Renewed interest in a difficult disease: Clostridium difficile infections--epidemiology and current treatment strategies

In Vitro and In Vivo Activities, Absorption, Tissue Distribution, and Excretion of OBP-4, a Potential Anti-Clostridioides difficile Agent

Clostridioides difficile infection (CDI) is considered a major concern of the health care system globally, with an increasing need for alternative therapies. OBP-4, a new oxazolidinone-fluoroquinolone hybrid with excellent in vitro activities and good safety, shows promising features as an antibacterial agent. Here, we further evaluated the in vitro and in vivo activities of OBP-4 against C. difficile and its absorption (A), distribution (D), and excretion (E) profiles in rats. In vitro assays indicated that OBP-4 was active against all tested C. difficile strains, with MICs ranging from 0.25 to 1 mg/liter. In addition, OBP-4 showed complete inhibition of spore formation at 0.5× MIC. In the mouse model of CDI, 5-day oral treatment with OBP-4 provided complete protection from death and CDI recurrence in infected mice. However, cadazolid (CZD) and vancomycin (VAN) showed less protection of infected mice than did OBP-4 in terms of diarrhea and weight loss, especially VAN. Subsequently, ADE investigations of OBP-4 with a reliable liquid chromatography-tandem mass spectrometry (LC-MS/MS) method showed extremely low systemic exposure and predominantly fecal excretion, resulting in a high local concentration of OBP-4 in the intestinal tract-the site of CDI. These results demonstrated that OBP-4 possesses good activity against C. difficile and favorable ADE characteristics for oral treatment of CDI, which support further development of OBP-4 as a potential anti-CDI agent.

Prospective Study on Incidence, Risk Factors and Outcome of Recurrent Clostridioides difficile Infections

BACKGROUND

Limited and wide-ranging data are available on the recurrent Clostridioides difficile infection (rCDI) incidence rate.

METHODS

We performed a cohort study with the aim to assess the incidence of and risk factors for rCDI. Adult patients with a first CDI, hospitalized in 15 Italian hospitals, were prospectively included and followed-up for 30 d after the end of antimicrobial treatment for their first CDI. A case-control study was performed to identify risk factors associated with 30-day onset rCDI.

RESULTS

Three hundred nine patients with a first CDI were included in the study; 32% of the CDI episodes (99/309) were severe/complicated; complete follow-up was available for 288 patients (19 died during the first CDI episode, and 2 were lost during follow-up). At the end of the study, the crude all-cause mortality rate was 10.7% (33 deaths/309 patients). Two hundred seventy-one patients completed the follow-up; rCDI occurred in 21% of patients (56/271) with an incidence rate of 72/10,000 patient-days. Logistic regression analysis identified exposure to cephalosporin as an independent risk factor associated with rCDI (RR: 1.7; 95% CI: 1.1-2.7, p = 0.03).

CONCLUSION

Our study confirms the relevance of rCDI in terms of morbidity and mortality and provides a reliable estimation of its incidence.

Retrospective Definition of Clostridioides difficile PCR Ribotypes on the Basis of Whole Genome Polymorphisms: A Proof of Principle Study

Clostridioides difficile is a cause of health care-associated infections. The epidemiological study of C. difficile infection (CDI) traditionally involves PCR ribotyping. However, ribotyping will be increasingly replaced by whole genome sequencing (WGS). This implies that WGS types need correlation with classical ribotypes (RTs) in order to perform retrospective clinical studies. Here, we selected genomes of hyper-virulent C. difficile strains of RT001, RT017, RT027, RT078, and RT106 to try and identify new discriminatory markers using in silico ribotyping PCR and De Bruijn graph-based Genome Wide Association Studies (DBGWAS). First, in silico ribotyping PCR was performed using reference primer sequences and 30 C. difficile genomes of the five different RTs identified above. Second, discriminatory genomic markers were sought with DBGWAS using a set of 160 independent C. difficile genomes (14 ribotypes). RT-specific genetic polymorphisms were annotated and validated for their specificity and sensitivity against a larger dataset of 2425 C. difficile genomes covering 132 different RTs. In silico PCR ribotyping was unsuccessful due to non-specific or missing theoretical RT PCR fragments. More successfully, DBGWAS discovered a total of 47 new markers (13 in RT017, 12 in RT078, 9 in RT106, 7 in RT027, and 6 in RT001) with minimum q-values of 0 to 7.40 × 10^-5, indicating excellent marker selectivity. The specificity and sensitivity of individual markers ranged between 0.92 and 1.0 but increased to 1 by combining two markers, hence providing undisputed RT identification based on a single genome sequence. Markers were scattered throughout the C. difficile genome in intra- and intergenic regions. We propose here a set of new genomic polymorphisms that efficiently identify five hyper-virulent RTs utilizing WGS data only. Further studies need to show whether this initial proof-of-principle observation can be extended to all 600 existing RTs.

Clostridium difficile Infection and Colorectal Surgery: Is There Any Risk?

Background and objectives: Clostridium difficile infection (CDI) is an important healthcare-associated infection, with important consequences both from a medical and financial point of view, but its correlation with anastomotic leaks after colorectal surgeries is scarcely reported in the literature. Materials and Methods: We conducted a retrospective study looking for patients who underwent open or laparoscopic surgery for colorectal cancers between January 2012 and December 2017, excluding emergency surgeries for complicated colorectal tumors. We also examined patient history for risk factors for CDI such as age, sex, comorbidities, and clinical findings at admission or during hospital stay as well as tumor characteristics. Results: A total of 360 patients were included in the study, out of which 320 underwent surgeries that included anastomoses. There were 19 cases of anastomotic leaks, out of which 13 patients were diagnosed with CDI, with a statistic significance for association between CDI and anastomotic leakage (p < 0.0001). Most patients who developed both CDI and anastomotic leaks had left-sided resections or a type of rectal resection, while none of the patients with right-sided resections had this association, but with no statistical significance possibly due to the limited number of cases. Conclusions: CDI is a relevant risk factor and should be taken into consideration when trying to prevent anastomotic leaks in patients undergoing gastrointestinal surgery for colon or rectal cancer. Thorough assessment of risk factors at admission should be mandatory in order to adequately prepare the patient and plan an optimal course of treatment. Further studies are needed to confirm our findings and a multidisciplinary approach, with a team which should always include the surgeon, is mandatory when it comes to CDI prevention.

Obesity as protective against, rather than a risk factor for, postoperative Clostridium difficile infection: A nationwide retrospective analysis of 1,426,807 surgical patients

BACKGROUND

Recent studies suggest that obesity is a risk factor for Clostridium difficile infection, possibly due to disruptions in the intestinal microbiome composition. We hypothesized that body mass index (BMI) is associated with increased incidence of C. difficile infection in surgical patients.

METHODS

In this nationwide retrospective cohort study in 680 American College of Surgeons National Surgical Quality Improvement Program participating sites across the United States, the occurrence of C. difficile infection within 30 days postoperatively between different BMI groups was compared. All American College of Surgeons National Surgical Quality Improvement Program patients between 2015 and 2016 were classified as underweight, normal-weight, overweight, or obese class I-III if their BMI was less than 18.5, 18.5 to 25, 25 to 30, 30 to 35, 35 to 40 or greater than 40, respectively.

RESULTS

A total of 1,426,807 patients were included; median age was 58 years, 43.4% were male, and 82.9% were white. The postoperative incidence of C. difficile infection was 0.42% overall: 1.11%, 0.56%, 0.39%, 0.35%, 0.33% and 0.36% from the lowest to the highest BMI group, respectively (p < 0.001 for trend). In univariate then multivariable logistic regression analyses, adjusting for patient demographics (e.g., age, sex), comorbidities (e.g., diabetes, systemic sepsis, immunosuppression), preoperative laboratory values (e.g., albumin, white blood cell count), procedure complexity (work relative unit as a proxy) and procedure characteristics (e.g., emergency, type of surgery [general, vascular, other]), compared with patients with normal BMI, high BMI was inversely and incrementally correlated with the postoperative occurrence of C. difficile infection. The underweight were at increased risk (odds ratio, 1.15 [1.00-1.32]) while the class III obese were at the lowest risk (odds ratio, 0.73 [0.65-0.81]).

CONCLUSION

In this nationwide retrospective cohort study, obesity is independently and in a stepwise fashion associated with a decreased risk of postoperative C. difficile infection. Further studies are warranted to explore the potential and unexpected association.

LEVEL OF EVIDENCE

Prognostic/Epidemiologic, Level IV.

2019 update of the WSES guidelines for management of Clostridioides (Clostridium) difficile infection in surgical patients

In the last three decades, Clostridium difficile infection (CDI) has increased in incidence and severity in many countries worldwide. The increase in CDI incidence has been particularly apparent among surgical patients. Therefore, prevention of CDI and optimization of management in the surgical patient are paramount. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of CDI in surgical patients according to the most recent available literature. The update includes recent changes introduced in the management of this infection.

Fecal microbiota transplantation in recurrent Clostridium difficile infection: the first prospective study of 30 patients in Romania

Introduction: The infection with Clostridium difficile has increased in incidence worldwide and it raises many problems with regard to therapy, resistance to treatment and especially recurrence. Recurrence is frequent in patients treated for Clostridium difficile infection, requiring vancomycin by mouth, with limited alternatives. The literature shows that one of the most efficient treatment methods in Clostridium difficile infection is the transplantation of gut microbiota, also known as fecal microbiota transplantation. Aim: We present our results following FMT performed in patients with recurrent Clostridium difficile infection, and propose a simple and effective protocol for fecal microbiota transplantation. Study design: The study was prospective. The phases of the FMT procedure: assessment of patient eligibility, patient’s consent, identification and screening of donors, discontinuation of antibiotics (vancomycin, metronidazole) 3 days prior to the procedure. Methods: Between 2013 and 2015, FMT was performed in 30 patients with recurrent Clostridium difficile infection, by direct infusion of extensively processed donor fecal matter via colonoscopy. We followed up the patients for 12 months. Results: Immediate post-transplantation outcome in what concerns stool frequency during the follow-up period (7 days) was encouraging in 93.33% of patients. The donors were healthy individuals (53% 1st degree relatives), previously screened for possible infections and infestations. This result was sustained at 6-month and 12-month follow-up. Post-transplantation recurrence occurred in 6.67% (2 patients), which responded well to treatment and did not require a new vancomycin course. Conclusions: Fecal microbiota transplantation via colonoscopy is effective, safe, easy to perform, it yields lasting results and is therefore a good option for recurrent or treatment-resistant Clostridium difficile infection.

Novel Antimicrobials for the Treatment of Clostridium difficile Infection

The current picture of Clostridium difficile infection (CDI) is alarming with a mortality rate ranging between 3% and 15% and a CDI recurrence rate ranging from 12% to 40%. Despite the great efforts made over the past 10 years to face the CDI burden, there are still gray areas in our knowledge on CDI management. The traditional anti-CDI antimicrobials are not always adequate in addressing the current needs in CDI management. The aim of our review is to give an update on novel antimicrobials for the treatment of CDI, considering the currently available evidences on their efficacy, safety, molecular mechanism of action, and their probability to be successfully introduced into the clinical practice in the near future. We identified, through a PubMed search, 16 novel antimicrobial molecules under study for CDI treatment: cadazolid, surotomycin, ridinilazole, LFF571, ramoplanin, CRS3123, fusidic acid, nitazoxanide, rifampin, rifaximin, tigecycline, auranofin, NVB302, thuricin CD, lacticin 3147, and acyldepsipeptide antimicrobials. In comparison with the traditional anti-CDI antimicrobial treatment, some of the novel antimicrobials reviewed in this study offer several advantages, i.e., the favorable pharmacokinetic and pharmacodynamic profile, the narrow-spectrum activity against CD that implicates a low impact on the gut microbiota composition, the inhibitory activity on CD sporulation and toxins production. Among these novel antimicrobials, the most active compounds in reducing spore production are cadazolid, ridinilazole, CRS3123, ramoplanin and, potentially, the acyldepsipeptide antimicrobials. These antimicrobials may potentially reduce CD environment spread and persistence, thus reducing CDI healthcare-associated acquisition. However, some of them, i.e., surotomycin, fusidic acid, etc., will not be available due to lack of superiority versus standard of treatment. The most CD narrow-spectrum novel antimicrobials that allow to preserve microbiota integrity are cadazolid, ridinilazole, auranofin, and thuricin CD. In conclusion, the novel antimicrobial molecules under development for CDI have promising key features and advancements in comparison to the traditional anti-CDI antimicrobials. In the near future, some of these new molecules might be effective alternatives to fight CDI.

Institutional review of the implementation and use of a Clostridium difficile infection bundle and probiotics in adult trauma patients

BACKGROUND

Clostridium difficile infection (CDI) is a common cause of healthcare associated infections contributing to morbidity and mortality. Our objective was to evaluate the impact of the implementation of a CDI bundle along with probiotic utilization.

METHODS

A retrospective review of trauma admissions from 2008 to 2014 was performed. The CDI bundle was implemented in stages from 2009 through 2014 with probiotics initiated in 2010. The bundle included changes in cleaning practices, education, screening, and contact precautions.

RESULTS

4632 (49%) patients received antibiotics with 21% receiving probiotics. Probiotic use was associated with increased age, male sex, more severely injured, and antibiotic use. CDI incidence decreased from 11.2 to 4.8 per 1000 admissions, p = .03. Among patients who received antibiotics CDI incidence decreased from 2.2% to 0.7%, p = .01.

CONCLUSIONS

We report the largest series of a CDI bundle implementation including probiotics. During the period of adoption of these interventions, the incidence of CDI decreased significantly.

Prediction of Recurrent Clostridium Difficile Infection Using Comprehensive Electronic Medical Records in an Integrated Healthcare Delivery System

BACKGROUND Predicting recurrent Clostridium difficile infection (rCDI) remains difficult.

METHODS

We employed a retrospective cohort design. Granular electronic medical record (EMR) data had been collected from patients hospitalized at 21 Kaiser Permanente Northern California hospitals. The derivation dataset (2007-2013) included data from 9,386 patients who experienced incident CDI (iCDI) and 1,311 who experienced their first CDI recurrences (rCDI). The validation dataset (2014) included data from 1,865 patients who experienced incident CDI and 144 who experienced rCDI. Using multiple techniques, including machine learning, we evaluated more than 150 potential predictors. Our final analyses evaluated 3 models with varying degrees of complexity and 1 previously published model. RESULTS Despite having a large multicenter cohort and access to granular EMR data (eg, vital signs, and laboratory test results), none of the models discriminated well (c statistics, 0.591-0.605), had good calibration, or had good explanatory power. CONCLUSIONS Our ability to predict rCDI remains limited. Given currently available EMR technology, improvements in prediction will require incorporating new variables because currently available data elements lack adequate explanatory power. Infect Control Hosp Epidemiol 2017;38:1196-1203.

Clostridium difficile infection in inflammatory bowel disease: challenges in diagnosis and treatment

The problem of Clostridium difficile infection (CDI) has reached epidemic proportions, particularly in industrialized nations. The pathophysiology, disease course and the potential complications are well appreciated in the general hospitalized patient. However, when CDI occurs in the setting of inflammatory bowel disease (IBD), a number of distinct differences in the diagnosis and clinical management of the infection in this population should be appreciated by gastroenterologists, hospitalists and other care providers. This review highlights the unique aspects of CDI when it occurs in IBD patients with an emphasis on the challenge of distinguishing persistent infection from exacerbation of underlying chronic colitis. An understanding of how CDI may differ in presentation and how management should be altered can prevent serious and life-threatening complications.

Fecal microbiota transplant to treat recurrent Clostridium difficile infections

The prevalence of recurrent or refractory Clostridium difficile infection has been steadily increasing since 2000. Consequently, alternative treatments to the standard antibiotic therapies are now being considered. One alternative treatment is fecal microbiota transplant. Although fecal microbiota transplant is relatively new--and not appealing to most people--it has been around for many years and has great promise as an inexpensive, safe, and efficient treatment of refractory and recurrent C difficile infection. With a better understanding of the intricacies of the colonic microbiome and its role in colonic physiology and pathophysiology, critical care nurses will recognize that fecal microbiota transplant has the potential to become the standard of care for treatment of recurrent or refractory C difficile infection. The American College of Gastroenterology and the Infectious Diseases Society of America provide the latest treatment guidelines for care of patients with these clostridial infections.

A Comprehensive Study of Costs Associated With Recurrent Clostridium difficile Infection

BACKGROUND Clostridium difficile infection (CDI) is the most common healthcare-associated infection and is associated with considerable morbidity. Recurrent CDI is a key contributing factor to this morbidity. Despite an estimated 83,000 recurrences annually in the United States, there are few accurate estimates of costs associated with recurrent CDI. OBJECTIVE We performed this study (1) to identify the health consequences of recurrent CDI including need for repeat hospitalization, intensive care unit (ICU) stay, and surgery; (2) to determine costs associated with recurrent CDI and identify determinants of such costs; and (3) to compare the outcomes and costs of recurrent CDI to those who develop reinfection. METHODS We identified all patients with confirmed recurrent CDI between January to December 2013 at a single referral center. Healthcare burden associated with recurrence including diagnostic testing, pharmacologic treatment, and inpatient and outpatient healthcare visits were identified in the 12 months following the first recurrence. Total healthcare costs were calculated, and the predictors of high healthcare utilization were identified. RESULTS Our study population included 98 patients with recurrent CDI. The median interval between the initial infection and recurrence was 37 days. The mean age of the cohort was 67 years, two-thirds were women (62%), and the mean Charlson index was 8.6. During the year following the first recurrence of CDI, each patient underwent a mean of 4.4 stool C. difficile toxin tests and received a mean of 2.5 prescriptions for oral vancomycin (range, 0-6). Most patients (84%) with recurrence had a CDI-related hospitalization, and 6% underwent colectomy. The mean total CDI-associated cost was $34,104 per patient, with hospitalization costs accounting for 68%, surgery 20%, and drug treatment 8% of this cost, respectively. Extrapolating to the United States overall, we estimate an annual cost of $2.8 billion related to recurrent CDI. CONCLUSION Recurrent CDI is associated with considerable morbidity and cost. Infect Control Hosp Epidemiol 2017;38:196-202.

'Get in Early'; Biofilm and Wax Moth (Galleria mellonella) Models Reveal New Insights into the Therapeutic Potential of Clostridium difficile Bacteriophages

Clostridium difficile infection (CDI) is a global health threat associated with high rates of morbidity and mortality. Conventional antibiotic CDI therapy can result in treatment failure and recurrent infection. C. difficile produces biofilms which contribute to its virulence and impair antimicrobial activity. Some bacteriophages (phages) can penetrate biofilms and thus could be developed to either replace or supplement antibiotics. Here, we determined the impact of a previously optimized 4-phage cocktail on C. difficile ribotype 014/020 biofilms, and additionally as adjunct to vancomycin treatment in Galleria mellonella larva CDI model. The phages were applied before or after biofilm establishment in vitro, and the impact was analyzed according to turbidity, viability counts and topography as observed using scanning electron and confocal microscopy. The infectivity profiles and efficacies of orally administered phages and/or vancomycin were ascertained by monitoring colonization levels and larval survival rates. Phages prevented biofilm formation, and penetrated established biofilms. A single phage application reduced colonization causing extended longevity in the remedial treatment and prevented disease in the prophylaxis group. Multiple phage doses significantly improved the larval remedial regimen, and this treatment is comparable to vancomycin and the combined treatments. Taken together, our data suggest that the phages significantly reduce C. difficile biofilms, and prevent colonization in the G. mellonella model when used alone or in combination with vancomycin. The phages appear to be highly promising therapeutics in the targeted eradication of CDI and the use of these models has revealed that prophylactic use could be a propitious therapeutic option.

Type IV pili promote early biofilm formation by Clostridium difficile

Increasing morbidity and mortality from Clostridium difficile infection (CDI) present an enormous challenge to healthcare systems. Clostridium difficile express type IV pili (T4P), but their function remains unclear. Many chronic and recurrent bacterial infections result from biofilms, surface-associated bacterial communities embedded in an extracellular matrix. CDI may be biofilm mediated; T4P are important for biofilm formation in a number of organisms. We evaluate the role of T4P in C. difficile biofilm formation using RNA sequencing, mutagenesis and complementation of the gene encoding the major pilin pilA1, and microscopy. RNA sequencing demonstrates that, in comparison to other growth phenotypes, C. difficile growing in a biofilm has a distinct RNA expression profile, with significant differences in T4P gene expression. Microscopy of T4P-expressing and T4P-deficient strains suggests that T4P play an important role in early biofilm formation. A non-piliated pilA1 mutant forms an initial biofilm of significantly reduced mass and thickness in comparison to the wild type. Complementation of the pilA1 mutant strain leads to formation of a biofilm which resembles the wild-type biofilm. These findings suggest that T4P play an important role in early biofilm formation. Novel strategies for confronting biofilm infections are emerging; our data suggest that similar strategies should be investigated in CDI.

Fecal Transplantation for Clostridium Difficile-"All Stool May Not Be Created Equal"

Clostridium difficile is a gram-positive bacterium that is recognized as a causative organism of pseudomembranous enterocolitis. This infection has become a major public health challenge and is a source of considerable morbidity and mortality in those infected. We present a 62-year-old African American female with a long history of HIV infection, who presented with abdominal pain and continuous diarrhea due to pseudomembranous colitis. After failing multiple episodes of conventional therapy, it was decided to treat her with fecal microbiota transplantation. Fecal microbiota transplantation was given on 3 separate occasions from a biological-related donor without success. It was only after a fourth transplant was done with a nonrelated donor that the patient resolved her diarrhea within 48 hours. We suggest that fecal samples from different donors have different abilities to cure Clostridium difficile colitis in at least this immunosuppressed patient.

Therapies on the horizon for Clostridium difficile infections

INTRODUCTION

Clostridium difficile infections are a leading cause of healthcare facility outbreaks of gastrointestinal illness that may have serious complications and a high rate of recurrent disease. Despite the availability of standard antibiotic treatments, data from national surveillance programs indicate that the incidence of this disease continues to increase, placing a heavy burden on healthcare systems. New emerging strategies are being tested to replace or augment these standard antibiotics.

AREAS COVERED

Thirty-two current investigational agents focusing on different strategies for both prevention and treatment of C. difficile infections are reviewed. Data was gathered from a literature search of public databases for published trials from 1999-November 13, 2015 and from the author's compendium of knowledge. Agents reviewed included 13 antibiotics, two antibiotic inactivators, seven bacteria or yeasts acting to enhance the normal microbiome, seven immunizing agents and three toxin binders. Of the 32 investigational treatments reviewed, 8 (25%) showed significant efficacy in phase II or III clinical trials and are actively being developed as new therapies for C. difficile infections.

EXPERT OPINION

A number of potential treatments have floundered during their development process, while others have shown promising results. The strongest efficacy has been in the areas of newer antibiotics, probiotics, monoclonal antibodies and vaccines. By targeting the pathogenic pathway of C. difficile infections, multiple strategies for prevention and treatment have been developed.

Cost-effectiveness in Clostridium difficile treatment decision-making

AIM: To develop a framework for the clinical and health economic assessment for management of Clostridium difficile infection (CDI).

METHODS: CDI has vast economic consequences emphasizing the need for innovative and cost effective solutions, which were aim of this study. A guidance model was developed for coverage decisions and guideline development in CDI. The model included pharmacotherapy with oral metronidazole or oral vancomycin, which is the mainstay for pharmacological treatment of CDI and is recommended by most treatment guidelines.

RESULTS: A design for a patient-based cost-effectiveness model was developed, which can be used to estimate the cost-effectiveness of current and future treatment strategies in CDI. Patient-based outcomes were extrapolated to the population by including factors like, e.g., person-to-person transmission, isolation precautions and closing and cleaning wards of hospitals.

CONCLUSION: The proposed framework for a population-based CDI model may be used for clinical and health economic assessments of CDI guidelines and coverage decisions for emerging treatments for CDI.

Mortality, Hospital Costs, Payments, and Readmissions Associated With Clostridium difficile Infection Among Medicare Beneficiaries

Supplemental digital content is available in the text.

Background

The management of Clostridium difficile infection (CDI) among hospitalized patients is costly, and ongoing payment reform is compelling hospitals to reduce its burden. To assess the impact of CDI on mortality, hospital costs, healthcare use, and Medicare payments for beneficiaries who were discharged with CDI listed as a secondary International Classification of Diseases, Ninth Revision, Clinical Modification claim diagnosis.

Methods

Data were analyzed from the 2009 to 2010 5% random sample Medicare Standard Analytic Files of beneficiary claims. Patients with index hospitalizations with CDI as a secondary diagnosis and no previous hospitalization within 30 days were identified. Outcomes included inpatient and 30-day mortality, inpatient costs, index hospital payments, all-provider payments, net hospital losses, payment to cost ratio, length of stay (LOS), and 30-day readmission; outcomes were each risk adjusted using propensity score matching and regression modeling techniques.

Results

A total of 3262 patients with CDI were identified after matching to patients without a CDI diagnosis. After risk adjustment, secondary CDI was associated with statistically significantly (all P < 0.05) greater inpatient mortality (3.1% vs. 1.7%), 30-day mortality (4.1% vs. 2.2%), longer LOS (7.0 days vs. 3.8 days), higher rates of 30-day hospital readmissions (14.8% vs. 10.4%), and greater hospital costs ($16,184 vs. $13,954) compared with the non-CDI cohort. The risk-adjusted payment-to-cost ratio was shown to be lower for patients with CDI than those without (0.76 vs. 0.85).

Conclusions

Secondary CDI is associated with greater adjusted mortality, costs, LOS, and hospital readmissions, while receiving similar hospital reimbursement compared with patients without CDI in a Medicare population.

WSES guidelines for management of Clostridium difficile infection in surgical patients

In the last two decades there have been dramatic changes in the epidemiology of Clostridium difficile infection (CDI), with increases in incidence and severity of disease in many countries worldwide. The incidence of CDI has also increased in surgical patients. Optimization of management of C difficile, has therefore become increasingly urgent. An international multidisciplinary panel of experts prepared evidenced-based World Society of Emergency Surgery (WSES) guidelines for management of CDI in surgical patients.

Clostridium difficile colitis: review of the therapeutic approach

Clostridium difficile infection (CDI) is the leading cause of antibiotic-associated and nosocomial infectious diarrhea. Presenting as clostridium difficile colitis, it is a significant cause of morbidity and mortality. Metronidazole is regarded as the agent of choice for CDl therapy and also for the first recurrence in most patients with mild to moderate CDI. Vancomycin is recommended as an initial therapy for patients with severe CDI. With recent Food and Drug Administration-approval fidaxomicin is available for clinical use and is as effective as vancomycin with lower relapse rates. Rifaximin and fecal bacteriotherapy are alternative approaches in patients with severe or refractory CDI, before surgical intervention. Antibiotic research is ongoing to add potential new drugs such as teicoplanin, ramoplanin, fusidic acid, nitazoxanide, rifampin, bacitracin to our armamentarium. Role of toxin-binding agents is still questionable. Monoclonal antibody and intravenous immunoglobulin are still investigational therapies that could be promising options. The ongoing challenges in the treatment of CDI include management of recurrence and presence of resistance strains such as NAP1/BI/027, but early recognition of surgical candidates can potentially decrease mortality in CDI.

Risk Factors, Clinical Characteristics, and Treatment Differences Between Residents With and Without Nursing Home- and Non-Nursing Home-Acquired Clostridium difficile Infection

BACKGROUND

The incidence of Clostridium difficile infection (CDI) in nursing home residents is believed to be high because of the prevalence of predisposing factors such as decreased immune response, multiple comorbidities, medications, increased risk of infection, close proximity of residents, and recent hospitalization. Yet, specific information on CDI in this population is scarce. 

OBJECTIVES

To investigate differences in clinical and demographic characteristics, treatment, and underlying comorbidities in residents who acquired CDI preadmission (non-nursing home-acquired [NNH-Acquired]) compared with those who acquired CDI after admission to a nursing home (nursing home-acquired [NH-Acquired]) and matched controls.

METHODS

We conducted a retrospective case-control study of CDI in nursing home residents with a cross-sectional and longitudinal aspect of linked and de-identified pharmacy claims and Minimum Data Set data (MDS) 2.0 records from October 1, 2009, to September 30, 2010. The control group was frequency matched 1:1 for gender, race, and age range to residents with CDI. 

RESULTS

Of 195,498 residents, 5,044 (2.6%) had a diagnosis of CDI. Compared with controls, CDI patients had less severe cognitive impairment (P  less than  0.01) and more severe functional impairment (P  less than  0.01), incontinence (P  less than  0.01), and diarrhea (P  less than  0.01). They were more likely to (a) have diabetes, stroke, heart failure, cancer, renal failure, and infections; (b) be treated with antibiotics, corticosteroids, megestrol, and proton pump inhibitors; and (c) be discharged to the hospital (29.3% vs. 14.7%, P = 0.001) than controls. NNH-Acquired CDI was 3 times more prevalent than NH-Acquired CDI. Most residents with NNH-Acquired CDI (85.0%) came from acute care hospitals and were more likely to have heart disease, cancer, and infections, while those with NH-Acquired CDI tended to have more cognitive impairment, reliance on staff for activities of daily living, incontinence, and stroke. Thirty-day retreatment rates for NH-Acquired CDI and NNH-Acquired CDI with metronidazole were 72.7% and 68.4%, and with vancomycin were 83.9% and 69.3%, respectively. The facility (Medicare Part A) was the payer for 93.6% of NNH-Acquired CDI and 75% of NH-Acquired CDI treatment; Medicare Part D was the prevalent secondary payer for NNH-Aquired CDI (19.4%) and NH-Acquired CDI (37.5%).

CONCLUSIONS

Residents with CDI had more comorbidities, and the NNH-Acquired group bore a higher burden of illness, resulting in differing treatment patterns and outcomes than the NH-Acquired CDI group.

Low awareness but positive attitudes toward fecal transplantation in Ontario physicians

Fecal transplantation has been shown to have remarkable efficacy for the treatment of recurrent Clostridium difficile infection, and is generally considered to be a low-risk procedure. However, uptake of this relatively new treatment has been low. The authors of this article conducted a questionnaire-based study to assess the knowledge of and attitudes toward fecal transplantation among a sample of health care professionals.

BACKGROUND:

Despite mounting evidence supporting fecal transplantation (FT) as a treatment for recurrent Clostridium difficile infection (CDI), adoption into clinical practice has been slow.

OBJECTIVE:

To determine the health literacy and attitudes of academic physicians in Toronto and infectious disease physicians in Ontario toward FT as a treatment for recurrent CDI, and to determine whether these are significant barriers to adoption.

METHODS:

Surveys were distributed to 253 general internists, infectious diseases specialists, gastroenterologists and family physicians.

RESULTS:

The response rate was 15%. More than 60% of physicians described themselves as being ‘not at all’ or ‘somewhat’ familiar with FT. Of the 76% of physicians who had never referred a patient for FT, the most common reason (50%) was lack of awareness of where to access the treatment. The ‘ick factor’ accounted for only 13% of reasons for not referring. No respondent believed that the procedure was too risky to consider.

CONCLUSION:

Despite general poor health literacy on FT, most physicians sampled share similar positive attitudes toward the treatment.

Epidemiological Patterns and Hospital Characteristics Associated with Increased Incidence ofClostridium difficileInfection in Quebec, Canada, 1998–2006

Objective.

To explore epidemiological patterns of the incidence ofClostridium difficileinfection (CDI) and hospital characteristics associated with increased incidence during nonepidemic and epidemic years.

Design.

Retrospective and prospective ecological study.

Setting.

Eighty-three acute care hospitals participating in CDI surveillance in the province of Quebec, Canada.

Methods.

A Serfling-type regression model applied to data obtained from an administrative database (1998-2006) and prospective Quebec CDI surveillance (2004-2006) was used to calculate expected CDI baseline incidence and to detect incidence exceeding the defined epidemic threshold at the provincial and hospital level. Multivariable Poisson regression was used to determine hospital characteristics associated with increased incidence during nonepidemic (1998-2001) and epidemic (2003-2005) periods.

Results.

During the study period (1998-2006), 4,525,847 discharges, including 45,508 with a CDI in any diagnosis field, were reported by 83 hospitals. During 1998-2001, the average Quebec incidence of CDI was 10,304 cases in 1,775,822 discharges (5.8 cases per 1,000 discharges) and presented a pattern of seasonality, with similar patterns at the hospital level for some hospitals. The Quebec epidemic started in October-November 2002 and peaked in March 2004 at 845 cases in 40,852 discharges (20.7 cases per 1,000 discharges). In multivariable analysis, higher incidence was associated with location in Montreal and surrounding regions, greater hospital size, larger proportion of hospitalized elderly patients, longer length of stay, and greater proportion of comorbidities in patients, whereas teaching profile was associated with decreased incidence during both nonepidemic and epidemic periods. The effect of geographical location on incidence was greater during the epidemic.

Conclusion.

Baseline incidence from nonepidemic years and hospital characteristics associated with CDI incidence should be taken into account when estimating the efficacy of interventions.

Biology and Diseases of Mice

Today’s laboratory mouse, Mus musculus, has its origins as the ‘house mouse’ of North America and Europe. Beginning with mice bred by mouse fanciers, laboratory stocks (outbred) derived from M. musculus musculus from eastern Europe and M. m. domesticus from western Europe were developed into inbred strains. Since the mid-1980s, additional strains have been developed from Asian mice (M. m. castaneus from Thailand and M. m. molossinus from Japan) and from M. spretus which originated from the western Mediterranean region.

Vitamin D deficiency is associated with community-acquired clostridium difficile infection: a case-control study

Background

Clostridium difficile infection (CDI) is increasingly recognized as an important community acquired pathogen causing disease (CA-CDI). Vitamin D [25(OH)D] has immune modulatory effects and plays an important role in intestinal immunity. The role of vitamin D in CA-CDI has not been examined previously.

Methods

This was a single referral center case–control study. Cases comprised of all patients with CA-CDI who had a serum 25(OH)D measured within 12 months prior to infection. Controls were drawn from patients who had 25(OH)D checked and matched based on age, gender, race and health status. Serum 25(OH)D was stratified as < 15 ng/mL, 15-30 ng/mL or > 30 ng/mL. Regression models adjusting for potential confounders were used to define independent association between vitamin D and CA-CDI.

Results

We identified 58 matched case–control pairs (66% women; 85% Caucasian). The mean age was 62 years. The mean serum 25(OH)D level was significantly lower in CA-CDI cases compared to controls (28.5 ng/mL vs. 33.8 ng/mL, p = 0.046). Cases had higher rate of antibiotic exposure and more comorbidity. Serum 25(OH)D < 15 ng/mL was associated with an increased risk of CA-CDI on univariate (Odds ratio (OR) 5.10, 95% confidence interval (CI) 1.51 – 17.24) and multivariate analysis (OR 3.84, 95% CI 1.10 – 13.42). Vitamin D levels between 15-30 ng/mL did not modify disease risk.

Conclusions

Low serum 25(OH)D < 15 ng/mL was associated with increased risk of CA-CDI. This suggests vitamin D may have a role in determining susceptibility to CA-CDI.

Risk factors for recurrence, complications and mortality in Clostridium difficile infection: a systematic review

BACKGROUND

Clostridium difficile infection (CDI) can lead to complications, recurrence, and death. Numerous studies have assessed risk factors for these unfavourable outcomes, but systematic reviews or meta-analyses published so far were limited in scope or in quality.

METHODS

A systematic review was completed according to PRISMA guidelines. An electronic search in five databases was performed. Studies published until October 2013 were included if risk factors for at least one CDI outcome were assessed with multivariate analyses.

RESULTS

68 studies were included: 24 assessed risk factors for recurrence, 18 for complicated CDI, 8 for treatment failure, and 30 for mortality. Most studies accounted for mortality in the definition of complicated CDI. Important variables were inconsistently reported, such as previous episodes and use of antibiotics. Substantial heterogeneity and methodological limitations were noted, mainly in the sample size, the definition of the outcomes and periods of follow-up, precluding a meta-analysis. Older age, use of antibiotics after diagnosis, use of proton pump inhibitors, and strain type were the most frequent risk factors for recurrence. Older age, leucocytosis, renal failure and co-morbidities were frequent risk factors for complicated CDI. When considered alone, mortality was associated with age, co-morbidities, hypo-albuminemia, leucocytosis, acute renal failure, and infection with ribotype 027.

CONCLUSION

Laboratory parameters currently used in European and American guidelines to define patients at risk of a complicated CDI are adequate. Strategies for the management of CDI should be tailored according to the age of the patient, biological markers of severity, and underlying co-morbidities.

Risk factors for recurrence, complications and mortality in Clostridium difficile infection: a systematic review

BACKGROUND

Clostridium difficile infection (CDI) can lead to complications, recurrence, and death. Numerous studies have assessed risk factors for these unfavourable outcomes, but systematic reviews or meta-analyses published so far were limited in scope or in quality.

METHODS

A systematic review was completed according to PRISMA guidelines. An electronic search in five databases was performed. Studies published until October 2013 were included if risk factors for at least one CDI outcome were assessed with multivariate analyses.

RESULTS

68 studies were included: 24 assessed risk factors for recurrence, 18 for complicated CDI, 8 for treatment failure, and 30 for mortality. Most studies accounted for mortality in the definition of complicated CDI. Important variables were inconsistently reported, such as previous episodes and use of antibiotics. Substantial heterogeneity and methodological limitations were noted, mainly in the sample size, the definition of the outcomes and periods of follow-up, precluding a meta-analysis. Older age, use of antibiotics after diagnosis, use of proton pump inhibitors, and strain type were the most frequent risk factors for recurrence. Older age, leucocytosis, renal failure and co-morbidities were frequent risk factors for complicated CDI. When considered alone, mortality was associated with age, co-morbidities, hypo-albuminemia, leucocytosis, acute renal failure, and infection with ribotype 027.

CONCLUSION

Laboratory parameters currently used in European and American guidelines to define patients at risk of a complicated CDI are adequate. Strategies for the management of CDI should be tailored according to the age of the patient, biological markers of severity, and underlying co-morbidities.

Genetic risk factors for Clostridium difficile infection in ulcerative colitis

BACKGROUND

Patients with inflammatory bowel disease (IBD) are at higher risk for Clostridium difficile infection (CDI). Disruption of gut microbiome and interaction with the intestinal immune system are essential mechanisms for pathogenesis of both CDI and IBD. Whether genetic polymorphisms associated with susceptibility to IBD are also associated with risk of CDI is unknown.

AIMS

To use a well-characterised and genotyped cohort of patients with UC to (i) identify clinical risk factors for CDI; (ii) examine if any of the IBD genetic risk loci were associated with CDI; and (iii) to compare the performance of predictive models using clinical and genetic risk factors in determining risk of CDI.

METHODS

We used a prospective registry of patients from a tertiary referral hospital. Medical record review was performed to identify all ulcerative colitis (UC) patients within the registry with a history of CDI. All patients were genotyped on the Immunochip. We examined the association between the 163 risk loci for IBD and risk of CDI using a dominant genetic model. Model performance was examined using receiver operating characteristics curves.

RESULTS

The study included 319 patients of whom 29 developed CDI (9%). Female gender and pancolitis were associated with increased risk, while use of anti-TNF was protective against CDI. Six genetic polymorphisms including those at TNFRSF14 [Odds ratio (OR) 6.0, P-value 0.01] were associated with increased risk while 2 loci were inversely associated. On multivariate analysis, none of the clinical parameters retained significance after adjusting for genetics. Presence of at least one high-risk locus was associated with an increase in risk for CDI (20% vs. 1%) (P = 6 × 10⁻⁹). Compared to 11% for a clinical model, the genetic loci explained 28% of the variance in CDI risk and had a greater AUROC.

CONCLUSION

Host genetics may influence susceptibility to Clostridium difficile infection in patients with ulcerative colitis.

Clostridium difficile infection in children: a comprehensive review

OBJECTIVE

To provide a comprehensive review of the literature relating to Clostridium difficile (C. difficile) infection (CDI) in the pediatric population.

METHODS

Two investigators conducted independent searches of PubMed, Web of Science, and Scopus until March 31st, 2013. All databases were searched using the terms 'Clostridium difficile infection', 'Clostridium difficile associated diarrhea' 'antibiotic associated diarrhea', 'C. difficile', in combination with 'pediatric' and 'paediatric'. Articles which discussed pediatric CDI were reviewed and relevant cross references also read and evaluated for inclusion. Selection bias could be a possible limitation of this approach.

FINDINGS

There is strong evidence for an increased incidence of pediatric CDI. Increasingly, the infection is being acquired from the community, often without a preceding history of antibiotic use. The severity of the disease has remained unchanged. Several medical conditions may be associated with the development of pediatric CDI. Infection prevention and control with antimicrobial stewardship are of paramount importance. It is important to consider the age of the child while testing for CDI. Traditional therapy with metronidazole or vancomycin remains the mainstay of treatment. Newer antibiotics such as fidaxomicin appear promising especially for the treatment of recurrent infection. Conservative surgical options may be a life-saving measure in severe or fulminant cases.

CONCLUSIONS

Pediatric providers should be cognizant of the increased incidence of CDI in children. Early and judicious testing coupled with the timely institution of therapy will help to secure better outcomes for this disease.

Fecal microbiota transplantation in relapsing Clostridium difficile infection

Clostridium difficile infection rates are Climbing in frequency and severity, and the spectrum of susceptible patients is expanding beyond the traditional scope of hospitalized patients receiving antibiotics. Fecal microbiota transplantation is becoming increasingly accepted as an effective and safe intervention in patients with recurrent disease, likely due to the restoration of a disrupted microbiome. Cure rates of > 90% are being consistently reported from multiple centers. Transplantation can be provided through a variety of methodologies, either to the lower proximal, lower distal, or upper gastrointestinal tract. This review summarizes reported results, factors in donor selection, appropriate patient criteria, and the various preparations and mechanisms of fecal microbiota transplant delivery available to clinicians and patients.

Detecting and treating Clostridium difficile infections in patients with inflammatory bowel disease

The prevalence of CDI in patients with IBD has increased over the last decade. The excess morbidity and mortality associated with CDI appears to be greater in patients with IBD than in those without preexisting bowel disease. The risk factors for CDI in IBD and non-IBD populations appear similar; unique IBD-related risk factors are use of maintenance immunosuppression and extent and severity of prior colitis. Nevertheless, a significant proportion of CDI-IBD patients may have the disease without traditional risk factors (ie, antibiotic use, recent hospitalization). The absence of such risk factors must not preclude considering CDI in the differential diagnosis of IBD patients presenting with a disease flare. Vancomycin and metronidazole appear to have similar efficacy with vancomycin being the preferred agent for severe disease. Early surgical consultation is key for improving outcomes of patients with severe disease. Several gaps in research exist; prospective multicenter cohorts of CDI-IBD are essential to improve our understanding of the impact of CDI on IBD patients and define appropriate therapeutic regimens to improve patient outcomes.

The role of compassion in the practice of evidence-based medicine

Patients with diseases having a high failure rate with standard treatments typically enroll in randomized clinical trials of new investigational treatments. Not all potential therapies are amenable to these types of designs and thus may be offered compassionately; however, claims of efficacy are thus viewed with caution. In a paper in this issue, 43 patients with recurrent Clostridium difficile infections were treated with fecal microbiota transplants using a compassionate use protocol. By using standardized healthy donor stool preparations and following standardized protocols, the 92% response rate can be viewed with more confidence than other case series reports.

Predictors of severe outcomes associated with Clostridium difficile infection in patients with inflammatory bowel disease

BACKGROUND

The increasing incidence of Clostridium difficile (C. difficile) infection (CDI) among patients with inflammatory bowel disease is well recognised. However, most studies have focused on demonstrating that CDI is associated with adverse outcomes in IBD patients. Few have attempted to identify predictors of severe outcomes associated with CDI among IBD patients.

AIM

To identify clinical and laboratory factors that predict severe outcomes associated with CDI in IBD patients.

METHODS

From a multi-institution EMR database, we identified all hospitalised patients with at least one diagnosis code for C. difficile from among those with a diagnosis of Crohn's disease or ulcerative colitis. Our primary outcome was time to total colectomy or death with follow-up censored at 180 days after CDI. Cox proportional hazards models were used to identify predictors of the primary outcome from among demographic, disease-related, laboratory and medication variables.

RESULTS

A total of 294 patients with CDI-IBD were included in our study. Of these, 58 patients (20%) met our primary outcome (45 deaths, 13 colectomy) at a median of 31 days. On multivariate analysis, serum albumin <3 g/dL (HR 5.75, 95% CI 1.34-24.56), haemoglobin below 9 g/dL (HR 5.29, 95% CI 1.58-17.69) and creatinine above 1.5 mg/dL (HR 1.98, 95% CI 1.04-3.79) were independent predictors of our primary outcome. Examining laboratory parameters as continuous variables or shortening our primary outcome to include events within 90 days yielded similar results.

CONCLUSION

Serum albumin below 3 g/dL, haemoglobin below 9 g/dL and serum creatinine above 1.5 mg/dL were independent predictors of severe outcomes in hospitalised IBD patients with Clostridium difficile infection.

Savings from the use of a probiotic formula in the prophylaxis of antibiotic-associated diarrhea

OBJECTIVE

Antibiotic-associated diarrhea (AAD) and particularly Clostridium difficile-associated diarrhea (CDAD) are the most common causes of healthcare associated infectious diarrhea. A double-blind, dose response, placebo-controlled trial of the probiotic formula (Bio-K+ Lactobacillus acidophilus CL1285 and Lactobacillus casei LBC80R formula) for prophylaxis of AAD and CDAD was published in 2010. The Bio-K+ Lactobacillus acidophilus CL1285 and Lactobacillus casei LBC80R formula is a registered trademark of Bio-K Plus International Inc. (Laval, Québec, Canada). Results indicated that the incidence of AAD and CDAD were lower for patients assigned to the probiotic formula compared with the placebo option. The present study aims to estimate the savings in direct medical costs that might result from the use of two different doses of the probiotic formula vs placebo.

METHODS

A cost-consequence analysis was conducted to compare the two doses of the probiotic formula compared to placebo. The analysis was based upon published data and adjusted to the North American context.

RESULTS

Economic analyses showed that the use of the probiotic formula would result in estimated mean per patients savings of US$1968 for the single dose and US$2661 for the double dose compared with the placebo option if used an average of 13 days by all patients at risk of developing AAD and CDAD.

LIMITATIONS

Several key parameters considered within the economic model were not captured within the Gao et al. study. Numerous sensitivity analyses were conducted to address this issue.

CONCLUSION

The use of the probiotic formula in prophylaxis of AAD and CDAD would lead to estimated savings in direct medical costs that would substantially offset its acquisition cost. Treating 1000 hospitalized patients on antibiotics with the double dose of the product compared to current practice would save a single payer system the sum of $2,661,218.

Clinical approach to severe Clostridium difficile infection: update for the hospital practitioner

The rising incidence of Clostridium difficile (C. difficile) infection or CDI is now a problem of pandemic proportions. The NAP1 hypervirulent strain of C. difficile is responsible for a majority of recent epidemics and the widespread use of fluoroquinolone antibiotics may have facilitated the selective proliferation of this strain. The NAP1 strain also is more likely to cause severe and fulminant colitis characterized by marked leukocytosis, renal failure, hemodynamic instability, and toxic megacolon. No single test suffices to diagnose severe CDI, instead; the clinician must rely on a combination of clinical acumen, laboratory testing, and radiologic and endoscopic modalities. Although oral vancomycin and metronidazole are considered standard therapies in the medical management of CDI, recently it has been demonstrated that vancomycin is the more effective antibiotic in cases of severe disease. Moreover, early surgical consultation is necessary in patients who do not respond to medical therapy or who demonstrate rising white blood cell counts or hemodynamic instability indicative of fulminant colitis. Subtotal colectomy with end ileostomy is the procedure of choice for fulminant colitis. When applied to select patients in a judicious and timely fashion, surgery can be a life-saving intervention. In addition to these therapeutic approaches, several investigational treatments including novel antibiotics, fecal bacteriotherapy and immunotherapy have shown promise in the care of patients with severe CDI.

Treating Clostridium difficile infection with fecal microbiota transplantation

Clostridium difficile infection is increasing in incidence, severity, and mortality. Treatment options are limited and appear to be losing efficacy. Recurrent disease is especially challenging; extended treatment with oral vancomycin is becoming increasingly common but is expensive. Fecal microbiota transplantation is safe, inexpensive, and effective; according to case and small series reports, about 90% of patients are cured. We discuss the rationale, methods, and use of fecal microbiota transplantation.

Clostridium difficile: a problem of concern in developed countries and still a mystery in Latin America

Clostridium difficile-associated disease (CDAD) is caused by a spore-forming bacterium and can result in highly variable disease, ranging from mild diarrhoea to severe clinical manifestations. Infections are most commonly seen in hospital settings and are often associated with on-going antibiotic therapy. Incidences of CDAD have shown a sustained increase worldwide over the last ten years and a hypervirulent C. difficile strain, PCR ribotype 027/REA type BI/North American pulsed-field (NAP) type 1 (027/BI/NAP-1), has caused outbreaks in North America and Europe. In contrast, only a few reports of cases in Latin America have been published and the hypervirulent strain 027/BI/NAP-1 has, so far, only been reported in Costa Rica. The potential worldwide spread of this infection calls for epidemiological studies to characterize currently circulating strains and also highlights the need for increased awareness and vigilance among healthcare professionals in currently unaffected areas, such as Latin America. This review attempts to summarize reports of C. difficile infection worldwide, especially in Latin America, and aims to provide an introduction to the problems associated with this pathogen for those countries that might face outbreaks of epidemic strains of C. difficile for the first time in the near future.

Clostridium difficile Infection and Inflammatory Bowel Disease: A Review

The incidence of Clostridium difficile infection (CDI) has significantly increased in the last decade in the United States adding to the health care burden of the country. Patients with inflammatory bowel disease (IBD) have a higher prevalence of CDI and worse outcomes. In the past, the traditional risk factors for CDI were exposure to antibiotics and hospitalizations in elderly people. Today, it is not uncommon to diagnose CDI in a pregnant women or young adult who has no risk factors. C. difficile can be detected at the initial presentation of IBD, during a relapse or in asymptomatic carriers. It is important to keep a high index of suspicion for CDI in IBD patients and initiate prompt treatment to minimize complications. We summarize here the changing epidemiology, pathogenesis, risk factors, clinical features, and treatment of CDI in IBD.

Human microbial ecology: lactobacilli, probiotics, selective decontamination

Health care-associated infections are closely associated with different medical interventions which interrupt the balance of human microbiota. The occasional predominance of opportunistic pathogens may lead to their translocation into the lymph nodes and bloodstream, causing endogenous (primary or secondary) hospital infections. The question is raised as to if there is a possibility for prevention of the imbalance of GI microbiota during medical interventions in critically ill patients. Prophylactic selective decontamination of the digestive tract (SDD) simultaneously applies three to four different antimicrobials for the suppression of enteric aerobic microbes, which are potentially pathogenic microorganisms. However, there is no convincing evidence that the indigenous beneficial intestinal microbiota are preserved, resulting in reduced mortality of high-risk patients. In this overview, we have evaluated the antimicrobial treatment guidelines of the Infectious Diseases Society of America (IDSA) for intra-abdominal infections in adults and seniors according to their safety for different Lactobacillus spp. The data from our group and in the literature have shown that all tested lactobacilli strains (nearly one hundred) were insusceptible to metronidazole while different species of lactobacilli of the three fermentation groups expressed particular antibiotic susceptibility to vancomycin, cefoxitin, ciprofloxacin and some new tetracyclines. We have relied on microbial ecology data showing that the GI tracts of adults and the elderly are simultaneously colonised at least with several (four to a maximum of 12) Lactobacillus species expressing variable intrinsic insusceptibility to the aforementioned antimicrobials, according to the provided data in table. This finding offers the possibility of preserving the colonisation of the intestine with some beneficial lactobacilli during antimicrobial treatment in critically ill patients with health care-associated infections. Several probiotic Lactobacillus spp. strains are intrinsically resistant to antimicrobials and can be used during antibacterial therapy, however, their application as an additive to antimicrobial treatment in critically ill patients needs to be investigated in well-designed clinical trials.

Evaluation of a loop-mediated isothermal amplification assay for diagnosis of Clostridium difficile infections

A new assay (illumigene C. difficile; Meridian Bioscience), based on the original loop-mediated isothermal amplification (LAMP) assay, was evaluated with 472 unformed stools from patients suspected of Clostridium difficile infection. Compared to the toxigenic culture, the sensitivity, specificity, and positive and negative predictive values were 91.8, 99.1, 91.8, and 99.1% for the illumigene C. difficile assay and 69.4, 100, 100, and 96.6% for the cytotoxicity assay, respectively.

Temporal trends in disease outcomes related to Clostridium difficile infection in patients with inflammatory bowel disease

BACKGROUND

Clostridium difficile has emerged as an important pathogen in patients with inflammatory bowel disease (IBD) and is associated with increased morbidity and mortality. No studies have examined the temporal change in severity of C. difficile infection (CDI) complicating IBD.

METHODS

Using data from the Nationwide Inpatient Sample, we identified all IBD-related hospitalizations during the years 1998, 2004, and 2007 and examined hospitalizations with a coexisting diagnosis of C. difficile. We compared the absolute outcomes of in-hospital mortality and colectomy in the C. difficile-IBD cohort during these timepoints, and also examined these outcomes relative to non-C. difficile IBD controls during each corresponding year.

RESULTS

During 1998, 2004, and 2007, approximately 1.4%, 2.3%, and 2.9% of all IBD hospitalizations nationwide were complicated by CDI (P < 0.001). The absolute mortality in the C. difficile-IBD cohort increased from 5.9%-7.2% (P = 0.052) with a nonsignificant increase in colectomy rate from 3.8%-4.5% between 1998 and 2007. Compared to non-C. difficile IBD controls, there was an increase in the relative mortality risk associated with C. difficile from 1998 (odds ratio [OR] 2.38, 95% confidence interval [CI]: 1.52-3.72) to 2007 (OR 3.38, 95% CI: 2.66-4.29) (P = 0.15) with a significant increase in total colectomy odds from 1998 (OR 1.39, 95% CI: 0.81-2.37) to 2007 (OR 2.51, 95% CI: 1.90-3.34) (P = 0.03).

CONCLUSION

There has been a temporal increase nationwide in CDI complicating IBD hospitalizations. The excess morbidity associated with C. difficile infection in hospitalized IBD patients has increased between 1998 and 2007.

Systematic review: Clostridium difficile and inflammatory bowel disease

BACKGROUND

There is increasing concern about the apparently rising incidence and worsening outcome of Clostridium difficile infection (CDI) associated with inflammatory bowel disease (IBD). We have systematically reviewed the literature to evaluate the incidence, risk factors, endoscopic features, treatment and outcome of CDI complicating IBD.

AIM

To systematically review: clostridium difficile & inflammatory bowel disease.

METHODS

Structured searches of Pubmed up to September 2010 for original, cross-sectional, cohort and case-controlled studies were undertaken.

RESULTS

Of 407 studies, 42 met the inclusion criteria: their heterogeneity precluded formal meta-analysis. CDI is commoner in active IBD, particularly ulcerative colitis, than in controls. Certainty about a temporal trend to its increasing incidence in IBD is compromised by possible detection bias and miscoding. Risk factors include immunosuppressants and antibiotics, the latter less commonly than in controls. Endoscopy rarely shows pseudomembranes and is unhelpful for diagnosing CDI in IBD. There are no controlled therapeutic trials of CDI in IBD. In large studies, outcome of CDI in hospitalised IBD patients appears worse than in controls.

CONCLUSIONS

The complication of IBD by Clostridium difficile infection has received increasing attention in the past decade, but whether its incidence is really increasing or its outcome worsening remains unproven. Therapeutic trials of Clostridium difficile infection in IBD are lacking and are needed urgently.

Clostridium difficile infection: epidemiology, risk factors and management

The epidemiology of Clostridium difficile infection (CDI) has changed over the past decade. There has been a dramatic worldwide increase in its incidence, and new CDI populations are emerging, such as those with community-acquired infection and no previous exposure to antibiotics, children, pregnant women and patients with IBD. Diagnosis of CDI requires identification of C. difficile toxin A or B in diarrheal stool. The accuracy of current diagnostic tests remains inadequate and the optimal diagnostic testing algorithm has not been defined. The first-line agents for CDI treatment are metronidazole and vancomycin, with the latter being the preferred agent in patients with severe disease as it has significantly superior efficacy. The incidence of metronidazole treatment failures has increased, emphasizing the need to find alternative treatment options. Disease recurrence continues to occur in 20-40% of patients and its treatment remains challenging. In patients with CDI who develop fulminant colitis, early surgical consultation is essential. Intravenous immunoglobulin and tigecycline have been used in patients with severe refractory disease but delaying surgery may be associated with worse outcomes. Infection control measures are key to prevent horizontal transmission of infection. Ongoing research into effective treatment protocols and prevention is essential.