Antibiotic prophylaxis in variceal hemorrhage:Timing,effectiveness and Clostridium difficile rates

AIM:To investigate if antibiotics administered within 8 h of endoscopy reduce mortality or increase the incidence of Clostridium difficile infection(CDI).METHODS:A 2-year retrospective analysis of all patients who presented with first variceal hemorrhage was undertaken.The primary outcome measure was 28-d mortality.Secondary outcome measures were 28-d rebleeding rates and 28-d incidence of CDI.All patients were admitted to a tertiary liver unit with a consultantled,24-h endoscopy service.Patients received standard care including terlipressin therapy.Data collection included:primary and secondary outcome measures,timing of first administration of intravenous antibiotics,eti-ology of liver disease,demographics,endoscopy details and complications.A prospective study was undertaken to determine the incidence of CDI in the study population and general medical inpatients admitted for antibiotic therapy of at least 5 d duration.Statistical analysis was undertaken using univariate,non-parametric tests and multivariate logistic regression analysis.RESULTS:There were 70 first presentations of variceal hemorrhage during the study period.Seventy percent of cases were male and 65.7% were due to chronic alcoholic liver disease.In total,64/70(91.4%) patients received antibiotics as prophylaxis during their admission.Specifically,53/70(75.7%) received antibiotics either before endoscopy or within 8 h of endoscopy [peri-endoscopy(8 h) group],whereas 17/70(24.3%) received antibiotics at > 8 h after endoscopy or not at all(non peri-endoscopy group).Overall mortality and rebleeding rates were 13/70(18.6%) and 14/70(20%),respectively.The periendoscopy(8 h) group was significantly less likely to die compared with the non peri-endoscopy group [13.2% vs 35.3%,P = 0.04,odds ratio(OR) = 0.28(0.078-0.997)] and showed a trend towards reduced rebleeding [17.0% vs 29.4%,P = 0.27,OR = 0.49(0.14-1.74)].On univariate analysis,the non peri-endoscopy group [P = 0.02,OR = 3.58(1.00-12.81)],higher model for end-stage liver disease(MELD) score(P = 0.02),presence of hepatorenal syndrome [P < 0.01,OR = 11.25(2.24-56.42)] and suffering a clinical episode of sepsis [P = 0.03,OR = 4.03(1.11-14.58)] were significant predictors of death at 28 d.On multivariate logistic regression analysis,lower MELD score [P = 0.01,OR = 1.16(1.04-1.28)] and periendoscopy(8 h) group [P = 0.01,OR = 0.15(0.03-0.68)] were independent predictors of survival at 28 d.The CDI incidence(5.7%) was comparable to that in the general medical population(5%).CONCLUSION:Antibiotics administered up to 8 h following endoscopy were associated with improved survival at 28 d.CDI incidence was comparable to that in other patient groups.

Clostridium difficile infections in China

Clostridium difficile （C.difficile） infection has become one of the major hospital-associated infections in Western countries in the last two decades.However,there is limited information on the status of C.difficile infection in Chinese healthcare settings.Given the large and increasing elderly population and the well-recognized problem of over-prescribing of broad spectrum antibiotics in China,it is critical to understand the epidemiology and potential risk factors that may contribute to C.difficile infection in China.A literature review of available published studies,including those in Chinese language-based journals,was conducted.A review of the currently available literature suggested the presence of C.difficile infections in China,but also suggested that these infections were not particularly endemic.This finding should lead to better designed and greatly expanded studies to provide a more reliable epidemiologically-based conclusion on the actual status of C.difficile infection in China,including the identification of any associated risk factors.Such information is ultimately valuable to develop appropriate strategies to prevent C.difficile infection and the vast negative impact of such infections in China and other developing countries.

Preventing pediatric antibiotic-associated diarrhea and Clostridium difficile infections with probiotics: A metaanalysis

AIM: To assess the efficacy and safety of probiotics for preventing pediatric:(1) antibiotic associated diarrhea and(2) Clostridium difficile(C. difficile) infections.METHODS: On June 3, 2013, we searched Pub Med(1960-2013), EMBASE(1974-2013), Cochrane Database of Systematic Reviews(1990-2013), CINAHL(1981-2013), AMED(1985-2013), and ISI Web of Science(2000-2013). Additionally, we conducted an extensive grey literature search including contact with National Institutes of Health Clinical Trials Registry, abstracts from annual infectious disease and gastroenterology meetings, experts in the field and correspondence with authors. The primary outcomes were the incidence of antibiotic-associated diarrhea(AAD) and C. difficile infections(CDI). Dichotomous outcomes(e.g., incidence of AAD or CDI) were pooled using a random-effects model to calculate the relative risk and corresponding 95% confidence interval(95%CI) and weighted on study quality. To explore possible explanations for heterogeneity, a priori subgroup analysis were conducted on probiotic strain type, daily dose, quality of study and safety of probiotics. The overall quality of the evidence supporting each outcome was assessed using the grading of recommendations, assessment, development and evaluation criteria.RESULTS: A total of 1329 studies were identified with 22 trials(23 treatment arms and 4155 participants) meeting eligibility requirements for our review of prevention of AAD and 5 trials(1211 participants) for the prevention of CDI. Trials in adult populations, trials of uncertain antibiotic exposure or studies which did not provide incidence of AAD were excluded. We found 12 trials testing a single strain of probiotic and 10 trials testing a mixture of probiotic strains. Probiotics(all strains combined) significantly reduced the incidence of pediatric AAD(pooled RR = 0.42, 95%CI: 0.33-0.53) and significantly reduced pediatric CDI(pooled RR = 0.35, 95%CI: 0.13-0.92). Of the two strains with multiple trials, both significantly reduced pediatric AAD: Saccharomyces boulardii lyo(pooled RR = 0.43, 95%CI: 0.32-0.60) and Lactobacillus rhamnosus GG(pooled RR = 0.36, 95%CI: 0.19-0.69). There was no significant effect by type of antibiotic, or by duration or dose of probiotic. No adverse events associated were found in the 22 controlled trials relating to the use of probiotics.CONCLUSION: This meta-analysis found that probiotics significantly prevented pediatric antibiotic associated diarrhea and pediatric CDI, but the efficacy varies significantly by the strain of the probiotic.

Global research on Clostridium difficile-associated diarrhoea:A visualized study

BACKGROUND Clostridioides(Clostridium)difficile(C.difficile)is still the most common cause of healthcare-associated diarrhoea and is increasing in prevalence as a communityacquired infection.In addition,the emergence of antibiotic resistance in C.difficile can increase the likelihood of the disease developing and/or spreading.AIM To provide an up-to-date picture of the trends in publications related to C.difficile infection,together with specific insights into hot-button issues in this field.METHODS Publications on C.difficile infections in the field of microbiology between 2001 and 2020 were identified from the Scopus database and Reference Citation Analysis.Bibliometric indicators were determined,including the number and type of publications,countries,affiliations,funding agencies,journals and citation patterns.VOSviewer was used to determine research areas and hot-button issues by identifying recurring terms with a high relative occurrence in the title and abstract.RESULTS A total of 8127 documents on‘C.difficile-associated diarrhoea’published between 2001 and 2020 were retrieved from the Scopus database.In the last decade,there has been a significant almost fourfold increase in the number of published papers on this topic.The United States was among the countries(44.11%)with the most publications,and the most involved institution was the University of Leeds in the United Kingdom(2.50%).Three clusters of research were identified and included‘illness spectrum and severity,as well as the signs,symptoms and clinical pathogenesis of C.difficile’;‘laboratory diagnosis and characterization of C.difficile’and‘risk factors for C.difficile infection’.CONCLUSION This study contains the most up-to-date and comprehensive data ever compiled in this field.More international research and cross-institutional collaborations are needed to address more global C.difficile concerns and to benefit from greater sharing of expertise,which will result in higher quality or more effective studies in the future.Promising research avenues in the near future may draw the attention of relevant scientists and funding organizations and open up novel C.difficile infection–based diagnosis and treatment approaches.

Faecal microbiota transplantation in patients with Clostridium difficile and significant comorbidities as well as in patients with new indications:A case series

Fecal microbiota transplantation(FMT) is effective in recurrent Clostridium difficile infection(r CDI). Knowledge of the safety and efficacy of FMT treatment in immune deficient patients is scarce. FMT has been suggested as a potential method for an increasing number of new indications besides r CDI. Among our FMT-treated r CDI patients, we reviewed those with major comorbidities: two human immunodeficiency virus patients, six haemodialysis patients, two kidney transplant patients, two liver transplant patients and a patient with chronic lymphatic leukaemia. We also reviewed those treated with FMT for indications other than r CDI: Salmonella carriage(two patients), trimethylaminuria(two patients), small intestinal bacterial overgrowth(SIBO;one patient), and lymphocytic colitis(one patient), as well as a common variable immunodeficiency patient with chronic norovirus infection and ESBL-producing Escherichia coli(E. coli) carriage. Of the thirteen r CDI patients treated with FMT, eleven cleared the CDI. The observed adverse events were not directly attributable to FMT. Concerning the special indications, both Salmonellas and ESBL-producing E. coli were eradicated. One trimethylaminuria patient and one SIBO-patient reported a reduction of symptoms. Three patients did not experience a benefit from FMT: chronic norovirus, lymphocytic colitis and the other fish malodour syndrome. There were no reported side effects in this group. FMT appeared to be safe and effective for immunocompromised patients with r CDI. FMT showed promise for the eradication of antibiotic-resistant bacteria, but further research is warranted.

Prevalence of diverticulosis in recurrent Clostridium difficile infection

AIM:To re-evaluate the theory that colonic diverticulosis is associated with relapse of Clostridium difficile associated disease (CDAD) in light of data suggesting increasing rates of CDAD infection and relapse.METHODS: Charts were reviewed for patients with recurrent CDAD who had also had a prior colonoscopy or flexible sigmoidoscopy. An age and gender matched control group was used to compare the prevalence of diverticulosis.RESULTS: Twenty-two patients met the study criteria, and the prevalence of diverticulosis in patients with CDAD relapse was 23% compared to 32% in age and sex matched controls (P=0.44). A significant proportion of patients with CDAD relapse had comorbidities associated with immune suppression.CONCLUSION: Diverticulosis does not appear to be associated with CDAD relapse.

Did the severe acute respiratory syndrome-coronavirus 2 pandemic cause an endemic Clostridium difficile infection?

BACKGROUND Clostridium difficile infection(CDI)has increased in prevalence during the last years.The coronavirus disease 2019(COVID-19)pandemic has negatively influenced patient outcomes.The majority of the severe acute respiratory syndrome-coronavirus 2(SARS-CoV-2)-infected patients received antibiotics during hospitalization.AIM To analyze the factors that influenced CDI development after SARS-CoV-2 infection.METHODS Between March 2020 to December 2020,we performed a prospective observational study including 447 patients diagnosed with CDI who were admitted to our tertiary referral university hospital.The diagnosis of CDI was based on the presence of diarrhea(≥3 watery stools within 24 h)associated with Clostridium difficile toxins A or B.We excluded patients with other etiology of acute diarrhea.RESULTS Among the total 447(12.5%)patients with CDI,most were male(54.3%)and mean age was 59.7±10.8 years.Seventy-six(17.0%)had history of COVID-19,most being elderly(COVID-19:62.6±14.6 years vs non-COVID-19:56.8±17.6 years,P=0.007),with history of alcohol consumption(43.4%vs 29.4%,P=0.017),previous hospitalizations(81.6%vs 54.9%,P<0.001)and antibiotic treatments(60.5%vs 35.5%,P<0.001),requiring higher doses of vancomycin and prone to recurrent disease(25.0%vs 13.1%,P=0.011).Age over 60 years[odds ratio(OR):2.591,95%confidence interval(CI):1.452-4.624,P=0.001],urban residence(OR:2.330,95%CI:1.286-4.221,P=0.005),previous antibiotic treatments(OR:1.909,95%CI:1.083-3.365,P=0.025),previous hospitalizations(OR:2.509,95%CI:1.263-4.986,P=0.009)and alcohol consumption(OR:2.550,95%CI:1.459-4.459,P=0.001)were risk factors of CDI in COVID-19.CONCLUSION CDI risk is unrelated to history of SARS-CoV-2 infection.However,previous COVID-19 may necessitate higher doses of vancomycin for CDI.

Risk factors of Clostridium difficile infection in ICU patients with hospital-acquired diarrhea: A case-control study

Objective:To identify the risk factors of Clostridium difficile infection(CDI)in diarrheal patients admitted to the intensive care unit(ICU)in Tehran Baharloo Hospital.Methods:A case-control study was conducted on ICU patients with hospital-acquired diarrhea.A total of 101 patients were divided into two groups:the case group(CDI positive,n=47)and the control group(CDI negative,n=54).The baseline information such as use of antibiotics,other drugs administration,treatments before diarrhea,laboratory results,and vital signs of the two groups were compared.Besides,logistic regression model was used to assess the correlation between CDI positivity and mortality.Results:Hospital stay length,ICU stay length,duration from admission to diarrhea onset,and nasogastric feeding duration,mechanical ventilation rate and its duration were significantly different from these of the control group(P<0.05).The frequency of proton pump inhibitor and carbapenem in the case group was significantly higher than that of the control group(P<0.05).In addition,age had a significant effect on the mortality of CDI patients.Conclusions:Patients with older age,longer duration of hospital or ICU stay,longer duration of endotracheal feeding and/or intubation were more susceptible to CDI.In addition,proton pump inhibitor and carbapenem use influenced the gut microbiome diversity and increased the CDI risk in patients.

Patients with Clostridium difficile infection and prior appendectomy may be prone to worse outcomes

BACKGROUND Clostridium difficile infection(CDI)occurs due to a dysbiosis in the colon.The appendix is considered a‘safe house’for gut microbiota and may help repopulate gut flora of patients with CDI.AIM To study the impact of prior appendectomy on the severity and outcomes of CDI.METHODS We retrospectively reviewed data of 1580 patients with CDI,admitted to our hospital between 2008 to 2018.Patients were grouped based on the presence or absence of the appendix.The primary aim was to(1)assess all-cause mortality and(2)the severity of CDI.Severity was defined as per the Infectious Diseases Society of America criteria.Logistic regression,and propensity score analysis using inverse probability of treatment weights(IPTW)was performed.RESULTS Of the 1580 patients,12.5%had a history of appendectomy.There was no statistical difference in mortality between patients with a prior appendectomy or without(13.7%vs 14%,P=0.877).However,a history of appendectomy affected the severity of CDI[odds ratio(OR)=1.32,95%confidence interval:1.01-1.75].On IPTW,this association remained significant(OR=1.59,P<0.05).On multivariable toxic megacolon(OR=5.37,P<0.05)and colectomy(OR=2.77,P<0.05).CONCLUSION Prior appendectomy may affect the severity of CDI,development of toxic megacolon and the eventual need for colectomy.Since treatment of CDI is governed by its severity,stronger antibiotic regimens or earlier use of fecal microbiota transplant may be a viable option for patients with prior appendectomy.

Clostridium difficile Toxin B: Insights into Its Target Genes

Clostridium difficile is a grossly Gram-positive anaerobic bacterium that has been a key factor in inducing imbalances in the gut microbiota in recent years, leading to intestinal-associated inflammation. The main pathogenic toxins of Clostridium difficile are toxin A (TcdA) and toxin B (TcdB). TcdB is the main pathogenic factor of Clostridium difficile infection. This review revealed the pathogenic mechanism of Clostridium difficile toxin B, expounded the impact of Clostridium difficile on the intestinal system, and predicted the genes on which TcdB may act, thereby providing a new therapeutic target for Clostridium difficile infection, offering theoretical basis and new strategies for clinical prevention and control.

Proton pump inhibitors as a risk factor for recurrence of Clostridium-difficile-associated diarrhea

AIM:To investigate the risk factors for Clostridiumdifficile-associated diarrhea(CDAD)recurrence,and its relationship with proton pump inhibitors(PPIs). METHODS:Retrospective data of 125 consecutive hospitalized patients diagnosed with CDAD between January 2006 and December 2007 were collected by medical chart review.Collected data included patient characteristics at baseline,underlying medical disease, antibiotic history before receiving a diagnosis of CDAD, duration of hospital stay,severity of CDAD,concurrenttreatment with PPIs,laboratory parameters,response to CDAD therapy,and recurrence of disease within 90 d of successful treatment.Various clinical and laboratory parameters were compared in patients in whom CDAD did or did not recur. RESULTS:Of the 125 patients(mean age,67.6± 13.9 years)that developed CDAD,98(78.4%)did not experience recurrence(non-recurrent group)and 27 (21.6%)experienced one or more recurrences(recurrent group).Prior to the development of CDAD,96% of the 125 patients were prescribed antibiotics,and 56(44.8%)of the patients received PPIs.Age older than 65 years(P=0.021),feeding via nasogastric tube(NGT)(P=0.045),low serum albumin level(P =0.025),and concurrent use of PPIs(P=0.014) were found to be risk factors for CDAD recurrence by univariate analysis.However,sex,length of hospital stay,duration and type of antibiotics used,severity of disease,leukocyte count and C-reactive protein(CRP) were not associated with risk of CDAD recurrence.On multivariate analysis,the important risk factors were advanced age(>65 years,adjusted OR:1.32,95% CI:1.12-3.87,P=0.031),low serum albumin level(< 2.5 g/dL,adjusted OR:1.85,95%CI:1.35-4.91,P= 0.028),and concurrent use of PPIs(adjusted OR:3.48, 95%CI:1.64-7.69,P=0.016). CONCLUSION:Advanced age,serum albumin level< 2.5 g/dL,and concomitant use of PPIs were found to be significant risk factors for CDAD recurrence.

Clinical and microbiological characterization of Clostridium difficile infection in a tertiary care hospital in Shanghai, China

Background Over the last decade,Clostridium difficile infection （CDI） has emerged as a significant nosocomial infection,yet little has been reported from China.This study aimed to characterize the clinical and microbiological features of CDI from a hospital in Shanghai.Methods Patients with CDI seen between December 2010 and March 2013 were included in this study,of which clinical data were retrospectively collected.The microbiological features of corresponding isolates were analyzed including genotype by multi-locus sequence typing （MLST）,antimicrobial susceptibility,toxin production,sporulation capacity,biofilm formation,and motility.Results Ninety-four cases of CDI were included during this study period,12 of whom were severe cases.By reviewing the clinical data,all patients were treated empirically with proton pump inhibitor or antibiotics or both,and they were distributed widely across various wards,most frequently to the digestive ward （28/94,29.79％）.Comparing the severe with mild cases,no significant differences were found in the basic epidemiological data or the microbiological features.Among the 94 isolates,31 were toxin A-negative toxin B-positive all genotyped as ST37.They generated fewer toxins and spores,as well as similar amounts of biofilm and motility percentages,but exhibited highest drug resistance to cephalosporins,quinolones,macrolide-lincosamide and streptogramin （MLSB）,and tetracycline.Conclusions No specific clinical genotype or microbiological features were found in severe cases; antimicrobial resistance could be the primary reason for epidemic strains leading to the dissemination and persistence of CDI.

Simultaneous detection and characterization of toxigenic Clostridium difficile directly from clinical stool specimens

We employed a multiplex polymerase chain reaction （PCR） coupled with capillary electrophoresis （mPCR-CE） targeting six Clostridium difficile genes, including tPi, tcdA, tcdB, cdtA, cdtB, and a deletion in tcdC for simultaneous detection and characterization of toxigenic C. difficile directly from fecal specimens. The mPCR-CE had a limit of detection of 10 colony-forming units per reaction with no cross-reactions with other related bacterial genes. Clinical validation was performed on 354 consecutively collected stool specimens from patients with suspected C. difficile infection and 45 isolates. The results were compared with a reference standard combined with BD MAX Cdiff, real-time cell analysis assay （RTCA）, and mPCR-CE. The toxigenic C. difficile species were detected in 36 isolates and 45 stool specimens by the mPCR-CE, which provided a positive rate of 20.3% （81/399）. The mPCR-CE had a specificity of 97,2% and a sensitivity of 96.0%, which was higher than RTCA （χ^2 = 5.67, P = 0.017） but lower than BD MAX Cdiff （P = 0.245）. Among the 45 strains, 44 （97.8%） were determined as non- ribotype 027 by the mPCR-CE, which was fully agreed with PCR ribotyping. Even though ribotypes 017 （n = 8, 17.8%）, 001 （n = 6, 13.3%）, and 012 （n = 7, 15.6%） were predominant in this region, ribotype 027 was an important genotype monitored routinely. The mPCR-CE provided an alternative diagnosis tool for the simultaneous detection of toxigenic C. difficile in stool and potentially differentiated between RT027 and non-RT027.

Role of Lactobacillus in the prevention of Clostridium difficile- associated diarrhea： a meta-analysis of randomized controlled trials

Background Clostridium difficile-associated diarrhea （CDAD） is a major public health problem because of significant morbidity and mortality, and many clinicians pay attention to Lactobacillus as a potentially effective treatment. The purpose of this meta-analysis was to evaluate the efficacy of Lactobacillus in the prevention of CDAD.

Insights into the Interactions Between Corrinoid Iron-sulfur Protein and Methyl Transferase from Human Pathogen Clostridium difficile

The human pathogen Clostridium difficile infection（CDI） is one of the most important healthcare- associated infections. Methyltransferase（MeTrca） and corrinoid iron-sulfur protein（CoFeSPca） are two key proteins in the acetyl-coenzyme A synthesis pathway of Clostridium difficile, which is essential for the survival of the pathogen and is absent in humans. Hence, the interaction between MeTrca and CoFeSPcd can become innovative targets for the treatment of human CDI. In this study, the interaction between MeTrca and CoFeSPca was verified by fluorescence resonance energy transfer measurements. The influence of the interaction on the tertiary structure of MeTrcd and CoFeSPcd was studied by ANS-labeled fluorescence measurements. Molecular docking was also performed to understand the mechanism of the protein interactions. These results provide a molecular basis for innovative drug design and development to treat human CDI.

Evaluation of inpatients Clostridium difficile prevalence and risk factors in Cameroon

Background Clostridium difficile,rarely found in hospitals,is a bacterium responsible for post-antibiotic diarrhea and Pseudomembranous Colitis(CPM).C.difficile selective pressure represents potential public health problem due to the production of toxins A and B serious pathologies effects/consequences.A transversal and analytic study was to assess the risk factors of C.difficile infection and to determine the prevalence of C.difficile in patients received in randomly selected five hospitals in Yaoundé,Cameroon.Methods A total of 300 stool samples were collected from consented patients using a transversal and analytic study conducted from 10th July to 10th November 2018 in five hospitals in Cameroon.The detection or diagnostic kit was CerTest C.difficile Glutamate Dehydrogenase+Toxin A+Toxin B based on immuno-chromatographic assay.A univariate and multivariate analysis allowed us to highlight the associated factors.Results The results showed a prevalence of C.difficile of 27.33%(82/300 stool patients’samples taken).Of these 27.33%,the production of Toxin A and Toxin B were 37.80 and 7.31%respectively.In univariate analysis,hospitalization was a significant(P=0.01)risk factor favoring C.difficile infection.In multivariate analysis,corticosteroids and quinolones use/administration were significantly(adjusted Odd Ratio,aOR=14.09,95%CI:1.62–122.54,P=0.02 and aOR=3.39,95%CI:1.00–11.34,P=0.05 respectively)risk factor for this infection.Conclusion The prevalence of C.difficile infections(CDI)remain high in these settings and may be related not only to permanent steroids and antibiotics.Promoting education to both medical staff and patients on the prevalence and public health impact of C.difficile can be core inimproving rationale prescription of steroids and antibiotics to patients and promote human health and exponential growth in Cameroon.

Detection of antibiotic resistance toxigenic Clostridium difficile in processed retail lettuce

Objectives:Clostridium difficile is the major cause of infectious diarrhoea in humans after antimicrobial treatment.Clostridium difficile has been isolated from food animals and meat.The main purpose of this study was to characterize C.difficile isolated from retail lettuce and determine the antibiotic resistance using five common clinical-selected antibiotics(metronidazole,vancomycin,clindamycin,erythromycin,and cefotaxime).Materials and Methods:Lettuce samples(grown in California,Arkansas,and Louisiana)were purchased from retail stores.Results:Toxigenic C.difficile was isolated from 13.8 per cent(41/297)of the lettuce samples.Among the toxigenic isolates,only 82.9 per cent(34/41)produced toxin B,17.1 per cent(7/41)produced both toxin A and toxin B,and two of the Louisiana C.difficile isolates were identified as ribotype 027.Under the treatment of the five antibiotics,the virulence C.difficile isolates were identified as having antibiotic resistance to metronidazole,vancomycin,and erythromycin.Conclusion:The present study reports the highest prevalence of toxigenic C.difficile in US retail lettuce.The antibiotic resistance to metronidazole,vancomycin,and erythromycin of the isolated C.difficile from retail lettuces could lead to public health concerns.

Overview of Clostridium difficile infection:implications for China

The incidence and severity of Clostridium difficile infection(CDI)have dramatically increased in the Western world in recent years.In contrast,CDI is rarely reported in China,possibly due to under-diagnosis.This article briefly summarizes CDI incidence,management and preventive strategies.The authors intend to raise awareness of this disease among Chinese physicians and health workers,in order to minimize the medical and economic burden of a potential epidemic in the future.

Tube feeding,the microbiota,and Clostridium diff icile infection

Clostridium difficile (C. difficile) is now the leading cause of nosocomial diarrhea in the USA, accounting for 30% of patients with antibiotic-associated diarrhea, 70% of those with antibiotic-associated colitis, and most cases of pseudomembranous colitis. The organism has evolved over the last 8 years to become more virulent and resistant to antimicrobials (NAP1/027 strain) causing a more severe form of the disease that has increased mortality and healthcare costs. While it is generally accepted that the problem results from the overuse of antibiotics, and in particular second and third generation cephalosporins, fluoroquinolones and macrolides, recent studies suggest that acid suppres-sion with proton pump inhibitors (PPIs) may be equally culpable. A further common, but less recognized, etiological factor is the prolonged use of elemental diets. Such diets are totally absorbed within the small intestine and therefore deprive the colonic microbiota of their source of nutrition, namely dietary fiber, fructose oligosaccharides, and resistant starch. The resultant suppression of colonic fermentation leads to suppression of the "good" bacteria, such as butyrate-producers (butyrate being essential for colonic mucosal health), and bifidobacteria and the creation of a "permissive" environment for C. difficile colonization and subsequent infection. Based on this analysis, the best chance of suppressing the emerging C. difficile epidemic is to adopt a 3-pronged attack consisting of (1) avoidance of the use of prophylactic antibiotics, (2) the avoidance of prophylactic PPIs, and (3) the conversion of elemental diet feeding to a diet containing adequate indigestible carbohydrate after the first week of critical illness. In this review, we highlight the rising worldwide incidence of C. difficile associated diarrhea and the role played by non-residue diets in destabilizing the colonic microbiota.

Fecal microbiota transplant for more than Clostridioides difficile: Dermatology a new frontier

Fecal microbiota transplant(FMT)has quickly become popular in research not only for recurrent Clostridioides difficile infections but for other chronic conditions as well.Recent,small dermatologic studies have reported improvements in inflammatory skin conditions in individuals treated with FMT,but larger studies are needed to clarify this possible relationship between the skin and the gut microbiome.We conducted a single-center,retrospective chart review to assess changes in acne,dermatitis herpetiformis and/or celiac disease,eczema,and psoriasis.Due to the retrospective nature of this study and the limitations of the current electronic medical record,we were unable to adequately assess cases of these diseases in relation to FMT.However,this study informs us that improvements in retrospective data are needed to formally evaluate this possible association.The better,but more cumbersome,study design would be a prospective,observational study.We encourage others to pursue further interdepartmental research on the influence of the gut microbiome on inflammatory skin diseases.