Utilizing antibiotics to prevent Clostridioides difficile infection: does exposure to a risk factor decrease risk? A systematic review

2020 ◽  
Vol 75 (10) ◽  
pp. 2735-2742
Author(s):  
Travis J Carlson ◽  
Anne J Gonzales-Luna
Keyword(s):  
Risk Factor ◽  
Antibiotic Prophylaxis ◽  
Data Extraction ◽  
Relevant Literature ◽  
Antibiotic Use ◽  
Risk Of Bias ◽  
Outcome Variable ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
Risk Ratios

Abstract Background Antibiotic use is a major risk factor for Clostridioides difficile infection (CDI). However, antibiotics recommended for CDI treatment are being utilized in clinical practice as prophylactic agents. Objectives To comprehensively summarize and critically evaluate the published literature investigating the effectiveness of antibiotic CDI prophylaxis. Methods A systematic search for relevant literature was conducted in PubMed and ClinicalTrials.gov. Two investigators independently screened each article for inclusion, and the references of the included articles were studied to identify additional relevant articles. Data extraction and an assessment of risk of bias was completed for all included studies. Unadjusted risk ratios and 95% CI were calculated for each study, with CDI being the outcome variable and prophylaxis (prophylaxis versus control) representing the exposure. Results In total, 13 articles were identified in PubMed and 9 ongoing or unpublished trials were identified in ClinicalTrials.gov. The effect of antibiotic prophylaxis on CDI rates varied between studies; however, most favoured the use of antibiotic prophylaxis. Conclusions The authors of this review conclude that the current literature carries a high risk of bias and the results should be interpreted with caution.

scholarly journals Durability of Response to Fecal Microbiota Transplantation After Exposure to Risk Factors for Recurrence in Patients With Clostridioides difficile Infection

2020 ◽  
Author(s):  
Srishti Saha ◽  
Kristin Mara ◽  
Darrell S Pardi ◽  
Sahil Khanna
Keyword(s):  
Risk Factors ◽  
Risk Factor ◽  
Fecal Microbiota Transplantation ◽  
Multivariable Analysis ◽  
Antibiotic Use ◽  
Fecal Microbiota ◽  
Additional Risk Factor ◽  
Durable Response ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection

Abstract Background Fecal microbiota transplantation (FMT) is highly effective for preventing recurrent Clostridioides difficile infection (CDI). Durability (no recurrence despite additional risk factor exposure) of FMT protection is largely unknown. We studied the durability of FMT in patients with recurrent CDI. Methods We conducted a retrospective study of adults undergoing FMT for recurrent CDI. Data collected included demographics, CDI risk factors (comorbidities, healthcare exposure, non-CDI antibiotic use, acid suppressant medications), and future CDI episodes. Durable response to FMT was defined as lack of CDI episodes within 1 year post-FMT despite risk factor exposure. Results Overall, 460 patients were included (median age, 57 years [18–94]; 65.2% female). Comorbidities included chronic liver disease, 12.8% (n = 59); cancer, 11.7% (n = 54); chronic kidney disease, 3.9% (n = 18); and inflammatory bowel disease, 21.9% (n = 101). Overall, 31.3% (n = 144) received antibiotics, 21.7% (n = 100) received acid suppressants, and 76.8% (n = 350) had healthcare exposure after FMT. Of 374 patients with risk factor exposure, 78.1% (95% confidence interval [CI], 72.7%–84.0%) had durable response to FMT at 1 year. On multivariable analysis, antibiotic use was independently associated with decreased durability of FMT (hazard ratio, 0.27; 95% CI, .15–.49; P < .001). Conclusions The majority of patients had a durable response to FMT despite exposure to CDI risk factors. Antibiotic exposure after FMT independently predicted loss of durability of FMT. Larger studies are needed to define predictors of durable response in patients with and without exposure to antibiotics.

scholarly journals Assessment of Testing and Treatment of Asymptomatic Bacteriuria Initiated in the Emergency Department

2020 ◽  
Vol 7 (12) ◽  
Author(s):  
Lindsay A Petty ◽  
Valerie M Vaughn ◽  
Scott A Flanders ◽  
Twisha Patel ◽  
Anurag N Malani ◽  
...  
Keyword(s):  
Emergency Department ◽  
Antibiotic Treatment ◽  
Asymptomatic Bacteriuria ◽  
Antibiotic Use ◽  
Altered Mental Status ◽  
Estimating Equation ◽  
Hospitalized Patients ◽  
Clostridioides Difficile ◽  
Cord Injury ◽  
Clostridioides Difficile Infection

Abstract Background Reducing antibiotic use in patients with asymptomatic bacteriuria (ASB) has been inpatient focused. However, testing and treatment is often started in the emergency department (ED). Thus, for hospitalized patients with ASB, we sought to identify patterns of testing and treatment initiated by emergency medicine (EM) clinicians and the association of treatment with outcomes. Methods We conducted a 43-hospital, cohort study of adults admitted through the ED with ASB (February 2018–February 2020). Using generalized estimating equation models, we assessed for (1) factors associated with antibiotic treatment by EM clinicians and, after inverse probability of treatment weighting, (2) the effect of treatment on outcomes. Results Of 2461 patients with ASB, 74.4% (N = 1830) received antibiotics. The EM clinicians ordered urine cultures in 80.0% (N = 1970) of patients and initiated treatment in 68.5% (1253 of 1830). Predictors of EM clinician treatment of ASB versus no treatment included dementia, spinal cord injury, incontinence, urinary catheter, altered mental status, leukocytosis, and abnormal urinalysis. Once initiated by EM clinicians, 79% (993 of 1253) of patients remained on antibiotics for at least 3 days. Antibiotic treatment was associated with a longer length of hospitalization (mean 5.1 vs 4.2 days; relative risk = 1.16; 95% confidence interval, 1.08–1.23) and Clostridioides difficile infection (CDI) (0.9% [N = 11] vs 0% [N = 0]; P = .02). Conclusions Among hospitalized patients ultimately diagnosed with ASB, EM clinicians commonly initiated testing and treatment; most antibiotics were continued by inpatient clinicians. Antibiotic treatment was not associated with improved outcomes, whereas it was associated with prolonged hospitalization and CDI. For best impact, stewardship interventions must expand to the ED.

scholarly journals 785. Association between Prevalence of Laboratory-Identified Clostridioides difficile Infections (CDIs) and CDI Antibiotic Treatment in U.S. Acute Care Hospitals, 2018

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S437-S437
Author(s):  
Kerui Xu ◽  
Andrea L Benin ◽  
Hsiu Wu ◽  
Jonathan R Edwards ◽  
Qunna Li ◽  
...  
Keyword(s):  
Acute Care ◽  
Acute Care Hospitals ◽  
Antibiotic Use ◽  
Prevalence Rates ◽  
Hospital Level ◽  
First Line ◽  
Oral Vancomycin ◽  
Patient Admissions ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection

Abstract Background Clostridioides difficile infections (CDIs) are an urgent public health threat, accounting for 223,900 infections and 12,800 deaths in hospitalized patients annually. In early 2018, the Infectious Disease Society of America (IDSA) recommended oral vancomycin or fidaxomicin as the first-line antibiotics for CDIs. To track the uptake of IDSA’s recommendations, we evaluated the association between CDI prevalence and use of first-line antibiotics in hospitals reporting to the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN). Methods We matched 2018 hospital-level, NHSN data on laboratory-identified CDIs with NHSN antimicrobial use (AU) data for the same time period. Hospitals that submitted < 6 months of either data type in 2018 were excluded. The association between quarterly hospital-level CDI prevalence rates per 100 patient-admissions and use of CDI antibiotics (oral vancomycin plus fidaxomicin) per 1,000 days-present was evaluated using Pearson’s linear correlation coefficient and using Goodman and Kruskal’s gamma (G) on ordinal quartiles to assess rates of discordant pairs. Results Among the 2735 hospital-level quarters based on 714 hospitals included in the study, CDI prevalence (median: 0.46 per 100 patient-admissions) and CDI antibiotic use (median: 8.85 antibiotic-days per 1,000 days-present) demonstrated only a moderately positive correlation (r = 0.48). Among hospitals in the highest quartile for CDI prevalence, 5.1% were in the lowest quartile for antibiotic use. Among hospitals in the highest quartile for antibiotic use, 5.3% were in the lowest quartile for CDI prevalence, and 54.2% were in the highest quartile for CDI prevalence (G = 0.60; 95% CI: 0.57–0.63). Correlation of hospital-level Clostridioides difficile infection (CDI) prevalence rates and oral vancomycin and fidaxomicin use in U.S. acute care hospitals, 2018 Distribution of hospital-level Clostridioides difficile infection (CDI) prevalence rates and oral vancomycin and fidaxomicin use in ordinal quartiles (Q1–Q4) to access rates of discordant pairs Conclusion The moderate correlation and discordant rates suggest that vancomycin and fidaxomicin are less frequently used as primary antibiotics in some hospitals; whereas in others, CDI antibiotic use is occurring in the absence of positive laboratory tests for CDI. To further investigate this discordance, there is a need to assess hospitals’ prescribing and testing practices in an ongoing manner. These findings may be useful to serve as baseline for measuring progress of appropriateness of treatment and testing for CDIs. Disclosures All Authors: No reported disclosures

scholarly journals Heart Failure Is a Risk Factor for Suffering and Dying of Clostridium difficile Infection. Results of a 15-Year Nationwide Study in Spain

2020 ◽  
Vol 9 (3) ◽  
pp. 614
Author(s):  
Manuel Méndez-Bailón ◽  
Rodrigo Jiménez-García ◽  
Valentín Hernández-Barrera ◽  
Javier de Miguel-Díez ◽  
José M. de Miguel-Yanes ◽  
...  
Keyword(s):  
Heart Failure ◽  
Risk Factor ◽  
Time Trends ◽  
Secondary Diagnosis ◽  
National Hospital ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
Comorbidity Index ◽  
Index 2 ◽  
Discharge Database

Background: We aimed to (1) analyze time trends in the incidence and in-hospital outcomes of heart failure (HF) patients suffering Clostridioides difficile infection (CDI); (2) compare clinical characteristics of CDI patients between those with HF and matched non-HF patients; and (3) identify predictors of in-hospital mortality (IHM) among HF patients suffering CDI. Methods: Retrospective study using the Spanish National Hospital Discharge Database from 2001 to 2015. Patients of age ≥40 years with CDI were included. For each HF patient, we selected a year, age, sex, and readmission status-matched non-HF patient. Results: We found 44,695 patients hospitalized with CDI (15.46% with HF). HF patients had a higher incidence of CDI (202.05 vs. 145.09 per 100,000 hospitalizations) than patients without HF (adjusted IRR 1.35; 95% CI 1.31–1.40). IHM was significantly higher in patients with HF when CDI was coded as primary (18.39% vs. 7.63%; p < 0.001) and secondary diagnosis (21.12% vs. 14.76%; p < 0.001). Among HF patient’s predictor of IHM were older age (OR 8.80; 95% CI 2.55–20.33 for ≥85 years old), those with more comorbidities (OR 1.68; 95% CI 1.12–2.53 for those with Charlson Comorbidity index ≥2), and in those with severe CDI (OR 6.19; 95% CI 3.80–10.02). Conclusions: This research showed that incidence of CDI was higher in HF than non-HF patients. HF is a risk factor for IHM after suffering CDI.

scholarly journals The efficacy of litter management strategies to prevent morbidity and mortality in broiler chickens: a systematic review and network meta-analysis

2019 ◽  
Vol 20 (2) ◽  
pp. 247-262
Author(s):  
Jan M. Sargeant ◽  
Michele D. Bergevin ◽  
Katheryn Churchill ◽  
Kaitlyn Dawkins ◽  
Bhumika Deb ◽  
...  
Keyword(s):  
Systematic Review ◽  
Broiler Chickens ◽  
Data Extraction ◽  
Meta Analysis ◽  
Relevant Literature ◽  
Management Strategies ◽  
Antibiotic Use ◽  
Peat Moss ◽  
Risk Of Mortality ◽  
Poor Reporting

AbstractA systematic review and network meta-analysis (NMA) were conducted to address the question, ‘What is the efficacy of litter management strategies to reduce morbidity, mortality, condemnation at slaughter, or total antibiotic use in broilers?’ Eligible studies were clinical trials published in English evaluating the efficacy of litter management in broilers on morbidity, condemnations at slaughter, mortality, or total antibiotic use. Multiple databases and two conference proceedings were searched for relevant literature. After relevance screening and data extraction, there were 50 trials evaluating litter type, 22 trials evaluating litter additives, 10 trials comparing fresh to re-used litter, and six trials evaluating floor type. NMAs were conducted for mortality (61 trials) and for the presence or absence of footpad lesions (15 trials). There were no differences in mortality among the litter types, floor types, or additives. For footpad lesions, peat moss appeared beneficial compared to straw, based on a small number of comparisons. In a pairwise meta-analysis, there was no association between fresh versus used litter on the risk of mortality, although there was considerable heterogeneity among studies (I2 = 66%). There was poor reporting of key design features in many studies, and analyses rarely accounted for non-independence of observations within flocks.

scholarly journals ASSOCIATION BETWEEN ETHNICITY AND SEVERE COVID-19 DISEASE: A SYSTEMATIC REVIEW AND META-ANALYSIS.

2020 ◽  
Author(s):  
Antony Raharja ◽  
Alice Tamara ◽  
Li Teng Kok
Keyword(s):  
Systematic Review ◽  
Risk Factor ◽  
Ethnic Minorities ◽  
Independent Risk Factor ◽  
Case Reports ◽  
Data Extraction ◽  
Meta Analysis ◽  
Risk Of Bias ◽  
Research Database ◽  
All Cause Mortality

Background: Multiple reports suggested disproportionate impact of Covid-19 on ethnic minorities. Whether ethnicity is an independent risk factor for severe Covid-19 illness is unclear. Purpose: Review the association between ethnicity and poor Covid-19 outcomes including all-cause mortality, hospitalisation, critical care admission, respiratory and kidney failure. Data Sources: MEDLINE, EMBASE, Cochrane COVID-19 Study Register, WHO COVID-19 Global Research Database up to 15/06/2020, and preprint servers. No language restriction. Study Selection: All studies providing ethnicity-aggregated data on the pre-specified outcomes, except case reports or interventional trials Data Extraction: Pairs of investigators independently extracted data, assessed risk of bias using Newcastle-Ottawa scale (NOS), and rated certainty of evidence following GRADE framework. Data Synthesis: Seventy-two articles (59 cohort studies with 17,950,989 participants; 13 ecological studies; 54 US-based and 15 UK-based; 41 peer-reviewed) were included for systematic review and 45 for meta-analyses. Risk of bias was low, with median NOS of 7 (interquartile range 6-8). In the unadjusted analyses, compared to white ethnicity, all-cause mortality risk was similar in Black (RR:0.96 [95%CI: 0.83-1.08]), Asian (RR:0.99 [0.85-1.16]) but reduced in Hispanic ethnicity (RR:0.69 [0.57-0.84]). Age and sex-adjusted-risks were significantly elevated for Black (HR:1.38 [1.09-1.75]) and Asian (HR:1.42 [1.15-1.75]), but not for Hispanic (RR:1.14 [0.93-1.40]). Further adjusting for comorbidities attenuated these association to non-significance; Black (HR:0.95 [0.72-1.25]); Asian (HR:1.17 [0.84-1.63]); Hispanic (HR:0.94 [0.63-1.44]). Similar results were observed for other outcomes. In subgroup analysis, there is a trend towards greater disparity in outcomes for UK ethnic minorities, especially hospitalisation risks. Limitations: Paucity of evidence on native ethnic groups, and studies outside US and UK. Conclusions: Currently available evidence cannot confirm ethnicity as an independent risk factor for severe Covid-19 illness, but indicates that disparity may be partially attributed to greater burden of comorbidities. Registration: PROSPERO, CRD42020188421 Funding source: none

scholarly journals A protocol for rapid evidence synthesis into soil loosening as an intervention to ameliorate compaction caused by dairy farming and the impacts of this for productivity and sustainability

2018 ◽  
Author(s):  
Helen Kendall ◽  
Amy Taylor ◽  
Mark Reed ◽  
Gavin Stewart
Keyword(s):  
Search Strategy ◽  
Data Extraction ◽  
Evidence Synthesis ◽  
Meta Analysis ◽  
Relevant Literature ◽  
Risk Of Bias ◽  
Rapid Review ◽  
Dairy Production ◽  
Inclusion Criteria ◽  
Data Synthesis

This is a protocol for a rapid review of the effectiveness of soil loosening to ameliorate compaction caused by cattle treading from dairy production on UK dairy farms. The review will synthesise relevant literature that explores the impacts that can be derived from mechanical soil loosening for improved soil quality, productivity (i.e. yield) and the environment. The protocol outlines the rationale, objectives, inclusion criteria, search strategy and screening processes for the meta-analysis, and the plans for data extraction, risk of bias and data synthesis approaches.

scholarly journals 2389. Assessing the Time Course of Proton Pump Inhibitor Use and Clostridioides difficile Infection

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S825-S825
Author(s):  
Katherine Panagos ◽  
Natalia Blanco ◽  
Surbhi Leekha ◽  
Erik von Rosenvinge ◽  
Emily Heil
Keyword(s):  
Proton Pump ◽  
Time Course ◽  
Conditional Logistic Regression ◽  
Academic Medical Center ◽  
Antibiotic Use ◽  
Clostridioides Difficile ◽  
Increased Risk ◽  
Significant Difference ◽  
Clostridioides Difficile Infection ◽  
The Impact

Abstract Background Proton pump inhibitors (PPIs) are a known risk factor for Clostridioides difficile infection (CDI) and recurrence, even in the absence of antibiotic use. No studies have specifically assessed the increased risk for CDI based on PPI duration, given that PPIs are frequently newly prescribed during hospitalizations and infrequently discontinued, even when CDI has occurred. The aim of this project was to assess the time course of PPI utilization and risk of CDI. Methods We conducted a retrospective matched case–control study comparing patients who developed CDI (cases) with patients who did not develop CDI (controls, matched on age, gender, date of admission and hospital location) from a cohort of patients with a C.difficile PCR test order from an academic medical center. Patient charts were reviewed for PPI use prior to the date of the positive test and whether the PPI was started in the hospital or as a home medication (>30d, 30–90d, 90–180d, >180d). The primary comparison was odds of PPI use between cases and controls using conditional logistic regression adjusted for antibiotic exposure (SAS 9.4, Cary, NC). Results A total of 348 patients were included in the study, 174 cases and 174 matched controls. 65% of patients in the study received a PPI, 85% a PPI or H2 blocker and 95% of patients received antibiotics during their admission. Patients on PPIs as home medications were not at an increased risk of CDI (OR = 1.08 (95% CI 0.60–1.93)) compared with those not on PPIs. Patients whose PPIs were initiated in the hospital were at increased risk of CDI compared with those not on PPIs (OR = 1.4 (95% CI 0.81–2.41)). No significant difference was observed across time periods of PPI use prior to admission and development of CDI. Conclusion Patients who started PPIs during inpatient stays were at a higher risk of developing CDI than patients not exposed to PPIs. However, PPI use was not found to be significantly associated with CDI in this analysis, regardless of the time or duration of PPI prescription. The results may be confounded by the high frequency of PPI use and concomitant antibiotic use in both cases and controls. Further study is needed to evaluate the impact of short-course PPI prescriptions in inpatient settings on CDI. Disclosures All authors: No reported disclosures.

scholarly journals Evaluation of Cycle Threshold, Toxin Concentration, and Clinical Characteristics of Clostridioides difficile Infection in Patients with Discordant Diagnostic Test Results

2020 ◽  
Vol 58 (5) ◽  
Author(s):  
Megan D. Shah ◽  
Joan-Miquel Balada-Llasat ◽  
Kelci Coe ◽  
Erica Reed ◽  
Johanna Sandlund ◽  
...  
Keyword(s):  
Clinical Characteristics ◽  
Laboratory Data ◽  
Antibiotic Use ◽  
Neutralization Assay ◽  
Test Results ◽  
Toxin Concentration ◽  
Content Type ◽  
Cycle Threshold ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection

ABSTRACT Clostridioides difficile infection (CDI) is one of the most common health care-associated infections that can cause significant morbidity and mortality. CDI diagnosis involves laboratory testing in conjunction with clinical assessment. The objective of this study was to assess the performance of various C. difficile tests and to compare clinical characteristics, Xpert C. difficile/Epi (PCR) cycle threshold (CT), and Singulex Clarity C. diff toxins A/B (Clarity) concentrations between groups with discordant test results. Unformed stool specimens from 200 hospitalized adults (100 PCR positive and 100 negative) were tested by cell cytotoxicity neutralization assay (CCNA), C. diff Quik Chek Complete (Quik Chek), Premier Toxins A and B, and Clarity. Clinical data, including CDI severity and CDI risk factors, were compared between discordant test results. Compared to CCNA, PCR had the highest sensitivity at 100% and Quik Chek had the highest specificity at 100%. Among clinical and laboratory data studied, prevalences of leukocytosis, prior antibiotic use, and hospitalizations were consistently higher across all subgroups in comparisons of toxin-positive to toxin-negative patients. Among PCR-positive samples, the median CT was lower in toxin-positive samples than in toxin-negative samples; however, CT ranges overlapped. Among Clarity-positive samples, the quantitative toxin concentration was significantly higher in toxin-positive samples than in toxin-negative samples as determined by CCNA and Quik Chek Toxin A and B. Laboratory tests for CDI vary in sensitivity and specificity. The quantitative toxin concentration may offer value in guiding CDI diagnosis and treatment. The presence of leukocytosis, prior antibiotic use, and previous hospitalizations may assist with CDI diagnosis, while other clinical parameters may not be consistently reliable.

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