-mail: (J-JW); (W-CK)
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Risk factors for mortality in Clostridium difficile infection in the general hospital population: a systematic review. J Hosp Infect 2012; 82:1-12. [PMID: 22727824 DOI: 10.1016/j.jhin.2012.05.008] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Accepted: 05/21/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is one of the most important healthcare-associated infections, causing considerable mortality. Numerous severity scores have been proposed to identify patients with CDI at risk of mortality, but a systematic review of the evidence upon which these are based has never been published. Such a review could permit future development of scores that better predict mortality. AIM A systematic review of the published literature investigating clinically useful risk markers for mortality in CDI. METHODS We searched MEDLINE 1950 to present, Web of Science with conference proceedings 1899 to present and BIOSIS Citation Index 1969 to present using PubMed and Web of Knowledge. Potential risk markers that had been evaluated by at least four studies were extracted. FINDINGS Twenty-six studies, of 1617 initially identified, met inclusion criteria. The majority were retrospective cohort studies, mostly based in the USA. Older age, higher white blood cell count (WBC), higher creatinine level, lower albumin levels and, to a lesser extent, corticosteroid use were most frequently associated with mortality. Presence of fever, haemoglobin/haematocrit level, diarrhoea severity, presence of renal disease, diabetes, cancer, or nasogastric tube use did not appear to be associated with mortality. CONCLUSION Our results support the use of age, WBC, serum creatinine, serum albumin level and possibly pre-existing corticosteroid use as potentially useful risk markers for mortality in CDI. Our results do not support the use of fever, haemoglobin/haematocrit, diarrhoea severity and several comorbidities as useful risk markers, raising questions about their inclusion in CDI severity scores.
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Mitchell BG, Gardner A. Mortality and Clostridium difficile infection: a review. Antimicrob Resist Infect Control 2012; 1:20. [PMID: 22958425 PMCID: PMC3533881 DOI: 10.1186/2047-2994-1-20] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 05/12/2012] [Indexed: 12/18/2022] Open
Abstract
Background Clostridium difficile infection (CDI) is a common cause of diarrhoea in hospitalised patients. Around the world, the incidence and severity of CDI appears to be increasing, particularly in the northern hemisphere. The purpose of this integrative review was to investigate and describe mortality in hospitalised patients with CDI. Methods A search of the literature between 1 January 2005 and 30 April 2011 focusing on mortality and CDI in hospitalised patients was conducted using electronic databases. Papers were reviewed and analysed individually and themes were combined using integrative methods. Results All cause mortality at 30 days varied from 9% to 38%. Three studies report attributable mortality at 30 days, varying from 5.7% to 6.9%. In hospital mortality ranged from 8% to 37.2% Conclusion All cause 30 day mortality appeared to be high, with 15 studies indicating a mortality of 15% or greater. Findings support the notion that CDI is a serious infection and measures to prevent and control CDI are needed. Future studies investigating the mortality of CDI in settings outside of Europe and North America are needed. Similarly, future studies should include data on patient co-morbidities.
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Affiliation(s)
- Brett G Mitchell
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Dickson, PO BOX 256, ACT, Australia.
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Mullane KM, Gorbach S. Fidaxomicin: first-in-class macrocyclic antibiotic. Expert Rev Anti Infect Ther 2012; 9:767-77. [PMID: 21810048 DOI: 10.1586/eri.11.53] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The incidence of Clostridium difficile has doubled over the past 15 years, and rising mortality rates associated with this infection have followed in its wake. C. difficile infection (CDI) has supplanted methicillin-resistant Staphylococcus aureus as the major cause of nosocomial infection. An insufficient response rate to currently available CDI therapies has prompted the search for new and alternative treatment modalities for this disease. The investigational pipeline includes evaluation of new antimicrobial agents that exhibit good activity against C. difficile without altering normal gut flora, C. difficile toxin-absorbing compounds, and preformed antibodies and vaccines against C. difficile toxin. In two robust clinical trials comparing fidaxomicin to vancomycin in the treatment of CDI, treatment with fidaxomicin demonstrated a superior global cure (cure without recurrence) rate compared with the current gold standard, vancomycin. Fidaxomicin, the first of a new class of macrocyclic antimicrobial agents, represents an advance in the management of CDI.
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Wenisch JM, Schmid D, Kuo HW, Simons E, Allerberger F, Michl V, Tesik P, Tucek G, Wenisch C. Hospital-acquired Clostridium difficile infection: determinants for severe disease. Eur J Clin Microbiol Infect Dis 2011; 31:1923-30. [PMID: 22210266 DOI: 10.1007/s10096-011-1522-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Accepted: 12/13/2011] [Indexed: 02/08/2023]
Abstract
Risk factors of severity (need for surgical intervention, intensive care or fatal outcome) were analysed in hospital-acquired Clostridium difficile infection (CDI) in a 777-bed community hospital. In a prospective analytical cross-sectional study, age (≥ 65 years), sex, CDI characteristics, underlying diseases, severity of comorbidity and PCR ribotypes were tested for associations with severe CDI. In total, 133 cases of hospital-acquired CDI (mean age 74.4 years) were identified, resulting in an incidence rate of 5.7/10,000 hospital-days. A recurrent episode of diarrhoea occurred in 25 cases (18.8%) and complications including toxic megacolon, dehydration and septicaemia in 69 cases (51.9%). Four cases (3.0%) required ICU admission, one case (0.8%) surgical intervention and 22 cases (16.5%) died within the 30-day follow-up period. Variables identified to be independently associated with severe CDI were severe diarrhoea (odds ratio [OR] 3.64, 95% confidence interval [CI] 1.19-11.11, p=0.02), chronic pulmonary disease (OR 3.0, 95% CI 1.08-8.40, p=0.04), chronic renal disease (OR 2.9, 95% CI 1.07-7.81, p=0.04) and diabetes mellitus (OR 4.30, 95% CI 1.57-11.76, p=0.004). The case fatality of 16.5% underlines the importance of increased efforts in CDI prevention, in particular for patients with underlying diseases.
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Affiliation(s)
- J M Wenisch
- Department of Medicine, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria
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Welfare M, Lalayiannis L, Martin K, Corbett S, Marshall B, Sarma J. Co-morbidities as predictors of mortality in Clostridium difficile infection and derivation of the ARC predictive score. J Hosp Infect 2011; 79:359-63. [DOI: 10.1016/j.jhin.2011.08.015] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Accepted: 08/14/2011] [Indexed: 12/28/2022]
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Venugopal AA, Riederer K, Patel SM, Szpunar S, Jahamy H, Valenti S, Shemes SP, Khatib R, Johnson LB. Lack of association of outcomes with treatment duration and microbiologic susceptibility data in Clostridium difficile infections in a non-NAP1/BI/027 setting. ACTA ACUST UNITED AC 2011; 44:243-9. [PMID: 22077148 DOI: 10.3109/00365548.2011.631029] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Concerns regarding the poor response of severe Clostridium difficile infection (CDI) treated with metronidazole have arisen over the last 5 y. METHODS We conducted a prospective, non-interventional study of CDI cases at our institution to evaluate the role of drug resistance, co-morbidities, and the emergence of hypervirulent strains on patient outcomes. A total of 118 adult inpatients with diarrhea and a positive stool for C. difficile toxin immunoassay had positive stool cultures and were included in the study. All 118 isolates had vancomycin and metronidazole susceptibility testing via the E-test method; rep-PCR was performed on 47 isolates. Of the 118 study patients, 107 were treated with either metronidazole or vancomycin. RESULTS Initial therapy was metronidazole in 98.1% (n = 105) and vancomycin in 1.9% (n = 2) patients. Evaluable clinical response within 5 days of treatment was noted in 52.5% (52/99) of cases. The mean duration of treatment was 11.7 ± 7.2 days. The 30-day all-cause mortality rate was 24.6% (29/118). Recurrence occurred in 23.6% (21/89). A recent stay in the intensive care unit was associated with increased 30-day mortality (odds ratio 3.58, p = 0.012). There were no isolates resistant to metronidazole or vancomycin. Only 1 isolate was possibly related to the NAP1/BI/027 reference strain. No strain-related differences in deaths or recurrence were noted. CONCLUSIONS Deaths related to CDI in our study appear to be related to multiple factors and did not appear to be independently related to antibiotic susceptibility, strain type, or treatment duration.
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Affiliation(s)
- Anilrudh A Venugopal
- Division of Infectious Diseases and Department of Medicine, St John Hospital and Medical Center, MI 48236, USA.
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