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PubMed1991

Risk factors for the development of Clostridium difficile-associated diarrhea during a hospital outbreak.

OBJECTIVE: To evaluate the risk factors associated with a nosocomial outbreak of Clostridium difficile-associated diarrhea. DESIGN: Case-control study with two control groups. SETTING: University-affiliated urban hospital. PATIENTS: A convenience sample of 26 patients was chosen out of a total of 78 hospitalized patients with C difficile-associated diarrhea, defined as the presence of diarrhea and a positive C difficile cytotoxin assay or stool culture. Twenty-six controls were matched for age, gender, ward, and date of admission; 18 additional controls were matched to surgical patients for date and ward of admission, as well as for the type of surgical procedure performed. RESULTS: Significant risk factors for the development of C difficile-associated diarrhea were gastrointestinal surgery (exposure odds ratio [EOR] = 7.9, p = .004, 95% confidence interval [CI] = 1.9, 35), use of neomycin (EOR = 15.6, p = .012, 95% CI = 1.7, 92), clindamycin (EOR = 15.6, p = .005, 95% CI = 1.7, 92), metronidazole (EOR = 5.7, p = .02, 95% CI = 1.4, 25), and excess antibiotic use (mean number of antibiotics = 4.2 versus 1.4, p less than .00005). The presence of systemic disease and the use of antacids or immunosuppressive drugs were similar in cases and controls. In surgical patients, no specific antibiotic could be linked to C difficile-associated diarrhea because of uniform perioperative antibiotic use. There was a significant difference in the number of antibiotics administered to cases and controls (mean = 3.1 versus 1.9, p less than .005). CONCLUSIONS: The results suggest that control of nosocomial C difficile-associated diarrhea may be attained by minimizing the administration of antibiotics, avoidance of high-risk antibiotics, and having a high index of suspicion of C difficile-associated diarrhea in patients who develop diarrhea after gastrointestinal surgery. Perioperative administration of metronidazole, when given with other antibiotics, failed to protect against the development of C difficile-associated diarrhea.

Anti-Bacterial Agents↗
PubMed1990

In-vitro activity of vancomycin, teicoplanin, daptomycin, ramoplanin, MDL 62873 and other agents against staphylococci, enterococci and Clostridium difficile.

The minimum inhibitory concentrations (MICs) of different antibiotics were determined by a broth microdilution method for staphylococci, enterococci and Clostridium difficile. The antimicrobial agents tested were vancomycin, teicoplanin, daptomycin, ramoplanin, MDL 62873, rifampicin and piperacillin, the latter limited to enterococci. In terms of MIC90S, daptomycin (0.89 mg/l). MDL 62873 (0.99 mg/l), and teicoplanin (1.50 mg/l) were found to be highly active against methicillin-resistant Staphylococcus aureus (MRSA). Daptomycin (MIC90 0.48 mg/l), MDL 62873 (0.95 mg/l) and ramoplanin (1.45 mg/l) were the most active drugs against methicillin-resistant S. epidermidis (MRSE). Teicoplanin (MIC90 0.45 mg/l) was the most active agent against enterococci, followed by MDL 62873 (0.65 mg/l) and daptomycin (1.60 mg/l). MDL 62873 gave the lowest MIC90 (0.17 mg/l) for C. difficile. Teicoplanin (MIC90 0.42 mg/l), daptomycin (0.87 mg/l) and ramoplanin (0.98 mg/l) were also very active. Our results indicate that teicoplanin, daptomycin, ramoplanin and MDL 62873, a teicoplanin derivative, are potentially effective alternative antibiotics for treatment of infections caused by staphylococci, enterococci and C. difficile.

Anti-Bacterial Agents↗
PubMed1995

Diarrhoea caused by Clostridium difficile: response time for treatment with metronidazole and vancomycin.

One hundred patients, known to have been excreting Clostridium difficile cytotoxin in faeces, were reviewed retrospectively to determine the response time for treatment with oral metronidazole and vancomycin, and the effect of the additional administration of anti-motility agents. Records were available for 78 patients of whom 58 had received treatment with either metronidazole or vancomycin. Response and relapse rates were similar for the two treatment regimens. However, the mean duration of symptoms was significantly shorter in evaluable patients treated with vancomycin (3.0 days, n = 22) compared with those given metronidazole (4.6 days, n = 28) (Mann-Whitney-U, P < 0.01). No difference in the duration of symptoms, irrespective of antibiotic therapy, was associated with use of anti-motility agents. The increased cost of vancomycin compared with metronidazole for the treatment of C. difficile infection may be justifiable by reductions in the length of stay in hospital or in the need for nursing in isolation facilities, consequent upon a shorter symptomatic response time. Administration of anti-motility agents did not appear to impair response in patients with mild to moderate C. difficile infection.

Adult↗
PubMed2000

In vitro activity of new generation fluoroquinolones against genotypically distinct and indistinguishable Clostridium difficile isolates.

We compared the activities of ciprofloxacin and levofloxacin with those of the newer fluoroquinolones grepafloxacin, moxifloxacin, sparfloxacin and trovafloxacin against Clostridium difficile isolates. As there is good evidence of marked clonal spread of C. difficile, we studied both genotypically distinct (n = 26) and indistinguishable (n = 28) isolates as determined by random amplified polymorphic DNA and ribosomal spacer PCR fingerprinting. The indistinguishable strains examined represent the main UK epidemic C. difficile clone. For 17 of 54 strains (31%) we were unable to read MICs following inocula preparation using Mueller-Hinton broth. Using Schaedler's broth for inocula preparation 93% of strains had readable MICs, although geometric mean MICs were uniformly higher (2.5- to 5.4-fold) compared with results using Mueller-Hinton broth. Moxifloxacin and trovafloxacin, followed by grepafloxacin, were the most active fluoroquinolones tested and were 3- to 4-fold more active than older agents such as ciprofloxacin by both MIC methods. Unexpectedly, clonal C. difficile strains had markedly reduced susceptibility compared with the distinct strains to each of the fluoroquinolones tested. Clonal strains were more than seven-fold or 12- to 29-fold less susceptible (according to geometric mean MICs) than distinct strains to both moxifloxacin and trovafloxacin, depending on the MIC method used. It remains to be seen whether the enhanced activity of new fluoroquinolones such as moxifloxacin in comparison with other fluoroquinolones against C. difficile implies that these agents are unlikely to be associated with C. difficile infection. However, clinical use of new generation fluoroquinolones in elderly hospitalized patients where C. difficile is endemic requires further study, particularly given the reduced antibiotic susceptibility to all fluoroquinolones of the readily transmissible UK C. difficile clone.

Anti-Infective Agents↗
PubMed1994

Comparison of the ToxA test with cytotoxicity assay and culture for the detection of Clostridium difficile-associated diarrhoea disease.

Stool samples (355 from 350 patients) were examined in a new commercial assay, the ToxA test, for the rapid diagnosis of Clostridium difficile-associated diarrhoea. The results were compared with direct assay of cytotoxin in McCoy cell tissue culture, and detection of toxigenic C. difficile by culture and cytotoxin testing of isolates. Discordant results were resolved by consultation of clinical records. Test sensitivities were 84.6% for the ToxA test, 78.5% for the direct cytotoxicity assay and 95.4% for culture. The specificity was 100% for all the tests. The ToxA test is a rapid and reliable alternative for the detection of toxigenic C. difficile where tissue culture facilities are unavailable.

Bacterial Proteins↗
PubMed1994

Toxin production by Clostridium difficile in a defined medium with limited amino acids.

Basal defined medium (BDM) containing vitamins, minerals and seven amino acids--(/L) tryptophan 0.1 g, methionine 0.2 g, valine 0.3 g, isoleucine 0.3 g, proline 0.3 g, leucine 0.4 g and cysteine 0.5 g--which appeared to be essential for good growth of Clostridium difficile was prepared. Addition of glycine 0.2 g/L and threonine 0.4 g/L to BDM produced better growth of strain VPI 10463, and this defined medium was designated minimum amino acid-defined medium (MADM). Production of toxins A and B by strain VPI 10463 in 6 x MADM containing (/L) tryptophan 0.6 g, methionine 1.2 g, valine 1.8 g, isoleucine 1.8 g, proline 1.8 g, leucine 2.4 g, cysteine 0.5 g, glycine 0.2 g and threonine 0.4 g, was much greater than in MADM. Toxin production by 20 C. difficile strains was examined in two defined media--6 x MADM and complete amino acid-defined medium (CADM) containing 18 amino acids--and one complex medium, modified brain heart infusion medium (m-BHI). Simultaneous production of toxins A and B by all test strains was demonstrated in m-BHI and the two defined media. It was also shown that 6 x MADM was generally better than CADM and as effective as m-BHI for stimulating toxin production by 13 strains. This defined medium would be useful for studies on the physiology, metabolism and pathogenicity of C. difficile.

Amino Acids↗
PubMed1998

Bacterial translocation, intestinal microflora and morphological changes of intestinal mucosa in experimental models of Clostridium difficile infection.

Bacteraemia and subsequent sepsis is one possible complication of Clostridium difficile infection. The aim of this study was to examine a correlation between bacterial translocation with morphological changes of intestinal mucosa and shifts of intestinal microflora in experimental models of C. difficile infection. A mouse model was used to study post-antibiotic shifts and mild C. difficile infection, and hamsters were used to study fatal enterocolitis. The influence of pro- and pre-biotics (lactobacilli and xylitol) were also studied in the hamster model. The quantitative composition of luminal and mucosal microflora was evaluated in different intestinal loci, inflammatory changes of mucosa were estimated in histological sections and bacterial translocation was detected in samples from blood, liver, spleen and mesenteric lymph nodes. In cases of mild C. difficile infection, the extent of disturbance of intestinal microflora appeared to be a more important promoting factor in translocation than inflammatory activity in the mucosa. Translocation was frequent in fatal enterocolitis, with facultative species predominating in the intestinal mucosa and also C. difficile in some cases. The combination of lactobacilli and xylitol had some protective effect against C. difficile infection in these models.

Ampicillin↗
PubMed2004

In vitro activity of OPT-80 against Clostridium difficile.

Clostridium difficile remains the major cause of nosocomial diarrhea. Reports on impaired susceptibility of C. difficile to metronidazole and vancomycin and frequent relapses of patients after therapy necessitate the search for new substances. With this study, the activity of OPT-80, a new macrocycle, against 207 C. difficile strains and against other obligately anaerobic bacteria was tested. OPT-80 showed high in vitro activity against all C. difficile strains tested.

Anti-Infective Agents↗
PubMed2005

ErmB determinants and Tn916-Like elements in clinical isolates of Clostridium difficile.

Erythromycin and tetracycline resistance was analyzed in 37 Clostridium difficile clinical isolates. Strains of different clonal origins showed different erythromycin and tetracycline resistance determinants and different genetic arrangements of the elements. In strains of recent isolation, the presence of Tn916-like elements, never found before in C. difficile clinical isolates, has been demonstrated.

Anti-Bacterial Agents↗
PubMed1997

Positive regulation of Clostridium difficile toxins.

The toxigenic element of Clostridium difficile VPI 10463 contains a small open reading frame (ORF) immediately upstream of the toxin B gene (G. A. Hammond and J. L. Johnson, Microb. Pathog. 19:203-213, 1995). The deduced amino acid sequence of the ORF, which we have designated txeR, encodes a 22-kDa protein which contains a helix-turn-helix motif with sequence identity to DNA binding regulatory proteins. We used a DNA fragment containing the C. difficile toxin A repeating units (ARU) as a reporter gene to determine if txeR regulates expression from the toxin A and toxin B promoters in Escherichia coli. To test the affect of txeR on expression, we fused the ARU gene fragment in frame with the toxin promoters. The fusions expressed a 104-kDa protein that contained the epitopes for monoclonal antibody PCG-4, which we used to measure levels of recombinant ARU by enzyme-linked immunosorbent assay. When txeR was expressed in trans with the toxin B promoter-ARU fusion contained on separate low-copy-number plasmid, expression of ARU increased over 800-fold. Furthermore, when we tested the toxin A promoter fused to ARU, expression increased over 500-fold with txeR supplied in trans. Our results suggest that TxeR is a positive regulator that activates expression of the C. difficile toxins.

Amino Acid Sequence↗
PubMed2003

Rapid detection of Clostridium difficile in feces by real-time PCR.

Clostridium difficile is the major causative agent of nosocomial antibiotic-associated diarrhea, colitis, and pseudomembranous colitis. The pathogenicity of C. difficile is closely related to the production of toxins A and B. Toxigenic C. difficile detection by a tissue culture cytotoxin assay is often considered the "gold standard." However, this assay is time consuming, as it implies an incubation period of at least 24 h. We have developed a rapid real-time fluorescence-based multiplex PCR assay targeting the C. difficile toxin genes tcdA and tcdB, with the Smart Cycler. Two molecular beacons bearing different fluorophores were used as internal probes specific for each amplicon type. The analytical sensitivity of the assay was around 10 genome copies for all nine C. difficile strains tested, representing the 6 most common toxinotypes. The specificity was demonstrated by the absence of amplification with DNA purified from bacterial species other than C. difficile (n = 14), including Clostridium sordellii for which the lethal toxin gene sequence is closely related to the toxin genes of C. difficile. Following a rapid (15 min) and simple fecal sample preparation protocol, both tcdA and tcdB were efficiently amplified from 28 of 29 cytotoxin-positive feces samples. There was no amplification observed with all 27 cytotoxin-negative feces samples tested. This is the first real-time PCR assay for the detection of C. difficile. It is rapid, sensitive, and specific and allows detection of C. difficile directly from feces samples.

Clostridioides difficile↗
PubMed2005

Molecular epidemiology of endemic Clostridium difficile infection and the significance of subtypes of the United Kingdom epidemic strain (PCR ribotype 1).

We previously identified two subtypes of the epidemic strain Clostridium difficile PCR ribotype 1, one clindamycin-sensitive strain (arbitrarily primed PCR [AP-PCR] type Ia) and a closely related clindamycin-resistant strain (AP-PCR type Ib) in our institution. We have now carried out prospective epidemiological surveillance for 4 years, immediately following the relocation of two acute medicine wards for elderly patients (wards A and B), to determine the clinical epidemiology of subtypes of the epidemic C. difficile PCR ribotype 1 group. To maximize the chance of strain discrimination, we used three DNA fingerprinting methods, AP-PCR, ribospacer PCR (RS-PCR), and pulsed-field gel electrophoresis (PFGE), to analyze C. difficile isolates recovered from symptomatic patients and from repeated environmental samplings. On ward B the incidence of C. difficile infection correlated significantly with the prevalence of environmental C. difficile both in ward areas closely associated with patients and health care personnel (r = 0.53; P < 0.05) and in high-reach sites (r = 0.85; P < 0.05). No such relationships were found on ward A. Seventeen distinct C. difficile genotypes were identified, 17 by AP-PCR, 12 by PFGE, and 11 by RS-PCR, but only 4 of 17 genotypes caused patient infection. Isolates recovered from the hospital ward environment were much more diverse (14 genotypes). AP-PCR type Ia represented >90% of the C. difficile isolates. In addition to this genotype, only two others were isolated from both patient feces and environmental surfaces. AP-PCR type Ib (clindamycin-resistant PCR ribotype 1 clone) was not associated with any cases of C. difficile infection and was isolated from the environment on only two occasions, after having been implicated in a cluster of six C. difficile infections 5 months before this study. The disappearance of this strain implies that differences in virulence and/or selective pressures may exist for this strain and the closely related, widespread C. difficile AP-PCR type Ia strain. Our findings emphasize the need to understand the epidemiology and virulence of clinically significant strains to determine successful control measures for C. difficile infections.

Aged↗
PubMed2006

Enhancing patient safety through the management of Clostridium difficile at Toronto East General Hospital.

In 2005 Toronto East General Hospital experienced a steady increase in the number of C. difficile cases diagnosed within the hospital. This was identified as a patient safety issue, and several areas of the hospital came together to address the problem. Pharmacy immediately started a medication review of past cases. Environmental services took the lead on the environmental cleaning, and a process was put into place with Infection Control so that housekeeping knew of every room that contained a patient with C. difficile and enhanced cleaning could be practised. Staff, including nursing, housekeeping and porters, were educated on C. difficile and the methods of transmission. A business case was developed for a disposable bedpan system, and this was approved by the senior team. A new washable product was tried out with success for the overhead patient light pulls and bathroom call bell systems. Infection rates were shared with staff through a variety of venues. As a result of the initiatives, the hospital has seen a decrease of 50% in the rates of C. difficile. A bonus was that our MRSA rates dropped as well.

Clostridioides difficile↗
PubMed1992

[Occurrence of Clostridium difficile in the digestive system of dogs].

This study was aimed at seeking strains of Clostridium difficile in feces and investigation of influence of antibiotics application on frequency of isolation and detection of toxing in vivo produced by this microorganism. Samples of feces were obtained from experimental dogs consisting of two groups. To groups I belonged 150 healthy dogs. Group II consisted of samples of feces received from four dogs before and after application of various antibiotics. Clostridium difficile was not isolated from group I dogs. From dogs belonging to group II, 28 strains were isolated. Production of toxing and classification to serological groups of the isolated strains were performed. Presence of this microorganism in feces of dogs is evident only after multiple application of antibiotics. Results of these studies suggest that dogs may constitute a reservoir of Clostridium difficile.

Animals↗
PubMed2006

[Clinical case of the month: clostridium difficile colitis].

A 55-year-old patient with mant e cels underwent a cytotoxic chemotherapy (D.H.A.P. + Rituximab). During the medullar aplasia related to the third cycle, diarrhoea due to Clostridium difficile arised and relapsed 15 days later despite normal blood counts. This colitis was very severe with pluribacterial peritonitis, but resolved with intensive medical treatment. The incidence, the patient's risk factors, the iatrogenic and nosocomial characters of cl. difficile colitis are discussed.

Anti-Bacterial Agents↗
PubMed1994

Practical considerations in the laboratory diagnosis of bacterial enteric infections.

Diarrheal diseases caused by bacterial pathogens are important causes of morbidity in the United States, and considerable laboratory resources are spent to detect these enteric pathogens. This article reviews recent developments in the detection and identification of Campylobacter spp, enterohemorrhagic Escherichia coli, and Clostridium difficile, and outlines cost-effective strategies for use of stool cultures.

Bacterial Infections↗
PubMed1996

Antibacterial activity of teicoplanin against Clostridium difficile.

The in vitro inhibitory action of teicoplanin, vancomycin, metronidazole and clindamycin against clinical isolates of Clostridium difficile was investigated. Minimum inhibitory concentrations (MICs) were determined using E test. Teicoplanin (MIC range 0.023-0.75 microgram/ml), vancomycin (MIC range 0.5-3 micrograms/ml) and metronidazole (MIC range 0.19-1 microgram/ml) were all very active against the isolates examined. No resistant strains of C. difficile to those three antimicrobial agents were observed, whereas resistance to clindamycin was found in 39.5% of the tested strains. Teicoplanin was about 4-times more potent than vancomycin. It appears to be a more promising antimicrobial for treatment of C. difficile enteric disease.

Anti-Bacterial Agents↗