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PubMed1994

Typing of Clostridium difficile by polymerase chain reaction with an arbitrary primer.

We assessed the use of the polymerase chain reactions (PCR) with an arbitrary primer (AP-PCR) to investigate a major hospital outbreak of diarrhoea due to Clostridium difficile. A single pattern consisting of three bands of 240, 580 and 1100 bp was obtained from all isolates studied. AP-PCR is a simple, rapid technique which should find increased application in the rapid investigation of suspected outbreaks of many different bacterial species, particularly new pathogens or those for which no accepted typing scheme exists.

Bacterial Typing Techniques↗
PubMed2000

Treatment and prevention of antibiotic associated diarrhea.

Mild or severe episodes of antibiotic-associated diarrhea (AAD) are common side effects of antibiotic therapy. The incidence of AAD differs with the antibiotic and varies from 5 to 25%. The major form of intestinal disorders is the pseudomembranous colitis associated with Clostridium difficile which occurs in 10-20% of all AAD. In most cases of AAD discontinuation or replacement of the inciting antibiotic by another drug with lower AAD risk can be effective. For more severe cases involving C. difficile, the treatment of diarrhea requires an antibiotic treatment, with glycopeptides (vancomycin) or metronidazole. Another approach to AAD treatment or prevention is based on the use of non-pathogenic living organisms, capable of re-establishing the equilibrium of the intestinal ecosystem. Several organisms have been used in treatment or prophylaxis of AAD such as selected strains of Lactobacillus acidophilus, L. bulgaricus, Bifidobacterium longum, and Enterococcus faecium. Another biotherapeutic agent, a non-pathogenic yeast, Saccharomyces boulardii has been used. In animal models of C. difficile colitis initiated by clindamycin, animals treated with S. boulardii (at end of vancomycin therapy) had a significant decrease in C. difficile colony-forming units, and of toxin B production. In several clinical randomised trials (versus placebo), S. boulardii has demonstrated its effectiveness by decreasing significantly the occurrence of C. difficile colitis and preventing the pathogenic effects of toxins A and B of C. difficile. It has been shown to be a safe and effective therapy in relapses of C. difficile colitis. A good response has been seen in children with AAD, treated by S. boulardii only. In ICUs prevention of AAD remains based on limitation of antibiotic overuse and spread of C. difficile or other agents of AAD should be prevented by improved hygiene measures (single rooms, private bathrooms for patients, use of gloves and hand washing for personnel). In addition the increasing use of biotherapeutic agents such as S. boulardii should permit the prevention of the major side effect of antibiotics, i.e. AAD in at risk patients.

Anti-Bacterial Agents↗
PubMed2000

Fusidic acid disk diffusion testing of clostridium difficile can be calibrated using single-strain regression analysis.

Single-strain regression analysis (SRA) was employed to calibrate the disk diffusion antibiotic susceptibility test for fusidic acid and Clostridium difficile. MIC determinations of 40 clinical isolates of C. difficile were performed with the E-test. The disk diffusion test was standardized according to the Swedish Reference Group for Antibiotics (SRGA). Disks used for SRA contained 1.5, 5, 15, 50 and 150 microg fusidic acid and the routine disk contained 50 microg fusidic acid. A control strain, ATCC 9689, was also tested. SRA constants A and B of the regression lines were calculated. This permitted the determination of zone breakpoints for C. difficile. When applying the pharmacological MIC S and R limits set by SRGA to the E-test results I strain of C. difficile was interpreted as resistant. Zone breakpoints corresponding to the pharmacological MIC limits and calculated using the mean SRA constants for the 40 clinical isolates lead to all strains being interpreted as susceptible. SRA calculations enable laboratories to set up calibrated disk tests with species-related and laboratory-specific interpretations.

Anti-Bacterial Agents↗
PubMed1994

Case report: transverse colon volvulus in a patient with Clostridium difficile pseudomembranous colitis.

Sixty-eight cases of transverse colon volvulus have been reported in the literature. The authors report the first case of transverse colon volvulus in association with Clostridium difficile pseudomembranous colitis, with a review of the available literature. It is possible that the acute inflammation of the colonic mucosa, which occurred from the pseudomembranous colitis in this patient, contributed to the development of volvulus. Further studies are needed to explore the role of mucosal inflammation in the occurrence of volvulus.

Clostridioides difficile↗
PubMed1993

Clostridium difficile diarrhea in patients with AIDS versus non-AIDS controls. Methods of treatment and clinical response to treatment.

We reviewed the hospital charts of 17 patients with AIDS and Clostridium difficile diarrhea to determine antibiotic use before C. difficile infection, methods of treatment for C. difficile diarrhea, and response of diarrhea to treatment. Left shift and total white blood cell count before and after treatment for C. difficile were also determined. Non-HIV-infected patients with C. difficile diarrhea served as controls. In the patients with AIDS, resolution of diarrhea was noted in 15 (88%) patients. In 25 (76%) control patients, diarrhea resolved with treatment. The patients with AIDS also had a significant decrease (p < 0.05) in left shift in white blood cell count with treatment; the controls did not. Our study therefore suggests that C. difficile diarrhea is at least as likely to resolve with antibiotic therapy in patients with AIDS as it is in those with the non-AIDS-related disorder. We also found that patients with AIDS and C. difficile diarrhea are more likely than patients without AIDS to have a decreased left shift in white blood cell count after antibiotic therapy.

AIDS-Related Opportunistic Infections↗
PubMed2002

In vitro activity of linezolid against Clostridium difficile.

We examined the in vitro activity of linezolid against Clostridium difficile, including isolates with reduced susceptibility to metronidazole or vancomycin. The MIC at which 50% of the isolates were inhibited (MIC50) and MIC90 were 0.5 and 2 microg/ml, respectively (range, 0.03 to 4 microg/ml). MICs were always <or= 4 microg/ml, and thus, all isolates were considered susceptible.

Acetamides↗
PubMed1993

Nutritional aspects of cytotoxin production by Clostridium difficile.

Arginine was the only amino acid used by Clostridium difficile that permitted cytotoxin synthesis in a peptone-based medium. Synthesis of cytotoxin was delayed when glucose was used as the substrate. Addition of rifampin or puromycin to cultures prior to release of cytotoxin inhibited the release of cytotoxin, suggesting that a protein essential for cytotoxin release is synthesized after cytotoxin is synthesized.

Arginine↗
PubMedDate not supplied

A staff nurse's perspective of infection control problems.

Earlier this month astonishing figures causing major concern were released from the Department of Health (DoH) showing the number of cases of Clostridium difficile in the over 65s in hospitals in England. This article focuses upon what is already known about infection control and concludes that a greater collaborative approach to infection control is needed, with a prudent use of broad spectrum antibiotics and a greater use of precautionary isolation measures based on patient symptoms, if infection rates are to fall.

Anti-Bacterial Agents↗
PubMed2005

Screening of yeasts as probiotic based on capacities to colonize the gastrointestinal tract and to protect against enteropathogen challenge in mice.

Probiotics are defined as viable microorganisms that exhibit a beneficial effect on the host's health when they are ingested. Two important criteria are used for selection of probiotic microorganisms: they must be able to survive in the gastrointestinal environment and to present at least one beneficial function (colonization resistance, immunomodulation or nutritional contribution). Generally, in vitro assays demonstrating these properties were used to select probiotics but it is unclear if the data can be extrapolated to in vivo conditions. In the present work, twelve Saccharomyces cerevisiae strains isolated from different environments (insect association, tropical fruit, cheese and "aguardente" production) and pre-selected for in vitro resistance to simulated gastrointestinal conditions were inoculated in germ-free mice to evaluate their real capacity to colonize the mammal digestive tract. Using these data, one of the yeasts (S. cerevisiae 905) was selected and tested in gnotobiotic (GN) and conventional (CV) mice for its capacity to protect against oral challenge with two enteropathogenic bacteria (Salmonella Typhimurium and Clostridium difficile). The yeast reached populational levels potentially functional in the gastrointestinal portions where the enteropathogens tested act. No antagonism against either pathogenic bacterium by the yeast was observed in the digestive tract of GN mice but, after challenge with S. Typhimurium, mortality was lower and liver tissue was better preserved in CV animals treated with the yeast when compared with a control group (p<0.05). Histopathological results of intestines showed that the yeast also presented a good protective effect against oral challenge with C. difficile in GN mice (p<0.05). In conclusion, among the 12 S. cerevisiae tested, strain 905 showed the best characteristics to be used as a probiotic as demonstrated by survival capacity in the gastrointestinal tract and protective effect of animals during experimental infections.

Animals↗
PubMed2002

Clostridium difficile-associated diarrhea and chronic renal insufficiency.

BACKGROUND: Clostridium difficile-associated diarrhea (CDAD) is a common cause of mortality and morbidity in hospitalized patients. Some case reports have implicated renal failure as a risk factor for CDAD. The aim of this study was to assess whether chronic renal insufficiency is a risk factor for CDAD and whether it increases mortality and morbidity. METHOD: We reviewed charts of 385 patients with diarrhea for CDAD, chronic renal insufficiency, mortality, and recurrence of CDAD. RESULTS: Seventy-seven patients had infection due to C difficile. There was no difference in the chronic renal insufficiency, mortality, and other comorbid conditions between patients who had C difficile infection and those who did not. The patients with CDAD and chronic renal insufficiency had significantly higher mortality and recurrence of CDAD than patients without chronic renal insufficiency. CONCLUSIONS: Chronic renal insufficiency is not a risk factor for CDAD, but its presence with CDAD increases mortality and recurrence of CDAD.

Clostridioides difficile↗
PubMedDate not supplied

A hospital outbreak of diarrhea due to an emerging epidemic strain of Clostridium difficile.

BACKGROUND: Increased Clostridium difficile-associated disease (CDAD) in a hospital and an affiliated long-term care facility continued despite infection control measures. We investigated this outbreak to determine risk factors and transmission settings. METHODS: The CDAD cases were compared according to where the disease was likely acquired based on health care exposure and characterization of isolates from case patients, asymptomatic carriers, and the environment. Antimicrobial susceptibility testing, strain typing using pulsed-field gel electrophoresis, and toxinotyping were performed, and toxins A and B, binary toxin, and deletions in the tcdC gene were detected using polymerase chain reaction. Risk factors were examined in a case-control study, and overall antimicrobial use was compared at the hospital before and during the outbreak. RESULTS: Significant increases were observed in hospital-acquired (0.19 vs 0.86; P < .001) and long-term care facility-acquired (0.04 vs 0.31; P = .004) CDAD cases per 100 admissions as a result of transmission of a toxinotype III strain at the hospital and a toxinotype 0 strain at the long-term care facility. The toxinotype III strain was positive for binary toxin, an 18-base pair deletion in tcdC, and increased resistance to fluoroquinolones. Independent risk factors for CDAD included use of fluoroquinolones (odds ratio [OR], 3.22; P = .04), cephalosporins (OR, 5.19; P = .006), and proton pump inhibitors (OR, 5.02; P = .02). A significant increase in fluoroquinolone use at the hospital took place during the outbreak (185.5 defined daily doses per 1000 patient-days vs 200.9 defined daily doses per 1000 patient-days; P < .001). CONCLUSIONS: The hospital outbreak of CDAD was caused by transmission of a more virulent, fluoroquinolone-resistant strain of C difficile. More selective fluoroquinolone and proton pump inhibitor use may be important in controlling and preventing such outbreaks.

Adult↗
PubMed2001

Pancytopenia and colitis with Clostridium difficile in a rheumatoid arthritis patient taking methotrexate, antibiotics and non-steroidal anti-inflammatory drugs.

Methotrexate (MTX) is widely used despite its side-effects. We describe a rheumatoid arthritis (RA) patient taking low-dose MTX who developed severe pancytopenia and colitis with Clostridium difficile after the administration of antibiotics for acute pyelonephritis. Our case suggests that low-dose MTX may seriously interact with antibiotics and that these side-effects should always be considered when RA patients are treated with MTX and antibiotics.

Aged↗
PubMed2005

Specific risk factors for Clostridium difficile-associated diarrhea: a prospective, multicenter, case control evaluation.

BACKGROUND: Clostridium difficile is a toxin-producing bacterium that is responsible for toxicity to the colonic mucosa, causing inflammation, necrosis, and, in some extreme cases, intestinal dilation and perforation. C difficile-associated diarrhea (CDAD) occurs when patients have a reduction in their natural gastrointestinal flora that allows for the proliferation of and toxin production by C difficile. METHODS: Using a multicenter, prospective observational case control study, we assessed and quantified risk factors associated with the development of diarrhea caused by Clostridium difficile, with particular attention to antibiotic use. All hospitalized patients with diarrhea requiring a C difficile toxin test as part of their routine clinical workup were considered for study inclusion. Patients with a negative specimen (controls) were considered for enrollment if matched (by age, sex, length of stay, and institution) to a case. Variables associated with CDAD were identified using univariate analysis. Significant factors were then entered into multivariate logistic regression analysis to identify independent factors. RESULTS: There were no significant differences in antibiotic use between cases and controls. Patient severity, classified by Horn's Index, was significantly different between cases and controls (P = .0022). No other significant variables were identified. CONCLUSION: The severity of illness of the cases was classified as more severe than the controls, but no significant differences in antibiotic use were identified between the groups. The negative C difficile toxin studies on the well-matched control patients indicate a different etiology of diarrhea (such as antibiotic-associated diarrhea), which may have developed in the presence of similar antibiotic use as the cases.

Adolescent↗
PubMed2004

Clostridium difficile diarrhea: infection control in horses.

C difficile has emerged as an important cause of diarrheic disease in horses. C difficile diarrhea is usually diagnosed in mature horses, mostly when they are treated with antimicrobials and hospitalized. It is important for clinicians at veterinary hospitals to have knowledge about the organism and the infection. To prevent C difficile diarrhea, judicious use of antimicrobials is important, as is minimizing different stress factors at the animal hospital or clinic. Infected horses must be isolated. Routine examination for C difficile and toxin A or B is recommended in horses with antibiotic-associated diarrhea. When treating foals for R equi pneumonia, it is important to avoid accidental ingestion of erythromycin by the dams. To reduce the number of environmental spores, thorough cleaning and surface disinfection of the animal hospital and clinic are important. Routine handwashing should be performed by all staff.

Animals↗
PubMed1997

Effects of epidermal growth factor and Clostridium difficile toxin B in a model of mucosal injury.

Numerous factors have been advocated as being paramount to the development of necrotizing enterocolitis (NEC) including hypoxia, abnormal bacterial flora, and by products of enteral feedings. In an effort to better understand mechanisms involved at the level of the intestinal mucosal barrier the authors have chosen the CACO-2 cell line to model the neonatal intestinal epithelium. By growing CACO-2 cells in transwell inserts, the authors have investigated the ability of Clostridium difficile toxin B, epidermal growth factor (EGF), and a model of mechanical injury to alter transepithelial resistance of CACO-2 monolayers. The findings show that toxin B diminishes resistance in this setting, and EGF can alter that resistance drop.

Analysis of Variance↗
PubMed2003

[Nosocomial diarrhea outbreak due to Clostridium difficile in a vascular surgery department].

INTRODUCTION: Clostridium difficile is considered the most common cause of nosocomial-acquired diarrhea. In Spain this condition is rarely reported. METHODS: Over a five-month period, 35 episodes of C. difficile diarrhea were diagnosed by toxin A detection in stool samples. Case-control studies were designed to assess risk factors for the outbreak. Twelve cases from the vascular surgery department were compared with 24 randomized controls, patients admitted to the same ward during this period, but without diarrhea. Statistical comparisons (SPSS software) were performed with the Student's t and X2 tests (OR with 95% CI). RESULTS: Overall incidence was 3.42 episodes: 48 episodes/1000 admissions to vascular surgery. Among the total, 80% had received antibiotics before admission and the mean number of antibiotics administered was 2.91 per patient. Comparative analyses disclosed that the cases had received a larger number of antibiotics during hospitalization (p 5 0.000) and in the two months before admission (p 5 0.031) than the controls. Clindamycin administered alone (p 5 0.001) or associated with aztreonam (p 0.000) were the most frequently used antibiotic treatments. CONCLUSIONS: C. difficile diarrhea is common in our setting. Diagnosis requires a high index of suspicion. We attribute the nosocomial outbreak in our vascular surgery department to broad-spectrum antibiotic use (clindamycin and aztreonam). Surveillance, together with restriction of antibiotic use was effective for control.

Aged↗
PubMed2001

Molecular characterization of the surface layer proteins from Clostridium difficile.

Many bacteria express a surface-exposed proteinaceous layer, termed the S-layer, which forms a regular two-dimensional array visible by electron microscopy. Clostridium difficile is unusual in expressing two S-layer proteins (SLPs), which are of varying size in a number of strains. In an approach combining molecular biology with mass spectrometric sequencing strategies, we have identified the structural gene (slpA) for the S-layer from three strains of C. difficile. Both proteins are derived from a common precursor, and processing involves the removal of a signal peptide and a second cleavage to release the two mature SLPs. To our knowledge, this is the first example in which two SLPs have been shown to derive from a single gene product through post-translational processing, rather than from the expression of separate genes. The higher molecular weight (MW) SLP is highly conserved among the three strains, whereas the lower MW SLP shows considerable sequence diversity, reflecting the results from Western blotting. The high-MW SLP shows weak homology to N-acetyl muramoyl-L-alanine amidase from Bacillus subtilis, and both the native SLP from C. difficile and a recombinant protein expressed in Escherichia coli were found to display amidase activity by zymography. The high-MW SLPs showed evidence of glycosylation, whereas the lower MW proteins did not. A family of genes with sequence homology to the amidase domain of the high-MW SLP was identified in the C. difficile strain 630 genome, some of which are located in the same region of the genome as slpA and were shown by reverse transcription-polymerase chain reaction (RT-PCR) analysis to be transcribed.

Amidohydrolases↗
PubMed2001

Health care costs and mortality associated with nosocomial diarrhea due to Clostridium difficile.

A total of 271 patients were prospectively followed up to determine whether patients whose hospital stay is complicated by diarrhea due to Clostridium difficile experience differences in cost and length of stay and survival rates when compared with patients whose stay is not complicated by C. difficile-associated diarrhea. Forty patients (15%) developed nosocomial C. difficile-associated diarrhea. These patients incurred adjusted hospital costs of $3669--that is, 54% (95% confidence interval [CI], 17%-103%)--higher than patients whose course was not complicated by C. difficile-associated diarrhea. The extra length of stay attributable to C. difficile-associated diarrhea was 3.6 days (95% CI, 1.5-6.2). C. difficile-associated diarrhea was not associated with excess 3-month or 1-year mortality after adjustment for age, comorbidity, and disease severity. On the basis of the findings of this study, a conservative estimate of the cost of this disease in the United States exceeds $1.1 billion per year.

Adult↗