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PubMed1993

The role of the clinical microbiology laboratory in the management of Clostridium difficile-associated diarrhea.

Nosocomial diarrhea due to infection with C. difficile is a major health care problem, causing 20% to 30% of institutionally acquired diarrhea and affecting up to 8% of hospitalized patients. The clinical microbiology laboratory should be able to provide both diagnostic and epidemiologic services for institutions where this disease occurs. Diagnostic testing includes culture for isolation of toxigenic C. difficile and detection of either toxin A or B from stool specimens. Epidemiologic services include providing appropriate media and specimen preparation for surveillance activities and performance of accurate typing of C. difficile strains when necessary to determine organism relatedness for development of effective infection control practices.

Bacterial Toxins↗
PubMed1994

Hospital carpeting and epidemiology of Clostridium difficile.

BACKGROUND: Clostridium difficile is the usual and most important cause of antibiotic-associated pseudomembranous enterocolitis. The source of nosocomial acquisition of the organism in nonepidemic settings has not been determined. METHODS: Epidemiologic and microbiologic studies were conducted in a community-teaching hospital complex to assess the impact of carpeting in patient rooms on environmental contamination with C. difficile, along with the prevalence of pseudomembranous enterocolitis. All C. difficile isolates were typed by means of a bacteriophage-bacteriocin typing scheme. RESULTS: No clear evidence of environmental acquisition of C. difficile in a nonepidemic setting of pseudomembranous enterocolitis was found. Carpeted floors were significantly more heavily contaminated for prolonged periods with clinical strains of C. difficile than were noncarpeted floors. CONCLUSION: There was no evidence that contamination of carpeting resulted in increased frequency of pseudomembranous enterocolitis in patients residing in carpeted rooms. Because there is strong evidence of exogenous acquisition of C. difficile during outbreaks, however, room carpeting should be considered a potential reservoir of this organism.

Clostridioides difficile↗
PubMed2005

Clostridium difficile: an important pathogen of food animals.

Human Clostridium difficile-associated disease (CDAD) is of unquestioned importance in humans, and has been a not-uncommon cause of enteric disease in horses, dogs, and ratites. Over the past 5 years, C. difficile has emerged as a major cause of neonatal enteritis in pigs. Piglets 1-7 days of age are affected, with gross lesions frequently including mesocolonic edema. Colonic contents may be pasty-to-watery and yellow, although some piglets are constipated or obstipated. Focal suppuration and segmental necrosis are seen on microscopic examination of cecal and colonic lamina propria, and exudation of neutrophils and fibrin into the lumen gives rise to the so-called volcano lesions. Results of one study revealed that more than one-third of piglets with enteritis were affected by C. difficile alone, while an additional quarter of affected piglets may have had mixed infections. C. difficile may be the most important uncontrolled cause of neonatal diarrhea in pigs.

Animals↗
PubMed2001

Association between antibody response to toxin A and protection against recurrent Clostridium difficile diarrhoea.

BACKGROUND: We have reported that symptom-free carriers of Clostridium difficile have a systemic anamnestic immune response to toxin A. The aim of this study was to determine whether an acquired immune response to toxin A, during an episode of C. difficile diarrhoea, influences risk of recurrence. METHODS: We prospectively studied 63 patients with nosocomial C. difficile diarrhoea. Serial serum IgA, IgG, and IgM concentrations against C. difficile toxin A, toxin B, or non-toxin antigens were measured by ELISA. Individuals were followed for 60 days. FINDINGS: 19 patients died (30%). Of the 44 who survived, 22 had recurrent C. difficile diarrhoea. Patients with a single episode of C. difficile diarrhoea (n=22) had higher concentrations of serum IgM against toxin A on day 3 of their first episode of diarrhoea than those with recurrent diarrhoea (n=22, p=0.004). On day 12, serum IgG values against toxin A were higher in patients who had a single episode of diarrhoea (n=7) than in those who subsequently had recurrent diarrhoea (n=9, p=0.009). The odds ratio for recurrence associated with a low concentration of serum IgG against toxin A, measured 12 days after onset of C. difficile diarrhoea, was 48.0 (95% CI 3.5-663). INTERPRETATION: A serum antibody response to toxin A, during an initial episode of C. difficile diarrhoea, is associated with protection against recurrence.

Aged↗
PubMed2001

Typing of Clostridium difficile.

Clostridium difficile is primarily recognised as a nosocomially acquired pathogen manifesting in gastrointestinal disease subsequent to the patient receiving broad-spectrum antibiotics. Infection can be sporadic, but outbreaks commonly occur within a ward or hospital as a result of cross-infection. Since the 1980s, the epidemiology of C. difficile disease has been studied by the application of many different typing or fingerprinting methods; these, and the lessons learned, are reviewed herein.

Clostridioides difficile↗
PubMed1996

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.

Anti-Bacterial Agents↗
PubMed1998

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.

Aged↗
PubMed1999

Enteric carriage of vancomycin-resistant Enterococcus faecium in patients tested for Clostridium difficile.

OBJECTIVE: To identify independent risk factors for enteric carriage of vancomycin-resistant Enterococcus faecium (VREF) in hospitalized patients tested for Clostridium difficile toxin. DESIGN: Retrospective case-cohort study. SETTING: Tertiary-care teaching hospital. PATIENTS: Convenience sample of 215 adult inpatients who had stool tested for C difficile between January 29 and February 25, 1996. RESULTS: 41 (19%) of 215 patients had enteric carriage of VREE Five independent risk factors for enteric VREF were identified: history of prior C difficile (odds ratio [OR], 15.21; 95% confidence interval [CI95], 3.30-70.10; P < .001), parenteral treatment with vancomycin for > or = 5 days (OR, 4.06; CI95, 1.54-10.73; P = .005), treatment with antimicrobials effective against gram-negative organisms (OR, 3.44; CI95, 1.20-9.87; P = .021), admission from another institution (OR, 2.95; CI95, 1.21-7.18; P =.017), and age > 60 years (OR 2.57; CI95, 1.13-5.82; P = .024). These risk factors for enteric VREF were independent of the patient's current C difficile status. CONCLUSIONS: Antimicrobial exposures are the most important modifiable independent risk factors for enteric carriage of VREF in hospitalized patients tested for C difficile.

Adult↗
PubMed2001

A comparison of multifaceted versus Clostridium difficile-focused VRE surveillance strategies in a low-prevalence setting.

We compared our current screening strategy for vancomycin-resistant Enterococcus (VRE) with a focused strategy that screens all stool samples sent for Clostridium difficile toxin assay but limits rectal swab screening to wards with new VRE cases detected via C. difficile samples. The proposed strategy detects 72.7% of new VRE cases, with substantial cost savings.

Clostridioides difficile↗
PubMed2006

Nitazoxanide for the treatment of Clostridium difficile colitis.

BACKGROUND: Clostridium difficile colitis has increased in incidence and severity, and treatment failure with metronidazole therapy has increasingly been documented. It is uncertain whether treatment with vancomycin is more effective than treatment with metronidazole, but concern over the emergence of vancomycin resistance has motivated the search for alternative therapy. Nitazoxanide, a nitrothiazolide, blocks anaerobic metabolism of eukaryocyes and effectively treats intestinal infestation due to Cryptosporidium or Giardia species. At low concentrations, this compound inhibits C. difficile in vitro. METHODS: We designed a prospective, randomized, double-blind study to compare nitazoxanide to metronidazole in treating hospitalized patients with C. difficile colitis. RESULTS: Thirty-four patients received metronidazole at a dosage of 250 mg 4 times per day for 10 days, 40 patients received nitazoxanide at a dosage of 500 mg 2 times per day for 7 days, and 36 patients received nitazoxanide at a dosage of 500 mg 2 times per day for 10 days. After 7 days of treatment, 28 (82.4%) of 34 patients had responded to metronidazole therapy, compared with 68 (89.5%) of 76 who had received nitazoxanide therapy (difference, 7.1%; 95% confidence interval, -7.1% to 25.5%). Thirty-one days after beginning treatment, sustained responses were observed in 19 (57.6%) of 33 patients who had received metronidazole therapy for 10 days, compared with 25 (65.8%) of 38 who had received nitazoxanide for 7 days and 26 (74.3%) of 35 who had received nitazoxanide for 10 days (P = .34). CONCLUSION: Nitazoxanide is at least as effective as metronidazole in treating C. difficile colitis.

Aged↗
PubMed1996

Risk factors associated with Clostridium difficile diarrhea in hospitalized adult patients: a case-control study--sucralfate ingestion is not a negative risk factor.

OBJECTIVES: To assess risk factors associated with Clostridium difficile diarrhea in hospitalized adult patients, and to test the hypothesis that sucralfate ingestion is associated with nondetection of C difficile cytotoxin in stool specimens. DESIGN: A retrospective case-control study of hospitalized adult patients who had stool specimens assayed for C difficile cytotoxin. For each patient who had positive C difficile cytotoxin, a patient who had negative C difficile cytotoxin was used as a control. The study period was January to December 1993. SETTING: A community teaching hospital affiliated with a medical school in northeastern Ohio. RESULTS: There were 91 case patients and 91 control patients. Cephalosporin exposure was identified as a risk factor in patients with C difficile diarrhea. The number of patients who had sucralfate ingestion was comparable in both groups of patients. CONCLUSIONS: Administration of cephalosporins was identified as a risk factor in patients with C difficile diarrhea. We were not able to confirm a recent report of the association between ingestion of sucralfate and nondetection of C difficile cytotoxin in stool specimens. Our findings suggest that sucralfate ingestion is not associated with nondetection of C difficile cytotoxin in stool specimens. Assay of C difficile cytotoxin in stool specimens remains a valid method of diagnosing C difficile diarrhea, even in patients who ingest sucralfate.

Adolescent↗
PubMed1997

Isolation of various genotypes of Clostridium difficile from patients and the environment in an oncology ward.

The epidemiology of Clostridium difficile-associated diarrhea (CDAD) is not well defined in nonepidemic situations because precise biotyping techniques have only recently become available. Arbitrarily primed polymerase chain reaction (AP-PCR) was used to determine strain identity of C. difficile isolates recovered on our oncology ward, at an incidence rate of 0.84%. Twenty-one strains of C. difficile, which were grouped into 18 different AP-PCR types, were isolated from patients' specimens. Forty-two C. difficile isolates recovered from the environment (33 toxigenic and 9 nontoxigenic) represented 9 different AP-PCR types. The most commonly found type, a toxigenic strain accounting for 29% of the environmental isolates, was widespread throughout the ward. None of the environmental types were found among the isolates from patients. Three patients' isolates were of the same AP-PCR type, and two of these patients had occupied neighboring rooms at the same time. The diversity of C. difficile isotypes suggests that endemic nosocomial CDAD is not necessarily clonally spread.

California↗
PubMed1994

Oligosaccharide sequences attached to an inert support (SYNSORB) as potential therapy for antibiotic-associated diarrhea and pseudomembranous colitis.

Toxin A produced by Clostridium difficile, the causative agent of pseudomembranous colitis and antibiotic-associated diarrhea, was shown to bind to synthetic oligosaccharide sequences attached to an inert support (SYNSORB). The oligosaccharide sequences that bind to toxin A were related to sequences previously identified as potential receptors for the toxin. Various SYNSORBs containing a variety of oligosaccharides were examined for their potential to neutralize toxin A activity from toxin-containing solutions as well as clinical stool samples from patients with either pseudomembranous colitis or antibiotic-associated diarrhea. The results from neutralization experiments suggest SYNSORB can effectively neutralize toxin A activity from stool samples and thus could serve as a potential therapy for C. difficile-associated diarrhea.

Animals↗
PubMed1992

Comparison of Clostridium sordellii toxins HT and LT with toxins A and B of C. difficile.

Clostridium sordellii produces two toxins, designated HT (haemorrhagic toxin) and LT (lethal toxin), that are similar to toxins A and B of C. difficile. The physicochemical properties of toxins HT and A were remarkably similar. The specific biological activities of toxin HT were almost the same as those of toxin A, and their NH2-terminal sequences shared close homology. The properties of toxins LT and B were similar, as were their NH2-terminal sequences, but toxin B was much more cytotoxic than toxin LT. Immunodiffusion analysis with specific antibodies showed that although toxins B and LT shared major antigenic determinants, each had unique epitopes. The results suggest that toxins B and LT have diverged more than toxins A and HT. Immunoblotting with antibodies to the toxins of C. difficile showed that toxins HT and LT had common antigenic determinants.

Amino Acid Sequence↗
PubMed1994

A particle counting immunoassay for the direct detection of Clostridium difficile serogroup specific antigen in faecal specimens.

The potential of a particle counting immunoassay (PACIA) for the direct detection of Clostridium difficile serogroup G specific antigen in faecal specimens was evaluated. F(ab')2 fragments from a rabbit anti-serogroup G antiserum were covalently coupled to carboxylated latex beads. This reagent was mixed with acid extracts of faecal specimens and the reaction was assayed with an optical counter which discriminated unagglutinated from agglutinated latex particles. Culture for C. difficile, faecal cytotoxin detection, PACIA and serogrouping of C. difficile isolates were performed on 249 stools. Of the 71 culture-negative specimens, none gave a positive result in the cytotoxin assay or in PACIA. Faecal cytotoxin was detected in 100 of the 178 culture-positive specimens. PACIA was positive for 63 of the 71 faecal specimens that yielded serogroup G C. difficile on culture. PACIA gave negative results for all other culture-positive stools tested with one exception, from which a serogroup A7 C. difficile strain was isolated. PACIA detection of serogroup G antigen in faecal specimens showed a sensitivity of 88.7%, a specificity of 99.7%, a predictive value of a positive culture with a serogroup G strain of 98.4%, and a predictive value for specimens that were culture-negative for a serogroup G strain of 95.6%. The results indicate that PACIA with specific antiserum is a rapid and reliable method for detecting serogroup specific antigens of C. difficile in faecal specimens. Clinical applications of the method are discussed.

Agglutination Tests↗
PubMed2006

NF-kappa B activation pathway is essential for the chemokine expression in intestinal epithelial cells stimulated with Clostridium difficile toxin A.

Intestinal epithelial cells are known to upregulate the expression of several chemokines in response to stimulation with bacterial toxin. However, the cellular mechanisms of Clostridium difficile toxin A-induced mucosal inflammation have not yet been fully elucidated. In this study, we investigated whether nuclear factor-kappa B (NF-kappaB) could regulate chemokine expression in intestinal epithelial cells. Toxin A increased the levels of NF-kappaB complexes containing p65/p50 heterodimers and p65/p65 homodimers. Concurrently, toxin A decreased the levels of IkappaBalpha. Toxin A stimulation also increased the signals of phosphorylated IkappaB kinase (IKK)alpha/beta and NF-kappaB-inducing kinase (NIK). In the toxin A-stimulated HT-29 cells, the suppression of IKK or NIK inhibited the upregulation of downstream target genes of NF-kappaB such as IL-8 and monocyte-chemotactic protein (MCP)-1 and similarly, inhibition of NF-kappaB also downregulated the expression of IL-8, growth-related oncogene-alpha, and MCP-1. These results suggest that NF-kappaB signalling events may be involved in the inflammatory responses to toxin A produced by toxigenic C. difficile.

Amino Acid Sequence↗