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Fernandez-Cotarelo MJ, Jackson-Akers JY, Nagy-Agren SE, Warren CA. Interaction of Clostridioides difficile infection with frailty and cognition in the elderly: a narrative review. Eur J Med Res 2023; 28:439. [PMID: 37849008 PMCID: PMC10580652 DOI: 10.1186/s40001-023-01432-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 10/05/2023] [Indexed: 10/19/2023] Open
Abstract
PURPOSE Clostridioides difficile infection (CDI) is the leading cause of antibiotic-related diarrhea and healthcare-associated infections, affecting in particular elderly patients and their global health. This review updates the understanding of this infection, with focus on cognitive impairment and frailty as both risk factors and consequence of CDI, summarizing recent knowledge and potential mechanisms to this interplay. METHODS A literature search was conducted including terms that would incorporate cognitive and functional impairment, aging, quality of life, morbidity and mortality with CDI, microbiome and the gut-brain axis. RESULTS Advanced age remains a critical risk for severe disease, recurrence, and mortality in CDI. Observational and quality of life studies show evidence of functional loss in older people after acute CDI. In turn, frailty and cognitive impairment are independent predictors of death following CDI. CDI has long-term impact in the elderly, leading to increased risk of readmissions and mortality even months after the acute event. Immune senescence and the aging microbiota are key in susceptibility to CDI, with factors including inflammation and exposure to luminal microbial products playing a role in the gut-brain axis. CONCLUSIONS Frailty and poor health status are risk factors for CDI in the elderly. CDI affects quality of life, cognition and functionality, contributing to a decline in patient health over time and leading to early and late mortality. Narrative synthesis of the evidence suggests a framework for viewing the cycle of functional and cognitive decline in the elderly with CDI, impacting the gut-brain and gut-muscle axes.
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Affiliation(s)
- Maria-Jose Fernandez-Cotarelo
- Department of Internal Medicine, Hospital Universitario de Mostoles, Faculty of Health Sciences, Universidad Rey Juan Carlos, Calle Doctor Luis Montes S/N, Mostoles, 28935, Madrid, Spain.
| | - Jasmine Y Jackson-Akers
- División of Infectious Disease and International Health, University of Virginia, Charlottesville, VA, USA
| | - Stephanie E Nagy-Agren
- Section of Infectious Diseases, Salem Veterans Affairs Medical Center, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Cirle A Warren
- Division of Infectious Disease and International Health, University of Virginia, Charlottesville, VA, USA
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Epidemiology and Economic Burden of Acute Infectious Gastroenteritis Among Adults Treated in Outpatient Settings in US Health Systems. Am J Gastroenterol 2023:00000434-990000000-00647. [PMID: 36728224 DOI: 10.14309/ajg.0000000000002186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/06/2023] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Acute infectious gastroenteritis (AGE) is a common reason for outpatient visits and hospitalizations in the United States. This study aimed to understand the demographic and clinical characteristics, common pathogens detected, health care resource utilization (HRU), and cost among adult outpatients with AGE visiting US health systems. METHODS A retrospective cohort study was conducted using one of the largest hospital discharge databases (PINC AI Healthcare Database) in the United States. Adult patients (aged ≥18 years) with a principal diagnosis of AGE during an outpatient visit between January 1, 2016, and June 30, 2021, were included. Pathogen detection analysis was performed in those with microbiology data available. RESULTS Among 248,896 patients, the mean age was 44.3 years (range 18-89+ years), 62.9% were female, and 68.5% were White. More than half (62.0%) of the patients did not have any preexisting comorbidity, and only 18.3% underwent stool workup at the hospital. Most patients (84.7%) were seen in the emergency department, and most (96.4%) were discharged home. Within 30 days of discharge, 1.0% were hospitalized, and 2.8% had another outpatient visit due to AGE. The mean cost of the index visit plus 30-day AGE-related follow-up was $1,338 per patient, amounting to $333,060,182 for the total study population. Among patients with microbiology data available (n = 12,469), common pathogens detected were Clostridioides difficile (32.2%), norovirus (6.3%), and Campylobacter spp. (4.0%). DISCUSSION AGE is a common and costly disease affecting adults of all ages and more females than males, including individuals with or without baseline conditions in a hospital-based outpatient setting. C. difficile was the most common pathogen detected.
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Haran JP, Ward DV, Bhattarai SK, Loew E, Dutta P, Higgins A, McCormick BA, Bucci V. The high prevalence of Clostridioides difficile among nursing home elders associates with a dysbiotic microbiome. Gut Microbes 2022; 13:1-15. [PMID: 33764826 PMCID: PMC8007149 DOI: 10.1080/19490976.2021.1897209] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Clostridioides difficile disproportionally affects the elderly living in nursing homes (NHs). Our objective was to explore the prevalence of C. difficile in NH elders, over time and to determine whether the microbiome or other clinical factors are associated with C. difficile colonization.We collected serial stool samples from NH residents. C. difficile prevalence was determined by quantitative polymerase-chain reaction detection of Toxin genes tcdA and tcdB; microbiome composition was determined by shotgun metagenomic sequencing. We used mixed-effect random forest modeling machine to determine bacterial taxa whose abundance is associated with C. difficile prevalence while controlling for clinical covariates including demographics, medications, and past medical history.We enrolled 167 NH elders who contributed 506 stool samples. Of the 123 elders providing multiple samples, 30 (24.4%) elders yielded multiple samples in which C. difficile was detected and 78 (46.7%) had at least one C. difficile positive sample. Elders with C. difficile positive samples were characterized by increased abundances of pathogenic or inflammatory-associated bacterial taxa and by lower abundances of taxa with anti-inflammatory or symbiotic properties. Proton pump inhibitor (PPI) use is associated with lower prevalence of C. difficile (Odds Ratio 0.46; 95%CI, 0.22-0.99) and the abundance of bacterial species with known beneficial effects was higher in PPI users and markedly lower in elders with high C. difficile prevalence.C. difficile is prevalent among NH elders and a dysbiotic gut microbiome associates with C. difficile colonization status. Manipulating the gut microbiome may prove to be a key strategy in the reduction of C. difficile in the NH.
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Affiliation(s)
- John P. Haran
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, USA,Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA,Program in Microbiome Dynamics, University of Massachusetts Medical School, Worcester, MA, USA,CONTACT John P. Haran Department of Emergency Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA01655
| | - Doyle V. Ward
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA,Program in Microbiome Dynamics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Shakti K. Bhattarai
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA,Program in Microbiome Dynamics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Ethan Loew
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA,Program in Microbiome Dynamics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Protiva Dutta
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Amanda Higgins
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Beth A. McCormick
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA,Program in Microbiome Dynamics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Vanni Bucci
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA,Program in Microbiome Dynamics, University of Massachusetts Medical School, Worcester, MA, USA
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Verma S, Dutta SK, Firnberg E, Phillips L, Vinayek R, Nair PP. Identification and engraftment of new bacterial strains by shotgun metagenomic sequence analysis in patients with recurrent Clostridioides difficile infection before and after fecal microbiota transplantation and in healthy human subjects. PLoS One 2021; 16:e0251590. [PMID: 34252073 PMCID: PMC8274925 DOI: 10.1371/journal.pone.0251590] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 04/29/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Recurrent Clostridioides diffícile infection (RCDI) is associated with major bacterial dysbiosis and colitis. Fecal microbiota transplantation (FMT) is a highly effective therapeutic modality for RCDI. While several studies have identified bacterial species associated with resolution of symptoms in patients, characterization of the fecal microbiome at the bacterial strain level in RCDI patients before and after FMT and healthy donors, has been lacking. The aim of this study was to examine the ability of bacterial strains from healthy donors to engraft in the gastrointestinal tract of patients with RCDI following FMT. METHODS Fecal samples were collected from 22 patients with RCDI before and after FMT and their corresponding healthy donors. Total DNA was extracted from each sample and analyzed by shotgun metagenomic sequencing. The Cosmos-ID analysis platform was used for taxonomic assignment of sequences and calculation of the relative abundance (RA) of bacterial species and strains. From these data, the total number of bacterial strains (BSI), Shannon diversity index, dysbiosis index (DI), and bacterial engraftment factor, were calculated for each strain. FINDINGS A marked reduction (p<0·0001) in the RA of total and specific bacterial strains, especially from phylum Firmicutes, was observed in RCDI patients prior to FMT. This change was associated with an increase in the DI (p<0·0001) and in pathobiont bacterial strains from phylum Proteobacteria, such as Escherichia coli O157:H7 and Klebsiella pneumoniae UCI 34. BSI was significantly lower in this group of patients as compared to healthy donors and correlated with the Shannon Index. (p<0·0001). Identification and engraftment of bacterial strains from healthy donors revealed a greater diversity and higher relative abundance of short-chain fatty acid (SCFA)-producing bacterial strains, including Lachnospiraceae bacterium 5_1_63FAA_u_t, Dorea formicigenerans ATCC 27755, Anaerostipes hadrusand others, in RCDI patients after FMT. INTERPRETATION These observations identify a group of SCFA-producing bacterial strains from healthy donors that engraft well in patients with RCDI following FMT and are associated with complete resolution of clinical symptoms and bacterial dysbiosis.
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Affiliation(s)
- Sandeep Verma
- Division of Gastroenterology, Sinai Hospital, Baltimore MD, United States of America
| | - Sudhir K. Dutta
- Division of Gastroenterology, Sinai Hospital, Baltimore MD, United States of America
- University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Elad Firnberg
- Division of Gastroenterology, Sinai Hospital, Baltimore MD, United States of America
| | - Laila Phillips
- Division of Gastroenterology, Sinai Hospital, Baltimore MD, United States of America
| | - Rakesh Vinayek
- Division of Gastroenterology, Sinai Hospital, Baltimore MD, United States of America
| | - Padmanabhan P. Nair
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- Noninvasive Technologies, Elkridge, MD, United States of America
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Characterizing Clostridioides difficile infections and hospital exposures in California using surveillance and administrative data, 2014-2015. Infect Control Hosp Epidemiol 2020; 42:292-297. [PMID: 32993820 DOI: 10.1017/ice.2020.447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To evaluate a method to identify hospitals contributing to Clostridioides difficile infections (CDI) at subsequent hospitalizations. DESIGN Retrospective cohort study. METHODS We merged 2014-2015 National Healthcare Safety Network (NHSN) inpatient CDI laboratory-identified events with hospital patient discharge data. For patients with incident community-onset CDI (CO CDI), we identified immediately preceding admissions (within 12 weeks) unrelated to CDI at different (exposure) hospitals. We calculated an exposure rate, and we selected hospitals with the highest (90th-100th percentile) rates by hospital type and compared these rates with reported standardized infection ratios (SIR) for CDI. RESULTS We successfully matched 44,691 of 58,842 NHSN CDI records (76.0%) with a hospital discharge record. Among 36,215 unique matched records, 5,234 (14.5%) had an admission not related to CDI within 12 weeks prior to an incident CO CDI event, and 1,574 of these admissions (30.1%) occurred in a different hospital. For 33 hospitals with an exposure ranking within the 90th-100th percentile, CDI SIRs for 22 (66.7%) were not significantly different; 3 (9.1%) were lower; and 8 (24.2%) were higher than the national baseline. Also, 12 (36.4%) had an SIR ≤1.0. CONCLUSIONS The identification of high-ranked exposure hospitals presents an alternative to SIR for measuring the contribution of hospitals to the CDI burden across the continuum of care. Further exploration of the potential factors leading to high exposure rank, such as antibiotic use and infection control practices, is indicated and may inform CDI prevention outreach to healthcare facilities and provider networks in California and elsewhere.
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Wainwright M. A New Penicillin? Antibiotics (Basel) 2020; 9:antibiotics9030117. [PMID: 32168863 PMCID: PMC7175144 DOI: 10.3390/antibiotics9030117] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 11/29/2022] Open
Abstract
The spectre of antimicrobial resistance looms very large indeed in the 21st century; the supply of efficacious conventional drugs is short and not guaranteed, for various reasons. It is time to look elsewhere for answers and for protocols which might be used in tandem with our diminishing arsenal in order to protect vital drugs. This could bridge the gap before new development in conventional antimicrobial therapy occurs, or might be a longer-term solution, particularly in the area of infectious disease prophylaxis (conventional-sensitive or -resistant). Reliable and safe protocols have been developed for the use of photoantimicrobials in this respect, offering much greater coverage, in terms of the microbial target, than Fleming ever imagined.
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Affiliation(s)
- Mark Wainwright
- School of Pharmacy & Biomolecular Sciences, Liverpool John Moores University, Byrom Street, Liverpool L3 3AF, UK
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Gleich S, Schaffer A, Mai CH, Schick S, Hirl B. [Clostridium difficile-associated deaths from 2013-2016 in Munich and Nuremberg : Reporting behavior and patient characteristics]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2019; 60:1067-1074. [PMID: 28852777 DOI: 10.1007/s00103-017-2605-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND A number of risk factors for C. difficile infection (CDI) are described in the literature, in particular an antibiotic therapy 4-6 weeks before disease, an age of >65 years, immunosuppression and living in a long-term care facility. Increasing incidence rates have been reported for Germany. CDI is the fourth most common nosocomial infection with 6.4%. AIM Due to the amendment of the Infection Protection Act of 01.05.2016, the proportion of all deaths that are C. difficile-associated deaths should be investigated to determine the extent to which the obligation to report is fulfilled in the case of a severe CDI. The epidemiological situation in Munich and Nuremberg should also be investigated and the characteristics of the deceased should be analyzed. MATERIAL AND METHODS A review of all death certificates for the period from 1 January 2013 to 30 June 2016 was carried out according to defined inclusion criteria for clostridia infection. All data were anonymized, standardized and statistically evaluated. RESULTS Almost every hundredth death is associated with C. difficile. Medical and outbreak reports are very poor and do not reflect the real situation. The age of the deceased and increased factors for the acquisition of a CDI correspond to the literature. The collected data from both cities show a good congruence. CONCLUSION For the first time, data from the health authorities can be submitted on the proportion of all deaths that are C. difficile-associated deaths, reporting behavior and patient characteristics in cases of severe CDI. This is a serious disease, especially for older people with regard to the existence of risk factors, and its frequency and effects are significantly underestimated.
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Affiliation(s)
- Sabine Gleich
- Referat für Gesundheit und Umwelt, Landeshauptstadt München, Bayerstr. 28 a, 80335, München, Deutschland.
| | | | | | - Sylvia Schick
- Institut für Rechtsmedizin, Ludwig-Maximilians-Universität, München, Deutschland
| | - Bertrand Hirl
- Referat für Gesundheit und Umwelt, Landeshauptstadt München, Bayerstr. 28 a, 80335, München, Deutschland
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Marra F, McCabe M, Sharma P, Zhao B, Mill C, Leung V, Chong M, Patrick DM. Utilization of Antibiotics in Long-Term Care Facilities in British Columbia, Canada. J Am Med Dir Assoc 2018; 18:1098.e1-1098.e11. [PMID: 29169741 DOI: 10.1016/j.jamda.2017.09.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 09/20/2017] [Accepted: 09/20/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Antibiotic use is highly prevalent in long-term care facilities (LTCFs); a resident's annual exposure to at least 1 course of antibiotic is approximately 50% to 80%. The objective of this study was to understand the extent of antibiotic use in the population of residents in British Columbia's (BC) LTCFs from 2007 to 2014. METHODS Antibiotic prescription data for LTCF residents was extracted from the central prescription database and linked to the physician billing plan to obtain antibiotic indication. Total defined daily dose (DDD) per 1000 residents per day was calculated. RESULTS Our database had 381 LTCFs with an average of nearly 24,694 residents annually and 419,036 antibiotic prescriptions. Antibiotic utilization did not change dramatically between 2007 and 2014, ranging from 39.2 in 2007 to 35.2 DDD per 1000 residents per day in 2014. Although usage of most antibiotics declined, use of moxifloxacin, amoxicillin-clavulanate, doxycycline, and amoxicillin increased significantly. The indication most frequently linked to prescription was urinary tract infection (6.58 DDD per 1000 residents per day), with nitrofurantoin, ciprofloxacin, and trimethoprim/sulfamethoxazole being the most commonly prescribed agents. This was followed closely by prescriptions for respiratory infections (5.34 DDD per 1000 residents per day), with moxifloxacin being the most commonly prescribed antibiotic, primarily for upper respiratory tract infection (URTI), whereas doxycycline is used commonly for lower respiratory tract infection. Duration of antibiotic therapy in LTCF residents has decreased significantly from 9.29 days to 7.3 days per prescription in 2014. CONCLUSION Antibiotic use in LTCFs is high relative to the general population. Our study underscores that stewardship in LTCFs should continue to focus on length of treatment, appropriate detection of urinary tract infections, and avoidance of treating URTIs with antibiotics.
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Affiliation(s)
- Fawziah Marra
- University of British Columbia, Vancouver, BC, Canada.
| | - Mark McCabe
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | | | - Bin Zhao
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Christopher Mill
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Victor Leung
- University of British Columbia, Vancouver, BC, Canada; St. Paul's Hospital, Vancouver, BC, Canada
| | - Mei Chong
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - David M Patrick
- University of British Columbia, Vancouver, BC, Canada; British Columbia Centre for Disease Control, Vancouver, BC, Canada
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Durovic A, Widmer AF, Tschudin-Sutter S. New insights into transmission of Clostridium difficile infection-narrative review. Clin Microbiol Infect 2018; 24:483-492. [PMID: 29427800 DOI: 10.1016/j.cmi.2018.01.027] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 01/22/2018] [Accepted: 01/27/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Traditionally, Clostridium difficile has been considered a typical healthcare-associated pathogen-that is, one transmitted within healthcare facilities and thus prevented by implementation of standard infection control measures. Recently this concept has been challenged by studies suggesting a relevant role for community acquisition of C. difficile. AIMS To discusses the current literature, compiled during the last decade, reporting on sources of acquisition of C. difficile and subsequent transmission. SOURCES The databases PubMed, Medline, Embase and the Cochrane Database were searched for articles published from 1 January 2007 to 30 June 2017 reporting on possible transmission pathways of C. difficile and/or suggesting a source of acquisition of C. difficile. All study types reporting on adult populations were considered; case reports and series were excluded. The PRISMA guidelines for the reporting of systematic reviews were followed. CONTENT Among 24 original articles included, 63% report on transmission of C. difficile in healthcare settings and 37% investigate sources and transmission of C. difficile in the community. Contact with symptomatic carriers (53.3%), the hospital environment (40.0%) and asymptomatic carriers (20%) were the most commonly reported transmission pathways within healthcare settings. The leading sources for acquisition of C. difficile in the community include direct contact with symptomatic and asymptomatic carriers in the community, including infants (30%) and residents of long-term non-acute care facilities (30%), followed by contact with contaminated environments in outpatient care settings (20%) and exposure to livestock or livestock farms (20%). IMPLICATIONS In healthcare settings, future control efforts may need to focus on extending cleaning and disinfection procedures beyond the immediate surroundings of symptomatic carriers. Potential targets to prevent acquisition of C. difficile in the community include household settings, long-term care facilities and outpatient settings, while the role of livestock in entertaining transmission requires further investigation.
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Affiliation(s)
- A Durovic
- Medical University Department, Division of Oncology and Hematology, Kantonsspital Aarau, Aarau, Switzerland
| | - A F Widmer
- Department of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - S Tschudin-Sutter
- Department of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, University Basel, Basel, Switzerland.
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The Epidemiology of Community Clostridium difficile Infection: A Five-Year Population-Based Study on the Bailiwick of Jersey, Channel Islands. Infect Control Hosp Epidemiol 2018; 39:603-607. [DOI: 10.1017/ice.2018.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We studied healthcare-associated and community-associated Clostridium difficile infection (CDI) in Jersey, Channel Islands (2008–2012). The Island’s stable population has reliable denominator data, a clearly defined at-risk population, and healthcare contact that is easily followed. The vast majority of CDI cases had had recent healthcare contact, and true community-associated disease is extremely rare.Infect Control Hosp Epidemiol 2018;39:603–607
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Reveles KR, Pugh MJV, Lawson KA, Mortensen EM, Koeller JM, Argamany JR, Frei CR. Shift to community-onset Clostridium difficile infection in the national Veterans Health Administration, 2003-2014. Am J Infect Control 2018; 46:431-435. [PMID: 29126751 DOI: 10.1016/j.ajic.2017.09.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 09/18/2017] [Accepted: 09/18/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) occurs frequently in inpatient settings; however, community-onset cases have been reported more frequently in recent years. This study evaluated hospital-onset and community-onset CDI in the national Veterans Health Administration (VHA) population over a 12-year period. METHODS This was a retrospective cohort study of all adult VHA beneficiaries with CDI between October 1, 2002, and September 30, 2014. Data were obtained from the Veterans Affairs Informatics and Computing Infrastructure. CDI was categorized into community-associated CDI (CA-CDI); community-onset, health care facility-associated CDI; and health care facility-onset CDI (HCFO-CDI). Each type was described longitudinally and was assessed as an independent risk factor for health outcomes using multivariable logistic regression. RESULTS Overall, 30,326 patients with a first CDI episode were included. HCFO-CDI was the predominant type (60.2%), followed by CO-HCFA-CDI (20.6%) and CA-CDI (19.2%). The proportion of patients with HCFO-CDI decreased from 73.5% during fiscal year 2003 to 53.2% during fiscal year 2014, whereas CA-CDI increased from 8.3% to 26.7%. HCFO-CDI was a positive predictor of severe CDI (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.59-1.84) and 30-day mortality (OR, 1.46; 95% CI, 1.32-1.61), but a negative predictor of 60-day recurrence (OR, 0.41; 95% CI, 0.37-0.46). CONCLUSIONS HCFO-CDI was the predominant CDI type. The proportion of patients with CA-CDI increased and HCFO-CDI decreased in recent years. Patients with HCFO-CDI experienced higher rates of severe CDI and mortality.
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Affiliation(s)
- Kelly R Reveles
- College of Pharmacy, The University of Texas at Austin, Austin, TX; Pharmacotherapy Education and Research Center, UT Health San Antonio, San Antonio, TX; South Texas Veterans Health Care System, San Antonio, TX.
| | - Mary Jo V Pugh
- South Texas Veterans Health Care System, San Antonio, TX; Department of Epidemiology and Biostatistics, UT Health San Antonio, San Antonio, TX
| | - Kenneth A Lawson
- College of Pharmacy, The University of Texas at Austin, Austin, TX
| | - Eric M Mortensen
- Department of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX; Department of General Internal Medicine, VA North Texas Health Care System, Dallas, TX
| | - Jim M Koeller
- College of Pharmacy, The University of Texas at Austin, Austin, TX; Pharmacotherapy Education and Research Center, UT Health San Antonio, San Antonio, TX
| | - Jacqueline R Argamany
- College of Pharmacy, The University of Texas at Austin, Austin, TX; Pharmacotherapy Education and Research Center, UT Health San Antonio, San Antonio, TX
| | - Christopher R Frei
- College of Pharmacy, The University of Texas at Austin, Austin, TX; Pharmacotherapy Education and Research Center, UT Health San Antonio, San Antonio, TX; South Texas Veterans Health Care System, San Antonio, TX
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A Surgical Clostridium-Associated Risk of Death Score Predicts Mortality After Colectomy for Clostridium difficile. Dis Colon Rectum 2017; 60:1285-1290. [PMID: 29112564 DOI: 10.1097/dcr.0000000000000920] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND A Clostridium difficile-associated risk of death score was recently developed and validated by using a national cohort of both nonsurgical and surgical patients admitted with C difficile infection. However, risk scores specifically derived from surgical cohorts and designed for patients with C difficile infection are currently unavailable. OBJECTIVE The aim of this study was to develop a risk of death score for patients with C difficile infection who are being considered for total abdominal colectomy because of the failure of medical therapy. DESIGN This is a retrospective cohort study. SETTINGS This study was conducted with the use of a national database. PATIENTS All patients undergoing total colectomy for C difficile infection were identified in the National Surgical Quality Improvement Program database from 2005 to 2014. MAIN OUTCOME MEASURES Variables similar to the original scoring system were used in multivariable analyses to determine the risk of 30-day mortality for patients, and a model was constructed to estimate the predicted probability of mortality after surgery. RESULTS Of 532 patients who underwent surgery, 32.7% experienced 30-day postoperative mortality. Patient covariates associated with significantly increased mortality included age greater than 80 years (OR 5.5, p = 0.003), need for preoperative mechanical ventilation (OR 3.1, p < 0.001), chronic steroid use (OR 2.9, p < 0.001), underlying cardiopulmonary disease (OR 2.0, p = 0.001), and acute renal failure (OR=1.7, p = 0.03). These and other comorbidities, including hepatic disease, a cancer diagnosis, and both insulin- and noninsulin-dependent diabetes mellitus, were used to construct a model to estimate the predicted probability of mortality, which ranged from 8.0% to 96.1% based on individual comorbidity profiles. These estimates differed substantially when compared with those obtained using the National Surgical Quality Improvement Program risk calculator, which estimated the risk of mortality among surgical patients as being consistently lower. LIMITATIONS This study was limited by its retrospective design. CONCLUSIONS Our surgical scoring system allows preoperative risk stratification for patients being evaluated for colectomy for C difficile infection, potentially helping to avoid futile surgery. See Video Abstract at http://links.lww.com/DCR/A434.
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Joyce NR, Mylonakis E, Mor V. Effect of Clostridium difficile Prevalence in Hospitals and Nursing Homes on Risk of Infection. J Am Geriatr Soc 2017; 65:1527-1534. [PMID: 28394408 DOI: 10.1111/jgs.14838] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To assess the effect of facility Clostridium difficile infection (CDI) prevalence on risk of healthcare facility (HFC) acquired CDI. DESIGN Retrospective cohort study. SETTING Medicare fee-for-service (FFS) claims and skilled nursing facility (SNF) Minimum Data Set 3.0 assessments. PARTICIPANTS Medicare beneficiaries with 90 days or more of no contact with a HCF before a hospital admission without a CDI diagnosis. Participants were separated into two cohorts: discharged to the community and discharged to a SNF. MEASUREMENTS Risk of HCF-acquired CDI associated with CDI prevalence at the index facility measured according to 30-day rehospitalization with a discharge diagnosis of CDI or diagnosis in the SNF after admission. Hospital and SNF CDI prevalence were categorized into three groups: 0% and above and below the median value for facilities with greater than 0% prevalence. RESULTS Of 817,900 eligible individuals, there were 553,423 admissions in the first cohort (discharged to the community) and 315,109 in the second (discharged to a SNF). In the first cohort, the risk of HCF-acquired CDI was higher for individuals admitted to hospitals with CDI prevalence less than the median (relative risk (RR) = 1.58, 95% confidence interval (CI) = 1.18-2.12) and greater than the median (RR = 2.56, 95% CI = 1.91-3.45) than for those with no CDI. In the second cohort, the risk of HCF-acquired CDI was greater for individuals admitted to a hospital (RR = 1.89, 95% CI = 1.49-2.39) and a SNF (RR = 1.48, 95% CI = 1.31-1.67) with CDI prevalence greater than the median. CONCLUSION The risk of HCF-acquired CDI is greater for noninfected individuals admitted to hospitals and SNFs with a high prevalence of CDI.
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Affiliation(s)
- Nina R Joyce
- Department of Health Care Policy, School of Medicine, Harvard University, Boston, Massachusetts
| | | | - Vincent Mor
- Department of Health Services, Policy and Practice, Brown University, Providence, Rhode Island.,Providence Veterans Administration Medical Center, Providence, Rhode Island
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Yu H, Baser O, Wang L. Burden of Clostridium difficile-associated disease among patients residing in nursing homes: a population-based cohort study. BMC Geriatr 2016; 16:193. [PMID: 27884118 PMCID: PMC5123396 DOI: 10.1186/s12877-016-0367-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 11/16/2016] [Indexed: 01/11/2023] Open
Abstract
Background Clostridium difficile (C. difficile) infection (CDI) is the leading cause of nosocomial diarrhea in the United States. This study aimed to examine the incidence of CDI and evaluate mortality and economic burden of CDI in an elderly population who reside in nursing homes (NHs). Methods This was a population-based retrospective cohort study focusing on US NHs by linking Medicare 5% sample, Medicaid, Minimum Data Set (MDS) (2008–10). NH residents aged ≥65 years with continuous enrollment in Medicare and/or Medicaid Fee-for-Service plan for ≥12 months and ≥2 quarterly MDS assessments were eligible for the study. The incidence rate was calculated as the number of CDI episodes by 100,000 person-years. A 1:4 propensity score matched sample of cohorts with and without CDI was generated to assess mortality and health care costs following the first CDI. Results Among 32,807 NH residents, 941 residents had ≥1 episode of CDI in 2009, with an incidence of 3359.9 per 100,000 person-years. About 30% CDI episodes occurred in the hospital setting. NH residents with CDI (vs without CDI) were more likely to have congestive heart failure, renal disease, cerebrovascular disease, hospitalizations, and outpatient antibiotic use. During the follow-up period, the 30-day (14.7% vs 4.3%, P < 0.001), 60-day (22.7% vs 7.5%, P < 0.001), 6-month (36.3% vs 18.3%, P < 0.001), and 1-year mortality rates (48.2% vs 31.1%, P < 0.001) were significantly higher among the CDI residents vs non-CDI residents. Total health care costs within 2 months following the first CDI episode were also significantly higher for CDI residents ($28,621 vs $13,644, P < 0.001). Conclusions CDI presents a serious public health issue in NHs. Mortality, health care utilization, and associated costs were significant following incident CDI episodes. Electronic supplementary material The online version of this article (doi:10.1186/s12877-016-0367-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Holly Yu
- Pfizer Inc, Arcola Road, Collegeville, PA, 19426, USA.
| | - Onur Baser
- Center for Innovation & Outcomes Research, Department of Surgery, Columbia University, New York, NY, USA.,STATinMED Research, New York, NY, USA
| | - Li Wang
- STATinMED Research, Plano, TX, USA
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Girotra M, Garg S, Anand R, Song Y, Dutta SK. Fecal Microbiota Transplantation for Recurrent Clostridium difficile Infection in the Elderly: Long-Term Outcomes and Microbiota Changes. Dig Dis Sci 2016; 61:3007-3015. [PMID: 27447476 DOI: 10.1007/s10620-016-4229-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 06/09/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Fecal microbiota transplantation (FMT) has become the cornerstone in management of recurrent Clostridium difficile infection (RCDI) in adults. However, data on efficacy, safety, long-term outcomes, and microbiota alterations are limited in elderly patients (>65 years). METHODS Twenty-nine consecutive elderly patients with RCDI underwent FMT with combined jejunal and colonic method and monitored for long-term outcomes. Fecal samples from five elderly RCDI patients (G65) were subjected to genomic analysis before and after FMT, and microbiota changes were compared with matched RCDI patients below 65 years (L65). RESULTS FMT resulted in marked improvement in all clinical parameters, including abdominal pain, bloating, and diarrhea in all elderly RCDI patients. Fecal C. difficile toxin was positive in all 29 patients and turned negative in all 27 patients, who agreed to undergo this test after FMT. Statistically significant improvement in leukocytosis was noted (p < 0.05). Only adverse events reported were transient mild fever (2/29) and bloating (3/29). Long-term follow-up over 25.4 ± 12.8 months did not reveal any additional adverse events or RCDI recurrence. Genomic analysis suggested that overall microbiota diversity increased post-FMT in elderly RCDI patients. However, this response was less robust than the younger group. While Firmicutes did not change markedly, Proteobacteria decreased significantly in post-FMT samples in elderly RCDI patients. CONCLUSIONS These observations suggest that FMT in elderly patients with RCDI appears to be highly efficacious with no recurrence of infection over long-term follow-up. Alterations in microbiota in this group of patients are characterized by less robust increase in microbial diversity and marked reduction in phylum Proteobacteria.
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Affiliation(s)
- Mohit Girotra
- Division of Gastroenterology, Department of Medicine, Johns Hopkins University/Sinai Hospital Program in Internal Medicine, Baltimore, MD, USA
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Shashank Garg
- Division of Gastroenterology, Department of Medicine, Johns Hopkins University/Sinai Hospital Program in Internal Medicine, Baltimore, MD, USA
- Division of Digestive Diseases and Nutrition, University of Kentucky, Lexington, KY, USA
| | - Rohit Anand
- Division of Gastroenterology, Department of Medicine, Johns Hopkins University/Sinai Hospital Program in Internal Medicine, Baltimore, MD, USA
| | - Yang Song
- Division of Gastroenterology, Department of Medicine, Johns Hopkins University/Sinai Hospital Program in Internal Medicine, Baltimore, MD, USA
- Institute of Genome Sciences, Baltimore, MD, USA
| | - Sudhir K Dutta
- Division of Gastroenterology, Department of Medicine, Johns Hopkins University/Sinai Hospital Program in Internal Medicine, Baltimore, MD, USA.
- University of Maryland School of Medicine, 2411 W. Belvedere Ave, Suite 305, Baltimore, MD, 21215, USA.
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16
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Awali RA, Kandipalli D, Pervaiz A, Narukonda S, Qazi U, Trehan N, Chopra T. Risk factors associated with interfacility transfers among patients with Clostridium difficile infection. Am J Infect Control 2016; 44:1027-31. [PMID: 27207161 DOI: 10.1016/j.ajic.2016.03.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 02/23/2016] [Accepted: 03/02/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Preventing the transmission of Clostridium difficile infection (CDI) over the continuum of care presents an important challenge for infection control. METHODS A prospective case-control study was conducted on patients admitted with CDI to a tertiary care hospital in Detroit between August 2012 and September 2013. Patients were then followed for 1 year by telephone interviews and the hospital administrative database. Cases, patients with interfacility transfers (IFTs), were patients admitted to our facility from another health care facility and discharged to long-term care (LTC) facilities. Controls were patients admitted from and discharged to home. RESULTS There were 143 patients included in the study. Thirty-six (30%) cases were compared with 84 (70%) controls. Independent risk factors of CDI patients with IFTs (compared with CDI patients without IFTs) included Charlson Comorbidity Index score ≥6 (odds ratio [OR], 5.30; P = .016) and hospital-acquired CDI (OR, 4.92; P = .023). Patients with IFTs were more likely to be readmitted within 90 days of discharge than patients without IFTs (OR, 2.24; P = .046). One-year mortality rate was significantly higher among patients with IFTs than among patients without IFTs (OR, 4.33; P = .01). CONCLUSIONS With the growing number of alternate health care centers, it is highly critical to establish better collaboration between acute care and LTC facilities to tackle the increasing burden of CDI across the health care system.
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Affiliation(s)
- Reda A Awali
- Division of Infectious Diseases, Detroit Medical Center & Wayne State University, Detroit, MI.
| | - Deepthi Kandipalli
- Division of Infectious Diseases, Detroit Medical Center & Wayne State University, Detroit, MI
| | - Amina Pervaiz
- Division of Infectious Diseases, Detroit Medical Center & Wayne State University, Detroit, MI
| | - Sandhya Narukonda
- Division of Infectious Diseases, Detroit Medical Center & Wayne State University, Detroit, MI
| | - Urooj Qazi
- Division of Infectious Diseases, Detroit Medical Center & Wayne State University, Detroit, MI
| | - Naveen Trehan
- Division of Infectious Diseases, Detroit Medical Center & Wayne State University, Detroit, MI
| | - Teena Chopra
- Division of Infectious Diseases, Detroit Medical Center & Wayne State University, Detroit, MI
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Bätzing-Feigenbaum J, Schulz M, Schulz M, Hering R, V. Kern W. Outpatient Antibiotic Prescription. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 113:454-9. [PMID: 27412990 PMCID: PMC4946328 DOI: 10.3238/arztebl.2016.0454] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 02/26/2016] [Accepted: 02/26/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND In view of the rise in antibiotic resistance and Clostridium difficile superinfection, close monitoring of antibiotic prescribing practices is essential so that targeted quality assurance measures can be taken. METHODS We analyzed nationwide data from multiple statutory health insurance carriers on prescriptions of systemic antibiotics in the years 2008-2014, with special attention to cephalosporins and fluoroqinolones. Prescribing rates were characterized in terms of defined daily doses (DDD) per 1000 statutory insurees per year and were analyzed separately for each age group and each federal state in Germany. Trends were analyzed with joinpoint regression. RESULTS Antibiotic prescribing rates for persons aged 15 to 69 increased slightly overall during the period of observation. On the other hand, there was a significant decline in antibiotic prescribing rates for persons under age 15 in all of the German states, with a mean annual decrease of 6.8%. There was also a slight decline in antibiotic prescribing rates for persons aged 70 and above, mainly accounted for by fluoroquinolones. Cephalosporin prescribing rates rose significantly in all states, by an overall average of 7.6% per annum. Cephalo - sporin prescribing rates rose significantly in all age groups except persons under age 15, for whom there was a decline that did not reach statistical significance. CONCLUSION This study revealed an overall decline in outpatient antibiotic prescriptions for persons under age 15 as well as other major changes in prescribing practices for the types of antibiotics studied. The observed marked rise in cephalosporin prescribing rates in all German states demands special attention because of the associated danger of increased antibiotic resistance and C. difficile superinfection. Oral cephalosporins are not recommended as drugs of first choice in current guidelines.
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Affiliation(s)
| | - Maike Schulz
- Central Research Institute of Ambulatory Health Care in Germany (ZI), Berlin
| | - Mandy Schulz
- Central Research Institute of Ambulatory Health Care in Germany (ZI), Berlin
| | - Ramona Hering
- Central Research Institute of Ambulatory Health Care in Germany (ZI), Berlin
| | - Winfried V. Kern
- Center of Infectious Diseases and Travel Medicine, Medical Center—University of Freiburg
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18
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Prasad N, Labaze G, Kopacz J, Chwa S, Platis D, Pan CX, Russo D, LaBombardi VJ, Osorio G, Pollack S, Kreiswirth BN, Chen L, Urban C, Segal-Maurer S. Asymptomatic rectal colonization with carbapenem-resistant Enterobacteriaceae and Clostridium difficile among residents of a long-term care facility in New York City. Am J Infect Control 2016; 44:525-32. [PMID: 26796684 DOI: 10.1016/j.ajic.2015.11.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 11/10/2015] [Accepted: 11/12/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Residents of long-term care facilities (LTCFs) are at increased risk for colonization and development of infections with multidrug-resistant organisms. This study was undertaken to determine prevalence of asymptomatic rectal colonization with Clostridium difficile (and proportion of 027/NAP1/BI ribotype) or carbapenem-resistant Enterobacteriaceae (CRE) in an LTCF population. METHODS Active surveillance was performed for C difficile and CRE rectal colonization of 301 residents in a 320-bed (80-bed ventilator unit), hospital-affiliated LTCF with retrospective chart review for patient demographics and potential risk factors. RESULTS Over 40% of patients had airway ventilation and received enteral feeding. One-third of these patients had prior C difficile-associated infection (CDI). Asymptomatic rectal colonization with C difficile occurred in 58 patients (19.3%, one-half with NAP1+), CRE occurred in 57 patients (18.9%), and both occurred in 17 patients (5.7%). Recent CDI was significantly associated with increased risk of C difficile ± CRE colonization. Multivariate logistic regression analysis revealed presence of tracheostomy collar to be significant for C difficile colonization, mechanical ventilation to be significant for CRE colonization, and prior CDI to be significant for both C difficile and CRE colonization. CONCLUSIONS The strong association of C difficile or CRE colonization with disruption of normal flora by mechanical ventilation, enteral feeds, and prior CDI carries important implications for infection control intervention in this population.
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Affiliation(s)
- Nishant Prasad
- Department of Medicine, NewYork-Presbyterian/Queens, Flushing, NY; The Dr. James J. Rahal Jr. Division of Infectious Diseases, NewYork-Presbyterian/Queens, Flushing, NY; Silvercrest Center for Nursing and Rehabilitation, Flushing, NY
| | - Georges Labaze
- Department of Medicine, NewYork-Presbyterian/Queens, Flushing, NY; Division of Geriatrics and Palliative Medicine, NewYork-Presbyterian/Queens, Flushing, NY
| | - Joanna Kopacz
- Department of Medicine, NewYork-Presbyterian/Queens, Flushing, NY; The Dr. James J. Rahal Jr. Division of Infectious Diseases, NewYork-Presbyterian/Queens, Flushing, NY; Silvercrest Center for Nursing and Rehabilitation, Flushing, NY
| | - Sophie Chwa
- Department of Medicine, NewYork-Presbyterian/Queens, Flushing, NY; Division of Geriatrics and Palliative Medicine, NewYork-Presbyterian/Queens, Flushing, NY
| | - Dimitris Platis
- Department of Medicine, NewYork-Presbyterian/Queens, Flushing, NY; Division of Geriatrics and Palliative Medicine, NewYork-Presbyterian/Queens, Flushing, NY
| | - Cynthia X Pan
- Department of Medicine, NewYork-Presbyterian/Queens, Flushing, NY; Division of Geriatrics and Palliative Medicine, NewYork-Presbyterian/Queens, Flushing, NY
| | - Daniel Russo
- Silvercrest Center for Nursing and Rehabilitation, Flushing, NY
| | | | - Giuliana Osorio
- Department of Pathology, NewYork-Presbyterian/Queens, Flushing, NY
| | - Simcha Pollack
- Computer Information Systems and Decision Sciences, St. John's University, Queens, NY
| | - Barry N Kreiswirth
- Public Health Research Institute, New Jersey Medical School, Rutgers University, Newark, NJ
| | - Liang Chen
- Public Health Research Institute, New Jersey Medical School, Rutgers University, Newark, NJ
| | - Carl Urban
- Department of Medicine, NewYork-Presbyterian/Queens, Flushing, NY; The Dr. James J. Rahal Jr. Division of Infectious Diseases, NewYork-Presbyterian/Queens, Flushing, NY
| | - Sorana Segal-Maurer
- Department of Medicine, NewYork-Presbyterian/Queens, Flushing, NY; The Dr. James J. Rahal Jr. Division of Infectious Diseases, NewYork-Presbyterian/Queens, Flushing, NY.
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McFarland LV, Ozen M, Dinleyici EC, Goh S. Comparison of pediatric and adult antibiotic-associated diarrhea and Clostridium difficile infections. World J Gastroenterol 2016; 22:3078-3104. [PMID: 27003987 PMCID: PMC4789985 DOI: 10.3748/wjg.v22.i11.3078] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 01/12/2016] [Accepted: 02/22/2016] [Indexed: 02/06/2023] Open
Abstract
Antibiotic-associated diarrhea (AAD) and Clostridum difficile infections (CDI) have been well studied for adult cases, but not as well in the pediatric population. Whether the disease process or response to treatments differs between pediatric and adult patients is an important clinical concern when following global guidelines based largely on adult patients. A systematic review of the literature using databases PubMed (June 3, 1978-2015) was conducted to compare AAD and CDI in pediatric and adult populations and determine significant differences and similarities that might impact clinical decisions. In general, pediatric AAD and CDI have a more rapid onset of symptoms, a shorter duration of disease and fewer CDI complications (required surgeries and extended hospitalizations) than in adults. Children experience more community-associated CDI and are associated with smaller outbreaks than adult cases of CDI. The ribotype NAP1/027/BI is more common in adults than children. Children and adults share some similar risk factors, but adults have more complex risk factor profiles associated with more co-morbidities, types of disruptive factors and a wider range of exposures to C. difficile in the healthcare environment. The treatment of pediatric and adult AAD is similar (discontinuing or switching the inciting antibiotic), but other treatment strategies for AAD have not been established. Pediatric CDI responds better to metronidazole, while adult CDI responds better to vancomycin. Recurrent CDI is not commonly reported for children. Prevention for both pediatric and adult AAD and CDI relies upon integrated infection control programs, antibiotic stewardship and may include the use of adjunctive probiotics. Clinical presentation of pediatric AAD and CDI are different than adult AAD and CDI symptoms. These differences should be taken into account when rating severity of disease and prescribing antibiotics.
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20
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Lübbert C, John E, von Müller L. Clostridium difficile infection: guideline-based diagnosis and treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 111:723-31. [PMID: 25404529 DOI: 10.3238/arztebl.2014.0723] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 08/14/2014] [Accepted: 08/14/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Clostridium difficile (C. difficile) is the pathogen that most commonly causes nosocomial and antibiotic-associated diarrheal disease. Optimized algorithms for diagnosis, treatment, and hygiene can help lower the incidence, morbidity, and mortality of C. difficile infection (CDI). METHODS This review is based on pertinent articles that were retrieved by a selective search in PubMed for recommendations on diagnosis and treatment(up to March 2014), with particular attention to the current epidemiological situation in Germany. RESULTS The incidence of CDI in Germany is 5 to 20 cases per 100,000 persons per year. In recent years, a steady increase in severe, reportable cases of CDI has been observed, and the highly virulent epidemic strain Ribotype 027 has spread across nearly the entire country. For therapeutic and hygiene management, it is important that the diagnosis be made as early as possible with a sensitive screening test, followed by a confirmatory test for the toxigenic infection. Special disinfection measures are needed because of the formation of spores. The treatment of CDI is evidence-based; depending on the severity of the infection, it is treated orally with metronidazole, or else with vancomycin or fidaxomicin. Fulminant infections and recurrences call for specifically adapted treatment modalities. Treatment with fecal bacteria (stool transplantation) is performed in gastroenterological centers that have experience with this form of treatment after multiple failures of drug treatment for recurrent infection. For critically ill patients, treatment is administered by an interdisciplinary team and consists of early surgical intervention in combination with drug treatment. A therapeutic algorithm developed on the basis of current guidelines and recommendations enables risk-adapted, individualized treatment. CONCLUSION The growing clinical and epidemiological significance of CDI compels a robust implementation of multimodal diagnostic, therapeutic, and hygienic standards. In the years to come, anti-toxin antibodies, toxoid vaccines, and focused bacterial therapy will be developed as new treatment strategies for CDI.
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Affiliation(s)
- Christoph Lübbert
- Division of Infectious Diseases and Tropical Medicine, Department of Gastroenterology and Rheumatology, Department of Internal Medicine, Neurology and Dermatology, Leipzig University Hospital, Department of General, Visceral and Vascular Surgery, University Hospital of Halle (Saale), Institute of Medical Microbiology and Hygiene, Saarland University Medical Center, National Advisory Laboratory for Clostridium difficile
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Kaiser AM, Hogen R, Bordeianou L, Alavi K, Wise PE, Sudan R. Clostridium Difficile Infection from a Surgical Perspective. J Gastrointest Surg 2015; 19:1363-1377. [PMID: 25917533 DOI: 10.1007/s11605-015-2785-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 02/18/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND The incidence and the severity of Clostridium difficile infection (CDI) have increased significantly over the last decade, especially in high-risk populations such as patients with inflammatory bowel disease (IBD). Surgeons must be able to both identify and minimize the risk of CDI in their own surgical patients and determine which CDI patients will benefit from surgery. PURPOSE We sought to define the risk factors, compare the treatment options, define the surgical indications, and identify factors that affect surgical outcomes for CDI based on the currently available literature. RESULTS Antibiotic use, exposure to the C. difficile bacteria, IBD, and higher levels of co-morbidity are all risk factors for CDI. The majority of CDI can be treated with antibiotics. Severe or fulminant colitis, however, has a high potential for poor outcome, but experience and some data suggest a lower mortality rate with colectomy rather than with continued medical treatment. Open total abdominal colectomy with end ileostomy is typically the preferred surgical strategy. It is often difficult to determine which patients will fail medical management as some may not manifest clinical signs of severe infection. Surrogate parameters of failure of medical therapy include respiratory and/or renal insufficiency, age greater than 60 years, peripheral vascular disease, congestive heart failure, and coagulopathy, all of which have been associated with worse surgical outcomes. Evidence suggests that in appropriately selected patients, colectomy performed before the development of shock requiring vasopressors, respiratory failure, renal failure, multi-organ dysfunction, and mental status changes may reduce mortality of the most severe forms of colitis. For less severe or recurrent presentations, creation of a loop ileostomy with intra-operative colonic lavage, fecal microbiota transfer, and C. difficile vaccinations are being discussed but have only been studied in small case-controlled series. CONCLUSIONS Prevention, containment, and non-surgical treatment are the cornerstone of management for CDI. However, the most severe forms with toxic colitis benefit from involvement of a surgical team. Swift open total abdominal colectomy with end ileostomy in patients with severe or fulminant C. difficile colitis has the best chance to reduce mortality if it is not delayed until shock, end organ damage, vasopressor requirement, mental status changes develop. Less aggressive approaches may be appropriate for milder and refractory forms but require further study before their applicability can be determined.
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Affiliation(s)
- Andreas M Kaiser
- Department of Surgery, Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, 1441 Eastlake Avenue, Suite 7418, Los Angeles, 90033, CA, USA,
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Ziakas PD, Zacharioudakis IM, Zervou FN, Grigoras C, Pliakos EE, Mylonakis E. Asymptomatic carriers of toxigenic C. difficile in long-term care facilities: a meta-analysis of prevalence and risk factors. PLoS One 2015; 10:e0117195. [PMID: 25707002 PMCID: PMC4338134 DOI: 10.1371/journal.pone.0117195] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 12/19/2014] [Indexed: 11/29/2022] Open
Abstract
Background The impact of Clostridium difficile colonization in C. difficile infection (CDI) is inadequately explored. As a result, asymptomatic carriage is not considered in the development of infection control policies and the burden of carrier state in long-term care facilities (LTCFs) is unknown. Purpose To explore the epidemiology of C. difficile colonization in LTCFs, identify predisposing factors and describe its impact on healthcare management. Data Sources PubMed, Embase and Web of Science (up to June 2014) without language restriction, complemented by reference lists of eligible studies. Study Selection All studies providing extractable data on the prevalence of toxigenic C. difficile colonization among asymptomatic residents in LTCFs. Data Extraction Two authors extracted data independently. Statistical Methods The pooled colonization estimates were calculated using the double arcsine methodology and reported along with their 95% random-effects confidence intervals (CIs), using DerSimonian-Laird weights. We assessed the impact of patient-level covariates on the risk of colonization and effects were reported as odds ratios (OR, 95% CI). We used the colonization estimates to simulate the effective reproduction number R through a Monte Carlo technique. Results Based on data from 9 eligible studies that met the specified criteria and included 1,371 subjects, we found that 14.8% (95%CI 7.6%-24.0%) of LTCF residents are asymptomatic carriers of toxigenic C. difficile. Colonization estimates were significantly higher in facilities with prior CDI outbreak (30.1% vs. 6.5%, p = 0.01). Patient history of CDI (OR 6.07; 95% CI 2.06–17.88; effect derived from 3 studies), prior hospitalization (OR 2.11; 95% CI 1.08–4.13; derived from 3 studies) and antimicrobial use within previous 3 months (OR 3.68; 95% CI 2.04–6.62; derived from 4 studies) were associated with colonization. The predicted colonization rate at admission was 8.9%. Conclusion Asymptomatic carriage of toxigenic C. difficile represents a significant burden in LTCFs and is associated with prior CDI outbreaks in the facility, a history of CDI, prior hospitalization and antimicrobial use. These findings can impact infection control measures at LTCFs.
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Affiliation(s)
- Panayiotis D. Ziakas
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
- * E-mail:
| | - Ioannis M. Zacharioudakis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Fainareti N. Zervou
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Christos Grigoras
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Elina Eleftheria Pliakos
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
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Fisher A, Varendran R. Letter: clinical predictors of Clostridium difficile infection - advanced age and residential status are important factors for prediction and prevention. Aliment Pharmacol Ther 2015; 41:232-3. [PMID: 25511770 DOI: 10.1111/apt.13014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 10/12/2014] [Indexed: 02/07/2023]
Affiliation(s)
- A Fisher
- Department of Geriatric Medicine, The Canberra Hospital, Canberra, ACT, Australia; Australian National University Medical School, Canberra, ACT, Australia.
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Nausea, Vomiting, and Noninflammatory Diarrhea. MANDELL, DOUGLAS, AND BENNETT'S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES 2015. [PMCID: PMC7173487 DOI: 10.1016/b978-1-4557-4801-3.00100-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Tartof SY, Yu KC, Wei R, Tseng HF, Jacobsen SJ, Rieg GK. Incidence of polymerase chain reaction-diagnosed Clostridium difficile in a large high-risk cohort, 2011-2012. Mayo Clin Proc 2014; 89:1229-38. [PMID: 25064782 DOI: 10.1016/j.mayocp.2014.04.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 04/10/2014] [Accepted: 04/24/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe incidence rates (IRs) of polymerase chain reaction (PCR)-diagnosed Clostridium difficile infection (CDI) in a large high-risk cohort. PATIENTS AND METHODS Members of Kaiser Permanente Southern California 1 year or older who were admitted to any of 14 Kaiser Permanente hospitals from January 1, 2011, through December 31, 2012, were included in the study. The CDI cases were identified by PCR in the inpatient and outpatient settings. The CDI IRs per 10,000 inpatient-days are estimated by year, surveillance category, age, sex, race/ethnicity, and Charlson comorbidity index. Recurrence rates are presented by age, sex, and race/ethnicity. Death and colectomy in the 30 days after CDI diagnosis, white blood cell count, and serum creatinine level are assessed. RESULTS Among 268,655 patients, 4286 (1.6%) had CDI. Among these patients, 671 (15.7%) had recurrent infections. The IR was highest among community-onset, health care facility-associated infections (11.1 per 10,000 inpatient-days). The CDI IRs differed by age, sex, and race/ethnicity. Overall, 528 patients (12.3%) died within 30 days of a positive CDI test result. The CDI IRs increased 34% with implementation of PCR testing. CONCLUSION Increasingly, PCR is being used because of its higher diagnostic sensitivity. Reassessing the epidemic using PCR updates our understanding of CDI risk. Our capacity to identify patients presenting in the outpatient setting after discharge provides a more accurate picture of health care-associated CDI rates, particularly because the community appears to assume an increasing role in CDI onset and possibly transmission. The CDI burden differs by race, comorbidity, sex, and previous health care use. The detected increase in CDI incidence after transitioning to PCR diagnosis was modest compared with previous studies.
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Affiliation(s)
- Sara Y Tartof
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena.
| | - Kalvin C Yu
- Department of Infectious Diseases, Southern California Permanente Medical Group, West Los Angeles
| | - Rong Wei
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Hung Fu Tseng
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Steven J Jacobsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Gunter K Rieg
- Department of Infectious Diseases, Southern California Permanente Medical Group, Harbor City
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Rodriguez C, Korsak N, Taminiau B, Avesani V, Van Broeck J, Delmée M, Daube G. Clostridium difficile infection in elderly nursing home residents. Anaerobe 2014; 30:184-7. [PMID: 25152228 DOI: 10.1016/j.anaerobe.2014.08.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 04/17/2014] [Accepted: 08/08/2014] [Indexed: 02/06/2023]
Abstract
Age-related changes in intestinal flora and host defences, the receipt of antibiotic treatment, and the presence of underlying diseases are some of the most common risk factors associated with Clostridium difficile infection. Therefore, retirement care facilities for elderly people have been pinpointed as frequent sources of contamination. There is only limited data regarding the presence and epidemiology of C. difficile in nursing homes, and this gap in the current literature emphasises the need to gain a better understanding of the situation in order to prevent the emergence of new outbreaks among this population group.
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Affiliation(s)
- C Rodriguez
- Food Science Department, FARAH, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium.
| | - N Korsak
- Food Science Department, FARAH, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
| | - B Taminiau
- Food Science Department, FARAH, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
| | - V Avesani
- Microbiology Unit, Catholic University of Louvain, Brussels, Belgium
| | - J Van Broeck
- Microbiology Unit, Catholic University of Louvain, Brussels, Belgium
| | - M Delmée
- Microbiology Unit, Catholic University of Louvain, Brussels, Belgium
| | - G Daube
- Food Science Department, FARAH, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
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28
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Wiuff C, Murdoch H, Coia JE. Control of Clostridium difficile infection in the hospital setting. Expert Rev Anti Infect Ther 2014; 12:457-69. [PMID: 24579852 DOI: 10.1586/14787210.2014.894459] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Clostridium difficile infection (CDI) has emerged as a leading challenge in the control of healthcare-associated infection (HCAI). The epidemiology of CDI has changed dramatically, this is associated with emergence of 'hypervirulent' strains, particularly PCR ribotype 027. Despite the epidemic spread of these strains, there are recent reports of decreasing incidence from healthcare facilities where multi-facetted targeted control programs have been implemented. We consider these changes in epidemiology and reflect on the tools available to control CDI in the hospital setting. The precise repertoire of measures adopted and emphasis on different interventions will vary, not only between healthcare systems, but also within different institutions within the same healthcare system. Finally, we consider both the sustainability of reductions already achieved, and the potential to reduce CDI further. This takes account of newly emerging data on more recent changes in the epidemiology of CDI, and the potential of novel interventions to decrease the burden of disease.
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Affiliation(s)
- Camilla Wiuff
- Health Protection Scotland, 5 Cadogan Street, Glasgow, G2 6QE, UK
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