Clostridioides difficile is a dangerous human pathogen because it can grow to high numbers in the intestine, cause colitis with its potent toxins, and persist as spores. C. difficile infection (CDI) is the primary hospital-acquired infection in North America and Europe, and it now is a global disease. Even with newer laboratory tests, there still is confusion on accurately diagnosing this disease. Three guidelines from three different healthcare-affiliated societies have recently been published. Consensus consolidated recommendations from these guidelines should be recognized by healthcare professionals, who need to understand why this disease continues to be difficult to diagnose and need a clear understanding of the advantages and limitations of current tests. Hopefully, these combined efforts will lead to an improvement in the recognition of this pathogen and a reduction in the suffering and economic loss caused by CDI.
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Over the past two decades there has been a sharp rise in the number and severity of infections caused by the bacteria Clostridium difficile (C. diff ) now the most common healthcare-acquired infection in the United States.
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But a new study suggests that the most routinely prescribed antibiotic is not the best treatment for severe cases. Scientists at the VA Salt Lake City Health Care System and University of Utah report that patients with a severe C. diff infection (CDI) were less likely to die when treated with the antibiotic vancomycin compared to the standard treatment of metronidazole.
The findings will be published online on Feb. 6, 2017 on the Journal of the American Medical Association (JAMA) Internal Medicine website.
C. diff does not cause illness outright. The bacterium produces two chemicals that are toxic to the human body. These toxins work in concert to irritate the cells of the Large intestinal lining producing the symptoms associated with the illness. Symptoms of CDI include watery diarrhea, fever, loss of appetite, nausea, and abdominal pain and tenderness. Severe cases are associated with inflammation of the colon.
Current guidelines primarily recommend two antibiotics metronidazole or vancomycin to treat CDI. While vancomycin was the original treatment, the medical community has favored metronidazole for the past few decades, because it is less expensive and will limit vancomycin resistance in other hospital-acquired infections. The guidelines are based on small clinical trials carried out about 30 years ago.
“For many years the two antibiotics were considered to be equivalent in their ability to cure C. diff and prevent recurrent disease,” says Stevens. “Our work and several other studies show that this isn’t always the case.” In the current issue of JAMA Internal Medicine, the research team looked at the effectiveness of the two drugs by comparing the risk of mortality after treatment with these two antibiotics.
The investigators conducted the largest study to date by examining the data from more than 10,000 patients treated for CDI through the US Department of Veterans Affairs healthcare system from 2005 to 2012. A severe case of CDI was defined as a patient with an elevated white blood cell count or serum creatinine within four days of the CDI diagnosis. A mild to moderate case of CDI was defined as a patient with normal white blood cell counts and creatinine levels. About 35 percent of cases in this study were considered severe.
Patients with a severe case of CDI had lower mortality rates when treated with vancomycin compared to metronidazole (15.3 percent versus 19.8 percent). The scientists calculated that only 25 patients with severe CDI would need to be treated with vancomycin to prevent one death. “That is a powerful, positive outcome for our patient’s well-being,” explains Stevens. She cautions that the researchers still do not understand how the choice of antibiotic affects mortality rates.
“Although antibiotics are one of the greatest miracles of modern medicine, there are still tremendous gaps in our knowledge about when and how to use them to give our patients the best health outcomes,” explains Michael Rubin, M.D., Ph.D., an associate professor in internal medicine and an investigator at the VA Salt Lake City Health Care System.
“This research shows that if providers choose vancomycin over metronidazole to treat patients with severe CDI, it should result in a lower risk of death for those critically ill patients,” said Rubin. This study showed that less than 15 percent of CDI patients, including severe cases, received vancomycin.
The study results did not show a difference in the rate of the illness returning following either antibiotic treatment whether the initial illness was mild to moderate or severe. Nor did it show a difference for the rate of death following either antibiotic treatment for mild to moderate CDI cases.
Stevens cautions that the study was observational in nature and does not prove cause and effect of the drug. In addition, the study focused on patients that were primarily men; however, past studies show that the C. diff treatment outcomes for men and women were similar.
According to Stevens, future work should balance the targeted application of vancomycin treatment, especially for severe CDI cases, with economic considerations and the consequences of antibiotic resistance. “The optimal way to move forward is to do decision analysis that allows us to weigh the pros and cons of the various treatment strategies,” she says.
The research was funded by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development.
In addition to Stevens and Rubin, co-authors include Richard Nelson, Karim Khader, Makoto Jones, Lindsay Croft and Matthew Samore (University of Utah and the VA Salt Lake City Health Care System), Elyse Schwab-Daugherty and Kevin A. Brown (Public Health Ontario and University of Toronto), Tom Greene (University of Utah), Melinda Neuhauser (VA Pharmacy Benefits Management Services) and Peter Glassman and Matthew Bidwell Goetz (VA Greater Los Angeles Healthcare System).
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Saving patients from sepsis is a race against time
CDC calls sepsis a medical emergency; encourages prompt action for prevention, early recognition
Sepsis is caused by the body’s overwhelming and life-threatening response to an infection and requires rapid intervention. It begins outside of the hospital for nearly 80 percent of patients. According to a new Vital Signs report released by CDC, about 7 in 10 patients with sepsis had used health care services recently or had chronic diseases that required frequent medical care. These represent opportunities for healthcare providers to prevent, recognize, and treat sepsis long before it can cause life-threatening illness or death.
“When sepsis occurs, it should be treated as a medical emergency,” said CDC Director Tom Frieden, M.D., M.P.H. “Doctors and nurses can prevent sepsis and also the devastating effects of sepsis, and patients and families can watch for sepsis and ask, ‘could this be sepsis?’”
Certain people with an infection are more likely to get sepsis, including people age 65 years or older, infants less than 1 year old, people who have weakened immune systems, and people who have chronic medical conditions (such as diabetes). While much less common, even healthy children and adults can develop sepsis from an infection, especially when not recognized early. The signs and symptoms of sepsis include: shivering, fever, or feeling very cold; extreme pain or discomfort; clammy or sweaty skin; confusion or disorientation; shortness of breath and a high heart rate.
According to the Vital Signs report, infections of the lung, urinary tract, skin, and gut most often led to sepsis. In most cases, the germ that caused the infection leading to sepsis was not identified. When identified, the most common germs leading to sepsis were Staphylococcus aureus, Escherichia coli (E. coli), and some types of Streptococcus.
Health care providers, patients and their family members can work as a team to prevent sepsis.
Health care providers play a critical role in protecting patients from infections that can lead to sepsis and recognizing sepsis early. Health care providers can:
· Prevent infections. Follow infection control requirements (such as handwashing) and ensure patients to get recommended vaccines (e.g., flu and pneumococcal).
· Educate patients and their families. Stress the need to prevent infections, manage chronic conditions, and, if an infection is not improving, promptly seek care. Don’t delay.
· Think sepsis. Know the signs and symptoms to identify and treat patients earlier.
· Act fast. If sepsis is suspected, order tests to help determine if an infection is present, where it is, and what caused it. Start antibiotics and other recommended medical care immediately.
· Reassess patient management. Check patient progress frequently. Reassess antibiotic therapy 24-48 hours or sooner to change therapy as needed. Determine whether the type of antibiotics, dose, and duration are correct.
CDC is working on five key areas related to sepsis:
· Increasing sepsis awareness by engaging clinical professional organizations and patient advocates.
· Aligning infection prevention, chronic disease management, and appropriate antibiotic use to promote early recognition of sepsis.
· Studying risk factors for sepsis that can guide focused prevention and early recognition.
· Developing tracking for sepsis to measure impact of successful interventions.
· Preventing infections that may lead to sepsis by promoting vaccination programs, chronic disease management, infection prevention, and appropriate antibiotic use.
CDC works 24/7 protecting America’s health, safety and security. Whether diseases start at home or abroad, are curable or preventable, chronic or acute, stem from human error or deliberate attack, CDC is committed to respond to America’s most pressing health challenges.
To access the live broadcast and Podcast Library C. diff. Spores and More Global Broadcasting Network please click on the logo above *
“C. diff. Spores and More,” Global Broadcasting Network – innovative and educational interactive healthcare talk radio program discusses
This Episode: “EuroBiotix CIC – Supporting Clinicians Within the UK Deliver Fecal Microbiota Transplantation (FMT) To Patients With Recurrent C.difficile Infection”
With Our Guest: James Mcllory
Listen to the PodCast available from the JUNE 7TH C.diff Spores and More episode as we discussed current C.difficile infection objectives for hospitals within the United Kingdom with James McIlroy, a medical student and founder of a not-for-profit stool bank based within the University of Aberdeen in Scotland
MORE ABOUT OUR GUEST:
James McIlroy is a senior medical student at the University of Aberdeen in Scotland. Previously, he earned his Bachelors in Medical Sciences with Honors in human Physiology at the University of Edinburgh. At the present time, James is undertaking a prestigious fellowship at the Royal Society of Edinburgh. During his time at medical school, James identified an unmet need for safe access to fecal microbiota transplantation (FMT) within the United Kingdom. He subsequently established a not-for-profit community interest company called EuroBiotix CIC, which seeks to support clinicians within the UK National Health Service provide FMT.
“C. diff. Spores and More “ Global Broadcasting Network spotlights world renowned topic experts, research scientists, healthcare professionals, organization representatives,C. diff. survivors, board members, and C Diff Foundation volunteers who are all creating positive changes in the C. diff. community worldwide.
Through their interviews, the C Diff Foundation mission will connect, educate, and empower many worldwide.
Questions received through the show page portal will be reviewed and addressed by the show’s Medical Correspondent, Dr. Fred Zar, MD, FACP, Dr. Fred Zar is a Professor of Clinical Medicine, Vice Head for Education in the Department of Medicine, and Program Director of the Internal Medicine Residency at the University of Illinois at Chicago. Over the last two decades he has been a pioneer in the study of the treatment of Clostridium difficile disease and the need to stratify patients by disease severity.
Programming for C. diff. Spores and More is made possible through our official Sponsor; Clorox Healthcare