Guidance document for prevention of Clostridium difficile infection in acute healthcare settings.

SCOPE: Clostridium difficile infection (CDI) is the most important infective cause of healthcare-associated diarrhoea in high income countries and one of the most important healthcare-associated pathogens in both Europe and the United States. It is associated with high morbidity and mortality resulting in both societal and financial burden. A significant proportion of this burden is potentially preventable by a combination of targeted infection prevention and control measures and antimicrobial stewardship. The aim of this guidance document is to provide an update on recommendations for prevention of CDI in acute care settings to provide guidance to those responsible for institutional infection prevention and control programmes. METHODS: An expert group was set up by the European society of clinical microbiology and infectious diseases (ESCMID) Study Group for C. difficile (ESGCD), which performed a systematic review of the literature on prevention of CDI in adults hospitalized in acute care settings and derived respective recommendations according to the GRADE approach. Recommendations are stratified for both outbreak and endemic settings. QUESTIONS ADDRESSED BY THE GUIDELINE AND RECOMMENDATIONS: This guidance document provides thirty-six statements on strategies to prevent CDI in acute care settings, including 18 strong recommendations. No recommendation was provided for three questions.

Consensus report: faecal microbiota transfer - clinical applications and procedures.

BACKGROUND: Faecal microbiota transplantation or transfer (FMT) aims at replacing or reinforcing the gut microbiota of a patient with the microbiota from a healthy donor. Not many controlled or randomised studies have been published evaluating the use of FMT for other diseases than Clostridium difficile infection, making it difficult for clinicians to decide on a suitable indication. AIM: To provide an expert consensus on current clinical indications, applications and methodological aspects of FMT. METHODS: Well-acknowledged experts from various countries in Europe have contributed to this article. After literature review, consensus has been achieved by repetitive circulation of the statements and the full manuscript among all authors with intermittent adaptation to comments (using a modified Delphi process). Levels of evidence and agreement were rated according to the GRADE system. Consensus was defined a priori as agreement by at least 75% of the authors. RESULTS: Key recommendations include the use of FMT in recurrent C. difficile infection characterised by at least two previous standard treatments without persistent cure, as well as its consideration in severe and severe-complicated C. difficile infection as an alternative to total colectomy in case of early failure of antimicrobial therapy. FMT in inflammatory bowel diseases (IBD), irritable bowel syndrome (IBS) and metabolic syndrome should only be performed in research settings. CONCLUSIONS: Faecal microbiota transplantation or transfer is a promising treatment for a variety of diseases in which the intestinal microbiota is disturbed. For indications other than C. difficile infection, more evidence is needed before more concrete recommendations can be made.

Highlighting clinical needs in Clostridium difficile infection: the views of European healthcare professionals at the front line.

BACKGROUND: Clostridium difficile infection (CDI) is the leading cause of infectious nosocomial diarrhoea in Europe. Despite increased focus, its incidence and severity are increasing in many European countries. AIM: We developed a series of consensus statements to identify unmet clinical needs in the recognition and management of CDI. METHODS: A consortium of European experts prepared a series of 29 statements representing their collective views on the diagnosis and management of CDI in Europe. The statements were grouped into the following six broad themes: diagnosis; definitions of severity; treatment failure, recurrence and its consequences; infection prevention and control interventions; education and antimicrobial stewardship; and National CDI clinical guidance and policy. These statements were reviewed using questionnaires by 1047 clinicians involved in managing CDI, who indicated their level of agreement with each statement. FINDINGS: Levels of agreement exceeded the 66% threshold for consensus for 27 out of 29 statements (93.1%), indicating strong support. Variance between countries and specialties was analysed and showed strong alignment with the overall consensus scores. CONCLUSION: Based on the consensus scores of the respondent group, recommendations are suggested for the further development of CDI services in order to reduce transmission and recurrence and to ensure that appropriate diagnosis and treatment strategies are applied across all healthcare settings.

Clostridium difficile PCR ribotype 046 is common among neonatal pigs and humans in Sweden.

Clostridium difficile PCR ribotype 046 was found in 67% of neonatal piglets (45/67) sampled from three separate pig-breeding farms in Sweden. Sows from the same farms were tested and 50% were colonized in faeces and 30% were colonized on skin. An environmental source was suggested because identical PCR ribotypes were isolated from faeces as well as externally. Human C. difficile infection outbreaks in southern Sweden by the identical PCR ribotype 046 indicate its zoonotic potential.

IgG antibody response to toxins A and B in patients with Clostridium difficile infection.

IgG antibodies against Clostridium difficile toxins A and B were followed in controls and in patients with an initial C. difficile infection (CDI). Of the 50 CDI patients, 38 were cured and 12 developed recurrence. Compared to controls, patients had significantly lower anti-toxin A and B IgGs at inclusion, but the subsequent levels rose slightly regardless of clinical outcome. The results imply that the general serum reactivity against toxins A and B in the population reduces the risk of CDI, which suggests implications for vaccine strategies.

Geographical clustering of cases of infection with moxifloxacin-resistant Clostridium difficile PCR-ribotypes 012, 017 and 046 in Sweden, 2008 and 2009.

We report the results of two nationwide surveillance studies of Clostridium difficile infection conducted during 2008 and 2009 in Sweden. The first study aimed to identify and quantify the proportion of C. difficile isolates with decreased susceptibility to moxifloxacin, particularly those of PCR-ribotype 027. From December 2007 to September 2008, 20 of 28 regional laboratories sent 585 isolates to the Swedish Institute for Infectious Disease Control for typing. A majority of the isolates (454 of 585; 78%) belonged to four PCR ribotypes (012, SE37, 017 and 046), all clustered in geographical regions. Only two type 027 isolates were found, both from the same patient. In the second study, involving all 28 regional laboratories, all consecutive C. difficile isolates collected during two time periods in 2009 (n=364) were typed and tested for susceptibility to clindamycin, erythromycin, moxifloxacin, metronidazole and vancomycin. The three most common PCR ribotypes were SE21, 001 and 020 (22% of all isolates). Types 012, 017, and 046 were geographically clustered and associated with decreased susceptibility to moxifloxacin, clindamycin and erythromcin. The extent of moxifloxacin prescription was highly variable among counties, indicating a need for careful monitoring of prescription rates to follow its role in C. difficile epidemiology.

A case of diphtheria in Sweden, October 2011.

In October 2011, a child who had arrived in Sweden from Somalia presented with atypical tonsillitis, was treated with penicillin and the symptoms resolved. A throat swab was positive for toxigenic Corynebacterium diphtheriae. The child's family were then vaccinated with diphtheria, tetanus and pertussis vaccine and screened for C. diphtheriae. No secondary cases were found. A high level of adherence to childhood vaccination programmes is an effective way to protect populations against diphtheria.

In vitro susceptibility to 17 antimicrobials of clinical Clostridium difficile isolates collected in 1993-2007 in Sweden.

This study investigated the MICs of 17 antimicrobials, for 606 toxigenic clinical isolates of Clostridium difficile collected between 1993 and 2007 in Sweden. Low MIC(90) values were found for metronidazole (0.5 mg/L), vancomycin (1.0 mg/L), teicoplanin (0.125 mg/L), fusidic acid (1.0 mg/L), linezolid (2.0 mg/L), daptomycin (2.0 mg/L) and tigecycline (0.064 mg/L). Three isolates (0.5%) had elevated MICs for vancomycin (4-8 mg/L); however, these isolates originated from the same patient, who was receiving long-term intravenous vancomycin treatment. High-level clindamycin resistant isolates (MIC >256 mg/L) peaked in 1997 with 39 of 95 (41%) and out of these, 36% were also highly resistant to erythromycin. beta-Lactams such as penicillin V and piperacillin displayed MIC(90)s of 8 and 32 mg/L, respectively, whereas MICs of cefuroxime were >256 mg/L for all isolates. Universal resistance to ciprofloxacin and levofloxacin was found, and resistance to moxifloxacin increased from 4% of isolates in 2004 to 23% in 2007. Notably, these moxifloxacin-resistant isolates did not belong to the recent epidemic PCR ribotype 027, but to the pre-existing epidemic type 012 (82%), and these isolates accounted for the majority of isolates that were resistant to clindamycin (70%), tetracycline (84%) and rifampicin (92%) as well. This investigation of susceptibility data on clinical C. difficile isolates showed variations of multiresistance to be due to a specific PCR ribotype 012, emphasizing the importance of genotyping when evaluating emerging resistance over time.

Mutations in fusA associated with posttherapy fusidic acid resistance in Clostridium difficile.

In silico, we identified fusA (2,067 bp) in Clostridium difficile 630. Sequencing of fusA in posttherapy fusidic acid-resistant C. difficile isolates from 12 patients with C. difficile-associated diarrhea (CDAD) identified fusA mutations, one or two nonsynonymous substitutions, or in one case a deletion of one codon associated with resistance. Five of these mutations have previously been described in fusA of fusidic acid-resistant Staphylococcus aureus, but seven were novel fusA mutations. Fusidic acid monotherapy for CDAD seemed to rapidly select conserved resistant mutants.

Frequent emergence of resistance in Clostridium difficile during treatment of C. difficile-associated diarrhea with fusidic acid.

Samples from patients with Clostridium difficile-associated diarrhea (CDAD) that were randomized to fusidic acid (n = 59) or metronidazole (n = 55) therapy for 7 days were cultured for Clostridium difficile in feces on days 1, 8 to 13, and 35 to 40. Of the patients who were culture positive only before treatment, 77% (36/47) were permanently cured (no treatment failure and no clinical recurrence), compared to 54% (22/41) of those with persistence of C. difficile at one or both follow-ups (P = 0.03). A similar association between bacterial persistence and a worse outcome of therapy was seen in both treatment groups. Resistance to fusidic acid was found in 1 of 88 pretherapy isolates available, plus in at least 1 subsequent isolate from 55% (11/20) of patients who remained culture-positive after fusidic acid therapy. In 10 of these 11 patients, the resistant follow-up isolate(s) belonged to the same PCR ribotype as the susceptible day 1 isolate, confirming frequent emergence of resistance to fusidic acid during treatment. Despite this, 5 of these 11 patients were permanently cured with fusidic acid, relative to 5 of 9 patients with susceptible C. difficile at follow-up (P = 1.0). None of the 36 PCR ribotypes of C. difficile identified was associated with any particular clinical outcome or emergence of fusidic acid resistance. In conclusion, culture positivity for C. difficile was common after both fusidic acid and metronidazole therapy and was associated with treatment failure or recurrence of CDAD. Development of resistance in C. difficile was frequent in patients given fusidic acid, but it was without apparent negative impact on therapeutic efficacy in the actual CDAD episode.

Demonstration of EGFR gene copy loss in colorectal carcinomas by fluorescence in situ hybridization (FISH): a surrogate marker for sensitivity to specific anti-EGFR therapy?

AIMS: To investigate EGFR gene copy number heterogeneity in colorectal carcinomas compared with copy number of chromosome 7 and immunohistochemical expression of the EGFR protein. METHODS AND RESULTS: Fluorescence in situ hybridization of the EGFR gene and CEP7 was carried out on paraffin-embedded material from 48 rectal carcinomas combined with immunohistochemical detection of EGFR with a polymer detection kit. EGFR gene copy number had a range of 1.4-7.3 with a mean of 2.5. CEP7 copy number had a range of 1.5-6.1 with a mean of 2.5. The EGFR gene/CEP7 ratio ranged from 0.4 to 1.5 with a mean of 0.96. Most cases had a balanced EGFR gene/CEP7 ratio (37 cases = 77%). Copy gain was found in seven cases (15%) with a ratio of up to 1.5, consistent with gain of one EGFR gene copy in one chromosome. Copy loss was found in four cases (8%). All cases with EGFR gene copy loss were immunohistochemically positive. CONCLUSIONS: Demonstration of EGFR gene copy loss might be a surrogate marker for EGFR mutation/deletion and could be used in a routine setting in pathology departments. Further studies are needed to determine whether this may be used to select patients that might benefit from specific anti-EGFR therapy.

Molecular epidemiology of hospital-associated and community-acquired Clostridium difficile infection in a Swedish county.

All episodes of Clostridium difficile associated diarrhea (CDAD) diagnosed in a defined population of 274,000 including one tertiary and two primary hospitals and their catchment areas were studied during 12 months. The annual CDAD incidence in the county was 97 primary episodes per 100,000, and 78% of all episodes were classified as hospital associated with a mean incidence of 5.3 (range, 1.4 to 6.5) primary episodes per 1,000 admissions. The incidence among hospitalized individuals was 1,300-fold higher than that in the community (33,700 versus 25 primary episodes per 100,000 persons per year), reflecting a 37-fold difference in antibiotic consumption (477 versus 13 defined daily doses [DDD]/1,000 persons/day) and other risk factors. Three tertiary hospital wards with the highest incidence (13 to 36 per 1,000) had CDAD patients of high age (median age of 80 years versus 70 years for other wards, P < 0.001), long hospital stay (up to 25 days versus 4 days), or a high antibiotic consumption rate (up to 2,427 versus 421 DDD/1,000 bed days). PCR ribotyping of C. difficile isolates available from 330 of 372 CDAD episodes indicated nosocomial acquisition of the strain in 17 to 27% of hospital-associated cases, depending on the time interval between index and secondary cases allowed (2 months or up to 12 months), and only 10% of recurrences were due to a new strain of C. difficile (apparent reinfection). In other words, most primary and recurring episodes were apparently caused by the patient's endogenous strain rather than by one of hospital origin. Typing also indicated that a majority of C. difficile strains belonged to international serotypes, and the distribution of types was similar within and outside hospitals and in primary and relapsing CDAD. However, type SE17 was an exception, comprising 22% of hospital isolates compared to 6% of community isolates (P = 0.008) and causing many minor clusters and a silent nosocomial outbreak including 36 to 44% of the CDAD episodes in the three high-incidence wards.

Histopathology of arterial lesions in LPA transgenic mice on cholesterol-enriched chow.

The aortic root from 21 LPA transgenic mice and 18 control litter mates on cholesterol enriched chow were studied histologically for the presence of atherosclerotic lesions. Serial sections were cut and the total area of the lesions was measured by use of computerised image analysis. Lipid staining lesions were found in 17 aortas of the transgenic mice and were five times more common than in the controls. Foam cell lesions were the only type of lesion in 12 of the aortas from transgenic animals, while five animals had developed fibrofatty lesions. Immunostaining revealed monocytes/macrophages on the endothelial surface, and in the subendothelial space of foam cell lesions. In fibrofatty lesions, spindle shaped cells formed a cap around the lipid core. This study supports the view that transgenic mice expressing human apolipoprotein (a) on a high fat and cholesterol diet, are more susceptible to aortic lesions than control mice and develop early atherosclerotic lesions comparable to lesions in man. Aminoguanidin in the drinking water had no effect on the aortic lesions, but lesion size was significantly, negatively correlated with plasma glucose concentration.

Deep soft-tissue infections caused by Streptococcus pneumoniae.

Three cases of deep soft-tissue infections caused by Streptococcus pneumoniae are presented. All patients were previously healthy adults. The first case was a man with a protracted illness in whom pelvic and inguinal abscesses developed at the site of a scar from a traumatic injury several years earlier. The second patient, a woman, had mastitis with systemic symptoms. The third patient was a woman who developed a gluteal abscess after an intramuscular injection of a contraceptive. Cellulitis and deep soft-tissue infections caused by Streptococcus pneumoniae are uncommon, but may occur even in immunocompetent adults.