The use of faecal microbiota transplant as treatment for recurrent or refractory Clostridioides difficile infection and other potential indications: second edition of joint British Society of Gastroenterology (BSG) and Healthcare Infection Society (HIS) guidelines.

The first British Society of Gastroenterology (BSG) and Healthcare Infection Society (HIS)-endorsed faecal microbiota transplant (FMT) guidelines were published in 2018. Over the past 5 years, there has been considerable growth in the evidence base (including publication of outcomes from large national FMT registries), necessitating an updated critical review of the literature and a second edition of the BSG/HIS FMT guidelines. These have been produced in accordance with National Institute for Health and Care Excellence-accredited methodology, thus have particular relevance for UK-based clinicians, but are intended to be of pertinence internationally. This second edition of the guidelines have been divided into recommendations, good practice points and recommendations against certain practices. With respect to FMT for Clostridioides difficile infection (CDI), key focus areas centred around timing of administration, increasing clinical experience of encapsulated FMT preparations and optimising donor screening. The latter topic is of particular relevance given the COVID-19 pandemic, and cases of patient morbidity and mortality resulting from FMT-related pathogen transmission. The guidelines also considered emergent literature on the use of FMT in non-CDI settings (including both gastrointestinal and non-gastrointestinal indications), reviewing relevant randomised controlled trials. Recommendations are provided regarding special areas (including compassionate FMT use), and considerations regarding the evolving landscape of FMT and microbiome therapeutics.

A case-control study of community-associated Clostridium difficile infection.

OBJECTIVES: The aim of this study was to determine the incidence of and risk factors for community-associated Clostridium difficile infection (CDI). METHODS: Prospective surveillance of community-derived faecal samples for C. difficile cytotoxin, followed by a questionnaire-based case-control study in two distinct patient cohorts (one semi-rural and the other urban). RESULTS: The proportion of randomly selected faecal samples positive for C. difficile cytotoxin was 2.1% in both patient cohorts (median ages 73 and 45 years for the urban and semi-rural cohorts, respectively). Exposure to antibiotics in the previous 4 weeks, particularly multiple agents (P < 0.001), aminopenicillins (P < 0.05) and oral cephalosporins (P < 0.05), was significantly more frequent among cases than controls. Hospitalization in the preceding 6 months was significantly associated with CDI (45% versus 23%; P = 0.022). However, almost half the cases had not received antibiotic therapy in the month before C. difficile detection, and approximately one-third neither had exposure to antibiotics nor recent hospitalization. Contact with infants aged < or =2 years was significantly associated with CDI (14% versus 2%; P = 0.02). Prior exposure to gastrointestinal-acting drugs (proton pump inhibitor, H2 antagonist or non-steroidal anti-inflammatory) was not significantly more common in CDI cases. C. difficile PCR ribotype 001 caused 60% and 13% of urban and semi-rural community-associated CDI cases, respectively. CONCLUSIONS: Reliance on antibiotic history and age (> or =65 years) will contribute to missed diagnoses of community-associated CDI. Potential risk factors for community-associated CDI should be explored further to explain the large proportion of cases not linked to recent antibiotic therapy or hospitalization.

Review article: antibiotic-induced Clostridium difficile infection.

The great majority of cases of Clostridium difficile infection are hospital-acquired, and the reported incidence in England and Wales has increased sixfold between 1990 and 1993, with at least 17 patients dying in a recent large nosocomial outbreak. C. difficile infection accounts for an average 3-week increased length of stay in hospital. Acquisition of a toxigenic strain of Clostridium difficile may be followed by asymptomatic carriage, diarrhoea, colitis or pseudomembranous colitis. Antibiotic treatment and older age are major risk factors for the development of symptomatic disease, but less well-defined differences in strain virulence and host susceptibility are also probably important. Accurate data on the relative risks of different antibiotics to induce symptomatic C. difficile infection are scarce, but third-generation cephalosporins are frequently implicated. New kits are becoming available for the laboratory diagnosis of C. difficile infection but many of these lack sensitivity. Oral metronidazole or vancomycin are the main treatment options but avoidance of further antibiotics should also be encouraged where possible. The role of environmental C. difficile spores, which are highly resistant to conventional disinfectants, needs to be defined. Proven strategies for the prevention of C. difficile infection are required, in particular protocols to ensure that cross-infection does not occur.

Methicillin-resistant Staphylococcus aureus infection of percutaneous endoscopic gastrostomy sites.

BACKGROUND: Antibiotic prophylaxis for percutaneous endoscopic gastrostomy insertion remains controversial. The bacteriology of peristomal infection following percutaneous endoscopic gastrostomy insertion has been poorly studied, leading to uncertainty regarding the optimum choice of antibiotic for prophylaxis. AIM: To investigate the bacteriology of peristomal infection following percutaneous endoscopic gastrostomy insertion and to determine the contribution of methicillin-resistant Staphylococcus aureus. METHODS: Nasal and pharyngeal swabs were taken from a consecutive series of patients prior to percutaneous endoscopic gastrostomy insertion over a 6-month period. Bacterial colonization and infection at the peristomal site were prospectively evaluated at days 2/3 and 7 post-insertion. RESULTS: Thirty-one patients underwent percutaneous endoscopic gastrostomy insertion (mean age, 68 years; cerebrovascular disease, 52%). Naso-pharyngeal colonization by methicillin-resistant Staphylococcus aureus (35%) invariably led to peristomal colonization following percutaneous endoscopic gastrostomy insertion. Peristomal infection occurred in eight (26%) cases (seven (88%) methicillin-resistant Staphylococcus aureus- positive). Peristomal infection was significantly more likely to occur in patients with naso-pharyngeal methicillin-resistant Staphylococcus aureus colonization (odds ratio, 10.8; 95% confidence interval, 1.6-70.9). CONCLUSIONS: Naso-pharyngeal methicillin-resistant Staphylococcus aureus colonization invariably predicts peristomal methicillin-resistant Staphylococcus aureus colonization following percutaneous endoscopic gastrostomy insertion, and is associated with an increased peristomal infection rate. Currently recommended antibiotic prophylaxis regimens may be inappropriate in institutions with significant methicillin-resistant Staphylococcus aureus colonization rates.

Prospective study of the risk of Clostridium difficile diarrhoea in elderly patients following treatment with cefotaxime or piperacillin-tazobactam.

BACKGROUND: Rates of Clostridium difficile diarrhoea have recently been rising, with the elderly being at highest risk. AIM: To compare the incidence of C. difficile colonization and diarrhoea in elderly patients treated for presumed infection with either empirical cefotaxime (CTX) or piperacillin-tazobactam (PT). METHODS: A prospective, ward-based, crossover study was carried out on two well-matched care of the elderly wards at a UK tertiary care hospital, in patients requiring empirical broad-spectrum antibiotic treatment. RESULTS: There was a highly significant increased incidence of C. difficile colonization (26/34 vs. 3/14, P=0.001) and diarrhoea (18/34 vs. 1/14, P=0.006) in patients who received CTX as opposed to PT. DNA fingerprinting suggested that most infections arose from strains acquired from the hospital environment. CONCLUSIONS: Elderly patients are significantly less likely to develop C. difficile diarrhoea after treatment with PT than after CTX. The source of C. difficile appears to be predominantly from the ward environment.

Recurrence of symptoms in Clostridium difficile infection--relapse or reinfection?

We have fingerprinted Clostridium difficile isolates from patients with symptomatic recurrences of infection, using random amplified polymorphic DNA (RAPD). The medical records of 55/79 patients were examined, from whom multiple C. difficile-positive faeces were received during hospitalization at least five days, but no more than two months, apart. In 20 of these cases symptoms either did not recur (i.e., absent for at least three days between episodes), or were explainable by other causes, such as laxative administration. Of the remaining 35 patients, 27 sets of C. difficile isolates (23 pairs and four triplicates) were available for RAPD fingerprinting. Differing C. difficile DNA fingerprints (at least three major bands difference) were obtained for 15/27 patients, and hence at least 56% of the clinical recurrences of infection were in fact due to re-infection as opposed to relapse. Since we found that an endemic C. difficile clone was present in 18 out of 27 patients (67%) and accounted for 53% (31/58) of all isolates, it is probable that the majority of symptomatic recurrences are in fact re-infections, with either a different or the same C. difficile strain. We conclude that more attention must be given to preventing the re-infection of C. difficile symptomatic patients. Isolation of symptomatic individuals is the preferred option for the protection of other patients, but measures must be taken to ensure that further strain acquisition by the index cases does not occur.

Program planning: the clinical utility of three activities of daily living assessment tools.

A jury of five occupational therapy experts was used to evaluate the clinical utility of three activities of daily living assessment tools that were originally designed for purposes other than individualized occupational therapy assessment or program planning. The three tools were the Index of Independence in Activities of Daily Living, PULSES Profile, and Physical Self-Maintenance Scale. Using the results from each tool, scored for a simulated patient with a right cerebrovascular accident, as well as medical information about the patient, the jury members were asked to plan a treatment program. The consensus of the jury was that the results from each tool did not provide enough information to help them identify the patient's specific performance problems or the causes of those problems. Therefore, the three tools were considered to have low clinical utility for planning individualized occupational therapy treatment. For use in planning an individualized treatment program, an activities of daily living assessment tool should provide specific information about which component of a task the patient found difficult or was unable to do and the type and level of assistance required.

Two-stage algorithm for Clostridium difficile: glutamate-dehydrogenase-positive toxin-negative enzyme immunoassay results may require further testing.

This study investigated 102 episodes in which a glutamate dehydrogenase-positive enzyme immunoassay (EIA)-toxin-negative result was obtained with a C. difficile testing protocol. Of these 102 stool samples, 46% were culture positive with a toxigenic strain and nine were followed by an EIA-toxin-positive result within 2-32 days. The data accord with our policy of keeping these patients in side-rooms until asymptomatic and of encouraging treatment of those with otherwise unexplained persistent diarrhoea. Adding a third testing modality [toxigenic culture or polymerase chain reaction (PCR)] appears desirable but there may be significant differences in sensitivity between different toxigenic culture or PCR methods.

Clostridium difficile.

The current impact of Clostridium difficile will have been noticed by many clinicians, particularly those managing elderly patients. Infection with this bacterium can give rise to a wide range of symptoms, from diarrhoea to fulminating colitis and toxic megacolon. Patients may also be asymptomatically colonized by C. difficile. In this article the epidemiology and aetiology of C.difficile infection will be discussed, followed by an explanation of how diagnosis of cases is best achieved, how the disease is optimally treated and how cross-infection can be minimized.

Vertebral osteomyelitis caused by Enterococcus raffinosus.

Enterococcus raffinosus is a rare isolate in clinical specimens. A case of vertebral osteomyelitis caused by E. raffinosus in an elderly patient is described and confirms this organism to be an opportunistic human pathogen.

An influenza outbreak due to A/USSR/77-like (H1N1) virus aboard a US Navy ship.

An explosive outbreak of influenza caused by an A/USSR/77-like (H1N1) virus occurred aboard a US Navy ship in December 1977 and January 1978. Two hundred volunteers aboard the ship were studied. Virus was isolated from 36 of 57 patients from whom isolation was attempted. Among virologically confirmed patients, headache (97%), chills (92%), malaise (86%), and cough (75%) were the most frequent symptoms. There were two virologically confirmed cases with complications: one with collapsed lung and the other with pneumonitis. The study subjects were 25 years of age or less, but there was little influenza-like disease in members of the crew greater than 25 years of age. Prior vaccination with bivalent vaccine, containing A/NJ/76 (Hsw1N1) virus, did not offer significant protection against disease caused by A/USSR/77-like virus. Serologic tests, either or both complement fixation and hemagglutination inhibition, were positive in only 14 of 22 virologically confirmed cases, indicating a poor serologic response to primary infection with this strain of virus. These findings prevented calculation of meaningful disease to infection ratios. However, inapparent infection occurred in 3 of 19 (16%) individuals who denied having illness during the outbreak yet had serologic evidence of recent influenza infection.