Relapses or reinfections: Analysis of a case of Clostridium difficile-associated colitis by two typing systems

Immunoblotting and pulsed-field gel electrophoresis of Clostridium difficile isolates were employed to differentiate reinfection by a newly acquired strain from relapse by an original strain in a 10-year-old patient with four episodes of C. difficile-associated colitis. Immunoblot typing demonstrated subserogroup K-1 of serogroup K for the first and second organisms, subserogroup A-1 of serogroup A for the third organism, and subserogroup G-4 of serogroup G for the fourth organism. PFGE analysis revealed consistent results with immunoblot analysis except that the strains from the fourth episode, whose DNA constantly degraded, were nontypable by this method. Five separate isolates of C. difficile from a specimen of each episode showed identical PFGE patterns, indicating that infections of multiple strains probably did not occur in this patient. These typing results suggested that the second episode after a 17-day course of vancomycin therapy represented a relapse by the strain causing the first episode, and that the third and fourth episodes after tapering vancomycin therapy were reinfections by other strains. Both immunoblot and PFGE typing systems are promising tools for analyzing recurrence of C. difficile infection. Received: 27 November 1995 / Revised: 1 January 1996 / Accepted: 22 March 1996     

上海部分地区儿童艰难梭菌相关性腹泻的临床分析

本文旨在监测儿童腹泻中艰难梭菌相关性腹泻(CDAD)的发病情况,并对其进行回顾性临床分析。对复旦大学附属儿科医院2007年2月～9月111例腹泻患儿的粪便标本进行艰难梭菌毒素A检测及粪便厌氧菌培养,对所有患儿进行回顾性病史采集及分析,并对粪便培养所得的4株艰难梭菌菌株用多位点可变数目串联重复序列分析(MLVA)技术进行同源性分析。111例患者中,艰难梭菌毒素A检测及艰难梭菌培养均为阳性者无,艰难梭菌毒素A阳性而艰难梭菌培养阴性者16例,艰难梭菌毒素A阴性而艰难梭菌培养阳性者4例,艰难梭菌毒素A及艰难梭菌培养均阴性者91例。比较院内、院外组3种不同病程腹泻CDAD的发病率,无显著差异。MLVA分析发现粪便培养得到的4株艰难梭菌菌株有部分同源性。结果提示,目前上海部分地区儿童CDAD发病情况为散发,但彼此之间有部分同源性;院内、外获得性腹泻的CDAD发病率无显著差异;艰难梭菌毒素A阳性或艰难梭菌培养阳性的病例在临床表现上与艰难梭菌毒素A阴性且艰难梭菌培养阴性的腹泻病例无显著差异。     

Clostridium difficile-associated diarrhea from a general hospital in Argentina

Clostridium difficile is responsible for 15-25% of all cases of antibiotic associated diarrhea. The incidence of infection with this organism is increasing in hospitals worldwide, consequent to the widespread use of broad-spectrum antibiotics. Although the clinical and financial impact of nosocomial C. difficile infection is believed to be significant, only limited information is available on the importance of C. difficile as a cause of diarrhea in Argentina. The aim of the study was to evaluate the impact and diagnosis methods of CDAD from symptomatic patients in a general hospital from Argentina. Consecutive diarrheal stool samples from symptomatic patients from a General Hospital in Argentina were screened for toxigenic C. difficile between April 2000 and April 2001. Toxins were detected in stools by the Premier Cytoclone A+B EIA. Each specimen was examined for toxigenic C. difficile strains by culture. From 104 specimens, 40 (38.5%) [32 of 87 patients (36.8%)] were positive and 64 (61.5%) [55 of 87 patients (63.2%)] were negative by stool toxin assay and/or toxigenic culture. In 11 of 40 positives samples C. difficile toxins were detected only by toxigenic culture. Five (15.6%) patients presented with symptomatic recurrences. Toxin-negative strains were not isolated. This data indicates that the high prevalence of toxigenic strains of C. difficile is of concern in routine diagnostic testing for C. difficile toxins in our study population. Detection of toxins in stools by EIA, coupled with testing strains for toxigenicity only in those cases in which direct toxin assay produces negative results, may be a satisfactory strategy. CDAD is an emerging nosocomial problem in our hospital. It will be necessary to evaluate the epidemiology and measures to control nosocomial spread.     

Acute infectious (not Clostridium difficile-associated) diarrhea in the elderly

Acute diarrhoea, non-antibiotic associated, is a common problem and a significant cause of morbidity and mortality in old age. In most cases diarrhoea has an infectious etiology. A number of different micro organisms can cause infectious diarrhoea. Most frequent are viral infections with a benign evolution. Rehydration is the only important therapeutic measure. Infections with bacteria are less common, antibiotics should be prescribed only in severe cases, and when there is suspicion of invasive infections by enteropathogenic bacteria.     

微生态制剂在控制艰难梭菌相关腹泻中的应用现状与前景

目的 以艰难梭菌感染为主的抗生素相关腹泻发病率和严重程度在全球范围内呈上升趋势,是一个备受关注的健康问题.本文主要介绍了微生态制剂的性质,以及其在艰难梭菌相关腹泻人群中应用的进展情况和作用机制,同时总结了微生态制剂在治疗和预防艰难梭菌相关腹泻中的生物安全性及其优点,对深入研发、推广使用针对抗生素相关腹泻的微生态制剂具有一定的参考价值.     

Probiotic therapy for the prevention and treatment of Clostridium difficile-associated diarrhea: a systematic review

BackgroundThe recent increase in the number and severity of cases of nosocomial Clostridium difficile-associated diarrhea (CDAD) has prompted interest in the use of probiotics for the prevention and treatment of this disease. We performed a systematic review of randomized controlled trials to assess the effectiveness of probiotic therapy.MethodsWe searched the PubMed, EMBASE, INAHTA, HEN and Cochrane Collaboration databases to identify trials in which the prevention or treatment of CDAD with probiotic therapy was the primary or secondary outcome. We extracted data on the number of patients randomly assigned to receive probiotic or placebo, the number of patients with CDAD, the type of probiotic, criteria for diagnosing CDAD, persistence of infection after treatment, compliance and adverse effects.ResultsWe identified 4 eligible studies in which prevention (n = 1) or treatment (n = 3) of CDAD was the primary outcome. The benefit of probiotic therapy seen in 2 of the studies was restricted to subgroups characterized by severe CDAD and increased use of vancomycin. The remaining 2 studies were too methodologically flawed for us to draw meaningful conclusions. We also identified 4 trials in which prevention of antibiotic-associated diarrhea with probiotics was the primary outcome and prevention of CDAD a secondary outcome. These studies were limited primarily by too few CDAD cases and provided no evidence of effective prophylaxis. Overall, heterogeneity in choice and dose of probiotic and in criteria for diagnosing CDAD makes it difficult to synthesize information from the 8 studies.InterpretationStudies conducted to date provide insufficient evidence for the routine clinical use of probiotics to prevent or treat CDAD. Better designed and larger studies are needed.Both the incidence and severity of Clostridium difficile-associated diarrhea (CDAD) have increased in hospitals across North America.^1,2,3,4 Recent outbreaks in Montreal and Sherbrooke resulted in a 4-fold increase in the number of CDAD cases as well as an increase in the number of attributable deaths.^1,5,6,7 CDAD is a debilitating and costly illness, particularly among patients with recurring episodes. Probiotics, or naturally occurring “good bacteria,” have been suggested as a means of both preventing and treating the disease.^8,9,10,11 The disturbance of normal gastrointestinal flora, particularly after antibiotic use, is believed to predispose patients to colonization by C. difficile;² probiotics, by delivering bacteria to the gastrointestinal tract, are believed to restore equilibrium in the altered gastrointestinal flora and thus protect against colonization.⁸ Probiotics that have been proposed for prevention and treatment of antibiotic-associated diarrhea and CDAD include various bacteria (Bifidobacterium, Lactobacillus GG, L. rhamnosus, L. casei, L. plantarum 299v, Enteroccus faecium [SF68]) and yeasts (Saccharomyces boulardii, S. cerevisiae). They are commonly available as lyophilized capsules or in the form of a fermented drink. We performed a systematic review of randomized controlled trials of probiotic therapy for the prevention and treatment of CDAD.     

Clostridium difficile-associated ileocecitis in clindamycin-treated infant hamsters

Infant hamsters, four days of age or older, developed aClostridium difficile-associated ileocecitis following clindamycin administration, whereas non-antibiotic-treated infant hamsters and hamsters less than four days old given clindamycin were asymptomatically colonized withC. difficile. The incidence of lethality among clindamycin-treated infant hamsters increased with age of the animals, such that all adult hamsters given clindamycin died within 72 h of treatment. Adult hamsters given clindamycin had significantly higher titers of cytotoxin throughout the intestinal tract compared with infant hamsters given clindamycin.     

Clostridium difficile-associated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity

Background

Recent reports suggest that Clostridium difficile colitis may be evolving into a more severe disease. During the second half of 2002 we noted an increase in the number of patients with severe C. difficile-associated diarrhea (CDAD) in our institution. We describe cases of CDAD at our institution over a 13-year period and investigate changes in illness severity.

Methods

We undertook a retrospective chart review of all cases of CDAD diagnosed at the Centre hospitalier universitaire de Sherbrooke from Jan. 1, 1991, to Dec. 31, 2003. Because the hospital serves a well-defined population of Quebec, we were also able to calculate population-based incidence during this period. We abstracted data on individual patients from patient charts and from hospital and pharmacy computer databases. We defined cases of CDAD as having a positive C. difficile cytotoxicity assay result, or endoscopic or histopathological evidence of pseudomembranous colitis. A case was considered complicated if one or more of the following was observed: megacolon, perforation, colectomy, shock requiring vasopressor therapy, or death within 30 days after diagnosis.

Results

A total of 1721 cases of CDAD were diagnosed during the study period. The incidence increased from 35.6 per 100 000 population in 1991 to 156.3 per 100 000 in 2003; among patients aged 65 years or more, it increased from 102.0 to 866.5 per 100 000. The proportion of cases that were complicated increased from 7.1% (12/169) in 1991–1992 to 18.2% (71/390) in 2003 (p < 0.001), and the proportion of patients who died within 30 days after diagnosis increased from 4.7% (8/169) in 1991– 1992 to 13.8% (54/390) in 2003 (p < 0.001). A high leukocyte count (20.0 х 10⁹/L or greater) and an elevated creatinine level (200 μmol/L or greater) were strongly associated with adverse outcomes: in 2003, 45 (40.9%) of 110 patients with a high leukocyte count or creatinine level, or both, had complicated CDAD and 28 (25.5%) died within 30 days after diagnosis. After adjustment for age and other confounding factors, patients initially given oral vancomycin therapy had a risk of progression to complicated CDAD that was 79% lower than the risk among patients initially treated with metronidazole (adjusted odds ratio 0.2, 95% confidence interval 0.06–0.8, p = 0.02).

Interpretation

An epidemic of CDAD with an increased case-fatality rate has had important consequences on the elderly population of our region. Our observational data suggest that the equivalence of vancomycin and metronidazole in the treatment of CDAD needs to be questioned.Clostridium difficile is an important cause of diarrhea in industrialized countries and the leading cause of infectious diarrhea among patients in hospital.^1,2,3,4,5,6 In the second half of 2002 we noted an increase in the number of patients with fulminant C. difficile colitis in our institution who required an emergency colectomy. Informal discussions with clinicians from other hospitals in southern Quebec suggested that this phenomenon was occurring in other cities as well. To investigate whether this was related merely to an increase in the number of cases of C. difficile-associated diarrhea (CDAD) or to an increase in the proportion of cases that developed severe colitis, we undertook a retrospective study of all cases of CDAD diagnosed at our institution over a 13-year period and investigated changes in illness severity.     

Antibiotic associated diarrhea and Clostridium difficile associated diarrhea in the elderly

Antibiotic associated diarrhea (AAD) is a common complication when antibiotics are used and is frequent in the elderly. It has an impact on the length of hospital stay and increases the comorbidity. Together with the type of antibiotic that is given, the length of antibiotical treatment and the combination of antibiotics is more predictive for the evolution of diarrhea when compared to the total given dose. Mostly AAD is benign, but an infection with C. difficile should always be excluded. C. difficile-enterocolitis is frequent among residents in nursing homes and in hospitalised patients. The clinical presentation varies from asymptomatic colonisation tot severe debilitating disease. A rapid diagnosis can be performed by detection of C. difficile toxin by an enzyme-linked immunoassay. Oral metronidazole and oral vancomycine are equally effective in the therapy. In relapsing infection an extended tapering regimen is sometimes necessary.     

Clostridium difficile-associated typhlitis in specific pathogen free guineapigs in the absence of antimicrobial treatment

Clostridium difficile (toxin) associated typhlitis was diagnosed in untreated barrier-maintained specific pathogen free guineapigs. It resembled the pathological lesions of antibiotic induced enterocolitis. The possible role of limited colonization resistance to C. difficile provided by mouse enteric microflora in the pathogenesis of the disease is discussed.     

Molecular analysis of transferable tetracycline resistance plasmids from Clostridium perfringens.

Conjugative tetracycline resistance plasmids from 15 Clostridium perfringens isolates from piggeries were analyzed by restriction endonuclease digestion and agarose gel electrophoresis. Seven isolates from one farm were found to carry a 47-kilobase pair (kb) plasmid, pJIR5, which had EcoRI, XbaI, and ClaI profiles that were identical to those of a previously characterized plasmid, pCW3. An isolate from a second farm was found to carry a plasmid, pJIR6, which also was indistinguishable from pCW3. Five additional isolates from a third farm carried a 67-kb plasmid, pJIR2, which had at least 29 kb of DNA in common with pCW3. Finally, two isolates from a fourth farm were found to carry a 50-kb plasmid pJIR4, which appeared to consist of an entire pCW3 molecule with a 3-kb insertion. Comparative restriction maps of pCW3, pJIR2, and pJIR4 that identified the regions of homology among these plasmids were constructed. We suggest that many conjugative tetracycline resistance plasmids in C. perfringens may contain a pCW3-like core.     

Molecular methods for the analysis of Clostridium perfringens relevant to food hygiene

Clostridium perfringens continues to be a common cause of food-borne disease. It produces an enterotoxin (CPE) which is released upon lysis of the vegetative cell during sporulation in the intestinal tract. Catering premises with insufficient cooling and reheating devices often seem to be the cause of outbreaks of C. perfringens food poisoning. Typing of C. perfringens is of great importance for investigating sources of food poisoning cases and for studying the epidemiology of this microorganism. This report describes the examination of 155 C. perfringens isolates by molecular methods. Isolates were taken from 10 food poisoning outbreaks and cases (n = 34, food and fecal isolates) and from meat and fish pastes (n = 121). Isolates were characterized by plasmid profiling, ribotyping, and/or macrorestriction analysis by pulsed-field gel electrophoresis (PFGE). Results show that all three methods are suitable for classifying C. perfringens isolates below the species level. Ribopatterns and PFGE patterns can be interpreted more easily than plasmid profiling results and can be recommended for contamination studies and epidemiologic investigation of food poisonings associated with C. perfringens.     

Clostridium difficile binary toxin (CDT) and diarrhea

Clostridium difficile is a major enteropathogen of humans. It produces two main virulence factors, toxins A and B. A third, less well known toxin, C. difficile toxin (CDT), is a binary toxin composed of distinct enzymatic (CdtA) and cell binding/translocation (CdtB) proteins. We used a novel enzyme linked immunoassay (EIA) to detect CdtB protein in feces and culture fluids. Additionally, PCR was used to assay C. difficile isolates from fecal samples for the CDT locus (CdtLoc). Although the results from 80 isolates suggest no relationship between toxin concentrations in situ and in vitro, there is a good correlation between PCR detection of the cdtB gene and EIA detection of CdtB protein in vitro. Possible implications of the detection of CDT in patients are discussed.     

Genotyping of Clostridium perfringens isolated from calves with neonatal diarrhea

Neonatal diarrhea is one of the main causes of losses in cattle herds. Clostridium perfringens is a widespread enteropathogen, and is responsible for many animal diseases such as bovine neonatal diarrhea. Fecal samples from 141 diarrheic calves and 129 healthy calves, aged up to 28 days and belonging to three herds were examined. Rates of culture positivity were 36.2% and 30.2% for diarrheic and nondiarrheic calves, respectively. Multiple isolates from primary isolation plates were subjected to simultaneous genotyping by multiplex PCR, with primers amplifying fragments of alpha (cpa), beta (cpb), epsilon (etx), iota (itxA), enterotoxin (cpe) and beta2 (cpb2) toxin-encoding genes. Only 17/51 (33.3%) and 17/39 (43.6%) of these mixtures from diarrheic and nondiarrheic calves, respectively, yielded genotype information, suggesting that this may not be a viable approach to genotyping of isolates. Fourteen isolate mixtures from animals with diarrhea had only cpa (type A), one had cpa and cpb2 (type A beta2 positive), one with cpa, itxA, and cpb2 (type E, beta2 positive), and one with cpa, etx, itxA, and cpb2 toxin producing strains. Among 17 isolate mixtures from healthy calves, 10 were exclusively type A, one was type A cpb2 positive, two were type E, three were type E cpb2 positive, and one was types D and E cpb2 positive. There was no correlation between isolation of a given toxin type and the presence of diarrhea.