scholarly journals Recent advances in the treatment of Clostridioides difficile infection: the ever-changing guidelines

2020 ◽  
Vol 9 ◽  
Author(s):  
Shruti Khurana ◽  
Alyssa Kahl ◽  
Kevin Yu ◽  
Andrew W DuPont
Keyword(s):  
Infectious Diseases ◽  
Diagnostic Testing ◽  
Antibody Therapy ◽  
Treatment Strategies ◽  
Current Evidence ◽  
Healthcare Associated Infection ◽  
The Past ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
Healthcare Associated

Clostridioides difficile infection (CDI), formerly known as Clostridium difficile, continues to be the most common healthcare-associated infection worldwide. With the shifting epidemiology towards higher a incidence of community-acquired CDI and the continued burden on the healthcare system posed by high rates of CDI recurrence, there has been an impetus to advance the diagnostic testing and treatment strategies. Recent advancements over the past decade have led to rapidly changing guidelines issued by the Infectious Diseases Society of America and European Society of Clinical Microbiology and Infectious Diseases. With our comprehensive review, we aim to summarize the latest advances in diagnosing and treating CDI and thus attempt to help readers guide best practices for patient care. This article also focusses on cost-effectiveness of various therapies currently available on the market and provides an analysis of the current evidence on a relatively new monoclonal antibody therapy, Bezlotoxumab, to treat recurrent CDI.

scholarly journals Defining the black box: a narrative review of factors associated with adverse outcomes from severe Clostridioides difficile infection

2021 ◽  
Vol 14 ◽  
pp. 175628482110481
Author(s):  
Adam Ressler ◽  
Joyce Wang ◽  
Krishna Rao
Keyword(s):  
The United States ◽  
Adverse Outcomes ◽  
Chronic Illnesses ◽  
Narrative Review ◽  
Healthcare Associated Infection ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
Patients At Risk ◽  
Hospital Deaths ◽  
Healthcare Associated

In the United States, Clostridioides difficile infection (CDI) is the leading cause of healthcare-associated infection, affecting nearly half a million people and resulting in more than 20,000 in-hospital deaths every year. It is therefore imperative to better characterize the intricate interplay between C. difficile microbial factors, host immunologic signatures, and clinical features that are associated with adverse outcomes of severe CDI. In this narrative review, we discuss the implications of C. difficile genetics and virulence factors in the molecular epidemiology of CDI, and the utility of early biomarkers in predicting the clinical trajectory of patients at risk of developing severe CDI. Furthermore, we identify associations between host immune factors and CDI outcomes in both animal models and human studies. Next, we highlight clinical factors including renal dysfunction, aging, blood biomarkers, level of care, and chronic illnesses that can affect severe CDI diagnosis and outcome. Finally, we present our perspectives on two specific treatments pertinent to patient outcomes: metronidazole administration and surgery. Together, this review explores the various venues of CDI research and highlights the importance of integrating microbial, host, and clinical data to help clinicians make optimal treatment decisions based on accurate prediction of disease progression.

scholarly journals Risk for Clostridioides difficile infection among hospitalized patients associated with multiple healthcare exposures prior to admission

2020 ◽  
Author(s):  
Aaron C Miller ◽  
Daniel K Sewell ◽  
Alberto M Segre ◽  
Sriram V Pemmaraju ◽  
Philip M Polgreen ◽  
...  
Keyword(s):  
Hospitalized Patients ◽  
Healthcare Associated Infection ◽  
Case Definitions ◽  
Multiple Exposures ◽  
Clostridioides Difficile ◽  
Increased Risk ◽  
Increase Risk ◽  
Clostridioides Difficile Infection ◽  
Degree Of Association ◽  
Healthcare Associated

Abstract Purpose Clostridioides difficile infections (CDIs) are a common healthcare-associated infection and often used as indicators of hospital safety or quality. However, healthcare exposures occurring prior to hospitalization may increase risk for CDI. We conduct a case-control study comparing hospitalized patients with and without CDI to determine if healthcare exposures prior to hospitalization (i.e., clinic visits, antibiotics, family members with CDI) were associated with increased risk for hospital onset CDI, and how risk varied with time between exposure and hospitalization. Methods Records were collected from a large insurance-claims database from 2001-2017 for hospitalized adult patients. Prior healthcare exposures were identified using inpatient, outpatient, emergency department, and prescription drug claims; results were compared between various CDI case definitions. Results Hospitalized patients with CDI had significantly more frequent healthcare exposures prior to admission. Healthcare visits, antibiotics and family exposures were associated with greater likelihood of CDI during hospitalization. The degree of association diminished with time between exposure and hospitalization. Results were consistent across CDI case definitions. Conclusions Many different prior healthcare exposures appear to increase risk for CDI presenting during hospitalization. Moreover, patients with CDI typically have multiple exposures prior to admission, confounding the ability to attribute cases to a particular stay.

scholarly journals 1016. Standardized Antimicrobial Administration Ratio (SAAR) and Clostridioides difficile Infection Standardized Infection Ratio (SIR): Are they connected? An Evaluation of 28 Hospitals

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S357-S357
Author(s):  
Danielle Sebastian ◽  
Florian Daragjati ◽  
Karl Saake ◽  
Lisa K Sturm ◽  
Mohamad G Fakih
Keyword(s):  
Antimicrobial Agent ◽  
Broad Spectrum ◽  
Antibacterial Agents ◽  
Control Strategies ◽  
Antibiotic Use ◽  
Healthcare Associated Infection ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
Healthcare Associated ◽  
Antimicrobial Administration

Abstract Background Clostridioides difficile infections (CDIs) are the most prevalent healthcare-associated infection in the U.S. Of all CDIs, most are related to healthcare exposures and are potentially preventable by reducing unnecessary antibiotic use and interrupting patient-to-patient transmission of CDI. Methods The adult SAARs for 4 antimicrobial agent categories were compared with the CDI SIR at 28 facilities with greater than 100 beds across the health system for the calendar year of 2018. The 4 adult antimicrobial agent categories chosen for comparison were: antibacterial agents posing the highest risk for CDI, broad-spectrum antibacterial agents predominantly used for hospital-onset infections (BSHO), broad-spectrum antibacterial agents predominantly used for community-acquired infections (BSCA) and all antibacterial agents. Results The 2018 aggregate CDI SIR for the 28 facilities was 0.609. The aggregate SAAR for the adult antimicrobial agent categories were 1.05 for the antibacterial agents posing the highest risk for CDI, 1.05 for BSHO, 0.88 for BSCA, and 1.03 for all antibacterial agents. No correlation was seen between any of the 4 adult SAAR antimicrobial agent categories and the facility CDI SIR (Figure 1–4). Conclusion While reducing unnecessary antibiotics is an important strategy in preventing CDIs, having a higher observed vs. predicted administration ratio in the four antimicrobial agent categories studied was not correlated with a higher CDI SIR, including the CDI SAAR category. Reduction of CDI is challenging requiring a multipronged approach to include infection control strategies, appropriate testing, and antimicrobial stewardship. Disclosures All authors: No reported disclosures.

scholarly journals 797. Management of Patients with Multiple Clostridioides difficile Infection Recurrences using a Tapered-Pulsed Fidaxomicin Strategy

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S441-S442
Author(s):  
Xing Tan ◽  
Andrew M Skinner ◽  
Benjamin Sirbu ◽  
Larry H Danziger ◽  
Dale N Gerding ◽  
...  
Keyword(s):  
First Episode ◽  
Initial Symptom ◽  
Once Daily ◽  
The Past ◽  
Clostridioides Difficile ◽  
Time To Recurrence ◽  
Clostridioides Difficile Infection ◽  
The Mean ◽  
Systemic Antibiotics

Abstract Background There is a paucity of data assessing outcomes of alternate fidaxomicin strategies in patients with recurrent Clostridioides difficile infection (rCDI). The objective of our study is to evaluate a tapered-pulsed (T-P) fidaxomicin regimen that was administered immediately following a course of CDI treatment with initial symptom resolution in patients with multiple rCDI. Methods We reviewed the characteristics and outcomes of 46 consecutive patients who received T-P fidaxomicin between January 1, 2014-June 30, 2019 in a specialty CDI clinic. The first episode in which fidaxomicin T-P was administered was analyzed. Failure was defined as the persistence of diarrhea and/or the need for additional CDI treatment at any time on T-P fidaxomicin. Sustained clinical cure (SCC) was defined as resolution of diarrhea without recurrence. Recurrence was defined as the return of diarrhea requiring retreatment with CDI therapy after completion of T-P fidaxomicin. Both SCC and recurrence were evaluated at 30 and 90 days after completion of T-P fidaxomicin. Results The mean±SD age of the 46 patients was 63.2±19.9 years, 71.7% were female, and the mean±SD CDI episodes within the past year was 3±1.4 . Most patients (73.9%) had previously failed a vancomycin tapered and/or pulsed regimen. Prior to administering T-P fidaxomicin, a treatment regimen was given to ensure resolution of symptoms. The CDI treatment most commonly used (58.7%) was vancomycin. The T-P fidaxomicin regimen used consisted of 200 mg given once daily for 7 days followed by 200 mg every other day for a median (min-max) duration of 33 (6-120) days. Two patients (4%) failed to respond to T-P fidaxomicin; 34 (74%) and 28 (61%) achieved SCC at 30 and 90 days, respectively. Among the 44 patients that successfully completed the T-P fidaxomicin regimen, recurrence developed in 10 (22.7%) and 16 (36.4%) of patients at 30 and 90 days, respectively, with a median (min-max) time to recurrence of 20 (3-87) days (Figure 1). Four patients with recurrence had received subsequent systemic antibiotics. Figure 1. Course of CDI therapy and follow-up Conclusion A tapered-pulsed fidaxomicin strategy may be effective in patients with multiply rCDI who are refractory to other treatments, including a vancomycin tapered and pulsed regimen. Disclosures Larry H. Danziger, PharmD, Merck (Speaker’s Bureau)

The Past, Present, and Future of Healthcare-Associated Infection Prevention in Pediatrics: Catheter-Associated Bloodstream Infections

2010 ◽  
Vol 31 (S1) ◽  
pp. S27-S31 ◽  
Author(s):  
Kristina A. Bryant ◽  
Danielle M. Zerr ◽  
W. Charles Huskins ◽  
Aaron M. Milstone
Keyword(s):  
Infection Prevention ◽  
Bloodstream Infections ◽  
Central Line ◽  
Morbidity And Mortality ◽  
Prevention Strategies ◽  
Healthcare Associated Infection ◽  
Research Topics ◽  
The Past ◽  
Healthcare Associated ◽  
Current Practices

Central line–associated bloodstream infections cause morbidity and mortality in children. We explore the evidence for prevention of central line–associated bloodstream infections in children, assess current practices, and propose research topics to improve prevention strategies.

The Past, Present, and Future of Healthcare-Associated Infection Prevention in Pediatrics: Viral Respiratory Infections

2010 ◽  
Vol 31 (S1) ◽  
pp. S22-S26 ◽  
Author(s):  
Danielle M. Zerr ◽  
Aaron M. Milstone ◽  
W. Charles Huskins ◽  
Kristina A. Bryant
Keyword(s):  
Influenza A ◽  
Infection Prevention ◽  
Virus Isolation ◽  
Respiratory Infections ◽  
Healthcare Associated Infection ◽  
The Past ◽  
Viral Respiratory Infections ◽  
Healthcare Associated ◽  
Pediatric Infection ◽  
Viral Respiratory

Viral respiratory infections pose a significant challenge to pediatric infection prevention programs. We explore issues regarding the prevention of viral respiratory infections by discussing transmission of influenza A virus, isolation of infected patients, and hospital programs for influenza vaccination.

scholarly journals 2373. Impact of a Change in Testing Strategy for Clostridioides difficile Infection on a Publicly Reported Metric and Treatment Days of Therapy

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S818-S819
Author(s):  
Ryan Miller ◽  
Jose A Morillas ◽  
Joanne Sitaras ◽  
Jacob Bako ◽  
Elizabeth A Neuner ◽  
...  
Keyword(s):  
Health System ◽  
Diagnostic Testing ◽  
Cleveland Clinic ◽  
Public Reporting ◽  
Testing Strategy ◽  
Clostridioides Difficile ◽  
Days Of Therapy ◽  
Before And After ◽  
Clostridioides Difficile Infection ◽  
The Impact

Abstract Background In an effort to optimize diagnostic testing for Clostridioides difficile infection (CDI) our health system changed from stand-alone PCR testing to a “2-step” approach wherein all positive PCR results reflexed to an EIA. We report the effects of this change on publicly reported CDI metrics and treatment days of therapy (DOT). Methods The setting includes 10 Cleveland Clinic Health System hospitals in northeast Ohio and one in Florida. On June 12, 2018, 9 NE Ohio hospitals changed from PCR alone to PCR followed by EIA. Stand-alone PCR testing remained at one and GDH / EIA / PCR for discordant for another. Testing volumes were obtained from the microbiology laboratory. C. difficile LabID event SIRs were obtained from NHSN. Public reporting interpretative categories were identified based on SIR for second half of 2018. DOT for CDI agents were obtained from an antimicrobial stewardship database. Results Among hospitals that changed strategy the volume of PCR testing and the percent PCR + was similar between time periods. EIA positivity ranged from 23% to 53%. 4/11 hospitals improved their public reporting category: 3/9 that changed testing strategy and 1/2 that did not (Table 1). Two of 3 that changed strategy and improved public reporting also had a decrease in DOT. DOT increased in the 2 hospitals that did not change strategy. Conclusion Six months after adopting a 2-step CDI testing strategy 7 of 9 hospitals had a lower SIR with 3 also demonstrating an improvement in public reporting category favorably impacting reputational and reimbursement risk for our healthcare system. CDI agent DOT was similar before and after the change. The impact of choice of test on publicly reported metrics demonstrates the difficulty of utilizing a proxy for hospital onset CDI, the CDI LabID event, as a measure of quality of care provided. Disclosures All authors: No reported disclosures.

scholarly journals 2356. Increased Clinical Specificity with Ultrasensitive Detection of Clostridioides difficile Toxins: Reduction of Overdiagnosis Compared with Nucleic Acid Amplification Tests

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S811-S812 ◽  
Author(s):  
Johanna Sandlund ◽  
Joel Estis ◽  
Phoebe Katzenbach ◽  
Niamh Nolan ◽  
Kirstie Hinson ◽  
...  
Keyword(s):  
Nucleic Acid ◽  
Disease Severity ◽  
Single Molecule ◽  
Clinical Performance ◽  
Neutralization Assay ◽  
Nucleic Acid Amplification ◽  
Clostridioides Difficile ◽  
Percent Agreement ◽  
Clostridioides Difficile Infection ◽  
Healthcare Associated

Abstract Background Clostridioides difficile infection (CDI) is one of the most common healthcare-associated infections, resulting in significant morbidity, mortality, and economic burden. Diagnosis of CDI relies on the assessment of clinical presentation and laboratory tests. We have evaluated the clinical performance of ultrasensitive Single Molecule Counting technology for detection of C. difficile toxins A and B. Methods Stool specimens from 298 patients with suspected CDI were tested with nucleic acid amplification test (NAAT; BD MAX™ Cdiff assay or Xpert® C. difficile assay) and Singulex Clarity® C. difficile toxins A/B assay. Specimens with discordant results were tested with cell cytotoxicity neutralization assay (CCNA), and results were correlated with disease severity and outcome. Results There were 64 NAAT-positive and 234 NAAT-negative samples. Of the 32 NAAT+/Clarity− and 4 NAAT-/Clarity+ samples, there were 26 CCNA− and 4 CCNA- samples, respectively. CDI relapse or overall death was more common in NAAT+/toxin+ patients than in NAAT+/toxin− and NAAT−/toxin− patients, and NAAT+/toxin+ patients were 3.7 times more likely to experience relapse or death (Figure 1). The clinical specificity of Clarity and NAAT was 97.4% and 89.0%, respectively, and overdiagnosis was over three times more common in NAAT+/toxin− than in NAAT+/toxin+ patients (Figure 2). Negative percent agreement between NAAT and Clarity was 98.3%, and positive percent agreement increased from 50.0% to effective 84.2% and 94.1% after CCNA testing and clinical assessment. Conclusion The Clarity assay was superior to NAATs in diagnosis of CDI, by reducing overdiagnosis and thereby increasing clinical specificity, and presence of toxins was associated with disease severity and outcome. Disclosures All authors: No reported disclosures.

scholarly journals Comparison of Fluoroquinolone Versus Non-Fluoroquinolone Therapy for Inpatient Treatment of Chronic Obstructive Pulmonary Disease Exacerbations

2019 ◽  
Vol 35 (6) ◽  
pp. 251-257
Author(s):  
Kassandra Ramos ◽  
Bryan Allen ◽  
Chad Cannon ◽  
Kristal Cunningham ◽  
Calvin Tucker
Keyword(s):  
Chronic Obstructive Pulmonary Disease ◽  
Pulmonary Disease ◽  
Antimicrobial Therapy ◽  
Current Evidence ◽  
Chronic Obstructive ◽  
Inpatient Setting ◽  
Obstructive Pulmonary Disease ◽  
Clinical Resolution ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection

Background: While antimicrobial use in the treatment of acute exacerbations of chronic obstructive pulmonary disease (COPD) is reserved for more severe cases, the current evidence available comparing fluoroquinolones (FQs) to other classes in the inpatient setting are lacking. Objective: To compare the effectiveness of FQ therapy compared with non-FQs (NFQs) during acute COPD exacerbations in hospitalized patients. Methods: In this single-centered institutional review board–approved retrospective chart review, participants were included if they were at least 18 years of age and hospitalized for an acute exacerbation of COPD. Patients were stratified into FQ or NFQ groups based on the initial antimicrobial regimen administered. The primary outcome was the clinical resolution rate after antimicrobial therapy. Secondary outcomes included length of hospital stay, duration of antimicrobial therapy, 30-day readmission rates, and Clostridioides difficile infection rates. Results: A total of 375 patients were included (FQ = 201; NFQ = 174). The NFQ group had a higher rate of clinical resolution (84.5% vs 76.1%, P = .0435). In a multivariable regression analysis, the association between NFQ therapy and higher rates of clinical resolution remained significant (odds ratio = 2.31; 95% confidence interval = 1.3-4.10; P = .0043). The FQ group had a shorter length of stay (4 vs 5 days; P = .0022) and shorter inpatient antibiotic duration (4 vs 5 days; P = .0200). Rates of Clostridioides difficile infection and readmission were similar between groups. Conclusions: NFQ therapy may provide a higher rate of clinical resolution while avoiding exposure to FQ therapy and known adverse effects associated with FQ use.

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