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      Risk Factors for Recurrence of Clostridium difficile Infection: Effect of Vancomycin-resistant Enterococci Colonization

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          Abstract

          Recurrent Clostridium difficile infection (CDI) is one of the most difficult problems in healthcare infection control. We evaluated the risk factors associated with recurrence in patients with CDI. A retrospective cohort study of 84 patients with CDI from December 2008 through October 2010 was performed at Pusan National University Yangsan Hospital. Recurrence occurred in 13.1% (11/84) of the cases and in-hospital mortality rate was 7.1% (6/84). Stool colonization with vancomycin-resistant enterococci (VRE) ( P = 0.006), exposure to more than 3 antibiotics ( P = 0.009), low hemoglobin levels ( P = 0.025) and continued use of previous antibiotics ( P = 0.05) were found to be more frequent in the recurrent group. Multivariate analysis indicated that, stool VRE colonization was independently associated with CDI recurrence (odds ratio, 14.519; 95% confidence interval, 1.157-182.229; P = 0.038). This result suggests that stool VRE colonization is a significant risk factor for CDI recurrence.

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          Changes in the composition of the human fecal microbiome after bacteriotherapy for recurrent Clostridium difficile-associated diarrhea.

          Alexander Khoruts, Johan Dicksved, Janet Jansson … (2015)
          Clostridium difficile-associated disease (CDAD) is the major known cause of antibiotic-induced diarrhea and colitis, and the disease is thought to result from persistent disruption of commensal gut microbiota. Bacteriotherapy by way of fecal transplantation can be used to treat recurrent CDAD, which is thought to reestablish the normal colonic microflora. However, limitations of conventional microbiologic techniques have, until recently, precluded testing of this idea. In this study, we used terminal-restriction fragment length polymorphism and 16S rRNA gene sequencing approaches to characterize the bacterial composition of the colonic microflora in a patient suffering from recurrent CDAD before and after treatment by fecal transplantation from a healthy donor. Although the patient's residual colonic microbiota, prior to therapy was deficient in members of the bacterial divisions-Firmicutes and Bacteriodetes, transplantation had a dramatic impact on the composition of the patient's gut microbiota. By 14 days posttransplantation, the fecal bacterial composition of the recipient was highly similar to that of the donor and was dominated by Bacteroides spp. strains and an uncharacterized butyrate producing bacterium. The change in bacterial composition was accompanied by resolution of the patient's symptoms. The striking similarity of the recipient's and donor's intestinal microbiota following after bacteriotherapy suggests that the donor's bacteria quickly occupied their requisite niches resulting in restoration of both the structure and function of the microbial communities present.
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            Meta-analysis to assess risk factors for recurrent Clostridium difficile infection.

            K W Garey, S. Sethi, Y. Yadav … (2008)
            Clostridium difficile infection (CDI) is the most common cause of hospital-acquired diarrhoea. It is estimated that 15-20% of patients experience recurrence of CDI. A limited number of studies have looked at the risk factors for recurrent CDI. We conducted a meta-analysis of observational studies and randomised controlled trials (RCTs) to assess risk factors for recurrent CDI. Studies were identified using the PubMed database and search terms 'Clostridium difficile associated diarrhoea' or 'pseudomembranous colitis'. Both observational studies and RCTs were included. In all, 1215 studies were identified of which 48 met the inclusion criteria. Twelve studies involving 1382 patients with CDI met the complete eligibility requirements. Odds ratios and information on study quality were abstracted by two investigators independently. To be included in the analysis, each risk factor was required to be evaluated by at least three separate studies. Continued use of non-C. difficile antibiotics after diagnosis of CDI (OR: 4.23; 95% CI: 2.10-8.55; P<0.001), concomitant receipt of antacid medications (OR: 2.15; 95% CI: 1.13-4.08; P=0.019), and older age (OR: 1.62; 95% CI: 1.11-2.36; P=0.0012) were significantly associated with increased risk of recurrent CDI. Significant prognostic risk factors were identified as risk factors for CDI recurrence. Additional or novel interventions may be required for these patients to prevent CDI recurrence.
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              Increasing risk of relapse after treatment of Clostridium difficile colitis in Quebec, Canada.

              Marie-Eve Alary, C Bourassa-Fulop, Katalin Fülöp … (2005)
              Clinicians who treat patients with Clostridium difficile-associated diarrhea (CDAD) in Quebec, Canada, have noted an apparent increase in the proportion of patients who experience relapse. To determine whether there was an increase in the frequency of treatment failure and of recurrence of CDAD after treatment, we reviewed data on cases that had been diagnosed in a hospital in the province of Quebec during the period 1991-2004. The frequency of recurrences within 60 days after the initial diagnosis was measured using Kaplan-Meier analysis, and Cox regression was used for multivariate analysis. Among patients who had initially been treated with metronidazole, the proportion whose regimens were switched to vancomycin or for whom vancomycin was added because of a disappointing response did not vary between 1991 and 2002 (66 [9.6%] of 688 patients overall) but more than doubled in 2003-2004 (112 [25.7%] of 435; P or = 65 years, respectively; during 2003-2004, the probabilities were 25.0%, 27.1%, and 58.4%, respectively. In 2003-2004, there was an increase in the proportion of patients with CDAD believed, by their attending physicians, to have experienced metronidazole treatment failure, as well as an increase in the frequency of post-metronidazole therapy recurrences, especially among elderly persons.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Korean Med Sci
                Journal ID (publisher-id): JKMS
                Title: Journal of Korean Medical Science
                Publisher: The Korean Academy of Medical Sciences
                ISSN (Print): 1011-8934
                ISSN (Electronic): 1598-6357
                Publication date (Print): July 2011
                Publication date (Electronic): 20 June 2011
                Volume: 26
                Issue: 7
                Pages: 859-864
                Affiliations
                Department of Internal Medicine, Division of Infections Disease, Medical Research Institute, Pusan National University School of Medicine, Busan, Korea.
                Author notes
                Address for Correspondence: Su Jin Lee, MD. Department of Internal Medicine, Pusan National University Yangsan Hospital, Beomeo-ri, Mulgeum-eup, Yangsan 626-700, Korea. Tel: +82.55-360-2373, Fax: +82.55-360-2150, beauty192@ 123456hanmail.net
                Article
                DOI: 10.3346/jkms.2011.26.7.859
                PMC ID: 3124713
                PubMed ID: 21738336
                SO-VID: 48a6a224-c9d4-4e78-99f8-81318b6a7899
                Copyright © © 2011 The Korean Academy of Medical Sciences.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 06 January 2011
                Date accepted : 21 April 2011
                Categories
                Subject: Original Article
                Subject: Infectious Diseases, Microbiology & Parasitology

                ScienceOpen disciplines: Medicine
                Keywords: clostridium difficile,risk factors,recurrence,vre
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: clostridium difficile, risk factors, recurrence, vre

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