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Deckey DG, Boddu SP, Verhey JT, Doxey SA, Spangehl MJ, Clarke HD, Bingham JS. Clostridium difficile Infection Prior to Total Hip Arthroplasty Independently Increases the Risk of Periprosthetic Joint Infection. J Arthroplasty 2024:S0883-5403(24)00274-2. [PMID: 38548233 DOI: 10.1016/j.arth.2024.03.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/18/2024] [Accepted: 03/20/2024] [Indexed: 04/23/2024] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) following total hip arthroplasty (THA) is associated with major morbidity. There may be a link between the gut microbiome and an individual's overall immune system. A Clostridium difficile (C. difficile) infection portends poor gut microbiome health and has been previously associated with increased 90-day complication rates in total joint arthroplasty (TJA). The purpose of this study was to determine the effect of a previous history of C. difficile infection within 2 years of undergoing THA on PJI within 2 years postoperatively. METHODS Patients undergoing THA from 2010 to 2021 were identified in a patient claims database (n = 770,075). Patients who had active records 2 years before and after THA as well as a history of C. difficile infection within 2 years prior to THA (n = 1,836) were included and propensity matched to a control group using age, sex, and Elixhauser comorbidity index. The primary outcome was the 2-year incidence of postoperative PJI. The exposed C. difficile infection cohort was stratified into 4 groups based on the time proximity of the C. difficile infection. Chi-square tests and logistic regressions were used to compare the groups. RESULTS A C. difficile infection anytime within 2 years prior to total hip arthroplasty was independently associated with higher odds of PJI (OR [odds ratio]: 1.49 [95% CI (confidence interval) 1.09 to 2.02, P = .014]). Proximity of C. difficile infection to arthroplasty was associated with increased risk of PJI (infection 0 to 3 months before THA: OR 2.01 [95% CI 1.23 to 3.20], infection 3 to 6 months before THA: OR 1.84 [95% CI 1.06 to 3.04], infection 6 to 12 months before THA: OR 1.10 [95% CI 0.65 to 1.77], infection 1 to 2 years before THA: OR 1.40 [95% CI 0.94 to 2.06]). CONCLUSIONS A C. difficile infection prior to THA is an independent risk factor for PJI. Proximity of C. difficile infection is associated with increased risk of PJI. Future investigations should evaluate how to adequately optimize patients prior to THA and pursue strategies to determine appropriate timing for proceeding with THA.
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Affiliation(s)
- David G Deckey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Sayi P Boddu
- Alix School of Medicine, Mayo Clinic, Scottsdale, Arizona
| | - Jens T Verhey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Stephen A Doxey
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington, Minnesota
| | - Mark J Spangehl
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Henry D Clarke
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Joshua S Bingham
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
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2
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Gao X, Zhou H, Hu Z, Wang Q, Chen Y, Zh F, Zhou G. Primary clostridium difficile infection in patients with ulcerative colitis: Case report and literature review. Medicine (Baltimore) 2024; 103:e36693. [PMID: 38335423 PMCID: PMC10861005 DOI: 10.1097/md.0000000000036693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/27/2023] [Indexed: 02/12/2024] Open
Abstract
RATIONALE Inflammatory bowel disease (IBD), including Crohn disease (CD) and ulcerative colitis (UC), is a chronic immune-mediated disorder characterized by inflammation of the gastrointestinal tract. Patients with IBD are susceptible to various complications, including the coexistence of Clostridioides difficile infection (CDI). The incidence of IBD combined with difficile infection is higher in patients with compromised immune function, which can lead to increased mortality. PATIENT CONCERNS A 43-year-old male presented with recurrent episodes of mucus and bloody stools persisting for more than a month without any identifiable triggering factors. Initially, the stool consistency was normal, but it progressively shifted to a loose and watery texture, with up to 8 occurrences daily. DIAGNOSES This case underscores the diagnosis of severe UC through colonoscopy and colonic biopsy, along with the supplementary identification of a positive result for Clostridioides difficile in the fecal sample. INTERVENTIONS The patient initiated infliximab therapy alongside a full vancomycin course, demonstrating the potential effectiveness of this intervention in managing early-stage ulcerative colitis with concurrent Clostridioides difficile infection. OUTCOMES Following the completion of a full vancomycin course, the patient initiated infliximab therapy. The patient was free from significant discomfort, exhibited no fever, and had no mucopurulent bloody stools. A follow-up blood test indicated reduced inflammatory markers compared to the preoperative period, and the stools were normal. LESSONS We illustrate the potential effectiveness of this medication by presenting an in-depth case report of a patient with early-stage UC. The report outlines the patient inclusion of infliximab to better manage UC inflammation alongside an adjunct vancomycin regimen, given the ineffectiveness of mesalazine therapy and the concurrent presence of Clostridium difficile infection. This case prompts consideration of therapeutic approaches for complex UC and contributes to advancing both research and clinical practice. Nonetheless, we should remain attentive to the variations and potential risks unique to each patient in order to formulate personalized treatment strategies.
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Affiliation(s)
- Xizhuang Gao
- Department of Clinical Medicine, Jining Medical University, Jining, Shandong, P.R. China
| | - Huihui Zhou
- Department of Gastroenterology, Affiliated Hospital of Jining Medical University, Jining Medical University, Jining, Shandong, P.R. China
| | - Zongjing Hu
- Department of Gastroenterology, Affiliated Hospital of Jining Medical University, Jining Medical University, Jining, Shandong, P.R. China
| | - Quanyi Wang
- Pathology Department, Affiliated Hospital of Jining Medical University, Jining Medical University, Jining, Shandong, P.R. China
| | - Yun Chen
- Department of Gastroenterology, Affiliated Hospital of Jining Medical University, Jining Medical University, Jining, Shandong, P.R. China
| | - Fengqin Zh
- Department of Gastroenterology, Affiliated Hospital of Jining Medical University, Jining Medical University, Jining, Shandong, P.R. China
| | - Guangxi Zhou
- Department of Gastroenterology, Affiliated Hospital of Jining Medical University, Jining Medical University, Jining, Shandong, P.R. China
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3
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Barron-Cervantes NM, Gonzalez-Salido J, Colado-Martinez J, Retana-Estrada E, Bibiano-Escalante HO. Reactive Arthritis as a Consequence of Infection by Clostridium difficile in a Pediatric Patient. Cureus 2024; 16:e54647. [PMID: 38529427 PMCID: PMC10961936 DOI: 10.7759/cureus.54647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/27/2024] Open
Abstract
Reactive arthritis (RA) is the development of a sterile inflammatory arthritis usually associated with a previously known infection, most commonly from the gastrointestinal or urogenital tract. The diagnosis is clinical, based on the presence of acute oligoarticular arthritis of larger joints developing within two to four weeks of the infection. However, in some cases where the infection is not clear, the diagnosis is a challenge, like in the case presented here. We must always rule out past infections as a cause of arthritis by directly asking about the presence of symptomatology associated with it, presented in the past few weeks. It's important to emphasize that human leukocyte antigen B27 (HLA-B27) should not be used as a diagnostic tool, and it always needs to be correlated with the clinical features. There is no confirmed evidence in the literature that is in favor of prescribing antibiotic therapy during an acute presentation of RA as it usually presents after the infection is cured.
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4
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Douchant K, He SM, Noordhof C, Greenlaw J, Vancuren S, Schroeter K, Allen-Vercoe E, Sjaarda C, Vanner SJ, Petrof EO, Sheth PM, Guzman M. Defined microbial communities and their soluble products protect mice from Clostridioides difficile infection. Commun Biol 2024; 7:135. [PMID: 38280981 PMCID: PMC10821944 DOI: 10.1038/s42003-024-05778-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/03/2024] [Indexed: 01/29/2024] Open
Abstract
Clostridioides difficile is the leading cause of antibiotic-associated infectious diarrhea. The development of C.difficile infection is tied to perturbations of the bacterial community in the gastrointestinal tract, called the gastrointestinal microbiota. Repairing the gastrointestinal microbiota by introducing lab-designed bacterial communities, or defined microbial communities, has recently shown promise as therapeutics against C.difficile infection, however, the mechanisms of action of defined microbial communities remain unclear. Using an antibiotic- C.difficile mouse model, we report the ability of an 18-member community and a refined 4-member community to protect mice from two ribotypes of C.difficile (CD027, CD078; p < 0.05). Furthermore, bacteria-free supernatant delivered orally to mice from the 4-member community proteolyzed C.difficile toxins in vitro and protected mice from C.difficile infection in vivo (p < 0.05). This study demonstrates that bacteria-free supernatant is sufficient to protect mice from C.difficile; and could be further explored as a therapeutic strategy against C.difficile infection.
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Affiliation(s)
- Katya Douchant
- The Gastrointestinal Disease Research Unit (GIDRU), Kingston Health Sciences Center, Kingston, K7L2V7, ON, Canada
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, K7L3N6, ON, Canada
| | - Shu-Mei He
- The Gastrointestinal Disease Research Unit (GIDRU), Kingston Health Sciences Center, Kingston, K7L2V7, ON, Canada
| | - Curtis Noordhof
- The Gastrointestinal Disease Research Unit (GIDRU), Kingston Health Sciences Center, Kingston, K7L2V7, ON, Canada
| | - Jill Greenlaw
- The Gastrointestinal Disease Research Unit (GIDRU), Kingston Health Sciences Center, Kingston, K7L2V7, ON, Canada
| | - Sarah Vancuren
- Department of Molecular and Cellular Biology, University of Guelph, Guelph, N1G2W1, ON, Canada
| | - Kathleen Schroeter
- Department of Molecular and Cellular Biology, University of Guelph, Guelph, N1G2W1, ON, Canada
| | - Emma Allen-Vercoe
- Department of Molecular and Cellular Biology, University of Guelph, Guelph, N1G2W1, ON, Canada
| | - Calvin Sjaarda
- The Gastrointestinal Disease Research Unit (GIDRU), Kingston Health Sciences Center, Kingston, K7L2V7, ON, Canada
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, K7L3N6, ON, Canada
- Division of Microbiology, Kingston Health Sciences Center, Kingston, K7L2V7, ON, Canada
| | - Stephen J Vanner
- The Gastrointestinal Disease Research Unit (GIDRU), Kingston Health Sciences Center, Kingston, K7L2V7, ON, Canada
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, K7L3N6, ON, Canada
| | - Elaine O Petrof
- The Gastrointestinal Disease Research Unit (GIDRU), Kingston Health Sciences Center, Kingston, K7L2V7, ON, Canada
| | - Prameet M Sheth
- The Gastrointestinal Disease Research Unit (GIDRU), Kingston Health Sciences Center, Kingston, K7L2V7, ON, Canada.
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, K7L3N6, ON, Canada.
- Division of Microbiology, Kingston Health Sciences Center, Kingston, K7L2V7, ON, Canada.
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, K7L3N6, ON, Canada.
| | - Mabel Guzman
- The Gastrointestinal Disease Research Unit (GIDRU), Kingston Health Sciences Center, Kingston, K7L2V7, ON, Canada
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5
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Ghazanfar H, Kandhi S, Acherjee T, Qureshi ZA, Shaban M, Yordanka DS, Cordero D, Chinta S, Jyala A, Patel H. Role of Fecal Microbiota Transplantation in Managing Clostridium Difficile Infection and Inflammatory Bowel Disease: A Narrative Review. Cureus 2023; 15:e51004. [PMID: 38259389 PMCID: PMC10802990 DOI: 10.7759/cureus.51004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2023] [Indexed: 01/24/2024] Open
Abstract
Fecal microbiota transplantation (FMT) has been emerging as an alternate treatment modality in the management of patients with dysbiosis by restoring abnormal gut microbiota composition through the transplantation of normal fecal microbiota from healthy donors. This technique has lately gained a lot of attention in the treatment of recurrent or refractory Clostridium difficile infection (CDI) owing to its high success rates combined with its favorable safety profile. FMT has also been attracting the interest of clinicians as a new treatment option for inflammatory bowel diseases (IBD). Here, we reviewed most of the recent advancements in the use of FMT for CDI as well as its use in the treatment of IBD.
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Affiliation(s)
| | - Sameer Kandhi
- Internal Medicine, BronxCare Health System, Bronx, USA
| | | | - Zaheer A Qureshi
- Medicine, The Frank H. Netter M.D. School of Medicine at Quinnipiac University, Bridgeport, USA
| | - Mohammed Shaban
- Internal Medicine, BronxCare Hospital Center, Icahn School of Medicine, New York, USA
| | | | | | | | | | - Harish Patel
- Internal Medicine, BronxCare Health System, Bronx, USA
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6
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Kim D, Canovas-Segura B, Jimeno-Almazán A, Campos M, Juarez JM. Spatial-temporal simulation for hospital infection spread and outbreaks of Clostridioides difficile. Sci Rep 2023; 13:20022. [PMID: 37974000 PMCID: PMC10654661 DOI: 10.1038/s41598-023-47296-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 11/11/2023] [Indexed: 11/19/2023] Open
Abstract
Validated and curated datasets are essential for studying the spread and control of infectious diseases in hospital settings, requiring clinical information on patients' evolution and their location. The literature shows that approaches based on Artificial Intelligence (AI) in the development of clinical-support systems have benefits that are increasingly recognized. However, there is a lack of available high-volume data, necessary for trusting such AI models. One effective method in this situation involves the simulation of realistic data. Existing simulators primarily focus on implementing compartmental epidemiological models and contact networks to validate epidemiological hypotheses. Nevertheless, other practical aspects such as the hospital building distribution, shifts or safety policies on infections has received minimal attention. In this paper, we propose a novel approach for a simulator of nosocomial infection spread, combining agent-based patient description, spatial-temporal constraints of the hospital settings, and microorganism behavior driven by epidemiological models. The predictive validity of the model was analyzed considering micro and macro-face validation, parameter calibration based on literature review, model alignment, and sensitive analysis with an expert. This simulation model is useful in monitoring infections and in the decision-making process in a hospital, by helping to detect spatial-temporal patterns and predict statistical data about the disease.
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Affiliation(s)
- Denisse Kim
- Med AI Lab, University of Murcia, Campus Espinardo, 30100, Murcia, Spain.
| | | | - Amaya Jimeno-Almazán
- Internal Medicine Service, Infectious Diseases Section, Hospital Universitario Santa Lucía, Cartagena, Spain
| | - Manuel Campos
- Med AI Lab, University of Murcia, Campus Espinardo, 30100, Murcia, Spain
- Murcian Bio-Health Institute (IMIB-Arrixaca), El Palmar, 30120, Murcia, Spain
| | - Jose M Juarez
- Med AI Lab, University of Murcia, Campus Espinardo, 30100, Murcia, Spain
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7
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Ferar K, Hall TO, Crawford DC, Rowley R, Satterfield BA, Li R, Gragert L, Karlson EW, de Andrade M, Kullo IJ, McCarty CA, Kho A, Hayes MG, Ritchie MD, Crane PK, Mirel DB, Carlson C, Connolly JJ, Hakonarson H, Crenshaw AT, Carrell D, Luo Y, Dikilitas O, Denny JC, Jarvik GP, Crosslin DR. Genetic variation in the human leukocyte antigen region confers susceptibility to Clostridioides difficile infection. Sci Rep 2023; 13:18532. [PMID: 37898691 PMCID: PMC10613277 DOI: 10.1038/s41598-023-45649-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 10/22/2023] [Indexed: 10/30/2023] Open
Abstract
Clostridioides difficile (C. diff.) infection (CDI) is a leading cause of hospital acquired diarrhea in North America and Europe and a major cause of morbidity and mortality. Known risk factors do not fully explain CDI susceptibility, and genetic susceptibility is suggested by the fact that some patients with colons that are colonized with C. diff. do not develop any infection while others develop severe or recurrent infections. To identify common genetic variants associated with CDI, we performed a genome-wide association analysis in 19,861 participants (1349 cases; 18,512 controls) from the Electronic Medical Records and Genomics (eMERGE) Network. Using logistic regression, we found strong evidence for genetic variation in the DRB locus of the MHC (HLA) II region that predisposes individuals to CDI (P > 1.0 × 10-14; OR 1.56). Altered transcriptional regulation in the HLA region may play a role in conferring susceptibility to this opportunistic enteric pathogen.
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Affiliation(s)
- Kathleen Ferar
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, USA.
| | - Taryn O Hall
- Optum Genomics, UnitedHealth Group, Minnetonka, MN, USA
| | - Dana C Crawford
- Department of Population and Quantitative Health Sciences, Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, OH, USA
- Department of Genetics and Genome Sciences, Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, OH, USA
| | - Robb Rowley
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | | | - Rongling Li
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Loren Gragert
- Division of Biomedical Informatics and Genomics, John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | | | - Mariza de Andrade
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Iftikhar J Kullo
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Catherine A McCarty
- University of Minnesota Medical School, Duluth, MN, USA
- Center for Human Genetics, Marshfield Clinic Research Foundation, Marshfield, WI, USA
| | - Abel Kho
- Divisions of General Internal Medicine and Preventive Medicine, Northwestern University, Chicago, IL, USA
| | - M Geoffrey Hayes
- Division of Endocrinology, Metabolism, and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Marylyn D Ritchie
- Department of Biochemistry and Molecular Biology, Center for Systems Genomics, Pennsylvania State University, University Park, PA, USA
| | - Paul K Crane
- Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | | | - Christopher Carlson
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - John J Connolly
- Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Hakon Hakonarson
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - David Carrell
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Yuan Luo
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ozan Dikilitas
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Joshua C Denny
- Department of Biomedical Informatics, Vanderbilt University, Nashville, TN, USA
| | - Gail P Jarvik
- Department of Medicine (Medical Genetics), University of Washington Medical Center, Seattle, WA, USA
| | - David R Crosslin
- Division of Biomedical Informatics and Genomics, John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA.
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8
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Pinto NC, Nadal Bosch J, Ng-Wong YK, Menowsky M, Shine R, Malcom J, Moya M, Galindo J, Serna S. A Case Report of Candida-Induced Emphysematous Gastritis. Cureus 2023; 15:e47870. [PMID: 38022357 PMCID: PMC10681031 DOI: 10.7759/cureus.47870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2023] [Indexed: 12/01/2023] Open
Abstract
Emphysematous gastritis is a rare entity that has not much literature available. It is known to manifest as a diffused wall inflammation and air within the wall of the stomach and has been associated with gas-forming organisms. We present a complex case of a middle-aged woman with a previous history of fulminant Clostridium difficile complicated with colectomy and diverting colostomy. She was admitted due to diabetic ketoacidosis, later complicated with worsening abdominal pain, and a CT scan of the abdomen and pelvis without contrast revealed findings consistent with ischemic bowel, severe pneumatosis intestinalis, and extensive portal venous gas. A stomach biopsy revealed hemorrhagic necrosis; a Gomori methenamine silver stain was compatible with fungal organisms, Candida species, correlating with Candida emphysematous gastritis. This case highlights the importance of early diagnosis of this syndrome in order to provide appropriate management, and early identification, to improve survival.
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Affiliation(s)
- Natalia C Pinto
- Internal Medicine, University of Texas Rio Grande Valley, Edinburg, USA
| | - Jorge Nadal Bosch
- Internal Medicine, University of Texas Rio Grande Valley, Edinburg, USA
| | - Yilen K Ng-Wong
- Internal Medicine, University of Texas Rio Grande Valley, Edinburg, USA
| | - Michael Menowsky
- Emergency Medicine/Critical Care, Doctors Hospital at Renaissance/University of Texas Rio Grande Valley, Edinburg, USA
| | - Ryan Shine
- Surgery, University of Texas Rio Grande Valley, Edinburg, USA
| | - Javier Malcom
- Medical Information, Doctors Hospital at Renaissance, Edinburg, USA
| | - Mario Moya
- Radiology, Doctors Hospital at Renaissance, Edinburg, USA
| | | | - Samuel Serna
- Radiology, Doctors Hospital at Renaissance, Edinburg, USA
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9
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Tubau-Juni N, Bassaganya-Riera J, Leber AJ, Alva SS, Baker R, Hontecillas R. Modulation of colonic immunometabolic responses during Clostridioides difficile infection ameliorates disease severity and inflammation. Sci Rep 2023; 13:14708. [PMID: 37679643 PMCID: PMC10485029 DOI: 10.1038/s41598-023-41847-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 08/31/2023] [Indexed: 09/09/2023] Open
Abstract
Clostridioides difficile infection (CDI) is the leading cause of antibiotic-associated diarrhea, and its clinical symptoms can span from asymptomatic colonization to pseudomembranous colitis and even death. The current standard of care for CDI is antibiotic treatment to achieve bacterial clearance; however, 15 to 35% of patients experience recurrence after initial response to antibiotics. We have conducted a comprehensive, global colonic transcriptomics analysis of a 10-day study in mice to provide new insights on the local host response during CDI and identify novel host metabolic mechanisms with therapeutic potential. The analysis indicates major alterations of colonic gene expression kinetics at the acute infection stage, that are restored during the recovery phase. At the metabolic level, we observe a biphasic response pattern characterized by upregulated glycolytic metabolism during the peak of inflammation, while mitochondrial metabolism predominates during the recovery/healing stage. Inhibition of glycolysis via 2-Deoxy-D-glucose (2-DG) administration during CDI decreases disease severity, protects from mortality, and ameliorates colitis in vivo. Additionally, 2-DG also protects intestinal epithelial cells from C. difficile toxin damage, preventing loss of barrier integrity and secretion of proinflammatory mediators. These data postulate the pharmacological targeting of host immunometabolic pathways as novel treatment modalities for CDI.
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Affiliation(s)
| | | | | | | | - Ryan Baker
- NIMML Institute, Blacksburg, VA, 24060, USA
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10
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Uchida-Fujii E, Niwa H, Senoh M, Kato H, Kinoshita Y, Mita H, Ueno T. Clostridioides difficile infection in thoroughbred horses in Japan from 2010 to 2021. Sci Rep 2023; 13:13099. [PMID: 37567893 PMCID: PMC10421859 DOI: 10.1038/s41598-023-40157-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 08/05/2023] [Indexed: 08/13/2023] Open
Abstract
We encountered 34 Clostridioides difficile (C. difficile) infection (CDI) cases among Thoroughbred horses in Japan from 2010 to 2021. Among them, 79.4% (27/34) either died or were euthanised. The risk factors associated with CDI and mortality among Japanese Thoroughbred horses remain unclear. We used genetic methods to examine C. difficile strains and their relationships with prognosis. Twenty-two (64.7%) cases were hospitalised at the onset of colitis. Outcomes were balanced for hospitalisation rates at the onset of colitis. The mortality rates of cases treated with metronidazole (65.0%) were significantly lower than untreated cases (100%). The predominant genotype of C. difficile isolate was polymerase chain reaction ribotype (RT) 078, isolated from 12 cases (35.3%), followed by RT014 (six cases, 17.6%). Binary toxin (C. difficile transferase [CDT])-positive strains, including all RT078 strains, were isolated from 16 horses. Mortality rates in RT078 strain (75.0%) or CDT-positive strain (83.3%) cases were comparable to that in cases of other types. Sufficient infection control is needed to prevent CDI in Thoroughbred horses. A timely and prompt CDI diagnosis leading to metronidazole treatment would improve CDI outcomes.
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Affiliation(s)
- Eri Uchida-Fujii
- Microbiology Division, Equine Research Institute, Japan Racing Association, Shiba 1400-4, Shimotsuke, Tochigi, 329-0412, Japan
| | - Hidekazu Niwa
- Microbiology Division, Equine Research Institute, Japan Racing Association, Shiba 1400-4, Shimotsuke, Tochigi, 329-0412, Japan.
| | - Mitsutoshi Senoh
- Department of Bacteriology II, National Institute of Infectious Diseases, Gakuen 4-7-1, Musashimurayama, Tokyo, 208-0011, Japan
| | - Haru Kato
- Antimicrobial Resistance Center, National Institute of Infectious Diseases, Aoba-Cho 4-2-1, Higashimurayama, Tokyo, 189-0002, Japan
| | - Yuta Kinoshita
- Microbiology Division, Equine Research Institute, Japan Racing Association, Shiba 1400-4, Shimotsuke, Tochigi, 329-0412, Japan
| | - Hiroshi Mita
- Clinical Veterinary Medicine Division, Equine Research Institute, Japan Racing Association, Shiba 1400-4, Shimotsuke, Tochigi, 329-0412, Japan
| | - Takanori Ueno
- Microbiology Division, Equine Research Institute, Japan Racing Association, Shiba 1400-4, Shimotsuke, Tochigi, 329-0412, Japan
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11
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Rafey A, Jahan S, Farooq U, Akhtar F, Irshad M, Nizamuddin S, Parveen A. Antibiotics Associated With Clostridium difficile Infection. Cureus 2023; 15:e39029. [PMID: 37323360 PMCID: PMC10266117 DOI: 10.7759/cureus.39029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2023] [Indexed: 06/17/2023] Open
Abstract
Introduction Clostridium difficile (C. difficile) is one of the major causes of diarrhea transmitted by the fecal-oral route. C. difficile type BI/NAP1/027 is responsible for the most severe C. difficile infection (CDI). It is a major cause of antibiotic-associated diarrhea followed by Clostridium perfringens, Staphylococcus aureus,and Klebsiella oxytoca. Historically, clindamycin, cephalosporins, penicillins, and fluoroquinolones were related to CDI. We conducted this study to evaluate the antibiotics associated with CDI in recent times. Methods We conducted a retrospective, single-center study over a period of eight years. A total of 58 patients were enrolled in the study. Patients with diarrhea and positive C. difficile toxin in stool were evaluated for antibiotics given, age, presence of malignancy, previous hospital stay for more than three days in the last three months, and any comorbidities. Results Among patients who developed CDI, prior antibiotics for at least four days duration were given in 93% (54/58) of patients. The most common antibiotics associated with C. difficile infection were piperacillin/tazobactam in 77.60% (45/58), meropenem in 27.60% (16/58), vancomycin in 20.70% (12/58), ciprofloxacin in 17.20% (10/58), ceftriaxone in 16% (9/58), and levofloxacin in 14% (8/58) of patients, respectively. Seven percent (7%) of patients with CDI did not receive any prior antibiotics. Solid organ malignancy was present in 67.20% and hematological malignancy in 27.60% of CDI patients. Ninety-eight percent (98%, 57/58) of patients treated with proton pump inhibitors, 93% of patients with a previous hospital stay for more than three days, 24% of patients with neutropenia, 20.1% of patients aged more than 65 years, 14% of patients with diabetes mellitus, and 12% of patients with chronic kidney disease also developed C. difficile infection. Conclusion The antibiotics associated with C. difficile infection are piperacillin/tazobactam, meropenem, vancomycin, ciprofloxacin, ceftriaxone, and levofloxacin. Other risk factors for CDI are proton pump inhibitor use, prior hospital admission, solid organ malignancy, neutropenia, diabetes mellitus (DM), and chronic kidney disease (CKD).
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Affiliation(s)
- Abdur Rafey
- Department of Internal Medicine and Infectious Diseases, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, PAK
| | - Shah Jahan
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, PAK
| | - Umer Farooq
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, PAK
| | - Furqana Akhtar
- Department of Infectious Diseases, Bahria International Hospital, Lahore, PAK
| | - Memoona Irshad
- Department of Infectious Diseases, Aga Khan University Hospital, Karachi, PAK
| | - Summiya Nizamuddin
- Department of Microbiology, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, PAK
| | - Azra Parveen
- Department of Internal Medicine and Infectious Diseases, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, PAK
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12
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Ozen C, Yalcinkaya A, Zarandi K, Haydal A, Pedersen SH, Leutscher PC. Antibiotic Practice in Patients With Acute Abdomen Admitted to a Danish Regional Hospital: A Clinical Qualitative Assurance Study. Cureus 2023; 15:e37706. [PMID: 37077367 PMCID: PMC10109216 DOI: 10.7759/cureus.37706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2023] [Indexed: 04/21/2023] Open
Abstract
Background Acute abdomen is often complicated by intra-abdominal infection requiring antibiotic therapy. Danish regional antibiotic guidelines emphasize the restricted use of broad-spectrum antibiotics such as cephalosporins. In this study, we aimed to evaluate antibiotic practices in relation to hospitalized patients with acute abdomen. Methodology This retrospective quality assurance study was conducted among patients admitted to the surgical emergency department at the North Denmark Regional Hospital during a four-month observation period. Data were extracted from electronic patient journals and entered in the Research Electronic Data Capture data management system for further analytical work. Results Of 331 patients, 174 (53%) were treated with antibiotics, of whom 98 (56%) had been treated with cephalosporin, 47 (27%) with benzylpenicillin and gentamicin, 22 (13%) with piperacillin/tazobactam, and seven (4%) with ciprofloxacin. Use of a cephalosporin-based antibiotic regimen was significantly more common in patients with acute appendicitis (75%) compared to other diagnostic groups, such as acute cholecystitis (57%), incarcerated hernia with strangulation (56%), acute pancreatitis (50%), and acute diverticulitis (30%). However, patients with uncomplicated diverticulitis (53%) were significantly more often treated with benzylpenicillin and gentamicin, whereas patients with complicated diverticulitis Hinchey stage 3-4 were significantly more often treated with piperacillin/tazobactam. In addition, as the severity of acute cholecystitis increased, it was more frequently treated with piperacillin/tazobactam. Conclusions The study revealed that cephalosporins are frequently used in patients hospitalized with acute abdomen. This finding conflicts with current regional antibiotic guidelines. Reinforcement of the guidelines is required as an essential measure against the development of antibiotic resistance associated with the use of cephalosporins.
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Affiliation(s)
- Cihan Ozen
- General and Colorectal Surgery, Aalborg University Hospital, Aalborg, DNK
- Research and Development, Center for Clinical Research, Hjoerring, DNK
| | - Ali Yalcinkaya
- Center for General Practice, Aalborg University Hospital, Aalborg, DNK
| | - Kasra Zarandi
- General Surgery, North Denmark Regional Hospital, Hjoerring, DNK
| | - Ashraf Haydal
- General Surgery, Aalborg University Hospital, Aalborg, DNK
| | | | - Peter Christian Leutscher
- Research and Development, North Denmark Regional Hospital Centre for Clinical Research, Hjoerring, DNK
- Medicine, Aalborg University Hospital, Aalborg, DNK
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13
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Chen B, Liu Z, Perry K, Jin R. Structure of the glucosyltransferase domain of TcdA in complex with RhoA provides insights into substrate recognition. Sci Rep 2022; 12:9028. [PMID: 35637242 PMCID: PMC9151644 DOI: 10.1038/s41598-022-12909-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/17/2022] [Indexed: 01/05/2023] Open
Abstract
Clostridioides difficile is one of the most common causes of antibiotic-associated diarrhea in developed countries. As key virulence factors of C. difficile, toxin A (TcdA) and toxin B (TcdB) act by glucosylating and inactivating Rho and Ras family small GTPases in host cells, which leads to actin cytoskeleton disruption, cell rounding, and ultimately cell death. Here we present the co-crystal structure of the glucosyltransferase domain (GTD) of TcdA in complex with its substrate human RhoA at 2.60-angstrom resolution. This structure reveals that TcdA GTD grips RhoA mainly through its switch I and switch II regions, which is complemented by interactions involving RhoA's pre-switch I region. Comprehensive structural comparisons between the TcdA GTD-RhoA complex and the structures of TcdB GTD in complex with Cdc42 and R-Ras reveal both the conserved and divergent features of these two toxins in terms of substrate recognition. Taken together, these findings establish the structural basis for TcdA recognition of small GTPases and advance our understanding of the substrates selectivity of large clostridial toxins.
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Affiliation(s)
- Baohua Chen
- Department of Physiology and Biophysics, School of Medicine, University of California, Irvine, CA, 92697, USA
| | - Zheng Liu
- Department of Physiology and Biophysics, School of Medicine, University of California, Irvine, CA, 92697, USA
| | - Kay Perry
- NE-CAT and Department of Chemistry and Chemical Biology, Argonne National Laboratory, Cornell University, Argonne, IL, 60439, USA
| | - Rongsheng Jin
- Department of Physiology and Biophysics, School of Medicine, University of California, Irvine, CA, 92697, USA.
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14
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Pruss KM, Enam F, Battaglioli E, DeFeo M, Diaz OR, Higginbottom SK, Fischer CR, Hryckowian AJ, Van Treuren W, Dodd D, Kashyap P, Sonnenburg JL. Oxidative ornithine metabolism supports non-inflammatory C. difficile colonization. Nat Metab 2022; 4:19-28. [PMID: 34992297 PMCID: PMC8803604 DOI: 10.1038/s42255-021-00506-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 11/12/2021] [Indexed: 01/08/2023]
Abstract
The enteric pathogen Clostridioides difficile (Cd) is responsible for a toxin-mediated infection that causes more than 200,000 recorded hospitalizations and 13,000 deaths in the United States every year1. However, Cd can colonize the gut in the absence of disease symptoms. Prevalence of asymptomatic colonization by toxigenic Cd in healthy populations is high; asymptomatic carriers are at increased risk of infection compared to noncolonized individuals and may be a reservoir for transmission of Cd infection2,3. Elucidating the molecular mechanisms by which Cd persists in the absence of disease is necessary for understanding pathogenesis and developing refined therapeutic strategies. Here, we show with gut microbiome metatranscriptomic analysis that mice recalcitrant to Cd infection and inflammation exhibit increased community-wide expression of arginine and ornithine metabolic pathways. To query Cd metabolism specifically, we leverage RNA sequencing in gnotobiotic mice infected with two wild-type strains (630 and R20291) and isogenic toxin-deficient mutants of these strains to differentiate inflammation-dependent versus -independent transcriptional states. A single operon encoding oxidative ornithine degradation is consistently upregulated across non-toxigenic Cd strains. Combining untargeted and targeted metabolomics with bacterial and host genetics, we demonstrate that both diet- and host-derived sources of ornithine provide a competitive advantage to Cd, suggesting a mechanism for Cd persistence within a non-inflammatory, healthy gut.
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Affiliation(s)
- Kali M Pruss
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA
| | - Fatima Enam
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA
| | - Eric Battaglioli
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
- Department of Molecular and Cellular Biology, Kennesaw State University, Kennesaw, GA, USA
| | - Mary DeFeo
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA
| | - Oscar R Diaz
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA
| | - Steven K Higginbottom
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA
| | - Curt R Fischer
- ChEM-H, Stanford University, Stanford, CA, USA
- Octant Bio, Emeryville, CA, USA
| | - Andrew J Hryckowian
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Medical Microbiology and Immunology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - William Van Treuren
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA
| | - Dylan Dodd
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Purna Kashyap
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
| | - Justin L Sonnenburg
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA.
- Center for Human Microbiome Studies, Stanford, CA, USA.
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15
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Richards SJG, Udayasiri DK, Jones IT, Hastie IA, Chandra R, McCormick JJ, Chittleborough TJ, Read DJ, Hayes IP. Delayed ileostomy closure increases the odds of Clostridium difficile infection. Colorectal Dis 2021; 23:3213-3219. [PMID: 34351046 DOI: 10.1111/codi.15858] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/30/2021] [Accepted: 07/31/2021] [Indexed: 01/06/2023]
Abstract
AIM A diverting ileostomy is typically performed to divert intestinal contents in high-risk colorectal anastomoses. Ileostomy closure is associated with high rates of postoperative Clostridium difficile infection (CDI). Risk factors for the development of CDI are unclear; however, a correlation has been observed with delayed closure. This study aimed to assess the odds of developing CDI in patients who had a delay to reversal of ileostomy, compared to those who had no delay. METHODS A retrospective cohort study was conducted of patients undergoing reversal of ileostomy between 2010 and 2019 at a single tertiary centre. A delay to reversal of ileostomy was defined if the procedure was performed at >365 days following the index procedure. CDI was defined as the presence of Clostridium difficile toxin associated with diarrhoea. Univariable logistic regression analysis was performed to estimate odds of CDI for each covariable, comparing patients who had a delay to reversal of ileostomy with those who did not. Multivariable logistic regression analysis was used to adjust for the potential confounding effects of covariables. RESULTS Of 195 patients, 11 (5.6%), developed postoperative CDI. Multivariable analysis showed that delay to reversal of ileostomy was associated with a nearly 7-fold increase in odds of CDI (OR = 6.95, CI: 1.06-81.6; p-value = 0.03). CONCLUSION A delay to reversal of ileostomy of >365 days was associated with a higher incidence of CDI postoperatively. Careful consideration should be given to the timing of reversal and appropriate preoperative counselling of patients.
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Affiliation(s)
- Simon J G Richards
- Colorectal Surgical Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Dilshan K Udayasiri
- Colorectal Surgical Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Ian T Jones
- Colorectal Surgical Unit, Department of Surgery, The Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Ian A Hastie
- Colorectal Surgical Unit, Department of Surgery, The Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Raaj Chandra
- Colorectal Surgical Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Colorectal Surgical Unit, Department of Surgery, Box Hill Hospital Melbourne, Monash University, Melbourne, Victoria, Australia
| | - Jacob J McCormick
- Colorectal Surgical Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Timothy J Chittleborough
- Colorectal Surgical Unit, Department of Surgery, The Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - David J Read
- Colorectal Surgical Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Ian P Hayes
- Colorectal Surgical Unit, Department of Surgery, The Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
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16
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Yanke E, Moriarty H, Carayon P, Safdar N. "The Invisible Staff": A Qualitative Analysis of Environmental Service Workers' Perceptions of the VA Clostridium difficile Prevention Bundle Using a Human Factors Engineering Approach. J Patient Saf 2021; 17:e806-e814. [PMID: 29894437 PMCID: PMC6800805 DOI: 10.1097/pts.0000000000000500] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Using a novel human factors engineering approach, the Systems Engineering Initiative for Patient Safety model, we evaluated environmental service workers' (ESWs) perceptions of barriers and facilitators influencing adherence to the nationally mandated Department of Veterans Affairs Clostridium difficile infection (CDI) prevention bundle. METHODS A focus group of ESWs was conducted. Qualitative analysis was performed employing a visual matrix display to identify barrier/facilitator themes related to Department of Veterans Affairs CDI bundle adherence using the Systems Engineering Initiative for Patient Safety work system as a framework. RESULTS Environmental service workers reported adequate cleaning supplies/equipment and displayed excellent knowledge of CDI hand hygiene requirements. Environmental service workers described current supervisory practices as providing an acceptable amount of time to clean CDI rooms, although other healthcare workers often pressured ESWs to clean rooms more quickly. Environmental service workers reported significant concern for CDI patients' family members as well as suggesting uncertainty regarding the need for family members to follow infection prevention practices. Small and cluttered patient rooms made cleaning tasks more difficult, and ESW cleaning tasks were often interrupted by other healthcare workers. Environmental service workers did not feel comfortable asking physicians for more time to finish cleaning a room nor did ESWs feel comfortable pointing out lapses in physician hand hygiene. CONCLUSIONS Multiple work system components serve as barriers to and facilitators of ESW adherence to the nationally mandated Department of Veterans Affairs CDI bundle. Environmental service workers may represent an underappreciated resource for hospital infection prevention, and further efforts should be made to engage ESWs as members of the health care team.
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Affiliation(s)
- Eric Yanke
- Department of Medicine, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
| | - Helene Moriarty
- Villanova University M. Louise Fitzpatrick College of Nursing, Villanova, Pennsylvania and Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Pascale Carayon
- Department of Industrial and Systems Engineering, Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Nasia Safdar
- William S. Middleton Memorial Veterans Hospital and Division of Infectious Diseases, Department of Medicine, University of Wisconsin Medical School and Infection Control Department, University of Wisconsin-Madison, Madison, Wisconsin
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17
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Gupta A, Savanti F, Singh B, Sachdev P, Raj D, Garg I, Aruwani SK, Shaukat F. Risk Factors Associated With Clostridium difficile-Associated Diarrhea. Cureus 2021; 13:e18115. [PMID: 34692326 PMCID: PMC8527547 DOI: 10.7759/cureus.18115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2021] [Indexed: 11/27/2022] Open
Abstract
Introduction: Recent years have been alarming due to the sudden, dramatic rise in the incidence of Clostridium difficile infection (CDI). Identifying and addressing the risk factors associated with CDI will help in reducing the incidence of infection and associated complications. Methods: This case-control study was conducted in a tertiary care hospital in Pakistan from June 2020 to March 2021, in which 200 patients diagnosed with Clostridium difficile-associated diarrhea (CDAD) were enrolled in the study. CDAD was diagnosed based on clinical symptoms and stool enzyme immunoassay. Another 200 participants without a diagnosis of CDAD were enrolled from the outpatient department as a control group. Participants were enrolled after seeking informed consent. Results: In patients older than 65, risk of CDI was higher compared to participants lower than 65 years old (15.5% vs. 8.0%; p value: 0.02). Hospitalization (25.5% vs. 6.0%; p value < 0.0001), the use of proton pump inhibitors in last 30 days (23.0% vs. 10.5%; p value: 0.001) , and use of antibiotics in the last 30 days (36.0% vs. 10.5%; p value < 0.0001) were significantly higher in participants with CDI. Conclusion: Hospitalization, the usage of proton pump inhibitors, and antibiotics in the last 30 days were significantly associated with CDI. A higher incidence of CDI was associated with risk factors like increased body mass index, diabetes, chronic kidney disease, and malignancy.
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Affiliation(s)
- Aarzoo Gupta
- Internal Medicine, Safdarjung Hospital, Faridabad, IND
| | - Fnu Savanti
- Internal Medicine, Liaquat National Hospital and Medical College, Karachi, PAK
| | - Balvender Singh
- Internal Medicine, Ghulam Mohammad Mahar Medical College, Sukkur, PAK
| | - Priyanka Sachdev
- Internal Medicine, Liaquat University of Medical and Health Sciences, Jamshoro, PAK
| | - Deepak Raj
- Internal Medicine, Liaquat University of Medical and Health Sciences, Jamshoro, PAK
| | - Ishan Garg
- Internal Medicine, Ross University School of Medicine, Miami, USA
| | - Suraj K Aruwani
- Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | - Faizan Shaukat
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
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18
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Patel AV, Turner RD, Rifflet A, Acosta-Martin AE, Nichols A, Awad MM, Lyras D, Gomperts Boneca I, Bern M, Collins MO, Mesnage S. PGFinder, a novel analysis pipeline for the consistent, reproducible, and high-resolution structural analysis of bacterial peptidoglycans. eLife 2021; 10:70597. [PMID: 34579805 PMCID: PMC8478412 DOI: 10.7554/elife.70597] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 08/08/2021] [Indexed: 12/12/2022] Open
Abstract
Many software solutions are available for proteomics and glycomics studies, but none are ideal for the structural analysis of peptidoglycan (PG), the essential and major component of bacterial cell envelopes. It icomprises glycan chains and peptide stems, both containing unusual amino acids and sugars. This has forced the field to rely on manual analysis approaches, which are time-consuming, labour-intensive, and prone to error. The lack of automated tools has hampered the ability to perform high-throughput analyses and prevented the adoption of a standard methodology. Here, we describe a novel tool called PGFinder for the analysis of PG structure and demonstrate that it represents a powerful tool to quantify PG fragments and discover novel structural features. Our analysis workflow, which relies on open-access tools, is a breakthrough towards a consistent and reproducible analysis of bacterial PGs. It represents a significant advance towards peptidoglycomics as a full-fledged discipline.
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Affiliation(s)
- Ankur V Patel
- School of Biosciences, University of Sheffield, Sheffield, United Kingdom
| | - Robert D Turner
- Department of Computer Science, University of Sheffield, Sheffield, United Kingdom
| | - Aline Rifflet
- Institut Pasteur, Unité Biologie et Génétique de la Paroi Bactérienne, Paris, France.,INSERM, Équipe Avenir, Paris, France.,CNRS, UMR 2001 "Microbiologie intégrative et moléculaire", Paris, France
| | - Adelina E Acosta-Martin
- biOMICS Facility, Faculty of Science Mass Spectrometry Centre, University of Sheffield, Sheffield, United Kingdom
| | | | - Milena M Awad
- Infection and Immunity Program, Monash Biomedicine Discovery Institute, Clayton, Australia
| | - Dena Lyras
- Infection and Immunity Program, Monash Biomedicine Discovery Institute, Clayton, Australia.,Department of Microbiology, Monash University, Clayton, Australia
| | - Ivo Gomperts Boneca
- Institut Pasteur, Unité Biologie et Génétique de la Paroi Bactérienne, Paris, France.,INSERM, Équipe Avenir, Paris, France.,CNRS, UMR 2001 "Microbiologie intégrative et moléculaire", Paris, France
| | | | - Mark O Collins
- School of Biosciences, University of Sheffield, Sheffield, United Kingdom.,biOMICS Facility, Faculty of Science Mass Spectrometry Centre, University of Sheffield, Sheffield, United Kingdom
| | - Stéphane Mesnage
- School of Biosciences, University of Sheffield, Sheffield, United Kingdom
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19
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Kumar A, Ghazanfar H, Davidson JM. A Rare Case of Arterial and Venous Thromboembolism in a Patient With Severe Clostridium difficile Infection. Cureus 2021; 13:e16103. [PMID: 34258130 PMCID: PMC8257462 DOI: 10.7759/cureus.16103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2021] [Indexed: 12/18/2022] Open
Abstract
Most cases of Clostridium difficile infection are hospital acquired; but in recent times, the incidence of community-acquired infections has increased. Patients with Clostridium difficile infections are at an increased risk for thrombosis. We report a case of an 82-year-old female who was admitted to the intensive care unit for acute hypoxic respiratory failure and septic shock. She was found to have Clostridium difficile infection at presentation. During the hospitalization, we discovered bilateral lower extremity venous thromboembolism, bilateral pulmonary embolism, multifocal thromboembolic brain infarctions, and acute arterial thromboembolic occlusion of right upper and lower extremities. This patient adds to the list of cases of venous thromboembolism associated with Clostridium difficile infections and is the first case of associated arterial embolic phenomenon. There is a need to further investigate the association of Clostridium difficile infections and thromboembolism.
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Affiliation(s)
- Aneesh Kumar
- Internal Medicine, BronxCare Health System, Bronx, USA
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20
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Abstract
Cardiovascular disease (CVD) is currently the leading cause of death worldwide. Although many well-known conditions cause CVD, recent research has suggested that alterations to the gut microbiome may also promote CVD. The gastrointestinal tract houses trillions of bacteria, some of which in large numbers are considered to be part of a healthy gut microbiome profile. These "good" bacteria have the ability to process and digest complex carbohydrates into short-chain fatty acids (SFCA). These SCFA serve as signaling molecules, immune-modulating molecules, and sources of energy. However, with gut dysbiosis, there is an overgrowth of certain bacteria and these bacteria overly produce phosphatidylcholine, choline, and carnitine into the waste product trimethylamine-N-oxide (TMAO). Elevated TMAO levels are associated with an increased risk of atherosclerosis, myocardial infarction, thrombosis, and stroke. Therefore, introducing therapeutic interventions that alter a dysbiotic gut profile back to a healthy gut microbiome may be the key to reducing the incidence of cardiovascular disease in some conditions. The purpose of this review is to critically examine and consolidate the relevant information bearing on this concept. Our goal is to provide the informational framework for the possible use of microbiome modification as an optional therapeutic modality.
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Affiliation(s)
- Andrea A Astudillo
- Osteopathic Medicine, Nova Southeastern University, Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, USA
| | - Harvey N Mayrovitz
- Medical Education, Nova Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Davie, USA
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21
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van Werkhoven CH, Ducher A, Berkell M, Mysara M, Lammens C, Torre-Cisneros J, Rodríguez-Baño J, Herghea D, Cornely OA, Biehl LM, Bernard L, Dominguez-Luzon MA, Maraki S, Barraud O, Nica M, Jazmati N, Sablier-Gallis F, de Gunzburg J, Mentré F, Malhotra-Kumar S, Bonten MJM, Vehreschild MJGT. Incidence and predictive biomarkers of Clostridioides difficile infection in hospitalized patients receiving broad-spectrum antibiotics. Nat Commun 2021; 12:2240. [PMID: 33854064 PMCID: PMC8046770 DOI: 10.1038/s41467-021-22269-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 03/03/2021] [Indexed: 02/06/2023] Open
Abstract
Trial enrichment using gut microbiota derived biomarkers by high-risk individuals can improve the feasibility of randomized controlled trials for prevention of Clostridioides difficile infection (CDI). Here, we report in a prospective observational cohort study the incidence of CDI and assess potential clinical characteristics and biomarkers to predict CDI in 1,007 patients ≥ 50 years receiving newly initiated antibiotic treatment with penicillins plus a beta-lactamase inhibitor, 3rd/4th generation cephalosporins, carbapenems, fluoroquinolones or clindamycin from 34 European hospitals. The estimated 90-day cumulative incidences of a first CDI episode is 1.9% (95% CI 1.1-3.0). Carbapenem treatment (Hazard Ratio (95% CI): 5.3 (1.7-16.6)), toxigenic C. difficile rectal carriage (10.3 (3.2-33.1)), high intestinal abundance of Enterococcus spp. relative to Ruminococcus spp. (5.4 (2.1-18.7)), and low Shannon alpha diversity index as determined by 16 S rRNA gene profiling (9.7 (3.2-29.7)), but not normalized urinary 3-indoxyl sulfate levels, predicts an increased CDI risk.
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Affiliation(s)
- Cornelis H van Werkhoven
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | | | - Matilda Berkell
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Mohamed Mysara
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
- Microbiology Unit, Environment Health and Safety, Belgian Nuclear Research Centre, SCK.CEN, Mol, Belgium
| | - Christine Lammens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Julian Torre-Cisneros
- Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba (UCO), Cordoba, Spain
| | - Jesús Rodríguez-Baño
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Departamento de Medicina, Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBiS), Sevilla, Spain
| | - Delia Herghea
- Oncology Institute Prof. Dr. I Chiricuta, Cluj Napoca, Romania
| | - Oliver A Cornely
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Chair Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Lena M Biehl
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Louis Bernard
- Centre hospitalo-universitaire de Tours, Tours, France
| | | | - Sofia Maraki
- University Hospital of Heraklion, Heraklion, Greece
| | - Olivier Barraud
- Université Limoges, INSERM U1092, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - Maria Nica
- Infectious and Tropical Diseases Hospital "Dr. Victor Babes", Bucharest, Romania
| | - Nathalie Jazmati
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Cologne, Germany
- Labor Dr. Wisplinghoff, Cologne, Germany
| | | | | | | | - Surbhi Malhotra-Kumar
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Maria J G T Vehreschild
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany.
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany.
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany.
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22
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Wadehra A, Alkassis S. Atypical Hemolytic Uremic Syndrome in the Setting of Acute Clostridium difficile Colitis. Cureus 2021; 13:e13244. [PMID: 33728192 PMCID: PMC7948306 DOI: 10.7759/cureus.13244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Hemolytic uremic syndrome (HUS) is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. HUS can be secondary to multiple etiologies such as infections, medications, and immune processes. A rare, yet significant, etiology of HUS includes acute Clostridium difficile colitis. Here, we present a case of atypical HUS secondary to acute C. difficile colitis, successfully treated with hemodialysis and systemic corticosteroids. It is imperative that clinicians are cognizant of C. difficile-associated HUS given the overall rising incidence of acute C. difficile infections.
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Affiliation(s)
- Anshu Wadehra
- Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, USA
| | - Samer Alkassis
- Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, USA
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23
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Littmann ER, Lee JJ, Denny JE, Alam Z, Maslanka JR, Zarin I, Matsuda R, Carter RA, Susac B, Saffern MS, Fett B, Mattei LM, Bittinger K, Abt MC. Host immunity modulates the efficacy of microbiota transplantation for treatment of Clostridioides difficile infection. Nat Commun 2021; 12:755. [PMID: 33531483 DOI: 10.1038/s41467-020-20793-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 12/21/2020] [Indexed: 01/30/2023] Open
Abstract
Fecal microbiota transplantation (FMT) is a successful therapeutic strategy for treating recurrent Clostridioides difficile infection. Despite remarkable efficacy, implementation of FMT therapy is limited and the mechanism of action remains poorly understood. Here, we demonstrate a critical role for the immune system in supporting FMT using a murine C. difficile infection system. Following FMT, Rag1 heterozygote mice resolve C. difficile while littermate Rag1-/- mice fail to clear the infection. Targeted ablation of adaptive immune cell subsets reveal a necessary role for CD4+ Foxp3+ T-regulatory cells, but not B cells or CD8+ T cells, in FMT-mediated resolution of C. difficile infection. FMT non-responsive mice exhibit exacerbated inflammation, impaired engraftment of the FMT bacterial community and failed restoration of commensal bacteria-derived secondary bile acid metabolites in the large intestine. These data demonstrate that the host's inflammatory immune status can limit the efficacy of microbiota-based therapeutics to treat C. difficile infection.
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24
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Kampouri E, Croxatto A, Prod’hom G, Guery B. Clostridioides difficile Infection, Still a Long Way to Go. J Clin Med 2021; 10:jcm10030389. [PMID: 33498428 PMCID: PMC7864166 DOI: 10.3390/jcm10030389] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 12/11/2022] Open
Abstract
Clostridioides difficile is an increasingly common pathogen both within and outside the hospital and is responsible for a large clinical spectrum from asymptomatic carriage to complicated infection associated with a high mortality. While diagnostic methods have considerably progressed over the years, the optimal diagnostic algorithm is still debated and there is no single diagnostic test that can be used as a standalone test. More importantly, the heterogeneity in diagnostic practices between centers along with the lack of robust surveillance systems in all countries and an important degree of underdiagnosis due to lack of clinical suspicion in the community, hinder a more accurate evaluation of the burden of disease. Our improved understanding of the physiopathology of CDI has allowed some significant progress in the treatment of CDI, including a broader use of fidaxomicine, the use of fecal microbiota transplantation for multiples recurrences and newer approaches including antibodies, vaccines and new molecules, already developed or in the pipeline. However, the management of CDI recurrences and severe infections remain challenging and the main question remains: how to best target these often expensive treatments to the right population. In this review we discuss current diagnostic approaches, treatment and potential prevention strategies, with a special focus on recent advances in the field as well as areas of uncertainty and unmet needs and how to address them.
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Affiliation(s)
- Eleftheria Kampouri
- Infectious Diseases Service, Department of Medicine, University Hospital and University of Lausanne, 1011 Lausanne, Switzerland;
| | - Antony Croxatto
- Institute of Microbiology, Department of Medical Laboratory and Pathology, University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; (A.C.); (G.P.)
| | - Guy Prod’hom
- Institute of Microbiology, Department of Medical Laboratory and Pathology, University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; (A.C.); (G.P.)
| | - Benoit Guery
- Infectious Diseases Service, Department of Medicine, University Hospital and University of Lausanne, 1011 Lausanne, Switzerland;
- Correspondence: ; Tel.: +41-21-314-1643
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25
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Baker SE, Monlezun DJ, Ambroze WL, Margolin DA. Anastomotic Leak is Increased With Clostridium difficile Infection After Colectomy: Machine Learning-Augmented Propensity Score Modified Analysis of 46 735 Patients. Am Surg 2020; 88:74-82. [PMID: 33356437 DOI: 10.1177/0003134820973720] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is now the most common cause of healthcare-associated infections, with increasing prevalence, severity, and mortality of nosocomial and community-acquired CDI which makes up approximately one third of all CDI. There are also increased rates of asymptomatic colonization particularly in high-risk patients. C difficile is a known collagenase-producing bacteria which may contribute to anastomotic leak (AL). METHODS Machine learning-augmented multivariable regression and propensity score (PS)-modified analysis was performed in this nationally representative case-control study of CDI and anastomotic leak, mortality, and length of stay for colectomy patients using the ACS-NSQIP database. RESULTS Among 46 735 colectomy patients meeting study criteria, mean age was 61.7 years (SD 14.38), 52.2% were woman, 72.5% were Caucasian, 1.5% developed CDI, 3.1% developed anastomotic leak, and 1.6% died. In machine learning (backward propagation neural network)-augmented multivariable regression, CDI significantly increases anastomotic leak (OR 2.39, 95% CI 1.70-3.36; P < .001), which is similar to the neural network results. Having CDI increased the independent likelihood of anastomotic leak by 3.8% to 6.8% overall, and in dose-dependent fashion with increasing ASA class to 4.3%, 5.7%, 7.6%, and 10.0%, respectively, for ASA class I to IV. In doubly robust augmented inverse probability weighted PS analysis, CDI significantly increases the likelihood of AL by 4.58% (95% CI 2.10-7.06; P < .001). CONCLUSIONS This is the first known nationally representative study on CDI and AL, mortality, and length of stay among colectomy patients. Using advanced machine learning and PS analysis, we provide evidence that suggests CDI increases AL in a dose-dependent manner with increasing ASA Class.
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Affiliation(s)
- Sarah E Baker
- Department of Colorectal Surgery, 5786Ochsner Clinic, LA, USA.,Georgia Colon & Rectal Surgical Associates, Northside Hospital, GA, USA
| | | | - Wayne L Ambroze
- Georgia Colon & Rectal Surgical Associates, Northside Hospital, GA, USA
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26
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Jochems PGM, Garssen J, Rietveld PCS, Govers C, Tomassen MMM, Wichers HJ, van Bergenhenegouwen J, Masereeuw R. Novel Dietary Proteins Selectively Affect Intestinal Health In Vitro after Clostridium difficile-Secreted Toxin A Exposure. Nutrients 2020; 12:E2782. [PMID: 32932980 PMCID: PMC7551268 DOI: 10.3390/nu12092782] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/01/2020] [Accepted: 09/10/2020] [Indexed: 12/25/2022] Open
Abstract
Bacterial gastroenteritis forms a burden on a global scale, both socially and economically. The Gram-positive bacterium Clostridium difficile is an inducer of gastrointestinal bacterial infections, often triggered following disruption of the microbiota by broad-spectrum antibiotics to treat other conditions. The clinical manifestatiaons, e.g., diarrhea, are driven by its toxins secretion, toxin A (TcdA) and toxin B (TcdB). Current therapies are focused on discontinuing patient medication, including antibiotics. However, relapse rates upon therapy are high (20-25%). Here, eighteen dietary proteins were evaluated for their capacity to restore gut health upon C. difficile-derived TcdA exposure. We used bioengineered intestinal tubules to assess proteins for their beneficial effects by examining the epithelial barrier, cell viability, brush-border enzyme activity, IL-6 secretion, IL-8 secretion and nitric oxide (NO) levels upon TcdA challenge. TcdA effectively disrupted the epithelial barrier, increased mitochondrial activity, but did not affect alkaline phosphatase activity, IL-6, IL-8 and NO levels. Intervention with dietary proteins did not show a protective effect on epithelial barrier integrity or mitochondrial activity. However, bovine plasma and potato protein increased alkaline phosphatase activity, egg-white protein increased IL-6 and IL-8 release and wheat, lesser mealworm and yeast protein increased NO levels after TcdA exposure. Hence, dietary proteins can influence parameters involved in intestinal physiology and immune activation suggesting that supplementation with specific dietary proteins may be of benefit during C. difficile infections.
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Affiliation(s)
- Paulus G. M. Jochems
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, 3584 CG Utrecht, The Netherlands; (P.G.M.J.); (J.G.); (P.C.S.R.); (J.v.B.)
| | - Johan Garssen
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, 3584 CG Utrecht, The Netherlands; (P.G.M.J.); (J.G.); (P.C.S.R.); (J.v.B.)
- Nutricia Research, Global Center of Excellence Immunology, 3584 CT Utrecht, The Netherlands
| | - Pascale C. S. Rietveld
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, 3584 CG Utrecht, The Netherlands; (P.G.M.J.); (J.G.); (P.C.S.R.); (J.v.B.)
| | - Coen Govers
- Food & Biobased Research, Wageningen University & Research, 6708 WE Wageningen, The Netherlands; (C.G.); (M.M.M.T.); (H.J.W.)
| | - Monic M. M. Tomassen
- Food & Biobased Research, Wageningen University & Research, 6708 WE Wageningen, The Netherlands; (C.G.); (M.M.M.T.); (H.J.W.)
| | - Harry J. Wichers
- Food & Biobased Research, Wageningen University & Research, 6708 WE Wageningen, The Netherlands; (C.G.); (M.M.M.T.); (H.J.W.)
| | - Jeroen van Bergenhenegouwen
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, 3584 CG Utrecht, The Netherlands; (P.G.M.J.); (J.G.); (P.C.S.R.); (J.v.B.)
- Nutricia Research, Global Center of Excellence Immunology, 3584 CT Utrecht, The Netherlands
| | - Rosalinde Masereeuw
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, 3584 CG Utrecht, The Netherlands; (P.G.M.J.); (J.G.); (P.C.S.R.); (J.v.B.)
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27
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Essrani R, Saturno D, Mehershahi S, Essrani RK, Hossain MR, Ravi SJK, Berger A, Mehmood A. The Impact of Appendectomy in Clostridium difficile Infection and Length of Hospital Stay. Cureus 2020; 12:e10342. [PMID: 33062466 PMCID: PMC7549846 DOI: 10.7759/cureus.10342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Introduction We aim to investigate Clostridium difficile infection (CDI) recurrence, severity, complications, and length of hospital stay in patients with and without prior history of appendectomy who were admitted to the hospital with CDI. Method We analyzed retrospective data for 862 patients, 18 years and older, with C. difficile inpatients diagnosed between January 1, 2017 and December 31, 2018 and sorted into two groups, with or without prior appendicectomy, to look for outcomes such as recurrence, hospital stay, complications, and related death in each group and use statistical analysis for comparison. Result There were 862 patients admitted with CDI, of which 122 (14.2%) had a prior history of appendectomy and 740 (85.8%) did not. Patients with an appendectomy prior were older (median age of 75 vs. 69, p = 0.0033) and had a higher proportion of females (68.9% vs. 53.6%, p = 0.0017). C. difficile recurrence in prior appendicectomy group vs. no appendectomy group was 12.3% and 9.3%, respectively, but no statistical difference was noted (p = 0.28). Also, there was no statistical difference in complications like ileus, colectomy, and mortality related to CDI in both groups. However, patients with appendectomies had significantly shorter hospital stays during C. difficile admission compared to patients without appendectomies (median of six days vs. seven days, p = 0.0014). Conclusion Our study shows that there is no statistical difference in the recurrence, severity, and complications of CDI in the presence or absence of the appendix but remarkably noted that people with prior appendicectomy had a shorter hospital stay.
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Affiliation(s)
- Rajesh Essrani
- Internal Medicine, Geisinger Medical Center, Danville, USA.,Internal Medicine, Lehigh Valley Health Network, Allentown, USA
| | - Dany Saturno
- General Internal Medicine, BronxCare Health System, Bronx, USA
| | | | | | | | | | - Andrea Berger
- Biostatistics, Geisinger Medical Center, Danville, USA
| | - Asif Mehmood
- Internal Medicine, Geisinger Medical Center, Danville, USA.,Internal Medicine, Abington Hospital - Jefferson Health, Abington, USA
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28
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Heindl SE, Tsouklidis N. Appendectomy as a Potential Predisposing Factor for the Development of Recurrent and Fulminant Clostridium Difficile. Cureus 2020; 12:e10091. [PMID: 32874818 PMCID: PMC7455376 DOI: 10.7759/cureus.10091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
This literature review assesses how the vermiform appendix has been considered a vestigial organ by many, but over the years, new research has allowed us to reconsider its potential purpose. Studies have indicated that the appendix plays an evident role in immune response and harbors a biofilm that may remain unaffected by gastrointestinal infections, such as infection with Clostridium difficile. Our research analyzes the prominent gut-associated lymphoid tissue (GALT) as a mechanism of defence in infection, as well as the robust biofilm that could aid in the reinoculation of beneficial bacteria within the colon. Furthermore, we wanted to determine if patients who have undergone a prior appendectomy, leading to decreased GALT and a lack of a bacterial reservoir, were predisposed to the development of Clostridium difficile, with particular emphasis in the recurrence and development of fulminant Clostridium difficile infections. Although research continues to be conflicting, there appears to be some connection between these variables, but prospective studies are needed in order to say for certain that there is a link.
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Affiliation(s)
- Stacey E Heindl
- Medicine, Avalon University School of Medicine, Willemstad, CUW.,Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Nicholas Tsouklidis
- Health Care Administration, University of Cincinnati Health, Cincinnati, USA.,Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Medicine, Atlantic University School of Medicine, Gros Islet, LCA
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29
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Austin K, Sweet M, Likar E, LaSala PR, Murray A, Wen S, Ross KG, Kanate AS, Veltri L, Matuga R, Cumpston A. Prospective assessment of Clostridioides (formerly Clostridium) difficile colonization and acquisition in hematopoietic stem cell transplant patients. Transpl Infect Dis 2020; 22:e13438. [PMID: 32767807 DOI: 10.1111/tid.13438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients undergoing hematopoietic stem cell transplant (HSCT) possess numerous risk factors for Clostridioides (formerly Clostridium) difficile infection (CDI) and experience a high rate of diarrhea. Colonization rates of Clostridium difficile vary greatly among subgroup analyses with recent studies demonstrating colonization rates in the blood and marrow transplant units up to nine times that of the general population. METHODS The primary objectives of this study were to identify the rate of C difficile colonization and acquisition in HSCT patients admitted to the blood and marrow transplant unit. This was a prospective study that included all adult patients admitted for hematopoietic stem cell transplantation. Stool specimens were routinely collected on admission and weekly thereafter for a maximum of six samples per patient. RESULTS Forty-two patients met inclusion criteria and had baseline samples available for analysis. The rate of C difficile colonization on admission was 24%, and an additional 9% of patients acquired the organism during admission. Twelve percent of patients developed CDI that was diagnosed clinically. Univariate analysis showed an increased risk of colonization for patients with three or more prior chemotherapy cycles. CONCLUSIONS Given high colonization rates coupled with high risk of CDI in this population, providers must be judicious when testing for CDI and interpreting test results for HSCT patients.
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Affiliation(s)
- Kristin Austin
- Department of Pharmacy, West Virginia University Medicine, Morgantown, WV, USA
| | - Michael Sweet
- Center for Quality Outcomes, West Virginia University Medicine, Morgantown, WV, USA
| | - Eric Likar
- Department of Pharmacy, West Virginia University Medicine, Morgantown, WV, USA
| | - P Rocco LaSala
- Department of Pathology, West Virginia University Medicine, Morgantown, WV, USA
| | - Amanda Murray
- Department of Microbiology, West Virginia University Medicine, Morgantown, WV, USA
| | - Sijin Wen
- Department of Biostatistics, West Virginia University, Morgantown, WV, USA
| | - Kelly G Ross
- Osborn Hematopoietic Malignancy and Transplantation Program, MBRCC, West Virginia University, Morgantown, WV, USA
| | - Abraham S Kanate
- Osborn Hematopoietic Malignancy and Transplantation Program, MBRCC, West Virginia University, Morgantown, WV, USA
| | - Lauren Veltri
- Osborn Hematopoietic Malignancy and Transplantation Program, MBRCC, West Virginia University, Morgantown, WV, USA
| | - Rebekah Matuga
- Department of Pharmacy, West Virginia University Medicine, Morgantown, WV, USA
| | - Aaron Cumpston
- Department of Pharmacy, West Virginia University Medicine, Morgantown, WV, USA.,Osborn Hematopoietic Malignancy and Transplantation Program, MBRCC, West Virginia University, Morgantown, WV, USA
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30
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Pizarro-Guajardo M, Calderón-Romero P, Romero-Rodríguez A, Paredes-Sabja D. Characterization of Exosporium Layer Variability of Clostridioides difficile Spores in the Epidemically Relevant Strain R20291. Front Microbiol 2020; 11:1345. [PMID: 32714296 PMCID: PMC7343902 DOI: 10.3389/fmicb.2020.01345] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/26/2020] [Indexed: 01/05/2023] Open
Abstract
Clostridioides difficile is a Gram-positive anaerobic intestinal pathogenic bacterium and the causative agent of antibiotic-associated diarrhea. C. difficile spore is a dormant state which acts as a vehicle of transmission and infection. In C. difficile spores, the outermost exosporium layer is the first barrier of interaction with the host and should carry spore ligands involved in spore-host interactions. C. difficile forms two types of spores (i.e., thin and thick exosporium layers). In this communication, we contribute to understand several biological aspects of these two exosporium morphotypes. By transmission electron microscopy, we demonstrate that both exosporium morphotypes appear simultaneously during sporulation and that spore-coat laminations are formed under anaerobic conditions. Nycodenz density-gradient allows enrichment of spores with a thick-exosporium layer morphotype and presence of polar appendage. Using translational fluorescent fusions with exosporium proteins BclA3, CdeA, CdeC, and CdeM as well as with several spore coat proteins, we observed that expression intensity and distribution of SNAP-translational fusions in R20291 strain is highly heterogeneous. Electron micrographs demonstrate that multicopy expression of CdeC, but not CdeM, SNAP translational fusion, increases the abundance of the thick exosporium morphotype. Collectively, these results raise further questions on how these distinctive exosporium morphotypes are made during spore formation.
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Affiliation(s)
- Marjorie Pizarro-Guajardo
- Microbiota-Host Interactions and Clostridia Research Group, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago, Chile.,Millennium Nucleus in the Biology of the Intestinal Microbiota, Santiago, Chile
| | - Paulina Calderón-Romero
- Microbiota-Host Interactions and Clostridia Research Group, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago, Chile
| | - Alba Romero-Rodríguez
- Microbiota-Host Interactions and Clostridia Research Group, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago, Chile.,Millennium Nucleus in the Biology of the Intestinal Microbiota, Santiago, Chile
| | - Daniel Paredes-Sabja
- Microbiota-Host Interactions and Clostridia Research Group, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago, Chile.,Millennium Nucleus in the Biology of the Intestinal Microbiota, Santiago, Chile
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31
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Sung S, Kwon JW, Lee SB, Lee HM, Moon SH, Lee BH. Risk Factors of Clostridium Difficile Infection After Spinal Surgery: National Health Insurance Database. Sci Rep 2020; 10:4438. [PMID: 32157186 PMCID: PMC7064609 DOI: 10.1038/s41598-020-61327-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 01/31/2020] [Indexed: 02/06/2023] Open
Abstract
The purpose of this study was to evaluate risk factors of Clostridium Difficile infection (CDI) after spinal surgery using the Health Insurance Review and Assessment Service (HIRA) data. The incidence of postoperative CDI was investigated using HIRA data from 2012 to 2016. Cases involving CDI that occurred within a 30-day postoperative period were identified. Risk factors, including age, sex, comorbidities, postoperative infection, spinal surgery procedure, type of antibiotic, and duration of antibiotic use, were evaluated. Duration of hospital stay, medical cost, and mortality were also evaluated. In total, 71,322 patients were included. Presumed cases of CDI were identified in 57 patients, with CDI rate of 0.54 per 10,000 patient days. Advanced age, staged operation, postoperative infection, and the use of multiple antibiotics were significant risk factors. First-generation cephalosporins were shown to be associated with a lower incidence of CDI. CDI was also associated with longer hospital stays and increased medical cost, and it was an independent risk factor for increased mortality. Extra attention should be paid to patients at high risk for the development of postoperative CDI, and unnecessary use of multiple antibiotics should be avoided. Level of Evidence: Level III, retrospective cohort study.
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Affiliation(s)
- Sahyun Sung
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Department of Orthopedic Surgery, College of Medicine, Ewha Womans University Seoul Hospital, Seoul, Korea
| | - Ji-Won Kwon
- Department of Orthopedic Surgery, National Health Insurance Corporation Ilsan Hospital, Goyang, Korea
| | - Soo-Bin Lee
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hwan-Mo Lee
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seong-Hwan Moon
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Ho Lee
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Bishop PA, Isache C, McCarter YS, Smotherman C, Gautam S, Jankowski CA. Clinical impact of a pharmacist-led antimicrobial stewardship initiative evaluating patients with Clostridioides difficile colitis. J Investig Med 2020; 68:888-892. [PMID: 32066570 DOI: 10.1136/jim-2019-001173] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2020] [Indexed: 12/12/2022]
Abstract
Clostridioides difficile is the most common cause of healthcare-associated infection and gastroenteritis-associated death in the USA. Adherence to guideline recommendations for treatment of severe C. difficile infection (CDI) is associated with improved clinical success and reduced mortality. The purpose of this study was to determine whether implementation of a pharmacist-led antimicrobial stewardship program (ASP) CDI initiative improved adherence to CDI treatment guidelines and clinical outcomes. This was a single-center, retrospective, quasi-experimental study evaluating patients with CDI before and after implementation of an ASP initiative involving prospective audit and feedback in which guideline-driven treatment recommendations were communicated to treatment teams and documented in the electronic health record via pharmacy progress notes for all patients diagnosed with CDI. The primary endpoint was the proportion of patients treated with guideline adherent definitive regimens within 72 hours of CDI diagnosis. Secondary objectives were to evaluate the impact on clinical outcomes, including length of stay (LOS), infection-related LOS, 30-day readmission rates, and all-cause, in-hospital mortality. A total of 233 patients were evaluated. The proportion of patients on guideline adherent definitive CDI treatment regimen within 72 hours of diagnosis was significantly higher in the post-interventional group (pre: 42% vs post: 58%, p=0.02). No differences were observed in clinical outcomes or proportions of patients receiving laxatives, promotility agents, or proton pump inhibitors within 72 hours of diagnosis. Our findings demonstrate that a pharmacist-led stewardship initiative improved adherence to evidence-based practice guidelines for CDI treatment.
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Affiliation(s)
- Paige A Bishop
- Department of Pharmacy, University of Florida Health at Jacksonville, Jacksonville, Florida, USA
| | - Carmen Isache
- Department of Medicine, UF Health Jacksonville, Jacksonville, Florida, USA
| | - Yvette S McCarter
- Department of Pathology and Laboratory Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Carmen Smotherman
- Center for Data Solutions, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Shiva Gautam
- Center for Data Solutions, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Christopher A Jankowski
- Department of Pharmacy, University of Florida Health at Jacksonville, Jacksonville, Florida, USA
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Mohammed Abdul MK, Bhandari S. Change in the Mortality Trend of Hospitalized Patients with Clostridium difficile Infection: A Nation-wide Study. Cureus 2020; 12:e6759. [PMID: 32140327 PMCID: PMC7039347 DOI: 10.7759/cureus.6759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background According to the Healthcare Cost and Utilization Project (HCUP), mortality in Clostridium difficile infection (CDI) has been rising since 2009, and an upward trend in mortality has been noted. Although there have been studies exploring the incidence of CDI and mortality in the national database, those studies were limited to one particular year. With the advent of newer modalities of diagnosis and treatment for CDI, the recent multiyear trend in disease-specific outcomes from large administrative databases is unknown. Objective To study the recent trend in nationwide hospital admissions and mortality along with hospital outcomes. Methods We queried the identified National Inpatient Sample from 2007 to 2011 to identify patients of age >18 years, with a discharge diagnosis of CDI identified by the International Classification of Diseases, 9th edition (ICD-9), clinical modification codes 008.45, respectively. Results We identified a decline in CDI mortality to 2.67% in 2011 as compared to 3.83% in 2007 (P<0.0001) with CDI as the primary discharge diagnosis and a downward trend in all-cause mortality from 9.2% in 2007 to 7.9% in 2011 (P<0.0001). We identified an upward trend in CDI-related hospital discharges from 2007 (N=325,022) to 2011 (N=333498). Hospital discharges with CDI as a primary discharge diagnosis also increased from 2007 (N=104,123) to 2011 (123,898). The mean length of stay decreased from 7.16 days in 2007 to 6.40 days in 2011 (P 0.0001). CDI was noted to be more common in the elderly (61-80), with a mean age of 68 years. Patients were of Caucasian descent (67%), female (64%), and primarily a Medicare payer (69%). Mean hospital charges increased from $31,551 to 35,654$ (P .04). Of interest, CDI was noted to be more common in large bed-sized non-teaching hospitals (57%) than large bed-sized teaching hospitals (42%). In terms of the geographical distribution of CDI, the southern states of the US had an increased incidence of CDI (36%) and the west coast (16%) had the least incidence. Conclusion Our study shows an improved trend in-hospital mortality outcomes and a decreased length of stay likely related to the advancement in CDI treatments. Hospital charges were increased from 2007 to 2011 in spite of a decrease in hospital length of stay.
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Affiliation(s)
| | - Sanjay Bhandari
- Internal Medicine, Medical College of Wisconsin, Milwaukee, USA
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Lamb CA, Kennedy NA, Raine T, Hendy PA, Smith PJ, Limdi JK, Hayee B, Lomer MCE, Parkes GC, Selinger C, Barrett KJ, Davies RJ, Bennett C, Gittens S, Dunlop MG, Faiz O, Fraser A, Garrick V, Johnston PD, Parkes M, Sanderson J, Terry H, Gaya DR, Iqbal TH, Taylor SA, Smith M, Brookes M, Hansen R, Hawthorne AB. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019; 68:s1-s106. [PMID: 31562236 PMCID: PMC6872448 DOI: 10.1136/gutjnl-2019-318484] [Citation(s) in RCA: 1147] [Impact Index Per Article: 229.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/10/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023]
Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
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Affiliation(s)
- Christopher Andrew Lamb
- Newcastle University, Newcastle upon Tyne, UK
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Nicholas A Kennedy
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- University of Exeter, Exeter, UK
| | - Tim Raine
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Philip Anthony Hendy
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Imperial College London, London, UK
| | - Philip J Smith
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Jimmy K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
- University of Manchester, Manchester, UK
| | - Bu'Hussain Hayee
- King's College Hospital NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Miranda C E Lomer
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Gareth C Parkes
- Barts Health NHS Trust, London, UK
- Barts and the London School of Medicine and Dentistry, London, UK
| | - Christian Selinger
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- University of Leeds, Leeds, UK
| | | | - R Justin Davies
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - Cathy Bennett
- Systematic Research Ltd, Quorn, UK
- Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | | | - Malcolm G Dunlop
- University of Edinburgh, Edinburgh, UK
- Western General Hospital, Edinburgh, UK
| | - Omar Faiz
- Imperial College London, London, UK
- St Mark's Hospital, Harrow, UK
| | - Aileen Fraser
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | | | - Miles Parkes
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Jeremy Sanderson
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Daniel R Gaya
- Glasgow Royal Infirmary, Glasgow, UK
- University of Glasgow, Glasgow, UK
| | - Tariq H Iqbal
- Queen Elizabeth Hospital Birmingham NHSFoundation Trust, Birmingham, UK
- University of Birmingham, Birmingham, UK
| | - Stuart A Taylor
- University College London, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Melissa Smith
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
- Brighton and Sussex Medical School, Brighton, UK
| | - Matthew Brookes
- Royal Wolverhampton NHS Trust, Wolverhampton, UK
- University of Wolverhampton, Wolverhampton, UK
| | - Richard Hansen
- Royal Hospital for Children Glasgow, Glasgow, UK
- University of Glasgow, Glasgow, UK
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Lamb CA, Kennedy NA, Raine T, Hendy PA, Smith PJ, Limdi JK, Hayee B, Lomer MCE, Parkes GC, Selinger C, Barrett KJ, Davies RJ, Bennett C, Gittens S, Dunlop MG, Faiz O, Fraser A, Garrick V, Johnston PD, Parkes M, Sanderson J, Terry H, Gaya DR, Iqbal TH, Taylor SA, Smith M, Brookes M, Hansen R, Hawthorne AB; IBD guidelines eDelphi consensus group. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019; 68:s1-s106. [PMID: 31562236 DOI: 10.1136/gutjnl-2019-318484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
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36
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Rogers E, Dooley A, Vu S, Haq F, Ferderigos S. Methicillin-resistant Staphylococcus Aureus Colitis Secondary to Complicated Acute Diverticulitis: A Rare Case Report. Cureus 2019; 11:e5013. [PMID: 31497443 PMCID: PMC6716748 DOI: 10.7759/cureus.5013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
A 33-year-old obese female with a recent diagnosis of acute diverticulitis (AD) was admitted to the hospital for severe abdominal pain, intractable nausea and vomiting, and diarrhea two days following oral antibiotic treatment for AD. Stool cultures collected upon her readmission were negative for Clostridium difficile (C. difficile) antigen and toxins A and B, but were notable for methicillin-resistant Staphylococcus aureus (MRSA). She was started on intravenous (IV) piperacillin/tazobactam, IV vancomycin, and an oral liquid vancomycin solution, which resulted in rapid resolution of her symptoms. Unfortunately, her symptoms recurred two weeks later and she eventually underwent laparoscopic low anterior resection (LAR) of her colon for continued diverticulitis. This resulted in complete and continued resolution of her symptoms.
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Affiliation(s)
- Everett Rogers
- Internal Medicine, Nova Southeastern University's Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, USA
| | | | - Samantha Vu
- Psychiatry, Largo Medical Center, Largo, USA
| | - Furqan Haq
- Internal Medicine, Oak Hill Hospital, Tampa, USA
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Dionne JC, Sullivan K, Mbuagbaw L, Takaoka A, Duan EH, Alhazzani W, Devlin JW, Duprey M, Moayyedi P, Armstrong D, Thabane L, Tsang JLY, Jaeschke R, Hamielec C, Karachi T, Cartin-Ceba R, Muscedere J, Alshahrani MSS, Cook DJ. Diarrhoea: interventions, consequences and epidemiology in the intensive care unit (DICE-ICU): a protocol for a prospective multicentre cohort study. BMJ Open 2019; 9:e028237. [PMID: 31248929 PMCID: PMC6597652 DOI: 10.1136/bmjopen-2018-028237] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 04/03/2019] [Accepted: 05/21/2019] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Diarrhoea is a frequent concern in the intensive care unit (ICU) and is associated with prolonged mechanical ventilation, increased length of ICU stay, skin breakdown and renal dysfunction. However, its prevalence, aetiology and prognosis in the critically ill have been poorly studied. The primary objectives of this study are to determine the incidence, risk factors and consequences of diarrhoea in critically ill adults. The secondary objectives are to estimate the incidence of Clostridium difficile-associated diarrhoea (CDAD) in ICU patients and to validate the Bristol Stool Chart and Bliss Stool Classification System characterising bowel movements in the ICU. Our primary outcome is the incidence of diarrhoea . Our secondary outcomes include: CDAD, ICU and hospital mortality and ICU and hospital length of stay. METHODS AND ANALYSIS This international prospective cohort study will enrol patients over 10 weeks in 12 ICUs in Canada, the USA, Poland and Saudi Arabia. We will include all patients 18 years of age and older who are admitted to the ICU for at least 24 hours and follow them daily until ICU discharge. Our primary outcome is the incidence of diarrhoea based on the WHO definition, during the ICU stay. Our secondary outcomes include: CDAD, ICU and hospital mortality and ICU and hospital length of stay. We will use logistic regression to identify factors associated with diarrhoea (as defined using WHO criteria) and the kappa statistic to measure agreement on diarrhoea rates between the WHO definition and the Bristol Stool Chart and Bliss Stool Classification System. ETHICS AND DISSEMINATION The protocol has been approved by the research ethics board of all participating centres. The diarrhoea interventions, consequences and epidemiology in the intensive care unit (DICE-ICU) study will generate evidence about diarrhoea and its frequency, predisposing factors and consequences, to inform critical care practice and future research. LAY SUMMARY Diarrhoea is a frequent clinical problem for hospitalised patients including those who are critically ill in the ICU. Diarrhoea can cause complications such as skin damage, dehydration and kidney problems. It is not clear how common diarrhoea is in the ICU, the factors that cause it or the best way for clinicians to assess it. The DICE-ICU study is an international prospective observational study to examine the frequency, risk factors and outcomes of diarrhoea during critical illness.
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Affiliation(s)
- Joanna C Dionne
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kristen Sullivan
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Alyson Takaoka
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Erick Huaileigh Duan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care Medicine, Department of Medicine, Niagara Health System, Saint Catharines Site, St. Catharines, Ontario, Canada
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - John W Devlin
- School of Pharamcy, Northeastern University, Bouve College of Health Sciences, Boston, Massachusetts, USA
| | - Matthew Duprey
- School of Pharamcy, Northeastern University, Bouve College of Health Sciences, Boston, Massachusetts, USA
| | - Paul Moayyedi
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - David Armstrong
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Jennifer L Y Tsang
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care Medicine, Department of Medicine, Niagara Health System, Saint Catharines Site, St. Catharines, Ontario, Canada
| | - Roman Jaeschke
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Cindy Hamielec
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Tim Karachi
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - John Muscedere
- Department of Critical Care Medicine, Kingston General Hospital, Kingston, Ontario, Canada
- Department of Critical Care Medicine, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Mohammed Saeed Saad Alshahrani
- Department of Emergency and Critical Care, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, Al Khobar, Saudi Arabia
| | - Deborah J Cook
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Abstract
A 48-year-old man was admitted for medical management of recurrent Clostridium difficile (C-dif) colitis. One month prior to presentation, he underwent right thoracotomy and lower lobectomy for a carcinoid tumor at another hospital. His postoperative course was complicated by C-dif colitis, gastroesophageal reflux, and epigastric pain. He underwent two esophagogastroduodenoscopy (EGD) procedures demonstrating mild esophagitis on the first procedure, followed by a linear ulcer on the second procedure 2 weeks later. On hospital day 9 of his current admission, he developed an acute abdomen and underwent an urgent exploratory laparotomy for presumed fulminant colitis. Findings included a healthy-appearing colon with only moderate distension, so a loop ileostomy was created for antegrade colonic irrigation. Postoperatively, a chest X-ray demonstrated a tension-appearing left pleural effusion, prompting tube thoracostomy placement. Initial output was greater than 2L of thin dark-brown fluid. An esophagram demonstrated a distal esophageal perforation (EP) and EGD was performed. Two medium-sized EPs were identified which appeared to arise from chronic-appearing ulcerations, one at 39 cm and one at 45 cm from the incisors (figure 1). A single 19mm×100 mm EndoMAXX fully covered stent was placed. Video-assisted thoracoscopic (VATS) drainage of the left hemithorax was performed in addition to placement of a right tube thoracostomy. Due to continued high output from the left thoracostomy tube, the stent was exchanged for a longer 23mm×100mm EndoMAXX fully covered stent. The patient stabilized for several days but again developed worsened sepsis, with EGD demonstrating inadequate coverage of the proximal perforation.Figure 1Endoscopic photograph showing left-sided esophageal perforation/fistula (black arrow). Gastroesophageal junction indicated by white arrow. NG, Nasogastric tube. What would you have done? Repeat esophageal stenting with wide drainage of the thoracic cavity.Esophageal T-tube placement and wide drainage of the thoracic cavity.Esophageal resection with gastrostomy drainage and proximal diversion.Bilateral tube thoracostomies and antibiotic/antifungal therapy.
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Affiliation(s)
- Dustin Price
- Surgery, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - David Skarupa
- Surgery, University of Florida College of Medicine, Jacksonville, Florida, USA
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Abdul Jabbar S, Sundaramurthi S, Elamurugan TP, Goneppanavar M, Nelamangala Ramakrishnaiah VP. An Unusual Presentation of Pseudomembranous Colitis. Cureus 2019; 11:e4570. [PMID: 31281753 PMCID: PMC6605694 DOI: 10.7759/cureus.4570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Pseudomembranous colitis, also called antibiotic-associated colitis, is caused by the gram-positive anaerobic bacterium Clostridium difficile (C.difficile). The infection is common in elderly patients on chronic antibiotic use and in immunosuppressed patients. We report a rare case of pseudomembranous colitis in a 49-year-old male who presented with cramping abdominal pain, abdominal distension, and loose stools, without any pre-existing immunosuppression or chronic drug intake. The computed tomography (CT) picture was suggestive of fulminant ulcerative colitis and the patient underwent total colectomy in view of severe disease. This patient also had rectal bleeding caused by a bleeding pseudoaneurysm of the right internal pudendal artery, which posed diagnostic and therapeutic challenges. Embolization of the pseudoaneurysm was done in the post-operative period. Though the clinical and radiological pictures were suggestive of ulcerative colitis in our patient, this was disproved in the histopathological examination and by the negative serum anti-Saccharomyces cerevisiae antibodies (ASCA) testing. The presence of extensive pseudomembranous colitis in this patient masked the bleeding pseudoaneurysm of the internal pudendal artery, as bleeding is a common presentation in fulminant colitis, leading to a delay in the management of the pseudoaneurysm. Such a presentation was not reported in the literature to the best of our knowledge. Considering co-existent pathologies, especially in patients who present with an unobvious clinical picture, can prevent delay in the definitive diagnosis of these conditions.
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Affiliation(s)
- Shabana Abdul Jabbar
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, IND
| | - Sudharsanan Sundaramurthi
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, IND
| | - T P Elamurugan
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, IND
| | - Mangala Goneppanavar
- Pathology, Mahatma Gandhi Medical College and Research Institute, Puducherry, IND
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40
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Abstract
Clostridium difficile (CD), a bacterium responsible for causing 15%-25% of all cases of infectious diarrhea, is most commonly associated with infection of the colon. Rarely, though with increasing frequency, it has been noted to infect the small intestine in what is referred to as CD enteritis. We present the case of a patient who was diagnosed and treated for CD enteritis, review the pathophysiology behind the infection, and discuss the diagnostic and treatment options available to healthcare professionals.
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Affiliation(s)
- Amreet K Aujla
- Internal Medicine, University of Connecticut Health Center, Farmington, USA
| | - Leon D Averbukh
- Internal Medicine, University of Connecticut Health Center, Farmington, USA
| | | | - Lisa Rossi
- Gastroenterology, Saint Francis Hospital, Hartford, USA
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41
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Carlson TJ, Endres BT, Bassères E, Gonzales-Luna AJ, Garey KW. Ridinilazole for the treatment of Clostridioides difficile infection. Expert Opin Investig Drugs 2019; 28:303-310. [PMID: 30767587 DOI: 10.1080/13543784.2019.1582640] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 02/11/2019] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Ridinilazole is a novel antibiotic being developed for the treatment of Clostridioides difficile infection (CDI). Ridinilazole has completed two phase II trials and phase III trials which are denoted Ri-CoDIFy 1 and 2, are planned (ClinicalTrials.gov identifiers: NCT03595553 and NCT03595566). Areas covered: This article covers the chemistry, mechanism of action, in vitro microbiology versus C. difficile and host microbiota, pre-clinical and clinical efficacy, pharmacokinetics, pharmacodynamics and safety and tolerability of ridinilazole. Expert opinion: Ridinilazole is a novel antibiotic with ideal properties for the treatment of CDI. Given the promising results from the phase II clinical trial, ridinilazole may have the capability to lower the risk for CDI recurrence thus improving sustained clinical response rates - a current unmet medical need. Assuming a positive phase III trial, ridinilazole will enter a market with heightened awareness on the importance of prevention of CDI. This along with further research into the economic consequences and decreased patient quality of life associated with recurrent CDI, should provide clinicians with further evidence for the need for therapy that limits CDI recurrence and improves sustained clinical cure.
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Affiliation(s)
- Travis J Carlson
- a Department of Pharmacy Practice and Translational Research , University of Houston College of Pharmacy , Houston , TX , USA
| | - Bradley T Endres
- a Department of Pharmacy Practice and Translational Research , University of Houston College of Pharmacy , Houston , TX , USA
| | - Eugénie Bassères
- a Department of Pharmacy Practice and Translational Research , University of Houston College of Pharmacy , Houston , TX , USA
| | - Anne J Gonzales-Luna
- a Department of Pharmacy Practice and Translational Research , University of Houston College of Pharmacy , Houston , TX , USA
| | - Kevin W Garey
- a Department of Pharmacy Practice and Translational Research , University of Houston College of Pharmacy , Houston , TX , USA
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Abstract
Clostridium difficile is a gram-positive bacterium notorious for causing epidemic diarrhea globally with a significant health burden. The pathogen is clinically challenging with increasing antibiotic resistance and recurrence rate. We provide here an in-depth review of one particular strain/ribotype 027, commonly known as NAP1/B1/027 or North American pulsed-field gel electrophoresis type 1, restriction endonuclease analysis type B1, polymerase chain reaction ribotype 027, which has shown a much higher recurrence rate than other strains.
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Affiliation(s)
- Rawish Fatima
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Muhammad Aziz
- Internal Medicine, University of Kansas Medical Center, Kansas City, USA
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Martínez JV, Raush A, Efrón ED, Zubiaurre I, Pinoni MV, Giorgio PL, Eusebio MJ, Verbanaz SC, Jordan R. [Refractory colitis by Clostridium difficile treated with fecal microbiota transplant]. Medicina (B Aires) 2019; 79:291-294. [PMID: 31487251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023] Open
Abstract
Clostridium difficile infection is an increasingly recognized cause of diarrhea in inpatients, frequently associated to high mortality. Vancomycin is the treatment of choice for all Clostridium difficile- associated diarrheas, with different degrees of severity. However, some patients develop refractory forms to that treatment and there are no alternative antibiotic schemes recommended for these cases. Fecal microbiota transplantation has been shown to be successful in a series of cases of severe diarrhea associated with this organism. We present a case of refractory C. difficile infection successfully treated with fecal microbiota transplantation.
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Affiliation(s)
- Jorge V Martínez
- Servicio de Infectología, Hospital Británico de Buenos Aires, Argentina. E-mail:
| | - Astrid Raush
- Servicio de Gastroenterología, Hospital Británico de Buenos Aires, Argentina
| | - Ernesto D Efrón
- Servicio de Infectología, Hospital Británico de Buenos Aires, Argentina
| | - Ignacio Zubiaurre
- Servicio de Gastroenterología, Hospital Británico de Buenos Aires, Argentina
| | | | | | | | - Sergio C Verbanaz
- Servicio de Infectología, Hospital Británico de Buenos Aires, Argentina
| | - Rosana Jordan
- Servicio de Infectología, Hospital Británico de Buenos Aires, Argentina
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Corsonello A, Lattanzio F, Bustacchini S, Garasto S, Cozza A, Schepisi R, Lenci F, Luciani F, Maggio MG, Ticinesi A, Butto V, Tagliaferri S, Corica F. Adverse Events of Proton Pump Inhibitors: Potential Mechanisms. Curr Drug Metab 2018; 19:142-154. [PMID: 29219052 DOI: 10.2174/1389200219666171207125351] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 10/15/2017] [Accepted: 11/11/2017] [Indexed: 01/06/2023]
Abstract
OBJECTIVE We aimed at summarizing current evidence about mechanisms for potentially harmful effects of Proton Pump Inhibitors (PPIs). METHODS A Pubmed search was performed, and 207 studies concerning the relationship between use of PPIs and cardiovascular diseases, kidney impairment, nutritional disorders, fractures, infections, functional decline, and mortality were selected and reviewed. RESULTS PPIs may cause potentially harmful effects by several mechanisms, including endothelial dysfunction, hypomagnesemia, drug interactions, reduced absorption of selected nutrients, increased gastric microbiota and small intestine bacterial overgrowth, reduced immune response, tubular-interstitial inflammation, increased bone turnover, accumulation of amyloid in the brain. Clinical and epidemiologic evidence is not consistent in regard to some negative outcomes during PPI treatment. Data from randomized clinical trials seem to deny most of them, but they are usually designed to investigate efficacy of drugs in ideal conditions and are not powered enough to detect adverse events. Besides being at special risk of experiencing negative outcomes during long-term treatment with PPIs, older and complex patients treated with polypharmacy regimens are persistently excluded from randomized clinical trials. Thus, large observational studies involving real-world patients should be considered as an important informative source about potential risks related to PPIs. CONCLUSIONS Current evidence suggests that use of PPIs may be associated with negative outcomes by eliciting several different pathophysiologic mechanisms. While short-term PPIs could be considered effective and safe in adult patients with acid-related disorders, their long-term and often inappropriate use in patients carrying vulnerability to adverse events and/or high risk of drug-interactions should be avoided.
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Affiliation(s)
- Andrea Corsonello
- Unit of Geriatric Pharmacoepidemiology, Research Hospital of Cosenza, Italian National Research Centre on Aging (INRCA), Cosenza, Italy
| | - Fabrizia Lattanzio
- Scientific Direction, Italian National Research Center on Aging (INRCA), Ancona, Italy
| | - Silvia Bustacchini
- Scientific Direction, Italian National Research Center on Aging (INRCA), Ancona, Italy
| | - Sabrina Garasto
- Unit of Geriatric Pharmacoepidemiology, Research Hospital of Cosenza, Italian National Research Centre on Aging (INRCA), Cosenza, Italy
| | - Annalisa Cozza
- Unit of Geriatric Pharmacoepidemiology, Research Hospital of Cosenza, Italian National Research Centre on Aging (INRCA), Cosenza, Italy
| | - Roberto Schepisi
- Unit of Geriatric Pharmacoepidemiology, Research Hospital of Cosenza, Italian National Research Centre on Aging (INRCA), Cosenza, Italy
| | - Federica Lenci
- Unit of Nephrology, Italian National Research Center on Aging (INRCA), Ancona, Italy
| | - Filippo Luciani
- Unit of Infectious Diseases, Annunziata Hospital, Cosenza, Italy
| | - Marcello Giuseppe Maggio
- Department of Clinical and Experimental Medicine, Unit of Geriatrics, University of Parma, Parma, Italy
| | - Andrea Ticinesi
- Department of Clinical and Experimental Medicine, Unit of Geriatrics, University of Parma, Parma, Italy
| | - Valeria Butto
- Department of Clinical and Experimental Medicine, Unit of Geriatrics, University of Parma, Parma, Italy
| | - Sara Tagliaferri
- Department of Clinical and Experimental Medicine, Unit of Geriatrics, University of Parma, Parma, Italy
| | - Francesco Corica
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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Beer LA, Tatge H, Reich N, Tenspolde M, Olling A, Goy S, Rottner K, Alekov AK, Gerhard R. Early cell death induced by Clostridium difficile TcdB: Uptake and Rac1-glucosylation kinetics are decisive for cell fate. Cell Microbiol 2018; 20:e12865. [PMID: 29904993 DOI: 10.1111/cmi.12865] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 05/23/2018] [Accepted: 05/26/2018] [Indexed: 12/29/2022]
Abstract
Toxin A and Toxin B (TcdA/TcdB) are large glucosyltransferases produced by Clostridium difficile. TcdB but not TcdA induces reactive oxygen species-mediated early cell death (ECD) when applied at high concentrations. We found that nonglucosylated Rac1 is essential for induction of ECD since inhibition of Rac1 impedes this effect. ECD only occurs when TcdB is rapidly endocytosed. This was shown by generation of chimeras using the trunk of TcdB from a hypervirulent strain. TcdB from hypervirulent strain has been described to translocate from endosomes at higher pH values and thus, meaning faster than reference type TcdB. Accordingly, intracellular delivery of the glucosyltransferase domain of reference TcdB by the trunk of TcdB from hypervirulent strain increased ECD. Furthermore, proton transporters such as sodium/proton exchanger (NHE) or the ClC-5 anion/proton exchanger, both of which contribute to endosomal acidification, also affected cytotoxic potency of TcdB: Specific inhibition of NHE reduced cytotoxicity, whereas transfection of cells with the endosomal anion/proton exchanger ClC-5 increased cytotoxicity of TcdB. Our data suggest that both the uptake rate of TcdB into the cytosol and the status of nonglucosylated Rac1 are key determinants that are decisive for whether ECD or delayed apoptosis is triggered.
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Affiliation(s)
| | - Helma Tatge
- Institute of Toxicology, Hannover Medical School, Hannover, Germany
| | - Nicole Reich
- Institute of Toxicology, Hannover Medical School, Hannover, Germany
| | - Michel Tenspolde
- Institute of Toxicology, Hannover Medical School, Hannover, Germany
| | - Alexandra Olling
- Institute of Toxicology, Hannover Medical School, Hannover, Germany
| | - Sebastian Goy
- Institute of Toxicology, Hannover Medical School, Hannover, Germany
| | - Klemens Rottner
- Division of Molecular Cell Biology, Zoological Institute, Braunschweig, Germany.,Molecular Cell Biology Group, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | | | - Ralf Gerhard
- Institute of Toxicology, Hannover Medical School, Hannover, Germany
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Al Momani LA, Abughanimeh O, Boonpheng B, Gabriel JG, Young M. Fidaxomicin vs Vancomycin for the Treatment of a First Episode of Clostridium Difficile Infection: A Meta-analysis and Systematic Review. Cureus 2018; 10:e2778. [PMID: 30112254 PMCID: PMC6089486 DOI: 10.7759/cureus.2778] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Clostridium difficile infection (CDI) continues to possess a significant disease burden in the United States (US) as well as all over the world. Given the increase in severity and recurrence rate, the decrease in cure rate, and the fact that the virulent ribotype 027 strain remains one of the most commonly identified strains in the US, the Infectious Diseases Society of America (IDSA) published a clinical practice guideline in February 2018 moving away from metronidazole as the first-line treatment for initial CDI and recommending either oral vancomycin or fidaxomicin. The aim of this study is to evaluate the clinical data available comparing the efficacy of primary treatment of CDI between those two antibiotics. We performed a PubMed, PubMed Central, and ScienceDirect database search without restriction to regions, publication types, or languages. A comprehensive literature search was performed from January 1, 1980 up to March 20, 2018. We used the following keywords in different combinations: Clostridium difficile, Clostridium difficile infection, CDI, C. diff, C. difficile, fidaxomicin, vancomycin, pseudomembranous colitis, and antibiotic-associated colitis. The search was limited to human studies. Data were independently extracted by two reviewers with disagreements resolved by a third author. We pooled an odds ratio (OR) on two primary outcomes: Clinical cure rate and rate of recurrence during the follow-up period. The computer search was also supplemented with manual searches by the authors of the retrieved review articles and primary studies. The search phrase “((Clostridium difficile) AND vancomycin) AND fidaxomicin” had the highest yield results. We identified four observational studies with a total of 2,303 patients with CDI that met our inclusion criteria. Compared with vancomycin, fidaxomicin use was associated with a significantly lower recurrence of CDI with a pooled OR of 0.47 (95% confidence interval (CI), 0.37 - 0.60, I2 = 0). On the other hand, there was no significant association of fidaxomicin use with CDI cure rate compared to vancomycin with a pooled OR of 1.22 (95% CI, 0.93 - 1.60, I2 = 0). In light of the recently updated clinical practice guidelines by the IDSA, our review suggests that fidaxomicin has a more sustained clinical response with a statistically significant lower recurrence rate. Although fidaxomicin appears to be the better drug with statistical significance, its cost-effectiveness continues to be an ongoing controversy. More randomized clinical trials are needed to shed light on this matter to assess if there is any clinical significance in fidaxomicin superiority.
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Affiliation(s)
- Laith A Al Momani
- Department of Internal Medicine, East Tennessee State University, Johnson City, USA
| | - Omar Abughanimeh
- Department of Internal Medicine, University of Missouri Kansas City School of Medicine, Kansas City, USA
| | | | | | - Mark Young
- Department of Gastroenterology, East Tennessee State University, Johnson City, USA
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47
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Zahid U, Sagar F, Al Mohajer M, Majeed A. Management of Recurrent Clostridium difficile Infection During Intensive Chemotherapy and Stem Cell Transplantation for Leukemia: Case with Literature Review. Cureus 2018; 10:e2413. [PMID: 29872594 PMCID: PMC5984265 DOI: 10.7759/cureus.2413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Immunocompromised patients undergoing chemotherapy for hematologic malignancy and hematopoietic stem cell transplant (HSCT) recipients are at increased risk of Clostridium difficile (C. difficile) infection (CDI). The recurrence of infection and its associated morbidity and mortality are due to multiple risk factors. Diarrhea is common in HSCT recipients, but the diagnosis of diarrhea caused by CDI is a therapeutic challenge due to frequent Clostridium difficile colonization with diarrhea secondary to non-infectious causes. The high recurrence rate is a significant challenge in the treatment of immunocompromised patients. Close monitoring of the patients, timely diagnosis, preventive measures, treatment with antibiotics, and the removal of offending agents can help in the management and cure of the disease. We review the literature on management and describe a patient with acute lymphoblastic leukemia (ALL) with multiple recurrences of CDI during leukemia therapy and allogeneic stem cell transplantation for leukemia.
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Affiliation(s)
- Umar Zahid
- Internal Medicine, University of Arizona, Tucson, USA
| | - Fnu Sagar
- Internal Medicine, University of Arizona, Tucson, USA
| | | | - Aneela Majeed
- Internal Medicine, University of Arizona, Tucson, USA
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48
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Vermeersch SJ, Vandenplas Y, Tanghe A, Elseviers M, Annemans L. Economic evaluation of S. boulardii CNCM I-745 for prevention of antibioticassociated diarrhoea in hospitalized patients. Acta Gastroenterol Belg 2018; 81:269-276. [PMID: 30024698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Interest in administration of probiotics to prevent antibiotic-associated diarrhoea (AAD) in hospitalized patients is increasing. We determined the cost of antibiotic-associated diarrhoea in hospital settings for non-complicated and Clostridium difficile (C.diff) complicated AAD, and performed a health-economic analysis of AAD prevention with S. boulardii CNCM I-745 (S. boulardii) from data collected in 1 university and 3 regional hospitals in Flanders. Using a decision tree analytic model, costs and effects of S. boulardii for AAD prevention are calculated. Incremental costs due to AAD, including increased length of hospitalization, were calculated using bottom-up and top-down costing approaches from a hospital, healthcare payer (HCP) and societal perspective. Model robustness was tested using sensitivity analyses. Additional costs per hospitalized patient range from € 277.4 (hospital) to € 2,150.3 (societal) for non-complicated and from € 588.8 (hospital) to € 2,239.1 (societal) for C. diff. complicated AAD. Using S. boulardii as AAD prevention results in cost savings between € 50.3 (bottom-up) and € 28.1 (topdown) per patient treated with antibiotics from the HCP perspective; and € 95.2 and € 14.7 per patient from the societal and hospital perspectives. Our analysis shows the potential for using S. boulardii as AAD prophylactic treatment in hospitalized patients. Based on 831,655 hospitalizations with antibiotic administration in 2014 and € 50.3 cost saving per patient on antibiotics, generalized use of S. boulardii could result in total annual savings up to € 41.8 million for the Belgian HCP.
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Affiliation(s)
| | - Y Vandenplas
- Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - M Elseviers
- Centre for Research and Innovation in Care (CRIC), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - L Annemans
- Department of Public Health, I-CHER Interuniversity Centre for Health Economic Research, Ghent University and Vrije Universiteit Brussel, Ghent and Brussels, Belgium
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49
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Goldenberg JZ, Yap C, Lytvyn L, Lo CK, Beardsley J, Mertz D, Johnston BC. Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults and children. Cochrane Database Syst Rev 2017; 12:CD006095. [PMID: 29257353 PMCID: PMC6486212 DOI: 10.1002/14651858.cd006095.pub4] [Citation(s) in RCA: 173] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Antibiotics can disturb gastrointestinal microbiota which may lead to reduced resistance to pathogens such as Clostridium difficile (C. difficile). Probiotics are live microbial preparations that, when administered in adequate amounts, may confer a health benefit to the host, and are a potential C. difficile prevention strategy. Recent clinical practice guidelines do not recommend probiotic prophylaxis, even though probiotics have the highest quality evidence among cited prophylactic therapies. OBJECTIVES To assess the efficacy and safety of probiotics for preventing C.difficile-associated diarrhea (CDAD) in adults and children. SEARCH METHODS We searched PubMed, EMBASE, CENTRAL, and the Cochrane IBD Group Specialized Register from inception to 21 March 2017. Additionally, we conducted an extensive grey literature search. SELECTION CRITERIA Randomized controlled (placebo, alternative prophylaxis, or no treatment control) trials investigating probiotics (any strain, any dose) for prevention of CDAD, or C. difficile infection were considered for inclusion. DATA COLLECTION AND ANALYSIS Two authors (independently and in duplicate) extracted data and assessed risk of bias. The primary outcome was the incidence of CDAD. Secondary outcomes included detection of C. difficile infection in stool, adverse events, antibiotic-associated diarrhea (AAD) and length of hospital stay. Dichotomous outcomes (e.g. incidence of CDAD) were pooled using a random-effects model to calculate the risk ratio (RR) and corresponding 95% confidence interval (95% CI). We calculated the number needed to treat for an additional beneficial outcome (NNTB) where appropriate. Continuous outcomes (e.g. length of hospital stay) were pooled using a random-effects model to calculate the mean difference and corresponding 95% CI. Sensitivity analyses were conducted to explore the impact of missing data on efficacy and safety outcomes. For the sensitivity analyses, we assumed that the event rate for those participants in the control group who had missing data was the same as the event rate for those participants in the control group who were successfully followed. For the probiotic group, we calculated effects using the following assumed ratios of event rates in those with missing data in comparison to those successfully followed: 1.5:1, 2:1, 3:1, and 5:1. To explore possible explanations for heterogeneity, a priori subgroup analyses were conducted on probiotic species, dose, adult versus pediatric population, and risk of bias as well as a post hoc subgroup analysis on baseline risk of CDAD (low 0% to 2%; moderate 3% to 5%; high > 5%). The overall quality of the evidence supporting each outcome was independently assessed using the GRADE criteria. MAIN RESULTS Thirty-nine studies (9955 participants) met the eligibility requirements for our review. Overall, 27 studies were rated as either high or unclear risk of bias. A complete case analysis (i.e. participants who completed the study) among trials investigating CDAD (31 trials, 8672 participants) suggests that probiotics reduce the risk of CDAD by 60%. The incidence of CDAD was 1.5% (70/4525) in the probiotic group compared to 4.0% (164/4147) in the placebo or no treatment control group (RR 0.40, 95% CI 0.30 to 0.52; GRADE = moderate). Twenty-two of 31 trials had missing CDAD data ranging from 2% to 45%. Our complete case CDAD results proved robust to sensitivity analyses of plausible and worst-plausible assumptions regarding missing outcome data and results were similar whether considering subgroups of trials in adults versus children, inpatients versus outpatients, different probiotic species, lower versus higher doses of probiotics, or studies at high versus low risk of bias. However, in a post hoc analysis, we did observe a subgroup effect with respect to baseline risk of developing CDAD. Trials with a baseline CDAD risk of 0% to 2% and 3% to 5% did not show any difference in risk but trials enrolling participants with a baseline risk of > 5% for developing CDAD demonstrated a large 70% risk reduction (interaction P value = 0.01). Among studies with a baseline risk > 5%, the incidence of CDAD in the probiotic group was 3.1% (43/1370) compared to 11.6% (126/1084) in the control group (13 trials, 2454 participants; RR 0.30, 95% CI 0.21 to 0.42; GRADE = moderate). With respect to detection of C. difficile in the stool pooled complete case results from 15 trials (1214 participants) did not show a reduction in infection rates. C. difficile infection was 15.5% (98/633) in the probiotics group compared to 17.0% (99/581) in the placebo or no treatment control group (RR 0.86, 95% CI 0.67 to 1.10; GRADE = moderate). Adverse events were assessed in 32 studies (8305 participants) and our pooled complete case analysis indicates probiotics reduce the risk of adverse events by 17% (RR 0.83, 95% CI 0.71 to 0.97; GRADE = very low). In both treatment and control groups the most common adverse events included abdominal cramping, nausea, fever, soft stools, flatulence, and taste disturbance. AUTHORS' CONCLUSIONS Based on this systematic review and meta-analysis of 31 randomized controlled trials including 8672 patients, moderate certainty evidence suggests that probiotics are effective for preventing CDAD (NNTB = 42 patients, 95% CI 32 to 58). Our post hoc subgroup analyses to explore heterogeneity indicated that probiotics are effective among trials with a CDAD baseline risk >5% (NNTB = 12; moderate certainty evidence), but not among trials with a baseline risk ≤5% (low to moderate certainty evidence). Although adverse effects were reported among 32 included trials, there were more adverse events among patients in the control groups. The short-term use of probiotics appears to be safe and effective when used along with antibiotics in patients who are not immunocompromised or severely debilitated. Despite the need for further research, hospitalized patients, particularly those at high risk of CDAD, should be informed of the potential benefits and harms of probiotics.
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Affiliation(s)
| | | | - Lyubov Lytvyn
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamiltonCanada
| | - Calvin Ka‐Fung Lo
- The University of British ColumbiaFaculty of MedicineVancouverCanada
| | | | - Dominik Mertz
- McMaster UniversityDivision of Infectious Diseases, Department of MedicineJuravinski Hospital and Cancer Center711 Concession Street, Section G, Level 0, Room 12HamiltonCanadaL8V 1C3
| | - Bradley C Johnston
- Dalhousie UniversityDepartment of Community Health and Epidemiology5790 University AvenueHalifaxCanadaB3H 1V7
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Anderson A, Click B, Ramos-Rivers C, Cheng D, Babichenko D, Koutroubakis IE, Hashash JG, Schwartz M, Swoger J, Barrie AM 3rd, Dunn MA, Regueiro M, Binion DG. Lasting Impact of Clostridium difficile Infection in Inflammatory Bowel Disease: A Propensity Score Matched Analysis. Inflamm Bowel Dis 2017; 23:2180-8. [PMID: 29084081 DOI: 10.1097/MIB.0000000000001251] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients with inflammatory bowel disease are at an increased risk of Clostridium difficile infection (CDI), but the impact of CDI on disease severity is unclear. The aim of this study was to determine the effect of CDI on long-term disease outcome in a matched cohort of patients with inflammatory bowel disease. METHODS Patients who tested positive for infection formed the CDI-positive group. We generated a 1:2 propensity matched case to control cohort based on risk factors for CDI in the year before infection. Health care utilization data (emergency department use, hospitalizations, and telephone encounters), medications, laboratories, disease activity, and quality-of-life metrics were compared by CDI status. RESULTS A total of 198 patients (66 CDI and 132 matched controls) were included (56.6% women; 60.1% Crohn's disease, and 39.9% ulcerative colitis). In the year of infection, having CDI was significantly associated with more steroid and antibiotic exposure, elevated C-reactive protein or erythrocyte sedimentation rate, low vitamin D, increased disease activity, worse quality of life, and increased health care utilization (all P < 0.01). During the next year after infection, patients with CDI continued to have increased exposure to CDI-targeted antibiotics (P < 0.001) and other antibiotics (P = 0.02). They also continued to have more clinic visits (P = 0.02), telephone encounters (P = 0.001), and increased health care financial charges (P = 0.001). CONCLUSIONS CDI in inflammatory bowel disease is significantly associated with markers of disease severity, increased health care utilization and poor quality of life during the year of infection, and a 5-fold increase in health care charges in the year after infection (see Video Abstract, Supplemental Digital Content, http://links.lww.com/IBD/B658).
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