RESUMEN
This study investigated 102 episodes in which a glutamate dehydrogenase-positive enzyme immunoassay (EIA)-toxin-negative result was obtained with a C. difficile testing protocol. Of these 102 stool samples, 46% were culture positive with a toxigenic strain and nine were followed by an EIA-toxin-positive result within 2-32 days. The data accord with our policy of keeping these patients in side-rooms until asymptomatic and of encouraging treatment of those with otherwise unexplained persistent diarrhoea. Adding a third testing modality [toxigenic culture or polymerase chain reaction (PCR)] appears desirable but there may be significant differences in sensitivity between different toxigenic culture or PCR methods.
Asunto(s)
Toxinas Bacterianas/análisis , Técnicas Bacteriológicas/métodos , Clostridioides difficile/aislamiento & purificación , Infecciones por Clostridium/diagnóstico , Glutamato Deshidrogenasa/análisis , Algoritmos , Infecciones por Clostridium/microbiología , Heces/microbiología , Humanos , Técnicas para Inmunoenzimas/métodos , Sensibilidad y EspecificidadRESUMEN
OBJECTIVES: The aim of this study was to determine the incidence of and risk factors for community-associated Clostridium difficile infection (CDI). METHODS: Prospective surveillance of community-derived faecal samples for C. difficile cytotoxin, followed by a questionnaire-based case-control study in two distinct patient cohorts (one semi-rural and the other urban). RESULTS: The proportion of randomly selected faecal samples positive for C. difficile cytotoxin was 2.1% in both patient cohorts (median ages 73 and 45 years for the urban and semi-rural cohorts, respectively). Exposure to antibiotics in the previous 4 weeks, particularly multiple agents (P < 0.001), aminopenicillins (P < 0.05) and oral cephalosporins (P < 0.05), was significantly more frequent among cases than controls. Hospitalization in the preceding 6 months was significantly associated with CDI (45% versus 23%; P = 0.022). However, almost half the cases had not received antibiotic therapy in the month before C. difficile detection, and approximately one-third neither had exposure to antibiotics nor recent hospitalization. Contact with infants aged < or =2 years was significantly associated with CDI (14% versus 2%; P = 0.02). Prior exposure to gastrointestinal-acting drugs (proton pump inhibitor, H2 antagonist or non-steroidal anti-inflammatory) was not significantly more common in CDI cases. C. difficile PCR ribotype 001 caused 60% and 13% of urban and semi-rural community-associated CDI cases, respectively. CONCLUSIONS: Reliance on antibiotic history and age (> or =65 years) will contribute to missed diagnoses of community-associated CDI. Potential risk factors for community-associated CDI should be explored further to explain the large proportion of cases not linked to recent antibiotic therapy or hospitalization.
Asunto(s)
Clostridioides difficile/aislamiento & purificación , Infecciones Comunitarias Adquiridas/epidemiología , Infecciones Comunitarias Adquiridas/microbiología , Enterocolitis Seudomembranosa/epidemiología , Enterocolitis Seudomembranosa/microbiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Antibacterianos/uso terapéutico , Técnicas de Tipificación Bacteriana , Estudios de Casos y Controles , Niño , Preescolar , Clostridioides difficile/clasificación , Clostridioides difficile/genética , Dermatoglifia del ADN , ADN Bacteriano/genética , Heces/microbiología , Femenino , Genotipo , Hospitalización , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Reacción en Cadena de la Polimerasa/métodos , Estudios Prospectivos , Factores de Riesgo , Población Rural , Encuestas y Cuestionarios , Factores de Tiempo , Población UrbanaAsunto(s)
Proteínas Bacterianas/análisis , Toxinas Bacterianas/análisis , Infecciones por Clostridium/diagnóstico , Enterotoxinas/análisis , Heces/microbiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Técnicas de Laboratorio Clínico/normas , Clostridioides difficile/patogenicidad , Diarrea/diagnóstico , Humanos , Persona de Mediana Edad , Vigilancia de la Población/métodos , Valor Predictivo de las PruebasRESUMEN
We have fingerprinted Clostridium difficile isolates from patients with symptomatic recurrences of infection, using random amplified polymorphic DNA (RAPD). The medical records of 55/79 patients were examined, from whom multiple C. difficile-positive faeces were received during hospitalization at least five days, but no more than two months, apart. In 20 of these cases symptoms either did not recur (i.e., absent for at least three days between episodes), or were explainable by other causes, such as laxative administration. Of the remaining 35 patients, 27 sets of C. difficile isolates (23 pairs and four triplicates) were available for RAPD fingerprinting. Differing C. difficile DNA fingerprints (at least three major bands difference) were obtained for 15/27 patients, and hence at least 56% of the clinical recurrences of infection were in fact due to re-infection as opposed to relapse. Since we found that an endemic C. difficile clone was present in 18 out of 27 patients (67%) and accounted for 53% (31/58) of all isolates, it is probable that the majority of symptomatic recurrences are in fact re-infections, with either a different or the same C. difficile strain. We conclude that more attention must be given to preventing the re-infection of C. difficile symptomatic patients. Isolation of symptomatic individuals is the preferred option for the protection of other patients, but measures must be taken to ensure that further strain acquisition by the index cases does not occur.
Asunto(s)
Clostridioides difficile , Enterocolitis Seudomembranosa/diagnóstico , Adulto , Anciano , Anciano de 80 o más Años , Clostridioides difficile/aislamiento & purificación , Dermatoglifia del ADN/métodos , Hospitalización , Humanos , Persona de Mediana Edad , Técnica del ADN Polimorfo Amplificado Aleatorio , Recurrencia , Estudios RetrospectivosRESUMEN
BACKGROUND: Rates of Clostridium difficile diarrhoea have recently been rising, with the elderly being at highest risk. AIM: To compare the incidence of C. difficile colonization and diarrhoea in elderly patients treated for presumed infection with either empirical cefotaxime (CTX) or piperacillin-tazobactam (PT). METHODS: A prospective, ward-based, crossover study was carried out on two well-matched care of the elderly wards at a UK tertiary care hospital, in patients requiring empirical broad-spectrum antibiotic treatment. RESULTS: There was a highly significant increased incidence of C. difficile colonization (26/34 vs. 3/14, P=0.001) and diarrhoea (18/34 vs. 1/14, P=0.006) in patients who received CTX as opposed to PT. DNA fingerprinting suggested that most infections arose from strains acquired from the hospital environment. CONCLUSIONS: Elderly patients are significantly less likely to develop C. difficile diarrhoea after treatment with PT than after CTX. The source of C. difficile appears to be predominantly from the ward environment.
Asunto(s)
Cefotaxima/efectos adversos , Diarrea/microbiología , Enterocolitis Seudomembranosa/etiología , Inhibidores Enzimáticos/efectos adversos , Ácido Penicilánico/análogos & derivados , Piperacilina/efectos adversos , Inhibidores de beta-Lactamasas , Anciano , Clostridioides difficile , Infección Hospitalaria/microbiología , Estudios Cruzados , Combinación de Medicamentos , Femenino , Humanos , Masculino , Infecciones Oportunistas/microbiología , Ácido Penicilánico/efectos adversos , Estudios Prospectivos , TazobactamRESUMEN
The great majority of cases of Clostridium difficile infection are hospital-acquired, and the reported incidence in England and Wales has increased sixfold between 1990 and 1993, with at least 17 patients dying in a recent large nosocomial outbreak. C. difficile infection accounts for an average 3-week increased length of stay in hospital. Acquisition of a toxigenic strain of Clostridium difficile may be followed by asymptomatic carriage, diarrhoea, colitis or pseudomembranous colitis. Antibiotic treatment and older age are major risk factors for the development of symptomatic disease, but less well-defined differences in strain virulence and host susceptibility are also probably important. Accurate data on the relative risks of different antibiotics to induce symptomatic C. difficile infection are scarce, but third-generation cephalosporins are frequently implicated. New kits are becoming available for the laboratory diagnosis of C. difficile infection but many of these lack sensitivity. Oral metronidazole or vancomycin are the main treatment options but avoidance of further antibiotics should also be encouraged where possible. The role of environmental C. difficile spores, which are highly resistant to conventional disinfectants, needs to be defined. Proven strategies for the prevention of C. difficile infection are required, in particular protocols to ensure that cross-infection does not occur.
Asunto(s)
Antibacterianos/efectos adversos , Clostridioides difficile/patogenicidad , Infección Hospitalaria/inducido químicamente , Enterocolitis Seudomembranosa/inducido químicamente , Infección Hospitalaria/tratamiento farmacológico , Infección Hospitalaria/microbiología , Enterocolitis Seudomembranosa/microbiología , HumanosRESUMEN
The current impact of Clostridium difficile will have been noticed by many clinicians, particularly those managing elderly patients. Infection with this bacterium can give rise to a wide range of symptoms, from diarrhoea to fulminating colitis and toxic megacolon. Patients may also be asymptomatically colonized by C. difficile. In this article the epidemiology and aetiology of C.difficile infection will be discussed, followed by an explanation of how diagnosis of cases is best achieved, how the disease is optimally treated and how cross-infection can be minimized.