Infecciones por Clostridioides difficile en pediatría. La visión del laboratorio a partir del diagnóstico microbiológico / Clostridioides difficile infections in pediatrics. The view of the laboratory based on microbiological diagnosis

La infección por Clostridioides difficile (ICD) es la principal responsable de diarreas nosocomiales en adultos. En los últimos años se registró un aumento en la incidencia de la ICD en la población adulta que, en cambio, no fue bien caracterizado en pediatría. El objetivo de este trabajo es analizar los datos resultantes del diagnóstico microbiológico de ICD en el Hospital de Pediatría "Prof. Dr. Juan P. Garrahan". Materiales y métodos: se realizó un estudio retrospectivo observacional descriptivo que abarcó desde el 01/01/2018 hasta el 31/12/2021. El diagnóstico se realizó mediante enzimoinmunoensayo para glutamato deshidrogenasa (GDH) y toxinas en materia fecal (MF). Cuando sólo se detectó GDH, se realizó un cultivo toxigénico (CT) de la MF para la detección de toxinas in vitro. Se registraron: edad, sexo y procedencia de los pacientes y recurrencias de las ICD. Se efectuaron estudios de sensibilidad de 387 cepas de C. difficile a metronidazol (MTZ) y vancomicina (VAN). Resultados: en 6632 muestras (1764 pacientes) se registraron 649 estudios positivos (9,8%) (139 pacientes), la mayoría correspondieron a pacientes internados en áreas no críticas. Edad promedio: 7 años (7 ± 4,7). Sexo: 55% masculino. Recurrencias: 62 (45%). Positivos detectados mediante CT: 43%. Sensibilidad antibiótica: 100% a MTZ y 99,7% a VAN. Conclusión: Nuestra población presenta un bajo porcentaje de positividad. Se destaca el rendimiento del CT que permitió el diagnóstico de más de un tercio de los casos. MTZ y VANCO tuvieron excelente actividad in vitro frente a C. difficile (AU)

Clostridioides difficile infection (CDI) is the main cause of nosocomial diarrhea in adults. In recent years there has been an increase in the incidence of CDI in the adult population; however, CDI has not been well characterized in pediatrics. The aim of this study was to analyze the data resulting from the microbiological diagnosis of CDI at Hospital de Pediatría Prof. Dr. Juan P. Garrahan. Materials and methods: a retrospective, observational and descriptive study was conducted from 01/01/2018 to 12/31/2021. Diagnosis was made using enzyme immunoassay for glutamate dehydrogenase (GDH) and toxins in stools. When only GDH was detected, toxigenic culture (TC) of stools was performed for in vitro toxin detection. The age, sex and origin of patients and CDI recurrences were recorded. Sensitivity studies of 387 strains of C. difficile to metronidazole (MTZ) and vancomycin (VAN) were performed. Results: In 6,632 samples (1,764 patients), 649 positive results (9.8%) were recorded (139 patients), most of which corresponded to patients hospitalized in noncritical areas. Mean age: 7 years (7 ± 4.7). Sex: 55% male. Recurrences: 62 (45%). TC-positive results: 43%. Antibiotic sensitivity: 100% to MTZ and 99.7% to VAN. Conclusion: A low percentage of positivity was found in our population. The performance of TC was outstanding, allowing for the diagnosis of more than one third of the cases. MTZ and VANCO had excellent in vitro activity against C. difficile (AU)

Study on the features of Clostridioides difficile infection among diarrhea patients in Kunming from 2018 to 2020 / 中华流行病学杂志

Objective: We analyze the characteristics of Clostridioides difficile (C. difficile) infection among diarrhea patients in Kunming from 2018 to 2020 and provide evidence for follow-up surveillance and prevention. Methods: A total of 388 fecal samples of diarrhea patients from four sentinel hospitals in Yunnan Province from 2018 to 2020 were collected. Real-time quantitative PCR was used to detect the fecal toxin genes of C. difficile. The positive fecal samples isolated the bacteria, and isolates were identified by mass spectrometry. The genomic DNA of the strains was extracted for multi-locus sequence typing (MLST). The fecal toxin, strain isolation, and clinical patient characteristics, including co-infection with other pathogens, were analyzed. Results: Among the 388 fecal samples, 47 samples with positive reference genes of C. difficile were positive, with a total positive rate of 12.11%. There were 4 (8.51%) non-toxigenic and 43 (91.49%) toxigenic ones. A total of 18 strains C. difficile were isolated from 47 positive specimens, and the isolation rate of positive specimens was 38.30%. Among them, 14 strains were positive for tcdA, tcdB, tcdC, tcdR, and tcdE. All 18 strains of C. difficile were negative for binary toxins. The MLST results showed 10 sequence types (ST), including 5 strains of ST37, accounting for 27.78%; 2 strains of ST129, ST3, ST54, and ST2, respectively; and 1 strain of ST35, ST532, ST48, ST27, and ST39, respectively. Fecal toxin gene positive (tcdB+) results were statistically associated with the patient's age group and with or without fever before the visit; positive isolates were only statistically associated with the patient's age group. In addition, some C. difficile patients have co-infection with other diarrhea-related viruses. Conclusions: The infection of C. difficile in diarrhea patients in Kunming is mostly toxigenic strains, and the high diversity of strains was identified using the MLST method. Therefore, the surveillance and prevention of C. difficile should be strengthened.

The fliL gene significantly affects the motility and sporulation abilities of Clostridioides difficile / 生物工程学报

Flagella are the main motility structure of Clostridioides difficile that affects the adhesion, colonization, and virulence of C. difficile in the human gastrointestinal tract. The FliL protein is a single transmembrane protein bound to the flagellar matrix. This study aimed to investigate the effect of the FliL encoding gene flagellar basal body-associated FliL family protein (fliL) on the phenotype of C. difficile. The fliL gene deletion mutant (ΔfliL) and its corresponding complementary strains (: : fliL) were constructed using allele-coupled exchange (ACE) and the standard molecular clone method. The differences in physiological properties such as growth profile, antibiotic sensitivity, pH resistance, motility, and spore production ability between the mutant and wild-type strains (CD630) were investigated. The ΔfliL mutant and the : : fliL complementary strain were successfully constructed. After comparing the phenotypes of strains CD630, ΔfliL, and : : fliL, the results showed that the growth rate and maximum biomass of ΔfliL mutant decreased than that of CD630. The ΔfliL mutant showed increased sensitivity to amoxicillin, ampicillin, and norfloxacin. Its sensitivity to kanamycin and tetracycline antibiotics decreased, and the antibiotic sensitivity partially returned to the level of CD630 strain in the : : fliL strain. Moreover, the motility was significantly reduced in the ΔfliL mutant. Interestingly, the motility of the : : fliL strain significantly increased even when compared to that of the CD630 strain. Furthermore, the pH tolerance of the ΔfliL mutant significantly increased or decreased at pH 5 or 9, respectively. Finally, the sporulation ability of ΔfliL mutant reduced considerably compared to the CD630 strain and recovered in the : : fliL strain. We conclude that the deletion of the fliL gene significantly reduced the swimming motility of C. difficile, suggesting that the fliL gene is essential for the motility of C. difficile. The fliL gene deletion significantly reduced spore production, cell growth rate, tolerance to different antibiotics, acidity, and alkalinity environments of C. difficile. These physiological characteristics are closely related to the survival advantage in the host intestine, which is correlated with its pathogenicity. Thus, we suggested that the function of the fliL gene is closely related to its motility, colonization, environmental tolerance, and spore production ability, which consequently affects the pathogenicity of C. difficile.

Clostridioides difficile infection following procalcitonin-guided antibiotic therapy for COVID-19

@#We present a case of a 50-year-old man with chronic kidney disease (CKD) presenting with acute diarrhea and fever. He was admitted a month prior for COVID-19, where he received antibiotics for radiographic findings of pneumonia and elevated procalcitonin. In the emergency department, his stool sample tested positive for Clostridioides difficile antigen and toxin. He was given oral vancomycin and intravenous metronidazole for fulminant C. difficile infection and was discharged with resolution of symptoms. This case documents a potential risk associated with routine antibiotic use during the pandemic and the pitfalls in interpreting procalcitonin, especially in patients with COVID-19 and CKD.

Trasplante de microbiota fecal por colonoscopía en paciente mayor de 65 años con infección recurrente de Clostridioides difficile: aún una estrategia subutilizada / Fecal microbiota transplantation in an older patient with Clostridioides difficile recurrent infection. Report of one case

Clostridioides difficile infection (CDI) is a major public health problem and responsible for significant morbidity and mortality. Eighty percent of CDIs occur in adults older than 65 years of age due to a decreased gastrointestinal microbial diversity, immunosenescence and frailty. Thus, the most reported risk factor for recurrent CDI is older age since nearly 60% of cases occur in individuals aged ≥ 65 years. Fecal microbiota transplantation (FMT) is a highly cost-effective alternative to antibiotic treatment for patients with recurrent CDI. We report a 75-year-old male with recurrent CDI, who received a FMT after several unsuccessful antimicrobial treatments. He had a satisfactory evolution after the procedure and remained without diarrhea during the ensuing five months.

Umbral del ciclo de amplificación del gen de la toxina B de Clostridioides difficile como predictor de gravedad / Clostridioides difficile toxin B gen amplification cycle threshold as a predictor of severity

INTRODUCCIÓN: La infección por Clostridioides dfficile (ICD) es la principal causa de diarrea nosocomial, generalmente asociada al consumo de antimicrobianos. Esta infección puede causar desde diarrea no complicada hasta colitis pseudomembranosa o megacolon tóxico. Estudios recientes han intentado relacionar el valor el ciclo umbral (Ct) de la RT-PCR con la mortalidad, como un método rápido, sencillo, objetivo y eficaz. OBJETIVO: Evaluar el Ct como predictor de mala evolución en pacientes con y sin criterio clínico de dicha gravedad. PACIENTES Y MÉTODOS: Realizamos un estudio retrospectivo entre enero 2015 y diciembre 2018, incluyendo todos los pacientes del área de referencia del Hospital Universitario de Canarias en Tenerife (396.483 habitantes) en pacientes con criterios clínicos de gravedad (de acuerdo a la Guía para la Práctica Clínica de la enfermedad por C. dfficile de la Sociedad de Epidemiología del Cuidado de la Salud de América (SHEA) y la Sociedad de Enfermedades Infecciosas de Norteamérica (IDSA) y pacientes sin criterios clínicos de gravedad evaluando el Ct como predictor de mala evolución. RESULTADOS: Se diagnosticó un total de 202 episodios de ICD. El 77,7% (n = 157) presentó criterios clínicos de gravedad. La presencia de colitis ulcerosa (p < 0,001), fiebre (p < 0,001), leucocitosis (p < 0,001), neutrofilia (p < 0,001), creatininemia (p = 0,005) se presentaron como factores de riesgo para el desarrollo de ICD grave. El sexo femenino, la institucionalización, el ingreso previo y el exitus se describieron con mayor frecuencia en el grupo con ICD-G, no encontrando diferencias significativas. No encontramos diferencias respecto a los días de estancia previa, o de estancia post-ICD, aunque en este último, la media fue mayor en el caso de los pacientes con ICD-G. No se encontraron diferencias significativas en cuanto al Ct en ambos grupos; siendo sólo un punto menor en pacientes con criterio de gravedad (Ct = 26,1) que sin criterios de gravedad (Ct = 27,4) (p = 0,326).

BACKGROUND: Clostridioides dfficile infection (CDI) is the main cause of nosocomial diarrhea, generally associated with the use of antibiotics. This infection can cause uncomplicated diarrhea to pseudomembranous colitis or toxic megacolon. Recent studies have attempted to relate the threshold cycle (Ct) value of RT-PCR with mortality, as a fast, simple, objective and efficient method. AIM: To evaluate Ct as a predictor of poor outcome in patients with C. dfficile disease with/without clinical signs of severity. METHODS: We carried out a retrospective study between January 2015 and December 2018, including all patients in the reference area of the Hospital Universitario de Canarias in Tenerife (396,483 inhabitants) in patients with clinical criteria of severity and patients without clinical severity criteria (according to the guide for the clinical practice of CDI of the Society of Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of North America (IDSA). RESULTS: A total of 202 CDI episodes were diagnosed. 77.7% (n = 157) presented clinical severity criteria. The presence of ulcerative colitis (p < 0.001), fever (p < 0.001), leukocytosis (p < 0.001), neutrophilia (p < 0.001), creatininemia (p = 0.005) were presented as risk factors for the development of severe CDI (S-CDI). Female sex, institutionalization, previous admission and death were described more frequently in the group with S-CDI, not finding significant differences. We found no differences with respect to the days of previous stay, or of post-CDI stay, although in the latter, the mean was higher in the case of S-CDI patients. No significant differences were found in terms of Ct in both groups; being only one point lower in patients with severity criteria (Ct = 26.1) than without severity criteria (Ct = 27.4) (p = 0.326). CONCLUSION: Based on the results of our study, it has not been possible to systematically implement the Ct value as a predictor of severity to the clinical report, and it is not possible to extrapolate this predictive variable from S-CDI and standardize the Ct value as a predictor of severity. Conclusion: Basándonos en los resultados de nuestro estudio, no ha sido posible la implementación sistemática del valor Ct como predictor de gravedad al informe clínico, no siendo posible extrapolar esta variable predictora de enfermedad por C difficile-G y estandarizar el valor Ct como factor predictor de gravedad.

Clostridioides difficile: achados epidemiológicos em animais domésticos em um Hospital Veterinário Universitário em ­ Teresina, PI / Clostridioides difficile: epidemiological findings in domestic animals in a University Veterinary Hospital in Teresina, PI

O objetivo deste estudo foi analisar a prevalência de Clostridioides difficile e suas toxinas (A/B) nas fezes de animais domésticos de um Hospital Veterinário Universitário de Teresina - PI. A detecção de C. difficile e suas toxinas foi realizada por meio de um ensaio imunoenzimático, denominado C. Diff Quik Chek Complete® (TECHLAB), capaz de detectar antígeno Glutamato Desidrogenase (GDH) e as toxinas A/B produzidas pelo bacilo, realizado em amostras fecais de cães (C. lupus) e e gatos (Felis catus) coletadas entre agosto de 2019 a setembro de 2020. Um total de 54 amostras fecais foram analisadas, das quais 16 foram positivas para C. difficile (29,63%). 68,75% (11/16) pertenciam a caninos, enquanto 31,25% (5/16) a felinos. Amostras diarreicas e não diarreicas foram utilizadas para o estudo e uma maior prevalência do bacilo pôde ser identificada em amostras diarreicas (33%). Nenhuma das amostras apresentou toxinas do patógeno. Os achados deste estudo evidenciam que C.difficile está presente no estado do Piauí. Foi possível identificá-lo em todas as espécies e em amostras diarreicas ou não, demonstrando que essa infecção pode se manifestar de formasintomática e assintomática, levantando a possibilidade de infecção cruzada entre o animal e seu tutor.

The aim of this study was to analyze the prevalence of Clostridioides difficile and its toxins (A/B) in the feces of domestic animals at a University Veterinary Hospital in Teresina - PI. The detection of C. difficile and its toxins was performed by an immunogenic enzyme, called C. Diff Quik Chek Complete® (TECHLAB), capable of detecting antigen glutamate dehydrogenase (GDH) and A/B toxins produced by this bacillus, performed in fecal samples of dogs (C. lupus) and cats (Felis catus) collected between August 2019 and September 2020.:54 stools were analyzed, of which 16 were positive for C. difficile (29.63%). 68.75% (11/16) belonged to canines, while 3.25% (5/16) to felines. Diarrheal and non-diarrheal diseases are used for the study and a higher prevalence of bacillus can be identified in diarrheal diseases (33%). None of the samples present pathogen toxins. The results of this study show that C. difficile is present in the state of Piauí. It can be identified in all species and in diarrheal or non-diarrheic samples, demonstrating that this infection can be symptomatic and asymptomatic, giving the possibility of cross-infection between the animal and its owner.

Experience of a gastroenterology center in fecal microbiota transplantation in the treatment of Clostridioides Difficile / Experiência de um centro de gastroenterologia em transplante de microbiota fecal no tratamento de Clostridioides difficile

Background: The treatment of Clostridioides difficile is based on an antibiotics cycle, but for individuals who have more than two recurrences, fecal microbiota transplantation can be considered as a therapeutic option. Objective: To describe the technique and results of fecal microbiota transplantation performed for recurrent infection by Clostridioides difficile. Methods: Retrospective, cross-sectional study based on a review of medical records of patients undergoing transplantation of fecal microbiota. Data were obtained on the criteria used to select the donor, the preparation of stools in the laboratory and the method of delivery of the material offered, as well as information regarding the characteristics of the recipient, such as: gender, age, comorbidities, hospitalizations, use of antibiotics prior to infection, clinical presentation, diagnosis and treatments performed for Clostridioides difficile. After transplantation, data on efficacy, outcome, follow-up time and procedure complications were considered. Results: Between 2012 and 2019, 11 patients underwent fecal microbiota transplantation. The use of antibiotics prior to infection occurred in 9 patients, no patient was hospitalized in the previous 6 months due to another etiology. All had at least 2 cycles of vancomycin for recurrent disease. Of the total of 11 patients, 2 required 2 infusions and 1 patient required 3, totaling 15 fecal microbiota transplants. The success rate was 81.8% with only one infusion and 90.9% resolution considering patients who needed more than one infusion. Conclusion: Fecal microbiota transplantation is a feasible therapy with resolution in 90.9% of cases as a treatment for recurrent Clostridioides difficile infection.

Contexto: O tratamento do Clostridioides difficile é baseado em ciclo antimicrobiano, mas para os indivíduos que apresentam mais de duas recorrências, pode-se considerar o transplante de microbiota fecal como opção terapêutica. Objetivo: Descrever a técnica e os resultados do transplante de microbiota fecal realizados para infecção recorrente por Clostridioides difficile. Métodos: Estudo retrospectivo, transversal, baseado em revisão de prontuários de pacientes submetidos ao transplante de microbiota fecal. Foram obtidos dados sobre os critérios empregados para seleção do doador, o preparo das fezes e o método de entrega do material, além de informações referentes às características do receptor, como: sexo, idade, comorbidades, internamentos, uso de antimicrobiano prévio à infecção, apresentação clínica, diagnóstico e tratamentos realizados para o Clostridioides difficile. Após o transplante, dados sobre eficácia, desfecho, tempo de seguimento e complicações do procedimento foram considerados. Resultados: Entre 2012 e 2019, 11 pacientes foram submetidos ao transplante de microbiota fecal. O uso de antimicrobiano prévio à infecção ocorreu em 9 pacientes, nenhum paciente internou nos 6 meses anteriores por outra etiologia. Todos fizeram pelo menos 2 ciclos de vancomicina para doença recorrente. Do total de 11 pacientes, 2 necessitaram de 2 infusões e 1 paciente necessitou de 3, totalizando 15 transplantes de microbiota fecal. O sucesso foi de 81,8% com apenas uma infusão e resolução de 90,9% considerando pacientes que necessitaram de mais de uma infusão. Conclusão: O transplante de microbiota fecal é uma terapia factível e com resolução em 90,9% dos casos como tratamento de infecção recorrente por Clostridioides difficile.

Transcriptomic analysis of the ΔPaLoc mutant of Clostridioides difficile and verification of its toxicity / 中华预防医学杂志

Objective: Comparative analyses of wild-type Clostridioides difficile 630 (Cd630) strain and pathogenicity locus (PaLoc) knockout mutant (ΔPaLoc) by using RNA-seq technology. Analysis of differential expression of Cd630 wild-type strain and ΔPaLoc mutant strain and measurement of its cellular virulence changes. Lay the foundation for the construction of an toxin-attenuated vaccine strain against Clostridioides difficile. Methods: Analysis of Cd630 and ΔPaLoc mutant strains using high-throughput sequencing (RNA-seq). Clustering differentially expressed genes and screening differentially expressed genes by DESeq software. Further analysis of differential genes using Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment. Finally, cytotoxicity assays of ΔPaLoc and Cd630 strains were performed in the African monkey kidney epithelial cell (Vero) and the human colonic cell (Caco-2) lines. Results: The transcriptome data showed that the ΔPaLoc mutant toxin genes tcdA and tcdB were not transcribed. Compared to the wild-type strain, CD630_36010, CD630_020910,CD630_02080 and cel genes upregulated 17.92,11.40,8.93 and 7.55 fold, respectively. Whereas the hom2 (high serine dehydrogenase), the CD630_15810 (spore-forming protein), CD630_23230 (zinc-binding dehydrogenase) and CD630_23240 (galactitol 1-phosphate 5-dehydrogenase) genes were down-regulated by 0.06, 0.075, 0.133 and 0.183 fold, respectively. The GO and KEGG enrichment analyses showed that the differentially transcribed genes in ΔPaLoc were enriched in the density-sensing system, ABC transport system, two-component system, phosphotransferase (PTS) system, and sugar metabolism pathway, as well as vancomycin resistance-related pathways. Cytotoxicity assays showed that the ΔPaLoc mutant strain lost its virulence to Vero and Caco-2 cells compared to the wild-type Cd630 strain. Conclusion: Transcriptional sequencing analysis of the Cd630 and ΔPaLoc mutant strains showed that the toxin genes were not transcribed. Those other differential genes could provide a reference for further studies on the physiological and biochemical properties of the ΔPaLoc mutant strain. Cytotoxicity assays confirmed that the ΔPaLoc mutant lost virulence to Vero and Caco-2 cells, thus laying the foundation for constructing an toxin-attenuated vaccine strain against C. difficile.

Development of a double-antibody sandwich ELISA targeting the receptor binding domain of TcdB toxin of ST11 type Clostridium difficile of porcine origin / 生物工程学报

Clostridium difficile is an important zoonotic intestinal pathogen, which is widely present in humans and a variety of animals. The ST11 type C. difficile is one of the most widespread and harmful subtypes in the world. As a large country in pig farming, China lacks efficient methods for detecting C. difficile of porcine origin, leaving hidden dangers for the prevention and control of C. difficile. The aim of this study was to develop a specific and sensitive double-antibody sandwich ELISA for the epidemiological investigation of ST11 type C. difficile of porcine origin. Firstly, a 97 kDa receptor binding domain (RBD) was expressed in a prokaryotic host and purified. A hybridoma cell line AE2D3 capable of stably secreting monoclonal antibody targeting the RBD was screened, and the antibody subtype was determined to be IgG2b (κ). Secondly, a double antibody sandwich ELISA method was developed, where the monoclonal antibody targeting the RBD was used as a detection antibody, and the rabbit polyclonal antibody was used as a capture antibody. The chessboard method was used to determine the matching concentration of the capture antibody and the detection antibody, the antigen coating conditions, the blocking conditions, the incubation conditions for detection antibody and samples to be tested, as well as the reaction conditions of HRP-conjugated and reaction conditions of TMB chromogenic solution. The negative cutoff OD450 was 0.152, and no cross-reaction with 13 strains of non-ST11 type C. difficile was found. The minimum detection concentration of RBD was 8.83 ng/mL. This specific and sensitive double-antibody sandwich ELISA provides a reliable serological detection method for epidemiological investigation of the ST11 type C. difficile in pig industry.

Resistance of Clostridioides difficile spores from the NAP CR1 strain (Clostridiales: Peptostreptococcaceae) to sodium dichloroisocyanurate / Resistencia de esporas de Clostridioides difficile de la cepa NAPCR1 (Clostridiales: Peptostreptococcaceae) al dicloroisocianurato de sodio

Abstract Introduction: Clostridioides difficile is a significant cause of diarrhea in hospitals and the community. This bacterial pathogen is transmitted through the ingestion of endospores, which are challenging to eliminate due to intrinsic resistance to a variety of chemical disinfection agents. The well-characterized laboratory strain CD630 displays low virulence, has not caused outbreaks, and is highly susceptible to disinfectants. Nonetheless, a closely related strain termed NAPCR1 caused outbreaks in Costa Rica and later became endemic in many hospitals from this country. This strain causes disease through unusual mechanisms and is genotypically distinct from CD630. Consequently, its epidemic potential could be influenced by as yet unknown spore phenotypes, such as increased resistance to disinfectants. Objective: To determine whether the NAPCR1 strain is more resistant to a conventional and highly effective C. difficile sporicidal agent than strain CD630 and to identify potential explanatory mechanisms at the genomic level. Methods: We used an in vitro dilution-neutralization method to calculate the sporicidal activity of sodium dichloroisocyanurate (DCC) against purified spores from three subtypes of NAPCR1 isolates (LIBA-2945, LIBA-5761, and LIBA-6276), CD630, and a representative of the highly virulent and epidemic NAP1 strain (LIBA-5758). This phenotypic characterization was complemented with a genomics-steered search of polymorphisms in 15 spore- or sporulation-related genes. Results: Whereas DCC at a final concentration of 0.1 % (w/v) eradicated CD630 endospores with high efficacy (log10 reduction factor (LFR) ≥ 5), it only partially inactivated NAPCR1 (average LFR range: = 1.77-3.37) and NAP1 endospores (average LRF = 3.58). As hypothesized, the three NAPCR1 subtypes tested were more resistant to DCC than strain CD630 (ANOVA, P < 0.05), with LIBA-5761 showing the highest level of DCC resistance overall (ANOVA, P < 0.05). All three NAPCR1 isolates showed large deletions in bclA1. Besides, isolates LIBA-5761 and LIBA-6276 had deletions in bclA2. Conclusions: Our in vitro tests revealed a differential resistance of spores from the C. difficile NAPCR1 strain to DCC. They highlight the importance of continuously evaluating the efficacy of deployed disinfection agents against circulating strains and hint to a potential role of structural proteins from the exosporium in resistance to disinfectants in C. difficile.

Resumen Introducción: Clostridioides difficile es una causa importante de diarrea a nivel hospitalario y comunitario. Esta bacteria se transmite por medio de la ingestión de endosporas, las cuales son difíciles de erradicar por su resistencia intrínseca a diferentes agentes químicos de desinfección. La cepa de referencia CD630 está bien caracterizada, es poco virulenta, no ha causado brotes, y es altamente susceptible a los desinfectantes. Además, pertenece al mismo clado MLST y es filogenéticamente muy cercana a la cepa NAPCR1. Sin embargo, solo la última ha causado brotes en Costa Rica y se ha convertido en una cepa endémica en varios hospitales locales. La cepa NAPCR1 causa enfermedad por mecanismos poco usuales y es genotípicamente diferente a la cepa CD630. Por lo tanto, su potencial epidémico podría estar influenciado por cambios fenotípicos en sus esporas, como una resistencia incrementada a los desinfectantes. Objetivo: Determinar si la cepa NAPCR1 presenta mayor resistencia que CD630 a un desinfectante de alta eficacia utilizado a nivel hospitalario y dilucidar posibles mecanismos a nivel genómico. Métodos: Se utilizó el método de dilución-neutralización para evaluar la actividad esporicida in vitro del dicloroisocianurato de sodio (DCC) contra esporas de 3 subtipos de la cepa NAPCR1 (LIBA-2945, LIBA-5761, y LIBA-6276), CD630 y un aislamiento representativo de la cepa epidémica e hipervirulenta NAP1 (LIBA-5758). Esta caracterización fenotípica fue complementada con una búsqueda genómica de polimorfismos en 15 genes relacionados con la estructura de la endospora o el proceso de esporulación. Resultados: El DCC a una concentración final de 0.1 % (p/v) erradicó las endosporas de la cepa CD630 con gran eficacia (factor de reducción logarítmica; FRL ≥ 5) y eliminó parcialmente las de las cepas NAPCR1 (FRL promedio = 1.77-3.64) y NAP1 (FRL promedio = 3.58). El perfil de susceptibilidad del aislamiento NAPCR1 LIBA-5761 fue único, ya que mostró un mayor nivel de resistencia hacia el DCC que los otros aislamientos NAPCR1 y la cepa NAP1 examinada (ANOVA, P < 0.05). Los tres aislamientos NAPCR1 mostraron deleciones en bclA1 y los aislamientos LIBA-5761 y LIBA-6276 tenían deleciones adicionales en bclA2. Conclusiones: Nuestros experimentos in vitro confirman la resistencia incrementada a los desinfectantes de la cepa NAPCR1 y una susceptibilidad diferencial en sus tres subtipos. Adicionalmente, señalan la importancia de evaluar continuamente la eficacia de los desinfectantes contra cepas circulantes y asignan un posible papel en la resistencia a los desinfectantes gracias a las proteínas del exosporio de C. difficile.

Infección comunitaria por Clostridium difficile asociada a colitis ulcerativa idiopática / Community Clostridium difficile infection associated to idiopathic ulcerative colitis

RESUMEN Clostridium difficile es una bacteria relacionada con la colitis, asociada a antibióticos y a la diarrea adquirida en pacientes hospitalizados. Sin embargo, su comportamiento ha cambiado en los últimos años, hasta el punto de ser considerada un problema de salud mundial. Su curso clínico varía desde casos asintomáticos, colitis, hasta complicaciones que ponen en peligro la vida del paciente. Dentro de los factores de riesgo descritos se encuentra la enfermedad inflamatoria intestinal, especialmente la colitis ulcerativa idiopática. El caso reportado versa sobre la presentación de esta infección asociada a un brote de colitis ulcerativa en un paciente joven, sin antecedentes de enfermedad inflamatoria intestinal, consumo de antibióticos ni hospitalización (AU).

ABSTRACT Clostridium difficile is a bacterium related to antibiotic-associated colitis and to diarrhea acquired in hospitalized patients. However, its behavior has changed in recent years to the point of being considered as a global health problem. Its clinical course ranges from asymptomatic cases, colitis, to complications with risk for the patient's life. The inflammatory bowel disease, especially idiopathic ulcerative colitis is found among the described risk factors. The case reported deals with the presentation of this infection associated to an outbreak of ulcerative colitis in a young patient, with no previous history of inflammatory bowel disease, consumption of antibiotics or hospitalization (AU).

Vasculitis leucocitoclásticas como manifestación extraintestinal dermatológica rara de la enfermedad inflamatoria intestinal asociada con Clostridium: reporte de un caso / Leukocytoclastic vasculitis as a rare extraintestinal dermatologic manifestation of inflammatory bowel disease associated with Clostridium difficile: Case report

Resumen Las vasculitis leucocitoclásticas se definen como el daño e inflamación de las paredes vasculares, son aquellas vasculitis de pequeños vasos que anatomopatológicamente presentan leucocitoclasia y puede observarse como una manifestación extraintestinal de la enfermedad inflamatoria intestinal. En la colitis ulcerativa se presentan en menor frecuencia, por inmunocomplejos generados en la mucosa intestinal debido a la exposición del tejido linfoide submucoso a antígenos fecales; podrían precipitarse en las paredes de los pequeños vasos. Se pueden asociar con Clostridium difficile, que es un bacilo grampositivo esporulado, anaerobio estricto, que se encuentra normalmente en el medio ambiente y produce colitis, que se manifiesta como un cuadro diarreico presentado después de la ingesta de antibióticos y altera la flora bacteriana común de este órgano. El caso se trata de un paciente 36 años de edad con cuadro de diarreas líquidas con moco y escaso sangrado; se realizó un estudio endoscópico y anatomopatológico en el que se observó colitis ulcerativa con coproparasitario positivo para antígeno de C. difficile, y en su hospitalización presentó lesiones dérmicas petequiales y necróticas en el cuarto dedo de la mano izquierda, que en la biopsia dio como resultado vasculitis de pequeños vasos. En este artículo se revisan de forma práctica los aspectos relacionados con la fisiopatología, histología, tratamiento y diagnósticos de la manifestación extraintestinal dermatológica rara, como la vasculitis leucocitoclástica en pacientes con colitis ulcerativas asociadas con Clostridium.

Abstract Leukocytoclastic vasculitis is defined as the damage and inflammation of the vascular walls. The term refers to vasculitis of the small vessels that anatomopathologically present leukocytoclasia and it can be seen as an extra-intestinal manifestation of inflammatory bowel disease. In ulcerative colitis, it occurs less frequently due to immune complexes produced in the intestinal mucosa by exposure of the submucosal lymphoid tissue to fecal antigens, which could precipitate in the walls of the small vessels. This condition can be associated with Clostridium difficile, which is a gram-positive, sporulated, strict anaerobic bacillus, normally found in the environment. It causes colitis that manifests as a diarrheal disease following the ingestion of antibiotics that alter the common bacterial flora of this organ. This is the case report of a 36-year-old patient with liquid diarrhea with mucus and scarce bleeding. Endoscopic and anatomopathological studies were performed, finding ulcerative colitis with positive coproparasite for Clostridium difficile antigen. The patient was hospitalized, and during his stay, he presented with petechiae and necrotic skin lesions on the fourth finger of the left hand. Skin biopsy showed small vessel vasculitis. This article is a practical review of the pathophysiology, histology, treatment, and diagnosis of a rare dermatologic extraintestinal manifestation, namely, leukocytoclastic vasculitis, in patients with C. difficile-associated ulcerative colitis.

Detección molecular de patógenos entéricos en niños con diarrea en un hospital centinela de vigilancia de rotavirus en Chile / Molecular detection of gastrointestinal pathogens among children under 5 years old with diarrhea in a hospital center for rotavirus sentinel surveillance in Chile

INTRODUCCIÓN: Las diarreas de causa infecciosa son un problema de salud pública, especialmente en niños bajo los cinco años. La identificación de los agentes etiológicos puede ser relevante para el manejo del cuadro clínico y, desde el punto de vista epidemiológico, para la implementación de medidas de control. OBJETIVO: Determinar la presencia de patógenos entéricos en niños bajo los cinco años que se hospitalizaron por diarrea aguda en uno de los centros centinelas de la red de vigilancia de rotavirus en Chile. PACIENTES Y MÉTODOS: Estudio observacional en niños menores de cinco años que se internaron por cuadros de diarrea en el Hospital Dr. Luis Calvo Mackenna, durante diciembre del 2015 a diciembre del 2019, el que forma parte de la red de vigilancia de rotavirus del Ministerio de Salud de Chile. Las muestras fecales se analizaron mediante un test molecular, FilmArray GI® panel, que permite la detección de 22 patógenos entéricos virales, bacterianos y parasitarios. RESULTADOS: Se analizaron 493 muestras fecales de niños con episodios de diarrea infecciosa, detectando al menos un patógeno en 427 muestras (87%). De estas muestras positivas, se detectó solo un patógeno en 174 muestras (41%) y dos o más patógenos en 253 muestras (59%). En el grupo de niños bajo un año y el grupo entre uno y cuatro años hubo un predominio de infecciones causadas por virus gastroentéricos, siendo rotavirus y norovirus los virus más detectados en ambos grupos de edad. Las bacterias más frecuentes fueron EPEC (27%), C. difficile (17%), EAEC (14%) y Campylobacter (9%). Respecto a los parásitos, se identificó Giardia lamblia y Cryptosporidium, en el 3 y 1% del total de las muestras, respectivamente. CONCLUSIÓN: La detección molecular utilizada permitió detectar un alto número de enteropatógenos en niños bajo los cinco años. La información generada por este tipo de vigilancia, podría ayudar a caracterizar en la población los episodios de diarrea causados por los principales patógenos entéricos y podría ser una herramienta para asesorar técnicamente a las autoridades en la toma de decisión para la implementación de medidas de control contra estos patógenos.

BACKGROUND: Infectious diarrhea is still a major problem in public health, especially in children under 5 years of age. The identification of the etiologic agent is important for the clinical management of the diarrhea episode and, from the epidemiological point of view, to implement control measures. AIM: To determine the presence of gastrointestinal pathogens in children under five years of age with diarrhea in a Chilean rotavirus surveillance center. METHODS: Observational study in children under five years of age who were hospitalized for diarrhea at the Dr. Luis Calvo Mackenna Hospital from December 2015 to December 2019. Molecular detection was performed using the FilmArray gastrointestinal (FilmArray GI®) panel. RESULTS: We analyzed 493 diarrheal stool samples of children, 427 samples (87%) were positive and 66 samples (13%) were negative. Of positive samples, 174 samples (41%) and 253 samples (59%) were positive for one or more pathogen, respectively. In children under one year and the group between one and four years there was a predominance of infections caused by enteric virus. Rotavirus and norovirus were the most common virus in both age groups. The most frequent bacteria were EPEC (27%), C. difficile (17%), EAEC (14%) and Campylobacter (9%). In parasites, Giardia lamblia and Cryptosporidium were identified, in 3% and 1% of the total samples, respectively. CONCLUSIONS: The molecular detection system used allowed an increase in the detection of enteropathogens in children under five years of age. The information generated by this type of surveillance could help to characterize the episodes of diarrhea in the population and might be a tool to technically advise the authorities in the decision-making process for the implementation of control measures.

¿La detección de toxinas de Clostridioides difficile es necesaria cuando se detecta la enzima glutamato deshidrogenasa? / Is Clostridioides difficile toxins detection necessary when the glutamate dehydrogenase enzyme is detected?

Resumen Introducción: Clostridioides difficile causa diarrea y colitis pseudomembranosa. Su diagnóstico se realiza con la detección de glutamato-deshidrogenasa (GDH) o las toxinas A y B y se confirma con pruebas de amplificación de ácidos nucleicos. Objetivo: Definir si la determinación de GDH es redundante a la de las toxinas. Métodos: Estudio observacional retrospectivo de muestras fecales de pacientes con sospecha de infección por Clostridioides difficile. Las toxinas y GDH se determinaron mediante inmunocromatografía. Se realizó una simulación bayesiana con los cocientes de probabilidad; se consideró significativo un valor de p < 0.05. Resultados: Se analizaron 329 resultados de GDH y toxinas A y B. Se encontró una prevalencia de infección de Clostridioides difficile de 18.2 %. La sensibilidad y especificidad de la prueba de GDH fue de 0.90 y 0.89, respectivamente. El cociente de probabilidad positivo fue de 8.9 y el negativo, de 0.11. Conclusiones: Un resultado negativo de GDH disminuye considerablemente la probabilidad de infección, pero no la descarta. La detección de toxinas de Clostridioides difficile puede ser necesaria en instituciones donde la amplificación de ácidos nucleicos no es económica o accesible.

Abstract Introduction: Clostridioides difficile causes diarrhea and pseudomembranous colitis. Its diagnosis is made with glutamate dehydrogenase (GDH) or toxins A and B detection and is confirmed with nucleic acid amplification tests. Objective: To define if GDH determination is redundant to that of toxins. Methods: Retrospective, observational study in diarrheal stools of patients with suspected Clostridioides difficile infection. Toxins and GDH were determined by immunochromatography. Bayesian simulation was performed with likelihood ratios; a p-value < 0.05 was regarded as significant. Results: 329 GDH and toxin A and B results were analyzed. Clostridioides difficile infection prevalence was 18.2 %. Sensitivity and specificity of the GDH test were 0.90 and 0.89, respectively. Positive likelihood ratio was 8.9, and negative was 0.11. Conclusions: A negative GDH result considerably reduces the probability of infection but does not rule it out. Clostridioides difficile toxins detection may be necessary in institutions where nucleic acid amplification is not affordable or accessible.

Assessing risk factors, mortality, and healthcare utilization associated with Clostridioides difficile infection in four Latin American countries

ABSTRACT Background: Clostridioides difficile infection (CDI) is the most common cause of healthcare-associated infections in Western countries. Risk factors, mortality, and healthcare utilization for CDI in Latin America are poorly understood. This study assessed risk factors and burden associated with nosocomial CDI in four Latin American countries. Methods: This retrospective, case-control study used databases and medical records from 8 hospitals in Argentina, Brazil, Chile, and Mexico to identify nosocomial CDI cases from 2014 − 2017. Cases were patients aged ≥18 years with diarrhea and a positive CDI test ≥72 h after hospital admission. Two controls (without diarrhea; length of hospital stay [LOS] ≥3 days; admitted ±14 days from case patient; shared same ward) were matched to each case. CDI-associated risk factors were assessed by univariate and multivariable analyses. CDI burden (LOS, in-hospital mortality) was compared between cases and controls. Results: The study included 481 cases and 962 controls. Mean age and sex were similar between cases and controls, but mean Charlson comorbidity index (4.3 vs 3.6; p< 0.001) and recent hospital admission (35.3% vs 18.8%; p< 0.001) were higher among cases. By multivariable analyses, CDI risk was associated with prior hospital admission within 3 months (odds ratio [OR], 2.08; 95% CI: 1.45, 2.97), recent antibiotic use (ie, carbapenem; OR, 2.85; 95% CI: 1.75, 4.64), acid suppressive therapy use (OR, 1.71; 95% CI: 1.14, 2.58), and medical conditions (ie, renal disease; OR, 1.48; 95% CI: 1.19, 1.85). In-hospital mortality rate (18.7% vs 6.9%; p< 0.001) and mean overall LOS (33.5 vs 18.8 days; p< 0.001) were higher and longer, respectively, in cases versus controls. Conclusion: Antibiotic exposure, preexisting medical conditions, and recent hospital admission were major risk factors for CDI in Argentina, Brazil, Chile, and Mexico. CDI was associated with increased in-hospital risk of death and longer LOS. These findings are consistent with published literature in Western countries.

Trasplante de microbiota fecal en la infección por Clostridioides difficile / Faecal microbiota transplantation for Clostridioides difficile infection

Resumen La infección por Clostridioides difficile (iCD) es la causa más frecuente de diarrea nosocomial. La primera línea terapéutica es la vancomicina asociada o no al metronidazol. En los últimos años se incrementó el número de fracasos terapéuticos con una mayor frecuencia de formas refractarias o recurrentes. El trasplante de microbiota fecal (TMF) ha surgido como una opción terapéutica para estos casos. Se evaluó la seguridad y la tasa de resolución empleando el TMF en un estudio observacional abierto y prospectivo de 21 pacientes con iCD recurrentes o refractarias internados entre los años 2016 y 2019. La edad media fue de 76.5 años (33-92). Diez presentaron una forma recurrente y 11 una refractaria, 18 fueron graves y 3 fulminantes. En 20 casos el TMF se administró por la vía digestiva alta y en uno por presentar íleo se utilizó la vía baja. Se empleó TMF de heces frescas en un caso y el resto recibió muestras congeladas de un banco de microbiota. Veinte pacientes (95.2%) tuvieron respuesta terapéutica favorable sin presentar recurrencias. Un caso recurrente, con osteomielitis y falla multiorgánica, no tuvo resolución tras dos TMF. La respuesta fue similar en las formas recurrentes y refractarias. Siete pacientes (31%) tuvieron efectos adversos leves y autolimitados. El TMF ha demostrado una alta eficacia como tratamiento de rescate de las formas graves de iCD, con escasos y leves efectos adversos. Contar con un banco de microbiota fecal resulta fundamental para disponer de este recurso terapéutico oportunamente.

Abstract Clostridiodes difficile infection (CDi) is the most common cause of nosocomial diarrhea. Vancomycin, associated or not to metronidazol, is the treatment of choice. However, the rate of treatment failure has increased over the last years and fecal microbiota transplantation (FMT) has emerged as a therapeutic option. To evaluate safety and efficacy of FMT were enrolled 21 hospitalized patients with refractory or recurrent CDi between 2016 and 2019. Fourteen (66%) patients were men and the average age was 76.5 years (range 33-92). Ten had recurrent and 11 refractory CDi, and 18 presented severe and 3 fulminant clinical forms. In 20 cases the FMT was delivered through a nasojejunal tube and in one patient with ileo via enema infusion. Frozen fecal from a stool bank were administered in 20 and in the remaining was used fresh fecal matter. The rate of resolution was observed in 20 patients (95.2%) and none presented recurrence. The response rate was similar in recurrent or refractory forms (9/10 vs 11/11 respectively). One patient with osteomyelitis and multiple organ failure received 2 FMT without response and died. Seven patients (31%) presented mild and self-limited adverse effects. FMT has shown a high efficacy as rescue treatment in cases with refractory or recurrent CDi regardless of severity, with mild side effects. Availability of a stool banks provide reliable, timely and equitable access to FMT for CDi.

Estruturação de centro de transplante de microbiota fecal em hospital universitário no Brasil / Structuring a fecal microbiota transplantation center in a university hospital in brazil

ABSTRACT BACKGROUND: Fecal microbiota transplantation (FMT) is an important therapeutic option for recurrent or refractory Clostridioides difficile infection, being a safe and effective method. Initial results suggest that FMT also plays an important role in other conditions whose pathogenesis involves alteration of the intestinal microbiota. However, its systematized use is not widespread, especially in Brazil. In the last decade, multiple reports and several cases emerged using different protocols for FMT, without standardization of methods and with variable response rates. In Brazil, few isolated cases of FMT have been reported without the implantation of a Fecal Microbiota Transplantation Center (FMTC). OBJECTIVE: The main objective of this study is to describe the process of implanting a FMTC with a stool bank, in a Brazilian university hospital for treatment of recurrent and refractory C. difficile infection. METHODS: The center was structured within the criteria required by international organizations such as the Food and Drug Administration, the European Fecal Microbiota Transplant Group and in line with national epidemiological and regulatory aspects. RESULTS: A whole platform involved in structuring a transplant center with stool bank was established. The criteria for donor selection, processing and storage of samples, handling of recipients before and after the procedure, routes of administration, short and long-term follow-up of transplant patients were determined. Donor selection was conducted in three stages: pre-screening, clinical evaluation and laboratory screening. Most of the candidates were excluded in the first (75.4%) and second stage (72.7%). The main clinical exclusion criteria were: recent acute diarrhea, overweight (body mass index ≥25 kg/m2) and chronic gastrointestinal disorders. Four of the 134 candidates were selected after full screening, with a donor detection rate of 3%. CONCLUSION: The implantation of a transplant center, unprecedented in our country, allows the access of patients with recurrent or refractory C. difficile infection to innovative, safe treatment, with a high success rate and little available in Brazil. Proper selection of qualified donors is vital in the process of implementing a FMTC. The rigorous clinical evaluation of donors allowed the rational use of resources. A transplant center enables treatment on demand, on a larger scale, less personalized, with more security and traceability. This protocol provides subsidies for conducting FMT in emerging countries.

RESUMO CONTEXTO: O Transplante de microbiota fecal (TMF) é uma importante opção terapêutica para a infecção recorrente ou refratária pelo Clostridioides difficile, sendo método seguro e eficaz. Resultados iniciais sugerem que o TMF também desempenha papel relevante em outras afecções cuja patogênese envolve a alteração da microbiota intestinal. No entanto, seu uso sistematizado é pouco difundido, especialmente no Brasil. Na última década, surgiram múltiplos relatos e séries de casos utilizando diferentes protocolos para o TMF, sem padronização de métodos e com taxas de resposta variáveis. No Brasil, poucos casos isolados de TMF foram relatados sem a implantação de um Centro de Transplante de Microbiota Fecal (CTMF). OBJETIVO: O principal objetivo deste estudo foi descrever o processo de implantação de um CTMF com banco de fezes, em hospital universitário brasileiro, para tratamento de infecção recorrente e refratária pelo C. difficile. MÉTODOS: O CTMF foi estruturado dentro dos critérios exigidos e aprovados por organismos internacionais como o Food and Drug Administration, Grupo Europeu de Transplante de Microbiota Fecal e em consonância com os aspectos epidemiológicos e regulatórios nacionais. RESULTADOS: Foi estabelecida toda uma plataforma envolvida na estruturação de um centro de transplante com fezes congeladas. Determinou-se os critérios para seleção de doadores, processamento e armazenamento de amostras, manejo dos receptores antes e após o procedimento, uniformização de vias de administração do substrato fecal e seguimento a curto e longo prazo dos pacientes transplantados. A seleção dos doadores foi conduzida em três etapas: pré-triagem, avaliação clínica e exames laboratoriais. Boa parte dos candidatos foram excluídos na primeira (75,4%) e segunda etapa (72,7%). Os principais critérios clínicos de exclusão foram: diarreia aguda recente, excesso de peso (IMC ≥25 kg/m2) e distúrbios gastrointestinais crônicos. Quatro dos 134 candidatos foram selecionados após a triagem completa, com taxa de detecção de doadores de 3%. CONCLUSÃO: A implantação de um CTMF, inédito no nosso meio, possibilita o acesso de pacientes com infecção recorrente e refratária pelo C. difficile a tratamento inovador, seguro, com elevada taxa de sucesso e pouco disponível no Brasil. A seleção apropriada de doadores qualificados é vital no processo de implantação de um CTMF. A avaliação clínica rigorosa dos doadores permitiu o uso racional de recursos para realização de exames laboratoriais. Um CTMF possibilita tratamento sob demanda, em maior escala, menos personalizados, com mais segurança e rastreabilidade. Este protocolo fornece subsídios para a realização de TMF em países emergentes.

Diarrea clostridial. Un patógeno nosocomial a tener en cuenta / Clostridial diarrhea. A nosocomial pathogen to take into account

La diarrea clostridial es una enfermedad aguda con compromiso colónico que puede poner en riesgo la vida de un paciente. Su agente etiológico es el Clostridium difficile y se ha asociado al uso indiscriminado y por largo plazo de antibióticos de amplio espectro. Su cuadro clínico es variable, puede ir desde un cuadro de diarrea hasta la perforación colónica, que puede determinar la realización de una colectomía de urgencia o incluso provocar la muerte del enfermo. El diagnóstico de certeza se realiza mediante la detección de la toxina clostridial en materia fecal, por técnicas de inmunoensayo enzimático. La terapéutica se realiza con metronidazol o vancomicina por vía oral. El tratamiento quirúrgico está indicado ante la presencia de megacolon tóxico o perforación intestinal, y en aquellos pacientes con toxicidad sistémica con fracaso de la terapéutica médica. (AU)

Clostridial diarrhea is an acute disease with colonic involvement that can be life-threatening for a patient. Its etiologic agent is the Clostridium difficile and it has been associated with the indiscriminate and long-term use of broad-spectrum antibiotics. Its clinical picture varies from a picture of diarrhea to colonic perforation that can determine the performance of an emergency colectomy or even the death of the patient. The certainty diagnosis is carried out by detecting clostridial toxin in fecal matter by enzyme immunoassay techniques. The therapy is carried out with metronidazole or vancomycin orally. Surgical treatment is indicated in the presence of toxic mega colon, intestinal perforation or in those patients with systemic toxicity with failure of medical therapy. (AU)

Detección de Clostridioides difficile toxigénico a partir de muestras diarreicas por reacción en cadena de la polimerasa, en pacientes hospitalizados en Paraguay. Periodo 2016-2018 / Detection of toxigenic Clostridioides difficile from diarrheic samples by polymerase chain reaction in hospitalized patients in Paraguay. Period 2016-2018

La infección por Clostridioides difficile (ICD) se considera la principal enfermedad diarreica asociada a pacientes internados en instituciones de salud, generalmente mayores de 61 años y al uso de antimicrobianos de espectro extendido. Es un bacilo grampositivo anaerobio estricto, esporulado. La alteración de la microbiota colónica por el tratamiento antimicrobiano permite la colonización e infección por este microorganismo, cuya manifestación clínica, se basa en la presentación de cuadro diarreico. El objetivo de este estudio fue detectar C. difficile toxigénico a partir de muestras diarreicas por reacción en cadena de la polimerasa en pacientes hospitalizados. Estudio descriptivo de corte transverso, prospectivo que utilizó como un instrumento de medición una ficha epidemiológica conteniendo las variables de estudio y consentimiento informado. En 901 muestras diarreicas, se detectaron las toxinas tcdA, tcdB, ctdA, ctdB y tcdC y del gen de especie. La prevalencia de C. difficile toxigénico fue de 19,7% (n=178) de las muestras que dieron positivas para una o ambas toxinas (toxinas A y B); el 98% presentó ambas toxinas. Se observó mayor presentación de ICD en pacientes con una mediana de 68 años, y en el sexo masculino en un 52%. Se evaluó el tratamiento antimicrobiano y el uso de los antimicrobianos, donde, el uso de clindamicina, cefalosporinas, fluoroquinolonas y vancomicina, presentó valores estadísticamente significativos. Los resultados obtenidos permitieron caracterizar epidemiológicamente la infección por este patógeno. Es de gran importancia realizar en forma temprana el diagnóstico y diseñar e implementar estrategias para evitar la emergencia de este patógeno

Clostridioides difficile infection is considered the main diarrheal disease associated with patients hospitalized in health institutions, older than 61 years and the use of extended spectrum antimicrobials. It is a strict anaerobic, sporulated gram-positive bacillus. The alteration of the colonic microbiota by antimicrobial treatment allows colonization and infection by this microorganism, whose clinical manifestation is based on the presentation of the diarrheal syndrome. The objective of this study was to detect toxigenic C. difficile from diarrheal samples by polymerase chain reaction in hospitalized patients. This was a descriptive, cross-sectional, prospective study in which an epidemiological record containing the study variables and informed consent were used. In 901 diarrheal samples, tcdA, tcdB, ctdA, ctdB and tcdC toxins and the species gene were detected. The prevalence of toxigenic C. difficile was 19.7% (n=178) of the samples, positives for one or both toxins (toxins A and B) while 98% presented both toxins. A higher frequency of ICD was observed in male patients (52%) who had a median age of 68 years. Antimicrobial treatment and use of antimicrobials were evaluated, where the use of clindamycin, cephalosporins, fluoroquinolones and vancomycin had statistically significant values. The results allowed infection by this pathogen to be epidemiologically characterized. It is very important to make early diagnosis and design and implement strategies to prevent the emergence of this pathogen