Management Of Clostridium Difficile Infection Research Articles

Diagnostic Approach and Management of Clostridium difficile Infection

Diagnostic Approach and Management of Clostridium difficile Infection

Diagnostic Approach and Management of Clostridium difficile Infection

Diagnostic Approach and Management of Clostridium difficile Infection

Faecal microbiota transplantation for bipolar disorder: A detailed case study.

Faecal microbiota transplantation for bipolar disorder: A detailed case study.

BEZLOTOXUMAB THERAPY FOR RECURRENT CLOSTRIDIUM DIFFICILE INFECTION IN AN ULCERATIVE COLITIS PATIENT

Clostridium difficile infection (CDI) is the most common infectious cause of nosocomial diarrhea, comprising 10-20% of all cases. CDI is a significant complication for IBD patients. Not only can CDI induce IBD flare, IBD patients also experience significantly higher CDI recurrence when compared to the general population. New monoclonal antibody (mAB) therapies, such as bezlotoxumab, have improved management of recurrent CDI (rCDI). The MODIFY I/II trial included 44 patients with known IBD, 28 of which received bezlotoxumab.

Clostridium difficile infection characteristics in a general surgery clinic.

Clostridium difficile (CD) is an anaerobic, gram-positive bacterium that can produce a spectrum of gastrointestinal diseases ranging from pseudomembranous colitis to diarrhea to toxic megacolon. The infection is even more difficult to manage as CD produces high-end spores, suggesting that this may be the cause of the dangerous recurrent disease as well as dissemination among healthy members in the community. Spores can be hosted in the digestive tract of both symptomatic and asymptomatic patients. The most relevant risk factor in the development of Clostridium difficile infection (CDI) seems to be the overuse of antimicrobials. Comorbidities are another risk factor that may predispose towards more serious CDI. Treatment options vary from oral antibiotics to extensive surgical interventions. The present study aimed to analyze the prevalence, severity, and management of CDIs in a general surgery department in an effort to determine the correlative elements between the infection and surgical pathology.

Fulminant Clostridium Difficile colitis after ileostomy reversal: Case Report and Review of Literature

Introduction: Clostridium Difficile infection (CDI) following restoration of intestinal continuity is uncommon and may progress to fulminant colitis. Fulminant CDI is associated with significant morbidity and mortality. In an unwell patient without clear evidence of an anastomotic leak, surgeons should be aware of the possibility of CDI and institute appropriate management. Presentation of Case: We report the case of a 71- year-old man, who presented for an elective loop ileostomy reversal after an ultra-low anterior resection for a low rectal cancer eight months prior. The patient deteriorated clinically on post-operative day (POD) 4 and by POD 5 was in septic shock with multi-organ failure. A relook laparotomy confirmed no anastomotic leak and a flexible sigmoidoscopy revealed typical appearance of pseudomembranous colitis. The patient continued to deteriorate in the intensive care unit despite oral and rectal Vancomycin. An abdominal computed tomography (CT)1 on POD 9 demonstrated severe pancolitis and enteritis necessitating surgical intervention. He underwent an emergency subtotal colectomy with an end ileostomy after failing medical management. Discussion: Many factors have been shown to increase the incidence of Clostridium difficile colonization in the colon including recent hospitalization, antibiotic use, and length of defunctioning beyond six months. The presence of risk factors associated with an increase in CDI such as proton pump inhibitor use, steroid use or immunosuppression and advanced age may allow surgeons to predict high risk patients. Conclusion: Although rare, fulminant CDI following reversal of ileostomy is a potentially fatal condition. Surgeons should be aware of the risk factors predisposing patients to CDI particularly in a patient with an acute abdomen without clear evidence of an anastomotic leak.

Severe Clostridium difficile infections in intensive care units: Diverse clinical presentations.

Clostridium difficile infections (CDIs) cause significant mortality and morbidity. Critically ill patients are susceptible to CDIs and tend to have severe CDIs, and their clinical presentations are not merely diarrhea. From September 2017 to March 2018, the adults with CDIs in the ICUs were included. Fecal specimens with positive results of glutamate dehydrogenase assay were cultured for C. difficile, and toxinotyping and ribotyping for available C. difficile isolates were done. The CDI cases were categorized into the diarrheal group and ileus group. Difficult-to-treat cases with the presentations of life-threatening complications (bowel perforation or bacteremia), toxic megacolon, and refractory diarrhea, were analyzed. Totally 23 cases, including 6 cases of ileus and 17 of diarrhea, were included. Overall, the incidence of CDI in the ICUs was 10.7 cases per 10,000 patient-days. The ileus group tended to have more severe presentation, shorter ICU stay, higher ICU mortality, and receive initial intravenous metronidazole therapy. Severe and fulminant CDIs accounted for 65.2% (15 cases). The ICU mortality rate was 39.1%, but only one death was directly related to CDI (4.3%). Of nine (39.1%) difficult-to-treat cases, there was only one isolate of RT611 with tcdC deletion and cdtA/cdtB from a case with toxic megacolon. No hypervirulent isolates of RT027 or 078 were detected. Severe CDIs in the ICU were not rare. Clinicians should be aware of abdominal symptoms and signs other than diarrhea, such as ileus, to make timely diagnosis and management of CDI.

Clostridioides difficile (formerly Clostridium difficile) infection in the critically ill: an expert statement.

Clostridioides difficile (formerly Clostridium difficile) infection (CDI) represents a worrisome condition, often underestimated, with severe clinical presentations, frequently requiring intensive care unit (ICU) admission. The aim of the present expert statement was to give an overview of the management of CDI in critically ill patients, for whom CDI represents a redoubtable problem, in large part related to the use and abuse of antibiotics. The available knowledge about pathophysiology, risk factors, diagnosis and treatment concerning critical care patients affected by CDI has been reviewed, even though most of the existing information come from studies performed outside the ICU and the evidence on several issues in this specific context is scarce. The adoption of potential preventive and therapeutic strategies aimed to stem the phenomenon were discussed, including the faecal microbiota transplantation. This possibility could represent a highly interesting option in critically ill patients, but current evidence is limited and future well designed studies are needed. A special insight on the specific challenges that the ICU physicians may face caring for the critically ill patients with CDI was also proposed.

Guidelines for Clostridium difficile infection in adults.

Clostridium difficile infection (CDI) has become a serious medical and epidemiological problem, especially in well developed countries. There has been evident increase in incidence and severity of CDI. Prevention, proper diagnosis and effective treatment are necessary to reduce the risk for the patients, deplete the spreading of infection and diminish the probability of recurrent infection. Antibiotics are the fundamental treatment of CDI. In patients who had recurrent CDI fecal microbiota transplantation seems to be promising and efficient strategy. These guidelines systematize existing data and include recent changes implemented in the management of CDI.

Clostridium Difficile Infection in Patients Impact Suspected Cytomegalovirus Infection in Patients with Inflammatory Bowel Disease.

Introduction:Clostridium difficile infection (CDI) has been reported to be a cause of flare-ups in patients with inflammatory bowel disease (IBD). Cytomegalovirus (CMV) infection can cause severe disease and complications in immunocompromised patients in consequence of disease or therapy.Aim:Our aim was to describe the prevalence and clinical outcomes of CDI with concomitant CMV infection in IBD patients hospitalized for flare-ups in association with the disease itself and medication used.Methods:We prospectively identified consecutive patients referred for CDI management during 2015-2017. Stool samples were tested for Clostridium difficile toxin A and/or B and Glutamate Dehydrogenase in patients with clinical symptoms. CDI patients with IBD history were tested for anti-CMV IgG and IgM antibodies by chemiluminescent microparticle immunoassay and underwent histological analysis for CMV on colon biopsies. Data were collected for demographic characteristics, treatment and outcome.Results:125 patients with CDI were enrolled. Among these patients, 14 (11.2%) were diagnosed with IBD. The mean patient age of IBD patients was 52.5±15.4 years at diagnosis of CDI, 85.7% had UC, 14.3% CD, while the age of patients was shared. Eleven of the total of 14 patients (78.6%) tested positive for anti-CMV IgG. Of these, 3 patients (21.4%) exhibited high CMV IgG avidity, without detectable anti-CMV IgM and biopsy-proven CMV colitis. Of the 14 IBD patients with CDI, 8 patients (57.1%) were receiving anti-tumor necrosis factor (anti-TNF) therapy (21.4 % infliximab or golimumab, 7.1% vedolizumab or adalimumab) and 43.5% of patients were being treated with systemic corticosteroids. Four UC patients (28.6%) on steroids of the 14 CDI patients underwent a colectomy whereas none of the not on steroids patients underwent colectomy (p=0.25). Among them, 1 patient (7.1%) had recurrent CDI after 5 months from the first episode of CDI.These patients were treated with vancomycin, metronidazole and fidaxomicin. The mean age of patients that had a colectomy 65.5±9.32 (n=4) was higher than the mean age of those 47.30±14.49 (n=10) who improved (UMann-Whitney=6. p=0.04).Conclusions:Immunosuppressive medications and older age are associated with increased risk of CDI and poor outcome. Although, CMV is a rare colonic pathogen in the immunocompetent patient, it should be included and screened when exacerbation of IBD occurs in patients receiving any type of immunosuppressive therapy.

Excess length of hospital stay, mortality and cost attributable to Clostridioides (Clostridium) difficile infection and recurrence: a nationwide analysis in Japan.

Clostridioides (Clostridium) difficile infection (CDI) is the leading cause of infectious diarrhoea in hospitalised patients, representing a substantial economic burden driven mainly by increased length of hospital stay (LoS). Currently in Japan, limited evidence on CDI-associated excess LoS is available. We conducted a retrospective, matched-cohort study using a large, Japanese, hospital-based administrative database. CDI was defined as CDI treatment plus either CDI diagnosis or positive enzyme immunoassay result. Propensity score matching at the time of CDI or recurrent CDI (rCDI) onset was applied to adjust baseline confounding and immortal time bias. The analysis included 5 994 054 hospitalisation records during 2008-2017, of which 11 823 were identified as CDI and 1359 as rCDI. The median excess LoS attributable to CDI and rCDI was 3 days and 6.5 days, respectively. The excess mortality attributable to CDI was 6.9%; there was no excess mortality attributable to rCDI (-1.9%). The median difference in costs attributable to CDI and rCDI during the residual stay was JPY 130 296 (USD 1185) and JPY 81 054 (USD 737) per hospitalisation, respectively. By adjusting the biases, the burden of CDI in Japan was evaluated. The findings could support decision making and resource allocation for CDI management in Japanese hospitals.

Clostridium difficile infection in fever patients with gynecological malignancies.

Although Clostridium difficile infection (CDI) often results in severe manifestations due to toxin-producing clostridium, the correlation between CDI and having a fever in gynecological malignancies is not completely understood. The incidence, and clinical features, and clinical management of CDI in patients with gynecological malignancies who have fevers were investigated, and the clinical managements of this complication are discussed. We retrospectively reviewed 485 patients newly diagnosed with invasive gynecological cancers who underwent anticancer treatment between July 2012 and December 2016. The diagnosis of CDI was performed using enzyme immunoassays for Cdifficile glutamate dehydrogenase and toxin A/B enzyme immunoassay. The cumulative risk of CDI was 9.5% (six of 63) in overall fever patients and 6.3% (six of 95) in patients with fever episodes. Two CDI patients (33.3%) did not show diarrheal symptoms, with the fever of unknown origin criteria prompting their CDI testing and diagnosis. CDI patients were treated using vancomycin or metronidazole without suffering from fatal clinical course. Overall, eight patients with gynecological malignancies were diagnosed with CDI, including two patients with fever lower than 38.5°C. The cumulative risk of CDI was 0.48% (eight of 1652) for all admitted patients and 1.6% (eight of 485) in those with gynecological malignancies. Of all the patients with confirmed CDI, only one had a history of administration of antibiotics prior to onset of CDI symptoms. CDI does not always present with typical manifestations in malignancy patients. Investigation of CDI, regardless of gastrointestinal symptoms or history of antibiotic use, is warranted in cases of fever of unknown origin in gynecological malignancy.

Management of Clostridioides (formerly Clostridium) difficile infection (CDI) in solid organ transplant recipients: Guidelines from the American Society of Transplantation Community of Practice

These updated guidelines from the American Society of Transplantation Infectious Diseases Community of Practice address the prevention and management of Clostridium difficile infection in solid organ transplant (SOT) recipients. Clostridioides (formerly Clostridium) difficile infection (CDI) is among the most common hospital acquired infections. In SOT recipients, the incidence of CDI varies by type and number or organs transplanted. While a meta-analysis of published literature found the prevalence of postoperative CDI in the general surgical population to be approximately 0.51%, the prevalence of CDI that is seen in the solid organ transplant population ranges from a low of 3.2% in the pancreatic transplant population to 12.7% in those receiving multiple organ transplants. There are no randomized, controlled trials evaluating the management of CDI in the SOT population. Herein is a review and summary of the currently available literature that has been synthesized into updated treatment guidelines for the management of CDI in the SOT population.

Healthcare provider diagnostic testing practices for identification of Clostridioides (Clostridium) difficile in children: an Emerging Infections Network survey.

To characterize healthcare provider diagnostic testing practices for identifying Clostridioides (Clostridium) difficile infection (CDI) and asymptomatic carriage in children. Electronic survey. An 11-question survey was sent by e-mail or facsimile to all pediatric infectious diseases (PID) members of the Infectious Diseases Society of America's Emerging Infections Network (EIN). Among 345 eligible respondents who had ever responded to an EIN survey, 196 (57%) responded; 162 of these (83%) were aware of their institutional policies for CDI testing and management. Also, 159 (98%) respondents knew their institution's C. difficile testing method: 99 (62%) utilize NAAT without toxin testing and 60 (38%) utilize toxin testing, either as a single test or a multistep algorithm. Of 153 respondents, 10 (7%) reported that formed stools were tested for C. difficile at their institution, and 76 of 151 (50%) reported that their institution does not restrict C. difficile testing in infants and young children. The frequency of symptom- and age-based testing restrictions did not vary between institutions utilizing NAAT alone compared to those utilizing toxin testing for C. difficile diagnosis. Of 143 respondents, 26 (16%) permit testing of neonatal intensive care unit patients and 12 of 26 (46%) treat CDI with antibiotics in this patient population. These data suggest that there are opportunities to improve CDI diagnostic stewardship practices in children, including among hospitals using NAATs alone for CDI diagnosis in children.

The Clinical and Laboratory Impact of Upgrading Clostridioides (formerly Clostridium) difficile Infection Testing from Routine to Molecular Based-Algorithm: an Observational Case-Study from the Eastern Province, Saudi Arabia.

Clostridioides (formerly Clostridium) difficile infection (CDI) is linked to misuse of antimicrobials. The prevalence of disease varies with difficulties of establishing the diagnosis because of the lack of sensitivity and specificity of laboratory tests. The clinical impact of upgrading CDI testing from routine to molecular based-algorithm is still unclear. The aim of this study is to assess the impact of upgrading CDI testing from routine to molecular based-algorithm on the management of CDI and evaluate the role of antimicrobials on the course of CDI. This is an observational case-study. A total of 564 patients were included from whom stool samples were tested by enzyme immunoassay (EIA) and Xpert for C. difficile. Data on the number and results of tests ordered, antimicrobial exposure, comorbidities, and treatment with metronidazole or vancomycin were collected. The main outcome measures were C. difficile tests (EIA and Xpert C. difficile Assay) and prevalence of CDI. CDI was found in 9 and 10 cases out of 313 and 254 patients tested by the EIA and Xpert C. difficile assay, respectively, giving an overall incidence of 0.03 per 1,000 patient tested. Reduction was noted in the number of tests ordered per patient for presumptive CDI after shifting to the Xpert C. difficile assay which was not statistically significant (p-value 0.2). Also, there was less metronidazole and vancomycin therapy initiated for patients with a negative C. difficile test (p-value 0.2) observed with molecular testing. Xpert C. difficile testing is a supportive tool for diagnosing CDI with rapid turnaround time that is helpful for patient management and initiating effective infection control measures. The clinical accuracy of the assay is still to be determined in the context of low carriage rate in the local patient population.

Pharmacologic Approach to Management of Clostridium difficile Infection

Clostridium difficile is a gram-positive, anaerobic, spore-forming bacterium that is the leading cause of nosocomial infections in hospitals in the United States. Critically ill patients are at high risk for C. difficile infection (CDI) and face potentially detrimental effects, including prolonged hospitalization, risk of recurrent disease, complicated surgery, and death. CDI requires a multidisciplinary approach to decrease hospital transmission and improve treatment outcomes. This article briefly reviews the current literature and guideline recommendations for treatment and prevention of CDI, with a focus on antibiotic treatment considerations including dosing, routes of administration, efficacy data, adverse effects, and monitoring parameters.

Fidaxomicin versus oral vancomycin for severe Clostridium difficile infection: a retrospective cohort study

ObjectivesThis study was conducted to compare clinical outcomes of fidaxomicin versus oral vancomycin in the management of severe Clostridium difficile infection (CDI). MethodsThe investigation was a retrospective, multicentre, propensity score-matched analysis using a national clinical administrative database. Veterans treated for severe CDI from any Veterans Affairs Medical Center between 1 June 2011 and 30 June 2017 were included if they received fidaxomicin or an oral vancomycin regimen for treatment. The two groups were matched by the nearest-neighbour method from a propensity score derived from independent variables associated with the selection of a fidaxomicin course. ResultsPropensity score matching resulted in two well-matched cohorts consisting of 213 fidaxomicin and 639 oral vancomycin courses. No statistically-significant difference was found for the primary outcome of combined clinical failure or recurrence (68/213 (31.9%) versus 163/639 (25.5%), respectively, p 0.071). Additionally, no statistically significant differences were found for the secondary outcomes of 30-day (23/213 (10.8%) versus 75/639 (11.7%), respectively, p 0.71), 90-day (48/213 (22.5%) versus 140/639 (21.9%), respectively, p 0.85), and 180-day mortality (62/213 (29.1%) versus 186/639 (29.1%), respectively, p 1.0) between the two treatment groups. ConclusionsCourses of fidaxomicin or oral vancomycin for severe CDI resulted in similar treatment outcomes. Study findings are consistent with current treatment guideline recommendations for the use of either agent in the management of severe CDI.

Management of adult Clostridium difficile digestive contaminations: a literature review.

Clostridium difficile infections (CDI) dramatically increased during the last decade and cause a major public health problem. Current treatments are limited by the high disease recurrence rate, severity of clinical forms, disruption of the gut microbiota, and colonization by vancomycin-resistant enterococci (VRE). In this review, we resumed current treatment options from official recommendation to promising alternatives available in the management of adult CDI, with regard to severity and recurring or non-recurring character of the infection. Vancomycin remains the first-line antibiotic in the management of mild to severe CDI. The use of metronidazole is discussed following the latest US recommendations that replaced it by fidaxomicin as first-line treatment of an initial episode of non-severe CDI. Fidaxomicin, the most recent antibiotic approved for CDI in adults, has several advantages compared to vancomycin and metronidazole, but its efficacy seems limited in cases of multiple recurrences. Innovative therapies such as fecal microbiota transplantation (FMT) and antitoxin antibodies were developed to limit the occurrence of recurrence of CDI. Research is therefore very active, and new antibiotics are being studied as surotomycin, cadazolid, and rinidazole.

1889. A Clinical Practice Assessment on Clostridium difficile Infection

BackgroundThis study assessed physicians’ current practice patterns in prevention and management of Clostridium difficile infection (CDI).MethodsA 25-question clinical practice assessment survey was made available to infectious disease (ID) specialists without monetary compensation or charge. Questions evaluated knowledge, competence, and barriers related to CDI, such as current and emerging strategies for limiting risk and achieving optimal outcomes related to antimicrobial use. The survey launched on a website dedicated to continuous professional development on October 27, 2017. Data were collected until January 16, 2018. Respondent confidentiality was maintained and responses were de-identified and aggregated prior to analyses.Results139 ID specialist physicians completed the survey during the study period. Key findings include: (a) 76% were not aware of CDI incidence in the United States. (b) 34% had 20 or more cases of CDI in their practice in the past year. (c) While only 7% admitted their institution had been penalized for CDI under value-based purchasing rules, 50% were unsure. (d) While 96% were correctly able to identify antibiotics most closely associated with development of CDI, only 22% reported they were very confident in recognizing host risk factors for CDI, and 64% were not aware of the risks of CDI-associated death in older patients vs. middle-aged patients. (e) 38% use PCR for CDI diagnosis; 36% use a 2-step method combining different test types. (f) 39% were not aware of the relationship of the gut microbiome and CDI, although 61% reported that they would initiate an FDA-approved agent aimed at protecting the gut microbiome from antibiotic-mediated dysbiosis. (g) About 33% were not aware of new strategies being investigated for prevention of CDI and their mechanisms of action. (h) 94% reported that achieving optimal clinical outcomes and reducing selection for antimicrobial-resistance were the most important goals of antimicrobial stewardship.ConclusionThis research yielded important insights into current clinical practice gaps among ID specialists regarding identification and prevention of CDI, and could serve to inform needs for continuing medical education.Disclosures D. Mathews, Synthetic Biologics: Employee, Salary. T. Delk, Synthetic Biologics: Employee, Salary.

Current management of Clostridioides (Clostridium) difficile infection in adults: a summary of recommendations from the 2017 IDSA/SHEA clinical practice guideline.

Clostridioides (formerly Clostridium) difficile infection (CDI) is the most common cause of health care–associated infectious diarrhea in the developed world. The Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America clinical guidelines on CDI were updated in 2017. The update reflects a decline in the incidence of CDI caused by ribotype 027 and an increased incidence of community‑associated CDI, current challenges in CDI diagnosis, the importance of antibiotic stewardship and contact and isolation precautions in infection prevention and control, and many significant changes in CDI management. This review summarizes and examines these new guidelines, how they compare to other recommendations, and more recent data on CDI management.