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PubMed2006

Frequent emergence of resistance in Clostridium difficile during treatment of C. difficile-associated diarrhea with fusidic acid.

Samples from patients with Clostridium difficile-associated diarrhea (CDAD) that were randomized to fusidic acid (n = 59) or metronidazole (n = 55) therapy for 7 days were cultured for Clostridium difficile in feces on days 1, 8 to 13, and 35 to 40. Of the patients who were culture positive only before treatment, 77% (36/47) were permanently cured (no treatment failure and no clinical recurrence), compared to 54% (22/41) of those with persistence of C. difficile at one or both follow-ups (P = 0.03). A similar association between bacterial persistence and a worse outcome of therapy was seen in both treatment groups. Resistance to fusidic acid was found in 1 of 88 pretherapy isolates available, plus in at least 1 subsequent isolate from 55% (11/20) of patients who remained culture-positive after fusidic acid therapy. In 10 of these 11 patients, the resistant follow-up isolate(s) belonged to the same PCR ribotype as the susceptible day 1 isolate, confirming frequent emergence of resistance to fusidic acid during treatment. Despite this, 5 of these 11 patients were permanently cured with fusidic acid, relative to 5 of 9 patients with susceptible C. difficile at follow-up (P = 1.0). None of the 36 PCR ribotypes of C. difficile identified was associated with any particular clinical outcome or emergence of fusidic acid resistance. In conclusion, culture positivity for C. difficile was common after both fusidic acid and metronidazole therapy and was associated with treatment failure or recurrence of CDAD. Development of resistance in C. difficile was frequent in patients given fusidic acid, but it was without apparent negative impact on therapeutic efficacy in the actual CDAD episode.

Anti-Bacterial Agents↗

PubMed1991

Correlation of immunoblot type, enterotoxin production, and cytotoxin production with clinical manifestations of Clostridium difficile infection in a cohort of hospitalized patients.

To determine whether strain-specific differences in immunoblot type, enterotoxin production, or cytotoxin production correlated with clinical presentation of Clostridium difficile infection, we evaluated isolates obtained from 428 prospectively studied hospitalized patients. Of 99 isolates available for immunoblot typing, 61 were recovered from asymptomatic carriers and 38 were from patients with C. difficile-associated diarrhea. Of 17 immunoblot types, the seven types comprising the majority of isolates (82 of 99; 83%) were variably associated with disease. Neither the presence of cytotoxin in the stool nor the production of cytotoxin or enterotoxin by isolates in vitro was significantly different for symptomatic versus asymptomatic patients. Selected host factors were more predictive of symptomatic disease than was the specific infecting C. difficile strain. These results suggest that variations in the clinical severity of C. difficile infection in different patients are not solely strain-specific phenomena related to immunoblot type or to the production of cytotoxin or enterotoxin.

Antibodies, Bacterial↗

PubMed2000

Epidemiology of recurrences or reinfections of Clostridium difficile-associated diarrhea.

Approximately 15 to 35% of patients with a first episode of Clostridium difficile-associated diarrhea relapse within 2 months. Between 1994 and 1997, strains from 93 hospitalized patients with C. difficile recurrences were fingerprinted by using both serotyping and PCR-ribotyping. The results showed that 48.4% of clinical recurrences were, in fact, reinfections with a different strain of C. difficile. Rates of clinical recurrences could therefore be reduced by implementing strict isolation precautions.

Adolescent↗

PubMed1993

Clostridium difficile after haemolytic uraemic syndrome.

Six children are described who developed diarrhoea associated with Clostridium difficile during the course of haemolytic uraemic syndrome. The significance of this infection is discussed within the context of the pathophysiology of haemolytic uraemic syndrome.

Adolescent↗

PubMed2006

Gut microbiota composition and development of atopic manifestations in infancy: the KOALA Birth Cohort Study.

BACKGROUND AND AIMS: Perturbations in intestinal microbiota composition due to lifestyle changes may be involved in the development of atopic diseases. We examined gut microbiota composition in early infancy and the subsequent development of atopic manifestations and sensitisation. METHODS: The faeces of 957 infants aged 1 month and participating in the KOALA Birth Cohort Study were analysed using quantitative real-time PCR. Information on atopic symptoms (eczema, wheeze) and potential confounders was acquired through repeated questionnaires. Total and specific IgE were measured in venous blood samples collected during home visits when the infant was 2 years old. During these home visits a clinical diagnosis of atopic dermatitis was made according to the UK-Working Party criteria. RESULTS: The presence of Escherichia coli was associated with a higher risk of developing eczema (OR(adj) = 1.87; 95% CI 1.15 to 3.04), this risk being increased with increasing numbers of E coli (p(for trend) = 0.016). Infants colonised with Clostridium difficile were at higher risk of developing eczema (OR(adj) = 1.40; 95% CI 1.02 to 1.91), recurrent wheeze (OR(adj) = 1.75; 95% CI 1.09 to 2.80) and allergic sensitisation (OR(adj) = 1.54; 95% CI 1.02 to 2.31). Furthermore, the presence of C difficile was also associated with a higher risk of a diagnosis of atopic dermatitis during the home visit (OR(adj) = 1.73; 95% CI 1.08 to 2.78). CONCLUSION: This study demonstrates that differences in gut microbiota composition precede the development of atopy. Since E coli was only associated with eczema and C difficile was associated with all atopic outcomes, the underlying mechanisms explaining these association may be different.

Bacteria↗

PubMed1994

Clinical significance of Clostridium difficile and its toxins in faeces of immunocompromised children.

In this study, clinical and laboratory findings were tested for correlation with the presence of Clostridium difficile. The toxigenicity of the isolated strains and the toxins were determined in faecal samples of immunocompromised children admitted to a single room for protective isolation. Using the toxin assay as the gold standard, the culture sensitivity of toxigenic C difficile was 94.1%, the specificity 93.8%, the positive predictive value 62.8%, and the negative predictive value 99.3%. Correction for stools with a positive culture of toxigenic C difficile preceding detection of toxin, resulted in a positive prediction value of 78.4%. A statistically significant association was found between a positive faecal toxin assay and fever, and between a positive culture of toxigenic C difficile and abdominal pain: 42% of the patients with positive toxin assays had fever versus 21% with negative toxin assays, and 66% of the patients with a positive culture for toxigenic C difficile had abdominal pain, versus 22% with negative cultures. Further analysis of the cultures and toxin assays showed no statistically significant association with diarrhoea, fever, white blood cell count, C reactive protein concentrations, or abdominal pain. Based on these findings, it is suggested that immunocompromised children should be treated when toxigenic C difficile is cultured or when toxin is detected in stool samples.

Abdominal Pain↗

PubMed1993

The prevalence and nosocomial acquisition of Clostridium difficile in elderly hospitalized patients.

Rectal swabs obtained from 10 of 49 chronic-care geriatric patients were positive for Clostridium difficile, for a prevalence rate of 20.4%. Simultaneous sampling of 29 patients in an acute geriatric ward revealed four colonized patients, for a prevalence rate of 13.7%. A prospective study of C. difficile colonization in 100 consecutive patients admitted to an acute geriatric ward was carried out. All patients were sampled upon admission and biweekly during hospitalization. Two patients (2%) were positive on admission, and 12 of the 98 initially negative patients became colonized, representing a nosocomial acquisition rate of 12.2%. A major determinant for C. difficile colonization in asymptomatic patients appears to be length of hospitalization. Previous antibiotic administration was not found to be a significant factor.

Aged↗

PubMed2006

Factors influencing the composition of the intestinal microbiota in early infancy.

OBJECTIVE: The aim of this study was to examine the contribution of a broad range of external influences to the gut microbiotic composition in early infancy. METHODS: Fecal samples from 1032 infants at 1 month of age, who were recruited from the KOALA Birth Cohort Study in the Netherlands, were subjected to quantitative real-time polymerase chain reaction assays for the enumeration of bifidobacteria, Escherichia coli, Clostridium difficile, Bacteroides fragilis group, lactobacilli, and total bacterial counts. Information on potential determinants of the gut microbiotic composition was collected with repeated questionnaires. The associations between these factors and the selected gut bacteria were analyzed with univariate and multivariate analyses. RESULTS: Infants born through cesarean section had lower numbers of bifidobacteria and Bacteroides, whereas they were more often colonized with C difficile, compared with vaginally born infants. Exclusively formula-fed infants were more often colonized with E coli, C difficile, Bacteroides, and lactobacilli, compared with breastfed infants. Hospitalization and prematurity were associated with higher prevalence and counts of C difficile. Antibiotic use by the infant was associated with decreased numbers of bifidobacteria and Bacteroides. Infants with older siblings had slightly higher numbers of bifidobacteria, compared with infants without siblings. CONCLUSIONS: The most important determinants of the gut microbiotic composition in infants were the mode of delivery, type of infant feeding, gestational age, infant hospitalization, and antibiotic use by the infant. Term infants who were born vaginally at home and were breastfed exclusively seemed to have the most "beneficial" gut microbiota (highest numbers of bifidobacteria and lowest numbers of C difficile and E coli).

Adult↗

PubMedDate not supplied

Is Clostridium difficile a pathogen in the newborn intensive care unit? A prospective evaluation.

OBJECTIVES: The purpose of this study was to investigate (1) the presence of Clostridium difficile toxin in patients in the newborn intensive care unit and (2) the association of C. difficile toxin with gastrointestinal tract symptoms in this population. STUDY DESIGN: A prospective, masked study was done in which twice-weekly stool specimens of subjects hospitalized in a newborn intensive care unit during a 4-month period were analyzed for C. difficile toxin A by enzyme immunoassay. Daily data collection included infant clinical status, stool frequency and character, presence of gastrointestinal tract symptoms, and actions taken for gastrointestinal tract symptoms. Infants hospitalized 5 or more days who had at least two stool assays comprised the study population. For data analysis, an infant with C. difficile toxin-positive status was defined as an infant with two or more toxin-positive stools. RESULTS: Of 87 infants who met study criteria, 42 (48%) had toxin-negative and 45 (52%) toxin-positive results on at least one specimen. Of the infants with toxin-positive findings, 27 (31%) had two or more positive stool assays and comprised the comparison group. The infants with toxin-positive results were smaller, less mature, and had a longer hospital stay than infants with toxin-negative results (p < 0.001). Infants with toxin-positive findings had more days per infant with frequent (> 6) stools and abnormal stools (p < 0.001). The total number of symptom days was 8.2 +/- 5.7 in infants in the toxin-positive group versus 2.2 +/- 2.2 in those in the toxin-negative group (p < 0.001). The mean number of times stools were sent for evaluation and culture was greater in infants with toxin-positive findings (p < or = 0.012) whereas there was no difference in the number of times oral feedings were withheld from infants or infants had abdominal films obtained (p > or = 0.18). CONCLUSIONS: Infants hospitalized in our newborn intensive care unit frequently had stools positive for C. difficile toxin A. When compared with infants with toxin-negative findings, infants with colonization had an increased number of days with gastrointestinal tract symptoms.

Bacterial Toxins↗

PubMed1997

[Value of proctosigmoidoscopy with bacteriological culture of colonic biopsies in the etiological diagnosis of post-antibiotic acute diarrhea in adults. Prospective study in 24 patients].

The aim of this study was to analyse the interest of proctosigmoidoscopy and biopsies microbiology in antibiotic-associated acute diarrhea in adults. Between February 1993 and October 1995, we have studied prospectively 24 patients with antibiotic-associated acute diarrhea. Ages ranged from 17 to 83 years. They had taken antibiotics: amoxicillin (n = 8) amoxicillin-clavulanic acid (n = 11), cephalosporinia (n = 3), cotrimoxazole (n = 1), macrolide (n = 1). For each patient, 2 stool cultures with Cytotoxin assay for Clostridium difficile and 3 fecal samples for parasitic enteropathogens were collected. Proctosigmoidoscopy with biopsies microbiology was carried out in all patients. Stool culture was always negative but colonic biopsies cultures were positive with Klebsiella oxytoca in 7 patients. Cytotoxin assay of C. difficile was positive in 11 patients. Proctosigmoidoscopy permitted also diagnosis of 2 pseudomembranous colitis without cytotoxin assay of C. difficile. Proctosigmoidoscopy permitted diagnosis of 83% of antibiotic-associated acute diarrhea. Complementary to Cytotoxin assay of C. difficile, it should be necessary in antibiotic-associated acute diarrhea in adults.

Acute Disease↗

PubMed1999

Association of Clostridium difficile with enterocolitis and lactose intolerance in a foal.

Diagnoses of Clostridium difficile enterocolitis and lactose intolerance were made in a neonatal foal with persistent diarrhea. It was determined that the foal had lactose intolerance on the basis of the results of a lactose tolerance test, and a diagnosis of C difficile enterocolitis was subsequently made. The foal responded to oral administration of metronidazole and lactase. Lactose intolerance is a secondary problem most commonly associated with rotavirus infection, but it can be caused by any condition affecting the small intestine. Because C difficile can affect the small intestine in foals, it was presumably the cause of the lactose intolerance in this foal with persistent diarrhea. Oral administration of lactase was not initially successful in this foal, most likely because of ongoing C difficile enterocolitis. Presumably, metronidazole was an effective treatment for C difficile enterocolitis and administration of lactase allowed for normal digestion of milk until endogenous lactose production returned. Clostridium difficile enterocolitis and lactose intolerance should be considered as differential diagnoses in neonatal foals with diarrhea, especially when the foal is bright and alert.

Animals↗

PubMedDate not supplied

Diarrhea in elderly patients due to Clostridium difficile associated with Salmonella and Shigella infection.

Clostridium difficile is the main cause of nosocomial diarrhea mainly in elderly hospitalized patients and in nursing homes, but less common in the community. We report three elderly patients living in the community, one frail and two in reasonable good health who recently developed diarrhea due to C. difficile associated with Salmonella group C in two cases and Shigella flexneri in the other. The association with Shigella has not previously been reported and there have only been a few cases with Salmonella. These findings may be important due to the possibility that diarrhea caused by C. difficile associated with other enteric bacteria may be more prevalent than expected in the aging population, thus necessitating awareness and consequently appropriate treatment and follow-up.

Aged↗

PubMed1995

Clostridium difficile colitis: correlation of CT findings with severity of clinical disease.

Clinical records and abdominal CT scans from 64 patients with documented Clostridium difficile disease were reviewed to determine if any correlation existed between CT findings of colitis and severity of clinical disease. Clostridium difficile disease was documented with stool toxin titre levels and CT scans were performed within 3 days of stool sample. Clinical disease severity was estimated by tabulating the degree of fever, WBC count, frequency and duration of diarrhoea. Thirty-nine of 64 patients showed CT evidence of colitis of which 28/39 showed evidence of focal colitis and 11/39 had pancolitis. CT findings suggesting colitis included colonic wall thickening (39 patients), nodular mucosal thickening (11 patients), the 'accordion pattern' (3 patients), pericolonic oedema (27 patients) and ascites (10 patients). Twenty-five of 64 patients showed no CT evidence of colitis. The clinical severity of disease did not statistically differ (P < 0.05) between patients with CT evidence of colitis and those without colitis. The only CT finding that correlated with clinical severity of disease was nodular mucosal thickening which was found with significantly (P < 0.05) more frequency in patients with a WBC count > 11,000 mm3. CT changes with Cl. difficile disease correlate poorly with the clinical severity. This and negative findings do not exclude the disease.

Adult↗

PubMed1991

Treatment with intravenously administered gamma globulin of chronic relapsing colitis induced by Clostridium difficile toxin.

We tested the hypothesis that children with chronic relapsing colitis induced by Clostridium difficile toxin have defective antibody responses to C. difficile toxins as a cause of their underlying illness. Six such children were tested for serum IgG and IgA antibody to C. difficile toxin A. These six children had lower IgG anti-toxin A levels than 24 healthy children (p = 0.026) and 18 healthy adults (p = 0.0008). Five patients treated with 400 mg intravenously administered gamma-globulin per kilogram every 3 weeks had significant increases in IgG (p = 0.01) but not IgA anti-toxin A (p = 0.406) levels, and all five had clinical resolution of their gastrointestinal symptoms as well as clearing of C. difficile cytotoxin B from their stools. These observations suggest that a deficiency of IgG anti-toxin A may predispose children to the development of chronic relapsing C. difficile-induced colitis. In such cases, intravenous gamma-globulin therapy may be effective in producing clinical remission.

Antibodies, Bacterial↗

PubMed1998

Community-acquired Clostridium difficile infection.

Clostridium difficile-associated disease (CDAD) is primarily a nosocomial condition. Community-acquired disease has been reported but the incidence is felt to be low and the rate of disease resulting in hospitalization is reported as negligible. We recently experienced a 6-month outbreak of CDAD (January to June 1995): 139 patients were involved and four deaths were attributable to pseudomembranous colitis. Early in the outbreak period we were aware that many new admissions presented with C. difficile cytotoxin B positive diarrhoea: in some cases this was the sole reason for hospitalization. This observation forms the basis of this report.

Adult↗

PubMed2003

Molecular cloning, overexpression in Escherichia coli, and purification of 6x his-tagged C-terminal domain of Clostridium difficile toxins A and B.

Genomic DNA from ribotype-01 and -17 Clostridium difficile strains was used for amplification of the sequences encoding the carboxy-terminal domain of toxins A (TcdA) and B (TcdB). The deduced C-terminal TcdB ribotype-01 and -17 domains share 99.5% amino acid sequence identity while TcdA ribotype-17 comprises a 607 amino acid deletion compared to TcdA-01. When compared to previously sequenced C. difficile toxins, 99.3% amino acid identity was found between TcdA-01 and TcdA from strain VPI10643 and 98.8% identity between TcdA-17 and TcdA from strain F-1470. The obtained sequences were fused in 3' to a sequence encoding a hexahistidine tag and cloned into an Escherichia coli expression vector. The recombinant proteins were expressed in E. coli and purified using single-step metal-chelate chromatography. The recombinant carboxy-terminal domain of TcdA-01 was purified from the soluble E. coli lysate fraction whereas TcdA-17 and TcdB-17 carboxy-terminal domains were purified from inclusion bodies. At least 40 mg of each protein was purified per liter of bacterial culture. The recombinant toxin domains were detected specifically by Western blot and ELISA with antibodies against native C. difficile toxins. This study demonstrated that the carboxy-terminal domains of TcdA and TcdB can be produced using an E. coli expression system and easily purified. These recombinant, stable, and non-toxic proteins provide a convenient source for use in the diagnosis of C. difficile infections, instead of native toxins, as controls and calibrators in immunoassay kits and to obtain specific monoclonal antibodies.

Animals↗

PubMed2001

Evaluation of six commercial assays for the rapid detection of Clostridium difficile toxin and/or antigen in stool specimens.

OBJECTIVE: To evaluate six commercially available assays for the detection of Clostridium difficile toxin and/or antigen in stool samples: one latex agglutination test (Culturette brand CDT, Becton Dickinson), two ELISAs (Culturette brand Toxin CD, Becton Dickinson, and Ridascreen C. difficile Toxin A/B, R-biopharm), two chromatographic assays (Clearview C. difficile A, Oxoid, and ColorPac Toxin A, Becton Dickinson) and one enzyme immunoassay for the simultaneous detection of C. difficile common antigen and toxin A (Triage C. difficile Panel, Biosite). METHODS: Over a period of 3 months, 366 liquid or semi-liquid stool samples were tested using cell-culture cytotoxin assay as standard, ethanol shock stool culture and latex agglutination (Culturette brand CDT). Of these, 78 samples, positive with at least one of these three methods, and 98 randomly selected negative samples were further evaluated using the other five kits. PCR was also performed on positive cultures to confirm the presence of toxin A and B genes. RESULTS: Triage C. difficile Panel had the best sensitivity (95%), followed by Clearview C. difficile and ColorPac Toxin A (both 89%), Culturette brand Toxin CD (73%), Ridascreen C. difficile Toxin A/B (57%) and Culturette brand CDT (23%). For Triage, the sensitivity of C. difficile antigen detection was 93%, and the sensitivity of toxin detection was lower (77%). Most false-positive results were obtained with the Triage C. difficile Panel (25 specimens) and Clearview C. difficile A (20 specimens). Culturette brand CDT had the best specificity (99%); followed by Ridascreen C. difficile Toxin A/B (97%), Culturette brand Toxin CD (95%), ColorPac Toxin A (89%), Clearview C. difficile A (83%) and Triage C. difficile Panel (75%). The positive predictive values ranged from 68% to 94%, and the negative predictive values from 83% to 98%. CONCLUSIONS: The sensitivity is much higher for Triage and the two new chromatographic assays than for the conventional EIAs. These tests also have a high negative predictive value. For Triage, C. difficile antigen-positive, toxin A-negative results can be obtained; the clinical value of these must be established by additional studies. Overall, the new-generation assays are still less sensitive than the cytotoxin assay; however, they provided same-day results, could be used as a screening test and may be useful in laboratories without tissue-culture facilities. Our results do not allow the recommendation of one single assay for the diagnosis of C. difficile-associated diarrhea. It remains the case that laboratory results must be correlated and interpreted with the clinical presentation of the patient.

Antigens, Bacterial↗

PubMed2006

Ertapenem versus cefotetan prophylaxis in elective colorectal surgery.

BACKGROUND: Ertapenem, a long-acting carbapenem, may be an alternative to the recommended prophylactic antibiotic cefotetan. METHODS: In this randomized, double-blind trial, we assessed the efficacy and safety of antibiotic prophylaxis with ertapenem, as compared with cefotetan, in patients undergoing elective colorectal surgery. A successful outcome was defined as the absence of surgical-site infection, anastomotic leakage, or antibiotic use 4 weeks postoperatively. All adverse events were collected until 14 days after the administration of antibiotic prophylaxis. RESULTS: Of the 1002 patients randomly assigned to study groups, 901 (451 in the ertapenem group and 450 in the cefotetan group) qualified for the modified intention-to-treat analysis, and 672 (338 in the ertapenem group and 334 in the cefotetan group) were included in the per-protocol analysis. After adjustment for strata, in the modified intention-to-treat analysis, the rate of overall prophylactic failure was 40.2% in the ertapenem group and 50.9% in the cefotetan group (absolute difference, -10.7%; 95% confidence interval [CI], -17.1 to -4.2); in the per-protocol analysis, the failure rate was 28.0% in the ertapenem group and 42.8% in the cefotetan group (absolute difference, -14.8%; 95% CI, -21.9 to -7.5). Both analyses fulfilled statistical criteria for the superiority of ertapenem. In the modified intention-to-treat analysis, the most common reason for failure of prophylaxis in both groups was surgical-site infection: 17.1% in the ertapenem group and 26.2% in the cefotetan group (absolute difference, -9.1; 95% CI, -14.4 to -3.7). In the treated population, the overall incidence of Clostridium difficile infection was 1.7% in the ertapenem group and 0.6% in the cefotetan group (P=0.22). CONCLUSIONS: Ertapenem is more effective than cefotetan in the prevention of surgical-site infection in patients undergoing elective colorectal surgery but may be associated with an increase in C. difficile infection. (ClinicalTrials.gov number, NCT00090272 [ClinicalTrials.gov].).

Adult↗