Optimizing the diagnostic testing of Clostridium difficile infection

Usefulness of Capillary Gel Electrophoresis-Based PCR for Detection of Clostridioides difficile Strains with Hypervirulent Ribotypes

Clostridioides difficile is a complex of anaerobic bacteria responsible for the epidemics of post-antibiotic diarrhea as one of the examples of CDI (Clostridioides difficile infection). As many as 70% of cases concern hospitalized patients, particularly those in intensive care units. Ribotyping is one of the most common methods for differentiating bacterial strains. The purpose of this work was to show the effectiveness of the gel electrophoresis-based PCR ribotyping method and the Webribo database for typing C. difficile isolates, including the hypervirulent 027 ribotype. DNA samples extracted from 69 C. difficile strains with previously marked genotypes were included in this study. PCR was performed using 16S-23S primers, and capillary gel electrophoresis was performed on the Applied Biosystem 3130xl Genetic Analyzer. The Webribo database was applied for ribotype assignment. Out of 69 samples, 48 belonged to already known ribotypes, 13 represented new ribotypes and 8 was indicated as similar to the existing ones, having some differences. Capillary gel electrophoresis-based PCR is an effective method for the differentiation of C. difficile ribotypes and can be recognized as a very useful tool in epidemiological studies, while the Webribo database is a useful and an accessible database for a quick analysis of C. difficile ribotypes.

Testing and Diagnosis of Clostridioides difficile Infection in Special Scenarios: A Systematic Review

INTRODUCTION

Clostridioides difficile infection (CDI) is a clinical and laboratory diagnosis. Populations at higher risk of developing disease require a high clinical index of suspicion for laboratory testing to avoid incorrect assumptions of colonization. Common risk factors include recent antibiotic use, elderly (>65 years old), and immunocompromised patients. C. difficile assays should be ordered in an algorithm approach to diagnose an infection rather than colonization. Screening tests are widely available in hospital systems, but novel molecular testing may aid in diagnosis in patients with inconclusive or discordant antigen and toxin test results.  Methods: Data was extracted from PubMed, Scopus, and Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases based on the keywords "clostridioides difficile", "toxin assay", and "toxic megacolon". The data extracted is based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. A total of 27 reports were included in this systematic review.

RESULTS

Testing patients with a significant gastrointestinal surgical history, hypogammaglobulinemia, inflammatory bowel disease, intensive care unit, and immunocompromised patients for CDI is highly recommended. Diarrhea in these subsets of patients requires correlation of clinical context and an understanding of assay results to avoid over- and under-treating.

CONCLUSION

CDI should be considered in all patients with traditional risk factors. Heightened clinical suspicion of CDI is required in patients with hypogammaglobulinemia, transplant recipients, patients with gastrointestinal surgical history, and inflammatory bowel disease. Testing should be limited to patients with clinical manifestations of CDI to ensure a high pretest probability for test interpretation. Healthcare workers should adhere to testing algorithms to optimize yield in the appropriate clinical context. Diagnostic assays should follow a sequential, stepwise approach to categorize the toxin expression status of the bacteria accurately.

A Rare Case of Polymerase Chain Reaction-Negative Severe Clostridioides difficile Infection

Accurately diagnosing Clostridioides difficile infection (CDI) is crucial for effective patient management. A misdiagnosis poses risks to patients, leads to treatment delays, and contributes to infection transmission in healthcare settings. While using polymerase chain reaction (PCR) to amplify the toxin B gene is a sensitive method for detecting toxigenic C. difficile, there is still a risk of false-negative results. These inaccuracies could have significant consequences for diagnosing and treating CDI, emphasizing the need for careful consideration and other diagnostic approaches. This case report highlights a patient with severe CDI who had negative PCR and toxin and a biopsy showing pseudomembranous colitis on further testing due to persistence and worsening of symptoms. In the diagnosis of C. difficile infection, healthcare providers should consider clinical symptoms, although diarrhea, which is a major sign of CDI, can be due to other causes. Even in the presence of negative PCR results, if a patient displays symptoms consistent with C. difficile-associated disease, healthcare providers may still contemplate treatment.

Bezlotoxumab in the treatment of Clostridioides difficile infections: a real-life experience

OBJECTIVE

Following the approval of bezlotoxumab in 2017, studies evaluating its effectiveness in prevention of Clostridioides difficile infection under "real-life" conditions are scarce.

METHODS

We conducted a retrospective study developed in a large tertiary care hospital describing the use and outcomes of patients with Clostridioides difficile infection (CDI) treated with bezlotoxumab.

RESULTS

A total of 16 patients were include, all of whom had an episode of CDI with high probability of recurrence and 14 of them had some kind of immunosuppression. Bezlotoxumab was effective in the prevention of CDI recurrence in 11 of the 14 cases in which follow up was possible, without significant side effects.

CONCLUSIONS

Bezlotoxumab was well tolerated and the incidence of recurrent CDI in a high-risk population for recurrence was only 21.4%.

First case of periprosthetic joint infection due to Clostridioides difficile in China

Background

Clostridioides difficile usually causes intestinal infections. However, a 75-year-old lady had a periprosthetic joint infection due to this microorganism. We report a C. difficile infection of a prosthetic hip joint. Such an infection is rarely reported around the world.

Case presentation

The elder female patient presented with a 2-year history of right hip pain with movement restriction. Her right leg was shorter than another. The skin around the right hip joint was red and swollen without sinus. Her lab test result showed elevator ESR and CRP. Her X-ray film showed a massive bone defect. The patient had a total hip arthroplasty 16years ago and had a revision 5 years ago. During this hospitalization, her cultures of the synovial fluid and tissue repeatedly grew C. difficile. She improved following two-stage revision surgery and antibiotic treatment. The patient has no recurrence of infection after a one-year follow-up.

Conclusion

A rapid and accurate sample collection is significant for culture results, making an outstanding contribution to the successful treatment.

[Updated review of Clostridium difficile infection in elderly]

Clostridium difficile infection is the most common cause of health care-associated diarrhoea, and its incidence increases with age. Clinical challenges, risk of resistance to treatment, risk of recurrence, and treatment responses are different in elderly. The aim of this review is to discuss the updated epidemiology, pathophysiology, diagnosis, and therapeutic management of C. difficile infection in elderly with the available data.

Recommendations for the diagnosis and treatment of Clostridioides difficile infection: An official clinical practice guideline of the Spanish Society of Chemotherapy (SEQ), Spanish Society of Internal Medicine (SEMI) and the working group of Postoperative Infection of the Spanish Society of Anesthesia and Reanimation (SEDAR)

This document gathers the opinion of a multidisciplinary forum of experts on different aspects of the diagnosis and treatment of Clostridioides difficile infection (CDI) in Spain. It has been structured around a series of questions that the attendees considered relevant and in which a consensus opinion was reached. The main messages were as follows: CDI should be suspected in patients older than 2 years of age in the presence of diarrhea, paralytic ileus and unexplained leukocytosis, even in the absence of classical risk factors. With a few exceptions, a single stool sample is sufficient for diagnosis, which can be sent to the laboratory with or without transportation media for enteropathogenic bacteria. In the absence of diarrhoea, rectal swabs may be valid. The microbiology laboratory should include C. difficile among the pathogens routinely searched in patients with diarrhoea. Laboratory tests in different order and sequence schemes include GDH detection, presence of toxins, molecular tests and toxigenic culture. Immediate determination of sensitivity to drugs such as vancomycin, metronidazole or fidaxomycin is not required. The evolution of toxin persistence is not a suitable test for follow up. Laboratory diagnosis of CDI should be rapid and results reported and interpreted to clinicians immediately. In addition to the basic support of all diarrheic episodes, CDI treatment requires the suppression of antiperistaltic agents, proton pump inhibitors and antibiotics, where possible. Oral vancomycin and fidaxomycin are the antibacterials of choice in treatment, intravenous metronidazole being restricted for patients in whom the presence of the above drugs in the intestinal lumen cannot be assured. Fecal material transplantation is the treatment of choice for patients with multiple recurrences but uncertainties persist regarding its standardization and safety. Bezlotoxumab is a monoclonal antibody to C. difficile toxin B that should be administered to patients at high risk of recurrence. Surgery is becoming less and less necessary and prevention with vaccines is under research. Probiotics have so far not been shown to be therapeutically or preventively effective. The therapeutic strategy should be based, rather than on the number of episodes, on the severity of the episodes and on their potential to recur. Some data point to the efficacy of oral vancomycin prophylaxis in patients who reccur CDI when systemic antibiotics are required again.

Barriers and facilitators to Clostridium difficile infection prevention: A nursing perspective

BACKGROUND

Clostridium difficile infection (CDI) is a critical patient safety issue. Consistent and regular performance of appropriate practices is effective in preventing CDI. Variation in adherence to these practices can impede their effective implementation and weaken CDI prevention.

METHODS

Using the Systems Engineering Initiative for Patient Safety (SEIPS) framework we convened a focus group of 10 nurses to identify barriers and facilitators to compliance with a CDI prevention bundle that includes (1) prompt diagnostic testing, (2) empirical isolation for patients with suspected CDI, (3) consistent and appropriate contact isolation, (4) hand hygiene, and (5) disinfection of the patient room and objects in the room. On completion of transcript coding, analyses were performed based on bundle intervention and the work system element of the SEIPS model.

RESULTS

A total of 58 excerpts were coded. Work system barriers or facilitators were associated with nearly every bundle intervention. The work system elements raised in over half of the excerpts were task (n = 31) (eg, amount of additional effort required to don and doff gloves and gowns) and organization (n = 30) (eg, recognition by all staff of the severity of CDI). Contact isolation was the most frequently discussed bundle intervention (n = 24).

CONCLUSIONS

The SEIPS systems engineering framework is useful to evaluate infection prevention practices for CDI and identify opportunities for improvement. Addressing the work system barriers and facilitators identified in this study is essential to effective implementation of infection prevention interventions, specifically for CDI.