C. difficile

Chased by an antibiotic-induced C difficile-shaped shadow

Jon Otter (@jonotter) Antibiotic resistance, C. difficile , , , , ,

shadow-abx

A fascinating new JAMA Internal Medicine study suggests that being admitted to a room when the prior occupant had taken antibiotics increases the risk of the subsequent occupant of the same room developing C. difficile infection (CDI). Quite a few convincing epi studies have showed that admission to a room when the prior occupant was known to have a number of key pathogens (including C. difficile) increased the chance of acquisition for the subsequent occupant. But this study extends the ‘prior room occupancy’ concept into a new dimension!

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Probiotics vs C. difficile

Jon Otter (@jonotter) C. difficile , , ,

probiotics

C. difficile infection is a disease of dysbiosis – the most common pathology is that antibacterial agents disturb the balance of micro-organisms in the gut leaving C. difficle the ecological space to produce toxin and cause diseases. So, could it be that ‘probiotics’ could fill the ecological space and reduce the risk of CDI? Despite numerous trials, the jury is out!

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Hydrogen peroxide vs. Clostridium difficile

Jon Otter (@jonotter) C. difficile , , , , ,

This study has just been published in the Journal of Hopsital Infection, showing that the introduction of hydrogen peroxide vapour (HPV) for the terminal disinfection of rooms vacated by patients with CDI was assocaited with a significant reduction in the rate of CDI, from 1.0 to 0.4 cases per 1000 patient days.

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Should we start admission screening for C. difficile carriage? A Kiernan vs. Otter pro-con debate!

Jon Otter (@jonotter) C. difficile , , , ,

debate

Both Martin and Jon wanted to post a blog about the same article, so thought we’d put our hands together, so to speak, into a pro-con format! We hope you find it useful.

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Are spores the secret of the success of FMT in treating recurrent CDI?

Jon Otter (@jonotter) C. difficile , , , ,

Characteristic of the aimes strain of b anthracis is the smooth

I have been following the literature around the use of faecal microbiota transplantation (FMT) for the treatment of recurrent Clostridium difficile infection (CDI). FMT is spectacularly effective but rather crude – and may have some associated risks, not least the possibility of transmissing infectious organisms we have not yet discovered! There is also the issue of administration. Compared with recurrent CDI, a duodenal infusion (aka tube up the backside) isn’t so bad – but an oral delivery would be preferable. The ‘crapsule’ (oral FMT) has been tested and is effective, but it requires a large number of crapsules to reach the required dose. So, the search is on to distill the effective elements of FMT into a format that can be delivered more easily. Some work has been done on exploring various combinations of live bacteria – with variable success.

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3.. 2.. 1.. Zero. Great, the 48 hours are up!

Martin Kiernan (@emrsa15) C. difficile, Contamination, Hand hygiene , ,

Slide1We often see those tasked with finding suitable isolation facilities counting down to when precaustions can be discontinued and the ’48 hours clear’ of symptoms of loose stools or vomiting has almost become one of the most welcome statements heard in healthcare settings. No more contact precautions, no more disinfectants sloshing around, normality beckons.. Or should it? Continue reading →

Crapsules part 2

Andreas Voss (@AVIPNL) C. difficile , ,

How do you like your crap? Fresh or frozen?

Schermafbeelding 2016-01-19 om 22.44.47Since Jon’s post on crapsules is one of the most favorite on the blog, I assumed that many of you might enjoy a sequel.

Clostridium difficile infections (CDI), most certainly after the emergence of hypervirulent strains at the beginning of this millennium, have become a major cause of morbidity and mortality in hospital and (to a lesser degree) community patients. One in four patients will suffer from recurrent CDI and treatment options are limited. Consequently, fecal microbiota transplantation (FMT) has become a valuable alternative, but is not readily available. Using frozen FMT would make the logistics far easier and finally something frozen seems to be as good as fresh, according to this JAMA study!

Cost of CDI – New estimate, but how accurate?

Martin Kiernan (@emrsa15) C. difficile, Finance

bank-17626_640To be honest I’m a bit fed up with quoting the £4000 per CDI case that was calculated by Mark Wilcox and colleagues back in 19 0 plonk (1996 to be exact) and so I was quite excited to stumble across a new estimate from Merseyside whilst browsing ‘Value in Health‘, one of my usual reads. Well, possibly not.. although perhaps it should be – and it does support open access.

Nakamura and colleagues presented an abstract at the 18th International Society for Pharmacoeconomics and Outcomes Research (ISPOR) meeting and have calculated the mean extra cost of a patient with CDI to be £10,956.82, although as the authors point out, how much of this is attributable to the extra cost of CDI rather than the multiple co-morbidities that likely contributed to the infection leading to the antibiotic treatment, which led to the CDI continues to elude us. The authors are continuing to work on this and I await their final findings with interest, however for now I’ll settle for £11,000 per case as opposed to the 1996 figure of £4000 (data collected in 1995) and is probably more realistic than just allowing for inflation that has averaged at 2.8% pa, which would have made it £6868. As we know (well all of us apart from the Treasury), health inflation is way ahead of normal financial indicators.

Molecular diagnostics for C. difficile infection: too much of a good thing?

Jon Otter (@jonotter) C. difficile , , , ,

A study in JAMA Internal Medicine suggests that we may be ‘overdiagnosising’ C. difficile in this era of molecular diagnostics. The researchers from California grouped the 1416 patients tested for C. difficile into three groups: Tox+/PCR+ (9%), Tox-/PCR+ (11%), and Tox-/PCR+ (79%) (see Figure). Perhaps unsurprisingly, compared with Tox+/PCR+ cases, Tox-/PCR+ cases had lower bacterial load, less prior antibiotic exposure, less faecal inflammation, a shorter duration of diarrhoea, were less likely to suffer complications, and were less likely to die within 30 days. Perhaps even more importantly, patients with Tox-/PCR+ were pretty much identical to patients with Tox-/PCR- specimens in all of these metrics. In short: these patients had C. difficile in their gut, but they did not have C. difficile infection. The key message here is that we should not be treating patients who are C. difficile “positive” by molecular tests only.

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Fidaxomicin reduces C. difficile environmental contamination

Jon Otter (@jonotter) C. difficile, Environment , , ,

It is well-established that fidaxomicin reduces the recurrence rate of C. difficile infection (CDI), but this study from my old research group at GSTT / KCL is the first to evaluate the impact of treatment with fidaxomicin on environmental contamination. The bottom line is that patients treated with fidaxomicin had less C. difficile contamination than patients treated with vancomycin / metronidazole.

In total, the rooms of 38 / 66 (57.6%) patients treated with metronidazole / vancomycin had one or more positive environmental cultures compared with 25 / 68 (36.8%) patients treated with fidaxomicin (P = 0.02). Similarly, when considering all of the sampled environmental sites (four per room), 68 / 264 (25.8%) were positive in patients treated with metronidazole / vancomycin compared with 47 / 272 (17.3%) in patients treated with fidaxomicin (P = 0.02) (see Figure below).

Fidax CDI

Figure: Environmental contamination with C. difficile in the rooms of patients treated with fidaxomicin vs. vancomycin / metronidazole.

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