Evaluation of a bedside scoring system for predicting clinical cure and recurrence of Clostridium difficile infections

PURPOSE

The accuracy of a bedside scoring system, ATLAS, for predicting clinical cure and recurrence of Clostridium difficile infections (CDIs) was evaluated.

METHODS

A single-center retrospective medical record review was performed for symptomatic adult patients with stool assay-diagnosed CDI treated with metronidazole or vancomycin or both. Multiple logistic regression analysis was performed to assess the potential association of the ATLAS score and other potential factors on achieving cure and 90-day CDI recurrence. ATLAS scores were calculated, and risk factors for severe CDI, severe-complicated CDI, decreased cure rates, and recurrence were recorded.

RESULTS

Data from 245 adult patients were assessed. ATLAS scores showed a significant inverse association with the cure rate (p = 0.009) but not with the 90-day recurrence rate (p = 0.901). The only ATLAS component to be independently associated (inversely) with cure was the concomitant use of antibiotics (p = 0.022). Metronidazole was initiated in 97% of patients, with 32% switching to oral vancomycin. Longer courses of vancomycin were associated with a higher cure rate (p = 0.0009) but not with recurrence (p = 0.170). Complicated cases were less likely to be cured (p = 0.027) and more likely to recur within 90 days (p = 0.002). Antibiotics continued after CDI treatment was associated with recurrence (p = 0.055).

CONCLUSION

A low ATLAS score was found to correlate with higher cure rates in patients with CDI receiving metronidazole, oral vancomycin, or both. However, the score could not predict CDI recurrence.

Probiotics for Clostridium difficile infection in adults (PICO): Study protocol for a double-blind, randomized controlled trial

BACKGROUND

Clostridium difficile is a pathogen of rapidly increasing public health importance. An estimated quarter of a million Clostridium difficile infections (CDI) occur in the United States annually, at a resultant cost of 14,000 deaths and 1 billion dollars. Clostridium difficile related deaths have risen 400% over the last decade, and current standard antibiotic treatments are only 75 to 85% successful. Besides increasing the risk of antibiotic resistance and side effects, these treatments are very expensive. The most vulnerable population for Clostridium difficile is older adults, who make up approximately half of the cases, but account for 90% of the related deaths. Probiotics may have potential as adjunctive therapeutic agents for CDIs, however, current data is limited.

METHODS

This pilot study is a single-site, randomized, placebo-controlled, double-blind, phase two clinical trial. The trial primarily evaluates the effect of four weeks of probiotic therapy in addition to standard of care on Clostridium difficile diarrhea duration and recurrence. Secondary outcomes include effect on fecal cytokines, fecal lactoferrin, and Clostridium difficile toxin density in stool, as well as patient functional status.

DISCUSSION

This pilot study will determine the feasibility and effect size to conduct larger randomized controlled trials of probiotic interventions in patients with CDI, to determine the impact of probiotics on the symptoms of CDI. ClinicalTrials.gov Identifier: NCT01680874.

A Clostridium difficile Infection (CDI) Stewardship Initiative Improves Adherence to Practice Guidelines for Management of CDI

A Clostridium difficile infection (CDI) stewardship initiative reduced inappropriate prescription of empirical CDI therapy and improved timeliness of treatment and adherence to clinical practice guidelines for management of CDI. The initiative required minimal resources and could easily be incorporated into traditional antimicrobial stewardship programs.

Fidaxomicin (OPT-80) for the treatment of Clostridium difficile infection

IMPORTANCE OF THE FIELD

Clostridium difficile infection (CDI) has become an increasingly important healthcare-associated complication in many countries. CDI outbreaks, a new 'hypervirulent' form and increased worldwide rates have underscored four urgent unmet needs for this disease: i) effective prevention of CDI; ii) therapies to produce faster resolution of CDI symptoms; iii) therapies to treat severe CDI more effectively and reduce its mortality; and iv) therapies to reduce the CDI recurrence rate following treatment.

AREAS COVERED IN THIS REVIEW

Fidaxomicin, a new macrocyclic antibiotic, has demonstrated potent in vitro activity against C. difficile with limited or no activity against normal fecal flora. It is minimally absorbed from the intestinal tract, even in the presence of intestinal inflammation. When tested against oral vancomycin in clinical studies of CDI therapy, it has equivalent efficacy for curing CDI at end of treatment and a comparable safety profile to that agent. However, fidaxomicin therapy of CDI is associated with significantly fewer CDI recurrences in the 28 days following treatment. Symptom resolution is also slightly quicker in some CDI patients. Additional fecal flora analysis in the CDI trials showed that fewer individuals developed intestinal colonization with vancomycin-resistant enterococci (VRE) among the fidaxomicin-treated group. This new molecule, which has just completed two large Phase III multicenter studies, successfully addresses two of the four urgent and unmet needs for dealing with CDI.

WHAT THE READER WILL GAIN

Fidaxomicin is as effective and as safe as vancomycin therapy for treating CDI but is associated with far fewer recurrences post-treatment and a decreased risk of VRE acquisition.

TAKE HOME MESSAGE

Fidaxomicin is a potential new therapy for CDI which has the capacity to substantially decrease post-treatment recurrences and is as safe and well-tolerated as standard vancomycin treatment.