Infecciones por Clostridioides difficile en pediatría. La visión del laboratorio a partir del diagnóstico microbiológico / Clostridioides difficile infections in pediatrics. The view of the laboratory based on microbiological diagnosis

La infección por Clostridioides difficile (ICD) es la principal responsable de diarreas nosocomiales en adultos. En los últimos años se registró un aumento en la incidencia de la ICD en la población adulta que, en cambio, no fue bien caracterizado en pediatría. El objetivo de este trabajo es analizar los datos resultantes del diagnóstico microbiológico de ICD en el Hospital de Pediatría "Prof. Dr. Juan P. Garrahan". Materiales y métodos: se realizó un estudio retrospectivo observacional descriptivo que abarcó desde el 01/01/2018 hasta el 31/12/2021. El diagnóstico se realizó mediante enzimoinmunoensayo para glutamato deshidrogenasa (GDH) y toxinas en materia fecal (MF). Cuando sólo se detectó GDH, se realizó un cultivo toxigénico (CT) de la MF para la detección de toxinas in vitro. Se registraron: edad, sexo y procedencia de los pacientes y recurrencias de las ICD. Se efectuaron estudios de sensibilidad de 387 cepas de C. difficile a metronidazol (MTZ) y vancomicina (VAN). Resultados: en 6632 muestras (1764 pacientes) se registraron 649 estudios positivos (9,8%) (139 pacientes), la mayoría correspondieron a pacientes internados en áreas no críticas. Edad promedio: 7 años (7 ± 4,7). Sexo: 55% masculino. Recurrencias: 62 (45%). Positivos detectados mediante CT: 43%. Sensibilidad antibiótica: 100% a MTZ y 99,7% a VAN. Conclusión: Nuestra población presenta un bajo porcentaje de positividad. Se destaca el rendimiento del CT que permitió el diagnóstico de más de un tercio de los casos. MTZ y VANCO tuvieron excelente actividad in vitro frente a C. difficile (AU)

Clostridioides difficile infection (CDI) is the main cause of nosocomial diarrhea in adults. In recent years there has been an increase in the incidence of CDI in the adult population; however, CDI has not been well characterized in pediatrics. The aim of this study was to analyze the data resulting from the microbiological diagnosis of CDI at Hospital de Pediatría Prof. Dr. Juan P. Garrahan. Materials and methods: a retrospective, observational and descriptive study was conducted from 01/01/2018 to 12/31/2021. Diagnosis was made using enzyme immunoassay for glutamate dehydrogenase (GDH) and toxins in stools. When only GDH was detected, toxigenic culture (TC) of stools was performed for in vitro toxin detection. The age, sex and origin of patients and CDI recurrences were recorded. Sensitivity studies of 387 strains of C. difficile to metronidazole (MTZ) and vancomycin (VAN) were performed. Results: In 6,632 samples (1,764 patients), 649 positive results (9.8%) were recorded (139 patients), most of which corresponded to patients hospitalized in noncritical areas. Mean age: 7 years (7 ± 4.7). Sex: 55% male. Recurrences: 62 (45%). TC-positive results: 43%. Antibiotic sensitivity: 100% to MTZ and 99.7% to VAN. Conclusion: A low percentage of positivity was found in our population. The performance of TC was outstanding, allowing for the diagnosis of more than one third of the cases. MTZ and VANCO had excellent in vitro activity against C. difficile (AU)

Actualización en el diagnóstico y manejo de la Infección por Clostridioides difficile / Update in diagnosis and management of Clostridioides difficile

El Clostridioides difficile (C. difficile) es una de las principales causas de infección asociada a la atención de salud con una elevada morbimortalidad, sobre todo en adultos mayores hospitalizados. El aumento en el uso de antibióticos ha ido de la mano con el incremento en el número de casos y de una mayor virulencia. Su presentación clínica va desde portadores asintomáticos hasta megacolon tóxico, escenarios que deben ser considerados al momento de realizar el estudio con exámenes de deposiciones (glutamato deshidrogenasa, toxinas A y B y técnicas de amplificación ácidos nucleares). Se han incorporado al arsenal terapéutico, con mayor nivel de evidencia, la fidaxomicina, trasplante microbiota fecal y recientemente nuevas terapias como anticuerpos monoclonales. Sin embargo, la gravedad de la infección, comorbilidad del paciente, presencia factores de recurrencia, el acceso y el costo económico de cada una de las opciones terapéuticas deben ser considerados. El objetivo de esta revisión es actualizar el manejo propuesto por las Sociedades Chilenas de Gastroenterología e Infectología publicadas el 2016 incorporando las últimas recomendaciones con respecto a prevención, diagnóstico y tratamiento de la infección por C. difficile.

Clostridioides difficile (C. difficile) is one of the leading causes of infection associated with health care with high morbidity and mortality, especially among hospitalized older adults. The increase in the use of antibiotics has been associated with a higher number of cases and greater virulence. Its clinical presentation ranges from asymptomatic carriers to toxic megacolon. Studies with stool tests (glutamate dehydrogenase, toxins A and B, and nuclear acid amplification techniques) should be considered in these cases. Fidaxomicin, fecal microbiota transplant, and new therapies such as monoclonal antibodies have been incorporated into the therapeutic arsenal, with a higher level of evidence. Nevertheless, the severity, patient comorbidity, recurrence risk factors, and the economic cost of each therapeutic option must be considered. This review aims to update the last guidelines proposed by the Chilean Societies of Gastroenterology and Infectious Diseases published in 2016, providing the latest recommendations regarding prevention, diagnosis, and treatment of C. difficile infection.

Diagnóstico microbiológico de infección por Clostridioides difficile en épocas de COVID-19 en un hospital pediátrico de alta complejidad / Microbiological diagnosis of Clostridioides difficile infection in times of COVID-19 in a high complexity pediatric hospital

Resumen La infección por Clostridioides difficile (ICD) puede variar desde diarrea hasta megacolon tóxico. Los objetivos del trabajo fueron mostrar la variación en el número de casos diagnosticados de ICD en este laboratorio entre 2020, cuando comenzó la pandemia de COVID-19 y 2019 y 2021 y detallar los casos precedidos por la infección de SARS-CoV-2. El presente es un estudio retrospectivo observacional en el que se registraron el número total de muestras procesadas con sospecha de ICD y el de positivas y los antecedentes clínicos de pacientes con ICD hasta dos meses después de su diagnóstico de COVID-19. Durante 2020 se procesaron menos muestras que en 2019 y 2021; sin embargo, el porcentaje de positividad fue de 13,1%, 7,2% y 7,8%, respectivamente. Esto pudo deberse a mejoras en el criterio clínico al momento de seleccionar las muestras con sospecha de ICD.

Abstract Clostridioides difficile infection (CDI) can cause anything from diarrhea to toxic megacolon. The objectives of this study were: to show the variation in the number of diagnosed cases of CDI in this center, comparing 2020, when the COVID-19 pandemic began, with 2019 and 2021 and to detail cases preceded by SARS-CoV-2 infection. This is an observational retrospective study in which the total number of samples processed with suspected CDI were recorded. The positive ones and the clinical history of patients with a diagnosis of CDI up to two months after their diagnosis of SARS-CoV-2 infection were recorded as well. During 2020 a smaller number of samples were processed. However, during this year the percentage of positivity was 13.1% vs. 7,2% and 7.8% during 2019 and 2021, respectively. It is believed that this may have been due to improvements in clinical suspicion and sample selection for CDI diagnosis.

Resumo A infecção por Clostridioides difficile (ICD) pode causar desde diarreia até megacólon tóxico. Os objetivos desta apresentação foram: mostrar a variação do número de casos diagnosticados de ICD neste laboratório, entre 2020 quando começou a pandemia de COVID-19 e 2019 e 2021 e, detalhar os casos precedidos pela infecção por SARS-CoV-2. Esse estudo foi retrospectivo observacional e foram registrados: o número total de amostras processadas com suspeita de ICD e de amostras positivas e os antecedentes clínicos daqueles pacientes com diagnóstico de ICD até dois meses após o diagnóstico de COVID 19. Durante 2020, foram processadas menos amostras do que em 2019 e 2021; no entanto, o percentual de positividade foi de 13,1%, 7,2% e 7,8%, respectivamente. Isso pode ter sido resultado de melhorias no critério clínico na hora de selecionar as amostras com suspeita de ICD.

Clostridioides difficile: achados epidemiológicos em animais domésticos em um Hospital Veterinário Universitário em ­ Teresina, PI / Clostridioides difficile: epidemiological findings in domestic animals in a University Veterinary Hospital in Teresina, PI

O objetivo deste estudo foi analisar a prevalência de Clostridioides difficile e suas toxinas (A/B) nas fezes de animais domésticos de um Hospital Veterinário Universitário de Teresina - PI. A detecção de C. difficile e suas toxinas foi realizada por meio de um ensaio imunoenzimático, denominado C. Diff Quik Chek Complete® (TECHLAB), capaz de detectar antígeno Glutamato Desidrogenase (GDH) e as toxinas A/B produzidas pelo bacilo, realizado em amostras fecais de cães (C. lupus) e e gatos (Felis catus) coletadas entre agosto de 2019 a setembro de 2020. Um total de 54 amostras fecais foram analisadas, das quais 16 foram positivas para C. difficile (29,63%). 68,75% (11/16) pertenciam a caninos, enquanto 31,25% (5/16) a felinos. Amostras diarreicas e não diarreicas foram utilizadas para o estudo e uma maior prevalência do bacilo pôde ser identificada em amostras diarreicas (33%). Nenhuma das amostras apresentou toxinas do patógeno. Os achados deste estudo evidenciam que C.difficile está presente no estado do Piauí. Foi possível identificá-lo em todas as espécies e em amostras diarreicas ou não, demonstrando que essa infecção pode se manifestar de formasintomática e assintomática, levantando a possibilidade de infecção cruzada entre o animal e seu tutor.

The aim of this study was to analyze the prevalence of Clostridioides difficile and its toxins (A/B) in the feces of domestic animals at a University Veterinary Hospital in Teresina - PI. The detection of C. difficile and its toxins was performed by an immunogenic enzyme, called C. Diff Quik Chek Complete® (TECHLAB), capable of detecting antigen glutamate dehydrogenase (GDH) and A/B toxins produced by this bacillus, performed in fecal samples of dogs (C. lupus) and cats (Felis catus) collected between August 2019 and September 2020.:54 stools were analyzed, of which 16 were positive for C. difficile (29.63%). 68.75% (11/16) belonged to canines, while 3.25% (5/16) to felines. Diarrheal and non-diarrheal diseases are used for the study and a higher prevalence of bacillus can be identified in diarrheal diseases (33%). None of the samples present pathogen toxins. The results of this study show that C. difficile is present in the state of Piauí. It can be identified in all species and in diarrheal or non-diarrheic samples, demonstrating that this infection can be symptomatic and asymptomatic, giving the possibility of cross-infection between the animal and its owner.

¿La detección de toxinas de Clostridioides difficile es necesaria cuando se detecta la enzima glutamato deshidrogenasa? / Is Clostridioides difficile toxins detection necessary when the glutamate dehydrogenase enzyme is detected?

Resumen Introducción: Clostridioides difficile causa diarrea y colitis pseudomembranosa. Su diagnóstico se realiza con la detección de glutamato-deshidrogenasa (GDH) o las toxinas A y B y se confirma con pruebas de amplificación de ácidos nucleicos. Objetivo: Definir si la determinación de GDH es redundante a la de las toxinas. Métodos: Estudio observacional retrospectivo de muestras fecales de pacientes con sospecha de infección por Clostridioides difficile. Las toxinas y GDH se determinaron mediante inmunocromatografía. Se realizó una simulación bayesiana con los cocientes de probabilidad; se consideró significativo un valor de p < 0.05. Resultados: Se analizaron 329 resultados de GDH y toxinas A y B. Se encontró una prevalencia de infección de Clostridioides difficile de 18.2 %. La sensibilidad y especificidad de la prueba de GDH fue de 0.90 y 0.89, respectivamente. El cociente de probabilidad positivo fue de 8.9 y el negativo, de 0.11. Conclusiones: Un resultado negativo de GDH disminuye considerablemente la probabilidad de infección, pero no la descarta. La detección de toxinas de Clostridioides difficile puede ser necesaria en instituciones donde la amplificación de ácidos nucleicos no es económica o accesible.

Abstract Introduction: Clostridioides difficile causes diarrhea and pseudomembranous colitis. Its diagnosis is made with glutamate dehydrogenase (GDH) or toxins A and B detection and is confirmed with nucleic acid amplification tests. Objective: To define if GDH determination is redundant to that of toxins. Methods: Retrospective, observational study in diarrheal stools of patients with suspected Clostridioides difficile infection. Toxins and GDH were determined by immunochromatography. Bayesian simulation was performed with likelihood ratios; a p-value < 0.05 was regarded as significant. Results: 329 GDH and toxin A and B results were analyzed. Clostridioides difficile infection prevalence was 18.2 %. Sensitivity and specificity of the GDH test were 0.90 and 0.89, respectively. Positive likelihood ratio was 8.9, and negative was 0.11. Conclusions: A negative GDH result considerably reduces the probability of infection but does not rule it out. Clostridioides difficile toxins detection may be necessary in institutions where nucleic acid amplification is not affordable or accessible.

Glutamato deshidrogenasa: Su valor diagnóstico en la diarrea por Clostridioides difficile / Glutamate dehydrogenase: Its diagnostic value in Clostridioides difficile diarrhea

Clostridioides difficile es el principal agente causal de diarreas asociadas al cuidado de la salud. Esta bacteria produce toxinas y una enzima que se encuentra muy conservada en la especie: la glutamato deshidrogenasa (GDH). El diagnóstico rápido y el tratamiento efectivo permiten la pronta mejoría del paciente, con el consecuente control de la diseminación del microorganismo. Sin embargo, aún no se cuenta con un método diagnóstico óptimo y se propone la realización de diversas pruebas, cuyos resultados se interpretan en el contexto de ciertos algoritmos. En este trabajo se evaluó el desempeño de la GDH como prueba de tamizaje en el diagnóstico de la diarrea por c. difficile. Se estudiaron 615 muestras de materia fecal. Se determinó la presencia de GDH y de toxinas mediante el equipo diagnóstico de enzimoinmunoensayo de membrana C. DIFF QUIK-CHEK COMPLETE® (TECHLAB) y se realizaron cultivos para la búsqueda de C. difficile. Se calcularon los valores de sensibilidad, especificidad, VPP y VPN con un nivel de significación p < 0,05. Se detectó GDH en 266 muestras (43,25%), con una sensibilidad del 100% y una especificidad del 87,10%, IC95: 84,58-91,42. Se hallaron toxinas en 218 muestras (35,45%) y C. difficile desarrolló en 235 cultivos (38,21%). De 48 muestras GDH positivas y sin producción de toxina/s, 17 fueron positivas al cultivo de C. difficile, con 15 aislamientos toxigénicos y 2 no toxigénicos. No hubo desarrollo de C. difficile en las 31 muestras restantes. Ninguna muestra GDH negativa dio resultado positivo de toxina/s ni desarrollo en el cultivo, por lo cual el VPN de la GDH fue del 100%, mientras que el VPP fue del 81,9%. Concluimos que la determinación de GDH representa un screening adecuado para descartar casos de diarrea por C. difficile, por lo tanto de valor en los algoritmos diagnósticos de las diarreas infecciosas.

Clostridioides difficile is the main etiological agent of diarrhea associated with health care, it produces toxins and glutamate dehydrogenase (GDH), an enzyme that is highly conserved in this species. Rapid diagnosis and effective treatment produce prompt improvement of the patient and subsequent control of the microorganism spread. There are several techniques whose results are interpreted in the context of algorithms. However, the optimal diagnostic method is yet unknown. The performance of GDH as a screening test for the diagnosis of C. difficile diarrhea was assessed. Six hundred and fifteen stool samples were studied. The presence of GDH and toxins presence was determined by TECHLAB® C. DIFF QUIK-CHEK COMPLETE and the samples were cultured for the search of C. difficile. The values of sensitivity, specificity, PPV and NPV were calculated with a p value of 0.05 or less. GDH was detected in 266 samples (43.25%), with a sensitivity of 100% and specificity of 87.10%, IC95: 84.58-91.42; toxin/s were detected in 218 (35.45%) and C. difficile developed in 235 cultures (38.21%). From 48 samples with positive GDH and negative toxin/s, 15 toxigenic and 2 non-toxigenic isolates were obtained, the remaining 31 samples were negative for C. difficile. All GDH-negative samples were negative for toxins or culture, therefore, GDH NPV was 100%, while PPV was 81.9%. We conclude that GDH is a suitable screening test for the diagnostic algorithm of C. difficile diarrhea.

Effect of honey supplementation on clostridium difficile infection in childhood cancer

Background: the treatment of cancer is associated with nausea and vomiting, oral mucositis, constipation, xerostomia and diarrhea and weight loss, additionally; chemotherapeutic agents promote inflammatory changes in the gut, intestinal necrosis, and anaerobic conditions, allowing proliferation of Clostridium Difficile. Honey, as a natural honeybee product, has antioxidant, antimicrobial, immunomodulatory and anticancer effects. Honey can fight microbial infection by its immuno-activating, anti-inflammatory and prebiotic activity

Objectives: the aim of this study was to evaluate the effect of honey supplementation on frequency of Clostridium Difficile infection [CDI] and gastrointestinal complications in pediatric patients undergoing chemotherapy

Design: a cross sectional study conducted on 40 patients with malignancy recruited from Children's Hospital, Ain Shams University, Oncology Unit and Clinic, Cairo, Egypt in the period from December 2015 to December 2016. Patients were divided into two groups; group I [25 patients] received honey in the dose of 2gm/kg 3 times dailyfor 1month] while group II [15 patients] did not receive honey. All the studied patients were subjected to medical history and clinical examination, with special emphasis on gastrointestinal complication including oral mucositis, vomiting, diarrhea, constipation, and abdominal pain. Follow up was done for weight, height z score, gastrointestinal complications and any adverse events. Stool analysis, culture, C difficle toxin A, B by ELISA was done to all patients at baseline and repeated to patients receiving honey at week 4 of supplementation. Main outcome measure frequency of CDI, gastrointestinal complication, febrile neutropenia

Results: the frequency of C difficle was 8% [2], the first case was 9 years old patient with ALL [50%] and the other 11 years old patient with Burkitts lymphoma both were diagnosed by positive stool culture and positive stool ELISA for toxin A, B. gastrointestinal complications were significantly less and improved in the supplemented group and mean of hemoglobin significant increase in group 1

Conclusion: the frequency of CDI in children with cancer 8% diagnosed by stool culture and toxin A, B study in stool. Honey improved the oral mucositis and different GIT complications associated with chemotherapy

Increasing rates of Clostridium difficile infection in Mexican hospitals

Abstract Introduction The epidemiology of Clostridium difficile infection (CDI) has changed in the last two decades. There is a lack of information regarding incidence and severity of CDI, especially in the developing world. Methods This was a retrospective and observational study from four hospitals of three Mexican cities. Patients were diagnosed with CDI when presented with loose stools and had at least one of the following tests positive: toxins assay, real-time PCR, or an endoscopic image compatible with pseudomembranous colitis. CDI was classified according to international guidelines. Demographic and clinical data as well as information regarding total hospital admissions, total length-of-hospital stay, and other variables related to hospitalization were gathered from the epidemiology and administration departments of each hospital. Results A total of 2050 hospital beds were analyzed with 288,171 patients hospitalized accumulating 1,576,446 days of hospitalization during the study period. The average rate of CDI per 1000 hospital-days was lower than the rates reported in the US and Europe, although in 2015 CDI rates were almost persistently above the mean rate for the study period. More than half of PCR positive patients were ribotype 027. Conclusion Hospital rates of CDI are increasing in Mexican hospitals with a predominance of infections caused by ribotype 027.

Detection of vancomycin-resistant enterococci (VRE) in stool specimens submitted for Clostridium difficile toxin testing

Abstract The aim of this study was to determine the association between Clostridium difficile (C. difficile) and vancomycin-resistant Enterococcus (VRE) and efficacy of screening stools submitted for C. difficile toxin assay for prevalence of VRE. Between April 2012 and February 2014, 158 stool samples submitted for C. difficile toxin to the Marmara University Microbiology Laboratory, were included in the study. Stool samples were analyzed by enzyme immuno assay test; VIDAS (bioMerieux, France) for Toxin A&B. Samples were inoculated on chromID VRE (bioMerieux, France) and incubated 24 h at 37 °C. Manuel tests and API20 STREP (bioMerieux, France) test were used to identify the Enterococci species. After the species identification, vancomycin and teicoplanin MIC's were performed by E test and molecular resistance genes for vanA vs vanB were detected by polymerase chain reaction (PCR). Of the 158 stool samples, 88 were toxin positive. The prevalence of VRE was 17%(n:19) in toxin positives however, 11.4% in toxin negatives(n:70). All VRE isolates were identified as Enterococcus faecium. These results were evaluated according to Fischer's exact chi-square test and p value between VRE colonization and C. difficile toxin positivity was detected 0.047 (p < 0.05). PPV and NPV were 79% and 47% respectively. In our study, the presence of VRE in C. difficile toxin positives is statistically significant compared with toxin negatives (p < 0.05). Screening for VRE is both additional cost and work load for the laboratories. Therefore VRE screening among C. difficile toxin positive samples, will be cost effective for determination of high risk patients in the hospitals especially for developing countries.

Analysis of risk factors and clinical manifestations associated with Clostridium difficile disease in Serbian hospitalized patients

Abstract Clostridium difficile is the leading cause of infectious diarrhoea in hospitalized patients. The aim of this study was to determine the risk factors important for the development of hospital-acquired Clostridium difficile-associated disease and clinical manifestations of Clostridium difficile-associated disease. The clinical trial group included 37 hospitalized patients who were selected according to the inclusion criteria. A control group of 74 hospitalized patients was individually matched with cases based on hospital, age (within 4 years), sex and month of admission.Clostridium difficile-associated disease most commonly manifested as diarrhoea (56.76%) and colitis (32%), while in 8.11% of patients, it was diagnosed as pseudomembranous colitis, and in one patient, it was diagnosed as fulminant colitis. Statistically significant associations (p < 0.05) were found with the presence of chronic renal failure, chronic obstructive pulmonary disease, cerebrovascular accident (stroke) and haemodialysis. In this study, it was confirmed that all the groups of antibiotics, except for tetracycline and trimethoprim-sulfamethoxazole, were statistically significant risk factors for Clostridium difficile-associated disease (p < 0.05). However, it was difficult to determine the individual role of antibiotics in the development of Clostridium difficile-associated disease. Univariate logistic regression also found that applying antibiotic therapy, the duration of antibiotic therapy, administration of two or more antibiotics to treat infections, administering laxatives and the total number of days spent in the hospital significantly affected the onset of Clostridium difficile-associated disease (p < 0.05), and associations were confirmed using the multivariate model for the application of antibiotic therapy (p = 0.001), duration of antibiotic treatment (p = 0.01), use of laxatives (p = 0.01) and total number of days spent in the hospital (p = 0.001). In this study of patients with hospital-acquired diarrhoea, several risk factors for the development of Clostridium difficile-associated disease were identified.

Isolation of recombinant antibodies directed against surface proteins of Clostridium difficile

Abstract Clostridium difficile has emerged as an increasingly important nosocomial pathogen and the prime causative agent of antibiotic-associated diarrhoea and pseudomembranous colitis in humans. In addition to toxins A and B, immunological studies using antisera from patients infected with C. difficile have shown that a number of other bacterial factors contribute to the pathogenesis, including surface proteins, which are responsible for adhesion, motility and other interactions with the human host. In this study, various clostridial targets, including FliC, FliD and cell wall protein 66, were expressed and purified. Phage antibody display yielded a large panel of specific recombinant antibodies, which were expressed, purified and characterised. Reactions of the recombinant antibodies with their targets were detected by enzyme-linked immunosorbent assay; and Western blotting suggested that linear rather than conformational epitopes were recognised. Binding of the recombinant antibodies to surface-layer proteins and their components showed strain specificity, with good recognition of proteins from C. difficile 630. However, no reaction was observed for strain R20291—a representative of the 027 ribotype. Binding of the recombinant antibodies to C. difficile M120 extracts indicated that a component of a surface-layer protein of this strain might possess immunoglobulin-binding activities. The recombinant antibodies against FliC and FliD proteins were able to inhibit bacterial motility.

Consenso chileno de prevención, diagnóstico y tratamiento de la diarrea asociada a Clostridium difficile / Chilean consensus of prevention, diagnosis and treatment of Clostridium difficile-associated diarrhea

Background: Clostridium dijfficile-associated diarrhea (CDAD) has become very important due to the increase in its incidence, severity, recurrence and the associated economic burden. Having a national consensus guideline is essential to improve its management. Objective: To build a multidisciplinary and evidence-based consensus in prevention, diagnosis and treatment of CDAD. Methods: We convened a panel of experts in the field of infectious diseases, gastroenterology, evidence-based medicine and consensus methodology. The panel conducted a structured review of published literature in CDAD evaluating evidence levels and recommendation degree according to the methodology proposed by the GRADE working-group. A modified three-round Delphi technique was used to reach a consensus among the experts. Results: A group of 16 experts was established, 12 of them answered 18 clinically relevant questions. The levels of agreement achieved by the panel of 16 experts were 79% in the first round and 100% in the second and third round. The main consensus recommendations in prevention are: restricting the use of proton-pump inhibitors, primary prophylaxis with probiotics in antibiotics users, education of health personnel, isolation for patients hospitalized with CDAD, and cleaning the rooms exposed to C. difficile with products based in chlorine or hydrogen peroxide. In the diagnosis: use of biology molecular-based techniques is preferred and if not available, glutamate dehydrogenase-based algorithms may be recommended. With regard to treatment: the use of oral metronidazole in mild-moderate CDAD and oral vancomycin in severe CDAD are recommended. Treat the first recurrence with the same antibiotics according to severity. In the case of second and subsequent recurrences consider prolonged therapy with vancomycin, rifaximin or fecal microbiota transplant. Conclusion: The first Chilean consensus on prevention, diagnosis and treatment of CDAD is presented, which is a major step in improving national standards in the management of this disease.

Introducción: La diarrea asociada a Clostridium difficile (DACD) ha adquirido gran relevancia debido al aumento en su incidencia, gravedad, capacidad de recurrencia y carga económica asociada. Contar con una guía de consenso local es fundamental para mejorar su manejo. Objetivo: Elaborar un consenso multidisciplinara y basado en la evidencia en la prevención, diagnóstico y tratamiento de la DACD. Métodos: Se convocó a un panel de expertos en el área de enfermedades infecciosas, gastroenterología, medicina basada en la evidencia y metodología de consenso. El panel realizó una revisión estructurada de la literatura científica publicada en DACD evaluando el nivel de la evidencia y recomendación utilizando el sistema GRADE. Una técnica de Delfi modificada de tres rondas fue utilizada para alcanzar un consenso entre los expertos. Resultados: Se estableció un grupo de 16 expertos, 12 de ellos respondieron 18 preguntas de relevancia clínica. Los niveles de acuerdo alcanzados por el panel de 16 expertos fueron de 79% en la primera ronda y 100% en la segunda y tercera ronda. Las principales recomendaciones en prevención son: restricción del uso de inhibidores de la bomba de protones, profilaxis primaria con probióticos en usuarios de antimicrobianos de corto plazo, educación del personal de salud, aislamiento de contacto en pacientes hospitalizados con DACD y aseo de las habitaciones expuestas a C. difficile con productos en base a cloro o peróxido de hidrógeno. En el diagnóstico se recomienda: el uso de técnicas basadas en biología molecular y como alternativa algoritmos en base a glutamato deshidrogenasa. Con respecto al tratamiento, se recomienda el uso de metronidazol oral en DACD leve-moderada y vancomicina oral en DACD grave. El tratamiento de la primera recurrencia es con los mismos antimicrobianos de acuerdo a la gravedad, considerando en la segunda recurrencia y posteriores terapia prolongada con vancomicina, rifaximina o trasplante de microbiota fecal. Conclusión: Se presenta el primer consenso chileno en prevención, diagnóstico y tratamiento de DACD, paso trascendental en mejorar los estándares locales en el manejo de esta enfermedad.

Evaluation of Xpert C. difficile, BD MAX Cdiff, IMDx C. difficile for Abbott m2000, and Illumigene C. difficile Assays for Direct Detection of Toxigenic Clostridium difficile in Stool Specimens

BACKGROUND: We evaluated the performance of four commercial nucleic acid amplification tests (NAATs: Xpert C. difficile, BD MAX Cdiff, IMDx C. difficile for Abbott m2000, and Illumigene C. difficile) for direct and rapid detection of Clostridium difficile toxin genes. METHODS: We compared four NAATs on the same set of 339 stool specimens (303 prospective and 36 retrospective specimens) with toxigenic culture (TC). RESULTS: Concordance rate among four NAATs was 90.3% (306/339). Based on TC results, the sensitivity and specificity were 90.0% and 92.9% for Xpert; 86.3% and 89.3% for Max; 84.3% and 94.4% for IMDx; and 82.4% and 93.7% for Illumigene, respectively. For 306 concordant cases, there were 11 TC-negative/NAATs co-positive cases and 6 TC-positive/NAATs co-negative cases. Among 33 discordant cases, 18 were only single positive in each NAAT (Xpert, 1; Max, 12; IMDx, 1; Illumigene, 4). Positivity rates of the four NAATs were associated with those of semi-quantitative cultures, which were maximized in grade 3 (>100 colony-forming unit [CFU]) compared with grade 1 (<10 CFU). CONCLUSIONS: Commercial NAATs may be rapid and reliable methods for direct detection of tcdA and/or tcdB in stool specimens compared with TC. Some differences in the sensitivity of the NAATs may partly depend on the number of toxigenic C. difficile in stool specimens.

Aborto séptico por Clostridium perfringens complicado con shock séptico / Septic abortion due to Clostridium perfringens complicated with septic shock

ANTECEDENTES: La sepsis por Clostridios es una entidad poco frecuente que conlleva una mortalidad del 8090% a pesar del tratamiento antibiótico y quirúrgico. A pesar de que la mayoría de los casos de septicemia secundaria a Clostridios se originan en el aparato genital femenino tras un aborto séptico, solo un pequeño porcentaje de abortos sépticos (1%) se siguen de septicemia. CASO CLÍNICO: Gestante de 15 semanas que acude a urgencias por rotura prematura de membranas pretérmino. Ante el deseo de la paciente se mantiene actitud conservadora con antibioterapia iv, produciéndose a las pocas horas el aborto de forma espontánea junto con aparición de signos de infección. Rápidamente la paciente evoluciona a sepsis grave, y ante la sospecha de aborto séptico se efectúa histerectomía. Tras la intervención ingresa en situación de shock séptico con insuficiencia renal, hepática y respiratoria. Durante el ingreso se confirma Clostridium perfringens como agente responsable del proceso séptico. Finalmente la paciente es dada de alta definitiva tras seis meses, una vez resueltas las alteraciones derivadas del proceso séptico.

BACKGROUND: Clostridial sepsis is a rare condition which carries a mortality of 80-90% despite antibiotic and surgical treatment. Although most cases of septicemia due to Clostridium are originated in female genital tract after septic abortion, only a small percentage of septic abortions (1%) are followed by septicemia. CLINICAL CASE: Our case is about a 15 weeks pregnant woman attended the emergency room for preterm premature rupture of membranes. Due to the desire of the patient we proceed conservative treatment with antibiotics iv, in the following few hours the abortion develops spontaneously along with signs of infection. Rapidly the patient progresses into a severe sepsis, due to suspected septic abortion, the patient is intervened urgently by hysterectomy. After the intervention she enters into septic shock state with respiratory, kidney and liver failure. During the admission Clostridium perfringens is confirmed as a causative agent for septic process. Finally the patient is discharge after six months once resolved all complications arising from septic process.

Diarrea asociada a Clostridium difficile en niños / Clostridium difficile associated diarrhea in children

Introduction: Clostridium difficile is the most commonly isolated organism in antimicrobial and health care-associated diarrhea and is growing in relevance in community-acquired infections. It is a Gram-positive bacillus acquired via the fecal-oral route in the community and in hospital setting. Epidemiology: 0.6 to 2.1% worldwide incidence, mortality ~ 1-5%. Colonization: High rates of asymptomatic colonization in healthy people, 37% in children: its presence in stools is of controversial significance. Risk factors in children are prior exposure to antibiotics, recent hospitalization, immunosuppression or inflammatory bowel disease. Clinical manifestations: secondary to intestinal involvement due to toxin production, ranging from asymptomatic colonization to fulminant disease. Diagnosis: Clinical diagnostic criteria plus high sensitivity and specificity laboratory certification. Recommendations AAP (American Academy of Pediatrics): under 1 year, avoid routine study, only in Hirschsprung disease and/or nosocomial outbreak, 1-3 year, a (+) result suggests C. difficile associated diarrhea (CDAD) is possible, and in children older than 3 years interpretation is equal to adults. Management: antimicrobial suspension, oral metronidazole as first line in mild to moderate CDAD, and oral or enema vancomycin or associated with intravenous metronidazole only in severe cases. Duration 10 days. Prevention: Antimicrobial control programs and environmental management. Conclusion: Given the increasing complexity of pediatric patients it is important to deepen the knowledge on this microorganism and its clinical manifestations, as its incidence, morbidity and mortality are increasing.

Introducción: Clostridium difficile, microorganismo más común en diarrea asociada a antimicrobianos, a atención de salud y en aumento en la comunidad es un bacilo grampositivo adquirido vía fecal oral en la comunidad y en el ambiente hospitalario. Epidemiología: Incidencia mundial 0,6-2,1%, mortalidad~1-5%. Colonización: Alta colonización asintomática en personas sanas, niños 37%, su presencia en las deposiciones es controversial. Factores de riesgo en niños: exposición previa a antimicrobianos, hospitalización reciente, inmunosupresión o enfermedad inflamatoria intestinal. Clínica: Compromiso intestinal secundario a la producción de toxinas. Puede variar desde una colonización asintomática hasta enfermedad fulminante. Diagnóstico: La certificación diagnóstica requiere de un criterio clínico más laboratorio rápido, con elevada sensibilidad y especificidad. Recomendaciones de American Academy of Pediatrics son en lactantes bajo un año, evitar estudio rutinario, sólo enfermedad de Hirschprung y/o brote nosocomial, entre 1-3 años; un resultado (+) indica DACD posible y en mayores de 3 años los criterios son igual a adultos. Manejo: Suspensión de antimicrobianos, metronidazol ev como primera línea en niños con DACD leve a moderada y vancomicina oral, enema o asociada a metronidazol intravenoso sólo en casos graves. Duración 10 días. Prevención: Control de antimicrobianos y manejo ambiental. Conclusión: Dada la creciente complejidad de pacientes pediátricos, es importante profundizar sobre este microorganismo y el desarrollo de enfermedad, ya que su incidencia y morbi-mortalidad van en aumento.

Application of the ATLAS score for evaluating the severity of Clostridium difficile infection in teaching hospitals in Mexico

Background: For clinicians, a practical bedside tool for severity assessment and prognosis of patients with Clostridium difficileinfection is a highly desirable unmet medical need.Setting: Two general teaching hospitals in northeast Mexico.Population: Adult patients with C. difficileinfection.Methods: Prospective observational study.Results: Patients included had a median of 48 years of age, 54% of male gender and an average of 24.3 days length of hospital stay. Third generation cephalosporins were the antibiotics most commonly used prior to C. difficileinfection diagnosis. Patients diagnosed with C. difficileinfection had a median ATLAS score of 4 and 56.7% of the subjects had a score between 4 and 7 points. Patients with a score of 8 through 10 points had 100% mortality.Conclusion: The ATLAS score is a potentially useful tool for the routine evaluation of patients at the time of C. difficileinfection diagnosis. At 30 days post-diagnosis, patients with a score of ≤3 points had 100% survival while all of those with scores ≥8 died. Patients with scores between 4 and 7 points had a greater probability of colectomy with an overall cure rate of 70.1%.

Evaluation of three enzyme immunoassays and a nucleic acid amplification test for the diagnosis of Clostridium difficile-associated diarrhea at a university hospital in Brazil

Introduction Despite the known importance of Clostridium difficile as a nosocomial pathogen, few studies regarding Clostridium difficile infection (CDI) in Brazil have been conducted. To date, the diagnostic tests that are available on the Brazilian market for the diagnosis of CDI have not been evaluated. The aim of this study was to compare the performances of four commercial methods for the diagnosis of CDI in patients from a university hospital in Brazil. Methods Three enzyme immunoassays (EIAs) and one nucleic acid amplification test (NAAT) were evaluated against a cytotoxicity assay (CTA) and toxigenic culture (TC). Stool samples from 92 patients with suspected CDI were used in this study. Results Twenty-five (27.2%) of 92 samples were positive according to the CTA, and 23 (25%) were positive according to the TC. All EIAs and the NAAT test demonstrated sensitivities between 59 and 68% and specificities greater than 91%. Conclusions All four methods exhibited low sensitivities for the diagnosis of CDI, which could lead to a large number of false-negative results, an increased risk of cross-infection to other patients, and overtreatment with empirical antibiotics. .

Clostridium difficile Infection: A Worldwide Disease

Clostridium difficile, an anaerobic toxigenic bacterium, causes a severe infectious colitis that leads to significant morbidity and mortality worldwide. Both enhanced bacterial toxins and diminished host immune response contribute to symptomatic disease. C. difficile has been a well-established pathogen in North America and Europe for decades, but is just emerging in Asia. This article reviews the epidemiology, microbiology, pathophysiology, and clinical management of C. difficile. Prompt recognition of C. difficile is necessary to implement appropriate infection control practices.