Fungemia following Saccharomyces cerevisiae var. boulardii probiotic treatment in an elderly patient / Fungemia posterior al tratamiento con Saccharomyces cerevisiae var. boulardii como probiótico en una paciente anosa

Abstract The yeast Saccharomyces cerevisiae var. boulardii is a biotherapeutic agent used for the prevention and treatment of several gastrointestinal diseases. We report a case of fungemia in a patient suffering from Clostridium difficile-associated diarrhea and treated with metronidazole and a probiotic containing S. cerevisiae var. boulardii. The yeasts isolated from the blood culture and capsules were identified by MALDI-TOF MS and API ID 32 C as S. cerevisiae, and showed the same appearance and color on CHROMAgar Candida. Treatment with fluconazole 400mg/day was initiated and the probiotic was stopped. The patient was discharged from hospital in good condition and was referred to a rehabilitation center. We suggest that the potential benefit of S. cerevisiae var. boulardii should be accurately evaluated, especially in elderly patients. Moreover, all physicians should be trained in the use of probiotic agents and enquire whether the use probiotics was included in the patients'medical histories. © 2019 Asociación Argentina de Microbiología. Published by Elsevier España, S.L.U. This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Resumen Saccharomyces cerevisiae var. boulardii es un agente bioterapéutico usado en la prevención y el tratamiento de varias enfermedades gastrointestinales. Informamos de un caso de fungemia en una paciente con diarrea asociada a Clostridium difficile, y tratada con metron-idazol y un probiótico que contenía S. cerevisiae var. boulardii. Las levaduras aisladas a partir del hemocultivo y del contenido de las cápsulas tomadas por la paciente se identificaron como S. cerevisiae mediante MALDI-TOF MS y API® ID 32C, las colonias mostraron el mismo color y aspecto en el medio CHROMAgar™ Candida. Se instauró un tratamiento con fluconazol 400mg/día y se suspendió el probiótico. La paciente fue dada de alta del hospital en buenas condiciones, y remitida a un centro de rehabilitación. Sugerimos que el beneficio potencial del uso de S. cerevisiae var. boulardii debe ser evaluado en cada paciente, especialmente en personas añosas. El uso de probióticos debería incluirse en los interrogatorios orientados al diagnóstico y formar parte de la historia clínica. © 2019 Asociación Argentina de Microbiología. Publicado por Elsevier España, S.L.U. Este es un artículo Open Access bajo la licencia CC BY-NC-ND (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Clostridium difficile in Antibiotic-Associated Diarrhoea and Detection of Toxin Producing Strains in a Tertiary Care Hospital in Western Maharashtra.

Background: Rampant and injudicious use of broadspectrum antibiotic in hospitalized patients hasincreased the incidence of Clostridium difficileAssociated Diarrhea (CDAD). In recent years,Clostridium difficile Infection (CDI) has become morefrequent, severe, and difficult to treat. Aim andObjective: A prospective, study was conducted toisolate C. difficile in Antibiotic-associated Diarrhoea(AAD) and to detect toxin producing strains of C.difficile from faecal samples of patients suspected tohave CDI. Material and Methods: A total of 111hospitalized patients who developed diarrhoea after>72 hours of admission and suspected of CDI wereenrolled for investigation. The samples were subjectedto anaerobic culture and toxin assay. Results: The totalsample size of the study was 111 patients who werehaving antibiotic associated diarrhoea. Majority of thepatients were from the age group 21-30 years and 41-50 years i.e., 23 (20.7%). Males 64 (57.7%) wereaffected more as compared to females 47 (42.3%).Third generation cephalosporins were the mostcommon group of antibiotics associated with bothAAD 36 (32.4%) and CDAD 9 (42.85%) cases,followed by carbapenem fluroquinolones incombination 3 (12.5%). Culture positivity was seen in12 (10.81%) of the 111 stool samples and 39 (35.13%)were toxin producers. Conclusion: The use of severalmedications was found to be associated with anincreased risk of CDAD. The only way to reduce Cl.difficile infection is to judiciously use antibiotics,strictly adhere to antibiotic policy and to give primeimportance to strict infection control measures.

A Comparison of Vancomycin and Metronidazole for the Treatment of Clostridium difficile-associated Diarrhea (CDAD) in Medical Intensive Care Unit (MICU)

BACKGROUND: Clostridium difficile associated diarrhea (CDAD) is a leading cause of hospital-associated gastrointestinal illness. Risk factors for CDAD include advanced age, long-term admission, antibiotics, proton-pump inhibitor or H₂ blocker use and immunosuppression. The practice guideline of American Journal of Gastroenterology (2013) suggests metronidazole for the first-line therapy of mild-moderate CDAD as well as vancomycin for severe CDAD. MICU inpatients receiving stress ulcer prophylaxis and antibiotics are susceptible to nosocomial CDAD. Therefore, this study aimed to evaluate occurrence and treatment of CDAD in MICU. METHODS: Patients who were admitted to the MICU and had CDAD from August 2012 to August 2015 were analyzed retrospectively. RESULTS: Of the 90 patients with CDAD, 20 patients (2.22%) had mild-moderate CDAD (16 received metronidazole and 4 received vancomycin therapy) and 70 patients (77.8%) had severe CDAD(54 received metronidazole and 16 received vancomycin therapy). Among the patients with mild-moderate CDAD, treatment with metronidazole or vancomycin resulted in same clinical cure in 50% of the patients (p=1.00). Among the patients with severe CDAD, treatment with metronidazole or vancomycin resulted in clinical cure in 40.7% and 50.0% of the patients, respectively (p=0.511). Clinical symptoms recurred in 7.4% of the severe CDAD patients treated with metronidazole and 6.3% of those treated with vancomycin (p=0.875). CONCLUSION: Our findings suggest that metronidazole and vancomycin are equally effective for the treatment of mild-moderate CDAD; however, vancomycin demonstrated higher clinical cure rate and lower recurrence rate for severe CDAD, although the difference was not statistically significant. For better clinical outcomes, appropriate medication use by disease severity is needed.

Prevention of Clostridium difficile infection in hamsters using a non-toxigenic strain / Prevenção da infecção por Clostridium difficile em hamsters usando uma estirpe não toxigênica

ABSTRACT: The present study aimed to evaluate five non-toxigenic strains of Clostridium difficile (NTCD) in vitro and to select one strain to prevent C. difficile (CDI) infection in hamsters (Mesocricetus auratus). The NTCD strains were evaluated for spore production in vitro, antimicrobial susceptibility and presence of antimicrobial resistance genes. Approximately 107 spores of the selected strain (Z31) were administered by esophageal gavage in hamsters pretreated with 30mg kg-1 of clindamycin. The challenge with a toxigenic strain of C. difficile was conducted at 36 and 72h, and the animals were observed for 28 days. The NTCD strain of C. difficile (Z31) was able to prevent CDI in all animals that received it.

RESUMO: O presente trabalho objetivou a avaliação in vitro de cinco estirpes não toxigênicas de Clostridium difficile (NTCD) e seleção de uma delas para prevenção de infecção por C. difficile (CDI) em hamsters (Mesocricetus auratus). As estirpes NTCD foram avaliadas quanto à produção de esporos in vitro, sensibilidade antimicrobiana e presença de genes de resistência a antimicrobianos. Aproximadamente 107 esporos da estirpe selecionada (Z31) foram administrados por gavagem esofágica em hamsters previamente tratados com 30mg kg-1 de clindamicina. O desafio com uma estirpe toxigênica de C. difficile ocorreu nos tempos experimentais 36 e 72h, e os animais foram observados por 28 dias. A estirpe NTCD de C. difficile (Z31) foi capaz de prevenir a CDI em todos os animais que a receberam.

Descripción clínica y epidemiológica de la infección por Clostridium difficile en población pediátrica / Clinic and epidemiologic description of Clostridium difficile infection in a pediatric population

Background: Clostridium difficile (CUj-associated disease (CDAD) and the role of the hypervirulent strain NAP1 have not been well characterized in Pediatrics. Aims: To describe clinical features of CDAD, and to estimate NAP1 frequency and association with disease severity in Pediatrics. Methods: Descriptive, transversal surveillance of diarrheal episodes in Chilean children, hospitalized between February 2012 and December 2013, positive for CD by molecular diagnosis. Results: A total of 66 episodes of diarrhea with identification of CD occurred thougout the study period in children between 1 month and 19 years of age of which 39% were younger than one year old. CD acquisition was predominantly nosocomial and the most common risk factors were: presence of comorbidities (98.6%), use of antibiotics (93.9%), proton pump inhibitors (84.8%), invasive mechanic ventilation (54.5%), feeding tube (48.5%) and immunosuppression (40.9%). Clinical course was mostly mild, but 12 cases presented an unfavorable course, of which 3/26 occurred in children less than one year. Only one case was positive for NAP1 and had a mild course. Conclusion: Diarrhea with identification of CD was present throughout all pediatric ages, including children less than one year old. Analytical and longitudinal studies are required to better characterize the pathogenic role of CD in this age group. CDAD occurred mostly in patients with risk factors, and the clinical course was predominantly mild.

Introducción: Aún no ha sido bien caracterizada la infección por Clostridium difficile ni el rol de la cepa hipervirulenta NAP1 en pediatría. Objetivos: Describir las características clínicas de la infección por C. difficile, la frecuencia de NAP1 y su asociación con gravedad en población pediátrica. Material y Método: Estudio transversal, descriptivo, de episodios de diarrea con identificación molecular de C. difficile en niños chilenos hospitalizados entre febrero de 2012 y diciembre de 2013. Resultados: Se estudiaron 66 episodios de diarrea por C. difficile, en niños entre 1 mes y 19 años, teniendo 39% menos de un año de edad. La adquisición fue predominantemente nosocomial. Los factores de riesgo más frecuentes fueron: co-morbilidades, uso de antimicrobianos, inhibidores de bomba de protones, ventilación mecánica invasora, sonda de alimentación e inmunosupresión. El curso clínico fue mayoritariamente benigno, con 12 casos de evolución desfavorable incluyendo lactantes bajo un año de edad. Un niño presentó la cepa NAP1, con un curso clínico leve. Discusión: En esta serie, la diarrea con identificación de C. difficile se presentó en niños de todas las edades, incluyendo aquellos bajo un año. Se necesitan estudios analíticos y longitudinales para determinar el rol patógeno en este último grupo etario. La infección afecta a niños con factores de riesgo y es de evolución predominantemente satisfactoria.

Rendimiento de índices pronósticos en infección asociada a Clostridium difficile grave: Análisis retrospectivo en un hospital universitario / Performance of prognostic index in severe Clostridium difficile-associated infection: Retrospective analysis in a university hospital

Introduction: By consensus severe, Clostridium difficile-associated infection (CDAI) is one that results in hospitalization in ICU, colectomy or death within 30 days. Multiple prognostic indices (IP) attempt to predict these adverse events. Objective: To evaluate the performance of 4 PI in predicting severe CDI. Methods: Hospitalized patients ≥ 18 years old with ICD were retrospectively evaluated. Patients with recurrent infection or hematological cancer were excluded. Four PI were evaluated: UPMC version 1, Calgary version 1, Hines VA and Calgary version 2. Results: Seven of 81 patients (8.1%) met the definition of severe CDI. Positive predicted value (PPV) and negative predicted value (NPV) of PI ranged from 20-75% and 91.3-95.7%, respectively. Only Hines VA index had a satisfactory Kappa index (0.74; 95% CI 0.41-1) with a PPV of 75% and NPV of 95,7%. However, because of the variables included, this PI could be calculated only in 32.6% of patients. Conclusion: Hines VA index has the best predicted value and agreement to rule out a severe CDI. Like others PI it has the limitation of including difficult variables to assess in all patients and tends to overestimate an unfavorable course.

Introducción: Por consenso, la infección asociada a Clostridium difficile (IACD) grave es aquella que resulta en hospitalización en unidad de cuidados intensivos, colectomía o muerte dentro de 30 días. Múltiples índices pronósticos (IP) intentan predecir estos eventos adversos. Objetivo: evaluar el rendimiento de cuatro IP en la predicción de IACD grave. Metodología: pacientes hospitalizados ≥ 18 años con IACD fueron evaluados retrospectivamente. Se excluyeron pacientes con infección recurrente o cáncer hematológico. Se evaluaron cuatro IP: UPMC versión 1, Calgary versión 1, Hines VA y Calgary versión 2. Resultados: Siete de 81 pacientes (8,1%) presentaron una IACD grave. El valor predictor positivo (VPP) y valor predictor negativo (VPN) de los IP varió entre 20-75% y 91,3-95,7%, respectivamente. Sólo el índice de Hines VA tuvo un índice Kappa satisfactorio (0,74;IC 95% 0,46-1) con un VPP de 75% y un VPN de 95,7%. Sin embargo, por las variables incluidas en este IP, sólo pudo ser calculado en 32,6% de los pacientes. Conclusión: El índice de Hines VA presenta el mejor valor predictor y concordancia para descartar una IACD grave. Como otros IP, tiene la limitación de incluir variables difícilmente evaluables en todos los pacientes y tiende a sobreestimar un curso desfavorable.

Enfermedad asociada a Clostridium difficile: prevalencia y diagnóstico por laboratorio / Clostridium difficile associated disease: Prevalence and diagnostic laboratory

Clostridium difficile es un bacilo gram positivo, anaerobio estricto, capaz de formar esporas que le permiten su supervivencia en aguas, suelos y en ambientes hospitalarios, donde puede permanecer hasta años. Inicialmente, fue descrito en 1935 como un agente normal de la microbiota intestinal de recién nacidos sanos. El presente escrito pretende revisar las generalidades del microorganismo y de la enfermedad asociada a C. difficile , enfatizando la prevalencia de ambos en nuestro medio, la problemática, el vacío del conocimiento que se presenta y los métodos de laboratorio que permiten su diagnóstico y estudio.

Clostridium difficile is a gram-positive, strictly anaerobic, bacillus capable of forming spores that enable it to survive in waters, soils, and in hospital environments, where it can remain for years. It was initially described in 1935 as a normal microorganism of the intestinal microbiota of healthy newborns. This article reviews the general features of the microorganism and the disease associated with C. difficile , emphasising the prevalence of both in our environment, the problems, the lack of knowledge on it, and the laboratory methods that help in its diagnosis and study.

Clinical risk factors for Clostridium difficile-associated diseases

Many factors appear to influence the chance of acquiring Clostridium difficile (C. difficile) infection, and an accurate identification of risk factors could be beneficial in many ways. Thus, in the present study, clinical risk factors for C. difficile-associated disease (CDAD) in Korea were identified. A total of 93 patients who met the inclusion criteria and 186 age/gender/ward/admission period-matched control patients were included in this study. Statistically significant associations were found with presence of chronic lung diseases (odds ratio [OR], 3.41; 95% confidence interval [CI], 1.25-9.32; p = 0.017), presence of ileus (OR, 10.05; 95% CI, 2.42-41.80; p = 0.001), presence of intensive care unit (ICU) stay (OR, 9.79; 95% CI, 3.03-31.68; p < 0.001), use of cephalosphorins (OR, 3.30; 95% CI, 1.13-9.62; p = 0.029), history of surgery (OR, 10.89; 95% CI, 3.96-29.92; p < 0.001), and history of long-term care facility stay (OR, 14.90; 95% CI, 4.02-55.26; p < 0.001). Awareness of CDAD is critical to provide appropriate clinical care. Surveillance of the national incidence rate and multicenter studies are needed, and the potential value of a C. difficile vaccine should be studied.

Management of Antibiotics-Associated Diarrhea / 대한소화기학회지

Antibiotics-associated diarrhea (AAD) is defined as unexplained diarrhea that occurs with the administration of antibiotics. Approximately 20% AAD cases are due to Clostridium difficile. Over the last decade, the incidence of Clostridium difficile-associated disease (CDAD) has progressively increased, and now a significant clinical problem. Recent change in the epidemiology of CDAD and the emergence of an epidemic hypervilruent strain suggest the need for greater attention for infection control, early diagnosis, and more effective treatment modality. However, since most cases of CDAD are both iatrogenic and nosocomial, careful selection of antibiotics, combined with proper hand hygiene and precaution by medical staffs are required.

Clinical Characteristics and Changing Epidemiology of Clostridium difficile-Associated Disease (CDAD) / 대한소화기학회지

BACKGROUND/AIMS: The spectrum of Clostridium difficile-associated disease (CDAD) ranges from mild diarrhea to life-threatening colitis. Recent studies reported an increase in incidence and severity of CDAD and the presence of severe community-acquired CDAD (CA-CDAD). The aims of this study were to investigate the incidence of CA-CDAD and non-antibiotics-associated CDAD, and to compare the clinical characteristics between hospital-acquired (HA) and CA-CDAD. METHODS: The medical records of 86 patients who were diagnosed as CDAD in Hanyang University Guri Hospital between January 2005 and October 2007 were retrospectively reviewed. RESULTS: Of the 86 patients (mean age 64 years), 53 patients were women. The most frequently prescribed antibiotics were cephalosporins (67.4%), followed by aminoglycosides (38.4%) and quinolones (14%). Of the 86 patients, the average duration of treatment and recovery time of symptoms were 11.5 days and 4.6 days, respectively. Seven percent of patients experienced relapse treatment. The overall incidence rate of CA-CDAD and non-antibiotics-associated CDAD were 10.5% and 22.1%, respectively. CA-CDAD group had lower rate of antimicrobial exposure whilst showing higher rate of complications compared to HA-CDAD group. Three patients in the CA-CDAD progressed towards a severe complicated clinical course, including septic shock. CONCLUSIONS: The incidence rate of CA-CDAD and non-antibiotics-associated CDAD were 10.5% and 22.1%, respectively. CA-CDAD tends to have a higher complication rate compared to HA-CDAD. Community clinicians needs to maintain a high level of suspicion for CDAD, whilst coping with the ever evolving epidemiologic change.

Clinical Characteristics of Renal Insufficiency Patients with Clostridium difficile-Associated Pseudomembranous Colitis / 대한신장학회지

PURPOSE:Clostridium difficile-associated diarrhea (CDAD) is a potentially life-threatening illness which has been shown to be more common and more severe in patient with chronic renal failure. The aim of this study was to investigate clinical characteristics of renal insufficiency patients with clostridium difficile-associated pseudomembranous colitis. METHODS:We reviewed charts of fifty-six patients with clostridium difficile-associated pseudomembranous colitis, who have clostridial toxin A assay in stool and a diagnosis made on histology of colonic biopsies. RESULTS:There was no difference in age, serum albumin, C-reactive protein (CRP) and negative incidence of clostridial toxin A between patients who had renal insufficiency with serum creatinine more than 1.5 mg/dL and those who did not. But duration of antibiotic use administered prior to development of the clostridium difficile infection was more shorter in patients with impaired renal function than in patients with normal renal function. CONCLUSION:These data suggest that it may take a short period to development of the clostridium difficile infection in patients with impaired renal function, and histologic evaluation by sigmoidoscopy should be performed to make a diagnosis in CDAD-suggested patients, who have impaired renal function and even negative clostridial toxin A.

Prognosis Factors of Clostridium difficile Associated Diarrhea / 감염과화학요법

BACKGROUND: Clostridium difficile associated diarrhea (CDAD) has a wide range of clinical manifestations. The prognostic factors of CDAD are not fully understood. MATERIALS AND METHODS: A retrospective cohort study of 115 patients with CDAD from Aug. 2002 to Dec. 2003 was conducted to evaluate prognostic factors of CDAD. Bacteriologic factors were determined by detecting the binary toxin gene, tcd A, tcd A rep and tcd B gene. Poor prognosis was defined as diarrhea more than 10 days even with classic treatment, recurrence, death, and moribund discharge. RESULTS: Approximately 79% of isolated strains were toxin A+/B+ strains and 21% were toxin A-/B+ strains. There was no difference in prognosis between toxin A+ and toxin A- strains. 39 (33.9%) cases showed poor prognosis and 76 (66.1%) cases showed good prognosis. Univariate analyses revealed that the poor prognostic factors were old age over 70 years old, male, the number of antibiotics used after onset of symptom, the administration of carbapenems, aminoglycosides, glycopeptides after onset of symptom, history of DM and stroke, and high Charlson comorbidity index. Multiple logistic regression analysis identified old age over 70 years old (odds ratio=3.378, P=0.009) and the administration of carbapenems after onset of symptom (odds ratio 7.210, P< 0.001) as the independent poor prognostic factors. CONCLUSION: Old age over 70 and the administration of carbapenems after onset of symptom were the poor prognostic factors for CDAD caused by none-binary toxin producing strains.

Prognosis Factors of Clostridium difficile Associated Diarrhea / 감염과화학요법

BACKGROUND: Clostridium difficile associated diarrhea (CDAD) has a wide range of clinical manifestations. The prognostic factors of CDAD are not fully understood. MATERIALS AND METHODS: A retrospective cohort study of 115 patients with CDAD from Aug. 2002 to Dec. 2003 was conducted to evaluate prognostic factors of CDAD. Bacteriologic factors were determined by detecting the binary toxin gene, tcd A, tcd A rep and tcd B gene. Poor prognosis was defined as diarrhea more than 10 days even with classic treatment, recurrence, death, and moribund discharge. RESULTS: Approximately 79% of isolated strains were toxin A+/B+ strains and 21% were toxin A-/B+ strains. There was no difference in prognosis between toxin A+ and toxin A- strains. 39 (33.9%) cases showed poor prognosis and 76 (66.1%) cases showed good prognosis. Univariate analyses revealed that the poor prognostic factors were old age over 70 years old, male, the number of antibiotics used after onset of symptom, the administration of carbapenems, aminoglycosides, glycopeptides after onset of symptom, history of DM and stroke, and high Charlson comorbidity index. Multiple logistic regression analysis identified old age over 70 years old (odds ratio=3.378, P=0.009) and the administration of carbapenems after onset of symptom (odds ratio 7.210, P< 0.001) as the independent poor prognostic factors. CONCLUSION: Old age over 70 and the administration of carbapenems after onset of symptom were the poor prognostic factors for CDAD caused by none-binary toxin producing strains.

Research on Clostridium Difficile Infection in Clinic Patients Feces Specimen / 中华医院感染学杂志

OBJECTIVE This study was to investigate the carrier and infection of Clostridium difficile in clinic feces specimen,to analyze clinic characteristics,and to improve isolation rate and to provide basis on efficient prevention.METHODS C.difficile toxin A&B kit and anaerobic culture was conducted in 20 cases with diarrhea.Colonies suspected to be C.difficile,on the basis of their macroscopic appearance and characteristic odor,oxygen tolerance experiment,were confirmed by their biochemical characteristics(API 20A,bioMerieux).RESULTS After C.difficile selective culture,8 suspected colonies from 20 feces specimen were conducted by feces smear and oxygen tolerance experiment.6 of 8 was G+ rod bacteria with positive oxygen tolerance experiment.4 stains of C.difficile were identified by API 20A,positive rate was 20%;toxin detect was positive in 1 specimen(5%).CONCLUSIONS Infection of C.difficile Is associated with the basic disease.Watery feces specimen was prone to culture positive.