Cause Of Healthcare-associated Diarrhea Research Articles

Induced sporicidal activity of chlorhexidine against Clostridium difficile spores under altered physical and chemical conditions.

BackgroundChlorhexidine is a broad-spectrum antimicrobial commonly used to disinfect the skin of patients to reduce the risk of healthcare-associated infections. Because chlorhexidine is not sporicidal, it is not anticipated that it would have an impact on skin contamination with Clostridium difficile, the most important cause of healthcare-associated diarrhea. However, although chlorhexidine is not sporicidal as it is used in healthcare settings, it has been reported to kill spores of Bacillus species under altered physical and chemical conditions that disrupt the spore’s protective barriers (e.g., heat, ultrasonication, alcohol, or elevated pH). Here, we tested the hypothesis that similarly altered physical and chemical conditions result in enhanced sporicidal activity of chlorhexidine against C. difficile spores.Principal Findings C. difficile spores became susceptible to heat killing at 80°C within 15 minutes in the presence of chlorhexidine, as opposed to spores suspended in water which remained viable. The extent to which the spores were reduced was directly proportional to the concentration of chlorhexidine in solution, with no viable spores recovered after 15 minutes of incubation in 0.04%–0.0004% w/v chlorhexidine solutions at 80°C. Reduction of spores exposed to 4% w/v chlorhexidine solutions at moderate temperatures (37°C and 55°C) was enhanced by the presence of 70% ethanol. However, complete elimination of spores was not achieved until 3 hours of incubation at 55°C. Elevating the pH to ≥9.5 significantly enhanced the killing of spores in either aqueous or alcoholic chlorhexidine solutions.ConclusionsPhysical and chemical conditions that alter the protective barriers of C. difficile spores convey sporicidal activity to chlorhexidine. Further studies are necessary to identify additional agents that may allow chlorhexidine to reach its target within the spore.

Prévalence des infections à Clostridium difficile chez les patients hospitalisés avec une diarrhée : résultats d’une étude française prospective multicentrique

Clostridium difficile infections represent the major cause of healthcare-associated diarrhea. The objective of the study was to determine the incidence of C. difficile infection (CDI) in 2012 and to assess the under-estimation of the disease in France. Seventy healthcare facilities participated in a prospective point prevalence study. Each laboratory was requested to send all the diarrheal stool samples from hospitalized patients during 2 days (one in December 2012 and one in July 2013) to the National Reference Laboratory (NRL) for C. difficile, irrespective of a medical request for C. difficile. At the NRL, stool samples were analyzed using the Quik Chek Complete assay (Alere). Positive samples for glutamate deshydrogenase or toxins were confirmed by the toxigenic culture. Results obtained by the NRL were then compared to those given by each healthcare facility. Incidence of CDI in 2012 was provided by each healthcare facility through a specific questionnaire. Mean incidence of CDI reported in 2012 by the HCF was 3.6 ± 2.9 per 10,000 patient-days; the incidence was positively correlated to the density testing (defined by the number of tests per 10,000 patient-days), which varied across the HCF (median 29.0 per 10,000 patient-days, IQR 19-50). During the bi-annual point prevalence survey, 651 stool samples were included and 90 were positive for C. difficile in culture. The overall prevalence of patients infected by a toxigenic C. difficile strain was 9.7% (63/651) and the prevalence of patients colonized by a non-toxigenic strain was 4.2% (27/651). Among the 65 cases of CDI detected by the NRL, 35 (55.6%) were missed by the participating HCF because of a lack of sensitivity of the methods used for the diagnosis (16/63, 25.4%) or because of a lack of clinical suspicion (19/63, 30.2%). The incidence of CDI in 2012 has increased in France compared to that of 2009 but is still underestimated because of a lack of clinical suspicion or a lack of sensitivity of methods used for toxin detection.

Predictors of asymptomatic Clostridium difficile colonization on hospital admission

Clostridium difficile (CD) is the leading cause of health care-associated diarrhea and can result in asymptomatic carriage. Rates of asymptomatic CD colonization on hospital admission range from 1.4%-21%. The objective of this study was to evaluate host and bacterial factors associated with colonization on admission. The Consortium de recherche québécois sur le Clostridium difficile study provided data for analysis, including demographic information, known risk factors, and potential confounding factors, prospectively collected for 5,232 patients from 6 hospitals in Quebec and Ontario over 15 months from 2006-2007. Stool or rectal swabs were obtained for culture on admission. Pulsed-field gel electrophoresis was performed on the isolates. The presence of antibody against CD toxins A and B was measured. There were 212 (4.05%) patients colonized with CD on admission, and 5,020 patients were not colonized with CD. Multivariate logistic regression analysis showed that hospitalization within the last 12 months, use of corticosteroids, prior CD infection, and presence of antibody against toxin B were associated with colonization on admission. Of patients colonized on admission, 79.4% had non-NAP1, non-NAP2 strains. There are identifiable risk factors among asymptomatic CD carriers that could serve in their detection and provide a basis for targeted screening.

How to eradicate Clostridium difficile from the environment

During the last decade, Clostridium difficile has emerged as a major cause of healthcare-associated diarrhoea and death. Transmission of this spore-forming bacterium is thought to occur via the hands of healthcare providers or via the contaminated environment. Therefore, enhanced environmental cleaning/disinfection of the rooms housing C.difficile-infected patients is warranted. Guidelines from various scientific bodies have been published. They recommend performing environmental decontamination of rooms of patients with C.difficile infection (CDI) using hypochlorite (diluted 1/10) or a sporicidal product. Compliance with cleaning and disinfection is a critical point and is often suboptimal. Novel 'no-touch' methods for room disinfection have recently been introduced. Ultraviolet (UV) light or hydrogen peroxide systems are most widely used. In-vitro studies suggest that hydrogen peroxide vapour (from 30% hydrogen peroxide) methods achieve a >6 log10 reduction in C.difficile spores placed on carriers, and that aerosolized hydrogen peroxide systems (from 5% to 6% hydrogen peroxide) achieve ∼4 log10 reduction, whereas UV-based methods achieve ∼2 log10 reduction. Very few studies have assessed the impact of these devices on the transmission of C.difficile. Major limitations of these devices include the fact that they can only be used after the patient's discharge, because patients and staff must be removed from the room. The new no-touch methods for room disinfection supplement, but do not replace, daily cleaning.

Clostridium difficile as a cause of healthcare-associated diarrhoea among children in Auckland, New Zealand: clinical and molecular epidemiology.

We aimed to determine the incidence of Clostridium difficile infection (CDI), the molecular epidemiology of circulating C. difficile strains and risk factors for CDI among hospitalised children in the Auckland region. A cross-sectional study was undertaken of hospitalised children <15years of age in two hospitals investigated for healthcare-associated diarrhoea between November 2011 and June 2012. Stool specimens were analysed for the presence of C. difficile using a two-step testing algorithm including polymerase chain reaction (PCR). C. difficile was cultured and PCR ribotyping performed. Demographic data, illness characteristics and risk factors were compared between children with and without CDI. Non-duplicate stool specimens were collected from 320 children with a median age of 1.2years (range 3days to 15years). Forty-six patients (14%) tested met the definition for CDI. The overall incidence of CDI was 2.0 per 10,000 bed days. The percentage of positive tests among neonates was only 2.6%. PCR ribotyping showed a range of strains, with ribotype 014 being the most common. Significant risk factors for CDI were treatment with proton pump inhibitors [risk ratio (RR) 1.74, 95% confidence interval (CI) 1.09-5.59; p = 0.002], presence of underlying malignancy (RR 2.71, 95% CI 1.65-4.62; p = 0.001), receiving chemotherapy (RR 2.70, 95% CI 1.41-4.83; p = 0.003) and exposure to antibiotics (RR 1.17, 95% CI 0.99-1.17; p = 0.03). C. difficile is an important cause of healthcare-associated diarrhoea in this paediatric population. The notion that neonatal populations will always have high rates of colonisation with C. difficile may not be correct. Several risk factors associated with CDI among adults were also found to be significant.

Clostridium difficile in a children's hospital: Assessment of environmental contamination

Clostridium difficile infection (CDI) is the most frequent infectious cause of health care-associated diarrhea. Three cases of CDI, in children age 2, 3, and 14 years, occurred in the hematology/oncology ward of our children's hospital over 48 hours. We aimed to assess environmental contamination with C difficile in the shared areas of this unit, and to determine whether person-to-person transmission occurred. C difficile was recovered from 5 of 18 samples (28%). We compared C difficile isolated from each patient and the environment using pulsed-field gel electrophoresis, and found that none of the patient strains matched any of the others, and that none matched any strains recovered from the environment, suggesting that person-to-person transmission had not occurred. We found that C difficile was prevalent in the environment throughout shared areas of the children's hospital unit. Molecular typing to identify mechanisms of transmission is useful for devising appropriate interventions.

Outbreak of Clostridium difficile PCR ribotype 027--the recent experience of a regional hospital.

BackgroundClostridium difficile infection (CDI) is the leading cause of healthcare-associated diarrhea, and several outbreaks with increased severity and mortality have been reported. In this study we report a C. difficile PCR ribotype 027 outbreak in Portugal, aiming to contribute to a better knowledge of the epidemiology of this agent in Europe.MethodsOutbreak report with retrospective study of medical records and active surveillance data of all inpatients with the diagnosis of CDI, from 1st January to 31th December 2012, in a Portuguese hospital. C. difficile isolates were characterized regarding ribotype, toxin genes and moxifloxin resistance. Outbreak control measures were taken, concerning communication, education, reinforcement of infection control measures, optimization of diagnosis and treatment of CDI, and antibiotic stewardship.ResultsFifty-three inpatients met the case definition of C. difficile-associated infection: 55% males, median age was 78.0 years (interquartile range: 71.0-86.0), 75% had co-morbidities, only 15% had a nonfatal condition, 68% had at least one criteria of severe disease at diagnosis, 89% received prior antibiotherapy, 79% of episodes were nosocomial. CDI rate peak was 13.89/10,000 bed days. Crude mortality rate at 6 months was 64.2% while CDI attributable cause was 11.3%. Worse outcome was related to older age (P = 0.022), severity criteria at diagnosis (leukocytosis (P = 0.008) and renal failure), and presence of fatal underlying condition (P = 0.025). PCR ribotype 027 was identified in 16 of 22 studied samples.ConclusionsThis is the first report of a 027-CDI outbreak in Portugal. We emphasize the relevance of the measures taken to control the outbreak and highlight the importance of implementing a close and active surveillance of CDI.

Severe clinical outcome is uncommon in Clostridium difficile infection in children: a retrospective cohort study

BackgroundClostridium difficile infection (CDI) is the most common cause of health care–associated diarrhea in children and adults. Although serious complications of CDI have been reported to be increasing in adults, this trend has not yet been demonstrated in children. The purpose of this study was to examine the features of CDI in a pediatric population, with special attention to the occurrence of CDI-related severe outcomes.MethodsA chart review was conducted for patients with C. difficile infection detected by cytotoxin assay between August, 2008 and July, 2012. Basic demographics, mode of acquisition (nosocomial versus community), laboratory and clinical features, treatment, and outcome data were collected. Pulsed-field gel electrophoresis and polymerase chain reaction detection of toxin A (tcdA), toxin B (tcdB), binary toxin (cdtB) and tcdC genes were performed on isolates from nosocomial cases by the National Microbiology Laboratory, Winnipeg, Manitoba.ResultsNinety percent of children with CDI experienced resolution of symptoms by 30 days after disease onset and 2% experienced a severe outcome. There were no cases where colectomy was performed for CDI, and only one case where CDI contributed to death. Various combinations of clinical and laboratory features were not predictive of a severe outcome. Seventy-four percent of cases were nosocomial-associated. Among all cultured strains, the NAP4 strain occurred most frequently (24%), followed by NAP1 (11%). There was no association between strain type and clinical outcome; however, relapses were significantly more frequent in NAP4-infected children.ConclusionsSevere outcomes due to CDI are uncommon in children compared to adults. Further prospective pediatric studies on CDI in community and hospital settings are required to better understand risk factors, optimal treatment and the significance of NAP4 in pediatric CDI.

An Unusual Case of Clostridium difficile Infection in Trinidad and Tobago

Clostridium difficile infection (CDI) is the leading cause of healthcare-associated diarrhea. Psuedomembraneous colitis is a major complication of CDI and its outbreaks with increased severity and mortality has been reported. In this study we report the first fatal case of a toxin A and B gene positive strain of C. difficile associated with pseudomembraneous colitis in a patient from Trinidad and Tobago. Patients admitted to tertiary hospitals with history of diarrhea were investigated and reviewed. A fatal case of a 47-year old Trinidadian of African descent who presented with diarrheal stool at a public hospital in Trinidad and Tobago was reviewed and is being reported. The identified patient had his stool sample analyzed using conventional and molecular microbiology procedures to identify the C. difficile bacteria, toxins and genes. The antimicrobial susceptibility profile was also determined using agar dilutions according to CLSI guidelines.This patient’s stool sample was positive for Clostridium difficile toxin and the enzyme glutamate dehydrogenase which were demonstrated using the Quick Check Complete® kit. The antimicrobial susceptibility test produced an unusual profile - being resistant to meropenem, ampicillin, ceftriaxone, cefotaxime and ciprofloxacin. PCR analysis demonstrated that the strain produced a 1266bp and 204bp DNA fragment corresponding to the toxin A and B gene respectively, based on the primers used. This organism was noted to be responsible for the development of psuedomembranous colitis that led to the demise of this patient. Surveillance work need to be instituted as well as antibiotics stewardship so as to prevent any more case of inflammatory bowel diseases prevalence in our country.

In VitroandIn VivoAntibacterial Evaluation of Cadazolid, a New Antibiotic for Treatment of Clostridium difficile Infections

Clostridium difficile is a leading cause of health care-associated diarrhea with significant morbidity and mortality, and new options for the treatment of C. difficile-associated diarrhea (CDAD) are needed. Cadazolid is a new oxazolidinone-type antibiotic that is currently in clinical development for treatment of CDAD. Here, we report the in vitro and in vivo antibacterial evaluation of cadazolid against C. difficile. Cadazolid showed potent in vitro activity against C. difficile with a MIC range of 0.125 to 0.5 μg/ml, including strains resistant to linezolid and fluoroquinolones. In time-kill kinetics experiments, cadazolid showed a bactericidal effect against C. difficile isolates, with >99.9% killing in 24 h, and was more bactericidal than vancomycin. In contrast to metronidazole and vancomycin, cadazolid strongly inhibited de novo toxin A and B formation in stationary-phase cultures of toxigenic C. difficile. Cadazolid also inhibited C. difficile spore formation substantially at growth-inhibitory concentrations. In the hamster and mouse models for CDAD, cadazolid was active, conferring full protection from diarrhea and death with a potency similar to that of vancomycin. These findings support further investigations of cadazolid for the treatment of CDAD.

Defining the Vulnerable Period for Re-Establishment of Clostridium difficile Colonization after Treatment of C. difficile Infection with Oral Vancomycin or Metronidazole

Background Clostridium difficile is an anaerobic, spore-forming bacterium that is the most common cause of healthcare-associated diarrhea in developed countries. A significant proportion of patients receiving oral vancomycin or metronidazole for treatment of Clostridium difficile infection (CDI) develop recurrences. However, the period of vulnerability to re-establishment of colonization by C. difficile after therapy is not well defined.Principal FindingsIn a prospective study of CDI patients, we demonstrated that most vancomycin-treated patients maintained inhibitory concentrations of vancomycin in stool for 4 to 5 days after therapy, whereas metronidazole was only detectable during therapy. From the time of elimination of the antibiotics to 14 to 21 days after therapy, a majority of stool suspensions supported growth of C. difficile and deep 16S rRNA sequencing demonstrated persistent marked alteration of the indigenous microbiota. By 21 to 28 days after completion of CDI treatment, a majority of stool suspensions inhibited growth of C. difficile and there was evidence of some recovery of the microbiota.ConclusionsThese data demonstrate that there is a vulnerable period for re-establishment of C. difficile colonization after CDI treatment that begins within a few days after discontinuation of treatment and extends for about 3 weeks in most patients.

Going Beyond Colon-Clostridium difficile Enteritis: A Rare but Real Entity!

Purpose:Clostridium difficile infection (CDI), a common cause of health care-associated diarrhea, is usually considered being restricted to colon. We present a rare case of isolated CDI of small bowel in a young patient without any major risk factors. Results: A 22-year-old female presented to the emergency department (ED) with complaints of worsening abdominal pain, nausea, and vomiting for 3 days. Patient denied fever, chills, hematemesis, hematochezia, melena, sick contact, recent antibiotic use, or recent hospitalization. She had never been diagnosed with inflammatory bowel disease nor had family history of the disease. Abdominal examination was remarkable for hypoactive bowel sounds and peri-umblical tenderness. CT scan of the abdomen showed ileus with small bowel wall thickening concerning for enteritis. Laboratory investigations were notable for white blood cell count of 14.3K/mm3 with 85% granulocytes and C-Reactive Protein (CRP) >380mg/L and serum creatinine of 0.5mg/dl. Stool Clostridium difficile toxin PCR was positive, and fecal WBC were negative. Patient was started on IV metronidazole 500 mg TID with improvement of symptoms and normalization of CRP in 1 week period. Patient was able to tolerate diet. A repeat abdominal CT scan showed interval improvement of small bowel thickening. Patient remained stable and was discharged home. A follow-up colonoscopy in 4 weeks did not show any evidence of IBD. Repeat abdominal CT scan showed complete resolution of bowel wall thickening. Patient remained symptom free on follow-up appointment. Conclusion:Clostridium difficile is considered to be a colonic pathogen. Untreated cases are associated with significant morbidity and mortality. C. difficile enteritis is a rare entity and is usually associated with immune compromised states, old age, and surgically altered intestinal anatomies. The fact that this is a relatively young patient with no predisposing medical illnesses and risk factors makes it a unique case. Reporting such cases will help recognize and provide future clinical insight into community acquired C.difficile enteritis. Clinical recognition of C. difficile infection not only in colon but also in small intestine can improve clinical outcomes in patients.

A Surview of Recent Patents on Anti-Infective Therapy for Clostridium difficile

Clostridium difficile has become the most common infectious cause of healthcare-associated diarrhea, with serious morbidity, prolonged hospitalization and even death. Treatment of the disease utilizing today's therapies does not guarantee a successful outcome. In the past decade, many new ideas and inventions have surfaced exploring different treatment strategies of Clostridium difficile associated diarrhea (CDAD). These treatments include antitoxins, novel antimicrobials, immunoglobulins and large inert synthetic compounds. In this paper, we survey of a number of representative patents issued from 2000 to the present targeting treatment of this difficult and dreaded disease.

Clostridium difficile Infection in Children

Clostridium difficile is the most common cause of health care-associated diarrhea among adults in the United States and is associated with significant morbidity and mortality. During the past decade, the epidemiology of C difficile infection (CDI) has changed, including a rise in the rate and severity of infection related to the emergence of a hypervirulent strain as well as an increase in disease among outpatients in community settings. Although less is known about CDI among pediatric patients, C difficile is increasingly recognized as an important pathogen among children. In this review, we discuss recent updates in the incidence and epidemiology of CDI among children, including risk factors for infection, and highlight the importance of CDI in special populations of children, particularly those with inflammatory bowel disease or cancer. In addition, we review current knowledge in the areas of diagnosis and management of CDI among children and highlight future areas for research.

Recent trends in the epidemiology and treatment of C. difficile infection in children

Clostridium difficile is the most common cause of healthcare-associated diarrhea among adults in Western countries, and is increasingly recognized as an important pathogen in children. This review provides an update on the changing epidemiology of C. difficile infection (CDI) for pediatric providers and summarizes current knowledge regarding available therapies. The incidence of CDI has more than doubled among adults over the past decade, with a particular rise in incidence among patients presenting from the community. CDI has also increased among children in both inpatient and outpatient settings and there is growing evidence that specific populations of children may be at highest risk. Antibiotic-based therapies remain the mainstay of treatment for CDI, but new therapies have been developed with potential future applications in children. Use of nonantibiotic-based therapies is limited in children, but their use has been studied among adults with intractable or recurrent disease. The rise in incidence of CDI over the past decade warrants increased recognition by pediatric providers. Knowledge of the pediatric populations at highest risk for infection as well as the options for therapy will improve understanding of this changing disease.

Characterization of a Stable, Metronidazole-Resistant Clostridium difficile Clinical Isolate

Background Clostridium difficile are Gram-positive, spore forming anaerobic bacteria that are the leading cause of healthcare-associated diarrhea, usually associated with antibiotic usage. Metronidazole is currently the first-line treatment for mild to moderate C. difficile diarrhea however recurrence occurs at rates of 15–35%. There are few reports of C. difficile metronidazole resistance in the literature, and when observed, the phenotype has been transient and lost after storage or exposure of the bacteria to freeze/thaw cycles. Owing to the unstable nature of the resistance phenotype in the laboratory, clinical significance and understanding of the resistance mechanisms is lacking.Methodology/Principal FindingsGenotypic and phenotypic characterization was performed on a metronidazole resistant clinical isolate of C. difficile. Whole-genome sequencing was used to identify potential genetic contributions to the phenotypic variation observed with molecular and bacteriological techniques. Phenotypic observations of the metronidazole resistant strain revealed aberrant growth in broth and elongated cell morphology relative to a metronidazole-susceptible, wild type NAP1 strain. Comparative genomic analysis revealed single nucleotide polymorphism (SNP) level variation within genes affecting core metabolic pathways such as electron transport, iron utilization and energy production.Conclusions/SignificanceThis is the first characterization of stable, metronidazole resistance in a C. difficile isolate. The study provides an in-depth genomic and phenotypic analysis of this strain and provides a foundation for future studies to elucidate mechanisms conferring metronidazole resistance in C. difficile that have not been previously described.

Clostridium Difficile Infection in Hospitalized Patients at University Clinical Center Tuzla, Bosnia and Herzegovina: a 4 Year Experience

Introduction:Clostridium difficile (C. difficile) is currently the leading cause of healthcare-associated diarrhea, but almost nothing is known about the extent of C. difficile infection (CDI) in Bosnia and Herzegovina.Goal:We aimed to retrospectively analyze CDI in hospitalized patients at University Clinical Center (UCC) Tuzla, Bosnia and Herzegovina from January 2009 through June 2012.Methods:We analyzed all patients (except children ages 0-2), diagnosed with CDI based on anamnestic and epidemiological, clinical picture and microbiological tests (proof of toxins in the stool by enzyme-linked immunosorbent assay).Results:From a total of 989 patients tested for C. difficile toxin (60.2 per 10,000 inpatient days) 347 (35.08%) were positives. The mean incidence rate of CDI was 2.23 per 10,000 inpatient days (range 1.32-2.87). Annual rates of hospitalization were 15.68 per 10,000 admissions (range 8.99-20.35). Most patients had a previously identified risk profile of old age, comorbidity and recent use of antibiotics. 41/276 (14.86%) patients had died, and 11/41 (26.82%) were CDI-associated deaths. Complicated CDI were registered in 53/276 (19.21%) patients, and recurrent infections in 65/276 (23.55%).Conclusion:Our data suggest that CDI is largely present in our setting which represents a serious problem and points to the importance of international surveillance, detection and control of CDI.

Safety and efficacy of fidaxomicin in the treatment of Clostridium difficile-associated diarrhea

Clostridium difficile-associated diarrhea (CDAD) is the most common cause of healthcare-associated diarrhea. The current recommended treatment regimens of metronidazole and vancomycin have not changed in nearly 25 years. Fidaxomicin, an exceedingly narrow spectrum macrolide antibiotic, was recently approved for the treatment of CDAD. In phase III clinical trials, fidaxomicin was noninferior to vancomycin in achieving clinical cure of CDAD. Furthermore, fidaxomicin was associated with fewer recurrences of CDAD compared with vancomycin in clinical trials. These results, combined with the ease of administration and a good safety profile, make fidaxomicin an attractive treatment option for treating CDAD.

Case fatality associated with a hypervirulent strain in patients with culture-positive Clostridium difficile infection: a retrospective population-based study

Clostridium difficile is a major infectious cause of healthcare-associated diarrhea. The epidemiology of C. difficile infection (CDI) is changing, with evidence of increased incidence and severity. The first patient with a hypervirulent strain type in Pirkanmaa Hospital District, Finland was reported in September 2008. We reviewed all culture-positive C. difficile episodes that occurred in Pirkanmaa Hospital District during the period September 2008 to May 2010. A total of 780 episodes of C. difficile occurred in 622 patients. A hypervirulent strain caused 14.2% of all episodes. The day 30 case fatality associated with CDI was 8.5% in episodes with a non-hypervirulent strain and 20.7% in episodes with a hypervirulent strain type (p<0.001, odds ratio 2.8, 95% confidence interval 1.6-4.8). The median age among those infected by a hypervirulent strain was higher than among those infected by a non-hypervirulent strain (83 vs. 75 years, p<0.001). Hypervirulent strain type remained a significant factor associated with case fatality in a logistic regression model. Blood leukocytes were significantly higher in episodes due to a hypervirulent strain (11.0 vs. 9.4 × 10(9)/l, p=0.007). Blood leukocytes and C-reactive protein (CRP) on the day of diagnosis were significantly higher in non-survivors compared to survivors in CDI (13.2 vs. 9.6 × 10(9)/l, p=0.009, and 106.0 vs. 79.4 mg/l, p<0.001, respectively). Infection due to a hypervirulent strain is a factor associated with increased case fatality in CDI. Blood leukocytes are significantly higher in CDI caused by a hypervirulent strain. Leukocyte count and CRP are useful prognostic biomarkers in patients with CDI.

Loop-Mediated Isothermal Amplification Compared to Real-Time PCR and Enzyme Immunoassay for Toxigenic Clostridium difficile Detection

Clostridium difficile infection is the primary cause of health care-associated diarrhea. While most laboratories have been using rapid antigen tests for detecting C. difficile toxins, they have poor sensitivity; newer molecular methods offer rapid results with high test sensitivity and specificity. This study was designed to compare the performances of two molecular assays (Meridian illumigene and BD GeneOhm) and two antigen assays (Wampole Quik Chek Complete and TechLab Tox A/B II) to detect toxigenic C. difficile. Fecal specimens from hospitalized patients (n = 139) suspected of having C. difficile infection were tested by the four assays. Nine specimens were positive and 109 were negative by all four methods. After discrepant analysis by toxigenic culture (n = 21), the total numbers of stool specimens classified as positive and negative for toxigenic C. difficile were 21 (15%) and 118 (85%), respectively. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were as follows: GeneOhm (95.2%, 100%, 100%, and 99.2%), illumigene (95.2%, 96.6%, 83.3%, and 99.2%), Tox A/B II (52.4%, 97.5%, 78.6%, and 92.4%), and Quik Chek Complete (47.6%, 100%, 100%, and 91.9%). The illumigene assay performed comparably to the GeneOhm assay with a slight decrease in test specificity; the sensitivities of both far exceeded those of the antigen assays. The clinical characteristics of the concordant and discrepant study patients were similar, including stool consistency and frequency. In the era of rapid molecular-based tests for toxigenic C. difficile, toxin enzyme immunoassays (EIAs) should no longer be considered the standard of care.