5,6-Fused heterocycle cholate derivatives as spore germination inhibitors of Clostridioides difficile.

Clostridioides difficile ribotypes (RTs) 001 and 176 dominate the epidemiology of C. difficile infection (CDI) in the Czech Republic. We applied whole-genome sequencing (WGS) and broad-range antimicrobial susceptibility testing (AST) to provide detailed characterization of these lineages. Between October and December 2019, 22 hospitals participated. CDI isolates were characterized by PCR ribotyping, toxin gene detection and AST to metronidazole, vancomycin and moxifloxacin. WGS and broad-range AST were performed on selected RT001 and RT176 isolates. The mean CDI incidence was 5.1 cases/10,000 patient-days. Isolates and epidemiological data were available for 495/524 (94.5%) CDIs. RT001 (n = 166, 33.5%), RT014 (n = 59, 11.9%) RT176 (n = 51, 10.3%) were the most prevalent. Among 21 RT001 isolates, wgMLST (3745 loci) revealed 0-120 allele differences and 21 genomic inserts, eight of which carried antimicrobial resistance (AMR) genes, including cfrB, which encodes linezolid resistance. In 13 RT176 isolates, wgMLST (3298 loci) showed 0-9 allele differences and 11 inserts, eight with AMR genes. The wgMLST confirmed clonal relatedness of RT001 and RT176 isolates from different hospitals (0-3 allelic differences), yet with variation in acquired AMR gene content. Differences between genotype and expected phenotype were observed in PnimBG and metronidazole, cfrE and linezolid and tet-genes and tetracycline. RT001 and RT176 predominate in the Czech Republic, and WGS confirmed their inter-hospital clonal relatedness. Importantly, the emergence of linezolid-resistant RT001 strains was detected in nine hospitals. The inclusion of AMR genes in genetic relatedness analysis showed higher discriminatory power compared to cgMLST or wgMLST alone.

Fecal microbiota transplantation (FMT) has emerged as a revolutionary treatment strategy for restoring gut microbiota in recurrent Clostridioides difficile infection and has also been explored across a broader range of dysbiosis-related diseases such as inflammatory bowel disease where it has demonstrated promising results and potential therapeutic benefits. The success of FMT largely depends on the careful implementation of best practices, which include selecting appropriate donors, preparing the stool properly, and choosing the right delivery methods. This mini-review explores the evolution of FMT methodologies, including donor screening protocols, advances in stool preparation, and innovations in administration routes. We also discuss emerging approaches, such as synthetic microbiota and microbiome engineering, alongside the challenges and future directions for standardizing FMT. These methodological advancements aim to enhance safety, efficacy, and accessibility of FMT, establishing it as a key player in microbiome-based therapies.

Clostridioides difficile infection (CDI) is principally precipitated by antibiotics, due to their disruption of gut commensal bacteria. The comparative role of nonantibiotic drugs is poorly characterized. We examined the contribution of antibiotic and nonantibiotic drugs to CDI risk among residents age >65 years old and not hospitalized in the prior 30 days, between 2018 and 2023. The study used a case-cohort study design, with logistic regression analysis. The case definition consisted of first incident CDI, identified using comprehensive C. difficile testing, hospitalization, and treatment data. Outpatient oral drug exposures were measured in a 1-90-day window prior to case and control days. Adjusted regression models included covariates for age, sex, year and quarter, region, comorbid conditions, healthcare exposures, and drug exposures. Among 16 196 CDI case patients and 549 831 controls, 335 drugs were included. After adjustment, the antibiotics amoxicillin-clavulanate (odds ratio [OR], 6.05 [95% confidence interval (CI), 5.69-6.43]), clindamycin (16.83 [15.53-18.24]), ciprofloxacin (3.83 [3.59-4.09]), and cephalexin (3.05 [2.86-3.25]), were the largest contributors to CDI risk. Nonantibiotic drugs pantoprazole (OR, 1.33 [95% CI, 1.27-1.39]) and ferrous fumarate (1.71 [1.61-1.82]) were the next largest. Metformin had a protective association (OR, 0.67 [95% CI, .63-.72]). In a meta-regression on a subset of 182 drugs, in vitro anticommensal activity was positively associated with CDI risk (P < .001). This study provides insights into CDI etiology and avenues for stewardship and drug repurposing to combat CDI and antimicrobial resistance.

The natural history of ulcerative colitis is characterized by the occurrence of recurrent flares. Flares in ulcerative colitis may be attributed to the natural history of the disease or other extraneous factors. Two important causes for iatrogenic flares are Clostridioides difficile infection and cytomegalovirus (CMV) colitis. We evaluated the prevalence of Clostridioides difficile infection in patients with moderate to severe ulcerative colitis admitted to a tertiary care hospital. This prospective study carried out at a tertiary care center in India evaluated patients of ulcerative colitis who presented with an acute flare of the disease over a 13-month period from May 2023 to May 2024. An enquiry of antibiotic exposure in the preceding eightweeks prior to the current admission was obtained. Simultaneous testing of glutamate dehydrogenase (GDH) and Clostridioides difficile toxin assay was done in all patients within 24hours of admission by the enzyme-linked immunosorbent assay (ELISA) technique. Of the 140 patients with an acute flare associated with ulcerative colitis who were evaluated for Clostridioides difficile infection, four tested positive for both GDH and toxin A and/or B giving an overall prevalence of 2.9%. Two of these four (50%) patients had prior exposure to antibiotics at the time of admission. Each of the four patients with Clostridioides difficile infection had an uneventful recovery post treatment with oral vancomycin and metronidazole. Our data suggests that C. difficile is not a major causative factor for flares in patients with moderate to severe ulcerative colitis at a tertiary care hospital in northern India.

To compare clinical outcomes for patients with a positive urine culture who were prescribed antibiotics vs those who were not prescribed antibiotics, as determined by pharmacist-conducted symptom evaluation via an outpatient culture follow-up program. This retrospective cohort study included adult female patients with a positive urine culture collected at an emergency department (ED) or urgent care (UC) visit who were contacted by a pharmacist for follow-up and symptom assessment. Patients with urinary symptoms had antibiotic therapy initiated or changed (standard of care [SOC]); however, patients without symptoms did not receive a new antibiotic prescription (intervention). The primary objective was to compare treatment for symptomatic urinary tract infection within 30 days of follow-up between the groups. Secondary objectives included evaluating pharmacist workload and comparing adverse events and Clostridioides difficile infection within 30 days between the groups. A total of 214 patients were included (97 in the SOC group and 117 in the intervention group). At their initial visit, 83.5% of patients in the SOC group reported urinary symptoms vs 53% of patients in the intervention group (P < 0.001). Empiric antibiotic prescribing was similar between the groups (SOC, 37.1%; intervention, 25.6%; P = 0.392). There was no difference in treatment of symptomatic urinary tract infection within 30 days of follow-up (SOC, 14.4%; intervention, 11.1%; P = 0.466). Follow-up occurred on average 2.5 days after discharge, requiring a median of 1 contact attempt and 15 minutes to conduct the call and documentation. Our findings support nonprescribing of antibiotics at follow-up for asymptomatic patients, despite a positive urine culture, as an appropriate stewardship intervention for ED and UC patients to prevent unnecessary antibiotic exposure.

Bloodstream infections (BSI) are a leading cause of mortality worldwide. Rapid detection of the causative pathogen can help optimise therapy, reduce mortality, curb antimicrobial resistance, and lower healthcare costs. This study evaluates the cost effectiveness of adding molecular rapid diagnostic tests (mRDTs) to microbiology standard-of-care (SoC) methods. mRDTs evaluated include the Cobas® Eplex blood culture identification (BCID) panels, BioFire BCID panel, BioFire BCID2 panel, Accelerate PhenoTest™ blood culture (BC) kit and Diasorin Verigene® BCID panels. A decision-tree model was built to quantify the incremental costs and outcomes associated with adding mRDTs to the SoC. The inputs were derived from the published literature. The analysis considered a population aged 65years and 45% female, admitted to a United States (US) hospital with a suspected BSI. Model outcomes included costs, 30-day mortality, quality-adjusted life years (QALYs) and adverse events (Clostridioides difficile infection and acute kidney injury [AKI]). A United Kingdom (UK) setting in place of the US setting was also considered in the scenario analysis. A strategy involving the Cobas Eplex BCID panels as an adjunct test to the SoC dominated SoC alone without Cobas Eplex BCID panels, saving US$164 per patient and averting 24 deaths per 10,000 patients. Earlier optimisation of ineffective empiric therapy generated half of the lives saved, with the majority of the remainder from reductions in AKI. This strategy was also dominant compared with other mRDTs. In a UK setting, Cobas Eplex BCID panels remained cost effective, saving £51 compared with SoC. Results were robust to scenarios varying key model inputs including time to pathogen identification with SoC. The model demonstrated improved patient survival and reduced average total costs with mRDT. The Cobas Eplex BCID panels, which have the largest pathogen coverage, reduced both mortality and overall costs compared with other mRDTs.

A multifunctional probiotic co-delivery platform for the treatment of Clostridium difficile infection.

Abstract Background Recurrence of Clostridioides difficile infection (CDI) is frequent, particularly in patients requiring subsequent systemic antibiotics. Observational studies suggest that secondary prophylaxis with oral vancomycin (SPV) may reduce recurrence risk, but randomized evidence remains scarce. Methods PREVAN (NCT05320068) was a phase III, double-blind, placebo-controlled randomized clinical trial conducted at a tertiary hospital in Spain. Adults with documented CDI within the previous 180 days who required hospitalization and systemic antibiotics were randomized (2:1) to receive oral vancomycin (125 mg every 6 h) or placebo for 10 days, stratified by type of index CDI episode. Primary endpoints were CDI recurrence within 60 days after end of therapy and CDI recurrence-free survival. Results Twenty-one patients were enrolled (14 SPV; 7 placebo). Mean age was 73.5 years and 76.7% had malignancy and/or immunosuppression. CDI recurrence occurred in 5 patients (23.8%): 2 (14.3%) in the SPV group and 3 (42.9%) in the placebo group (P = 0.30). CDI recurrence-free survival at 60 days was 83% (95% CI 48–95) with SPV versus 42% (95% CI 6–77) with placebo (log-rank P = 0.09). No treatment-related serious adverse events were observed; one mild diarrhoeal event occurred in a placebo-treated patient. Conclusions In high-risk patients with recent CDI requiring systemic antibiotics, SPV appeared safe and was associated with a clinically relevant reduction in recurrence, although the trial was underpowered. These findings support further adequately powered randomized studies to define the role of SPV in preventing CDI recurrence.

The pharmacological management of acid-related disorders has been revolutionized by proton pump inhibitors (PPIs), yet their widespread use has led to a global epidemic of overprescription. This review addresses the silent metabolic and infectious consequences of chronic PPI administration, providing a safety guide for front-line clinicians. A systematic narrative synthesis was conducted using PubMed, Embase, and the Cochrane Library, utilizing MeSH terms and PRISMA 2020 guidelines to analyze over 2,600 identified citations. Findings reveal that chronic acid suppression significantly impairs the absorption of Vitamin B12 and magnesium, the latter linked to genetic polymorphisms in TRPM6/7 transporters. Furthermore, long-term use is associated with a 72 percent increased risk of chronic kidney disease and a 1.7-fold to 2.3-fold increase in Clostridioides difficile infection risk. Emerging evidence also links PPIs to vascular senescence through the accumulation of asymmetric dimethylarginine and potential cognitive decline via V-ATPase inhibition. The review concludes that while PPIs are safe for short-term mucosal healing, their chronic use carries substantial iatrogenic risks. Rational prescribing requires biannual clinical reassessment and the implementation of proactive deprescribing protocols to mitigate systemic harm and ensure patient safety in long-term therapy.

Clostridioides difficile infection (CDI) requiring colectomy carries substantial mortality risk, with optimal timing of surgery remaining poorly defined. We examined temporal trends in colectomy among inpatients with CDI, identified predictors of surgical intervention and postoperative mortality, and evaluated the association between surgical timing and patient outcomes. A retrospective cohort study was conducted using the National Inpatient Sample database from 2018 to 2022. We compared patients undergoing colectomy with those managed medically. To minimize confounding by hospital-onset cases, the analysis of surgical timing and mortality was restricted to patients undergoing colectomy within 8 days of admission. Predictors were identified using survey-weighted logistic regression and LASSO regression models. Among 240,564 CDI hospitalizations (representing 1,207,995 weighted nationally), 717 patients underwent colectomy (3,585 weighted). CDI prevalence declined from 0.99% (2018) to 0.76% (2022), while colectomy rates increased from 0.28% to 0.34%. Peritonitis (OR 5.42; 95% CI, 4.46-6.59), coagulopathy (OR 4.96; 95% CI, 3.76-6.55), and sepsis/septic shock (OR 3.89; 95% CI, 3.39-4.47) were the strongest predictors of colectomy. Among patients undergoing colectomy within 8 days (2,830 weighted), in-hospital mortality was 26.5% overall, increasing from 21.0% (2018) to 30.7% (2022). Sepsis/septic shock (OR 8.20; 95% CI 2.92-23.07) and coagulopathy (OR 7.27; 95% CI 3.31-15.97) predicted mortality. Each additional day from admission to colectomy was associated with a 16% (OR 1.16; 95% CI 1.04-1.28) increased mortality risk. In this nationally representative cohort, surgical timing was an independent and modifiable determinant of survival in patients with CDI requiring colectomy. Our findings underscore the importance of early surgical consultation for CDI patients with peritonitis, sepsis, and coagulopathy.

Following an extended period of declining prevalence of the epidemic Clostridioides difficile ribotype 027 (RT027) in Portugal, a genetically distinct, multidrug-resistant (MDR) RT027 strain with reduced susceptibility to vancomycin has emerged, causing a 15-month outbreak. This investigation provides epidemiological and genomic evidence for renewed circulation and evolutionary adaptation of this high-risk lineage. A comprehensive outbreak investigation was conducted in a tertiary-care hospital in northern Portugal between 2023 and 2025. Epidemiological and clinical data, antimicrobial exposures, and infection-control measures were analysed. Whole-genome sequencing (WGS) was performed to characterize the outbreak clone. Sixty-six RT027 C. difficile infection (CDI) cases were confirmed, with incidence peaking at 5.46 cases per 10,000 patient-bed days in April 2024. WGS revealed an unusual accumulation of AMR determinants conferring a broad MDR phenotype. Notably, all isolates harboured the VanR T115A substitution, a rare mutation previously linked to reduced vancomycin susceptibility, raising concerns regarding evolving antimicrobial tolerance within RT027. The close relatedness to 2016-2018 USA isolates suggests a recent emergence of this clone. Transmission was facilitated by structural constraints, limited isolation capacity and shared sanitary facilities. This prolonged outbreak documents the re-emergence and genomic evolution of a hypervirulent RT027 lineage, characterised by a concerning expansion of antimicrobial resistance and decreased vancomycin susceptibility and a high recurrence rate (25%). These findings highlight the ongoing adaptive potential of C. difficile under antimicrobial pressure and underscore the need for strengthened surveillance, genomic monitoring, and infection-prevention strategies to mitigate re-establishment of epidemic RT027 strains in Europe and beyond.

Clinical utility of the MN severity criteria in predicting recurrent Clostridioides difficile infection.

ZBTB16 controls the onset of Clostridium difficile colitis through the Pyrin inflammasome.

Objective. To perform a comparative analysis of surgical and conservative treatment of pseudomembranous colitis (PMC) and to identify risk factors associated with the need for surgical intervention. Material and methods. The study was conducted at the Loginov Moscow Clinical Scientific and Practical Center between 2017 and 2023. A total of 67 patients with clinically confirmed severe and fulminant PMC were included. Surgical treatment was performed in 11 patients, while 56 patients received conservative therapy. Clinical, endoscopic, and laboratory parameters, as well as the incidence of complications, were analyzed. Multivariate analysis with odds ratio (OR) estimation was used to identify risk factors for surgical intervention, followed by the development of a prognostic model. Results. Patients who underwent surgical treatment more frequently presented with fever (p=0.001; OR=8.821; 95% CI 2.039—38.162), stool frequency ≥10 times per day (p=0.045), and hematochezia (p=0.004; OR=6.944; 95% CI 1.616—29.841). Endoscopic examination more often revealed contact bleeding of the colonic mucosa (p=0.032; OR=4.622; 95% CI 1.062—20.127) and difficulty in pseudomembrane fragmentation (p=0.046). Among complications, colonic bleeding (p&lt;0.001; OR=31.429; 95% CI 3.063—322.434) and colonic dilatation (p=0.016; OR=12.222; 95% CI 1.001—149.161) were significantly more common in surgically treated patients. Preoperative red blood cell transfusion was performed more frequently in the surgical group (45.5% vs 10.7%; p=0.004). The prognostic model demonstrated high diagnostic accuracy (AUC=0.916; p&lt;0.001), with a sensitivity of 97.6% and specificity of 63.6%. Conclusions. Risk factors for surgical intervention in PMC include hematochezia, fever at hospital admission, contact bleeding of the colonic mucosa, development of colonic bleeding, colonic dilatation, and the need for red blood cell transfusion.

Clostridioides difficile infection (CDI) is a major public health concern, particularly in aging populations. The aim of this study was to evaluate global trends in CDI-related mortality to inform sustainable and cost-effective management strategies. We conducted an observational study using mortality data from the World Health Organization (WHO) database spanning 2001 to 2023. Sixty-three countries with satisfactory data quality and at least 12 years of data between 2001 and 2023 were included. Crude and age-standardized CDI-related mortality rates per 1,000,000 individuals were calculated after stratification by age, sex, WHO region, and sociodemographic index (SDI). Global trends were analyzed using locally weighted regression. The global age-standardized CDI-related mortality rate was 0.76 per 1,000,000 individuals in 2001, peaked at 4.08 in 2010, and declined to 2.44 in 2023. The most notable downward trends were observed in the Americas and high-SDI countries. These improvements may reflect the impact of multidisciplinary efforts in CDI prevention and management. Although CDI-related mortality has declined globally over the past decade, the disease remains a significant threat, especially in older populations. Ongoing global efforts are essential to further reduce CDI-related deaths.

Towards better severity stratification in Clostridioides difficile infection: bridging the gap between surveillance and clinical practice.

MALDI-TOF mass spectrometry coupled with machine learning: an accurate tool to detect toxigenic Clostridioides difficile strains.

Clostridioides difficile infection (CDI) is recognized as the leading cause of antibiotic-associated diarrhea. There are several case reports of C. difficile enteritis in patients who have undergone colectomy and end ileostomy or ileal pouch-anal anastomosis. This case report describes a unique case of recurrent C. difficile enteritis following proctocolectomy and ileoanal pouch, treated successfully with faecal microbiota transplantation (FMT) via anterograde and retrograde delivery into the small bowel.

Faecal microbiota transplantation (FMT) is highly effective for recurrent Clostridioides difficile infection but yields inconsistent benefits in chronic indications. As a crude whole-microbiota transplant, FMT contains numerous undefined active components, complicating efforts to ensure treatment predictability and stability. Therefore, we propose Advance Microbiota Transplantation (AMT), a comprehensive, phase-based hypothesis that employs an addition-subtraction strategy throughout the pre-, peri- and post-transplant stages. AMT comprises donor and recipient pre-treatment, procedural optimisation and post-transplant adjuvant interventions to mitigate donor variability, ecological resistance, procedural heterogeneity and unstable engraftment. Through a systematic synthesis of current evidence-based FMT research, we explored how the addition-subtraction strategy can be operationalised to shape the AMT concept and define testable, phase-specific levers, thereby providing a foundation for future clinical translation. In parallel, we appraised the reporting quality using the Preferred Reporting Items for Microbiotherapy (PRIM) and identified six persistently under-reported items that limit the interpretability, comparability, and reproducibility of FMT research. This review aims to facilitate the integration of AMT into clinical practice.