• Clostridium difficile
• Diagnosis and treatment
• Epidemiology
• Prevention
• Pseudomembranous colitis
• Public health safety

• Antibiotics
• antimicrobial resistance
• chronic infections
• lifelong antibiotic therapy
• suppressive antibiotic treatment

• Complications
• Gastrointestinal bleeding
• Spinal cord injury
• Stress ulcer
• Stress ulcer prophylaxis

• Humans
• Gastroenterology/standards
• Germany
• Gastrointestinal Diseases/therapy
• Gastrointestinal Diseases/diagnosis
• Practice Guidelines as Topic

• Catchment
• Clostridioides difficile
• Electronic health record
• External validity
• Prediction modelling
• Urban safety-net hospital

• Humans
• Clostridioides difficile
• Safety-net Providers
• Clostridium Infections/diagnosis
• Clostridium Infections/epidemiology
• Sensitivity and Specificity
• ROC Curve
• Recurrence
• Retrospective Studies

• Humans
• Anti-Bacterial Agents/adverse effects
• Proton Pump Inhibitors/adverse effects
• Streptogramins
• Clostridium Infections/epidemiology
• Quinolones

• Centre for Translational Microbiome Research
• Karolinska Instituted, Sweden
• Research Collaboration Agreement with Ferring Pharmaceuticals

• Humans
• Anti-Bacterial Agents/therapeutic use
• Hospitals, University
• Clostridioides difficile
• Cross Infection/drug therapy
• Cross Infection/epidemiology
• Carbapenems
• Clostridium Infections/drug therapy
• Clostridium Infections/epidemiology
• Incidence
• Retrospective Studies

• antibiotic-associated diarrhea (AAD)
• microbiome
• probiotics

Fluoroquinolones are associated with an increased risk of Clostridioides difficile infection (CDI). Probiotic supplementation has been shown to reduce the risk of antibiotic-associated diarrhea with variable effects on CDI. The objective of this study was to evaluate receipt of probiotics on development of primary CDI among hospitalized patients receiving fluoroquinolones. A retrospective cohort was evaluated that consisted of two groups of 100 patients each, admitted August 2018 through August 2020 that received ≥3 days of definitive monotherapy with levofloxacin or ciprofloxacin within 72 h of admission. Primary outcome was incidence of CDI. Secondary outcomes included rates of C. difficile diagnostic stool testing, additional infectious diagnostic testing, and non-CDI related gastrointestinal side effects. Patients on fluoroquinolones who received probiotics had a non-statistically significantly lower incidence in overall cases of CDI compared to those who did not receive probiotics (0% vs. 3%, p = 0.246). Patients who received probiotics had statistically significantly fewer C. difficile diagnostic stool tests performed (4% vs. 16%, p = 0.005) and fewer additional infectious diagnostic testing performed (4% vs. 10%, p = 0.096), respectively. Further research is warranted to optimize and standardize probiotic prescribing in high-risk patients.

• CDI
• Clostridioides difficile
• antibiotic-associated diarrhea
• ciprofloxacin
• levofloxacin
• probiotics

Expert guidelines discourage use of antipseudomonal β-lactams and fluoroquinolones in lower-risk patients with community-acquired complicated intra-abdominal infection (CA cIAI). Compliance with these recommendations across US hospitals is unclear. This study sought to determine treatment patterns and associated outcomes among adult hospitalized lower-risk patients with CA cIAI.

A study using data from the Premier Healthcare Database (10/2015–12/2017) was performed. Inclusion criteria: age ≥18 years; hospitalized; had a cIAI at admission; and received antibiotics within the first 4 hospital days. Patients were excluded if they were high risk, were transferred from another health care facility, had a recent hospital admission, or received dialysis within 30 days of admission. Empiric antibiotic treatment patterns and associated outcomes were quantified.

Overall, 46722 (66%) patients with cIAIs met the lower-risk CA IAI study criteria. Among lower-risk CA IAI patients, the mean (SD) age was 53.4 (18.2) years, and 71% had a Charlson Comorbidity Index score of 0. The most common diagnosis was acute appendicitis with peritonitis (59.7%). Among lower-risk CA IAI patients, 54% received piperacillin/tazobactam, 20% received a fluoroquinolone (FQ), 11% received ceftriaxone, and 7% received ampicillin/sulbactam. Overall, the median hospital length of stay was 4 days and median costs were $12345 USD. Nearly 90% of patients were discharged home, and <1% died. Outcomes were similar across all empiric treatments received.

Overuse of antipseudomonal β-lactams and fluoroquinolones was commonplace among lower-risk CA IAI patients. These findings can serve as the basis for an antimicrobial stewardship initiative in hospitals aspiring to reduce the use of broad-spectrum antibiotics.

• cIAI
• infection
• outcomes
• treatment

• Adult
• Aged
• Aged, 80 and over
• Clostridioides difficile/isolation & purification
• Clostridium Infections/epidemiology
• Clostridium Infections/prevention & control
• Cross Infection/epidemiology
• Cross Infection/prevention & control
• Female
• Humans
• Male
• Middle Aged
• Predictive Value of Tests
• Risk Assessment/methods
• Risk Factors
• United States/epidemiology

Clostridium difficile infection (CDI) is an emerging healthcare problem in the world. The purpose of this study was to perform a systematic epidemiological research of CDI in Tongji hospital, the central of China.

Stool samples from hospitalized adults suspected of CDI were enrolled. The diagnosis of CDI were based on the combination of clinical symptoms and laboratory results. Clinical features of CDI and non-CDI patients were compared by appropriate statistical tests to determine the risk factors of CDI. Multilocus sequence typing (MLST) was employed for molecular epidemiological analysis. Susceptibility testing and relevant antimicrobial agent resistance genes were performed as well.

From June 2016 to September 2017, 839 hospitalized adults were enrolled. Among them, 107 (12.8%, 107/839) patients were C. difficile culture positive, and 73 (8.7%, 73/839) were infected with toxigenic C. difficile (TCD), with tcdA + tcdB+ strains accounting for 90.4% (66/73) and tcdA-tcdB+ for 9.6% (7/73). Meanwhile, two TCD strains were binary toxin positive and one of them was finally identified as CD027. Severe symptoms were observed in these two cases. Multivariate analysis indicated antibiotic exposure (p = 0.001, OR = 5.035) and kidney disease (p = 0.015, OR = 8.329) significantly increased the risk of CDI. Phylogenetic tree analysis demonstrated 21 different STs, including one new ST (ST467); and the most dominant type was ST54 (35.6%, 26/73). Multidrug-resistant (MDR) TCD were 53.4% (39/73); resistance to ciprofloxacin, erythromycin, and clindamycin were > 50%. Other antibiotics showed relative efficiency and all strains were susceptible to metronidazole and vancomycin. All moxifloxacin-resistant isolates carried a mutation in GyrA (Thr82 → Ile), with one both having mutation in GyrB (Ser366 → Ala).

Knowledge of epidemiological information for CDI is limited in China. Our finding indicated tcdA + tcdB+ C. difficile strains were the dominant for CDI in our hospital. Significant risk factors for CDI in our setting appeared to be antibiotic exposure and kidney disease. Metronidazole and vancomycin were still effective for CDI. Although no outbreak was observed, the first isolation of CD027 in center China implied the potential spread of this hypervirulent clone. Further studies are needed to enhance our understanding of the epidemiology of CDI in China.

The online version of this article (10.1186/s12879-019-3841-6) contains supplementary material, which is available to authorized users.

• Clostridium difficile infection
• Clostridium difficile ribotype 027
• Drug resistance
• Molecular characterization
• Risk factor

• Acid-suppressive therapy
• Adverse drug events
• Gastrointestinal hemorrhage
• Histamine-2-receptor antagonists
• Neurocritical care
• Proton pump inhibitors
• Stress ulcer prophylaxis

• Critical Illness/therapy
• Gastrointestinal Hemorrhage/etiology
• Gastrointestinal Hemorrhage/prevention & control
• Histamine H2 Antagonists/adverse effects
• Histamine H2 Antagonists/economics
• Histamine H2 Antagonists/pharmacology
• Humans
• Peptic Ulcer/etiology
• Peptic Ulcer/prevention & control
• Proton Pump Inhibitors/adverse effects
• Proton Pump Inhibitors/economics
• Proton Pump Inhibitors/pharmacology
• Stress, Physiological
• Trauma, Nervous System/complications

• Clostridium difficile
• elderly
• long-term care facilities
• microbiome
• vulnerable population

• Clostridium difficile
• metronidazole
• vancomycin

• Clostridium difficile
• Meta-analyses

• asymptomatic clostridium difficile colonization
• clinical pathway specified on ppis use
• clostridium difficile infection
• omeprazole
• postoperation of colon cancer

• Aged, 80 and over
• Clostridium Infections/chemically induced
• Colonic Neoplasms/surgery
• Diagnosis, Differential
• Humans
• Injections, Intravenous
• Male
• Omeprazole/administration & dosage
• Omeprazole/adverse effects
• Proton Pump Inhibitors/administration & dosage
• Proton Pump Inhibitors/adverse effects

To perform a systematic review and meta-analysis on proton pump inhibitors (PPIs) therapy and the risk of Clostridium difficile infection (CDI).

METHODS

We conducted a systematic search of MEDLINE/PubMed and seven other databases through January 1990 to March 2017 for published studies that evaluated the association between PPIs and CDI. Adult case-control and cohort studies providing information on the association between PPI therapy and the development of CDI were included. Pooled odds ratios (ORs) estimates with 95% confidence intervals (CIs) were calculated using the random effect. Heterogeneity was assessed by I² test and Cochran’s Q statistic. Potential publication bias was evaluated via funnel plot, and quality of studies by the Newcastle-Otawa Quality Assessment Scale (NOS).

Fifty-six studies (40 case-control and 16 cohort) involving 356683 patients met the inclusion criteria and were analyzed. Both the overall pooled estimates and subgroup analyses showed increased risk for CDI despite substantial statistical heterogeneity among studies. Meta-analysis of all studies combined showed a significant association between PPI users and the risk of CDI (pooled OR = 1.99, CI: 1.73-2.30, P < 0.001) as compared with non-users. The association remained significant in subgroup analyses: by design-case-control (OR = 2.00, CI: 1.68-2.38, P < 0.0001), and cohort (OR = 1.98, CI: 1.51-2.59, P < 0.0001); adjusted (OR = 1.95, CI: 1.67-2.27, P < 0.0001) and unadjusted (OR = 2.02, CI: 1.41-2.91, P < 0.0001); unicenter (OR = 2.18, CI: 1.72-2.75, P < 0.0001) and multicenter (OR = 1.82, CI: 1.51-2.19, P < 0.0001); age ≥ 65 years (OR = 1.93, CI: 1.40-2.68, P < 0.0001) and < 65 years (OR = 2.06, CI: 1.11-3.81, P < 0.01). No significant differences were found in subgroup analyses (test for heterogeneity): P = 0.93 for case-control vs cohort, P = 0.85 for adjusted vs unadjusted, P = 0.24 for unicenter vs multicenter, P = 0.86 for age ≥ 65 years and < 65 years. There was significant heterogeneity across studies (I² = 85.4%, P < 0.001) as well as evidence of publication bias (funnel plot asymmetry test, P = 0.002).

This meta-analysis provides further evidence that PPI use is associated with an increased risk for development of CDI. Further high-quality, prospective studies are needed to assess whether this association is causal.

• Proton pump inhibitors
• Clostridium difficile infection
• Risk
• Systematic review
• Meta-analysis

• Adult
• Clostridioides difficile/isolation & purification
• Clostridium Infections/epidemiology
• Clostridium Infections/etiology
• Clostridium Infections/microbiology
• Gastrointestinal Diseases/drug therapy
• Gastrointestinal Diseases/microbiology
• Humans
• Incidence
• Prospective Studies
• Proton Pump Inhibitors/adverse effects
• Risk Factors

• Clostridium difficile infection
• Meta-analysis
• Proton-pump inhibitor

• Antibiotics
• Clostridium difficile￢ﾀﾔassociated diarrhoea
• Probiotics

• cdi
• ppi
• nosocomial diarrhea
• infection control
• gastric acid suppression

• Clostridioides difficile
• Clostridium Infections/epidemiology
• Clostridium Infections/etiology
• Cross Infection/epidemiology
• Cross Infection/etiology
• Cross Infection/microbiology
• Diarrhea
• Humans
• Proton Pump Inhibitors/adverse effects
• Proton Pump Inhibitors/therapeutic use
• Risk Factors

• T32 GM008692 NIGMS NIH HHS
• TL1 TR000429 NCATS NIH HHS
• UL1 TR000427 NCATS NIH HHS

• Campylobacter
• Clostridium difficile
• Diarrhea, nosocomial
• Infectious diarrheal disease
• Shigella

Clostridium difficile infection (CDI) unresponsive to the standard treatments of metronidazole and oral vancomycin requires aggressive medical management and possible surgical intervention including colectomy. Intracolonic vancomycin therapy has been reported to be particularly promising in the setting of severe CDI in the presence of ileus. This is a descriptive case series exploring the effect of adjunctive intracolonic vancomycin therapy on the morbidity and mortality in patients with moderate to severe CDI.

A retrospective chart review was conducted on 696 patients with CDI seen at a single institution. Each patient was assigned a severity score and 127 patients with moderate to severe CDI were identified. We describe the clinical presentation, risk factors and hospital course comparing those that received adjunctive intracolonic vancomycin to those that only received standard therapy.

The group that received adjunctive intracolonic vancomycin had higher rates of toxic megacolon, intensive care unit (ICU) admission, and colectomy, and yet maintained a similar mortality rate as the group that received only standard treatment.

The intracolonic vancomycin group experienced more complications but showed a similar mortality rate to the standard therapy group, suggesting that intracolonic vancomycin may impart a protective effect. This study adds further evidence for the need of a randomized controlled study using intracolonic vancomycin as adjunctive therapy in patients presenting with severe CDI.

• Clostridium difficile
• Colitis
• Intracolonic vancomycin
• Mortality
• Risk factors

• Clostridium difficile-associated diarrhea
• antibiotic-associated diarrhea
• probiotics

Patients submitted to hematopoietic stem cell transplantation have an increased risk of Clostridium difficile infection and multiple risk factors have been identified. Published reports have indicated an incidence from 9% to 30% of transplant patients however to date there is no information about infection in these patients in Chile.

A retrospective analysis was performed of patients who developed C. difficile infection after hematopoietic stem cell transplantations from 2000 to 2013. Statistical analysis used the Statistical Package for the Social Sciences software.

Two hundred and fifty patients were studied (mean age: 39 years; range: 17–69), with 147 (59%) receiving allogeneic transplants and 103 (41%) receiving autologous transplants. One hundred and ninety-two (77%) patients had diarrhea, with 25 (10%) cases of C. difficile infection being confirmed. Twenty infected patients had undergone allogeneic transplants, of which ten had acute lymphoblastic leukemia, three had acute myeloid leukemia and seven had other diseases (myelodysplastic syndrome, chronic myeloid leukemia, severe aplastic anemia). In the autologous transplant group, five patients had C. difficile infection; two had multiple myeloma, one had amyloidosis, one had acute myeloid leukemia and one had germinal carcinoma. The overall incidence of C. difficile infection was 4% within the first week, 6.4% in the first month and 10% in one year, with no difference in overall survival between infected and non-infected groups (72.0% vs. 67.6%, respectively; p-value = 0.56). Patients infected after allogeneic transplants had a slower time to neutrophil engraftment compared to non-infected patients (17.5 vs. 14.9 days, respectively; p-value = 0.008). In the autologous transplant group there was no significant difference in the neutrophil engraftment time between infected and non-infected patients (12.5 days vs. 11.8 days, respectively; p-value = 0.71). In the allogeneic transplant group, the median time to acute graft-versus-host disease was similar between the two groups (p-value = 0.08), as was the incidence of grades 1–4 acute graft-versus-host disease (40% vs. 48%; p-value >0.05).

The incidence of C. difficile infection after hematopoietic stem cell transplantation was low, with a significant number of cases occurring shortly after transplantation. Allogeneic transplants had a three-time higher risk of infection compared to autologous transplants, but this was not associated with increased mortality, decreased overall survival or higher risk of acute graft-versus-host disease.

• Clostridium difficile
• Hematopoietic stem cell transplantation
• Infection
• Outcomes

An adverse effect of acid-suppression medications on the occurrence of Clostridium difficile infection (CDI) has been a common finding of many, but not all studies. We hypothesized that association between acid-suppression medications and CDI is due to the residual confounding in comparison between patients with infection to those without, predominantly from non-tested and less sick subjects. We aimed to evaluate the effect of acid suppression therapy on incidence of CDI by comparing patients with CDI to two control groups: not tested patients and patients suspected of having CDI, but with a negative test.

We conducted a case-control study of adult patients hospitalized in internal medicine department of tertiary teaching hospital between 2005–2010 for at least three days. Controls from each of two groups (negative for CDI and non-tested) were individually matched (1∶1) to cases by primary diagnosis, Charlson comorbidity index, year of hospitalization and gender. Primary outcomes were diagnoses of International Classification of Diseases (ICD-9)–coded CDI occurring 72 hours or more after admission.

Patients with CDI were similar to controls with a negative test, while controls without CDI testing had lower clinical severity. In multivariable analysis, treatment by acid suppression medications was associated with CDI compared to those who were not tested (OR = 1.88, p-value = 0.032). Conversely, use of acid suppression medications in those who tested negative for the infection was not associated with CDI risk as compared to the cases (OR = 0.66; p = 0.059).

These findings suggest that the reported epidemiologic associations between use of acid suppression medications and CDI risk may be spurious. The control group choice has an important impact on the results. Clinical differences between the patients with CDI and those not tested and not suspected of having the infection may explain the different conclusions regarding the acid suppression effect on CDI risk.