Natasha Bagdasarian

Diagnosis and Treatment of Clostridium difficile in Adults: A Systematic Review

IMPORTANCE Since 2000, the incidence and severity of Clostridium difficile infection (CDI) have increased. OBJECTIVE To review current evidence regarding best practices for the diagnosis and treatment of CDI in adults (age ≥ 18 years). EVIDENCE REVIEW Ovid MEDLINE and Cochrane databases were searched using keywords relevant to the diagnosis and treatment of CDI in adults. Articles published between January 1978 and October 31, 2014, were selected for inclusion based on targeted keyword searches, manual review of bibliographies, and whether the article was a guideline, systematic review, or meta-analysis published within the past 10 years. Of 4682 articles initially identified, 196 were selected for full review. Of these, the most pertinent 116 articles were included. Clinical trials, large observational studies, and more recently published articles were prioritized in the selection process. FINDINGS Laboratory testing cannot distinguish between asymptomatic colonization and symptomatic infection with C difficile. Diagnostic approaches are complex due to the availability of multiple testing strategies. Multistep algorithms using polymerase chain reaction (PCR) for the toxin gene(s) or single-step PCR on liquid stool samples have the best test performance characteristics (for multistep: sensitivity was 0.68-1.00 and specificity was 0.92-1.00; and for single step: sensitivity was 0.86-0.92 and specificity was 0.94-0.97). Vancomycin and metronidazole are first-line therapies for most patients, although treatment failures have been associated with metronidazole in severe or complicated cases of CDI. Recent data demonstrate clinical success rates of 66.3% for metronidazole vs 78.5% for vancomycin for severe CDI. Newer therapies show promising results, including fidaxomicin (similar clinical cure rates to vancomycin, with lower recurrence rates for fidaxomicin, 15.4% vs vancomycin, 25.3%; P = .005) and fecal microbiota transplantation (response rates of 83%-94% for recurrent CDI). CONCLUSIONS AND RELEVANCE Diagnostic testing for CDI should be performed only in symptomatic patients. Treatment strategies should be based on disease severity, history of prior CDI, and the individual patients risk of recurrence. Vancomycin is the treatment of choice for severe or complicated CDI, with or without adjunctive therapies. Metronidazole is appropriate for mild disease. Fidaxomicin is a therapeutic option for patients with recurrent CDI or a high risk of recurrence. Fecal microbiota transplantation is associated with symptom resolution of recurrent CDI but its role in primary and severe CDI is not established.

Seasonal influenza A (H1N1) infection in early pregnancy and second trimester fetal demise

A second trimester fetal demise followed influenza-like illness in early pregnancy. Influenza A virus (H1N1) was identified in maternal and fetal tissue, confirming transplacental passage. These findings suggested a causal relationship between early exposure and fetal demise. Management of future influenza outbreaks should include evaluation of products of conception associated with fetal loss.

Infectious Complications of Dialysis Access Devices

Infectious complications remain a major source of morbidity and mortality for patients with end-stage renal disease on dialysis. The majority of these complications are related to dialysis access devices, and as such represent a potentially modifiable risk factor. This article reviews the important infectious complications associated with dialysis access, including both hemodialysis and peritoneal dialysis. The discussion highlights the epidemiology, management, and prevention of dialysis access infections.

Distinguishing Zika and Dengue Viruses through Simple Clinical Assessment, Singapore

Dengue virus and Zika virus coexist in tropical regions in Asia where healthcare resources are limited; differentiating the 2 viruses is challenging. We showed in a case–control discovery cohort, and replicated in a validation cohort, that the diagnostic indices of conjunctivitis, platelet count, and monocyte count reliably distinguished between these viruses.

Treatment for Clostridium difficile Infection in Adults—Reply

Discussion | Nearly 35% of all adults and 50% of those aged 60 years or older were estimated to have the metabolic syndrome, a concerning observation given the aging US population. Previous analyses of NHANES through 2006 demonstrated increasing rates of the metabolic syndrome, whereas our study suggests that the prevalence has remained stable overall since 2007 and declined in women.5 Greater awareness of the metabolic syndrome and its health consequences may have contributed to improvements in optimizing treatment of risk factors such as hypertension and diabetes. Furthermore, recent NHANES data demonstrate that obesity prevalence in the United States also appears to have stabilized, which also may contribute to the stabilizing prevalence of the metabolic syndrome.6 Limitations of our study include potential misclassification of individuals taking diabetes or hypertension medications for other reasons. In addition, our study did not evaluate differences in the prevalence of individual components of the metabolic syndrome. Even though we used concurrent use of hypertension or diabetes medication as satisfying those components of the metabolic syndrome, only data for cholesterol medication in general were available for analyses and not specifically for treatment of triglycerides or HDL cholesterol. We did not include these to avoid overestimation of metabolic syndrome prevalence.

Changing Epidemiology and Control of Clostridium difficile in Older Adults

Clostridium difficile infection (CDI) presents unique clinical challenges among older adults. Older patients tend to have more severe disease, more treatment failures, and higher rates of relapse. As the burden of CDI in older adults continues to grow, better paradigms for the prevention and treatment of CDI in this vulnerable population will be essential. In this review, we offer an overview of the changing epidemiology of C. difficile, with a review of CDI prevention, diagnosis and treatment, with a focus on older patients.