Mortality Following Clostridioides difficile Infection in Europe: A Retrospective Multicenter Case-Control Study.

We aimed to describe the clinical presentation, treatment, outcome and report on factors associated with mortality over a 90-day period in Clostridioides difficile infection (CDI). Descriptive, univariate, and multivariate regression analyses were performed on data collected in a retrospective case-control study conducted in nine hospitals from seven European countries. A total of 624 patients were included, of which 415 were deceased (cases) and 209 were still alive 90 days after a CDI diagnosis (controls). The most common antibiotics used previously in both groups were ß-lactams; previous exposure to fluoroquinolones was significantly (p = 0.0004) greater in deceased patients. Multivariate logistic regression showed that the factors independently related with death during CDI were older age, inadequate CDI therapy, cachexia, malignancy, Charlson Index, long-term care, elevated white blood cell count (WBC), C-reactive protein (CRP), bacteraemia, complications, and cognitive impairment. In addition, older age, higher levels of WBC, neutrophil, CRP or creatinine, the presence of malignancy, cognitive impairment, and complications were strongly correlated with shortening the time from CDI diagnosis to death. CDI prevention should be primarily focused on hospitalised elderly people receiving antibiotics. WBC, neutrophil count, CRP, creatinine, albumin and lactate levels should be tested in every hospitalised patient treated for CDI to assess the risk of a fatal outcome.

Fructooligosaccharides and mannose affect Clostridium difficile adhesion and biofilm formation in a concentration-dependent manner.

The aim of this study was to investigate the effects that prebiotic and candidates for prebiotics on Clostridium difficile strains to adhere to various human epithelial cell lines and to compare the adhesive properties of specific C. difficile strains. We also sought to examine the effect of different concentrations of fructooligosaccharides and mannose on the formation of biofilms by C. difficile strains. The influence of cellobiose, fructooligosaccharides, inulin, mannose, and raffinose on the adherence properties of various C. difficile strains, including motile 630, non-motile M120, and 10 clinical motile ribotype 027 strains, to non-mucous secreting HT-29, mucous secreting HT-29 MXT, and CCD 841 CoN cells lines. The most effective prebiotics were used in biofilm formation assays. We demonstrated that all C. difficile strains adhered to all cell lines. However, the C. difficile M120 non-motile strain was statistically more likely to adhere to all three cell lines (CFU median, 40) compared to the motile strains (CFU median, 3; p < 0.001). Furthermore, among the carbohydrates examined, only fructooligosaccharides and mannose were found to significantly decrease adhesion (p < 0.001) of C. difficile strains. Alternatively, using a biofilm assay, we observed, via confocal laser scanning microscopy, that sub-inhibitory concentrations (1%) of fructooligosaccharides and mannose functioned to increase biofilm formation by C. difficile. We demonstrated that specific prebiotics and candidate prebiotics exhibit varying anti-adhesive properties towards C. difficile in vitro and that treatment with sub-inhibitory concentrations of prebiotics can cause an increase in biofilm formation by C. difficile.

Metronidazole or Rifaximin for Treatment of Clostridium difficile in Pediatric Patients with Inflammatory Bowel Disease: A Randomized Clinical Trial.

BACKGROUND: Interestingly, Clostridium difficile infection (CDI) worsens the course of inflammatory bowel disease (IBD); however, there is a paucity of data regarding the treatment of CDI in this group of patients. METHODS: This was a prospective, single-blind trial. Children with flare of IBD and CDI were randomly assigned to receive metronidazole or rifaximin orally for 14 days. CDI was diagnosed based on a positive well-type enzyme immunoassay (EIA) toxins A/B stool test for C. difficile toxins A and/or B. The cure rate was defined as the percentage of patients with a negative EIA stool test for C. difficile toxins A/B measured 4 weeks after the end of treatment. Recurrence was defined as a repeat CDI within 2 to 8 weeks. RESULTS: In total, we included 31 patients with IBD including 12 patients with Crohn's disease and 19 with ulcerative colitis. Of them, 17 received metronidazole and 14 received rifaximin. There were no statistically significant differences between the 2 study groups including age, type of treatment, and disease activity. There was no statistically significant difference in the cure rate between patients treated with metronidazole and rifaximin (70.6% versus 78.6%, respectively, P = 0.5). We found no difference in recurrence rate between the 2 study treatment types (17% versus 0%, respectively, P = 0.3). We did not find an association between immunosuppressive therapy and CDI cure rate or CDI recurrence rate. CONCLUSIONS: Metronidazole and rifaximin were similarly effective treatments for CDI in pediatric patients with IBD.

Enterotoxigenic Clostridium perfringens infection and pediatric patients with inflammatory bowel disease.

BACKGROUND AND AIMS: Clostridium difficile is the major cause of antibiotic-associated diarrhea and is the most well known bacterial pathogen associated with inflammatory bowel disease (IBD). Enterotoxigenic Clostridium perfringens has also been detected in up to 15% of antibiotic-associated diarrhea cases, and it has not been found in healthy people. The aim of this study was to investigate the prevalence of C. perfringens infection in pediatric patients with IBD. METHODS: This was a prospective, controlled study evaluating pediatric IBD patients in the Department of Pediatric Gastroenterology and Nutrition in Warsaw, Poland. All of the patients were diagnosed according to the Porto criteria. There were two control groups: (1) non-IBD patients that were suspected for bacterial diarrhea and (2) healthy children. Stool samples were collected on the day of admission. C. perfringens infection diagnosis was based on a positive stool enzyme immunoassay (C. perfringens enterotoxin test kit TechLab). RESULTS: 91 fecal specimens from patients with IBD were collected. The average patient age was 11.7 years in IBD group, 7.4 years in non-IBD patients with diarrhea, and 7.4 years in healthy children. The prevalence of C. perfringens infection was 9% (8/91; CI 95% 4.6-16.4). There were more Crohn's patients (6/8) in the C. perfringens positive group. There was no C. perfringens infection in the two control groups. CONCLUSION: Our pilot data add evidence to the hypothesis that Clostridia other than C. difficile may play a significant role in the clinical course of IBD. However, further studies are needed to confirm this.

Three-step diagnostic algorithm in diagnosing patients suspected of Clostridium difficile-associated diarrhea.

UNLABELLED: Clostridium difficile is a predominant etiological agent of healthcare-associated infectious diarrhea. Immunoenzymatic tests for detecting toxins A/B from faecal samples are still used in routine diagnosis of Clostridium difficile-associated diseases in a number of healthcare centers in Poland. Recently, however, new diagnostic tests were introduced which allow for detecting toxigenic strains of C. difficile in a more effective and precise manner. It is of importance, especially in the light of hypervirulent strain occurrence. AIM: The aim of the present paper was to evaluate the efficacy of three-step algorithm in the diagnosis of Clostridium difficile-associated diseases (CDAD), considering the occurrence of false negative test results for toxins while using exclusively immunoenzymatic tests. MATERIALS AND METHODS: In the present study, faecal samples collected from patients presenting diarrhea were tested. Immunoenzymatic tests were used for detecting glutamate dehydrogenase (GDH) and toxins A/B. Culture and RT-PCR were also employed. RESULTS: Of 615 study participants, toxigenic strains GDH (+) TOX (+) were identified in 108 patients while for 67 patients, test results remained unspecified GDH (+) TOX (-). Further analysis of unspecified samples revealed 32 patients infected with toxigenic strains, i.e. 22.9% of all positive test results (n=140). CONCLUSION: Three-step diagnostic algorithm is an effective and reliable tool for diagnosing C.difficile- associated diseases.

[The use of two-stage algorithm in the diagnosis of patients with low levels of Clostridium difficile toxins A/B in feces confirmed by using enzyme immunoassay]. / Zastosowanie dwustopniowego algorytmu w diagnostyce chorych z niskim poziomem toksyn A/B Clostridium difficile w kale potwierdzonym testem immunoenzymatycznym.

INTRODUCTION: Clostridium difficile infection (CDI) is a serious problem in hospitalized patients. Rapid and accurate laboratory diagnosis is the key to reducing of CDI. The suboptimal sensitivity and specificity of many commercial enzyme immunoassays have limited their utility. The aim of this study was analysis of faecal samples obtained from patients with clinical evidence of CDI, with non-detectable or questionable result of toxins A/B C. difficile recognized by toxins A/B EIA test. METHODS: A two-step algorithm for diagnostics of C. difficile infection (CDI) in patients with non-detectable or questionable result of toxins A/B C. difficile confirmed by C. difficile enzyme immunoassay (EIA) (Wampole, TOX A/B II, TechLab, USA) was used. Sixty nine faecal samples obtained from patients with nosocomial diarrhea were retested. All faecal samples were cultured on selective medium CLO C. difficile (BioMérieux, Francja). The positive samples on selective medium were tested by using Real Time-PCR (Xpert CD assay, Cepheid, Sunnyvale, CA, USA). Xpert CD assay is a real time multiplex PCR that can be used to detect toxigenic C. difficile strains and differentiate the C. difficile presumptive NAP1/BI/027 strain. All results when faecal samples were negative in culture growth on selective medium and result of EIA test were questionable was confirmed by use a RT-PCR test. RESULTS: Among 69 faecal samples 56 were negative for toxins A/B using EIA test and 13 gave questionable results. By anaerobic culture 60 of 69 specimens yielded C. difficile isolates. Among 69 faecal samples 55 were positive using RT-PCR. Thirty four (62%) of patients was infected by presumptive C. difficile NAP1/BI/027. CONCLUSIONS: C. difficile testing by use of culture and Real Time PCR (RT-PCR) increases diagnostic yield in a hospital patients with non-detectable or low level of toxins A/B in stool samples of patients infected by toxigenic C. difficile strains including presumptive C. difficile NAP1/BI/027.

Clostridium difficile infection in newly diagnosed pediatric patients with inflammatory bowel disease: prevalence and risk factors.

BACKGROUND: Epidemiological and microbiological data suggest that Clostridium difficile infection (CDI) plays a substantial role in the clinical initiation of inflammatory bowel disease (IBD). The aim of the present study was to investigate the prevalence and risk factors of CDI in newly diagnosed pediatric patients with IBD. METHODS: The current investigation was a retrospective study. All patients newly diagnosed with IBD in the pediatric gastroenterology clinic in Warsaw between 2007 and 2010 were included in the present study. The patients were diagnosed according to Porto criteria and microbiology evaluation screening tests for CDI were conducted. Risk factors including prior hospitalization, use of antibiotics within 2 months of CDI detection, colonic involvement, and the duration of symptoms were evaluated. CDI diagnosis was based on a positive stool enzyme immunoassay. RESULTS: In the present study, 134 patients were evaluated (54 patients with Crohn's disease, and 80 with ulcerative colitis; 87% of the patients had colonic disease). The average age of the patients was 12.3 years, and the prevalence of CDI was 47% (95% confidence interval [CI], 38%-56%). Significant differences in the prevalence of CDI between patients with Crohn's disease and ulcerative colitis (P = 0.72; odds ratio [OR] = 1.187, 95% CI, 0.56-2.52) were not observed. The risk of CDI was associated with an increase in the age of the patient and the severity of the disease. CONCLUSIONS: The prevalence of CDI in newly diagnosed IBD patients was high and was independent of the type of disease.

Clostridium difficile is no longer just a nosocomial infection or an infection of adults.

Clostridium difficile is the main cause of nosocomial gastrointestinal disorders. Historically, C. difficile has usually affected older patients, hospital inpatients, and long-term care facility residents. Recent reports suggest that the occurrence and severity of C. difficile-associated disease (CDAD) is increasing in populations previously considered to be at low risk of the infection, and increasing numbers of community-acquired cases of CDAD are being reported. Risk factors for CDAD in paediatric patients include disruption of the normal microflora of the gastrointestinal tract (antibiotic-associated and non-antibiotic-associated), age, immune status, diet, underlying conditions, concurrent infections, and cancer. CDAD in populations previously thought to be at low risk is an emerging problem.

Prevalence and association of PCR ribotypes of Clostridium difficile isolated from symptomatic patients from Warsaw with macrolide-lincosamide-streptogramin B (MLSB) type resistance.

Isolates (79 in total) of Clostridium difficile obtained over a 2 year period from 785 patients suspected of having C. difficile-associated diarrhoea (CDAD) and being hospitalized in the University Hospital in Warsaw were characterized by toxigenicity profile and PCR ribotyping. Furthermore, their susceptibility to clindamycin and erythromycin was determined. Among the 79 C. difficile isolates, 35 were classified as (A+)B+, 1 as (A+)(B+)CDT+, 36 as (A-)B+ and 7 as (A-)B-. A total of 21 different PCR ribotypes was detected. Two main (A+)B+ strains circulated in our hospital: ribotype 014 and ribotype 046. Unexpectedly, the predominant PCR ribotype was type 017, a known (A-)B+ strain, and this accounted for about 45.5 % of all isolates cultured from patients with CDAD. Isolates belonging to PCR ribotype 017 were found in cases from epidemics of antibiotic-associated diarrhoea in the internal and surgery units. High-level resistance (MIC > or = 256 mg l(-1)) to clindamycin and erythromycin was found in 39 (49 %) of the C. difficile isolates. Interestingly, 34 (94 %) of macrolide-lincosamide-streptogramin B (MLSB) type resistance strains did not produce toxin A, but produced toxin B and were (A-)B+ ribotype 017. Thirty-seven of the high-level resistance strains harboured the erythromycin-resistance methylase gene (ermB). C. difficile isolates (2/29) that had high-level clindamycin and erythromycin resistance, and belonged to PCR ribotype 046, were ermB negative. These investigations revealed that the predominant C. difficile strain isolated from symptomatic patients hospitalized in University Hospital in Warsaw was MLSB-positive clindamycin/erythromycin-resistant PCR ribotype 017.

[Detection of ermB gene responsible for high level resistance to clindamycin (MLS type resistance) among Clostridium difficile strains isolated from antibiotic associated diarrhea (AAD)]. / Wykrywanie genu ermB warunkujacego wysoka opornosc na klindamycyne (opornosc typu MLS) w szczepach Clostridium difficile izolowanych z przypadków biegunki poantybiotykowej (AAD).

In 68 C. difficile strains isolated from feacal samples of patients with antibiotic associated diarrhoea (AAD) investigated presence of ermB gene transferable of high level resistance to clindamycin. The primers set 2980/2981 used for identification of ermB gene amplified a 688 bp segment. We used the Etest to assess all strains for susceptibility to clindamycin. This study demonstrates that 57% of strains isolated from faecal samples of patients with AAD were highly resistant to clindamycin (minimal inhibitory concentration (MIC) of clindamycin, 256 mg/L) and possessed the ermB gene.