WikiPortallus: Clostridium difficile.html

C. difficile is the most significant cause of pseudomembranous colitis.² It is a severe infection of the colon, often happening after normal gut flora is eradicated by use of antibiotics. The C. difficile bacteria, which naturally reside in the body, become overgrown: The overgrowth is harmful because the bacterium releases toxins that can cause bloating, constipation, and diarrhea with abdominal pain, which may become severe. The latent symptoms often mimic some flu-like symptoms. Treatment is performed by stopping current treatment and commencing specific anticlostridial antibiotics, e.g., metronidazole or vancomycin.

Bacteriology

Clostridia are motile bacteria that are ubiquitous in nature and are especially prevalent in soil. Under the microscope after Gram staining, they appear as long drumsticks with a bulge located at their terminal ends. Clostridium difficile cells are Gram-positive and show optimum growth on blood agar at human body temperatures in the absence of oxygen. When stressed, the bacteria produce spores, which tolerate extreme conditions that the active bacteria cannot tolerate.

First described by Hall and O'Toole in 1935, "the difficult clostridium" was resistant to early attempts at isolation and grew very slowly in culture.³

C. difficile is a commensal bacterium of the human intestine in a minority of the population. Patients who have been staying long-term in a hospital or a nursing home have a higher likelihood of being colonized by this bacterium. In small numbers it does not result in disease of any significance. Antibiotics, especially those with a broad spectrum of activity, cause disruption of normal intestinal flora, leading to an overgrowth of C. difficile, which flourishes under these conditions. This leads to pseudomembranous colitis.

C. difficile is resistant to most antibiotics. It is transmitted from person to person by the fecal-oral route. Because the organism forms heat-resistant spores, it can remain in the hospital or nursing home environment for long periods of time. It can be cultured from almost any surface in the hospital. Once spores are ingested, they pass through the stomach unscathed because of their acid-resistance. They change to their active form in the colon and multiply.

It has been observed that several disinfectants commonly used in hospitals may fail to kill the bacteria, and may actually promote spore formation. However, disinfectants containing bleach are effective in killing the organisms⁴.

Toxins

Pathogenic C. difficile strains produce various toxins. The most well-characterized are enterotoxin (toxin A) and cytotoxin (toxin B).¹ These two toxins are both responsible for the diarrhea and inflammation seen in infected patients, although their relative contributions have been debated by researchers. Another toxin, binary toxin, has also been described, but its role in disease is not yet fully understood.⁵

Role in disease

With the introduction of broad-spectrum antibiotics in the latter half of the twentieth century, antibiotic-associated diarrhea became more common. Pseudomembranous colitis was first described as a complication of C. difficile infection in 1978,⁶ when a toxin was isolated from patients suffering from pseudomembranous colitis and Koch's postulates were met.

C. difficile infection (CDI) can range in severity from asymptomatic to severe and life-threatening, and many deaths have been reported, especially among the aged. People are most often infected in hospitals, nursing homes, or institutions, although C. difficile infection in the community, outpatient setting is increasing. C. difficile associated diarrhea (aka CDAD) has been linked to use of broad-spectrum antibiotics such as cephalosporins and clindamycin, though the use of quinolones is now probably the most likely culprit; quinolones are frequently used in hospital settings. Frequency and severity of C. difficile colitis remains high and seems to be associated with increased death rates. Immunocompromised status and delayed diagnosis appear to result in elevated risk of death. Early intervention and aggressive management are key factors to recovery.

The rate of C. difficile acquisition is estimated to be 13% in patients with hospital stays of up to 2 weeks, and 50% in those with hospital stays longer than 4 weeks.

Increasing rates of community-acquired Clostridium difficile-associated infection/disease (CDAD) have also been linked to the use of medication to suppress gastric acid production: H2-receptor antagonists increased the risk twofold, and proton pump inhibitors threefold, mainly in the elderly. It is presumed that increased gastric pH, (alkalinity), leads to decreased destruction of spores.⁷

Diagnosis

To prevent complications, clinicians often begin treatment based on clinical presentation before definitive results are available. Knowledge of the local epidemiology of intestinal flora of a particular institution can guide therapy.

Symptoms and signs

Cytotoxicity assay

C. difficile toxin detection as cytopathic effect in cell culture, and neutralized with specific anti-sera is the practical gold standard for studies investigating new CDAD diagnostic techniques. Toxigenic culture, in which organisms are cultured on selective medium and tested for toxin production, remains the gold standard and is the most sensitive and specific test, although it is slow and labour-intensive.⁹

Toxin ELISA

Experts recommend sending as many as three samples to rule-out disease if initial tests are negative. C. difficile toxin should clear from the stool of previously infected patients if treatment is effective. However, many hospitals test only for the prevalent toxin A. Strains that express only the B toxin are now present in many hospitals, and ordering both toxins should occur.^{citation needed} Not testing for both may contribute to a delay in obtaining laboratory results, which is often the cause of prolonged illness and poor outcomes.

Other stool tests

Stool leukocyte measurements and stool lactoferrin levels have also been proposed as diagnostic tests, but may have limited diagnostic accuracy.¹⁰

Computed tomography

In a recent study, a patient who received a diagnosis of CDC on the basis of computed tomography (CT scan) had an 88% probability of testing positive on stool assay.¹¹ Wall thickening is the key CT finding in this disease. Once colon wall thickening is identified as being >4 mm, the best ancillary findings were pericolonic stranding, ascites, and colon wall nodularity. The presence of wall thickness plus any one of these ancillary findings is 70% sensitive and 93% specific.

Using criteria of >=10 mm or a wall thickness of >4 mm and any of the more-specific findings does not add significantly to the diagnosis but gives equally satisfactory results. In this study with a prevalence of positive C. difficile toxin of 54%, the PPV was 88%. Patients who have antibiotic-associated diarrhea who have CT findings diagnostic of CDC merit consideration for treatment on that basis. A weakness of this study was not using a gold standard cytotoxicity assay.

Treatment

Many persons will also be asymptomatic and colonized with Clostridium difficile. Treatment in asymptomatic patients is controversial, also leading into the debate of clinical surveillance and how it intersects with public health policy.

Patients should be treated as soon as possible when the diagnosis of Clostridium difficile colitis (CDC) is made to avoid frank sepsis or bowel perforation.

Pharmacotherapy

Three antibiotics are effective against C. difficile. Metronidazole 500 mg orally three times daily is the drug of choice, because of lower price and comparable efficacy.¹³ Oral vancomycin 125 mg four times daily is second-line therapy, but is avoided due to theoretical concerns of converting intestinal flora into vancomycin resistant organisms. However, it is used in the following cases: severe C. difficile diarrhea¹⁴ (the duration of diarrhea is reduced to 3 versus 4.6 days with metronidazole^{citation needed}); no response to oral metronidazole; the organism is resistant to metronidazole; the patient is allergic to metronidazole; the patient is either pregnant or younger than 10 years of age. Vancomycin must be administered orally because IV administration does not achieve gut lumen minimum therapeutic concentration. The use of linezolid may be considered, too, and newer drugs such as ramoplanin are in clinical development.

It has been known that drugs traditionally used to stop diarrhea worsen the course of C. difficile-related pseudomembranous colitis. Loperamide, diphenoxylate and bismuth compounds are indeed contraindicated, because slowing of fecal transit time is thought to result in extended toxin-associated damage. Cholestyramine, a powder drink occasionally used to lower cholesterol, is effective in binding both Toxin A and B, and slows bowel motility and helps prevent dehydration.¹⁵ The dosage can be 4 grams daily, to up to four doses a day: Caution should be exercised to prevent constipation, or drug interactions, most notably the binding of drugs by cholestyramine, preventing their absorption. Powdered banana flakes given twice daily is an alternative to cholestyramine and allow for stool bulking. Treatment with probiotics ("good" intestinal flora) has also been shown effective.^{citation needed} Provision of Saccharomyces boulardii (Florastor) or Lactobacillus acidophilus twice daily times 30 days along with antibiotics has been clinically shown to shorten the duration of diarrhoea. A last-resort treatment in immunosuppressed patients is intravenous immunoglobulin (IVIG).¹⁵

Colectomy

In those patients that develop systemic symptoms of CDC, colectomy may improve the outcome if performed before the need for vasopressors.

Fecal bacteriotherapy

Fecal bacteriotherapy, a procedure related to probiotic research, has been suggested as a potential cure for the disease. It involves infusion of bacterial flora acquired from the feces of a healthy donor in an attempt to reverse bacterial imbalance responsible for the recurring nature of the infection. It has a success rate of nearly 95% according to some sources.¹⁶¹⁷¹⁸

Recurrence

The evolution of protocols for patients with recurrent C. difficile diarrhea also present a challenge: There is no known proper length of time or universally accepted alternative drugs with which one should be treated. However, re-treatment with metronidazole or vancomycin at the previous dose for 10 to 14 days is generally successful. The addition of rifampin to vancomycin also has been effective. Prophylaxis with competing, nonpathogenic organisms such as Lactobacillus spp. or Saccharomyces boulardii has been found to be helpful in preventing relapse in small numbers of patients (see, for example, Florastor, or Lactinex). It is thought that these organisms, also known as probiotics, help to restore the natural flora in the gut and make patients more resistant to colonization by C. difficile.¹⁹

Prevention

The most effective method for preventing CDAD is proper antimicrobial prescribing. In the hospital setting, where CDAD is most common, nearly all patients that develop CDAD are exposed to antimicrobials. Although proper antimicrobial prescribing sounds easy to do, approximately 50% of antimicrobial use is considered inappropriate. This is consistent whether in the hospital, clinic, community, or academic setting. Several studies have demonstrated a decrease in CDAD by limiting antibiotics most strongly associated with CDAD or by limiting unnecessary antimicrobial prescribing in general, both in outbreak and non-outbreak settings. The testing of all hospital inpatients over the age of 65 with diarrhea for CDiff became a compulsory NHS practice in January 2008, when it became evident that many outbreaks were being disguised as Noroflu in the UK, by hospital Risk Managers, who can be sacked by the Department of Health if CDiff infection rates are too high, but cannot be sacked over Noroflu outbreaks {see Department of Health website: insert link]. Patients most at risk are those with a prescription medicine history of broad-range antibiotics such as penicillins, and proton pump inhibitor drugs like omeprazole.

Infection control measures, such as wearing gloves when caring for patients with CDAD, have been proven to be effective at preventing CDAD. This works by limiting the spread of C. difficile in the hospital setting. In addition, washing with soap and water will eliminate the spores from contaminated hands, but alcohol-based hand rubs are ineffective.²⁰

Polysan sprays are proven to be effective at preventing CDAD, not only by killing CDAD but also by killing the Spores, on all surfaces. Because it also creates a polymer boundary over the surface, it continues to bo be effective and kill for up to seven days in its dry form.

Treatment with various oral supplements containing live bacteria has been studied in efforts to prevent Clostridium difficile-associated infection/disease. A randomized controlled trial using a probiotic drink containing Lactobacillus casei, L bulgaricus, and Streptococcus thermophilus was reported to have some efficacy. This study was sponsored by the company that produces the drink studied.²¹ Although intriguing, several other studies have been unable to demonstrate any benefit of oral supplements of similar bacteria at preventing CDAD.^{citation needed} Of note, patients on the antibiotics most strongly associated with CDAD were excluded from this study. On January 29, 2008, scientists revealed that they have found a vaccination to prevent Clostridium difficile. They stated it will be released in about three years' time.

Notable outbreaks

On June 4, 2003, two outbreaks of a highly virulent strain of this bacterium were reported in Montreal, Quebec and Calgary, Alberta, in Canada. Sources put the death count as low as 36 and as high as 89, with approximately 1,400 cases in 2003 and within the first few months of 2004. C. difficile infections continued to be a problem in the Quebec health care system in late 2004. As of March 2005, it had spread into the Toronto, Ontario area, hospitalizing 10 people. One died while the others were being discharged.

A similar outbreak took place at Stoke Mandeville Hospital in the United Kingdom between 2003 and 2005. The local epidemiology of C. difficile may offer clues on how its spread may relate to the amount of time a patient spends in hospital and/or a rehabilitation center. It also samples institutions' ability to detect increased rates, and their capacity to respond with more aggressive hand-washing campaigns, quarantine methods, and availability of yoghurt to patients at risk for infection.

It has been suggested that both the Canadian and English outbreaks were related to the seemingly more virulent Strain NAP1/027 of bacterium. This novel strain, also known as Quebec strain, has also been implicated in an epidemic at two Dutch hospitals (Harderwijk and Amersfoort, both 2005). A theory for explaining the increased virulence of 027 is that it is a hyperproducer of both toxins A and B, and that certain antibiotics may actually stimulate the bacteria to hyperproduce.

On December 2, 2005, The New England Journal of Medicine, in an article spearheaded by Drs. Vivian Loo, Louise Poirier, and Mark Miller, reported the emergence of a new, highly toxic strain of C. difficile, resistant to fluoroquinolone antibiotics, such as Cipro (ciprofloxacin) and Levaquin (levofloxacin), said to be causing geographically dispersed outbreaks in North America.²² The Centers for Disease Control in Atlanta has also warned of the emergence of an epidemic strain with increased virulence, antibiotic resistance, or both.²³

As one analyzes the pool of patients with the spores, many that are asymptomatic will pass the organism to individuals that are immunocompromised and, hence, susceptible to increasing rates of diarrhea and poor outcome. It seems notable that the clusters described above represent a challenge to epidemiologists trying to understand how the illness spreads via the convergence of information technology with clinical surveillance.

On October 1, 2006, C.diff was said to have killed at least 49 people at hospitals in Leicester, England over eight months, according to a National Health Service investigation. Another 29 similar cases were investigated by coroners.²⁴ A UK Department of Health memo leaked shortly afterwards revealed significant concern in government about the bacterium, described as being "endemic throughout the health service"²⁵

On October 27, 2006, 9 deaths were attributed to the bacterium in Quebec, Canada.²⁶

On November 18, 2006, the bacterium was reported to have been responsible for 12 deaths in Quebec, Canada. This 12th reported death was only two days after the St. Hyacinthe's Honoré Mercier announced that the outbreak was under control. Thirty-one patients were diagnosed with Clostridium difficile and four (as of Sat. Nov 18th) were still under observation. Cleaning crews took measures in an attempt to clear the outbreak.²⁷

On February 27, 2007, a new outbreak was identified at Trillium Health Centre in Mississauga, Ontario, where 14 people were diagnosed with the bacteria. The bacteria was of the same strain as the one in Quebec. Officials have not been able to determine whether C. difficile was responsible for deaths of four patients over the prior two months.²⁸

Between February and June 2007, three patients at Loughlinstown Hospital in Dublin, Ireland were found by the coroner to have died as a result of C.diff infection. In an inquest, the Coroner's Court found that the hospital had no designated infection control team or consultant microbiologist on staff. ²⁹

In October 2007, Maidstone and Tunbridge Wells NHS Trust was heavily criticized by the Healthcare Commission regarding its handling of a major outbreak of C. difficile in its hospitals in Kent from April 2004 to September 2006. In its report, the Commission estimated that about 90 patients "definitely or probably" died as a result of the infection. ³⁰³¹

In November 2007, the 027 strain has spread into several hospitals in southern Finland, with ten deaths out of 115 infected patients reported on 2007-12-14. ³²

Clostridium difficile was mentioned on 6,480 death certificates in 2006 in UK. ³³

Sequencing the genome of the Quebec strain

On December 14, 2005, researchers at McGill University in Montreal, Quebec, led by Dr. Ken Dewar and Dr. Andre Dascal and in collaboration with province-organized NPO Genome Quebec's research facility, announced they had sequenced the genome of the highly virulent Quebec strain of C. difficile. This was accomplished by using ultra-high-throughput sequencing technology. The tests involved doing 400,000 DNA parallel sequencing reactions which took the bacterium's genome apart and reassembled it so it could be studied.²²³⁴

It is expected this will allow quicker detection of the disease and better treatment.

Pronunciation

A common practice has developed of pronouncing its specific name difficile as /dɪfɪsi:lˈ/ (as though it were French).

References

^ ^a ^b Ryan KJ, Ray CG (editors) (2004). Sherris Medical Microbiology, 4th ed., McGraw Hill, pp. 322-4. ISBN 0-8385-8529-9.
^ Curry J (2007-07-20). "Pseudomembranous Colitis". eMedicine. WebMD. Retrieved on 2008-11-17.
^ Hall I, O'Toole E (1935). "Intestinal flora in newborn infants with a description of a new pathogenic anaerobe, Bacillus difficilis". Am J Dis Child 49: 390.
^ "Cleaning agents 'make bug strong'", BBC News Online (2006-04-03). Retrieved on 17 November 2008.
^ Barth H, Aktories K, Popoff M, Stiles B (2004). "Binary bacterial toxins: biochemistry, biology, and applications of common Clostridium and Bacillus proteins". Microbiol Mol Biol Rev 68 (3): 373–402, table of contents. doi:10.1128/MMBR.68.3.373-402.2004. PMID 15353562.
^ Larson H, Price A, Honour P, Borriello S (1978). "Clostridium difficile and the aetiology of pseudomembranous colitis". Lancet 1 (8073): 1063–6. doi:10.1016/S0140-6736(78)90912-1. PMID 77366.
^ Dial S, Delaney J, Barkun A, Suissa S (2005). "Use of gastric acid-suppressive agents and the risk of community-acquired Clostridium difficile-associated disease". JAMA 294 (23): 2989–95. doi:10.1001/jama.294.23.2989. PMID 16414946.
^ ^a ^b Katz DA, Lynch ME, Littenberg B (1996). "Clinical prediction rules to optimize cytotoxin testing for Clostridium difficile in hospitalized patients with diarrhea". Am. J. Med. 100 (5): 487–95. doi:10.1016/S0002-9343(95)00016-X. PMID 8644759.
^ Murray PR, Baron EJ, Pfaller EA, Tenover F, Yolken RH (editors) (2003). Manual of Clinical Microbiology, 8th ed, Washington DC: ASM Press. ISBN 1-55581-255-3.
^ Vaishnavi C, Bhasin D, Kochhar R, Singh K (2000). "Clostridium difficile toxin and faecal lactoferrin assays in adult patients". Microbes Infect 2 (15): 1827–30. doi:10.1016/S1286-4579(00)01343-5. PMID 11165926.
^ Kirkpatrick ID, Greenberg HM (2001). "Evaluating the CT diagnosis of Clostridium difficile colitis: should CT guide therapy?". AJR. American journal of roentgenology 176 (3): 635–9. PMID 11222194, http://www.ajronline.org/cgi/content/full/176/3/635.
^ Nelson R. Antibiotic treatment for Clostridium difficile-associated diarrhea in adults. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD004610. PMID 17636768
^ Teasley DG, Gerding DN, Olson MM, Peterson LR, Gebhard RL, Schwartz MJ, Lee JT Jr. Prospective randomised trial of metronidazole versus vancomycin for Clostridium-difficile-associated diarrhoea and colitis. Lancet. 1983 Nov 5;2(8358):1043-6. PMID 6138597
^ Zar FA, Bakkanagari SR, Moorthi KM, Davis MB (2007). "A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity". Clin. Infect. Dis. 45 (3): 302–7. doi:10.1086/519265. PMID 17599306.
^ ^a ^b Stroehlein J (2004). "Treatment of Clostridium difficile Infection". Curr Treat Options Gastroenterol 7 (3): 235–239. doi:10.1007/s11938-004-0044-y. PMID 15149585.
^ Schwan A, Sjölin S, Trottestam U, Aronsson B (1983). "Relapsing clostridium difficile enterocolitis cured by rectal infusion of homologous faeces". Lancet 2 (8354): 845. doi:10.1016/S0140-6736(83)90753-5. PMID 6137662.
^ Paterson D, Iredell J, Whitby M (1994). "Putting back the bugs: bacterial treatment relieves chronic diarrhoea". Med J Aust 160 (4): 232–3. PMID 8309401.
^ Borody T (2000). ""Flora Power"-- fecal bacteria cure chronic C. difficile diarrhea". Am J Gastroenterol 95 (11): 3028–9. PMID 11095314, http://www.cdd.com.au/pdf/paper32.pdf.
^ "Inhibition of Clostridium difficile strains by intestinal Lactobacillus species". Society for General Microbiology. Retrieved on 2008-09-17.
^ http://www.medscape.com/viewarticle/563232
^ Hickson M, D'Souza AL, Muthu N, et al (2007). "Use of probiotic Lactobacillus preparation to prevent diarrhoea associated with antibiotics: randomised double blind placebo controlled trial". BMJ 335 (7610): 80. doi:10.1136/bmj.39231.599815.55. PMID 17604300.
^ ^a ^b Loo V, Poirier L, Miller M, Oughton M, Libman M, Michaud S, Bourgault A, Nguyen T, Frenette C, Kelly M, Vibien A, Brassard P, Fenn S, Dewar K, Hudson T, Horn R, René P, Monczak Y, Dascal A (2005). "A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality". N Engl J Med 353 (23): 2442–9. doi:10.1056/NEJMoa051639. PMID 16322602.
^ McDonald L (2005). "Clostridium difficile: responding to a new threat from an old enemy". Infect Control Hosp Epidemiol 26 (8): 672–5. doi:10.1086/502600. PMID 16156321, http://www.cdc.gov/ncidod/dhqp/pdf/infDis/Cdiff_ICHE08_05.pdf.
^ Trust confirms 49 superbug deaths - BBC News
^ Nigel Hawkes (2007-01-11). "Leaked memo reveals that targets to beat MRSA will not be met". The Times. Retrieved on 2007-01-11.
^ "C. difficile blamed for 9 death in hospital near Montreal". cNews (11th January 200). Retrieved on 2007-01-11.
^ 12th person dies of C. difficile at Quebec hospital - CBC News
^ CTV Toronto - C. difficile outbreak linked to fatal strain - CTV News, Shows and Sports - Canadian Television
^ Irish Independent, Superbug in hospitals linked to four deaths, 10 October, 2007
^ Healthcare Commission press release: Healthcare watchdog finds significant failings in infection control at Maidstone and Tunbridge Wells NHS Trust, 11 October 2007
^ Daily Telegraph, Health Secretary intervenes in superbug row, 11 October 2007
^ Ärhäkkä suolistobakteeri on tappanut jo kymmenen potilasta - HS.fi - Kotimaa
^ Hospitals struck by new killer bugAn article by Manchester free newspaper 'Metro', May 7, 2008
^ Scientists map C. difficile strain - Institute of Public Affairs, Montreal

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