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PubMed1997

Clostridium difficile-associated diarrhea in HIV-infected patients: epidemiology and risk factors.

A retrospective analysis of all the cases of Clostridium difficile-associated diarrhea (CDAD) in hospitalized patients infected with HIV was performed over a 52-month period to assess the incidence, epidemiology, and risk factors of CDAD. A case of CDAD was defined as a patient with diarrhea and a positive stool cytotoxin B assay. Sixty-seven cases of CDAD were recorded in HIV-infected patients between January 1991 and April 1995. The annual incidence of CDAD ranged from 1.7 to 6.4 per 100 HIV-infected patients discharged from hospital. The 67 CDAD cases included 48 (72%) first episodes and 19 (28%) relapses. Serogroup C accounted for 69% of strains from initial episodes of CDAD. To identify risk factors for CDAD, 34 HIV-infected patients with a first episode were compared with 66 HIV-infected controls matched for the length of hospital stay. Three independent factors remained significantly associated with CDAD among HIV-infected patients: CD4+ cell counts <50/mm3 (OR = 5.2; 95% CI = 1.4-19.3; p = 0.01), clindamycin use (OR = 5.0; 95% CI = 1.3-18.3; p = 0.02) and penicillin use (OR = 4.6; 95% CI = 1.1-18.8; p = 0.03). C. difficile is a common enteric pathogen responsible for nosocomial diarrhea in HIV-infected patients. Clinicians should keep this pathogen in mind when searching for the cause of diarrhea in these patients, especially those who are severely immunocompromised or have received clindamycin or penicillin.

Adult↗
PubMed1998

Clostridium difficile colitis associated with treatment of Helicobacter pylori infection.

Helicobacter pylori infection of the stomach is being detected and treated more often now than ever before. This is likely to result in an increase in complications such as antibiotic-associated diarrhea. However, there is no literature on the incidence of such diarrhea, particularly Clostridium difficile colitis, in patients treated for Helicobacter pylori infection. We report the case of a patient who developed Clostridium difficile colitis after treatment for Helicobacter pylori infection with metronidazole, amoxicillin, H2 blockers, and bismuth subsalicylate. This patient presented with severe diarrhea that responded to a course of metronidazole with rapid disappearance of symptoms. The incidence of Clostridium difficile colitis in patients treated for Helicobacter pylori infection has not been studied. This unique association, although not unexpected, has not yet been reported in the literature. The increasing number of patients being diagnosed and treated for this infection requires a heightened awareness on the part of physicians, to assure early diagnosis and treatment of this treatable, yet potentially dangerous, complication.

Aged↗
PubMed1998

Small GTP-binding proteins of the Rho- and Ras-subfamilies are not involved in the actin rearrangements induced by attaching and effacing Escherichia coli.

Attaching and effacing Escherichia coli (AEEC) are extracellular pathogens that induce the formation of actin-rich structures at their sites of attachment to eukaryotic host cells. We analysed whether small GTP-binding proteins of the Rho- and Ras-subfamilies, which control the cellular actin system, are essential for these bacterial-induced microfilament reorganizations. For this purpose we specifically inactivated them using the Clostridium difficile toxins TcdB-10463 and TcdB-1470. Such treatment led to a dramatic breakdown of the normal actin cytoskeleton, but did not abrogate the bacterial-induced actin rearrangements. Our data therefore indicate that the microfilament reorganizations induced by AEEC are independent of those small GTP-binding proteins that under normal conditions control the dynamics and maintenance of the actin cytoskeleton.

Actin Cytoskeleton↗
PubMed2000

[Role of the microbiology laboratory in the diagnosis of nosocomial diarrhea].

Diarrhea that occurs in hospitalized patients is frequent and may be due to infectious or noninfectious causes. In adults with nosocomial diarrhea, the most commonly detected agent is Clostridium difficile; in children, rotaviruses are predominant. Various studies have shown that bacterial enteric pathogens (e.g. Salmonella spp., Shigella spp., Campylobacter spp...) or parasites are common causes of community-acquired diarrhea but rarely cause nosocomial enteritis. Stool cultures for these pathogens and ova and parasite examination should not be performed in patients hospitalized for more than three days unless there are plausible clinical or epidemiological reasons to do so. In contrast, C. difficile toxins assay (and rotavirus screening in children) should be primarily requested. The detection of C. difficile toxin B by stool cytotoxicity assay remains the 'gold standard'. Identification of toxin A (or A + B) can also be performed by immuno-enzymatic (ELISA) tests: results may be obtained in three hours. Electronic microscopy is the standard method for rotavirus diagnosis but tests using latex agglutination or immuno-enzymatic assay are now available. Various typing methods have been developed and may be routinely used in epidemiological investigations.

Adult↗
PubMed1992

Antibiotic-associated colitis and cystic fibrosis.

The use of antibiotics in patients with cystic fibrosis is widespread, and fecal carriage of Clostridium difficile occurs in up to 50% of these patients; however, antibiotic-associated colitis appears to be a rare occurrence. The reasons why this is so remain unknown. A case of antibiotic-associated colitis occurring in a patient with cystic fibrosis is described. Possible mechanisms for the rarity of antibiotic-associated colitis are reviewed and implications for prompt diagnosis and therapy are discussed.

Adult↗
PubMed2003

Clostridium difficile in a geriatric unit: a prospective epidemiological study employing a novel S-layer typing method.

Clostridium difficile is the major identifiable cause of antibiotic-associated diarrhoea in the UK. The aim of this study was to employ traditional culture, toxin detection and a novel typing method to determine the level of C. difficile colonization and disease in a population of elderly patients and to investigate the association between strains in the patients and their environment. Three hundred and ninety patients between 62 and 101 years of age admitted to a geriatric unit in the Royal Victoria Hospital (RVH), Edinburgh, were investigated for the presence of C. difficile. C. difficile was cultured from 100 (26 %) patients using pre-reduced cycloserine-cefoxitin egg yolk agar, and toxin(s) was detected in the faeces of 34 of these patients using the Techlab ELISA test kit for the detection of C. difficile toxins A and/or B. Toxin(s) was detected in a further 18 patients from whom no C. difficile was detected in culture. Of the patients in whom C. difficile was detected, 49 % had diarrhoea, with the highest proportion of patients with diarrhoea being both culture- and toxin-positive for C. difficile. Environmental sampling of the patient environment yielded C. difficile from 14 % of samples. The organism was most frequently isolated from floors, sluice-rooms and toilet areas. The variation in the molecular mass of the C. difficile S-layer proteins was exploited as the basis of a novel typing method for C. difficile. Isolates from patients in the RVH were given a four-digit 'S-type' number based on their S-layer protein profile. A total of seven S-types were identified, with one type, toxigenic S-type 5236, accounting for 73 % of all clinical isolates and 91 % of environmental isolates.

Aged↗
PubMedDate not supplied

[The value of rectosigmoidoscopy and the bacteriologic culture of colon biopsies in the etiologic diagnosis of acute diarrhea of adults. A prospective study of 65 patients].

The goal of this study was to evaluate the contribution of sigmoidoscopy with bioptic microbiology to the etiologic diagnosis of acute diarrhea in adults. Patients and methods. Sixty-five patients with acute diarrhea were included prospectively from February 1993 to November 1994. Ages ranged from 17 to 83 years. In each patient, two stool samples were cultured and three examined for parasites. Clostridium difficile toxin was looked for in the 18 patients who had taken antimicrobials before onset of the diarrhea. Sigmoidoscopy with collection of biopsy specimens for bacteriologic cultures was performed routinely. Results. A pathogenic organism was identified in 35 patients (54%). Eighteen patients (28%) had positive stool cultures. Clostridium difficile toxin was detected in six patients. Colonic biopsy cultures were positive in 26 patients (40%). Endoscopic findings established the diagnosis of pseudomembranous colitis with negative tests for C. difficile toxin in two patients, diverticulitis in one, ischemic colitis in two, and cryptogenic colitis in seven. Conclusions. Sigmoidoscopy ensured the diagnosis in over 72% of cases of acute diarrhea. This investigation complements stool cultures and should be done routinely in adults with severe acute diarrhea.

Acute Disease↗
PubMed1991

Non-radioactive restriction fragment length polymorphism (RFLP) typing of Clostridium difficile.

A typing method for Clostridium difficile based on restriction fragment length polymorphisms (RFLP) is described. The technique utilizes commercially available Escherichia coli ribosomal ribonucleic acid (rRNA) as probe material. Probe labelling, hybridization and detection was performed using the Enhanced Chemiluminescence (ECL) gene detection system. The probe labelling procedure was easy to perform, taking only 20 min. The complete typing method was comparatively simple, reproducible and readily adaptable to most bacterial genera.

Australia↗
PubMed1998

Simultaneous outbreaks of two strains of toxigenic Clostridium difficile in a general hospital.

We report an outbreak of Clostridium difficile-associated disease (CDAD) in a large Dublin hospital. From January to June 1995, inclusive, 139 patients were affected; the mean age of cases was 68.8 +/- 19 years. Clinical information is available for 73 cases identified during the first four months of the outbreak. The majority of patients presented with abrupt onset of watery diarrhoea; however, 19.2% presented with an unexplained pyrexia following a course of antimicrobial therapy and 5.5% presented with a surgical acute abdomen. Twenty patients (27.4%) experienced relapsing disease and seven (9.6%) patients died. Seventy-six percent of cases received a cephalosporin prior to the onset of disease, the highest relative risks occurring with third-generation agents; however, 9.6% of patients affected had not been exposed to antimicrobial therapy in the preceding eight weeks. Pyrolysis mass spectrometry identified two clusters of isolates, representing two strains of C. difficile. There was marked spatial clustering of these strains, with each confined to a separate area of the hospital. Infection control measures and an antibiotic policy were introduced. Throughout the outbreak period the use of the most frequently used cephalosporin in the hospital increased; this was accompanied paradoxically by a reduction in the number of new cases of CDAD.

Aged↗
PubMed2003

Gut changes attributed to ageing: effects on intestinal microflora.

PURPOSE OF REVIEW: There is increased evidence of several impaired gastrointestinal functions with ageing. In the elderly, however, most gastrointestinal functions remain relatively intact because of the large reserve capacity of the intestine and the great secretion capacity of the pancreas. This review will focus on changes in gut microflora observed in the elderly and on the potential benefit of probiotics in this population. RECENT FINDINGS: Recent studies suggest that age affects the intestinal microflora with a decrease in anaerobes and bifidobacteria population and an increase in enterobacteria. These changes and the reduced intestinal immunity of the aged may favour gastrointestinal infections that are frequent in the elderly. Clostridium difficile-associated diarrhoea, one of the most common nosocomial infections in the elderly, has a profound effect on morbidity, mortality and health costs. Probiotics may have interesting positive effects on intestinal function, and the efficacy of treatment with Lactobacilli and Saccharomyces boulardii in Clostridium difficile-associated diarrhoea has been well established in a recent meta-analysis. Studies performed in healthy elderly patients suggest that diet supplementation with probiotics may reduce the impaired immunity associated with ageing. SUMMARY: Important changes in intestinal microflora of the elderly have recently been demonstrated and may have important clinical consequences. Further studies should be conducted to determine if the consumption of probiotics is associated with a lower infection rate and a higher effectiveness of vaccines.

Aged↗
PubMed2002

Development and evaluation of a PCR method for detection of the Clostridium difficile toxin B gene in stool specimens.

A PCR assay detecting Clostridium difficile toxin B gene in stool specimens was compared to the cytotoxicity assay as the reference standard for the diagnosis of C. difficile antibiotic-associated diarrhea (CDAD). Overall, 118 stool samples were tested. All of the specimens that were negative by the cytotoxicity assay (59 out of 118) were also negative by the PCR method (specificity of 100%). Of the 59 cytotoxin-positive samples, 54 were PCR positive (sensitivity of 91.5%). This PCR method is promising for rapid diagnosis of CDAD.

Animals↗
PubMed2004

Multilocus sequence typing analysis of human and animal Clostridium difficile isolates of various toxigenic types.

A multilocus sequence typing (MLST) scheme was developed to study the genetic relationships and population structure of 72 Clostridium difficile isolates from various hosts, geographic sources, PCR ribotypes, and toxigenic types (determined by PCR targeting tcdA and tcdB genes). MLST was performed by DNA sequence analysis of seven housekeeping genes (aroE, ddl, dutA, tpi, recA, gmk, and sodA). The number of alleles ranged from five (dutA and ddl) to eleven (recA). Allelic profiles allowed the definition of 34 different sequence types (STs). These STs lacked correlation with geographic source but were well correlated to toxigenic type. The dendrogram generated from a matrix of pairwise genetic distances showed that animal isolates did not constitute a distinct lineage from human isolates and that there was no hypervirulent lineage within the population of toxigenic human isolates (isolates recovered from pseudomembranous colitis and antibiotic-associated diarrhea did not cluster in distinct lineages). However, A(-) B(+) variant isolates shared the same ST that appeared as a divergent lineage in the population studied, indicating a single evolutionary origin. The population structure was further examined by analysis of allelic polymorphism. The dendrogram generated from composite sequence-based analysis revealed a homogeneous population associated with three divergent lineages, one of which was restricted to A(-) B(+) variant isolates. C. difficile exhibited a clonal population structure, as revealed by the estimation of linkage disequilibrium (Ia) between loci. The analysis of alleles within clonal complexes estimated that point mutation generated new alleles at a frequency eightfold higher than recombinational exchange, and the congruence of the dendrograms generated from separate housekeeping loci confirmed the mutational evolution of this species.

Alleles↗
PubMed2004

Molecular epidemiology of hospital-associated and community-acquired Clostridium difficile infection in a Swedish county.

All episodes of Clostridium difficile associated diarrhea (CDAD) diagnosed in a defined population of 274,000 including one tertiary and two primary hospitals and their catchment areas were studied during 12 months. The annual CDAD incidence in the county was 97 primary episodes per 100,000, and 78% of all episodes were classified as hospital associated with a mean incidence of 5.3 (range, 1.4 to 6.5) primary episodes per 1,000 admissions. The incidence among hospitalized individuals was 1,300-fold higher than that in the community (33,700 versus 25 primary episodes per 100,000 persons per year), reflecting a 37-fold difference in antibiotic consumption (477 versus 13 defined daily doses [DDD]/1,000 persons/day) and other risk factors. Three tertiary hospital wards with the highest incidence (13 to 36 per 1,000) had CDAD patients of high age (median age of 80 years versus 70 years for other wards, P < 0.001), long hospital stay (up to 25 days versus 4 days), or a high antibiotic consumption rate (up to 2,427 versus 421 DDD/1,000 bed days). PCR ribotyping of C. difficile isolates available from 330 of 372 CDAD episodes indicated nosocomial acquisition of the strain in 17 to 27% of hospital-associated cases, depending on the time interval between index and secondary cases allowed (2 months or up to 12 months), and only 10% of recurrences were due to a new strain of C. difficile (apparent reinfection). In other words, most primary and recurring episodes were apparently caused by the patient's endogenous strain rather than by one of hospital origin. Typing also indicated that a majority of C. difficile strains belonged to international serotypes, and the distribution of types was similar within and outside hospitals and in primary and relapsing CDAD. However, type SE17 was an exception, comprising 22% of hospital isolates compared to 6% of community isolates (P = 0.008) and causing many minor clusters and a silent nosocomial outbreak including 36 to 44% of the CDAD episodes in the three high-incidence wards.

Clostridioides difficile↗
PubMed1996

Clostridium difficile contamination of blood pressure cuffs: a call for a closer look at gloving practices in the era of universal precautions.

We report an outbreak of Clostridium difficile-associated diarrhea at our medical center following adoption of Universal Precautions. Environmental cultures revealed unexpected contamination of blood pressure cuffs at a rate similar to that for bedside commodes (10% and 11.5%, respectively). An observational survey revealed that healthcare workers in the patient care areas not infrequently failed to remove their potentially stool-contaminated gloves prior to touching clean surfaces, which might have contributed to contamination of blood pressure cuffs.

Blood Pressure Determination↗
PubMed2000

Clostridium difficile toxin: cytoskeletal changes and lactate dehydrogenase release in hepatocytes.

BACKGROUND: We have found that Clostridium difficile toxins can evoke hepatocyte acute-phase protein synthesis, and that this effect is dependent on a functioning interleukin-1 (IL-1) receptor. The present study was undertaken to determine if C. difficile toxicity, as determined by actin rearrangement and lactate dehydrogenase (LDH) release, also requires a functioning IL-1 receptor. METHODS: Primary hepatocyte cultures were prepared from normal mice, knockout mice deficient in the IL-1-converting enzyme (ICE), and knockout mice deficient in the IL-1 p80 receptor. Hepatocytes were treated for 24 h with C. difficile culture extract, purified C. difficile toxin A, or purified C. difficile toxin B. The actin cytoskeleton was examined using confocal microscopy, and LDH release was measured by spectrophotometric analysis. RESULTS: C. difficile culture extract, toxin A, and toxin B induced collapse of the actin cytoskeleton in hepatocytes from normal mice. Hepatocytes from both the ICE-deficient mice and the IL-1 p80 receptor-deficient mice demonstrated similar responses to both toxins. These toxins also induced significant LDH release in a concentration-dependent fashion in the normal hepatocytes and the ICE-deficient hepatocytes. However, no significant increase in LDH release was observed in hepatocytes from IL-1 p80 receptor-deficient mice. CONCLUSIONS: C. difficile toxins induce actin cytoskeletal collapse independent of IL-1 or the IL-1 receptor. In contrast, toxin-stimulated LDH release was dependent on the presence of the IL-1 receptor. Thus, separate pathways appear to mediate toxic effects as manifested by actin rearrangement and LDH release.

Actins↗
PubMed2005

Genomics of clostridial pathogens: implication of extrachromosomal elements in pathogenicity.

The recently decoded genomes of the major clostridial toxin-producing pathogens Clostridium perfringens, Clostridium tetani, Clostridium botulinum and Clostridium difficile have provided a huge amount of new sequence data. Recent studies have focused on the identification and investigation of pathogenic determinants and the regulatory events governing their expression. The sequence data revealed also the genomic background of virulence genes, as well as the contribution of extrachromosomal elements to a pathogenic phenotype. This has generated new insights in clostridial pathogenesis - and will continue to do so in the future - and has deepened our understanding of the anaerobic lifestyle of clostridial species.

Clostridioides difficile↗
PubMed2001

Bacterial protein toxins inhibiting low-molecular-mass GTP-binding proteins.

The Rho GTPases, which belong to the Ras superfamily of low-molecular-mass GTP-binding proteins, are the preferred intracellular targets of bacterial protein toxins. The Rho GTPases RhoA/B/C, Rac1/2 and Cdc42 are the master regulators of the actin cytoskeleton. Clostridium difficile toxins A and B, the causative agents of the antibiotic-associated pseudomembranous colitis, are intracellularly acting cytotoxins which mono-glucosylate the Rho GTPases. Clostridium botulinum C3 toxin, which is not related to the clostridial neurotoxins, catalyses ADP-ribosylation of RhoA/B/C but not of other Rho GTPases. Glucosylation as well as ADP-ribosylation result in functional inactivation of Rho causing disassembly of the actin cytoskeleton.

Animals↗
PubMed1991

Risk factors for Clostridium difficile cytotoxin-positive diarrhea after control for horizontal transmission.

OBJECTIVE: This study identifies risk factors that predispose hospitalized patients to diarrhea caused by Clostridium difficile. DESIGN: Unlike most previous studies, this case-control study accounts for horizontal (person-to-person) transmission of this infectious organism by matching on location. SETTING: An urban community hospital of 600 beds with both primary care and referred patients. PATIENTS: Both the 36 cases and the 36 controls came from billing printouts for C difficile cytotoxin assays. Exclusion criteria included out-patient specimens and stays of 38 days or more. Controls had negative assays and were individually matched on the basis of the floor and by the general date of specimen collection. RESULTS: Cases had a longer mean duration of antibiotic use (6.7 versus 4.1 days, p = .006). Of the other 22 factors that were evaluated for their risk of predisposing to C difficile, only clindamycin (OR = 3.50, p = .09) and third-generation cephalosporins (OR = 3.00, p = .04) showed any association. The odds ratio for third-generation cephalosporins in the absence of clindamycin was 3.50 (p = .09). Data were collected by physicians who were not blinded. CONCLUSIONS: This study found that the clindamycin and third-generation cephalosporins were risk factors for C difficile-associated diarrhea after controlling for horizontal transmission. First-generation cephalosporins were not risk factors (OR = 0.86), while sample size considerations prevented firm conclusions about second-generation cephalosporins (OR = 1.67, p = .23). Many of the previously alleged risk factors might be explained by the horizontal transmission of an infectious disease; for instance, this seems a better explanation for an outbreak on a surgery ward than does surgery itself.

Bacterial Proteins↗