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Di Bella S, Sanson G, Monticelli J, Zerbato V, Principe L, Giuffrè M, Pipitone G, Luzzati R. Clostridioides difficile infection: history, epidemiology, risk factors, prevention, clinical manifestations, treatment, and future options. Clin Microbiol Rev 2024; 37:e0013523. [PMID: 38421181 PMCID: PMC11324037 DOI: 10.1128/cmr.00135-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
SUMMARYClostridioides difficile infection (CDI) is one of the major issues in nosocomial infections. This bacterium is constantly evolving and poses complex challenges for clinicians, often encountered in real-life scenarios. In the face of CDI, we are increasingly equipped with new therapeutic strategies, such as monoclonal antibodies and live biotherapeutic products, which need to be thoroughly understood to fully harness their benefits. Moreover, interesting options are currently under study for the future, including bacteriophages, vaccines, and antibiotic inhibitors. Surveillance and prevention strategies continue to play a pivotal role in limiting the spread of the infection. In this review, we aim to provide the reader with a comprehensive overview of epidemiological aspects, predisposing factors, clinical manifestations, diagnostic tools, and current and future prophylactic and therapeutic options for C. difficile infection.
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Affiliation(s)
- Stefano Di Bella
- Clinical Department of
Medical, Surgical and Health Sciences, Trieste
University, Trieste,
Italy
| | - Gianfranco Sanson
- Clinical Department of
Medical, Surgical and Health Sciences, Trieste
University, Trieste,
Italy
| | - Jacopo Monticelli
- Infectious Diseases
Unit, Trieste University Hospital
(ASUGI), Trieste,
Italy
| | - Verena Zerbato
- Infectious Diseases
Unit, Trieste University Hospital
(ASUGI), Trieste,
Italy
| | - Luigi Principe
- Microbiology and
Virology Unit, Great Metropolitan Hospital
“Bianchi-Melacrino-Morelli”,
Reggio Calabria, Italy
| | - Mauro Giuffrè
- Clinical Department of
Medical, Surgical and Health Sciences, Trieste
University, Trieste,
Italy
- Department of Internal
Medicine (Digestive Diseases), Yale School of Medicine, Yale
University, New Haven,
Connecticut, USA
| | - Giuseppe Pipitone
- Infectious Diseases
Unit, ARNAS Civico-Di Cristina
Hospital, Palermo,
Italy
| | - Roberto Luzzati
- Clinical Department of
Medical, Surgical and Health Sciences, Trieste
University, Trieste,
Italy
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Yu SJ, Heo JH, Choi EJ, Kim JH, Lee HS, Kim SY, Lim JH. Role of multidetector computed tomography in patients with acute infectious colitis. World J Clin Cases 2022; 10:3686-3697. [PMID: 35647171 PMCID: PMC9100710 DOI: 10.12998/wjcc.v10.i12.3686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 09/14/2021] [Accepted: 03/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The role of multidetector computed tomography (MDCT) in patients with acute infectious colitis is still unclear.
AIM To examine the usefulness of MDCT in distinguishing the etiology of acute infectious colitis.
METHODS Overall, 244 patients who met the criteria for acute infectious colitis and visited the Hospital from February 2015 to 2018 were retrospectively enrolled and divided into two groups (bacterial: 204, viral: 40) according to causes of acute colitis, based on stool PCR. Eleven MDCT parameters, including wall thickening, submucosal edema, mucosal enhancement, serosa involvement, empty colon sign, small bowel involvement, comb sign, continuous distribution, accordion sign, mucosal thickening, and lymph node enlargement, were constructed in a blinded fashion.
RESULTS MDCT parameters of wall thickening (OR: 13.60; 95%CI: 5.80–31.88; P < 0.001), submucosal edema (OR: 36.08; 95%CI: 13.54–96.13; P < 0.001), mucosal enhancement (OR: 22.55; 95%CI: 9.28–54.81; P < 0.001), serosal involvement (OR: 14.50; 95%CI: 3.33–63.23; P < 0.001), empty colon sign (OR: 6.68; 95%CI: 2.44–18.32; P < 0.001), continuous distribution (OR: 24.09; 95%CI: 9.38–61.90; P < 0.001), accordion sign (OR: 9.02; 95%CI: 1.12–72.35; P = 0.038), mucosal thickening (OR: 46.41; 95%CI: 10.38–207.51; P < 0.001), and lymph node enlargement (OR: 4.39; 95%CI: 1.22–15.72; P = 0.023) were significantly associated with bacterial colitis. At least one positive finding in four CT outcomes (submucosal edema, mucosal enhancement, continuous distribution, mucosal thickening) in summer showed a high probability of bacterial colitis (sensitivity, 41.67; specificity, 92.50; OR: 24.95).
CONCLUSION MDCT provides many clues that can be useful in suggesting a specific etiology of acute infectious colitis.
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Affiliation(s)
- Seung Jung Yu
- Department of Internal Medicine, Inje University Busan Paik Hospital, Busan 47392, South Korea
| | - Jae Hyuk Heo
- Department of Internal Medicine, Inje University Busan Paik Hospital, Busan 47392, South Korea
| | - Eun Jeong Choi
- Department of Internal Medicine, Inje University Busan Paik Hospital, Busan 47392, South Korea
| | - Jong Hyuk Kim
- Department of Radiology, Myongji Hospital, Hanyang University College of Medicine, Goyang 10475, South Korea
| | - Hong Sub Lee
- Department of Internal Medicine, Inje University Busan Paik Hospital, Busan 47392, South Korea
| | - Sun Young Kim
- Department of Cancer Control and Population Health, National Cancer Center, Goyang 10408, South Korea
| | - Jae Hoon Lim
- Department of Radiology, Myongji Hospital, Hanyang University College of Medicine, Goyang 10475, South Korea
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Abstract
PURPOSE Existing clinical or microbiological scores are not sensitive enough to obtain prompt identification of patients at risk of complicated Clostridium difficile infection (CDI). Our aim was to use a CDI animal model to evaluate 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography ([18F]FDG-PET) as a marker of severe course of infection. PROCEDURES CDI was induced with cefoperazone for 10 days followed by clindamycin 1 day before C. difficile inoculation. Mice were divided into wild type (n = 6), antibiotic without infection (AC n = 4), h001-infected (n = 5, ribotype 001), and h027-infected (n = 5, ribotype 027). Two days after inoculation, [18F]FDG-PET was acquired. Weight, general animal condition, and survival were monitored daily for 9 days. RESULTS h001 group showed symptoms for 4 days with 0 % mortality and a similar colon uptake than control animals (h001 0.52 ± 0.20, WT 0.42 ± 0.07, and AC 0.36 ± 0.06). The h027 group showed symptoms up to 7 days, with 66.7 % of mortality 4 days after infection, and significantly higher colon uptake (0.93 ± 0.38, p < 0.05). Clinical score was associated to colon and cecum uptake (rho = 0.78, p = 0.0001) (rho = 0.73, p = 0.0003). CONCLUSION High toxin producer ribotype 027 induced more severe CDI infections, correlating with higher colon and cecum [18F]FDG uptake. Colon uptake may purportedly serve as early predictor of CDI severity.
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Clostridioides difficile Infection. Dis Colon Rectum 2021; 64:650-668. [PMID: 33769319 DOI: 10.1097/dcr.0000000000002047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Nakao S, Hasegawa S, Shimada K, Mukai R, Tanaka M, Matsumoto K, Uranishi H, Masuta M, Ikesue H, Hashida T, Iguchi K, Nakamura M. Evaluation of anti-infective-related Clostridium difficile-associated colitis using the Japanese Adverse Drug Event Report database. Int J Med Sci 2020; 17:921-930. [PMID: 32308545 PMCID: PMC7163355 DOI: 10.7150/ijms.43789] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/06/2020] [Indexed: 12/23/2022] Open
Abstract
Clostridium difficile-associated colitis (CDAC) may cause gastrointestinal illness, ranging in severity from mild diarrhea to fulminant colitis and even mortality. The purpose of this study was to evaluate anti-infective-related CDAC profiles using the Japanese Adverse Drug Event Report (JADER) database. Methods: We selected case reports of adverse events of CDAC as specified in the Medical Dictionary for Regulatory Activities. The association between the number of administered anti-infectives and aging was evaluated using reporting odds ratio (ROR) and adjusted for covariates using multiple-logistic regression. We also evaluated anti-infective-related CDAC-onset profiles using Weibull shape parameter. Results: The JADER database contained 534 688 reports from April 2004 to June 2018. There were 1222 anti-infective related CDAC events. The top five anti-infectives were as follows: third-generation cephalosporins (Anatomical Therapeutic Chemical (ATC) code: J01DD, 313 cases), fluoroquinolones (ATC code: J01MA, 201 cases), macrolides (ATC code: J01FA, 146 cases), carbapenems (ATC code: J01DH, 143 cases), and penicillins with extended spectrum (ATC code: J01CA, 103 cases). The adjusted RORs (95% confidence interval) in individuals using 1, 2, and ≥ 3 anti-infectives were 8.88 (7.05-11.18), 9.77 (6.89-13.86), and 18.39 (11.85-28.54), respectively. Moreover, 47.2% of CDACs occurred within 7 days of anti-infective therapy initiation. The adjusted ROR of interaction terms of ≥ 70 years × 1 drug was 21.81 (14.56-32.68). Conclusion: Our results suggest that the number of administered anti-infectives and patient age are associated with CDAC. These data may be particularly beneficial to prescribers and would contribute to improving the management of CDAC.
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Affiliation(s)
- Satoshi Nakao
- Laboratory of Drug Informatics, Gifu Pharmaceutical University; Gifu, Japan
| | - Shiori Hasegawa
- Laboratory of Drug Informatics, Gifu Pharmaceutical University; Gifu, Japan.,Department of pharmacy, Kobe City Medical Center General Hospital; Kobe, Japan
| | - Kazuyo Shimada
- Laboratory of Drug Informatics, Gifu Pharmaceutical University; Gifu, Japan
| | - Ririka Mukai
- Laboratory of Drug Informatics, Gifu Pharmaceutical University; Gifu, Japan
| | - Mizuki Tanaka
- Laboratory of Drug Informatics, Gifu Pharmaceutical University; Gifu, Japan
| | - Kiyoka Matsumoto
- Laboratory of Drug Informatics, Gifu Pharmaceutical University; Gifu, Japan
| | - Hiroaki Uranishi
- Current address: Division of Pharmacy, Nara Medical University Hospital, 840, Shijocho, Kashihara-shi, Nara, 634-8522, Japan
| | - Mayuko Masuta
- Current address: Division of Pharmacy, Kyoto City Hospital, 1-2, Mibu Higashitakadacho, Nakagyo-ku Kyoto-shi, Kyoto, 604-8845, Japan
| | - Hiroaki Ikesue
- Department of pharmacy, Kobe City Medical Center General Hospital; Kobe, Japan
| | - Tohru Hashida
- Department of pharmacy, Kobe City Medical Center General Hospital; Kobe, Japan
| | - Kazuhiro Iguchi
- Laboratory of Community Pharmacy, Gifu Pharmaceutical University; Gifu, Japan
| | - Mitsuhiro Nakamura
- Laboratory of Drug Informatics, Gifu Pharmaceutical University; Gifu, Japan
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Duffin C, Mirpour S, Catanzano T, Moore C. Radiologic Imaging of Bowel Infections. Semin Ultrasound CT MR 2019; 41:33-45. [PMID: 31964493 DOI: 10.1053/j.sult.2019.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Although radiologic imaging of bowel infections is often a precursor to definitive diagnosis by endoscopy, biopsy, or stool cultures, imaging can provide critical information for diagnosis and management. Many infectious entities such as viral, bacterial, and parasitic infections can be discovered on imaging. Furthermore, imaging characterizes the extent of infection, involvement of specific bowel segments, and presence of complications in the abdomen. Utilizing a multimodality approach using ultrasound, computed tomography, and magnetic resonance imaging, we describe the spectrum of imaging findings that distinguish a number of infectious etiologies that affect the bowel, as well as differentiate from ischemic and inflammatory bowel processes.
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Affiliation(s)
- C Duffin
- Department of Radiology, University of Massachusetts Medical School, Baystate Medical Center, Springfield, MA.
| | - S Mirpour
- Department of Radiology, University of Massachusetts Medical School, Baystate Medical Center, Springfield, MA
| | - T Catanzano
- Department of Radiology, University of Massachusetts Medical School, Baystate Medical Center, Springfield, MA
| | - C Moore
- Department of Radiology, University of Massachusetts Medical School, Baystate Medical Center, Springfield, MA
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Guerri S, Danti G, Frezzetti G, Lucarelli E, Pradella S, Miele V. Clostridium difficile colitis: CT findings and differential diagnosis. Radiol Med 2019; 124:1185-1198. [PMID: 31302848 DOI: 10.1007/s11547-019-01066-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 07/07/2019] [Indexed: 12/17/2022]
Abstract
Clostridium difficile infection (CDI) is a severe and potentially deadly infectious colitis whose incidence is dramatically increasing in the last decades, with more virulent strains. CDI should be suspected in case of unexplained diarrhea and abdominal pain in patients with a recent history of antibiotic use and healthcare exposures; diagnosis is based on a combination of clinical and laboratory findings with demonstration of C. difficile toxins by stool test. The advantages of contrast-enhanced computed tomography (CECT) are the noninvasiveness and the ability to evaluate both the colonic wall and the adjacent soft tissues. Considerable overlap exists between the CECT findings of CDI and those of colitis of other origins, such as typhlitis, ischemic colitis, graft-versus-host disease, radiation colitis and inflammatory bowel diseases; however, some features may help distinguish between these conditions. This paper provides a comprehensive overview of the imaging features of Clostridium difficile colitis and its mimics, with a view to assist the radiologist in reaching the correct diagnosis.
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Affiliation(s)
- Sara Guerri
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, Largo G.A. Brambilla 3, 50134, Florence, Italy
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, S. Orsola-Malpighi Hospital, Via Massarenti 9, 40138, Bologna, Italy
| | - Ginevra Danti
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, Largo G.A. Brambilla 3, 50134, Florence, Italy
| | - Gianluca Frezzetti
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, Largo G.A. Brambilla 3, 50134, Florence, Italy
| | - Edvige Lucarelli
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, Largo G.A. Brambilla 3, 50134, Florence, Italy
| | - Silvia Pradella
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, Largo G.A. Brambilla 3, 50134, Florence, Italy.
| | - Vittorio Miele
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, Largo G.A. Brambilla 3, 50134, Florence, Italy
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8
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Abstract
Clostridioides difficile (formerly Clostridium difficile) infection is the most frequently identified health care-associated infection in the United States. C difficile has also emerged as a cause of community-associated diarrhea, resulting in increased incidence of community-associated infection. Clinical illness ranges in severity from mild diarrhea to fulminant colitis and death. Appropriate management of infection requires understanding of the various diagnostic assays and therapeutic options as well as relevant measures to infection prevention. This article provides updated recommendations regarding the prevention, diagnosis, and treatment of incident and recurrent C difficile infection.
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Affiliation(s)
- Alice Y Guh
- From the Centers for Disease Control and Prevention, Atlanta, Georgia. (A.Y.G., P.K.K.)
| | - Preeta K Kutty
- From the Centers for Disease Control and Prevention, Atlanta, Georgia. (A.Y.G., P.K.K.)
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Kothari K, Friedman B, Grimaldi GM, Hines JJ. Nontraumatic large bowel perforation: spectrum of etiologies and CT findings. Abdom Radiol (NY) 2017; 42:2597-2608. [PMID: 28493071 DOI: 10.1007/s00261-017-1180-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Large bowel perforation is an abdominal emergency that results from a wide range of etiologies. Computed tomography is the most reliable modality in detecting the site of large bowel perforation. The diagnosis is made by identifying direct CT findings such as extraluminal gas or contrast and discontinuity along the bowel wall. Indirect CT findings can help support the diagnosis, and include bowel wall thickening, pericolic fat stranding, abnormal bowel wall enhancement, abscess, and a feculent collection adjacent to the bowel. Common etiologies that cause large bowel perforation are colon cancer, foreign body aspiration, stercoral colitis, diverticulitis, ischemia, inflammatory and infectious colitides, and various iatrogenic causes. Recognizing a large bowel perforation on CT can be difficult at times, and there are various entities that may be misinterpreted as a colonic perforation. The purpose of this article is to outline the MDCT technique used for evaluation of suspected colorectal perforation, discuss relevant imaging findings, review common etiologies, and point out potential pitfalls in making the diagnosis of large bowel perforation.
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Affiliation(s)
- Kunal Kothari
- Department of Radiology, Northwell Health System, Hofstra Northwell School of Medicine, Manhasset, NY, USA.
| | - Barak Friedman
- Department of Radiology, Northwell Health System, Hofstra Northwell School of Medicine, Manhasset, NY, USA
| | - Gregory M Grimaldi
- Department of Radiology, Northwell Health System, Hofstra Northwell School of Medicine, Manhasset, NY, USA
| | - John J Hines
- Department of Radiology, Northwell Health System, Hofstra Northwell School of Medicine, Manhasset, NY, USA
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10
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Clostridium difficile disease: Diagnosis, pathogenesis, and treatment update. Surgery 2017; 162:325-348. [DOI: 10.1016/j.surg.2017.01.018] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 01/25/2017] [Indexed: 12/16/2022]
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11
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Diagnosis and treatment of Clostridium difficile (C. diff) colitis: Review of the literature and a perspective in gynecologic oncology. Gynecol Oncol 2017; 144:428-437. [DOI: 10.1016/j.ygyno.2016.11.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 11/08/2016] [Accepted: 11/12/2016] [Indexed: 12/16/2022]
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12
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Paláu-Dávila L, Lara-Medrano R, Negreros-Osuna AA, Salinas-Chapa M, Garza-González E, Gutierrez-Delgado EM, Camacho-Ortiz A. Efficacy of computed tomography for the prediction of colectomy and mortality in patients with clostridium difficile infection. Ann Med Surg (Lond) 2016; 12:101-105. [PMID: 27942384 PMCID: PMC5137169 DOI: 10.1016/j.amsu.2016.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 11/07/2016] [Accepted: 11/07/2016] [Indexed: 10/27/2022] Open
Abstract
AIM To develop a CT predictor scale for the need for colectomy and to evaluate predictors of all-cause mortality within 30 days after diagnosis ofC. difficile infection (CDI). METHODS We conducted a retrospective study of adult hospitalized patients whounderwent abdominal CT within 72 h of diagnosis of CDI. RESULTS Presence of abnormal wall thickening in caecum (OR 8.0; CI 1.37-46.81; p = 0.021), transverse colon (OR 6.7; CI 1.15-35.60; p = 0.034), sigmoid colon (OR 12.6; CI 1.37-115.97; p = 0.025), pancolitis (OR 7.0; CI 1.36-36.01; p = 0.02) and bowel dilation (OR 16.5; CI 2.41-112.83; p = 0.004) predicted colectomy. With these values, a five parameter radiological scale from 0 to 24 was developed (sensitivity and NPV of 100%, cut-off of 6). Furthermore, wall thickening of caecum (OR 6.2; CI 1.06-35.57; p = 0.043), ascending colon (OR 12.0; CI 1.29-111.32; p = 0.029), descending colon (OR 17.0; CI 1.81-160.05; p = 0.013) and sigmoid (OR 10.2; CI 1.10-94.10; p = 0.041) independently predicted mortality within 30 days of CDI diagnosis. CONCLUSION We designed a CT scale to predict colectomy, able to rule out the development of fulminant colitis and the need for surgical procedure. Patients with wall thickening of the caecum, ascending, descending or sigmoid colon were more likely to die within 30 days of CDI diagnosis.
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Affiliation(s)
- Laura Paláu-Dávila
- Servicio de Infectología, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, 64460 Monterrey, NL, Mexico
| | - Reynaldo Lara-Medrano
- Servicio de Infectología, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, 64460 Monterrey, NL, Mexico
| | - Adrián A Negreros-Osuna
- Departamento de Radiología e Imagenología Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, 64460 Monterrey, NL, Mexico
| | - Matías Salinas-Chapa
- Departamento de Radiología e Imagenología Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, 64460 Monterrey, NL, Mexico
| | - Elvira Garza-González
- Servicio de Gastroenterología, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, 64460 Monterrey, NL, Mexico
| | - Eva Marìa Gutierrez-Delgado
- Servicio de Infectología, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, 64460 Monterrey, NL, Mexico
| | - Adrián Camacho-Ortiz
- Coordinación de Epidemiología Hospitalaria, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, 64460 Monterrey, NL, Mexico
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Fehér C, Mensa J. A Comparison of Current Guidelines of Five International Societies on Clostridium difficile Infection Management. Infect Dis Ther 2016; 5:207-30. [PMID: 27470257 PMCID: PMC5019978 DOI: 10.1007/s40121-016-0122-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Indexed: 12/31/2022] Open
Abstract
Clostridium difficile infection (CDI) is increasingly recognized as an emerging healthcare problem of elevated importance. Prevention and treatment strategies are constantly evolving along with the apperance of new scientific evidence and novel treatment methods, which is well-reflected in the differences among consecutive international guidelines. In this article, we summarize and compare current guidelines of five international medical societies on CDI management, and discuss some of the controversial and currently unresolved aspects which should be addressed by future research.
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Affiliation(s)
- Csaba Fehér
- Department of Infectious Diseases, Hospital Clínic of Barcelona, C/Villarroel 170, 08036, Barcelona, Spain.
| | - Josep Mensa
- Department of Infectious Diseases, Hospital Clínic of Barcelona, C/Villarroel 170, 08036, Barcelona, Spain
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14
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McNally L, Brown SP. Building the microbiome in health and disease: niche construction and social conflict in bacteria. Philos Trans R Soc Lond B Biol Sci 2016; 370:rstb.2014.0298. [PMID: 26150664 PMCID: PMC4528496 DOI: 10.1098/rstb.2014.0298] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Microbes collectively shape their environment in remarkable ways via the products of their metabolism. The diverse environmental impacts of macro-organisms have been collated and reviewed under the banner of ‘niche construction’. Here, we identify and review a series of broad and overlapping classes of bacterial niche construction, ranging from biofilm production to detoxification or release of toxins, enzymes, metabolites and viruses, and review their role in shaping microbiome composition, human health and disease. Some bacterial niche-constructing traits can be seen as extended phenotypes, where individuals actively tailor their environment to their benefit (and potentially to the benefit of others, generating social dilemmas). Other modifications can be viewed as non-adaptive by-products from a producer perspective, yet they may lead to remarkable within-host environmental changes. We illustrate how social evolution and niche construction perspectives offer complementary insights into the dynamics and consequences of these traits across distinct timescales. This review highlights that by understanding the coupled bacterial and biochemical dynamics in human health and disease we can better manage host health.
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Affiliation(s)
- Luke McNally
- Centre for Immunity, Infection and Evolution, University of Edinburgh, Edinburgh EH9 3FL, UK Institute of Evolutionary Biology, School of Biological Sciences, University of Edinburgh, Edinburgh EH9 3FL, UK
| | - Sam P Brown
- Centre for Immunity, Infection and Evolution, University of Edinburgh, Edinburgh EH9 3FL, UK Institute of Evolutionary Biology, School of Biological Sciences, University of Edinburgh, Edinburgh EH9 3FL, UK
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15
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Abstract
Clostridium difficile (C. difficile) infection (CDI) is the most common cause of healthcare-associated infections in US hospitals. The epidemic strain NAP1/BI/ribotype 027 accounts for outbreaks worldwide, with increasing mortality and severity. CDI is acquired from an endogenous source or from spores in the environment, most easily acquired during the hospital stay. The use of antimicrobials disrupts the intestinal microflora enabling C. difficile to proliferate in the colon and produce toxins. Clinical diagnosis in symptomatic patients requires toxin detection from stool specimens and rarely in combination with stool culture to increase sensitivity. However, stool culture is essential for epidemiological studies. Oral metronidazole is the recommended therapy for milder cases of CDI and oral vancomycin or fidaxomicin for more severe cases. Treatment of first recurrence involves the use of the same therapy used in the initial CDI. In the event of a second recurrence oral vancomycin often given in a tapered dose or intermittently, or fidaxomicin may be used. Fecal transplantation is playing an immense role in therapy of recurrent CDI with remarkable results. Fulminant colitis and toxic megacolon warrant surgical intervention. Novel approaches including new antibiotics and immunotherapy against CDI or its toxins appear to be of potential value.
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Affiliation(s)
- Andrew Ofosu
- Department of Medicine, Jefferson Medical College, Philadelphia, USA
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16
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Hamdeh S, Abdelrahman AAM, Elsallabi O, Pathak R, Giri S, Mosalpuria K, Bhatt VR. Clinical approach to diarrheal disorders in allogeneic hematopoietic stem cell transplant recipients. World J Hematol 2016; 5:23-30. [DOI: 10.5315/wjh.v5.i1.23] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 10/03/2015] [Accepted: 11/25/2015] [Indexed: 02/05/2023] Open
Abstract
Diarrhea is a common complication of allogeneic hematopoietic stem cell transplant (HSCT), with an average incidence of approximately 40%-50%. A wide variety of etiologies can contribute to diarrhea in HSCT patients, including medication-induced mucosal inflammation, infections, graft-vs-host disease and cord colitis syndrome in umbilical cord blood transplant. Clinical manifestations can vary from isolated diarrheal episodes, to other organ involvement including pneumonia or myocarditis, and rarely multiorgan failure. The approach for diagnosis of diarrheal disorders in HSCT patients depends on the most likely cause. Given the risk of life-threatening conditions, the development of clinically significant diarrhea requires prompt evaluation, supportive care and specific therapy, as indicated. Serious metabolic and nutritional disturbances can happen in HSCT patients, and may even lead to mortality. In this review, we aim to provide a practical approach to diagnosis and management of diarrhea in the post-transplant period.
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Rashidi A, Lin MF, Cashen AF. Early post-transplant contrast-enhanced abdominopelvic CT scan predicts the risk of subsequent acute GvHD. Bone Marrow Transplant 2015; 51:150-2. [PMID: 26437071 DOI: 10.1038/bmt.2015.232] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- A Rashidi
- Section of Bone Marrow Transplant and Leukemia, Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - M F Lin
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, USA
| | - A F Cashen
- Section of Bone Marrow Transplant and Leukemia, Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
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19
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Imaging of Fluid in Cancer Patients Treated With Systemic Therapy: Chemotherapy, Molecular Targeted Therapy, and Hematopoietic Stem Cell Transplantation. AJR Am J Roentgenol 2015; 205:709-19. [DOI: 10.2214/ajr.15.14459] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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20
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Wiener-Well Y, Kaloti S, Hadas-Halpern I, Munter G, Yinnon AM. Ultrasound diagnosis of Clostridium difficile-associated diarrhea. Eur J Clin Microbiol Infect Dis 2015; 34:1975-8. [PMID: 26173691 DOI: 10.1007/s10096-015-2439-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 06/26/2015] [Indexed: 01/05/2023]
Abstract
Clostridium difficile colitis is diagnosed using an immunoassay or polymerase chain reaction (PCR) assay for toxins A/B. Since ultrasound is frequently used as a screening test for hospitalized patients suffering from different abdominal morbidities, we searched for sonographic indicators of C. difficile infection (CDI). In a prospective and blinded case-control study, abdominal ultrasound was performed on hospitalized patients for whom stool samples were sent for C. difficile toxin immunoassay. All patients with positive toxin were included as the case group and patients with negative toxin comprised the control group. Sonographic parameters of both groups were compared. Demographic variables of the 67 patients in the toxin-positive group were similar to those of the 71 patients in the toxin-negative group. The sonographic parameters which were found to be associated with CDI included colonic wall thickening, appearing in 61 (91%) patients of the toxin-positive group versus 15 (21%) patients of the toxin-negative group (p < 0.001), and also internal ring (24 versus 0%, p < 0.001), external ring (15 versus 0%, p < 0.001), ascites (24 versus 10%, p < 0.001), and diminution of large bowel content (16 versus 1%, p < 0.001). Bowel wall thickening had high positive and negative predictive values (0.80 and 0.90, respectively), while the other features had only high positive predictive values (0.7-1.0). Abdominal ultrasound may contribute to the diagnosis of C. difficile colitis in patients developing hospital-acquired diarrhea.
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Affiliation(s)
- Y Wiener-Well
- Infectious Disease Unit, Shaare Zedek Medical Center, affiliated with the Hadassah-Hebrew University Medical School, P.O. Box 3235, Jerusalem, 91031, Israel.
| | - S Kaloti
- Radiology Department, Shaare Zedek Medical Center, affiliated with the Hadassah-Hebrew University Medical School, Jerusalem, Israel
| | - I Hadas-Halpern
- Radiology Department, Shaare Zedek Medical Center, affiliated with the Hadassah-Hebrew University Medical School, Jerusalem, Israel
| | - G Munter
- Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with the Hadassah-Hebrew University Medical School, Jerusalem, Israel
| | - A M Yinnon
- Infectious Disease Unit, Shaare Zedek Medical Center, affiliated with the Hadassah-Hebrew University Medical School, P.O. Box 3235, Jerusalem, 91031, Israel.,Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with the Hadassah-Hebrew University Medical School, Jerusalem, Israel
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To KB, Napolitano LM. Clostridium difficile infection: update on diagnosis, epidemiology, and treatment strategies. Surg Infect (Larchmt) 2015; 15:490-502. [PMID: 25314344 DOI: 10.1089/sur.2013.186] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Clostridium difficile infection (CDI) has increased in incidence and severity over the past quarter century, and is now considered a major cause of healthcare-associated infections. METHODS Review of the pertinent English-language medical literature. RESULTS There has been a substantial change in the management of CDI. The emergence of the NAP1/BI/O27 strain in the early to mid-2000s has been associated with more severe forms of CDI. The pathophysiology, epidemiology, clinical manifestations and diagnosis, as well as new strategies for medical and surgical management are discussed in this review. CONCLUSIONS Clostridium difficile infection can range from benign diarrhea to severe disease associated with substantial morbidity and mortality. Treatment modalities vary based on disease severity and timing of onset. The mainstay of medical treatment remains metronidazole and oral/rectal vancomycin. New management strategies are evolving, including adjunctive treatments such as monoclonal antibodies, vaccination, and fecal transplant. In patients with severe disease or clinical deterioration, early surgical consultation for total colectomy or loop ileostomy may be life-saving. Infection control measures are vital to mitigating the spread of CDI.
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Affiliation(s)
- Kathleen B To
- Department of Surgery, University of Michigan , Ann Arbor, Michigan
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22
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Acute colitis: differential diagnosis using multidetector CT. Clin Radiol 2015; 70:262-9. [PMID: 25522900 DOI: 10.1016/j.crad.2014.11.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 10/10/2014] [Accepted: 11/10/2014] [Indexed: 12/26/2022]
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Ferrer Márquez M, Hernández Martínez Á, Reina Duarte Á, Rosado Cobián R. Current Status of the Treatment of Fulminant Colitis. Cir Esp 2015; 93:276-82. [PMID: 25649534 DOI: 10.1016/j.ciresp.2014.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 09/22/2014] [Accepted: 09/25/2014] [Indexed: 02/08/2023]
Abstract
Fulminant colitis is not a well-defined entity, that constitutes a severe complication. It usually occurs in the course of úlcerative colitis and Clostridium difficile colitis. A multidisciplinary management combining gastroenterologist and surgeons is crucial with intensive medical treatment and early surgery in non-responders. It is important to distinguish if we are facing a flare of IBD or, on the contrary, it is an infectious colitis, due to the fact that although general therapeutic measures to adopt will be the same, they will demand opposed specific measures.
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Affiliation(s)
- Manuel Ferrer Márquez
- Servicio de Cirugía General y Aparato Digestivo, Hospital Torrecárdenas, Almería, España.
| | | | - Ángel Reina Duarte
- Servicio de Cirugía General y Aparato Digestivo, Hospital Torrecárdenas, Almería, España
| | - Rafael Rosado Cobián
- Servicio de Cirugía General y Aparato Digestivo, Hospital Torrecárdenas, Almería, España
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24
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Felder SI, Larson B, Balzer B, Wachsman A, Haker K, Fleshner P, Annamalai A, Margulies DR. Fulminant Clostridium difficile Colitis: Comparing Computed Tomography with Histopathology: Are They Concordant? Am Surg 2014. [DOI: 10.1177/000313481408001033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
A Total abdominal colectomy (TAC) is recommended for fulminant Clostridium difficile colitis (FCDC) because intraoperative assessment of diseased segments is inaccurate. To determine whether computerized tomography (CT) provides an accurate assessment of disease, we examined the concordance between CT and histopathologic colitis distribution in patients undergoing TAC for FCDC. The ileocolon was divided into seven distinct segments. Of 20 patients meeting criteria, the median interval between preoperative CT and TAC was 1.5 days (range, 0 to 23 days), and mortality was 65 per cent. The CT distribution of colitis was pancolitis in 12 patients and segmental in eight. Nine of the 12 patients with CT pancolitis had histologic pancolitis (75% concordance). Four of the eight patients with CT-diagnosed segmental disease had histologic segmental disease (50% concordance). For patients with FCDC, the distribution of colitis on CT agrees with the histopathologic extent of disease in the majority of patients. However, discordance between CT and histologic extent of disease was present in 25 to 50 per cent of patients. Therefore, the recommendation for TAC rather than segmental resection for FCDC remains justified.
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Affiliation(s)
- Seth I. Felder
- Departments of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Brent Larson
- Departments of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Bonnie Balzer
- Departments of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ashley Wachsman
- Radiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Katherine Haker
- Radiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Phillip Fleshner
- Departments of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Alagappan Annamalai
- Departments of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel R. Margulies
- Departments of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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26
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Snyder JR, Paquette IM. Clinical and radiographic findings in the patient with Clostridium difficile infection. SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2014.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Walters PR, Zuckerbraun BS. Clostridium difficile Infection: Clinical Challenges and Management Strategies. Crit Care Nurse 2014; 34:24-34; quiz 35. [DOI: 10.4037/ccn2014822] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Clostridium difficile has become the leading cause of nosocomial diarrhea in adults. A substantial increase has occurred in morbidity and mortality associated with disease caused by C difficile and in the identification of new hypervirulent strains, warranting a high clinical index of suspicion for infections due to this organism. Prevention of infection requires a multidisciplinary approach, including early recognition of disease, effective contact isolation precautions, adherence to disinfectant policies, and judicious use of antibiotics. Current treatment approaches are based on the severity of illness. As hypervirulent strains evolve, unsuccessful treatments are more common. Complicated colitis caused by C difficile may benefit from surgical intervention. Subtotal colectomy and end ileostomy have been the procedures of choice, but are associated with a high mortality rate because of late surgical consultation and use of surgery as a salvage therapy. A promising surgical alternative is creation of a diverting loop ileostomy with colonic lavage.
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Affiliation(s)
- Pamela R. Walters
- Pamela R. Walters is a nurse practitioner for the University of Pittsburgh Center for Sports Medicine, Pittsburgh, Pennsylvania
| | - Brian S. Zuckerbraun
- Brian S. Zuckerbraun is an associate professor at the University of Pittsburgh and the VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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28
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Campo LD, León NG, Palacios DC, Lagana C, Tagarro D. Abdominal Complications Following Hematopoietic Stem Cell Transplantation. Radiographics 2014; 34:396-412. [DOI: 10.1148/rg.342135046] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Belmares J, Gerding DN, Tillotson G, Johnson S. Measuring the severity ofClostridium difficileinfection: implications for management and drug development. Expert Rev Anti Infect Ther 2014; 6:897-908. [DOI: 10.1586/14787210.6.6.897] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Aisenberg GM, Grimes RM. Computed tomography in patients with abdominal pain and diarrhoea: does the benefit outweigh the drawbacks? Intern Med J 2013; 43:1141-4. [PMID: 24134171 DOI: 10.1111/imj.12262] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 05/20/2013] [Indexed: 12/25/2022]
Abstract
The role of computed tomography (CT) in the evaluation of abdominal pain is well established. However, concern exists in regard to procedure-related radiation levels, contrast-medium toxicity and costs. We sought to determine whether the use of abdominal CT caused major changes in the management of patients who had abdominal pain and diarrhoea. We reviewed all abdominal CT examinations that were performed at our hospital from October through December 2010. We selected 574 scans that had been performed in patients who presented with or without diarrhoea. We examined the selected medical records to determine whether the CT scan changed patients' management. A scan was considered to be management changing if a decisive intervention occurred on the basis of the scan results. Among 124 scans in patients with diarrhoea and 450 scans in patients without diarrhoea, the scan results changed management in 13 of the patients with diarrhoea (11%) and in 233 of those without diarrhoea (52%) (P < 0.001). When management changed, the changes resulted from findings unrelated to diarrhoea. Despite its defined role in the assessment of abdominal pain, CT of patients that also had diarrhoea seldom caused a major change in management. The probability of CT causing such a change does not outweigh the cost, radiation risk or potential for contrast-induced nephropathy.
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Affiliation(s)
- G M Aisenberg
- Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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31
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Portela F, Lago P. Fulminant colitis. Best Pract Res Clin Gastroenterol 2013; 27:771-82. [PMID: 24160933 DOI: 10.1016/j.bpg.2013.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Revised: 07/26/2013] [Accepted: 08/11/2013] [Indexed: 01/31/2023]
Abstract
Fulminant colitis is an ill-defined entity that is usually viewed as the most severe form of uncomplicated acute colitis. It usually occurs in the course of ulcerative colitis and infectious colitis, but can also be seen in other forms of colitis. Every patient with clinical criteria for severe or fulminant colitis should be approached in a systematic way, based on two premises - intense medical treatment and early surgery in non-responders.
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Abstract
Patients in the setting of the intensive care unit can develop intra-abdominal complications that may worsen outcome. Clinical suspicion of such complications coupled with early diagnosis and treatment may reduce morbidity and mortality associated with these processes. This article addresses the diagnosis and management of some of the common causes of intra-abdominal catastrophes.
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Affiliation(s)
- Joao B Rezende-Neto
- Department of Surgery, St. Michael's Hospital, 30 Bond Street 16CC-044, Toronto, Ontario M5B1W8, Canada
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33
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Pant C, Deshpande A, Altaf MA, Minocha A, Sferra TJ. Clostridium difficile infection in children: a comprehensive review. Curr Med Res Opin 2013; 29:967-84. [PMID: 23659563 DOI: 10.1185/03007995.2013.803058] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To provide a comprehensive review of the literature relating to Clostridium difficile (C. difficile) infection (CDI) in the pediatric population. METHODS Two investigators conducted independent searches of PubMed, Web of Science, and Scopus until March 31st, 2013. All databases were searched using the terms 'Clostridium difficile infection', 'Clostridium difficile associated diarrhea' 'antibiotic associated diarrhea', 'C. difficile', in combination with 'pediatric' and 'paediatric'. Articles which discussed pediatric CDI were reviewed and relevant cross references also read and evaluated for inclusion. Selection bias could be a possible limitation of this approach. FINDINGS There is strong evidence for an increased incidence of pediatric CDI. Increasingly, the infection is being acquired from the community, often without a preceding history of antibiotic use. The severity of the disease has remained unchanged. Several medical conditions may be associated with the development of pediatric CDI. Infection prevention and control with antimicrobial stewardship are of paramount importance. It is important to consider the age of the child while testing for CDI. Traditional therapy with metronidazole or vancomycin remains the mainstay of treatment. Newer antibiotics such as fidaxomicin appear promising especially for the treatment of recurrent infection. Conservative surgical options may be a life-saving measure in severe or fulminant cases. CONCLUSIONS Pediatric providers should be cognizant of the increased incidence of CDI in children. Early and judicious testing coupled with the timely institution of therapy will help to secure better outcomes for this disease.
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Affiliation(s)
- Chaitanya Pant
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Clostridium difficile colitis: increasing incidence, risk factors, and outcomes in solid organ transplant recipients. Transplantation 2012; 93:1051-7. [PMID: 22441318 DOI: 10.1097/tp.0b013e31824d34de] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Clostridium difficile-associated diarrhea (CDAD) is an increasingly important diagnosis in solid organ transplant recipients, with rising incidence and mortality. We describe the incidence, risk factors, and outcomes of colectomy for CDAD after solid organ transplantation. METHODS Patients with CDAD were identified from a prospective transplant database. Complicated Clostridium difficile colitis (CCDC) was defined as CDAD associated with graft loss, total colectomy, or death. RESULTS From 1999 to 2010, we performed solid organ transplants for 1331 recipients at our institution. The incidence of CDAD was 12.4% (165 patients); it increased from 4.5% (1999) to 21.1% (2005) and finally 9.5% (2010). The peak frequency of CDAD was between 6 and 10 days posttransplantation. Age more than 55 years (hazard ratio [HR]: 1.47, 95% confidence interval [CI]=1.16-1.81), induction with antithymocyte globulin (HR: 1.43, 95% CI=1.075-1.94), and transplant other than kidney alone (liver, heart, pancreas, or combined kidney organ) (HR: 1.41, 95% CI=1.05-1.92) were significant independent risk factors for CDAD. CCDC occurred in 15.8% of CDAD cases. Independent predictors of CCDC were white blood cell count more than 25,000/μL (HR: 1.08, 95% CI=1.025-1.15) and evidence of pancolitis on computed tomography scan (HR: 2.52, 95% CI=1.195-5.35). Six patients with CCDC underwent colectomy with 83% patient survival and 20% graft loss. Of the medically treated patients with CCDC (n=20), the patient survival was 35% with 100% graft loss. CONCLUSIONS We have identified significant risk factors for CDAD and predictors of progression to CCDC. Furthermore, we found that colectomy can be performed with excellent survival in selected patients.
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Pant C, Sferra TJ, Deshpande A, Minocha A. Clinical approach to severe Clostridium difficile infection: update for the hospital practitioner. Eur J Intern Med 2011; 22:561-8. [PMID: 22075280 DOI: 10.1016/j.ejim.2011.04.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Revised: 04/17/2011] [Accepted: 04/26/2011] [Indexed: 12/18/2022]
Abstract
The rising incidence of Clostridium difficile (C. difficile) infection or CDI is now a problem of pandemic proportions. The NAP1 hypervirulent strain of C. difficile is responsible for a majority of recent epidemics and the widespread use of fluoroquinolone antibiotics may have facilitated the selective proliferation of this strain. The NAP1 strain also is more likely to cause severe and fulminant colitis characterized by marked leukocytosis, renal failure, hemodynamic instability, and toxic megacolon. No single test suffices to diagnose severe CDI, instead; the clinician must rely on a combination of clinical acumen, laboratory testing, and radiologic and endoscopic modalities. Although oral vancomycin and metronidazole are considered standard therapies in the medical management of CDI, recently it has been demonstrated that vancomycin is the more effective antibiotic in cases of severe disease. Moreover, early surgical consultation is necessary in patients who do not respond to medical therapy or who demonstrate rising white blood cell counts or hemodynamic instability indicative of fulminant colitis. Subtotal colectomy with end ileostomy is the procedure of choice for fulminant colitis. When applied to select patients in a judicious and timely fashion, surgery can be a life-saving intervention. In addition to these therapeutic approaches, several investigational treatments including novel antibiotics, fecal bacteriotherapy and immunotherapy have shown promise in the care of patients with severe CDI.
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Affiliation(s)
- Chaitanya Pant
- Department of Pediatrics, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
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36
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Toro DH, Amaral-Mojica KM, Rocha-Rodriguez R, Gutierrez-Nuñez J. An Innovative Severity Score Index for Clostridium difficile Infection. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2011. [DOI: 10.1097/ipc.0b013e31821895a8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Kachrimanidou M, Malisiovas N. Clostridium difficile infection: a comprehensive review. Crit Rev Microbiol 2011; 37:178-87. [PMID: 21609252 DOI: 10.3109/1040841x.2011.556598] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Clostridium difficile is one of the most important causes of healthcare acquired diarrhea. The disease spectrum caused by C. difficile infection ranges from mild, self-limited, illness to a severe, life-threatening colitis. The incidence of C. difficile associated disease has risen dramatically over the last decade, leading to increased research interest aiming at the discovery of new virulence factors and the development of new treatment and prevention regimens. This review summarizes the pathogenesis and changing epidemiology of C. difficile associated disease, the clinical spectrum and laboratory methods to diagnose C. difficile infection, and current treatment strategies.
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Affiliation(s)
- Melina Kachrimanidou
- Nuffield Department of Clinical Medicine, Oxford University, John Radcliffe Hospital Oxford, UK, OX3 9DU.
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38
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Mahgerefteh SY, Sosna J, Bogot N, Shapira MY, Pappo O, Bloom AI. Radiologic Imaging and Intervention for Gastrointestinal and Hepatic Complications of Hematopoietic Stem Cell Transplantation. Radiology 2011; 258:660-71. [DOI: 10.1148/radiol.10100025] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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39
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Lethal Clostridium difficile Colitis Associated with Paclitaxel and Carboplatin Chemotherapy in Ovarian Carcinoma: Case Report and Review of the Literature. Obstet Gynecol Int 2010; 2010. [PMID: 20706661 PMCID: PMC2913858 DOI: 10.1155/2010/749789] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2010] [Accepted: 05/31/2010] [Indexed: 12/21/2022] Open
Abstract
Clostridium difficile colitis, although rare, could represent a serious complication following chemotherapy. Prior antibiotic use has been considered the single most important risk factor in the development of C. difficile infection. Recently, the association between antineoplastic therapy and C. difficile-associated diarrhea in the absence of a prior antibiotic therapy has become more apparent. A 75-year-old woman with serous adenocarcinoma of the ovary developed lethal pancolitis caused by C. difficile after five cycles of paclitaxel- and carboplatin-based chemotherapy. She presented with diarrhea, coffee-ground emesis, and oliguria and was hospitalized immediately for aggressive treatment. Despite all the medical efforts, her condition worsened and she died after twenty days. We describe the second case reported of a patient developing a severe C. difficile colitis following chemotherapy without any recent antibiotic use and review the data of the literature, emphasizing the need to a prompt diagnosis and management that can significantly decrease the morbidity and life-threatening complications associated with this infection.
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40
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Olivas AD, Umanskiy K, Zuckerbraun B, Alverdy JC. Avoiding Colectomy during Surgical Management of FulminantClostridium difficileColitis. Surg Infect (Larchmt) 2010; 11:299-305. [DOI: 10.1089/sur.2010.026] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Andrea D. Olivas
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Konstantin Umanskiy
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Brian Zuckerbraun
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John C. Alverdy
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
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41
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Review of medical and surgical management of Clostridium difficile infection. Tech Coloproctol 2010; 14:97-105. [PMID: 20454824 DOI: 10.1007/s10151-010-0574-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2009] [Accepted: 03/15/2010] [Indexed: 12/17/2022]
Abstract
Clostridium difficile infection (CDI) has become an important area in our daily clinical practice. C. difficile is known to cause a broad spectrum of conditions ranging from asymptomatic carriage, through mild or moderately severe disease with watery diarrhoea, to the life-threatening pseudomembranous colitis (PMC), with toxic megacolon and ileus. Peoples who have been treated with broad-spectrum antibiotics, patients with serious underlying co-morbidities and the elderly are at greatest risk. Over 80% of CDIs reported are in people aged over 65. Due to the alarming increase in its frequency, appearance of more virulent strains and occasional need for life-saving surgical intervention, a more coherent multidisciplinary approach is needed. Combination of rapid turn round time and accurate diagnosis will result in a better management of CDI and a timely implementation of infection control measure. Discontinuation of causative agents such as antibiotic treatment is often curative. In more serious cases, oral administration of metronidazole or vancomycin is the treatment of choice. Relapses of CDI have been reported in about 20-25% of cases, this may increase to 45-60% after the first recurrence. Patients should be treated as soon as possible when the diagnosis of Clostridium difficile colitis is made to avoid sepsis or bowel perforation. Colectomy may improve the outcome of the patient with systemic or complicated Clostridium difficile colitis. This article reviews the changing epidemiological picture, microbiology, histopathology and both medical and surgical managements.
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Chung CH, Wu CJ, Lee HC, Yan JJ, Chang CM, Lee NY, Chen PL, Lee CC, Hung YP, Ko WC. Clostridium difficile Infection at a Medical Center in Southern Taiwan: Incidence, Clinical Features and Prognosis. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2010; 43:119-25. [DOI: 10.1016/s1684-1182(10)60019-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2009] [Revised: 08/26/2009] [Accepted: 08/28/2009] [Indexed: 11/16/2022]
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Abougergi MS, Broor A, Cui W, Jaar BG. Intravenous immunoglobulin for the treatment of severe Clostridium difficile colitis: an observational study and review of the literature. J Hosp Med 2010; 5:E1-9. [PMID: 20063275 DOI: 10.1002/jhm.542] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clostridium difficile colitis (CDC) is the most common cause of hospital-acquired diarrhea. The increase in the incidence and fatality rate of CDC over the past decade has stimulated a search for new therapies, including intravenous immunoglobulin (IVIG). We report our experience with IVIG for the treatment of 21 patients with severe CDC. METHOD Retrospective review of patients with severe CDC who received IVIG between July 2002 and April 2006 at a teaching hospital. The existing literature on IVIG infusion for severe CDC was also reviewed. RESULTS Twenty-one of 1230 patients with CDC were treated with IVIG. The mean age was 68 (range, 35-98) years, with mean hospital stay of 23 (range, 9-64) days. Conventional treatment was used for an average of 8 (range, 1-25) days before IVIG infusion. All patients had evidence of pancolitis (radiologically) or ileus (clinically). The mean Acute Physiological Assessment and Chronic Health Evaluation (APACHE II) score was 25 (range, 6-39) at day 1 of IVIG infusion. Nine patients (43%) survived their hospitalization with colitis resolution while 12 (57%) died. One patient developed pulmonary edema after IVIG infusion. Symptoms resolved after an average of 10 (range, 2-20) days for survivors. Two patients underwent urgent colectomy. CONCLUSIONS This is the largest case series describing IVIG use for patients with severe CDC and the one with the highest mortality rate to date. The use of IVIG in this setting does not seem to benefit all patients. Benefit appears to depend on the extent of systemic involvement. Further studies are needed before adopting IVIG as routine treatment for severe CDC.
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Affiliation(s)
- Marwan S Abougergi
- Department of Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland 21224, USA.
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Leclair MA, Allard C, Lesur O, Pépin J. Clostridium difficile infection in the intensive care unit. J Intensive Care Med 2009; 25:23-30. [PMID: 20034951 DOI: 10.1177/0885066609350871] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Clostridium difficile infection (CDI) is an increasing nosocomial problem in North America and Western Europe, where outbreaks caused by a more virulent, toxin-hyperproducing strain have been recently reported. Clostridium difficile infection is now characterized by a higher incidence, more frequent relapses, and a higher case-fatality ratio. As a consequence, fulminant cases requiring admission to the intensive care unit (ICU) are much more common than previously. In recent years, metronidazole has appeared to lose some of its effectiveness in CDI management and vancomycin is now recognized as the first-line treatment of severe cases. Rapid diagnosis and institution of infection control measures are critical components of CDI management. The current review focuses on recent changes in the epidemiology, diagnostic methods, and treatment of CDI, with special emphasis on complicated cases managed in the ICU.
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Affiliation(s)
- Marc-André Leclair
- Intensive Care Unit, Department of Medicine, Université de Sherbrooke, Sherbrooke, Québec, Canada
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Abstract
Clostridium difficile infection (CDI) is becoming more common worldwide. The morbidity and mortality associated with C difficile is also increasing at an alarming rate. Critically ill patients are at particularly high risk for CDI because of the prevalence of multiple risk factors in this patient population. Treatment of C difficile continues to be a difficult problem in patients with severe or recurrent disease. This article seeks to provide a broad understanding of CDI in the intensive care unit, with special emphasis on risk factor identification, treatment options, and disease prevention.
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Imaging of the gastrointestinal complications of systemic chemotherapy. Clin Radiol 2009; 64:724-33. [DOI: 10.1016/j.crad.2009.02.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2008] [Revised: 01/21/2009] [Accepted: 02/05/2009] [Indexed: 01/03/2023]
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Abstract
BACKGROUND Identifying individuals with severe Clostridium difficile infection (CDI) at risk for major complications has become an important objective. Presence of clinical variables that predict complications from CDI would have the potential to strongly influence management. AIM To determine which clinical variables predict complications from CDI. METHODS Cross-sectional study of all individuals admitted to Temple University Hospital between 12/1/03 and 7/1/08 with the primary discharge diagnosis of CDI were eligible. Only patients experiencing their first episode of CDI were included. Abstracted data included demographic, physiological, laboratory, radiological, endoscopic, pharmacy and outcome data. Response was categorized as none, partial or complete. Complications attributed to CDI were defined as colon resection or death. RESULTS Overall 32 of 200 patients (16%) experienced a complication due to CDI including death (n = 20) and colectomy (n = 12). White blood cell count above 30,000 cells/mm(3) (OR = 4.06; 95% CI, 1.28-12.87) and a rise in the creatinine to over 50% above baseline (OR = 7.13; 95% CI, 3.05-16.68) predicted a complication. AROC for percent rise in serum creatinine was 0.73 (95% CI: 0.64-0.85) and 0.62 (95% CI: 0.58-0.80) for white blood cell count. CONCLUSIONS Severe white blood cell count elevation and a rise in the creatinine to over 50% above baseline are important independent predictors of serious adverse events due to CDI. These patients likely would benefit from more intensive care and early surgical consultation.
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Affiliation(s)
- D Gujja
- Department of Medicine, Abington Memorial Hospital, Abington, PA, USA
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Park BS, Kim JH, Seo HI, Kim HS, Kim DH, Cho HJ, Jeon TY, Kim DH, Sim MS, Kim S, Kang HS. Pseudomembranous Colitis after Gastrointestinal Operation. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2009. [DOI: 10.4174/jkss.2009.77.2.106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Byung Soo Park
- Department of Surgery, Postgraduate School of Medicine, Pusan National University, Busan, Korea
| | - Jae Hun Kim
- Department of Surgery, Postgraduate School of Medicine, Pusan National University, Busan, Korea
| | - Hyung Il Seo
- Department of Surgery, Postgraduate School of Medicine, Pusan National University, Busan, Korea
| | - Hyun Sung Kim
- Department of Surgery, Postgraduate School of Medicine, Pusan National University, Busan, Korea
| | - Dae Hwan Kim
- Department of Surgery, Postgraduate School of Medicine, Pusan National University, Busan, Korea
| | - Hong Jae Cho
- Department of Surgery, Postgraduate School of Medicine, Pusan National University, Busan, Korea
| | - Tae Yong Jeon
- Department of Surgery, Postgraduate School of Medicine, Pusan National University, Busan, Korea
| | - Dong Heon Kim
- Department of Surgery, Postgraduate School of Medicine, Pusan National University, Busan, Korea
| | - Mun Sup Sim
- Department of Surgery, Postgraduate School of Medicine, Pusan National University, Busan, Korea
| | - Suk Kim
- Department of Radiology, Postgraduate School of Medicine, Pusan National University, Busan, Korea
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Jaber MR, Olafsson S, Fung WL, Reeves ME. Clinical review of the management of fulminant clostridium difficile infection. Am J Gastroenterol 2008; 103:3195-203; quiz 3204. [PMID: 18853982 DOI: 10.1111/j.1572-0241.2008.02198.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a frequent cause of morbidity and mortality among elderly hospitalized patients. A small but increasing number of patients have developed fulminant CDI, and a significant number of these patients require emergency colectomy. In this review, we discuss the risk factors, pathophysiology, diagnosis, and management of fulminant CDI. DATA SOURCES A literature search (Medline, Embase, Cochrane Library, Biosis, Science Citation Index, Ovid Journals) was performed from the period between January 1980 and June 2008 using the key words "Clostridium difficile,""pseudomembranous enterocolitis,""colectomy,""acute abdomen,""antibiotic-associated diarrhea," or "fulminant Clostridium difficile colitis." Articles not in English or not related to human subjects were excluded. For this review, we analyzed the articles identified in our original search and those articles cited in the original review articles. No randomized trials were found on the surgical management of fulminant CDI and only retrospective studies with a minimum of five patients were used in the review. With respect to medical treatment, we based our review on guideline articles, systematic reviews, and available randomized trials. CONCLUSION Both the incidence and severity of CDI are increasing. Fulminant CDI is underappreciated as a life-threatening disease because of a lack of awareness of its severity and its nonspecific clinical syndrome. Early diagnosis and treatment are essential for a good outcome, and early surgical intervention should be used in patients who are unresponsive to medical therapy. The surgical procedure of choice is a total abdominal colectomy with end ileostomy, although the mortality rate remains high.
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Affiliation(s)
- M Raffat Jaber
- Department of Surgery, Loma Linda University Medical Center, Loma, Linda, California 92354, USA
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Johnston BL, Conly JM. Clostridium difficile: The evolving story. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2007; 18:341-5. [PMID: 18978983 PMCID: PMC2533571 DOI: 10.1155/2007/615827] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2007] [Accepted: 11/06/2007] [Indexed: 12/18/2022]
Affiliation(s)
- BL Johnston
- Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia
| | - JM Conly
- Departments of Medicine, Pathology and Laboratory Medicine, and Microbiology and Infectious Diseases, University of Calgary, Calgary, Alberta
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