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PubMed2002

Difference in the incidence of Clostridium difficile among patients infected with human immunodeficiency virus admitted to a public hospital and a private hospital.

OBJECTIVE: To compare the occurrence of Clostridium difficile among inpatients infected with human immunodeficiency virus (HIV) in two different hospitals. DESIGN: Prospective, observational study. SETTING: Specialized HIV inpatient units. PATIENTS: HIV-infected inpatients at Cook County Hospital (CCH) and Rush Presbyterian St. Luke's Medical Center (RPSLMC). INTERVENTIONS: A clinical and epidemiologic assessment of patient risk factors for C. difficile was performed. C. difficile isolates found on stool, rectal, and environmental cultures were typed by pulsed-field gel electrophoresis. RESULTS: Twenty-seven percent of patients admitted to CCH versus 4% of patients admitted to RPSLMC had positive cultures for C. difficile (P = .001). At CCH, 14.7% of environmental cultures were positive versus 2.9% at RPSLMC (P = .002). Risk factors for C. difficile acquisition included hospitalization at CCH, more severe HIV, use of acyclovir and H2-blockers, and longer hospital stay. Patients admitted to CCH were taking more antibiotics, had longer hospital stays, and more frequently had a history of C. difficile infection. During the study, two strains (CD1A and CD4) extensively contaminated the CCH environment. However, only CD1A caused an outbreak. CONCLUSIONS: The C. difficile acquisition rate at CCH was sevenfold higher than that at RPSLMC, and CCH had a more contaminated environment. Differences in patient acquisition rates likely reflect a greater prevalence of traditional C. difficile risk factors and a concurrent outbreak at CCH. Although two strains heavily contaminated the environment at CCH, only one caused an outbreak, suggesting that factors other than the environment are important in initiating C. difficile outbreaks.

Chicago↗
PubMed2004

Leukemoid reactions complicating colitis due to Clostridium difficile.

BACKGROUND: We sought to describe the characteristics of patients who had Clostridium difficile colitis complicated by leukemoid reactions (total leukocyte count greater than 35 x 10(9)/L) and to determine whether this complication is associated with higher morbidity or mortality than C difficile colitis without leukemoid reactions. METHODS: We performed a retrospective case series analysis of patients with a positive fecal assay for C difficile toxin and a peak leukocyte count greater than 35 x 10(9)/L during 1998 and 1999. Twenty cases that met these criteria were compared with 65 randomly selected control patients (patients with a positive C difficile toxin and a peak leukocyte count less than 35 x 10(9)/L). RESULTS: The mean peak leukocyte count was 52 +/- 18.2 x 10(9)/L (+/- SD) in the case group and 14.9 +/- 6.5 x 10(9)/L in the control group. Patients with a leukemoid reaction had a lower temperature, a lower serum albumin level, and a higher hematocrit value. Multivariable logistic regression showed respiratory tract infection and lower temperature to be independent predictors of a leukemoid reaction. There were 10 deaths (50%) in the leukemoid reaction group and 5 deaths (7.7%) in the control group. All seven patients with a peak leukocyte count greater than 50 x 10(9)/L died, compared with eight deaths (10.3%) among the remaining 78 patients whose peak leukocyte count was less than 50 X 10(9)/L. CONCLUSION: Patients with C difficile colitis and a leukocyte count greater than 35 x 10(9)/L have a poor prognosis with a much higher mortality rate than patients who have C difficile colitis without a leukemoid reaction.

Aged↗
PubMed1993

Serogroup F strains of Clostridium difficile produce toxin B but not toxin A.

Most toxigenic strains of Clostridium difficile produce two toxins: an enterotoxin (toxin A) and a cytotoxin (toxin B). Only one strain (strain 8864) has been reported to produce toxin B but no toxin A. Serogroup F strains (44) of C. difficile, often isolated from asymptomatic infants, have been examined for toxin production. These strains, which were from distinct geographical and clinical sources, did not produce any detectable toxin A in vitro when examined in three distinct immunoassays. Nevertheless, all the strain produced a cytotoxin. Immunological differences between the cytotoxin of the serogroup F strains and that produced by C. difficile strain VPI 10463 (serogroup G) were demonstrated with monoclonal antibodies specific for either the toxin B produced by C. difficile strain VPI 10463 or C. sordellii lethal toxin (LT). Polymerase chain reaction amplification with primers derived from C. difficile strain VPI 10463 toxin A and B genes showed that serogroup F strains seem to possess a toxin B gene homologous with that of strain VPI 10463 and at least fragments of the toxin A gene. When axenic mice were inoculated with serogroup F strains, the animals survived; they did not develop diarrhoea and no toxin A could be detected in their faeces. However, cytotoxin was detected. Furthermore, these mice were protected against subsequent challenge with the otherwise lethally toxigenic C. difficile strain VPI 10463. The serogroup F strains appeared to be homogeneous and distinct from other C. difficile strains with regard to toxin production.

Animals↗
PubMed2005

Acd, a peptidoglycan hydrolase of Clostridium difficile with N-acetylglucosaminidase activity.

A gene encoding a putative peptidoglycan hydrolase was identified by sequence similarity searching in the Clostridium difficile 630 genome sequence, and the corresponding protein, named Acd (autolysin of C. difficile) was expressed in Escherichia coli. The deduced amino acid sequence of Acd shows a modular structure with two main domains: an N-terminal domain exhibiting repeated sequences and a C-terminal catalytic domain. The C-terminal domain exhibits sequence similarity with the glucosaminidase domains of Staphylococcus aureus Atl and Bacillus subtilis LytD autolysins. Purified recombinant Acd produced in E. coli was confirmed to be a cell-wall hydrolase with lytic activity on the peptidoglycan of several Gram-positive bacteria, including C. difficile. The hydrolytic specificity of Acd was studied by RP-HPLC analysis and MALDI-TOF MS using B. subtilis cell-wall extracts. Muropeptides generated by Acd hydrolysis demonstrated that Acd hydrolyses peptidoglycan bonds between N-acetylglucosamine and N-acetylmuramic acid, confirming that Acd is an N-acetylglucosaminidase. The transcription of the acd gene increased during vegetative cellular growth of C. difficile 630. The sequence of the acd gene appears highly conserved in C. difficile strains. Regarding deduced amino acid sequences, the C-terminal domain with enzymic function appears to be the most conserved of the two main domains. Acd is the first known autolysin involved in peptidoglycan hydrolysis of C. difficile.

Acetylglucosaminidase↗
PubMed2000

DNA sequence of the insertional hot spot of Tn916 in the Clostridium difficile genome and discovery of a Tn916-like element in an environmental isolate integrated in the same hot spot.

Tn916 is a broad host range tetracycline resistance conjugative transposon. In most bacteria, this element enters the bacterial genome at multiple sites. However, in Clostridium difficile, the element has a strong hot spot when introduced by filter mating from Bacillus subtilis. In this work, the DNA sequence of the preferred insertion site (att916) was obtained. An environmental isolate of C. difficile was also discovered which contained an element indistinguishable from Tn916, Tn916CD. Tn916CD was found integrated at att916.

Bacillus subtilis↗
PubMed2004

[Bacteremia due to Clostridium difficile].

We describe a case of bacteremia due to Clostridium difficile, which was successfully treated by intravenous vancomycin. A 69-year-old woman was admitted to our hospital because of third degree burn injuries. She was treated with cefazolin for two weeks followed with flomoxef for one week before the operation (debridement and grafting of skin). On the third postoperative day high fever (temperature 40 degrees C), abdominal pain and severe watery diarrhea developed. Antibiotic-associated colitis with bacteremia was diagnosed presumptively, flomoxef was stopped, and oral and intravenous therapy with vancomycin was started. A blood culture taken before the administration of vancomycin yielded C. difficile accompanied with Enterococcus faecalis and Enetrococcus casseliflavus. A stool culture taken on the next day yielded C. difficile, and a stool latex agglutination test was also positive. The patient improved slowly. Parenteral vancomycin was discontinued after two weeks. One week later, the patient developed pneumonia, and imipenem/cilastatin was added. Soon after addition of the agent, she developed recurrent diarrhea despite continual oral vancomycin therapy. The fecal samples obtained at this time were positive for C. difficile by culture and positive for toxins A & B. She was satisfactorily treated with oral vancomycin for a total of four weeks. After the following two weeks, however, recurrence of diarrhea developed again, which rapidly decreased with oral vancomycin for seven days. The patient did well thereafter and was discharged. All three C. difficile isolates from blood and fecal specimens were positive for toxins A & B, and identified the same PCR ribotyping pattern.

Aged↗
PubMed1997

Use of cycloserine-cefoxitin-fructose agar and L-proline-aminopeptidase (PRO Discs) in the rapid identification of Clostridium difficile.

The PRO Disc (Carr-Scarborough Microbiologicals, Inc., Decatur, Ga.) can be used to screen for L-proline-aminopeptidase produced by Clostridium difficile grown on cycloserine-cefoxitin-fructose agar (CCFA). Fifty stored isolates of C. difficile (48 toxin-positive and 2 toxin-negative isolates) and 47 fresh C. difficile isolates (39 toxin-positive and 8 toxin-negative isolates) were all PRO Disc positive. Other Clostridium species that were PRO Disc positive could be differentiated from C. difficile by failure to grow on CCFA, different colonial morphology on CCFA, or morphology upon Gram staining.

Agar↗
PubMed1991

Modulation of Clostridium difficile induced mortality as a function of the dose and the viability of the Saccharomyces boulardii used as a preventative agent in gnotobiotic mice.

The ability of viable and nonviable Saccharomyces boulardii to protect gnotobiotic mice from Clostridium difficile induced mortality was tested. With the exception of irradiated S. boulardii, which retained some activity, only viable yeast protected the mice from lethality. The survival of C. difficile infected mice was dependent on the dose of the yeast provided in the drinking water.

Amphotericin B↗
PubMed2003

Clostridium difficile-associated diarrhea in a pediatric hospital.

This retrospective cohort analysis examined the risk factors, symptoms, and severity of disease associated with C. difficile in pediatric inpatients. Risk factors for a C. difficile-positive test were an oncologic diagnosis, diarrhea of more than 2 days' duration, and gastrointestinal symptoms, especially abdominal pain. Over a 3.5-year period, there was a total of 22 C. difficile-positive patients, and most had mild, self-limiting diarrheal illness. No cases of C. difficile diarrhea were identified. Seventy-eight percent of the C. difficile-positive patients were found to have alternate risk factors for diarrhea. Our data indicate that C. difficile rarely causes severe diarrhea in pediatric inpatients and that C. difficile testing should be limited to patients with severe prolonged diarrhea and abdominal pain.

Anti-Bacterial Agents↗
PubMed2001

[Diarrhea due to Clostridium difficile toxin in hemato-oncological patients].

In two patients with multiple myeloma, men aged 72 and 54 years, diarrhoea developed upon chemotherapy with vincristin, doxorubicin and dexamethasone (VAD). In the second patient, diarrhoea developed after subsequent peripheral stem cell mobilisation. Pseudomembranous colitis was seen in the first patient during endoscopy but an enzyme immunoassay of the faeces was false negative for Clostridium difficile enterotoxin. The bacterium was later cultured from stool samples and toxins were detected in a repeated immunoassay. Stool samples of the second patient were positive for C. difficile enterotoxin. For both patients an antibiotic treatment resulted in a rapid recovery. In haemato-oncological patients, diarrhoea is often caused by oncolytic therapy. However, consideration should also be given to C. difficile infection as an alternative cause which is easily treatable.

Aged↗
PubMed2005

Co-infection of hamsters with toxin A or toxin B-deficient Clostridium difficile strains.

Male Syrian hamsters (Mesocricetus auratus) were used to study interactions between different toxin deficient strains of C. difficile. After sensitization with clindamycin, hamsters were intragastrically co-infected with the appropriate dilutions corresponding to 100, 1000 and 10,000 cells of four (toxin A or B-deficient) C. difficile strains (8864, P-829, W-38 and W-74). In addition, a group of hamsters was infected with C. difficile VPI 10463, a reference toxigenic strain. Colonization and mortality was observed within 48 hours in the group of hamsters infected with the reference toxigenic strain. No clinical disease was observed in the groups of hamsters co-infected with the toxin A or B-deficient strains. Re-infection of these hamsters (co-infected with toxin deficient isolates) with C. difficile VPI 10463 resulted in clinical disease and death suggesting that these strains do not confer protection against infection with a toxigenic strain. Macroscopic and microscopic observations of the cecum of re-infected hamsters demonstrated uniformly multiple large hemorrhagic areas without pseudomembranes. Hamsters infected with as few as 100-500 cells of the toxigenic strain--VPI 10463 alone demonstrated pseudomembranes and multiple hemorrhages. These results suggest that even though the toxin deficient strains did not prevent re-infection with a toxigenic strain of C. difficile, they may play a role in the histopathologic changes after re-infections in the hamster model. Further studies with a larger number of hamsters and C. difficile strains of various molecular profiles are required to better understand the interaction between these strains.

Animals↗
PubMed1993

Clostridium difficile-related disease: evaluation and prevalence among inpatients with diarrhea in two freestanding rehabilitation hospitals.

Clostridium difficile has been associated with diarrhea in hospitalized patients receiving antibiotic therapy, and may be nosocomially acquired. Rehabilitation hospital inpatients may require frequent antibiotic intervention and are thus at risk, though few reports of epidemics at such centers have been published. This study describes the evaluation and prevalence of C difficile-related disease, among rehabilitation hospital inpatients. A retrospective review was conducted of all diarrhea evaluations performed among inpatients in two freestanding rehabilitation hospitals over a two-year period. A total of 303 laboratory tests were performed among the 115 patients evaluated. C difficile was determined to be the etiologic agent of diarrhea in 25% of patients undergoing enteric evaluation, and in 39% of patients specifically assayed for C difficile toxin B. Giardiasis was detected in one patient, and no evidence of Salmonella, Shigella, Campylobacter, or Yersinia infection was found. The estimated prevalences for diarrhea and C difficile-related disease were 3.7% and 1.1%, respectively. Thus, C difficile is an important cause of diarrhea among rehabilitation hospital inpatients, though its true prevalence may be underestimated due to inadequate diagnostic evaluation. Enteric bacterial pathogens such as Campylobacter, Salmonella, Shigella, Yersinia, and Giardia are insignificant causes of diarrhea among these patients. Elimination of routine testing for these pathogens would reduce costs without compromising diagnostic utility. Diagnostic evaluation should include C difficile toxin assay, and if positive, appropriate therapy instituted.

Adolescent↗
PubMed1993

[Yield of detection of Clostridium difficile toxin versus stool culture in the study of nosocomial diarrhea].

BACKGROUND: The aim of the study was to determine whether the detection of Clostridium difficile toxin in stools may be more profitable than conventional stool cultures for the etiologic study of nosocomial diarrhea and to analyze what risk factors favor the development of nosocomial diarrhea by C. difficile. METHODS: The presence of enteropathogens and A and B toxins of C. difficile were investigated (by monoclonal antibody enzymoimmunoassay) in stools of patients with nosocomial diarrhea. A series of patients simultaneously admitted without diarrhea were selected as the control group. RESULTS: During a 6 month period 92 patients with nosocomial diarrhea and 82 controls without diarrhea were studied. The C. difficile toxin was detected in 8 of these 174 patients (4.6%). Eight point seven percent of the nosocomial diarrheas were related with C. difficile while only 1% were due to an enteropathogen (Salmonella enteritidis). C. difficile toxin was not detected in any patient who did not have diarrhea. In comparison with the patients with diarrhea due to other causes, the patients with diarrhea by C. difficile had more frequently received antibiotics over the previous 7 days (57 vs 88%) and had been hospitalized for a longer time (> or = 7 days) (58 vs 88%) (p < 0.05). CONCLUSIONS: In the author's institution infection by Clostridium difficile is the most frequent cause of nosocomial infectious diarrhea, especially in patients admitted for a prolonged time or who receive antibiotics. The routine investigation of enteropathogens in the cases of nosocomial diarrhea does not seem justified while the detection of the A and B toxins of C. difficile may be more profitable.

Bacterial Proteins↗
PubMed1997

Frequency of isolation of toxigenic Clostridium difficile from healthy adults.

An attempt was made to isolate Clostridium difficile from 129 faecal specimens from 87 young and 42 elderly healthy adults. C.difficile was isolated using bacterial culture from 7 (5.4%) specimens and the frequency of isolation of toxigenic C. difficile as detected by cytotoxin (tissue culture) assay was 1.1 per cent and 2.4 per cent in healthy young and elderly adults respectively. The carrier rate of toxigenic C. difficile amongst healthy adults is relatively low in this part of our country.

Adolescent↗
PubMed2002

Inhibition of in vitro cell adherence of Clostridium difficile by Saccharomyces boulardii.

The influence on the adherence of Clostridium difficile to Vero cells of the yeast Saccharomyces boulardii, the yeast fractions (cytoplasm and cell wall) and the culture supernatant was investigated in vitro. C. difficile adherence was significantly inhibited when bacteria were pre-incubated with the whole yeast and the cell wall fraction; this adherence inhibition was dose-dependent. The cell wall fraction also acts upon the target cultured cells inasmuch as the level of adherence was significantly decreased when Vero cells were preincubated with it. The same experiments carried out in the presence of an inhibitor of serine proteases resulted in no inhibition of bacterial adherence. These results suggest that the yeast could inhibit adherence of C. difficile to cells thanks to its proteolytic activity but also through steric hindrance.

Animals↗
PubMed1993

Heterogeneity of Clostridium difficile isolates from infants.

In order to improve our understanding of the role of Clostridium difficile in infants we characterised the strains isolated from this population. The production of toxin A and toxin B was studied. The toxin A, playing a major role in the disease, was searched for in faecal samples. The serogroup of the isolates was determined because some serogroups have been shown to be more pathogenic than others. Over a 9-month period, 102 faecal samples from 102 hospitalised infants (0-12 months) were analysed and 26% of the children were colonised with C. difficile. Fifteen isolates secreted neither toxin A nor B (62.5%). Nine isolates were toxigenic and secreted both toxins (37.5%). Of the eight toxigenic strains tested, six were from serogroup H and two serogroup K. Of the 13 nontoxigenic strains tested, 8 belonged to serogroup D, 2 to serogroup X, and 1 each to serogroup A, serogroup B and serogroup C. Three infants out of 102 studied had toxin A in their faeces. In summary, the infants can be colonised by (1) nontoxigenic strains, most of them from nonpathogenic serogroup D, without toxin A in the faeces; (2) toxigenic strains of virulent serogroups H and K, with or without toxin A in the faeces. Although some infants had diarrhoea, none needed a specific treatment for C. difficile. No specific C. difficile pathology could be retained and different mechanisms are advanced to explain this absence of pathogenicity.

Bacterial Toxins↗
PubMed2004

Outcome after colectomy for Clostridium difficile colitis.

PURPOSE: Clostridium difficile colitis is a relatively common entity, yet large series of patients with fulminant C. difficile colitis are infrequently reported. This study was designed to identify risk factors, clinical characteristics, and outcome of patients who required colectomy for fulminant C. difficile colitis. METHODS: A population-based study on all patients in 159 hospitals of the Department of Veterans Affairs from 1997 to 2001 was performed. Data were compiled from several national computerized Department of Veterans Affairs data sets. Supplementary information including demographic information, discharge summaries, operative reports, and pathology reports were obtained from local medical records. Patient variables were entered into a computerized database and analyzed using the Pearson chi-squared and Fisher's exact tests. Statistical significance was designated as P < 0.05. RESULTS: Sixty-seven patients (mean age, 69 (range, 40-86) years; 99 percent males) were identified. All 67 patients had C. difficile verified in the colectomy specimens. Thirty-six of 67 patients (54 percent) developed C. difficile colitis during a hospitalization for an unrelated illness, and 30 of 36 patients (87 percent) after a surgical procedure. Thirty-one of 67 (46 percent) developed C. difficile colitis at home. There was no history of diarrhea in 25 of 67 patients (37 percent). Thirty of 67 patients (45 percent) presented in shock (blood pressure, <90 mmHg). Forty-three of 67 patients (64 percent) presented with an acute surgical abdomen. Mean white blood cell count was 27.2; mean percent bands was 12. Twelve of 67 patients (18 percent) had a negative C difficile colitis stool assay. Abdominal computed tomography correctly diagnosed 45 of 46 patients (98 percent) who were imaged. Twenty-six of 67 patients (39 percent) underwent colonoscopy; all 26 were found to have severe inflammation or pseudomembranes. Fifty-three of 67 patients (80 percent) underwent total colectomy; 14 of 67 underwent segmental colonic resection. Perforation and infarction were found in 59 of 67 patients (58 percent) at surgery. Overall mortality was 48 percent (32/67). Mean hospitalization was 36 (range, 2-297) days. CONCLUSIONS: Patients with fulminant C. difficile colitis often present with an unexplained abdominal illness with a marked leukocytosis that rapidly progresses to shock and peritonitis. Although frequently developed during a hospitalization and often after a surgical procedure, it may develop outside of a hospital setting. Diarrhea may be absent and stool cytology may be negative for C. difficile toxin. Perforation and infarction are frequently found at surgery. In those patients who survive, a prolonged hospitalization is common. Mortality from fulminant C. difficile colitis remains high despite surgical intervention.

Adult↗