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PubMed2001

Laboratory diagnosis of Clostridium difficile-associated diarrhea and colitis: usefulness of Premier Cytoclone A+B enzyme immunoassay for combined detection of stool toxins and toxigenic C. difficile strains.

Detection of Clostridium difficile toxins A and B in stools by Premier Cytoclone A+B enzyme immunoassay (EIA) was compared with detection by stool culture for C. difficile followed by detection of toxigenic isolates using the same EIA. Chart reviews were performed to evaluate the likelihood of C. difficile-associated diarrhea and colitis (CADC) for all patients with at least one positive toxin assay. While the toxins were detected in 58 of 85 consecutive CADC patients by both assays, CADC in 5 patients was detected only by stool toxin assay, and in 22 patients CADC was detected only by toxigenic culture. Our results suggest that for laboratories using a rapid toxin A+B EIA, direct toxin detection in stools should be combined with toxigenic culture in cases in which there is a negative stool toxin assay.

Bacterial Proteins↗
PubMed1997

IL-2 signaling controls actin organization through Rho-like protein family, phosphatidylinositol 3-kinase, and protein kinase C-zeta.

IL-2 and IL-4 induce proliferation of TS1 alpha beta cells. Activation of the zeta isoform of protein kinase C is an important step in IL-2-, but not IL-4-mediated proliferation. In addition, protein kinase C-zeta is implicated in IL-2-mediated actin organization. Given the established involvement of the Rho family of small guanine nucleotide-binding proteins in organization of actin structures, we analyze the possible relationships between Rho and protein kinase C-zeta. Using the Rho-like protein family-specific toxin B from Clostridium difficile, we report in this work that IL-2, but not IL-4, induces a Rho-dependent activation of protein kinase C-zeta. This signaling event is mediated by the activation of phosphatidylinositol 3-kinase. In contrast, IL-4 induces a Rho-independent, phosphatidylinositol 3-kinase-mediated activation of protein kinase C-zeta, but this pathway has no implications in cytoskeleton organization.

Actins↗
PubMed2006

The comparative pathology of Clostridium difficile-associated disease.

Clostridium difficile is a confirmed pathogen in a wide variety of mammals, but the incidence of disease varies greatly in relation to host species, age, environmental density of spores, administration of antibiotics, and possibly, other factors. Lesions vary as well, in severity and distribution within individuals, and in some instances, age groups, of a given species. The cecum and colon are principally affected in most species, but foals and rabbits develop severe jejunal lesions. Explanations for variable susceptibility of species, and age groups within a species, are largely speculative. Differences in colonization rates and toxin-receptor densities have been proposed. Clostridium difficile-associated disease is most commonly diagnosed in Syrian hamsters, horses, and neonatal pigs, but it is reported sporadically in many other species. The essential virulence factors of C. difficile are large exotoxins, toxin A (TcdA) and toxin B (TcdB). Receptor-mediated endocytosis of the toxins is followed by endosomal acidification, a necessary step for conversion of the toxin to its active form in the cytosol. Cell-surface receptors have been characterized for TcdA, but remain to be identified for TcdB. Both TcdA and TcdB disrupt the actin cytoskeleton by disrupting Rho-subtype, intracellular signaling molecules. Disruption of the actin cytoskeleton is catastrophic for cellular function, but inflammation and neurogenic stimuli are also involved in the pathogenesis of the disease.

Animal Diseases↗
PubMed1999

["Second look" at cytotoxin B of Clostridium difficile in the course of diarrhea associated with antibiotic therapy].

UNLABELLED: Clostridium difficile is a sporulated obligate anaerobe responsible for most cases of antibiotic-associated colitis, for 15 to 25% of cases of antibiotic-related diarrhea, and for a substantial proportion of nosocomial infections. The most important laboratory test for the diagnosis of C. difficile infection is examination of the stool for C. difficile toxins A and/or B. Detection of cytotoxin B using the direct cytotoxicity assay (D-CA) is the gold standard test. Whether routine isolation of the organism from stool is warranted remains controversial. OBJECTIVES: To evaluate second-look CA done on C. difficile culture-positive filtrates from stool samples negative by the D-CA. METHODS: 300 consecutive stool samples sent to the Alfred Fournier Institute from April through October 1998 for a CA were routinely cultured on modified Cefoxitin Cycloserine Fructose Agar medium (CCFA). All CA-negative samples that grew C. difficile were examined by second-look CA. RESULTS: 245 stool specimens (81.7%) were negative by both CA and culture. The remaining 55 specimens all yielded C. difficile by culture; 32 (58.2%) had a positive D-CA and nine (16.4%) a negative D-CA with a positive second-look CA done on culture filtrates. CONCLUSION: Our data suggest that stool specimens sent for a direct CA should be routinely cultured to provide material for a second-look CA on culture-positive filtrates if the first CA prove negative. Culturing also allows to study antimicrobial drug resistance phenotypes and epidemiological markers.

Adolescent↗
PubMed1991

[The diagnosis and treatment of Clostridium difficile enterocolitis].

Sixteen strains of Clostridium difficile (C.d) were isolated from 29 patients with antibiotic-associated diarrhoea (AAD). 9 of 14 C.d positive and 1 of 6 C.d negative fecal specimens were detected as cytotoxin positive. 10 AAC patients received colonoscopy and 6 had congestion, edema and erosion of mucosa. Three had yellow-white pseudomembrane on the surface of colon. In 17 Clostridium difficile enterocolitis (CDEC) was diagnosed by C.d isolation, cytotoxin detection and (or) colonoscopic finding. All the 17 patients received antibiotics before diarrhoea. The risk antibiotics were gentamycin, ampicillin and cephalosporin. Of 17 CDEC, 4 were cured when the complicated antibiotics were discontinued. 7 received vancomycin therapy. 6 cured but 1 had once symptomatic recurrence and C.d re-appearance. 4 were cured by metronidazole. 2 patients died of CDEC and respiratory failure prospectively before diagnosis. Eleven fecal specimens of CDEC were analysed for intestinal microflora. The results showed that E. coli and Bifidobacteria in CDEC patients were significantly lower.

Adult↗
PubMed1997

Clostridium difficile infection: pathophysiology and diagnosis.

Clostridium difficile is a relatively common enteric pathogen encountered most frequently in association with antibiotic use and as a nosocomial pathogen. Four factors dictate clinical expression: (1) acquisition of the organism from environmental sources or previous colonization; (2) distortion of the competing colonic flora by antibiotics; (3) toxin production; and (4) age-related susceptibility. Characteristics of clinical features include inflammatory diarrhea (cramps, fecal leukocytes, systemic response), endoscopic evidence of colitis or pseudomembranous colitis, and protein-losing enteropathy. The usual diagnostic tests are designed to detect toxin B with a tissue culture assay or toxin A with an enzyme immunoassay.

Clostridioides difficile↗
PubMed1998

ASHP therapeutic position statement on the preferential use of metronidazole for the treatment of Clostridium difficile-associated disease.

ASHP supports preferential use of oral metronidazole for treating CDAD when antimicrobial therapy is indicated. Oral vancomycin should be reserved for severe, potentially life-threatening cases or when oral metronidazole cannot be used. Oral metronidazole is as safe and effective as oral vancomycin and is considerably less costly. In addition, preliminary data suggest that routine use of oral vancomycin for CDAD may contribute to the spread of VRE--emerging nosocomial pathogens that can be extraordinarily difficult to treat. Pharmacists should work to foster preferential prescribing of oral metronidazole for the treatment of CDAD. Pharmacists should also actively seek opportunities to educate health care providers and counsel patients about the risks associated with the indiscriminate use of vancomycin and other antimicrobial agents.

Anti-Bacterial Agents↗
PubMed2002

Variation in human intestinal microbiota with age.

The large intestinal microbiota plays an important role in normal bowel function and the maintenance of host health, through the formation of short chain fatty acids, modulation of immune system reactivity and development of colonisation resistance. However, the effects of ageing on bacterial community structure in the colon are not well documented. Aim of this study is to assess bacterial species diversity in the human faecal microbiota with respect to age and Clostridium difficile infection. Bacterial populations were quantified from stool samples obtained from children (16 months to seven years), young adults (21-34 years), healthy elderly people (67-88 years) and patients diagnosed with Clostridium difficile-associated diarrhoea (68-73 years). Microbial diversity was assessed to species level for samples from the latter three subject groups. Marked interindividual variations occurred in microbial composition at genus and species levels. The faecal microbiota of children was found to be bacteriologically less complex whilst advancing age was associated with decreased bifidobacteria and increased bacteroides species diversity. Changes in microbial composition with age or disease will alter the metabolic capacity of the gut microbiota and has important implications for therapies aimed at modulating the large intestinal microbiota.

Adult↗
PubMed2001

The pathogenicity of Clostridium difficile.

It is now well established that the major virulence factors of C. difficile are the two toxins A and B. However, the organism possesses an array of other putative virulence factors that may be important for localisation within the colon, and in evasion of the immune system. It has been observed that certain types of C. difficile are more commonly found causing disease than others, and this seems to be independent of toxin production. Is this simply a reflection of their abundance in the hospital environment, or is it due to their virulence determinants? This review covers our current knowledge of the modes of action of toxins A and B at the cellular and molecular level. Many unanswered questions are posed that require answers before we can fully understand the pathogenic mechanisms of the organism and be in a position to manage better the spectrum of diseases it causes.

Bacterial Proteins↗
PubMed1997

Review article: treatment of Clostridium difficile infection.

AIM: A systematic review of controlled trials of therapy of Clostridium difficile intestinal infection using methodology described by the Cochrane Collaboration. METHODS: Trials were identified by searching computer databases over the years 1978-1996. Trials were included if they were (a) prospective randomized, controlled trials and (b) included patients with symptomatic disease. The primary end-point was clinical resolution of diarrhoea. Secondary end-points were clinical relapse and stool clearance of C. difficile and C. difficile toxin. RESULTS: Nine trials (469 patients) satisfying the inclusion criteria were identified. Two trials were placebo controlled. Six trials compared vancomycin to other antibiotics (fusidic acid, bacitracin, teicoplanin and metronidazole). For clinical resolution response rates ranged from 21 (placebo) to 100% (vancomycin). On pooling the trials, no antibiotic showed clear therapeutic superiority. Rates of clinical relapse ranged from 5 to 42%. Only one trial showed significant advantage of one antibiotic over another for prevention of relapse (teicoplanin vs. fusidic acid). CONCLUSION: The published data are limited, and further studies are required.

Anti-Bacterial Agents↗
PubMed2003

Lactobacillus plantarum 299v for the treatment of recurrent Clostridium difficile-associated diarrhoea: a double-blind, placebo-controlled trial.

A double-blind, placebo-controlled trial was performed to analyse the ability of Lactobacillus plantarum 299v to prevent further recurrent episodes of Clostridium difficile-associated diarrhoea (RCDAD). Recurrence of clinical symptoms (main outcome) was seen in 4 of 11 patients who received metronidazole in combination with L. plantarum 299v and in 6 of 9 treated with metronidazole in combination with placebo. The lactobacilli treatment had no side-effects. Although the small sample size does not allow any conclusion to be drawn concerning the efficacy of L. plantarum in patients with RCDAD, these results may contribute to the ongoing discussion about the benefits of probiotics in patients with RCDAD and encourage the performance of larger multicentre studies.

Aged↗
PubMedDate not supplied

Clostridium difficile colitis: recent therapeutical and immunological considerations.

Clostridium difficile is the main etiological agent of antibiotic associated diarrhoea and pseudomembranous colitis (PMC). It is considered as the most frequent agent of infectious diarrhoea occurring in hospitalized patients, in whom it is responsible for a high morbidity and occasional mortality even when the diagnosis and the treatment are pursued aggressively (1). The pathology is due to the production of at least two toxins: toxin A is an enterotoxin which induces intestinal tissue damage and a fluid response and toxin B is a cytotoxin which lacks any enterotoxic activity but is believed to exert an additive effect in vivo (2).

Clostridioides difficile↗
PubMedDate not supplied

Detection of Clostridium difficile toxin by an indigenously developed latex agglutination assay.

An indigenously developed latex agglutination assay using C. sordelli antitoxin was used to screen 211 stool samples received from hospitalized patients. Of 126 samples from patients receiving single to multiple antibiotics for various ailments, 38 (30%) were positive by the toxin assay, whereas only 6/85 (7%) of samples of patients not receiving antibiotics were also positive. Thus, of 211 samples a total of 44 (20.8%) were positive by our toxin assay, giving titers ranging from 1 in 5 to 1 in 320. The test developed by us is simple, rapid, easy and reliable and can be easily adapted to all microbiology laboratories.

Anti-Bacterial Agents↗
PubMed2006

Antimicrobial therapy of Clostridium difficile-associated diarrhea.

Clostridium difficile-associated diarrhea (CDAD) is the most common etiologically-defined cause of hospital-acquired diarrhea. Caused by the toxins of certain strains of C difficile, CDAD represents a growing concern, with epidemic outbreaks in some hospitals where very aggressive and difficult-to-treat strains have recently been found. Incidence of CDAD varies ordinarily between 1 to 10 in every 1,000 admissions. Evidence shows that CDAD increases morbidity, length of stay, and costs. This article described the clinical manifestations of CDAD, related risk factors, considerations for confirming CDAD, antimicrobial and non-antimicrobial treatment of CDAD, and issues related to relapses. The article concludes with a discussion of recent epidemic outbreaks involving CDAD.

Aged↗
PubMed2003

Detection of Clostridium difficile toxin A and B genes from stool samples of Thai diarrheal patients by polymerase chain reaction technique.

The prevalence of Clostridium difficile isolated from stools of Thai adult patients with suspected antibiotic-associated diarrhea (AAD) was 18.64 per cent. The recovery rate of toxin genes (tcdA and tcdB) by polymerase chain reaction (PCR) from stool samples yielded almost the same compared to the recovery rate of the toxin detection by enzyme immunoassay (EIA), which were 44.9 per cent and 46.7 per cent, respectively. Correlation of toxin gene detection by PCR and toxin detection by EIA was 90.6 per cent. All but one stool sample, the tcdA gene was detected together with the tcdB gene. Both genes were always detected together from tox gene-positive strains. Although, there were some discrepancy results for certain samples, the direct PCR-based-detection of C. difficile tox genes in stool samples seems to be the appropriate method for the diagnosis of C. difficile diarrhea. The PCR assay should be a recommended technique to be used routinely in laboratories. Further optimization of the technique to increase the sensitivity of the PCR assays is still needed. However, a quantitative isolation of the organism from stools of suspected antibiotic-associated diarrhea (AAD) or antibiotic-associated colitis (AAC) patients may give some evidence for clinicians in hospitals who cannot perform PCR-based or EIA-based techniques, since 48.6 per cent of the isolates were demonstrated as toxigenic strains.

Adult↗
PubMedDate not supplied

[Reactive arthritis due to Clostridium difficile].

Extracolonic manifestations of Clostridium difficile infections have rarely been reported as a cause of reactive arthritis. We report the case of a monoarticular arthritis following pseudomembranous colitis. A 45 year-old man was admitted for fever and monoarthritis of the left knee, 8 days after the onset of a C. difficile enterocolitis associated with urethritis. Samples obtained from the knee, urine, and blood cultures remained sterile. Bone scintigraphy revealed a left knee and forefoot hyperfixations. The association of arthritis and urethritis led us to the diagnosis of Fiessinger-Leroy-Reiter syndrome. Antibiotics for arthritis were ineffective and stopped, but they were continued for colitis. NSAIDs were prescribed and clinical manifestations disappeared within 24 hours, the patient resumed walking after 48 hours. Four months later there was no relapse and no sequela.

Abscess↗
PubMed2005

Etiology of diarrhea in pediatric outpatient settings.

BACKGROUND: The frequency with which bacteria cause diarrhea evaluated in ambulatory settings is often unknown. We attempted to determine the microbiologic etiology of diarrhea in a private pediatric practice (site A) and a clinic serving largely immigrant children (site B) and to establish guidelines for bacterial culture. METHODS: Children with diarrhea were prospectively enrolled, and their stools were examined for diarrheagenic bacteria, viruses and parasites. RESULTS: A total of 123 and 103 children were enrolled at sites A and B, respectively. Stools from all (100%), 126 (55.8%), 104 (46.0%) and 75 (33.2%) were tested for bacterial enteric pathogens, parasites, Clostridium difficile toxin and viruses, respectively. Of the 75 patients whose stool underwent complete testing, 36 (48%) contained at least 1 definitive or plausible pathogen. Twelve stools (5.3%) tested positive for bacteria [Campylobacter jejuni (n = 7), Yersinia enterocolitica, Shigella flexneri, Shigella sonnei, Salmonella serogroup D and Salmonella Braenderup (n = 1 each)]. One contained Blastocystis hominis, 8 contained C. difficile toxin and 16 contained viruses (9 rotavirus, 5 adenovirus and 2 astrovirus). Visible fecal blood (P = 0.029), increased stool frequency (P = 0.035), abdominal tenderness (P = 0.011) and fecal white (P < 0.001) or red blood cells (P = 0.002) were associated with bacterial infection. All children with stool yielding diarrheagenic bacteria or C. difficile toxin had at least 1 of these factors, but so did 75% of children without these agents (positive predictive value, 11%; negative predictive value, 100%; sensitivity, 100%; specificity, 25%). CONCLUSIONS: The bacterial diarrhea prevalence is similar to that in other ambulatory studies, although the spectrum differs. Exclusion criteria for stool testing in diarrhea remain elusive. Studies to determine the etiology of unexplained diarrhea and cost-effective algorithms for diarrhea diagnosis, are needed.

Bacterial Toxins↗
PubMed2002

Treatment of Clostridium difficile-associated diarrhea.

OBJECTIVE: To review the literature related to the treatment and infection control of Clostridium difficile-associated diarrhea (CDAD). DATA SOURCES: A MEDLINE search (1966-August 2001) of the English literature was conducted. DATA SYNTHESIS: C. difficile is a leading cause of antibiotic-related diarrhea. The clinical spectrum extends from simple diarrhea to fulminant colitis. Cessation of antibiotic therapy alone is sufficient for mild cases; however, the majority of cases require oral metronidazole as the drug of choice. Vancomycin orally is reserved for patients who have failed to respond to metronidazole, are pregnant, or are severely ill. There is an important role for infection control interventions. CONCLUSIONS: CDAD is a common infection. Appropriate antibiotic treatment and infection control policies can prevent the spread and reduce the morbidity associated with this disease.

Anti-Bacterial Agents↗