Characteristics of Clostridium difficile infection in patients with discordant diagnostic test results.

BACKGROUND: Clinical features of Clostridium difficile infection (CDI) cases diagnosed by detection of polymerase chain reaction (PCR), with negative toxin enzyme immunoassay results (EIA) have not been fully elucidated. The purpose of this study was to determine the magnitude of CDI patients who had negative EIA toxin determinations but positive PCR tests, and their differences in clinical presentation. METHODS: We performed a retrospective study comparing the clinical features of CDI cases detected by EIA (toxins A + B) with cases detected by PCR (toxin negative, PCR positive) over a 16-month period. Only patients with an initial Clostridium difficile infection episode that fulfilled a standardized definition were included. RESULTS: During the study period, 107 episodes of CDI were detected. Seventy-four patients (69%) had positive glutamate dehydrogenase (GDH) antigen and EIA determinations (EIA positive patients). Thirty-three patients (31%) had GDH positive, negative toxin EIA and positive PCR determination (PCR positive patients). PCR positive patients were younger, 57 (27) years (mean [SD]), than EIA positive patients, 71 (16) years, (p < 0.001). Fewer PCR positive patients were receiving proton pump inhibitors (21 patients, 64%) than EIA positive patients (61 patients, 82%, p = 0.034). The clinical presentation was similar in both groups. In the multivariate analysis, lower age was identified as the only independent variable associated with PCR positive patients. CONCLUSIONS: One third of Clostridium difficile infection patients present negative toxin EIA and PCR positive tests. Performing PCR determination after the negative EIA test is more relevant in younger patients.

Risk factors for Clostridium difficile diarrhea in patients with inflammatory bowel disease.

BACKGROUND: Despite the growing incidence of Clostridium difficile diarrhea (CCD) in patients with inflammatory bowel disease (IBD), little is known about the associated risk factors. METHOD: A retrospective study comparing cases of CCD in patients with IBD to IBD carriers who did not develop CCD. A comparison was also made with patients who developed CCD but did not suffer IBD. RESULTS: Three cases (20%) with IBD and CCD had received antibiotics during the previous three months versus none of the controls (IBD without CCD, p = 0.22). Ten cases (67%) received treatment with proton pump inhibitors (PPIs) versus 2 (13%) in the control group (IBD without CCD, p = 0.001). Seven cases underwent colonoscopy and pseudomembranes were seen in one (14%). Fourteen (93%) patients demonstrated a favourable response to metronidazole. Patients with IBD and CCD presented with younger age (36 ± 10 years), a higher degree of community-acquired infection (13 patients, 87%), immunosuppressive treatment (7 patients, 47%) and less patients had received previous antibiotic treatment (3 patients, 20%) than those with CCD without IBD. The proportion of patients who received treatment with PPIs was similar (66% and 80%, respectively p = 0.266). CONCLUSIONS: CCD in IBD carriers affects younger patients, the majority are community acquired (less nosocomial) and it is more related to previous treatment with PPIs than with the antibiotic treatment. Clinical evolution is also favourable.

[Clostridium difficile enteritis]. / Enteritis por Clostridium difficile.

INTRODUCTION: Clostridium difficile infection of the small intestine is infrequent. METHOD: We present the first case of C. difficile enteritis (CDE) diagnosed in Spain and provide a review of the literature. RESULTS: A 30-year-old man underwent surgery for recurrence of a retroperitoneal germ cell tumor. Seven days later the patient developed vomiting, diarrhea and, finally, intestinal obstruction due to pseudomembranes caused by CDE. Only 57 cases of CDE have been reported in the literature. The mean age was 52±17 years with a range of 18 to 86 years. Twenty-nine patients (50%) had inflammatory bowel disease. Forty-seven (81%) had a history of colon or small intestine surgery. Mortality was higher in older patients and in those without inflammatory bowel disease. CONCLUSION: CDE is characterized by high severity and mortality.

Risk Factors for Clostridioides Difficile Diarrhea In Solid Organ Transplantation Recipients.

BACKGROUND: There is limited knowledge about risk factors for Clostridioides difficile infection (CDI) and recurrent CDI in solid organ transplant (SOT) recipients. METHODS: A case-control study of CDI in SOT recipients compared with controls (SOT recipients who did not present CDI). RESULTS: Sixty-seven patients from 1089 SOT recipients (6.2%) suffered at least one episode of CDI. The mean age was 55 ± 12 years and 20 cases (69%) were men. The accumulated incidence was 8% in liver transplantation, 6.2% in lung transplantation, 5.4% in heart transplantation, and 4.7% in kidney transplantation. Twenty-nine cases (43.3%) were diagnosed during the first 3 months after SOT. Forty-one cases (61.2%) were hospital acquired. Thirty-one patients with CDI presented with mild-moderate infection (46.3%), 30 patients with severe infection (44.8%), and 6 patients with severe-complicated disease (9%). Independent variables found to be related with CDI were hospitalization in the previous 3 months (odds ratio: 2.99; [95% confidence interval 1.21-7.37]) and the use of quinolones in the previous month (odds ratio: 3.71 [95% confidence interval 1.16-11.8]). Eleven patients (16.4%) had at least one recurrence of CDI. Previous treatment with amoxicillin-clavulanate, severe-complicated index episode, and high serum creatinine were associated with recurrent CDI in the univariant analysis CONCLUSIONS: Liver transplant recipients presented the highest incidence of CDI among SOT recipients. Risk factors for CDI were hospitalization in the previous 3 months and the use of quinolones in the previous month.

Proposal for a Novel Score to Determine the Risk of Cardiac Implantable Electronic Device Infection.

INTRODUCTION AND OBJECTIVES: The use of cardiac implantable electronic devices (CIEDs) has expanded in recent years. Infection related to these devices constitutes one of the main complications and is associated with high morbidity, mortality, and financial cost. The aim of this study was to construct a predictive risk score of acquiring CIED infection. METHODS: We designed a retrospective, nested case-control study. Both cases and controls belonged to a cohort that included all patients who underwent a CIED-related procedure between January 2009 and December 2015. Cases were defined as patients with infection, and 3 infection-free controls were randomly selected from the cohort for each case included. RESULTS: During the study period, 2323 procedures were performed. A total of 33 CIED-related infections were identified. Ninety-nine patients were selected as controls. Independent risk factors were the Charlson index (OR, 1.33; 95%CI, 1.07-1.67), oral anticoagulation (OR, 3.51; 95%CI, 1.44-8.54), revision or replacement of a previous device (OR, 2.75; 95%CI, 1.12-6.71) and the presence of more than 2 leads (OR, 3.42; 95%CI, 1.25-9.37). A predictive risk score was generated and denominated CIED-AI (Charlson Index, more than 2 leads/Electrodes, Device revision/replacement, oral Anticoagulation, previous Infection). This score had an area under the receiver operating characteristic curve of 0.79 (95%CI, 0.71-0.88). CONCLUSIONS: The CIED-AI score may help to identify patients at higher risk of infection, who could be candidates for intensive preventive measures.