Laurie Archbald-Pannone

Elevated levels of intestinal inflammation in Clostridium difficile infection associated with fluoroquinolone-resistant C. difficile

Madam, The Clostridium difficile restriction endonuclease analysis (REA) type BI [polymerase chain reaction (PCR) ribotype 027] strain, with cdtA/cdtB (genes for binary toxin CDT), an 18 bp tcdC deletion, elevated toxin A and B concentrations, and fluoroquinolone resistance, is possibly responsible for the increased Clostridium difficile infection (CDI) incidence, severity, and mortality observed recently.1–4 The historic BI strain, present at least since the early 1980s also contained the 18 bp deletion, cdtA/cdtB, and levofloxacin resistance, but has not previously been associated with outbreaks.5 The recent BI strain, however, has additionally acquired resistance to moxifloxacin and gatifloxacin.5 From 2002 to 2005, the number of cases of CDI at the University of Virginia Hospital (UVH) doubled and cases associated with ciprofloxacin use increased (LAP, personal communication). Previous work showed that high levels of fecal lactoferrin, a marker of leucocytes and intestinal inflammation, were associated with moderate to severe clinical CDI.6 Therefore, our aim was to determine whether the BI strain was present at UVH, and if there was a correlation between genotype, strain type, or moxifloxacin resistance patterns, and lactoferrin levels. Fifty-two de-identified fecal specimens from inpatients at UVH with a clinical suspicion of CDI and testing positive for toxins A or B by enzyme-linked immunosorbent assay (ELISA) were collected. Thirty-four C. difficile strains were then successfully isolated from these faecal specimens. Moxifloxacin resistance was determined using E-test strips; only fully sensitive [minimum inhibitory concentration (MIC) 32 μg/mL) isolates were observed. DNA was extracted and amplified by PCR for the presence of gdh (glutamate dehydrogenase), tcdA (toxin A gene), tcdB (toxin B gene), tcdC, and cdtA/cdtB. To determine if the BI strain was present, REA was performed on 33 of 34 isolates by the C. difficile Microbiology Reference Laboratory (MRL) at the Hines Veterans Administration Hospital. We further sequenced the tcdC gene of 12 representative isolates (10 resistant and two susceptible), to determine if our BI/027 strains contained a single nucleotide base pair deletion associated with toxin A and B hypersecretion. Faecal specimens were evaluated for lactoferrin using the IBD Scan ELISA (TechLab, Inc.) and grouped according to lactoferrin concentration: >72.5 μg/g (10-fold greater than the set point for a positive test) or ≤72.5 μg/g. Eighteen (53%) isolates tested positive for the tcdC deletion, 19 (56%) for cdtA/cdtB, and 26 (76%) were moxifloxacin resistant. Eighteen of 33 (55%) were REA type BI. All BI/027 isolates had the 18 bp tcdC deletion and cdtA/cdtB, and 16 (89%) were moxifloxacin resistant. All sequenced BI/027 strains contained a single base pair deletion at position 117. Using χ2-analysis, we noted that faecal specimens with higher levels of lactoferrin were significantly associated with the presence of moxifloxacin-resistant isolates, and that susceptible isolates were associated with lower levels of lactoferrin (Figure 1a, P = 0.041). Elevated lactoferrin levels were not independently associated with the presence of the 18 bp tcdC deletion (Figure 1b) or cdtA/cdtB (data not shown). Figure 1 24 (71%) fecal specimens had lactoferrin levels ≤72.5 μg/g. A. Of the 10 specimens with lactoferrin levels >72.5, all were associated with the presence of moxifloxacin resistant isolates; in addition, all susceptible isolates were ... We report that higher levels of intestinal inflammation, as measured by quantitative fecal lactoferrin, are associated with moxifloxacin-resistant CDI. Notably, only moxifloxacin resistance, as opposed to the tcdC deletion or cdtA/cdtB, was significantly associated with lactoferrin levels >72.5 μg/g. We observed that the BI/027 strain is present at UVH and that moxifloxacin resistance, present in 76% of our strains, appears to be a factor leading to intestinal inflammation in patients with CDI. This study does not aim to place a precise concentration indicating what constitutes elevated lactoferrin levels in CDI, but only to recognize that in our set of faecal specimens the highest lactoferrin levels, and thus the greatest levels of intestinal inflammation, were associated with moxifloxacin-resistant CDI, including but not limited to the BI/027 strain. A larger study looking at the correlation of faecal lactoferrin with patient characteristics, severity of disease, and presence of moxifloxacin-resistant CDI is needed to validate or refute this preliminary finding that fluoroquinolone resistance may be an important factor leading to more severe intestinal inflammation in CDI.

Diarrhea, Clostridium difficile, and Intestinal Inflammation in Residents of a Long-Term Care Facility

INTRODUCTION Long-term care facilities (LTCF) residents have been estimated to have the highest incidence of diarrheal illness among adults living in the developed world. This study describes undiagnosed diarrhea, intestinal inflammation, and Clostridium difficile colonization in a LTC population and explores whether these are associated with functional decline, as defined by weight loss or a change in cognitive or ADL status. METHODS An observational study of a convenience sampling of residents in a 180-bed LTCF was obtained; evaluation of stool and medical records was done. Stool specimens were evaluated for consistency, gross blood, inflammation (via quantitative fecal lactoferrin, IBD-SCAN), and C difficile (via PCR for gdh). SPSS and STATA were used and significance was set at P < .05. RESULTS There were 46 stools collected; 13 of the subjects were male, 28 were older than 65 years, and 35 were prescribed 5 to 15 medications. Twenty-six of the 46 stools collected had elevated quantitative fecal lactoferrin levels. Although only 5 subjects were reported to have diarrhea (4 with elevated lactoferrin), 28 stool specimens were observed to be liquid or semi-solid (19 with elevated lactoferrin), and these liquid/ semisolid stools were significantly correlated with lactoferrin positivity (P = .017). In analysis of functional status, there was no statistically significant association between change in ADL (n = 17) or cognitive status (n = 5) and elevated lactoferrin. However, all 3 subjects who had significant weight loss had elevated lactoferrin, although the mean fecal lactoferrin was not statistically different from those without weight loss. Of the 2 samples with C difficile, both were liquid and, when compared with all other liquid stools (n = 22), the mean lactoferrin was statistically higher (134.1 versus 28.8 microg/mL, P = .008). These 2 subjects had neither weight loss nor change in cognitive status, but 1 had a change in ADL status. DISCUSSION AND CONCLUSIONS Diarrhea in LTCF residents is underdiagnosed. Diarrhea and the presence of C difficile in the stool are associated with intestinal inflammation, as detected by fecal lactoferrin. With our small numbers, we were not able to identify a specific link; however, we were able to identify a correlation between weight loss and intestinal inflammation, but, with just 2 samples, not C difficile colonization. This relationship highlights the importance of larger studies to further examine the rate of diarrhea in LTCF; the effect of diarrhea and intestinal inflammation on weight loss; and the interaction of C difficile colonization with weight loss, malnutrition, and functional decline.

Clostridium difficile ribotype 027 is most prevalent among inpatients admitted from long-term care facilities.

Intestinal inflammation was evaluated using faecal lactoferrin and ribotype in 196 hospitalized adults with Clostridium difficile infection to determine the impact of ribotype 027 in long-term care facilities (LTCFs). LTCF residents (n=28) had greater antibiotic use (P=0.049) and more ribotype 027 infection [odds ratio (OR): 4.87; 95% confidence interval (CI): 2.02-11.74; P<0.01], compared to those admitted from home. Patients infected with ribotype 027 strains had worse six-month mortality (OR: 1.90; 95% CI: 1.08-3.34; P=0.03) and more inflammation (95.26 vs 36.08 μg/mL; P=0.006), compared to those infected with non-027 strains. This study was not designed to determine acquisition site, but, in this population, suggests that the location from which the patient has been admitted is strongly associated with ribotype 027 and more severe C. difficile disease.

Probiotics for Clostridium difficile infection in adults (PICO): Study protocol for a double-blind, randomized controlled trial.

BACKGROUND Clostridium difficile is a pathogen of rapidly increasing public health importance. An estimated quarter of a million Clostridium difficile infections (CDI) occur in the United States annually, at a resultant cost of 14,000 deaths and 1 billion dollars. Clostridium difficile related deaths have risen 400% over the last decade, and current standard antibiotic treatments are only 75 to 85% successful. Besides increasing the risk of antibiotic resistance and side effects, these treatments are very expensive. The most vulnerable population for Clostridium difficile is older adults, who make up approximately half of the cases, but account for 90% of the related deaths. Probiotics may have potential as adjunctive therapeutic agents for CDIs, however, current data is limited. METHODS This pilot study is a single-site, randomized, placebo-controlled, double-blind, phase two clinical trial. The trial primarily evaluates the effect of four weeks of probiotic therapy in addition to standard of care on Clostridium difficile diarrhea duration and recurrence. Secondary outcomes include effect on fecal cytokines, fecal lactoferrin, and Clostridium difficile toxin density in stool, as well as patient functional status. DISCUSSION This pilot study will determine the feasibility and effect size to conduct larger randomized controlled trials of probiotic interventions in patients with CDI, to determine the impact of probiotics on the symptoms of CDI. ClinicalTrials.gov Identifier: NCT01680874.

A randomized controlled trial of probiotics for Clostridium difficile infection in adults (PICO)

Background Clostridium difficile is the most common cause of hospital-acquired infections, responsible for >450000 infections annually in the USA. Probiotics provide a promising, well-tolerated adjunct therapy to standard C. difficile infection (CDI) treatment regimens, but there is a paucity of data regarding their effectiveness for the treatment of an initial CDI. Objectives We conducted a pilot randomized controlled trial of 33 participants from February 2013 to February 2015 to determine the feasibility and health outcomes of adjunct probiotic use in patients with an initial mild to moderate CDI. Methods The intervention was a 28 day, once-daily course of a four-strain oral probiotic capsule containing Lactobacillus acidophilus NCFM, Lactobacillus paracasei Lpc-37, Bifidobacterium lactis Bi-07 and B. lactis Bl-04. The control placebo was identical in taste and appearance. Registered at clinicaltrials.gov: trial registration number = NCT01680874. Results Probiotic adjunct therapy was associated with a significant improvement in diarrhoea outcomes. The primary duration of diarrhoea outcome (0.0 versus 1.0 days; P = 0.039) and two exploratory outcomes, total diarrhoea days (3.5 versus 12.0 days; P = 0.005) and rate of diarrhoea (0.1 versus 0.3 days of diarrhoea/stool diary days submitted; P = 0.009), all decreased in participants with probiotic use compared with placebo. There was no significant difference in the rate of CDI recurrence or functional improvement over time between treatment groups. Conclusions Probiotics are a promising adjunct therapy for treatment of an initial CDI and should be further explored in a larger randomized controlled trial.

Survey of C. difficile-Specific Infection Control Policies in Local Long-Term Care Facilities.

Introduction The incidence and severity of Clostridium difficile infection (CDI) has been increasing and long-term care facility (LTCF) residents are at high risk given their age, co-morbidities, and high antibiotic exposure. Infection control policies are crucial for controlling CDI, but there are currently no regulatory guidelines in the United States. Therefore, we evaluated infection control policies in local LTCFs to define the CDI-specific policies and the administrative and staff understanding of CDI, so as to identify perceived barriers for compliance. Methods IRB approval was sought and exemption granted, all 8 local LTCFs were asked to participate. Each facility was visited by study personnel who interviewed the administrative Infection Control Practitioner (ICP) and 3 - 4 Licensed Practical Nurses (LPNs) with distinct survey format. Infection control policies were then compared to the SHEA recommendations for CDI in LTCFs. Results Of the eligible facilities, 75% (n = 6) participated. ICP (n = 6) and LPNs (n = 21) were interviewed. All facilities accept residents with active CDI and 2 had written CDI-specific infection control policies. All facilities had hand hygiene or glove use policies and 2 had policies for the use of sporicidal environmental cleaning. No facility restricted antibiotic use. Each facility has a policy to instruct their staff through in-services, either annually or upon new hire, but 33% (n = 7) LPNs reported no facility-based CDI training. While 80% (n = 17) of LPNs felt comfortable with the facility CDI policies, only 11 accurately restated it. ICPs felt the most relevant barrier to staff compliance was time constraints (n = 4, 67%), however, LPNs felt it was limited knowledge (n = 10, 48%) and poor communication (n = 2, 10%). Discussion and Conclusions With the increasing incidence and severity of CDI in LCTF, few of the facilities surveyed had CDI-specific policies. Despite CDI-specific training, there is a perceived knowledge and communication gap for staff caring for residents with CDI.

Peripheral Inflammation and Functional Decline in the National Health and Nutrition Examination Survey Elderly Population

them about their medications before they left the hospital, nine of these 25 (36%) reported that they shared their values and preferences regarding medications, and eight of these nine (88.9%) thought that the clinician took their values and preferences into account. All 16 participants who reported that they did not share their values or preferences regarding medications endorsed the sentiment that the “doctor knows best.” For the 17 participants who complete the Patient Activation Measure, activation scores ranged from 31.1 to 77.5 (mean 49.5, median 47.4). Specifically, 53% disagreed or disagreed strongly with the statement, “I know what each of my prescribed medications does.”