Tag Archives: Clostridioides difficile Infection

Data Collected Finding Clostridioides difficile in COVID-19 Patients, Detroit, Michigan, USA

Clostridioides difficile in COVID-19 Patients, Detroit, Michigan, USA, March–April 2020

Avnish Sandhu, Glenn Tillotson, Jordan Polistico, Hossein Salimnia, Mara Cranis, Judy Moshos, Lori Cullen, Lavina Jabbo, Lawrence Diebel, and Teena ChopraComments to Author
Author affiliations: Detroit Medical Center, Detroit, Michigan, USA (A. Sandhu, J. Polistico, H. Salimnia, M. Cranis, J. Moshos, L. Cullen, L. Jabbo, T. Chopra)Wayne State University School of Medicine, Detroit (A. Sandhu, J. Polistico, H. Salimnia, L. Diebel, T. Chopra)GST Micro LLC, Henrico, Virginia, USA (G. Tillotson)

 

Abstract

We describe 9 patients at a medical center in Detroit, Michigan, USA, with severe acute respiratory syndrome coronavirus 2 and Clostridioides difficile. Both infections can manifest as digestive symptoms and merit screening when assessing patients with diarrhea during the coronavirus disease pandemic. These co-infections also highlight the continued importance of antimicrobial stewardship.

Coronavirus disease (COVID-19), which is caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), predominantly includes pulmonary symptoms; however, <10% of cases also include gastrointestinal events, including abdominal pain, diarrhea, and vomiting (14). During the COVID-19 pandemic, clinicians must be vigilant of co-infections in patients with COVID-19.

Several studies have collected data on concomitant antibiotic use in patients with COVID-19. A single-center study of 52 critically ill patients cited hospital-acquired infection in only 7 (13.5%) patients, yet 49 (94%) patients received antibiotic therapy (5). Another study, which analyzed 113 deceased patients from a cohort of 799 moderate-to-severely ill COVID-19 patients during January 13–February 12, 2020, reported that 105 (93%) deceased patients and 144 (89%) survivors had received empiric antibacterial therapy with either moxifloxacin, cefoperazone, or azithromycin (6). These antibiotics are strongly associated with C. difficile infection (CDI) (7). We report an observation of CDI as a co-occurrence or sequalae of overuse of antibiotics in COVID-19 patients.

We conducted a clinical surveillance review of CDI for all laboratory-confirmed COVID-19 patients treated at any of the hospitals belonging to Detroit Medical Center (Detroit, Michigan, USA). We screened patients by using TheraDoc software (https://www.theradoc.comExternal Link) during March 11–April 22, 2020. We abstracted data regarding baseline demographics, medical history, symptoms, laboratory values, microbiologic findings, concomitant antibiotic use, and treatment for CDI. We obtained institutional review board approval for this study.

We identified 9 cases of co-infection with SARS-CoV-2 and C. difficile. This cohort mainly included elderly patients who were predominantly female (Table). The rate of CDI at the center was 3.32/10,000 patient-days during January–February 2020 and increased to 3.6/10,000 patient-days during March–April 2020.

We noted prior CDI in 3 patients; these infections occurred 1–4 months before admission. All patients were confirmed to be positive for C. difficile by PCR and showed symptoms of diarrhea in addition to other characteristic signs and symptoms, such as abdominal pain, nausea, and vomiting. Two patients had diarrhea and were found to be positive for C. difficile at admission, whereas the remaining 7 had onset of diarrhea only after COVID-19 diagnosis; median duration from CDI diagnosis to COVID-19 diagnosis in these 7 patients was 6 days. This group of patients were severely ill, having high ATLAS scores (https://www.mdcalc.com/atlas-score-clostridium-difficile-infectionExternal Link) and multiple underlying conditions; hypertension (n = 8) and diabetes (n = 5) were the most frequent of these conditions.

Three patients received antibiotics in the month before admission; 8 received antibiotics at admission. One patient was initiated on antibiotics on day 15; this patient was also receiving antibiotics the month before admission. The most commonly administered antibiotics were cefepime (n = 5), ceftriaxone (n = 3), meropenem (n = 2), and azithromycin (n = 2). Specific CDI therapies were oral vancomycin (n = 6); vancomycin and intravenous metronidazole (n = 1); no treatment (n = 1); and a combination of oral vancomycin, intravenous metronidazole, rectal vancomycin, fidaxomicin, and fecal microbiota transplantation (n = 1). One patient who did not receive antibiotics was considered to be colonized with C. difficile. Four (44.4%) patients died during hospital admission, 1 (11.1%) was discharged to hospice, 1 (11.1%) is still hospitalized, and 3 (33.3%) were discharged to a long-term care facility.

CDI is a challenging disease, with a recurrence rate of 15%–20% and a mortality rate of 5% (8). When CDI is present as a co-infection with COVID-19, CDI therapy can be difficult to monitor if diarrhea persists because of COVID-19.

These cases highlight the importance of judicious use of antibiotics for potential secondary bacterial infection in patients with COVID-19. Antibiotics are known to have unintended consequences, such as C. difficile infection. All 9 patients received antibiotics; the median duration of antibiotic use before PCR-positive CDI was 5 days. All patients in our cohort were elderly, an age group at higher risk for complications from overuse of antibiotics, such as adverse events, antibiotic resistance, and concomitant infections like CDI (9). Secondary infections on top of CDI can increase the risk for death in patients with severe COVID-19; in this cohort, 4 patients died and 1 was discharged to hospice. To prevent CDI co-infections during the COVID-19 pandemic, integrated use of antimicrobial stewardship is needed to monitor appropriate antibiotic use.

Symptoms of CDI can complicate diagnosis of COVID-19 because both conditions can have similar manifestations; in a study of 206 COVID-19 patients, 19.4% had diarrhea as the first symptom onset (10). Of the 2 patients who had CDI diagnosed at admission, 1 patient solely had gastrointestinal symptoms, which possibly led to delayed diagnosis of COVID-19. Both COVID-19 and CDI should be considered when evaluating patients with diarrhea during the COVID-19 pandemic. Distinguishing between actual CDI versus colonization also is vital; 1 patient in our cohort was colonized. A limitation of this study is the small number of cases. However, in the face of the COVID-19 pandemic and the extensive use of antibiotics, clinicians should remain awaren of possible CDI and SARS-CoV-2 co-infection.

Dr. Sandhu is an infectious diseases–epidemiology fellow at Detroit Medical Center, Wayne State University School of Medicine. Her current research interest is in multidrug-resistant hospital-acquired infections.

Acknowledgment

G.T. is a consultant to Melinta, Crestone, Ferring, AirMmax, and Shionogi. Other authors in the manuscript have no relevant conflict of interest or financial disclosure. No funding was needed for this manuscript.

References

  1. US Centers for Disease Control and Prevention. Interim clinical guidance for management of patients with confirmed coronavirus disease (COVID-19) [cited 2020 May 1]. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management
  2. Guan  WJNi  ZYHu  YLiang  WHOu  CQHe  JXet al.China Medical Treatment Expert Group for Covid-19Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med2020;382:170820DOIExternal LinkPubMedExternal Link
  3. Chen  NZhou  MDong  XQu  JGong  FHan  Yet al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet2020;395:50713DOIExternal LinkPubMedExternal Link
  4. Wang  DHu  BHu  CZhu  FLiu  XZhang  Jet al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA2020;323:10619DOIExternal LinkPubMedExternal Link
  5. Yang  XYu  YXu  JShu  HXia  JLiu  Het al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med2020;8:47581DOIExternal LinkPubMedExternal Link
  6. Chen  TWu  DChen  HYan  WYang  DChen  Get al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ2020;368:m1091DOIExternal LinkPubMedExternal Link
  7. Brown  KAKhanafer  NDaneman  NFisman  DNMeta-analysis of antibiotics and the risk of community-associated Clostridium difficile infection. Antimicrob Agents Chemother2013;57:232632DOIExternal LinkPubMedExternal Link
  8. Guh  AYMu  YWinston  LGJohnston  HOlson  DFarley  MMet al. Emerging Infections Program Clostridioides difficile Infection Working Group. Trends in US burden of Clostridium difficile infection and outcomes. N Engl J Med2020;382:132030DOIExternal LinkPubMedExternal Link
  9. Biedron  CChopra  TIssues surrounding antibiotic use in older adults. Curr Transl Geriatr Exp Gerontol Rep2013;2:1518DOIExternal Link
  10. Han  CDuan  CZhang  SSpiegel  BShi  HWang  Wet al. Digestive symptoms in COVID-19 patients with mild disease severity: clinical presentation, stool viral RNA testing, and outcomes. Am J Gastroenterol2020;1Epub ahead of printDOIExternal LinkPubMedExternal Link

 

 

Source:  https://wwwnc.cdc.gov/eid/article/26/9/20-2126_article

C. difficile Food Surveillance Project Results Described by Researchers in Slovenia

Researchers in Slovenia have described results from a long-term, national Clostridioides difficile food surveillance project. Positive results were found in meat, fresh produce and poultry.

The three-year period of testing revealed a low proportion of Clostridioides — formerly Clostridium — difficile contaminated food and high genotype variability. As the risk of infection associated with Clostridioides difficile contaminated food is unknown, no measures were recommended for positive results.

Because of an increasing association between Clostridioides difficile and food, in 2015, the Administration of the Republic of Slovenia for Food Safety, Veterinary Sector and Plant Protection (UVHVVR) included it in national food surveillance. In Slovenia, the number of cases increased from 316 in 2013 to 665 in 2017.

Retail minced meat and meat preparations such as beef, pork and poultry were sampled from 2015 to 2017. They were collected at food markets and grocery stores in all Slovenian regions. Selected raw retail vegetables, leaf salads and root vegetables, and ready-to-eat salads were sampled during 2016 and 2017 and seafood only in 2017.

18 foods positive from several countries
Altogether, 434 samples were tested, with 12 of 336 raw and minced meat samples and six of 98 raw vegetables contaminated with Clostridioides difficile. Results were published in the journal Eurosurveillance.

Samples included raw poultry meat, meat preparations from poultry, minced pork and/or beef meat, meat preparations from pork and/or beef, shrimp and bivalve mollusks. Vegetable samples included different types of raw green leafy salads, ready-to-eat salads and root vegetables such as carrots, parsley and beetroot.

Of 319 meat and meat preparation samples, 266 were labelled made in Slovenia, 21 made in Austria, 11 made in Croatia, nine made in Germany and one each for Hungary and Denmark.

Samples of shrimp originated from Lithuania, Denmark, Ecuador and the Czech Republic, while all bivalve mollusks came from Slovenia. Of the 98 vegetable products, most were labelled made in Slovenia. Eight were made in Italy, two in Poland and one each from Austria, Croatia, Hungary, Germany, the Netherlands and Spain.

In 2015, three of 119 meat samples tested positive for Clostridioides difficile, five of 130 samples in 2016 and four of 87 meat and seafood samples were positive in 2017. Of the 12 positive samples, five were poultry preparations, three beef and/or pork meat preparations, three raw poultry and one bivalve mollusk. Ten of these were made in Slovenia and two in Austria.

For retail fresh vegetables, in 2016, two of 48 tested samples were positive and four of 50 samples tested positive in 2017. Of these six positives, three were raw leaf salads, one was parsley and two were ready-to-eat salads. Vegetables from three positive samples were grown in Italy, two in Slovenia and one in Poland.

Yearly increase for positive samples
For meat, the most direct way of Clostridioides difficile contamination is fecal during slaughtering, but post-production processing could play a role. For poultry it could be a post-slaughter contamination source in the production line. The main sources of vegetable contamination are soil or indirect fecal contamination via irrigation or manuring. A possible source for meat and vegetables could also be via contaminated hands during handling.

The study found the proportion of Clostridioides difficile positive meat and vegetable samples increased every year.

“However, the number of tested samples was too low to speculate on any possible trends. The changes in samples sizes and produce types could have contributed to this observation,” said researchers.

Given the low detected prevalence of contaminated samples, the food safety risks for the tested food types are likely very low.

“On the other hand, although the levels of food contamination with Clostridioides difficile spores are usually low, the constant exposure to the low spore levels in combination with a disrupted gut microbiota or immune incompetence could represent increased risk for Clostridioides difficile infection.”

 

 

 

 

To read the article in its entirety please click on the following link

https://www.foodsafetynews.com

What Is SARS-CoV-2 and the Disease It Causes Named coronavirus disease 2019 or Better Known As COVID-19

 

 

 

What is Coronavirus?

The virus has been named “SARS-CoV-2” and the disease it causes has been named “COVID-19.”

Coronaviruses are a large family of viruses that may cause respiratory illnesses in humans ranging from common colds to more severe conditions such as Severe Acute Respiratory Syndrome (SARS) and Middle Eastern Respiratory Syndrome (MERS).

‘Novel coronavirus’ is a new, previously unidentified strain of coronavirus. The novel coronavirus involved in the current outbreak has been named SARS-CoV-2 by the World Health Organization (WHO). The disease it causes has been named “coronavirus disease 2019” (or “COVID-19”).

 

LISTEN AT YOUR LEISURE

Special Episode with Dr. Teena Chopra, MD, MPH

and Jennifer Wood, C. diff. Survivor – discussing the COVID-19 and C. difficile infection information

 

How does the virus spread?

COVID-19 can spread from person to person usually through close contact with an infected person or through respiratory droplets that are dispersed into the air when an infected person coughs or sneezes.  It may also be possible to get the virus by touching a surface or object contaminated with the virus and then touching your mouth, nose or eyes, but it is not thought to be the main way the virus spreads.

 

 

Where has COVID-19 spread to?

As of the March 6, 2020, there are over 95,000 confirmed cases of infection by the virus—and 3,381 of that number have resulted in death. While most cases of COVID-19 infection are in China, the virus has spread to 88 other countries.

What are the symptoms?

Similar to other respiratory illnesses, the symptoms of COVID-19 may include fever, cough, and shortness of breath.

People infected with COVID-19 may experience any range of these symptoms along with aches and pains, nasal congestion, runny nose, sore throat and diarrhea. Symptoms can start to show up anywhere from two to 14 days after exposure to the virus3. It may be possible for an infected person who is not yet showing any symptoms to spread the virus. Older persons, and those with pre-existing medical illnesses like heart disease and diabetes, however, seem to be more likely to experience severe respiratory symptoms and complications.

How to protect yourself from coronavirus

The best preventative action is to avoid being exposed to the virus. You can do this by taking a few cautionary steps—the same as you would if you were trying to avoid getting any respiratory illness.

  1. Wash your hands with soap and water frequently. If soap and water are not readily accessible, use alcohol-based sanitizers.
  2. Avoid contact with sick people.
  3. Avoid touching your eyes, nose, and mouth with your hands if they are unwashed.
  4. Cover your mouth and nose with a tissue or your bent elbow when you sneeze or cough. Make sure to dispose of the tissue immediately.
  5. If you are feeling unwell, stay home.
  6. If you have no respiratory symptoms such cough, a medical mask is not necessary.  Only use the mask if you have symptoms such as coughing or sneezing or suspect a COVID-19 infection. A mask is recommended for those caring for anyone with COVID-19.

What to do if you suspect you are infected?

The symptoms of COVID-19 are very similar to those of a cold or the flu, making it challenging to identify the specific cause of any respiratory symptoms. If you suspect you have been infected by COVID-19, you should seek medical care as soon as possible.

Until you can access medical care, you should follow these guidelines to reduce your likelihood of infecting others:

  • Restrict your outdoor activities and stay at home as much as you can. If it is feasible, stay in a separate room, and use a different bathroom from others in your household.
  • Clean and/or disinfect objects and surfaces that you touch regularly.
  • Track your symptoms as accurately as possible, so you can provide medical personnel with useful information.

Are there any treatments or vaccines?

There are currently no treatments, drugs, or vaccines available to treat or prevent COVID-19. People infected with the virus should receive medical treatment to relieve and alleviate the symptoms they are experiencing.

For Additional Information Please Visit the CDC Website:

https://www.cdc.gov/coronavirus/2019-ncov/about/index.html

 

Resource:  https://www.gethealthystayhealthy.com/articles/what-know-about-coronavirus-covid-19-explained

What Is SARS-CoV-2 and the Disease It Causes Named coronavirus disease 2019 or Better Known As COVID-19

 

 

 

What is Coronavirus?

The virus has been named “SARS-CoV-2” and the disease it causes has been named “COVID-19.”

Coronaviruses are a large family of viruses that may cause respiratory illnesses in humans ranging from common colds to more severe conditions such as Severe Acute Respiratory Syndrome (SARS) and Middle Eastern Respiratory Syndrome (MERS).

‘Novel coronavirus’ is a new, previously unidentified strain of coronavirus. The novel coronavirus involved in the current outbreak has been named SARS-CoV-2 by the World Health Organization (WHO). The disease it causes has been named “coronavirus disease 2019” (or “COVID-19”).

 

LISTEN AT YOUR LEISURE

Special Episode with Dr. Teena Chopra, MD, MPH

and Jennifer Wood, C. diff. Survivor – discussing the COVID-19 and C. difficile infection information

 

How does the virus spread?

COVID-19 can spread from person to person usually through close contact with an infected person or through respiratory droplets that are dispersed into the air when an infected person coughs or sneezes.  It may also be possible to get the virus by touching a surface or object contaminated with the virus and then touching your mouth, nose or eyes, but it is not thought to be the main way the virus spreads.

 

 

Where has COVID-19 spread to?

As of the March 6, 2020, there are over 95,000 confirmed cases of infection by the virus—and 3,381 of that number have resulted in death. While most cases of COVID-19 infection are in China, the virus has spread to 88 other countries.

What are the symptoms?

Similar to other respiratory illnesses, the symptoms of COVID-19 may include fever, cough, and shortness of breath.

People infected with COVID-19 may experience any range of these symptoms along with aches and pains, nasal congestion, runny nose, sore throat and diarrhea. Symptoms can start to show up anywhere from two to 14 days after exposure to the virus3. It may be possible for an infected person who is not yet showing any symptoms to spread the virus. Older persons, and those with pre-existing medical illnesses like heart disease and diabetes, however, seem to be more likely to experience severe respiratory symptoms and complications.

How to protect yourself from coronavirus

The best preventative action is to avoid being exposed to the virus. You can do this by taking a few cautionary steps—the same as you would if you were trying to avoid getting any respiratory illness.

  1. Wash your hands with soap and water frequently. If soap and water are not readily accessible, use alcohol-based sanitizers.
  2. Avoid contact with sick people.
  3. Avoid touching your eyes, nose, and mouth with your hands if they are unwashed.
  4. Cover your mouth and nose with a tissue or your bent elbow when you sneeze or cough. Make sure to dispose of the tissue immediately.
  5. If you are feeling unwell, stay home.
  6. If you have no respiratory symptoms such cough, a medical mask is not necessary.  Only use the mask if you have symptoms such as coughing or sneezing or suspect a COVID-19 infection. A mask is recommended for those caring for anyone with COVID-19.

What to do if you suspect you are infected?

The symptoms of COVID-19 are very similar to those of a cold or the flu, making it challenging to identify the specific cause of any respiratory symptoms. If you suspect you have been infected by COVID-19, you should seek medical care as soon as possible.

Until you can access medical care, you should follow these guidelines to reduce your likelihood of infecting others:

  • Restrict your outdoor activities and stay at home as much as you can. If it is feasible, stay in a separate room, and use a different bathroom from others in your household.
  • Clean and/or disinfect objects and surfaces that you touch regularly.
  • Track your symptoms as accurately as possible, so you can provide medical personnel with useful information.

Are there any treatments or vaccines?

There are currently no treatments, drugs, or vaccines available to treat or prevent COVID-19. People infected with the virus should receive medical treatment to relieve and alleviate the symptoms they are experiencing.

For Additional Information Please Visit the CDC Website:

https://www.cdc.gov/coronavirus/2019-ncov/about/index.html

 

Resource:  https://www.gethealthystayhealthy.com/articles/what-know-about-coronavirus-covid-19-explained

The Food and Drug Administration (FDA) Informs Health Care Providers and Patients of the Potential Risk of Transmission of SARS-CoV-2 Virus and COVID-19 By the Use of Fecal Microbiota for Transplantation (FMT)

The global public health community is responding to a rapidly evolving pandemic of respiratory disease caused by a novel coronavirus that was first detected in China.

 

The virus has been named “SARS-CoV-2” and the disease it causes has been named “COVID-19.”

The Food and Drug Administration (FDA) is informing health care providers and patients of the potential risk of transmission of SARS-CoV-2 virus by the use of fecal microbiota for transplantation (FMT) and that FDA has determined that additional safety protections are needed.

Summary of the Issue

Several recent studies have documented the presence of SARS-CoV-2 ribonucleic acid (RNA) and/or SARS-CoV-2 virus in stool of infected individuals.1,2,3 This information suggests that SARS-CoV-2 may be transmitted by FMT, although the risk of such transmission is unknown.4 At this time, testing nasopharyngeal specimens from stool donors for SARS-CoV-2 may not be widely available. Furthermore, there is limited information on the availability and sensitivity of direct testing of stool for SARS-CoV-2.

Additional Protections for the Use of FMT

At this time, FDA is advising that clinical use of FMT has the potential to transmit SARS-CoV-2, whether used as part of a study under an Investigational New Drug Application (IND) on file with the FDA or under FDA’s enforcement discretion policy. To address the risk, stool used for FMT should have been donated before December 1, 2019. Due to the potential for serious adverse events to occur, FDA has determined that the following protections are needed for any use of FMT that is found to be necessary for clincal care if it involves stool donated after December 1, 2019:

  • Donor screening with questions directed at identifying donors who may be currently or recently infected with SARS-CoV-2;
  • Testing donors and/or donor stool for SARS-CoV-2, as feasible;
  • Development of criteria for exclusion of donors and donor stool based on screening and testing; and
  • Informed consent that includes information about the potential for transmission of SARS-CoV-2 via FMT, including FMT prepared from stool from donors who are asymptomatic for COVID-19.

Actions

FDA is in the process of notifying IND holders of the potential risk of transmission of SARS-CoV-2 via FMT and of FDA’s determination that additional safety protections that are needed.

FDA is communicating this information with this statement to all other stakeholders to ensure that everyone is fully informed.

As the scientific community learns more about SARS-CoV-2 and COVID-19, FDA will provide further information as warranted.

Information for Health Care Providers and Patients on Enforcement Discretion

In July 2013, FDA issued a guidance document stating that it intends to exercise enforcement discretion under limited conditions regarding the IND requirements for the use of FMT products to treat C. difficile infection in patients that have not responded to standard therapies. The guidance states that FDA intends to exercise enforcement discretion provided that the treating physician obtains adequate consent for the use of FMT from the patient or his or her legally authorized representative. The consent should include, at a minimum, a statement that the use of FMT to treat C. difficile is investigational and a discussion of its potential risks.

Reporting Adverse Events

FDA encourages all health care providers and patients to report any suspected adverse events or side effects related to the administration of FMT products to the FDA at 1-800-FDA-1088 or http://www.fda.gov/medwatch.

 


1 Xiao F, Tang M, Zheng X, Liu Y, Li X, Shan H, Evidence for gastrointestinal infection of SARS-CoV-2, Gastroenterology (2020), doi: https://doi.org/10.1053/j.gastro.2020.02.055External Link Disclaimer
2 Tang A, Tong Z-d, Wang H-l, Dai Y-x, Li K-f, Liu J-n, et al. Detection of novel coronavirus by RT-PCR in stool specimen from asymptomatic child, China. Emerg Infect Dis. (2020), https://doi.org/10.3201/eid2606.200301External Link Disclaimer from https://wwwnc.cdc.gov/eid/article/26/6/20-0301_article
3 Wang, W, Xu, Y, Gao, R, et al., Detection of SARS-CoV-2 in Different Types of Clinical Specimens. JAMA (2020), https://doi.org/10.1001/jama.2020.3786External Link Disclaimer
4 Gu J, Han B, Wang J, COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission, Gastroenterology (2020), doi: https://doi.org/10.1053/j.gastro.2020.02.054