Tag Archives: Clostridium difficile research and development

Researchers Find Systematically Addressing Penicillin Allergies May Be An Important Public Health Strategy to Reduce the Incidence of MRSA and C. difficile Among Patients With a Penicillin Allergy

BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2400 (Published 27 June 2018) Cite this as: BMJ 2018;361:k2400

  1. Kimberly G Blumenthal, assistant professor of medicine123,
  2. Na Lu, biostatistician1,
  3. Yuqing Zhang, professor of medicine13,
  4. Yu Li, research assistant12,
  5. Rochelle P Walensky, professor of medicine234,
  6. Hyon K Choi, professor of medicine13

Author affiliations

  1. Correspondence to: K G Blumenthal kblumenthal1@partners.org (or @KimberlyBlumen1 on Twitter)
  • Accepted 30 April 2018


Objective To evaluate the relation between penicillin allergy and development of meticillin resistant Staphylococcus aureus (MRSA) and C difficile.

Design Population based matched cohort study.

Setting United Kingdom general practice (1995-2015).

Participants 301 399 adults without previous MRSA or C difficile enrolled in the Health Improvement Network database: 64 141 had a penicillin allergy and 237 258 comparators matched on age, sex, and study entry time.

Main outcome measures The primary outcome was risk of incident MRSA and C difficile. Secondary outcomes were use of β lactam antibiotics and β lactam alternative antibiotics.

Results:       Among 64 141 adults with penicillin allergy and 237 258 matched comparators, 1365 developed MRSA (442 participants with penicillin allergy and 923 comparators) and 1688 developed C difficile (442 participants with penicillin allergy and 1246 comparators) during a mean 6.0 years of follow-up.

Among patients with penicillin allergy the adjusted hazard ratio for MRSA was 1.69 (95% confidence interval 1.51 to 1.90) and for C difficile was 1.26 (1.12 to 1.40). The adjusted incidence rate ratios for antibiotic use among patients with penicillin allergy were 4.15 (95% confidence interval 4.12 to 4.17) for macrolides, 3.89 (3.66 to 4.12) for clindamycin, and 2.10 (2.08 to 2.13) for fluoroquinolones. Increased use of β lactam alternative antibiotics accounted for 55% of the increased risk of MRSA and 35% of the increased risk of C difficile.

Conclusions Documented penicillin allergy was associated with an increased risk of MRSA and C difficile that was mediated by the increased use of β lactam alternative antibiotics. Systematically addressing penicillin allergies may be an important public health strategy to reduce the incidence of MRSA and C difficile among patients with a penicillin allergy label.


One third of patients report a drug allergy (ie, adverse or allergic reaction),1 the most commonly implicated drug being penicillin and documented in 5-16% of patients.12345 Being labelled with a penicillin allergy affects future prescribing for infections in both outpatients and inpatients, with prescribed antibiotics often more broad spectrum and toxic.2678 Unnecessary use of broad spectrum antibiotics leads to the development of drug resistant bacteria, including meticillin resistant Staphylococcus aureus (MRSA), and healthcare associated infections such as Clostridium difficile related colitis.910111213

Most patients with a documented penicillin allergy are not allergic—that is, there is no immediate hypersensitivity.1415 After evaluation by an allergist, about 95% of patients with reported penicillin allergies were found to be penicillin tolerant.14 The discrepancy between labelled and confirmed penicillin allergy stems from misdiagnosis (eg, a viral exanthem is misinterpreted as an allergy), misassumptions (eg, an intolerance, such as a headache, is listed as an allergy), and remote timing of the allergy evaluation, since 80% of patients with immediate hypersensitivity to penicillin are no longer allergic after 10 years.16 Most patients with a penicillin allergy label therefore unnecessarily avoid penicillins, and often other related β lactam antibiotics, such as cephalosporins.67

To evaluate the public health consequences of having a penicillin allergy label, we conducted a population based matched cohort study and examined the relation between a newly recorded penicillin allergy and the risk of incident MRSA and C difficile.


Data source

We used data from the Health Improvement Network (THIN), an electronic medical record database of 11.1 million patients registered with general practices in the United Kingdom. Because the National Health Service requires people to register with a general practice regardless of health status, THIN is a population based cohort representative of the UK general population.17 During consultations with patients in primary care, general practitioners (GPs) enter clinical data, including height, weight, smoking status, diagnoses, and prescription drugs. Patient diagnoses are recorded using READ codes, the UK’s standard clinical terminology system.18 Drug allergies are linked to a drug prescription, or recorded as a diagnosis (eg, personal history of penicillin allergy). The GP enters details of the drug allergy, including reaction type, severity of reaction, and certainty of diagnosis. All GPs are trained in data entry, with the quality of their data periodically reviewed. Previous studies using THIN have confirmed the validity of both prescriptions and diagnoses.1920

Study design

We performed a matched cohort study among participants aged more than 18 years, who were enrolled in the THIN database between 1995 and 2015. Eligible participants had no history of MRSA or C difficile diagnoses before study entry and were required to have at least one year of enrolment with a general practice before entering the study to allow for assessment of exposure and covariates. We identified adults with their first recorded penicillin allergy and selected up to five penicillin users without a penicillin allergy matched on age (one year either way), sex, and study entry time (within one year either way). Such comparators were chosen to further ensure the comparability of indications for penicillin use (eg, infection tendency) and associated features. The index date for cases was the date of first entry of an allergy diagnosis in the THIN database; the matched index date for comparators was within one year of a penicillin prescription.

Assessment of exposure and outcomes

The exposure of interest was a documented penicillin allergy, defined as an allergy to a penicillin antibiotic linked to a penicillin prescription, or one or more relevant READ diagnosis codes for a penicillin allergy or adverse effect (see supplemental table 1).

The primary outcomes were incident cases of doctor diagnosed MRSA and C difficile during the follow-up period. We identified MRSA and C difficile by the presence of one or more relevant READ diagnosis codes.21222324 For MRSA, codes indicated MRSA infection, carriage, eradication, or decontamination whereas for C difficile, codes indicated C difficile infection or detection of antigen or toxin (see supplementary table 1).

We also assessed antibiotic utilization during the follow-up period, derived from the prescription record. We grouped all antibiotics prescribed into classes: penicillins, first generation cephalosporins, macrolides, clindamycin, fluoroquinolones, tetracyclines, and sulfonamides. Given that vancomycin, aminoglycosides, and linezolid are commonly administered parenterally and therefore seldom administered to outpatients by GPs, we assessed these antibiotics separately.

Assessment of covariates

We identified demographic and lifestyle factors before the index date, such as age, sex, body mass index, socioeconomic status, smoking status, and alcohol use. READ diagnosis codes at the index date were used to ascertain relevant comorbidities (diabetes, renal disease, hemodialysis, malignancy, liver disease, and infection with human immunodeficiency virus (HIV)) and to calculate the adapted Charlson comorbidity index25 at baseline. Using the prescription records, we identified the number of antibiotics prescribed in the year before the index date and whether proton pump inhibitors or systemic corticosteroids were used at baseline. Concomitant allergies to cephalosporin antibiotics and other antibiotics were linked to prescriptions or identified using READ diagnosis codes. We determined participants who were residents of nursing homes at baseline. Finally, we calculated the number of visits to a GP and hospital admissions during the year before the index date.

Statistical analysis

We compared baseline characteristics between participants with penicillin allergy and their comparators. Follow-up time for each participant was calculated from the index date to the date of one of several events: the study endpoints (MRSA or C difficile), death, or end of the study (31 December 2015), whichever occurred first.

We identified incident MRSA cases and number of person years of follow-up for each cohort separately. We calculated the hazard ratios for the relation of penicillin allergy status to the risk of MRSA using Cox proportional hazard models. In the multivariable Cox model we adjusted for age, sex, body mass index, socioeconomic status, smoking status, alcohol use, Charlson comorbidity index, hemodialysis, number of antibiotic prescriptions, proton pump inhibitor use, corticosteroid use, other antibiotic allergies, resident of nursing home, visits to a GP, and admissions to hospital. We repeated the same analyses for the risk of C difficile. We also calculated the absolute risk difference.

In both the penicillin allergy cohort and the comparison cohort we determined the rates of subsequent antibiotic utilization by class. We used Poisson regression models to estimate the incidence rate ratio for the relation of penicillin allergy status to the rates of subsequent antibiotic use, while adjusting for the same covariates.

We performed mediation analyses to examine the extent to which the effect of penicillin allergy status on the risk of MRSA or C difficile was through its effect on utilization of β lactam alternative antibiotics.26 Specifically, we grouped utilization into five categories based on previous studies that evaluated the impact of various antibiotics on the risk of MRSA and C difficile910111213: fluoroquinolones, clindamycin, macrolides, vancomycin, aminoglycosides, and linezolid (all β lactam alternative antibiotics considered in this study); fluoroquinolones, clindamycin, and macrolides; fluoroquinolones and macrolides; fluoroquinolones and clindamycin; and fluoroquinolones alone. Using marginal structural models we then estimated the natural direct effect (ie, the effect of penicillin allergy status on the risk of MRSA or C difficile not through a specific group of antibiotics) and the natural indirect effect (ie, the effect of penicillin allergy status on the risk of MRSA or C difficile through a specific group of antibiotics), while adjusting for the same confounding variables,26 and reported the adjusted risk ratio and percentage mediated.

For all analyses we imputed unknown values for covariates (ie, missing body mass index, alcohol use, and smoking status) using a sequential regression method based on a set of covariates as predictors. To minimize random error, we imputed five datasets and then combined estimates from these datasets by calculating effect estimates from each imputed dataset and then averaging estimates and their confidence intervals using Rubin’s rules.27 All analyses were performed using SAS, version 9.2 (SAS Institute, Cary, NC).

Patient and public involvement

No patients were involved in setting the research question or the outcome measures, nor were they involved in developing plans for implementation of the study. No patients were asked to advise on interpretation or writing up of results. There are no plans to disseminate the results of the research to study participants or the relevant patient community. Individual patient consent was not sought given the use of anonymized data.


Cohort identification and characteristics

We identified 64 141 patients with a documented penicillin allergy and 237 258 matched comparators (table 1). Patients with penicillin allergy were identified through allergies linked to prescriptions for penicillin antibiotics (63 245/64 141, 98.6%). Documented penicillin allergies consisted of allergies (74.4%), intolerances (14.5%), and adverse effects (11.1%). Most allergies were considered of moderate severity (86.0%) with likely certainty (73.6%).

Table 1

Reactions in patients with penicillin allergy (n=64 141)

Patients with penicillin allergy were similar to their comparators for age, sex, body mass index, socioeconomic status, smoking status, and alcohol use (table 2). They were also similar for diabetes, renal disease, hemodialysis, malignancy, liver disease, HIV, Charlson comorbidity index, previous antibiotic prescriptions, use of proton pump inhibitors and systemic corticosteroids, nursing home residency, visits to a GP, and hospital admissions. Other antibiotic allergies were more common in patients with a penicillin allergy.

Table 2

Cohort characteristics according to penicillin allergy status. Values are numbers (percentages) unless stated otherwise

Penicillin allergy and risk of MRSA and C difficile

During the mean follow-up time of 6.0 years for patients with penicillin allergy and 6.1 years for comparator patients, 442 patients with penicillin allergy and 923 comparator patients developed MRSA, and 442 patients with penicillin allergy and 1246 comparator patients developed C difficile (table 3 and supplemental table 2).

Table 3

Impact of listed penicillin allergy on risk of meticillin resistant Staphylococcus aureus (MRSA)and Clostridium difficile

The age, sex, and study entry time matched hazard ratios for patients with penicillin allergy were 1.84 (95% confidence interval 1.64 to 2.06) for MRSA and 1.37 (1.23 to 1.53) for C difficile. The matched and multivariable adjusted hazard ratios for patients with penicillin allergy were 1.69 (1.51 to 1.90) for MRSA and 1.26 (1.12 to 1.40) for C difficile, respectively. The corresponding adjusted risk differences were 49/100 000 person years for MRSA and 27/100 000 person years for C difficile.

Penicillin allergy and subsequent antibiotic utilization

Patients with penicillin allergy were less often prescribed penicillin than their comparators (adjusted incidence rate ratio 0.30, 95% confidence interval 0.30 to 0.31), but had increased use of macrolide antibiotics (4.15, 4.12 to 4.17), clindamycin (3.89, 3.66 to 4.12]), fluoroquinolones (2.10, 2.08 to 2.13), tetracyclines (1.75, 1.73 to 1.76), and sulfonamide antibiotics (1.26, 1.25 to 1.27; table 4). Though vancomycin, aminoglycosides, and linezolid were overall infrequently prescribed, they were more often prescribed to patients with penicillin allergy than to their comparators (supplemental table 3).

Table 4

Impact of listed penicillin allergy on antibiotic use

Mediation effects of alternative antibiotic use

Compared with patients who did not receive penicillins, patients receiving penicillins did not have an increased risk of MRSA (adjusted risk ratio 1.07, 95% confidence interval 0.95 to 1.20), but had an increased risk of C difficile (1.18, 1.06 to 1.31; supplemental table 4). Patients receiving macrolide antibiotics had an increased risk of MRSA (1.72, 1.54 to 1.91) and C difficile (1.30, 1.18 to 1.43). Patients receiving clindamycin had an increased risk of MRSA (2.97, 2.11 to 4.16) and C difficile (2.76, 2.00 to 3.81). Patients receiving fluoroquinolones had an increased risk of MRSA (2.38, 2.12 to 2.67) and C difficile (1.72, 1.54 to 1.93).

The effect of a penicillin allergy on the risk of MRSA was 55% mediated through β lactam alternative antibiotic classes; 55% mediated through fluoroquinolones, clindamycin, and macrolides; 54% mediated through fluoroquinolones and macrolides; 26% mediated through fluoroquinolones and clindamycin; and 24% mediated through fluoroquinolones alone (table 5). The effect of penicillin allergy on C difficile was 35% mediated through β lactam alternative antibiotic classes; 26% mediated through fluoroquinolones, clindamycin, and macrolides; 24% mediated through fluoroquinolones and macrolides; 20% mediated through fluoroquinolones and clindamycin; and 16% mediated through fluoroquinolones alone.

Table 5

Mediation analysis to estimate the indirect effect of listed penicillin allergy on meticillin resistant Staphylococcus aureus (MRSA) and Clostridium difficile


In this large cohort study reflective of the United Kingdom general population, we found that a penicillin allergy label was associated with a 69% increased risk of MRSA and a 26% increased risk of C difficile. Once documented, a penicillin allergy resulted in increased use of β lactam alternative antibiotics, with a fourfold increased incidence of macrolides and clindamycin utilization, and a twofold increased incidence of fluoroquinolone utilization. Furthermore, more than half of the increased MRSA risk and more than one third of the increased C difficile risk among patients with penicillin allergy was attributable to administered β lactam alternative antibiotics.

Comparison with other studies and policy implications

We found that patients with a penicillin allergy label had nearly a 70% increased risk of new MRSA than their matched comparators, even after adjustment for known MRSA risk factors.28 This provides supporting evidence for a previous US study that showed a 14% increased MRSA prevalence in inpatients who were allergic to penicillin.8 Our result emphasises that outpatient use of antibiotics is strongly associated with the risk of developing MRSA.2228 Consistent with previous studies, we found that β lactam alternative antibiotics increased the risk of MRSA to a greater degree than did penicillins12132930; whereas the mechanism of resistance is not known, the same factors that predispose staphylococcus to develop resistance to meticillin are thought to predispose staphylococcus to multidrug resistance that includes resistance to meticillin.122931 With more than half of the increased MRSA risk among patients with listed penicillin allergy directly attributable to increased outpatient β lactam alternative antibiotic use (largely fluoroquinolones and macrolides), this risk appears modifiable if prescribing patterns among those with penicillin allergy could be altered.

C difficile is responsible for almost one half million infections and 15 000 deaths each year in the US, and the Centers for Disease Control and Prevention consider C difficile one of three urgent threats to public health.32 Patients with penicillin allergy in this study had a 26% increased C difficile risk compared with age, sex, and study entry time matched comparators after adjustment for other known risk factors for C difficile.10333435 This result also corroborates the previous US study, which found a 23% increased C difficile prevalence in hospital patients with a penicillin allergy.8 While other studies similarly identified that clindamycin and fluoroquinolones were associated with the greatest risk of C difficile,91011 we found that 35% of the heightened risk of C difficile in patients with penicillin allergy was directly attributable to use of β lactam alternative antibiotics, with quinolone use alone responsible for 16% of the heightened risk. The mechanism by which antibiotic use precipitates C difficile is through disruption of the host microbiome and creation of an environment where C difficile can overgrow.36 Antibiotics not captured in this dataset (eg, those administered at dialysis or in hospitals) and non-antibiotic risk factors234 are likely responsible for the remainder of C difficile cases. Although current efforts to reduce C difficile largely focus on reducing C difficile infections in hospitals and rehabilitation centers, one third of C difficile infections occur in the community, and occur in outpatients.37 Our findings suggest that more systematic efforts to identify patients with listed penicillin allergy who are not truly allergic to penicillins could help decrease rates of community associated C difficile.

In this study, patients with documented penicillin allergy had an increased incidence of broad spectrum antibiotic use, including the extended Gram positive spectrum antibiotics vancomycin and linezolid, which should be reserved for patients with suspected or known MRSA (or vancomycin resistant enterococci for linezolid).3839 Use of the most narrow spectrum antibiotic that is effective for a given infection is a cornerstone of evidence based treatment for infection and is responsible antibiotic stewardship.38 Antibiotic stewardship committees enforce this aim in the hospital setting, with evaluations for penicillin allergy occasionally included in stewardship efforts.40 This analysis emphasises the importance of performing outpatient antibiotic stewardship and the role that penicillin allergy evaluations might play. Although diagnostic testing for penicillin allergy was developed in the 1960s, and has recently garnered the support of a variety of professional organizations,384142 less than 0.1% of patients with a penicillin allergy label undergo confirmatory testing.15 Evaluation of penicillin allergy often involves a skin test, and if the result of skin testing is negative, a challenge dose of penicillin or amoxicillin is administered under medical observation.15 With these evaluation tools, evaluation of penicillin allergy has a more than 99% negative predictive value, takes less than three hours to perform, and costs about $220 (£165; €188; 2016 currency conversion).1543 Previous observational cohorts have shown that more than 90% of patients with listed penicillin allergies can be safely treated with penicillins.141540

Strengths and limitations of this study

In this study we used a representative population based cohort to increase the generalizability of our findings. Clinical data to characterise drug use, outcomes, and covariates were entered by physicians and captured electronically. The dataset used included granular allergy data linked to penicillin prescriptions and defined by type, severity, and certainty. Our study design used a comparator group who had recently been prescribed a penicillin but did not have a resultant penicillin allergy. Patients had high antibiotic use in the previous year since almost the entire cohort had recently had a penicillin (for infection) at baseline for cohort eligibility. Our GP practice based dataset could have missed the detection of some inpatient cases of MRSA and C difficile; however, these potential non-differential misclassifications would have biased our results towards the null, rendering our findings conservative. MRSA and C difficile were identified by physician diagnosis records. This approach has been successfully used in many previous epidemiologic studies,131920212223244445 as microbial infections such as MRSA and C difficile are made objectively using highly accurate microbiologic and serologic tests. Although we used composite outcomes for MRSA and C difficile that were not restricted to infections, it is unlikely that GPs would screen asymptomatic patients and more likely that diagnoses occurred in relevant clinical contexts where infections were suspected. Further, our findings remained consistent and strong when we restricted the analyses to code subgroups suggestive of infections. Additionally, MRSA carriage alone is an important outcome that confers an increased risk of MRSA infection,46 and indicates antibiotic resistance—a healthcare priority throughout the world.3947 Finally, by choosing to study only the first documentation of MRSA and C difficile, we ensured capture of only new colonization or infection, which are clinically important outcomes. Although we controlled for many known potential confounders in these data, our observational study cannot rule out potential unknown or residual confounding.


In this population based cohort study, a listed penicillin allergy was associated with a statistically significantly increased risk of MRSA and C difficile compared with patients matched by age, sex, and study entry time. Approximately one third to more than one half of this risk was attributed to use of non-β lactam antibiotics administered to outpatients. As infections with resistant organisms increase, systematic efforts to confirm or rule out the presence of true penicillin allergy may be an important public health strategy to reduce the incidence of MRSA and C difficile.

What is already known on this topic

  • Penicillin allergy is the most commonly documented drug allergy, reported by about 10% of patients

  • Although documented allergies impact prescribing behavior, a documented penicillin allergy does not often represent true, immediate hypersensitivity to penicillin

  • Previous studies have identified specific antibiotic uses that increase the risk of MRSA and Clostridium difficile

What this study adds


  • Patients with a documented penicillin allergy have an increased risk of new MRSA and C difficile that are modifiable, to some degree, through changes in antibiotic prescribing

There Are Smart Antibiotics to treat C.difficile infections being developed by Researchers

Cationic amphiphilic bolaamphiphile-based delivery of antisense oligonucleotides provides a potentially microbiome sparing treatment

for C. difficile

The Journal of Antibiotics (2018) | Download Citation


Conventional antibiotics for C. difficile infection (CDI) have mechanisms of action without organismal specificity, potentially perpetuating the dysbiosis contributing to CDI, making antisense approaches an attractive alternative. Here, three (APDE-8, CODE-9, and CYDE-21) novel cationic amphiphilic bolaamphiphiles (CABs) were synthesized and tested for their ability to form nano-sized vesicles or vesicle-like aggregates (CABVs), which were characterized based on their physiochemical properties, their antibacterial activities, and their toxicity toward colonocyte (Caco-2) cell cultures. The antibacterial activity of empty CABVs was tested against cultures of E. coli, B. fragilis, and E. faecalis, and against C. difficile by “loading” CABVs with 25-mer antisense oligonucleotides (ASO) targeting dnaE. Our results demonstrate that empty CABVs have minimal colonocyte toxicity until concentrations of 71 µM, with CODE-9 demonstrating the least toxicity. Empty CABVs had little effect on C. difficile growth in culture (MIC90 ≥ 160 µM). While APDE-8 and CODE-9 nanocomplexes demonstrated high MIC90 against C. difficile cultures (>300 µM), CYDE-21 nanocomplexes demonstrated MIC90 at CABV concentrations of 19 µM. Empty CABVs formed from APDE-8 and CODE-9 had virtually no effect on E. coli, B. fragilis, and E. faecalis across all tested concentrations, while empty CYDE-21 demonstrated MIC90 of >160 µM against E. coli and >40 µM against B. fragilisand E. faecalis. Empty CABVs have limited antibacterial activity and they can deliver an amount of ASO effective against C. difficile at CABV concentrations associated with limited colonocyte toxicity, while sparing other bacteria. With further refinement, antisense therapies for CDI may become a viable alternative to conventional antibiotic treatment.


C. difficile infection (CDI) is the most frequently reported nosocomial bacterial infection [1] in the United States, accounting for more than 450,000 new cases annually and for more than four billion dollars in CDI-attributable annual health care costs [2]. CDI has a strong reliance on intestinal dysbiotic states, which, when combined with the presence of C. difficile in the human gut, represents the most common pathogenesis for CDI. The high prevalence of this infection is, in large part, due to formidable recurrence rates of 15–25% following first treatment [3] with conventional antibiotics (CAs). CAs have long been recognized as the most important risk factor for the development of CDI [4], due to their mechanisms of action lacking organismal specificity, leading to widespread changes in gut ecology [5], which can lead to CDI by disrupting the gut microbial community. Given the important role of intestinal dysbiosis in the development of CDI, there has also been recent interest in studying the effects of difficile-directed conventional antibiotics on the bacterial and fungal communities of human subjects being treated for CDI, as a way of potentially explaining the high persistence and recurrence rates of this disease. These more recent data [6] suggest that even difficile-directed conventional antibiotics could potentially contribute to the perpetuation of dysbiotic states, which in turn could perpetuate CDI, potentially leading to even primary treatment failures.

There has been previous [7, 8] interest in the development of antisense therapies to treat bacterial infections, in part due to concerns regarding antibiotic resistance to traditional drugs. Given the dependence of CDI on dysbiotic states, approaches using therapeutic antisense oligonucleotides (ASO) complimentary to specific C. difficile mRNAs could limit or prevent the expression of important bacterial genes leading to bacterial death, all while sparing other organisms. This approach would offer significant advantages over CAs, especially in terms of a more limited impact on gut microbial communities. Developing clinically effective antisense therapies targeting a Gram-positive organism requires several elements. Since antisense oligonucleotides will not be efficiently introduced into bacteria without assistance given the presence of both a cell membrane and a thick cell wall, a carrier molecule must be used to deliver the ASO. This carrier must complex with the ASO strongly enough to concentrate it, to protect it from degradation in the extracellular environment, and to focus its delivery on its target cell. In order to accomplish these activities, the carrier-ASO complex itself must be stable in the in vivo environment of the gut. Once at the cell, the carrier must be able to release its cargo. Simultaneously, the carrier must demonstrate both limited gut toxicity and limited antibacterial activity at the doses required to effectively treat the target bacteria.

Our group published the first [9] in vitro data for antisense therapies against CDI by complexing cyclohexyl dequalinium analogs to various ASO-targeting essential C. difficile genes. However, since dequalinium has both antibacterial activity as well as toxicity at higher doses, a better delivery compound for ASO is required if antisense approaches to CDI are to be further developed. Here, we report our data on vesicles formed from novel cationic amphiphilic bolaamphiphiles (CABs) as carriers for chimeric 25-mer 2′-O-methyl phosphorothioate ASO. CABs, characteristic of all bola-like compounds, have hydrophilic, positively charged end groups separated by a hydrophobic linker chain. This molecular structure enables CABs to form nano-sized vesicle-like aggregates (CABVs), which in turn allow them to complex with negatively charged oligonucleotides in addition to promoting electrostatic interactions with bacterial cell membranes for intracellular delivery of ASO. The synthesis, physiochemical properties, toxicity, and antibacterial properties of three novel CABs and their respective CABVs are described, and their specificity for C. difficile compared to several other organisms is also provided.

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C.difficile Study Using C. difficile Conditioned Medium of Six Different C. difficile Strains






Clostridium difficile infection (CDI) is typically associated with disturbed gut microbiota and changes related to decreased colonization resistance against C. difficile are well described.

However, nothing is known about possible effects of C. difficile on gut microbiota restoration during or after CDI.

In this study, we have mimicked such a situation by using C. difficile conditioned medium of six different C. difficile strains belonging to PCR ribotypes 027 and 014/020 for cultivation of fecal microbiota.

A marked decrease of microbial diversity was observed in conditioned medium of both tested ribotypes. The majority of differences occurred within the phylum Firmicutes, with a general decrease of gut commensals with putative protective functions (i.e. Lactobacillus, Clostridium_XIVa) and an increase in opportunistic pathogens (i.e. Enterococcus). Bacterial populations in conditioned medium differed between the two C. difficile ribotypes, 027 and 014/020 and are likely associated with nutrient availability. Fecal microbiota cultivated in medium conditioned by E. coli, Salmonella Enteritidis or Staphylococcus epidermidis grouped together and was clearly different from microbiota cultivated in C. difficile conditioned medium suggesting that C. difficile effects are specific.

Our results show that the changes observed in microbiota of CDI patients are partially directly influenced by C. difficile.


Vitality Biopharma Researchers Unlock the Use of Cannabinoid Compounds For the Treatment of Microbes Including Clostridium difficile

Vitality Biopharma a corporation dedicated to the development of cannabinoid prodrug pharmaceuticals, and to unlocking the power of cannabinoids for the treatment of serious neurological and inflammatory disorders, today announced that it has obtained positive results demonstrating antimicrobial activity of cannabinoids and filed for patent protection on the use of cannabinoid compounds for the treatment of microbes including Clostridium difficile and other “superbug” pathogens.

Utilizing a list of the top drug-resistant pathogens from the United States Centers for Disease Control and Prevention (CDC), Vitality researchers screened for antimicrobial activity in their portfolio of compounds. Vitality Biopharma discovered new antimicrobial activities for cannabinoids, and as a result has filed for patent protection on the use of cannabinoids and cannabinoid prodrugs for the treatment of multiple pathogenic bacterial infections.

At the top of the CDC’s list is Clostridium difficile (C. diff), which is classified as an urgent threat to human health. The CDC reported in 2015 that it infected almost 500,000 Americans and was directly responsible for 15,000 deaths. Vitality successfully demonstrated antimicrobial reactivity of a cannabinoid against C. diff, and is currently conducting follow-on studies designed to enable pharmaceutical use of their targeted cannabinoid prodrugs for this application.

The Company also confirmed that cannabinoids have antimicrobial activity towards methicillin-resistant Staphylococcus aureus (MRSA), a pathogen that was recently listed on the World Health Organization’s (WHO) list of priority pathogens that pose a significant threat to human health globally. Additional antimicrobial activity was seen towards other antibiotic-resistant bacterial species that were included on the CDC and WHO lists, and Vitality is seeking broad intellectual property coverage for use of cannabinoids against these pathogens as well.

“Our cannaboside prodrugs enable the targeted delivery of cannabinoids into the large intestine, where C.diff infections colonize, take over, and can cause severe damage.  Our compounds are uniquely suited for performing this task, and it’s now clear they may provide benefits to gut health through multiple mechanisms.” said Dr. Brandon Zipp, Director of R&D at Vitality.  Robert Brooke, the Company’s CEO, adds that, “This is a logical extension of our work that has been focused on gastrointestinal disease, and represents a new opportunity to treat a serious and life-threatening condition.”


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Clostridium difficile Infection Incidence In Mainland China – A Systematic Review


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It has been widely reported that the incidence and severity of Clostridium difficile infection (CDI) have increased dramatically in North America and Europe. However, little is known about CDI in Mainland China. In this study, we aimed to investigate the incidence of CDI and the main epidemic and drug-resistant strains of C. difficile in Mainland China through meta-analysis of related studies published after the year 2010. A total of 51 eligible studies were included. The pooled incidence of toxigenic C. difficile among patients with diarrhoea was 14% (95% CI = 12-16%). In Mainland China, ST-37 and ST-3 were the most prevalent strains; fortunately, hypervirulent strains, such as ST-1 (BI/NAP1/027) and ST-11 (RT 078), have only occurred sporadically to date.

The rates of C. difficile resistance to ciprofloxacin (98.3%; 95% CI = 96.9-99.7%), clindamycin (81.7%; 95% CI = 76.1-87.3%) and erythromycin (80.2%; 95% CI = 73.5-86.9%) are higher than in other counties; however, none of the C. difficile isolates reported in Mainland China were resistant to metronidazole (n/N = 0/960), vancomycin (n/N = 0/960), tigecycline (n/N = 0/41) or piperacillin/tazobactam(n/N = 0/288).

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C. difficile Researcher Kirk Hevener Of ISU And Research Group At Texas A&M University and University of Hawaii Work On A New Way To Treat Clostridium difficile

Kirk Hevener of the ISU Department of Biomedical and Pharmaceutical Sciences is part of a group that is working on a new way to treat Clostridium difficile, commonly called
C. difficile or C. diff. Working with researchers from Texas A&M University and the University of Hawaii
, Hevener is researching a new target that could change the way C. diff is treated through a $415,000 grant from the National Institute of Health.

C. diff  is a bacteria that commonly causes infection of the colon and can lead to severe damage, and in some cases can even be fatal. It is also highly drug-resistant and extremely transmittable.

Hevener identified C. diff as a possible candidate for research while working with a completely different bacteria during his postdoctoral fellowship in Chicago.

Porphyromonas gingivalis is a bacteria that causes disease in the mouth.

While these two bacteria are unrelated, they have two common traits. Both are pathogenic, meaning they cause disease, and contain an enzyme called FabK.

FabK is not found in many other bacteria, so Hevener decided that C. diff would be a good candidate to extend his work in Chicago to, with FabK being the focus of his current work.

This enzyme is part of the fatty acid synthesis pathway. This creates lipids that are used to create the cell membrane, among other functions of the cell. Within C. diff, it is also is part of the mechanism that creates the bacteria’s spores. These spores are inactive forms of the bacteria and are extremely difficult to kill.  They are the reason that recurrence and transmission rates are so high inside of hospitals.

Hevener is studying ways this enzyme can be targeted specifically, with molecules known as inhibitors.

If he and his team can prove that FabK is targetable, it could lead to the development of new medications specific to the treatment of C. diff.

Hevener wanted to make clear that he is currently working on target validation, and not drug development. He and his team are validating that by inhibiting this enzyme, the bacteria would not be able to able to reproduce and create spores, which would then allow others to develop a medication to leverage this mechanism.

By targeting FabK specifically, Hevener’s team would create a narrow spectrum method of treatment, as opposed to the more common broad spectrum approach.

Broad spectrum antibiotics affect all bacteria, regardless if they are pathogenic or beneficial.

There are many bacteria found inside of the human body that aid in different ways from digestion to preventing harmful organisms causing infection.

This narrow spectrum approach has two benefits for a medication developed using it: it does not kill helpful organisms and it helps slow the development of resistance.

Hevener explained that it is impossible to create an antibiotic that is immune to the development of resistance, but because a medication of this type would affect only C. diff, other bacteria would not develop resistance and transfer that genetic mutation to other bacteria. This would slow the progress of a medication becoming less effective or possibly obsolete over time.

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Belgian Nursing Home Survey of Clostridium difficile Presence and Gut Microbiota Composition

  • Cristina Rodriguez+
  • Bernard Taminiau,
  • Nicolas Korsak,
  • Véronique Avesani,
  • Johan Van Broeck,
  • Philippe Brach,
  • Michel Delmée and
  • Georges Daube
Contributed equally
BMC MicrobiologyBMC series – open, inclusive and trusted201616:229

DOI: 10.1186/s12866-016-0848-7

The Author(s). 2016m,Received: 13 April 2016,Accepted: 23 September 2016

Published: 1 October 2016



Increasing age, several co-morbidities, environmental contamination, antibiotic exposure and other intestinal perturbations appear to be the greatest risk factors for C. difficile infection (CDI). Therefore, elderly care home residents are considered particularly vulnerable to the infection. The main objective of this study was to evaluate and follow the prevalence of C. difficile in 23 elderly care home residents weekly during a 4-month period. A C. difficile microbiological detection scheme was performed along with an overall microbial biodiversity study of the faeces content by 16S rRNA gene analysis.


Seven out of 23 (30.4 %) residents were (at least one week) positive for C. difficile. C. difficile was detected in 14 out of 30 diarrhoeal samples (43.7 %). The most common PCR-ribotype identified was 027. MLVA showed that there was a clonal dissemination of C. difficile strains within the nursing home residents. 16S-profiling analyses revealed that each resident has his own bacterial imprint, which was stable during the entire study. Significant changes were observed in C. difficile positive individuals in the relative abundance of a few bacterial populations, including Lachnospiraceae and Verrucomicrobiaceae. A decrease of Akkermansia in positive subjects to the bacterium was repeatedly found.


A high C. difficile colonisation in nursing home residents was found, with a predominance of the hypervirulent PCR-ribotype 027. Positive C. difficile status is not associated with microbiota richness or biodiversity reduction in this study. The link between Akkermansia, gut inflammation and C. difficile colonisation merits further investigations.


C. difficile Elderly care home residents 16S rRNA gene analysis


Clostridium difficile is a Gram-positive, anaerobic, spore-forming, rod-shaped bacterium that has been widely described in the intestinal tract of humans and animals. In 1978, C. difficile was recognized as a major cause of antibiotic associated diarrhoea and, in the most serious cases pseudomembranous colitis [1, 2, 3]. Since then, many outbreaks have been reported; most of them were associated with the emergence of a specific subtype, hyper-virulent PCR-ribotype 027 [4]. Nowadays, C. difficile is a worldwide public health concern as it is considered the major cause of antibiotic-associated infections in healthcare settings [5]. A recent report of C. difficile infection (CDI) cost-of-illness attributes a mean cost ranging from 8,911 to 30,049 USD for hospitalised patients (per patient/admission/episode/infection) in the USA [6] and annual economic burden estimated around 3,000 million euro in Europe [7].

CDI is more commonly diagnosed among older people in nursing homes. High isolation frequencies have been described in USA, with up to 46 % of elderly residents testing positive for C. difficile, while in Europe or Canada the reported rates are much lower, varying between 0.8 and 10 % [8]. This is partly because elderly people are more commonly in hospitals, have an antibiotic treatment and age-related changes in intestinal flora and host defences, as well as the presence or other underlying health problem [8, 9, 10]. These factors can have an impact on the intestinal microbiota, which may promote C. difficile colonisation and the development of the infection [11]. Therefore, a new concern of several studies has been the identification of the microbial communities implicated in the CDI through the use of new sequencing techniques, like metagenomics [12].

The aim of this study was to evaluate and follow the prevalence of C. difficile among the residents of a Belgian nursing home. Multilocus variable number of tandem repeats analysis (MLVA) was performed to determine the genetic diversity of the C. difficile isolates and possible cross-infection between patients. Additionally, 16S rRNA gene sequencing was used to characterise the faecal microbiota of the elderly residents, to evaluate the global evolutions of the total microbiota and to identify possible relationships between certain bacteria populations and C. difficile colonisation, diarrhoea and antibiotic treatment.


Prevalence of C. difficile

A total of 242 faecal samples were collected from 23 residents in seventeen consecutive weeks (resident number 11 was excluded from the study as he finally did not agree to participate in the survey). Two subjects passed away within the four-month study period. Seven out of 23 monitored residents were positive for C. difficile at least once (Table 1).
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