Toxin-producing Clostridium Difficile Research Articles

The impact of intensive staff education on rate of Clostridium difficile-associated disease in hospitalized geriatric patients

Toxin-producing Clostridium difficile is the most common cause of nosocomial diarrhea in geriatric units. The purpose of study was to check the impact of intensive staff education on rate of Clostridium difficile-associated disease in hospitalized geriatric patients. The sampling frame was all patients suffering from diarrhea checked for Clostridium difficile toxin during the years 2017-2018. Clostridium difficile-positive patients were compared to a similar number of Clostridium difficile toxin-negative patients. The data were compared to our previous study, followed by medical staff's educational program for Clostridium difficile control and prevention. Among 217 patients with diarrhea, 60 (27.6%) were positive for Clostridium difficile toxin. The study group tended to be of older age (p = 0.06), and showed higher rate of functional impairment (p < 0.001) and mortality (p < 0.001) than Clostridium difficile toxin negative patients. The rate of Clostridium difficile toxin-positive patients did not significantly differ between the previous and current studies (20.0% and 27.6%, respectively). In spite of findings, that patients tended to be older, with high rate of mortality, the rate of Clostridium difficile did not change from the previous study.

Community-acquired fulminant colitis caused by binary toxin-producing Clostridium difficile in Japan

We report a case of community-acquired fulminant colitis caused by Clostridium difficile in Japan. A 46-year-old woman was diagnosed with severe infectious enterocolitis and was admitted at another hospital. The stool culture was positive for toxigenic C. difficile. Since the patient presented with fulminant C. difficile infection (CDI) with toxic megacolon, respiratory insufficiency, and circulatory failure, she was transferred to Kyorin University Hospital for intensive care. Intubation and antibiotic therapy were performed. The general condition improved with conservative treatment, and she was discharged without sequelae. While the recovered isolate was toxin A and B-positive and binary toxin-positive, it was identified as polymerase chain reaction (PCR) ribotype ts0592 and slpA sequence type ts0592. The isolate was different from PCR ribotype 027 epidemic in Europe and North America. In Japan, binary toxin-producing strains are rare and have not caused an epidemic to date. Furthermore, there are few data on community-acquired CDI in Japan. In this case, a non-elderly woman with no major risk factors such as antibiotic use, administration of proton pump inhibitor and history of gastrointestinal surgery developed community-acquired fulminant CDI caused by the binary toxin-positive strain, and ICU treatment was required. Further studies focusing on the role of binary toxin-positive C. difficile in the severity of community-acquired CDI are necessary.

Rapid visual detection of binary toxin producing Clostridium difficile by loop-mediated isothermal amplification.

The binary toxin Clostridium difficile transferase (CDT) is frequently observed in C. difficile strains and is associated with an increased severity of C. difficile infection. CDT-producing C. difficile infections cause higher fatality rates than infections with CDT negative isolates. Thus, the rapid and accurate identification of a CDT positive C. difficile infection is critical for effective treatment. The present study demonstrates how loop-mediated isothermal amplification (LAMP) can be used to detect CDT-producing C. difficile based on visual observation. This is a low complexity, rapid molecular method that has the potential to be used within a point of care setting. The specificity and sensitivity of the primers in the LAMP reactions for CDT detection were determined using two different methods, a real-time turbidity monitor and visual detection after the addition of calcein to the reaction tube. The results revealed that target DNA was amplified and visualized by these two detection methods within 60 min at a temperature of 60°C. The sensitivity of the LAMP assay was identified to be 10-fold greater than that of polymerase chain reaction analysis. When 25 alternative bacterial strains lacking CDT were tested, the results of the amplification were negative, confirming the specificity of the primers. In conclusion, the visual LAMP method established in the present study may be a rapid, reliable and cost-effective tool for detecting CDT-producing C. difficile strains at the point of care.

The Use and Efficacy of Fecal Microbiota Transplantation for Refractory Clostridium difficile in Patients with Inflammatory Bowel Disease.

Clostridium difficile (CD) is an anaerobic, spore-forming bacillus that is responsible for a spectrum of gastrointestinal illness ranging from asymptomatic carriage to toxic megacolon and death. The prevalence of CD infection is increasing in both hospitalized and community-based inflammatory bowel disease populations. Standard antibiotic therapy fails to cure or prevent recurrence in more than 50% of patients, thus increasing the need for alternative therapies. Recently, fecal microbiota transplantation has received renewed attention as a therapy for refractory or recurrent CD infection. A high success rate combined with a favorable safety profile makes this therapy an attractive option for patients who have failed standard antibiotic therapy. Increasingly, this therapy is used in patients with CD infection and inflammatory bowel disease, as the combination of active inflammation and toxin-producing CD provides a challenging mix for clinicians.

Prevalence and Severity of Binary Toxin Producing Clostridium Difficile Isolates in ICU, Zagazig University Hospitals

Background: Clostridium difficile is an important pathogen that causes antibiotic-associated diarrhoea and pseudomembranous colitis with two virulence factors of toxins A (TcdA) and B (TcdB). A third toxin, called binary toxin (CDT), can be detected in some strains and has a role in Clostridium difficile associated disease (CDAD) pathogenesis. Objectives : To determine the prevalence of binary toxin producing isolates in C. difficile associated disease in ICU, Zagazig University Hospitals, Egypt. Also, to assess the risk factors and clinical characterizations among binary and non-binary toxin associated infections. Methodology: Stools samples were collected from 200 patients who were admitted to ICU, Zagazig University Hospitals, Egypt, during 2013-2015 and suspected of having CDAD. They were subjected to toxigenic culture and direct detection of toxin A-B by enzyme immunoassay (EIA) and 5plex PCR test. A 5-plex PCR was used for the detection of the C. difficile toxin genes, with 16S rDNA. Results: Out of the 200 stools samples obtained, 28 (14%) were positive by toxigenic culture, and 20 (10%)of them were positive by direct EIA of toxin A and B. Twenty –six isolates (13%) were PCR positive for toxin A and B genes, and 8 isolates were binary toxin positive. Regarding antibiotic use as a risk factors for infection, meropenem was a risk factor more frequently presented in binary toxin producing isolates, (OR (95% CI); 0.02 (0.0-0.27); P < 0.001), and the third generation cephalosporin was more frequently encountered in non-binary toxin isolates (P, 0.023). It was found that binary toxin producing isolates were associated with disease severity (P< 0.001). The evaluation of the direct PCR in diagnosis of CDAD in comparison to toxigenic culture, showed sensitivity of 92.9%, Specificity of 100%, and Accuracy of 90%. Conclusion : Infection caused by binary toxin producing Cl difficile is an emerging medical problem and significantly associated with disease severity. The 5-plex PCR detection of C. difficile toxin genes is a sensitive screening method.

Therapeutic effects and the possible mechanism of fecal transplantation on rats with Clostridium difficile-associated pseudomembranous colitis

Objective To investigate the therapeutic effects and the possible mechanism of fecal transplantation on rats with Clostridium difficile-associated pseudomembranous colitis. Methods A total of 40 Sprague-Dawley rats were divided into four groups including the healthy control group, model group, fecal transplant treatment group and vancomycin treatment group. Rats in three experimental groups were subcutaneously injected with clindamycin phosphate (10 mg), followed by treatment with toxin producing Clostridium difficile (ACTT43255) enema 24 hours later. The rats in fecal transplant treatment group and vancomycin treatment group were respectively treated with fecal suspension and vancomycin one day after modeling. The rats were fasted for one day after the last administration and then executed. The levels of potassium ion (K), sodium ion (Na), albumin (ALB), white blood cells (WBC), C-reaction protein (CRP), interleukin-1β (IL-1β), interleukin-10 (IL-10), interleukin-12 (IL-12) and interleukin-17 (IL-17) as well as the percentage of neutrophils (N%) in serum samples were detected. The colon tissue samples were collected for pathology examination. Results The rat model of pseudomembranous colitis was successfully established by subcutaneous injection of clindamycin in combination with toxin-producing Clostridium difficile (ACTT43255) enema. The signs of intestinal inflammation including serious weight loss, remarkably shortened colon length and significantly increased colon wet weight index were observed in rats from the model group (P<0.05). Compared with the rats from model group, the rats received fecal transplant showed significantly increased levels of K, ALB, IL-10 and IL-10/IL-12 in serum and decreased levels of WBC, N%, CRP, IL-1β and IL-17 (P<0.05). Conclusion Fecal transplantation was proved to be an effective approach for the treatment of pseudomembranous colitis. The therapeutic mechanism might due to its impacts on serum inflammatory factors. Key words: Fecal transplantation; Pseudomembranous colitis; Inflammatory factor

Toxin-Producing Clostridium difficile Strains as Long-Term Gut Colonizers in Healthy Infants

Clostridium difficile is a colonizer of the human gut, and toxin-producing strains may cause diarrhea if the infectious burden is heavy. Infants are more frequently colonized than adults, but they rarely develop C. difficile disease. It is not known whether strains of C. difficile differ in the capacity to colonize and persist in the human gut microbiota. Here, we strain typed isolates of C. difficile that had colonized 42 healthy infants followed from birth to ≥12 months of age by using PCR ribotyping of the 16S-23S rRNA intergenic spacer region. The isolates were also characterized regarding carriage of the toxin genes tcdA, tcdB, and cdtA/B and the capacity to produce toxin B in vitro. Most strains (71%) were toxin producers, and 51% belonged to the 001 or 014 ribotypes, which often cause disease in adults. These ribotypes were significantly more likely than others to persist for ≥6 months in the infant micobiota, and they were isolated from 13/15 children carrying such long-term-colonizing strains. Ribotype 001 strains were often acquired in the first week of life and attained higher population counts than other C. difficile ribotypes in newborn infants' feces. Several toxin-negative ribotypes were identified, two of which (GI and GIII) were long-term colonizers, each found in one infant. Our results suggest that the toxin-producing C. difficile ribotypes 001 and 014 have special fitness in the infantile gut microbiota. Toxin-producing strains colonizing young children for long time periods may represent a reservoir for strains causing disease in adults.

Coinfection in acute gastroenteritis predicts a more severe clinical course in children

The objectives of this study were to determine the incidence of enteric pathogens causing acute gastroenteritis (AGE) among hospitalized children in a large Italian hospital, to measure the incidence of coinfections, and to compare the clinical characteristics of those infected with one versus multiple agents. A prospective study was conducted from March 2010 to April 2011 at the Bambino Gesù Pediatric Hospital in Rome, Italy. All patients between 1 month and 16 years of age admitted to the Pediatric Department with a diagnosis of AGE were eligible for enrollment. Two stool samples for each patient were tested for gastrointestinal pathogens. We summarized the clinical severity of episodes, describing the duration of diarrhea, duration and frequency of vomiting, fever, and severity of dehydration. All the patients underwent medical evaluation with estimation of dehydration. One or more etiological agents were detected in 151 out of 232 patients (65.1%), while we did not detect any etiological agent in 81 (34.9%). Rotavirus was detected in 96 (63.6%), adenovirus in 17 (11.2%), norovirus in 7 (4.6%), toxin-producing Clostridium difficile in 23 (15.2%), Salmonella spp. in 15 (9.9%, B group in 12/15 and D group in 3/15), C. perfringens in 12 (7.9%), Campylobacter spp. in 6 (4%), and verotoxigenic Escherichia coli (VTEC) in 2 (1.3%). In 27 children out of 151 (17.9%), we found evidence of coinfection. Coinfection with rotavirus and toxin-producing C. difficile was the most common (63%). Children with coinfection had a more severe clinical presentation and had a higher probability to be severely dehydrated, independently of age and living community type.

Disposable biocidal cubical curtains: can they prevent the transfer of bacterial pathogens?

Potentially harmful bacteria have been shown to contaminate traditional cloth cubical curtains. Health care-associated bacteria may, therefore, have the potential to be transmitted from curtains to patients via the hands of health care workers, especially if hand hygiene is not adequate. Over the past few years disposable biocidal curtains have become available which can offer antimicrobial capabilities, less frequent changes, as well as cost savings on laundering. Microbial testing was undertaken on two types of disposable polypropylene curtains: one coated with the biostatic agent didecyl dimethyl ammoniumchloride and the other coated with polysiloxane. Samples were inoculated with Gram-negative bacteria ( Escherichia coli and Pseudomonas aeruginosa ), Gram-positive bacteria ( Staphylococcus aureus and Enterococcus faecalis ), as well as a toxin-producing Clostridium difficile (containing spores). Finger imprints and curtain impressions were made on agar after 1 day, 10 days, 1 month and 2 months. Both types of curtains showed similar results. Gram-negative bacteria did not grow after 1 day but S. aureus and E. faecalis could be detected at 10 days with no growth thereafter. However, C. difficile persisted up to 2 months post sample contamination, most likely due to the persistence of spores. This study demonstrated that biocide-treated disposable curtains eliminated or reduced the number of hand-transferred bacteria tested; however, spore-forming C. difficile persisted for long periods of time in the environment. Therefore, newer biocide-treated disposable curtains need to contain sporicidal formulations in order to control contamination by this nosocomial pathogen.

Rare extraintestinal infection caused by toxin-producing Clostridium difficile

Toxigenic Clostridium difficile is a well known cause of antibiotic-associated diarrhea mainly among hospitalized patients, at the same time we have little information about extraintestinal infections caused by this bacterium. We report here on rare extraintestinal infection caused by toxigenic C. difficile: 31-year-old male, accident victim was admitted to the hospital because of polytrauma. Microbiological examination of the pus revealed a toxin-producing C. difficile as an etiologic factor of this infection. Empiric antibiotic treatment with cefuroxime had been administered right after the positive microbiological result. On the basis of antibiotic susceptibility testing, the isolated strain was susceptible to most antimicrobials, except from cefoxitin, thus cefuroxime was changed to imipenem.

A Case of Pseudomenbranous Colitis after Paclitaxel and Carboplatin Chemotherapy

Antibiotics-associated pseudomembranous colitis is well documented and caused by abnormal overgrowth of toxin producing Clostridium difficile colonizing the large bowel of patients undergoing antibiotic therapy. Administration of chemotherapeutic agents is frequently complicated by diarrhea and enterocolitis. However, pseudomembranous colitis related to chemotherapeutic agent usage is very rare. We experienced a 67 old-years male patient diagnosed of non-small cell lung carcinoma who complained of watery diarrhea and abdominal pain after treated with paclitaxel and carboplatin. Sigmoidoscopic examination revealed diffusely scattered, whitish to yellowish pseudomembrane with background edematous hyperemic mucosa from sigmoid colon to rectum. Histopathologic findings were consistent with pseudomembranous colitis as typical volcano-like exudate. The symptoms improved after stopping chemotherapy and treatment with metronidazole. In patients with persistent diarrhea and abdominal pain after receiving chemotherapy agents, although rare, pseudomembranous colitis should be considered as a differential diagnosis.

In vitro activity of OPT-80 tested against clinical isolates of toxin-producing Clostridium difficile.

Agar dilution antimicrobial susceptibility testing (CLSI, M11-A7, 2007) performed for 208 toxin-producing clinical isolates of Clostridium difficile resulted in OPT-80 MICs ranging from 0.06 to 1 microg/ml, with 90% of the isolates inhibited by a concentration of 0.5 microg/ml. The in vitro activity of OPT-80 was independent of the susceptibilities of isolates to nine other antimicrobial agents.

Pseudomembranous colitis presenting as an isolated colonic stricture

Dear Editor: Pseudomembranous colitis (PMC) is an increasingly common complication secondary to antibiotic use in hospitalised patients. Antibiotic therapy alters the gastrointestinal flora, resulting in an overgrowth of the toxin-producing organism Clostridium difficile, which is the causative organism in PMC. There is a wide spectrum of acute disease severity ranging from mild diarrhoea to toxic megacolon, and the vast majority of infectious colitis episodes resolve with antibiotic therapy, although some require surgery. Longterm complications are rare. We describe a case of symptomatic PMC presenting as an emergency to hospital with symptoms secondary to an isolated stricture and continuing colitis 2 years after antibiotic treatment. A 68-year-old man was admitted to the hospital with a 2year history of abdominal pain and bloody diarrhoea. Over the previous 6 months he reported a weight loss of 3 stone. In the 3 weeks before admission, his symptoms had become progressively worse. He had a history of antibiotic therapy with flucloxacillin for paronychia 2 years previously, and the symptoms of pain and diarrhoea commenced shortly after. There was a family history of Crohn's disease. Abdominal examination was unremarkable. An abdominal X-ray showed a loaded ascending and transverse colon. C. difficile toxin was detected in stool samples. He was treated with 10 days of metronidazole, 400 mg orally three times per day, but the bloody diarrhoea continued. A Gastrograffin enema showed a 20-cm stricture in his sigmoid colon. Colonoscopy revealed inflammation of the sigmoid colon with a membranous appearance typical of pseudomembranous colitis. The stricture was seen but the scope could not pass through. Biopsies of the stricture were taken. These confirmed pseudomembranous colitis. A Hartmann's procedure and closed mucus fistula was performed with removal of the strictured, inflamed segment. Histopathology of the sigmoid colon showed florid pseudomembranous colitis. The patient's recovery was uncomplicated. PMC is characterised by acute severe diarrhoea usually following antibiotic therapy. This leads to replacement of normal colonic flora by the enteric pathogen C. difficile. Cases that are not associated with antibiotic therapy have been reported but are rare. Macroscopically, a pseudomembrane covers the inflamed oedematous mucosa of the large bowel. Most infections respond to oral metronidazole or vancomycin therapy and the duration of symptoms are short. The history of our patient suggests that untreated symptomatic infections with C. difficile can be long-standing—2 years in our case. The authors can find no reported cases of such prolonged continuous symptoms, although unusual cases may have relapsing symptoms over a number of years. In a paper by Miller et al., a series of 40 cases was reviewed. Four of these had chronic diarrhoea for 9 to 12 months after antibiotic therapy [1]. Int J Colorectal Dis (2007) 22:1293–1294 DOI 10.1007/s00384-006-0170-1

Clostridium difficile associated severe enterocolitis: A feature of Hirschsprung's disease in a neonate presenting late

We report a case of Hirschsprung's disease presenting late in the newborn period with severe enterocolitis and Clostridium difficile toxin detectable in the stool. Enterocolitis associated with Hirschsprung's disease is a potentially fatal complication that may occur at presentation or later in the life of an affected child. Its association with toxin-producing Clostridium difficile growth in the bowel may be under recognized, especially in newborns.

Outbreak from a high-toxin intruder: Clostridium difficile

In today's Lancet, we feel the “cold wind of another threatening epidemic” emerging in the face of our frequent use of broad-spectrum antibiotics within the hospital environment. Michel Warny and colleagues focus on the appearance of a highly toxin-producing Clostridium difficile genotype (NAP1/027) as a cause of a recent five-fold increase of nosocomial diarrhoea in Quebec, Canada.1 The great achievement of this study is the novel approach in relating clinical aspects such as morbidity and mortality to the known virulence factor of toxin production, as well as the sporulation capacity to nosocomial spread of disease.

Limited clinical utility of Clostridium difficile toxin testing in infants in a pediatric hospital

Previous studies have shown high rates of asymptomatic carriage of toxin-producing Clostridium difficile in infants. We performed a retrospective case control study comparing infants younger than 1 year old with diarrhea and C. difficile toxin (CDT) in the stool, to age-matched controls with diarrhea lacking CDT in the stool. We found no difference in clinical characteristics including fever, vomiting, or hematochezia. Treatment with metronidazole had no significant effect on the clinical outcome. Alternative etiologies for diarrhea (most commonly viral) were found in more than 50% of patients in both groups. We recommend that other causes of diarrhea be considered before C. difficile colitis in this age group.

Reduced Mitotic Activity of Intestinal Mucosal Cells in Germ-free Rats Mono-associated with Toxin-ProducingClostridium difficile

The aim of the study was to investigate whether, and to what extent, mono-association of germ-free rats with Clostridium difficile influences intestinal cell kinetics and epithelial structure. Young male germ-free rats were mono-associated with either a toxin-producing (group I) or a non-toxin-producing (group II) strain of C. difficile , for 3, 7 and 21 days. The mitotic activity was blocked with vincristine, and specimens from eight parts of the intestine were taken for microscopic examination. Aliquots of intestinal content were analysed for the presence of C. difficile and its toxins. All animals remained healthy throughout the study. After 3 days of mono-association, the mitotic activity increased in all compartments in both groups of animals. After 7 days, a marked fall in mitotic activity was observed in all compartments except caecum in the animals in group I and after 21 days, the mitotic activity was again increased in the small intestine but still low in the distal parts of the colon. At days 7 and 21, only minor alterations were seen in the animals in group II. In general, the morphological alterations were less pronounced than alterations in mitotic activity. A disrupted epithelial border was seen in one animal only (day 7, group I). Toxin could be detected in contents from large intestine at 7 and 21 days in the animals in group I. We conclude that the establishment of a toxin-producing C. difficile in a gnotobiotic rat model gives a marked but transient inhibition of mitotic activity and we hypothesize that this inhibition may give an opportunity for other bacteria to contribute to disease.

Clinical impact and associated costs of Clostridium difficile-associated disease.

Toxin-producing Clostridium difficile is the commonest cause of nosocomial diarrhoea and, as such, poses a major problem in our hospitals. The main population susceptible to disease is the elderly, for reasons that remain unclear. By contrast, carriage rates in neonates are high, but disease is low. The organism also has a major clinical impact in the immunosuppressed host, patients undergoing surgery (especially gastrointestinal) and those with severe underlying disease and longer hospital stay. Other interventions with high-risk associations are enemas, nasogastric and gastrostomy tubes and anti-peristaltic drugs. Data on the associated costs of C. difficile diarrhoea are not freely available, but one estimate is that in an average-sized district general hospital, 100 cases of C. difficile infection can be expected each year with an extra annual cost of 400,000 pound sterling and 2100 lost bed days.

Ceftriaxone: pharmacokinetics and effect on the intestinal microflora in patients with acute bacterial infections.

12 patients with acute bacterial infections were treated with ceftriaxone, 1.5 g intravenously twice daily for 7-13 days. Pharmacokinetic variables were studied in 11 patients. In older subjects, serum half-lives were longer and serum clearances lower than in younger individuals. After the last dose, a larger increase in AUC compared to the first dose was observed in older patients and a biphasic elimination curve appeared in all patients but 2, with a terminal half-life of 15.6 h and 11.4 in old and young subjects, respectively. Estimated biliary clearances showed large individual variation, with a range of 0-16 ml/min X 1.73 m2. Changes in the colonic microflora were pronounced. Almost total disappearance of staphylococci, streptococci and enterobacteria was found, and there was a marked tendency to overgrowth of yeasts and enterococci. One patient with the highest estimated biliary clearance of ceftriaxone developed diarrhoea after 7 days of therapy. A toxin-producing Clostridium difficile was isolated from the stool.

Occurrence of toxin-producing Clostridium difficile in antibiotic-associated diarrhea in Sweden.

From 1324 patients with antibiotic-associated diarrhea (AAD) 1643 stool samples were analyzed by a cell test for Clostridium difficile toxin in stool filtrates and cultivation for occurrence of C. difficile strains. In patients with no detectable toxin in their stool strains of C. difficile were isolated in 2.2% whereas when toxin was detectable, the isolation rate varied from 17% to 36%. Furthermore, there was a correlation between toxin titre in stool filtrate and production of cytotoxin in vitro by the corresponding C. difficile strains. Five clostridial strains, not belonging to the species C. difficile, were found to produce typical cytotoxin in vitro. However, five strains identified as C. difficile by biochemical reactions and gas liquid chromatography, did not produce an extracellular cytotoxin. The antibiotic susceptibility patterns of the Clostridium strains were investigated. No correlation was recognized between antibiotic resistance of isolated Clostridium strains and the AAD-inducing antibiotic penicillins and linco/clindamycin. Neither did cases of relapse of diarrheal disease after vancomycin treatment harbour C. difficile strains with increased resistance to vancomycin. It is concluded that the pathogenesis of antibiotic-associated enterocolitis is more complex than a mere intestinal overgrowth of resistant strains of C. difficile.