Tag Archives: John G Bartlett MD

C. difficile, a leading Healthcare-Associated Infection, Brings Together World Topic Experts At the International Raising C. diff. Awareness Conference and Health EXPO in Boston, MA on November 9th

 2015 International Raising C. diff. Awareness Conference & Health EXPO

Boston, MA, USA   ~    November 9th

7:30 a.m – 5:00 p.m

conferencesanjuanprJoin us at our 3rd annual International Raising C. diff. Awareness Conference and Health EXPO on November 9th.  Not just another educational conference but one that pairs
world-renowned topic experts with presentations on state-of-the-art health care topics pertaining to a leading Healthcare-Associated Infection (HAI); C. difficile

*Prevention
*Treatments
*Research
*Prevention and Treatment Clinical trials and studies
*Microbiome research
*Infection Prevention
*Environmental Safety
*Fecal Microbiota Restoration and Transplants
……………………..and much more.

The panel of world-renowned topic experts will also discuss the burden of C. diff. the risk factors pertaining to current and emerging treatment options along with the importance of applying evidence-based clinical approaches to the prevention of  a C. diff. infection (CDI), one of the leading Hospital-Acquired Infections.

Clostridium difficile (also known as C. diff.) is an important cause of infectious disease death in the United States.  Nearly half a million Americans suffered from Clostridium difficile (C. diff.) infections in a single year according to a study released February 25, 2015 by the Centers for Disease Control and Prevention (CDC). • More than 100,000 of these infections developed among residents of U.S. nursing homes alone.*  Approximately 29,000 patients died within 30 days of the initial diagnosis of a C. diff. infection.   Of these 29,000 – 15,000 deaths were estimated to be directly related to a  C. diff. infection. Therefore; C. diff. is an important cause of infectious disease death in the U.S.  (Source: CDC)

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Conference Venue:

Double Tree Suites Hotel – Boston – Cambridge
400 Soldiers Field Road, Boston, MA  02134  USA
1-617-783-0090 For Hotel Accommodations *   * There are hotel accommodations available for Sunday evening offered at a special event rate for guests of the C Diff Foundation.  Please inform the DoubleTree representative at the time of creating a reservation to receive the special event room rate.

Exclusive Admission:   $75.00

Student Admission:     $50.00

Each exclusive and student ticket includes admission to all presentations, formal and informal Q&A sessions, introductions to fellow healthcare professionals, continental breakfast  (7:30 a.m.) , a plated four course luncheon with the choice of Chicken Florentine or Petite Filet Mignon main entree, Access to the Health EXPO, a conference book, a educational DVD, and formal conference program.  

To Register and obtain tickets, please click on the following link

NOTE:  *Presentations should not be recorded audio or video or published without prior written and signed permission from the guest speaker and addressed by each attendee seeking publication of said presentations.

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Guest Speakers

Key Speaker and Conference Chair:  Professor Mark Wilcox;  Professor of Medical Microbiology, Leeds Institute of Biomedical and Clinical Sciences, UK. Professor Mark Wilcox is a Consultant Microbiologist, Head of Microbiology and Academic Lead of Pathology at the Leeds Teaching Hospitals, Professor of Medical Microbiology at the University of Leeds, and is the Lead on Clostridium difficile for the Public Health England. He has formerly been the Director of Infection Prevention, Infection Control Doctor and Clinical Director of Pathology at Leeds Teaching Hospitals.

Dr. John Bartlett, MD; Assistant Professor Medicine, UCLA/Sepulveda Veterans Admin Hospital 1972-5, Associate Professor and Professor of Medicine, Tufts University School of Medicine, Boston, 1975-80, Professor of Medicine and Chair Division of Infectious Diseases Division, Johns Hopkins University School of Medicine 1980 – 2006; Professor of Medicine, 2006 – 13; Professor of Medicine emeritus, Johns Hopkins University School of Medicine, 2013.Dominant research interests: anaerobic infections and pulmonary infections 1968 – 74; community acquired pneumonia and diagnostic methods, 1974-1980; Bowel prep for elective colon surgery; Protected bronchoscopy brush catheter-1977; Clostridium difficile 1977 – 84, HIV 1983 – 2014; bioterrorism 1999 –2004; Clostridium difficile infection, HIV/AIDS and antibiotic resistance 2006-2013 with  Major current interests: Clostridium difficile infection, HIV infection, antibiotic resistance, careers in infectious diseases.
Presentation Topic: “The discovery of Clostridium difficile as the cause of antibiotic-associated colitis.”

Professor Simon M. Cutting, Professor of Molecular Microbiology at Royal Holloway, University of London is a bacterial geneticist with over 25 years of experience with Bacillus since graduating from Oxford University with a D. Phil in 1986. His D.Phil was on understanding the genetic control of spore formation in Bacillus. After spending 7 years in the renowned laboratory of Professor Richard Losick at Harvard University Biological Laboratories (USA) he spent 3 years as an Assistant Professor at the University of Pennsylvania Medical School in Philadelphia. He returned to the UK in 1996 and since then has worked on developing bacterial spores as novel oral vaccines at
Royal Holloway, University of London. The Cutting lab has developed a number of prototype oral vaccines and is now entering a ‘first in man’ phase 1/IIa clinical trial of a prototype oral vaccine to 
Clostridium difficile (see www.cdvax.org). His other expertise is in the use of Bacillus spores as probiotics and has a number of contracts and consultancies with European and US companies in the food and feed sectors 
(see SporeGen.com).
Presentation Topic: “Mucosal Vaccination: Decolonisation is Essential to Full Protection Against C. difficile

Dr. Sadeq A. Quraishi, MD, MHA, MMSc   Anesthesiologist/Intensive Care physician in the Department of Anesthesia, Critical Care and Pain Medicine at the Massachusetts General Hospital in Boston, MA. He is also Assistant Professor of Anaesthesia at Harvard Medical School in Boston, MA. Dr. Quraishi’s overall research goal is to better define how macro- and micro-nutrient status influence outcomes during acute stress and critical illness. In particular, his research group has focused on the immunomodulatory effects of vitamin D in the perioperative setting, during acute care hospitalization, and for patients in the intensive care unit. Recently, Dr. Quraishi’s group has identified vitamin D status as a potentially modifiable risk factor for hospital acquired C. diff infections and that the severity of C. Diff infections may also be related to vitamin D status .
Presentation Topic:  “Vitamin D as nutritional immunomodulation
for Clostridium difficile infections.”

Dr. Mary Beth Dorr , Phd, studied Pharmacy at the University of the Sciences in Philadelphia and received a PhD in pharmacokinetics and drug metabolism from the University of North Carolina. For the last 28 years Dr. Dorr has worked in the pharmaceutical industry in various capacities, with the majority of the time devoted to the design and implementation of Phase 1 to 4 clinical trials, primarily for anti-infective products.  Prior to joining Merck, Dr. Dorr directed several large, international clinical studies of the efficacy and safety of two IV antibiotics, Synercid and dalbavancin.  She also directed clinical research programs for gastrointestinal and women’s health products.  Mary Beth joined Merck in February 2011 and is currently a Clinical Director in the Late Stage Clinical Development Department as the Clinical Monitor directing 2 large pivotal Phase 3 trials investigating the safety and efficacy of the monoclonal antibodies actoxumab and bezlotoxumab as adjunctive therapy for the prevention of C. difficile recurrence.
Presentation Topic: Bezlotoxumab for Prevention of Recurrent C. difficile Infection in Patients on Standard of Care Antibiotics:  Results of Phase 3 Trials (MODIFY I and MODIFY II)

Dr. Hudson Garrett, Jr., PhD, MSN, MPH, FNP, CSRN, VA-BC, CDONA,FACONA,DON-CLTC
Dr. Hudson Garrett is currently employed as the VP, Clinical Affairs for PDI and NIce-Pak, and is responsible for the global Clinical Affairs program and also the Medical Science Liaison program for all divisions within the company. He holds a Bachelor of Science degree in Biology/Chemistry and Nursing, a dual Masters in Nursing and Public Health, Post-Masters Certificate as a Family Nurse Practitioner, a Post-Masters Certificate in Infection Prevention and Infection Control and a PhD in Healthcare Administration and Policy. He has completed the Johns Hopkins Fellows Program in Hospital Epidemiology and Infection Control, and the CDC Fundamentals of Healthcare Epidemiology program, and is board certified in family practice, critical care, vascular assess, moderate sedation, legal nurse consulting, and a director of nursing in long term care.  Dr. Garrett is also a Fellow in the Academy of National Associations of Directors of Nursing Administration in Long Term Care.
Presentation Topic:  Preventing Clostridium difficile thru Antibiotic Stewardship

Dr. David Cook, PhD;  A scientist and entrepreneur who has held senior operating and management positions in the biotechnology industry over his 20-year career. Before joining Seres Therapeutics, he was the chief operating officer for the International AIDS Vaccine Initiative, a global R&D organization whose mission is to develop a safe, globally accessible vaccine for HIV. Prior to IAVI, David was the founding CEO at Anza Therapeutics, a biotechnology start-up developing a novel microbial vaccine platform to induce cellular immune responses to fight or prevent diseases such as cancer, hepatitis C, malaria and tuberculosis. He is also a co-inventor on over twenty-five patents. He received his undergraduate degree from Harvard College and his PhD in chemistry from the University of California, Berkeley. Dr Cook is presently Executive Vice President of R&D, Chief Scientific Officer with Seres Therapeutics, Inc.. Presentation Topic: “The role of the microbiome in resisting
C. difficile infection and the mechanism of Ecobiotic drugs.”

Julie Gubb, PhD, CIC,   has worked in the field of Infection Prevention in varying roles at healthcare facilities in multiple states for more than two decades. After graduating from the University of Detroit Mercy with a degree in Medical Technology, she began her career as Senior Clinical Microbiologist at an acute care hospital in Detroit, Michigan, where she developed an interest in Infection Control while managing the activities of a full-service microbiology laboratory. She was the Director of Infection Control at Mount Clemens Regional Medical Center in Michigan, and has also held positions in Infection Prevention at healthcare facilities in California and Nevada. As a Senior Infection Preventionist for Xenex, Julie works closely with hospitals throughout the United States to understand their infection prevention goals and develop strategies for attaining those goals. As an active member of the national organization Association for Professionals in Infection Control & Epidemiology (APIC), she has maintained Board Certification in Infection Control and Epidemiology since 1993 and speaks frequently at APIC chapter meetings.
Presentation Topic: Stand Up for Cleanliness / Enhanced Room Disinfection

Dr. Patricia J. Freda Pietrobon, PhD: Associate Vice President, R&D,
Sanofi Pasteur, has over 25 years of experience in the Vaccine & Diagnostic industries and more then 20 years in leadership roles focusing on research & development of new vaccines. Patricia began her career in diagnostic assay development with a focus on validation and quality alignment to regulatory requirements and GXPs. Patricia has been with Sanofi Pasteur for over 25 years and has contributed to the development and licensure of new bacterial & viral vaccines for pediatric & adult populations worldwide.

Barley Chironda, Manager of Infection Prevention and Control (IPAC) and Medical Device Reprocessing Device at St. Joseph Health Centre in Toronto, Canada. He is certified in Infection prevention and control (CIC TM) and has worked extensively as an Infection Preventionist. Barely has been an integral to the successful decline in Clostridium difficile infections through implementing innovative technology and quality improvement behavioral changes.   Barley’s presentation will show a behind the scenes account of the C. diff. management from the healthcare facilities perspective while providing a call to action.

Dr. Martha Clokie, PhD, Leicester UK, Professor in Microbiology.  Dr. Cloakie’s research focuses on phages that infect bacterial pathogens of medical relevance and  has published 41 papers in this area. Her major focus has been on Clostridium difficile where she has  isolated a large phage collection. In vitro and in vivo data has shown that the viruses have therapeutic potential. A patent has been filed  on these phages and  working with AmpliPhi to develop a product. Dr. Cloakie  has regular contact with the BBC and other media to talk about her work, and other phage projects, and has consulted with Science museum, London and Eden Project, UK to advise on bacteriophage displays.

Lee Jones, Founder, President and CEO of Rebiotix Inc, has over thirty years of experience in the medical technology industry in large and small companies and academia. Most recently Lee was Chief Administrative Officer of the Schulze Diabetes Institute at the University of Minnesota, Minneapolis, MN and is the former president and chief executive officer of Inlet Medical. Inlet Medical was sold to Cooper Surgical in 2006. Lee will introduce Rebiotix Inc.,  a biotechnology company founded in 2011 in Roseville, MN to revolutionize the treatment of challenging gastrointestinal diseases by harnessing the power of the human microbiome The company is developing an entirely new kind of biological drug designed to reverse pathogenic processes responsible for disease through the transplantation of live human-derived microbes into a sick person’s intestinal tract.
Presentation Topic:  Blazing a Trail with the Gut Microbiome

Professor Nancy Sheridan,   a C. diff. Survivor and  Associate Professor at the Fashion Institute of Technology and a winner of the prestigious SUNY Chancellor’s Award for Excellence in Teaching. Professor Sheridan will share her personal experience being treated for a painful and extended journey with a C. diff. infection (CDI).  Professor Sheridan has been teaching since fall 2000 in the Fashion Merchandising Management Department within the School of Business and Technology. For the past seven years, she has also taught at the University of Pennsylvania, Wharton Business School to undergraduate and MBA students.

Dr Mel Thomson, PhD,  completed her Honors degree in microbiology and immunology at the University of Melbourne . She then immigrated to the UK where she worked on various projects as diverse as allergy and cancer before undertaking further studies. She completed a Masters of Research in functional genomics before reading for a PhD in microbial genetic regulation in Neisseria species, both at University of York, UK. After the award of her PhD, Dr Thomson became interested the host-pathogen interactions at the Leeds Institute of Molecular Medicine, UK.  Dr Thomson returned to Australia in 2011 to start her own research group studying host-pathogen interactions in the GI tract, at Deakin Medical School. A passionate science communicator, and has recently become a national ‘torch bearer’ for the concept of crowd funding academic research, which a track record of three successful ‘Pozible’ crowd funding campaigns, ‘Mighty Maggots’, ‘Hips 4 Hipsters’ and ‘No more Poo Taboo’
Presentation Topic: All that glitters is C.diff awareness gold and Crowdfunding: The ‘No more poo taboo’ animation”

Dr Rahma Wehelie – LifeClean International AB – Sweden; LifeClean International AB is a Swedish company with an international orientation that conducts research, development, and production in the spore, bacteria, and virus eliminating industry. LifeClean was established in 2013 after many years of research and the headquarter lies in Uddevalla, Sweden.
Presentation Topic: Dr Wehelie will be discussing LifeClean’s research, development and production eliminating Clostridium difficile, Norovirus, and other multidrug-resistant bacteria

Dr. Klaus Gottlieb, MD, FACG,Synthetic Biologics, Inc.,Vice President, Clinical;Regulatory Affairs   Dr. Gottlieb is an experienced board-certified internist and gastroenterologist with a strong clinical science, business and drug development background. He joined Synthetic Biologics after serving as Senior Medical Director-Therapeutic Strategy Lead Gastroenterology of Quintiles, a Fortune 500 company and the world’s largest provider of biopharmaceutical development and commercial outsourcing services. At Quintiles, Dr. Gottlieb served as Global Medical Advisor for three separate large Phase 3 inflammatory bowel disease (IBD) trials and provided significant input on the shaping, design and evaluation of numerous IBD and other gastrointestinal (GI) clinical trials throughout all stages of development programs. Prior to joining Quintiles in 2013, he was with the FDA in Silver Spring, MD as a Senior Clinical Reviewer for the Division of Gastroenterology and Inborn Errors Products. Widely published, his academic contributions have been recognized by an appointment as Professor of Medicine (Clinical) at George Washington University and the following elected fellowships: Fellow American College of Physicians, Fellow American College of Gastroenterology, Fellow American Society of Gastrointestinal Endoscopy.  Presentation Topic: Protecting the Gut Microbiome

For additional information contact the C Diff Foundation: (919) 201-1512 or
info@cdifffoundation.org

To Register and obtain tickets, please click on the following link

We would like to sincerely thank the following Exclusive and Supporting Corporate Sponsors for their continued support  and joining the Foundation in
Raising C. diff. Awareness worldwide.

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C. difficile – Update From The Expert

In The News May 20, 2014 *

Editor’s Note: Dr. John Bartlett, MD, gave an update on Clostridium difficile infection (CDI) at the April 2014 meeting of the American College of Physicians. He provided Medscape with this synopsis.

 

 

We are going to talk about CDI. It is a disease that seemed like it was well covered a decade or two ago, but all of a sudden there is a rush of new information that is clinically important. I would like to review the more recent information.

 

 

The first thing to acknowledge is that we got a thrust of new cases in the early 2000s in Europe and in North America, including Canada and the United States, reflecting the NAP-1 strain.[1] NAP-1 wasn’t a particularly virulent strain, but it was resistant to fluoroquinolones, and that drove its epidemiology. The slide shows the rush of cases in the United States, a 4- or 5-fold increase over that rather short 8-year period of time.

 

 

More recently, we received guidelines from the European Society of Clinical Microbiology and Infectious Diseases.[2] I think these are really good. They are similar to the Infectious Diseases Society of America (IDSA) guidelines but much newer — 3 years newer. They said that for mild or not severe disease, metronidazole would be the preferred drug 500 mg 3 times/day, and for severe disease, vancomycin 125 mg 4 times/day. No change there. A helpful hint for the treatment of patients who can’t take oral drugs is intravenous metronidazole combined with vancomycin enemas. For relapse, they like the taper and pulse, which was recommended earlier. It has never been studied but seems to work. The new drug on the block, fidaxomicin, also seems to do well in relapsing disease. Stool transplant is hot, and I will talk more about that. Interestingly, probiotics were not recommended, which is highly controversial. I won’t say much about it except that I don’t personally recommend them, but I don’t mind if my patients take it.

 

 

The next slide is about a trial comparing vancomycin with fidaxomicin in patients who have relapsing CDI.[3] Fidaxomicin works just as well as vancomycin for primary disease. It is less likely to prompt a relapse, probably because it has a less profound effect on the colonic microbiome. It re-establishes the pathophysiology that was intended. What it shows here is a difference in relapse rate of 36% vs 20%, which is substantial. That is for relapsing disease.

 

 

Next is an interesting slide about the epidemiology, which has really changed our concept of epidemiology completely.[4] Most people have always thought that CDI was a hospital-acquired infection, but this great study from the Centers for Disease Control and Prevention (CDC) reviewed 10,000 cases and showed that only about 25% of patients with CDI acquired the disease in the hospital where it was expressed. Therefore, the majority of patients came into the hospital with CDI, which obviously has big implications in regard to infection control. The patient who comes in with it has to be protected from getting it with antibiotic control and also has to protect others from contagion, which is not the way it has been advocated.

 

 

The next slide is the British system.[5] They are running away with this disease especially in terms of the epidemiology of the disease. The UK had a lot of CDI with the NAP1 strain, and the hospitals were told to get rid of it. They were very aggressive in dealing with their epidemic of CDI and, in fact, managed to accomplish a 61% decrease in CDI rates. They did that largely by the control of antibiotics, primarily fluoroquinolones. They essentially stopped fluoroquinolones and also had a major reduction in the use of cephalosporins, the 2 big contenders. Of course, clindamycin is in that mix, but it was not prominently used at the time, so that didn’t make a big difference. But they achieved a decrease in CDI rates, and the reason was that they controlled antibiotics.

 

 

One of the things they have done magnificently is chain sequencing to show epidemiologic patterns. The next slide shows that they were able to demonstrate patient-to-patient transmission within a ward in only 23% of the cases. Chain sequencing is probably the ultimate infection control tool. This has contributed to our changing concepts of the epidemiology of C difficile. Many patients are already colonized when they are hospitalized. That reverses the standard teaching that you get CDI when you go to a ward that has the disease.

 

 

The next slide is not clinically important, but it’s fun to talk about The Netherlands beagle.[6] Of course, dogs have an incredible sense of smell. The dog was trained to smell p-cresol so that it can make an identification of CDI. Its performance was essentially 100% in detecting positives and negatives. I contacted the author to find out what they were doing now with the dog, and they said that they only take the dog on the ward, but they do it regularly. The reason they don’t do it in individual cases is that they simply don’t have enough cases in the lab. So they screen wards, not individual patients, with the dog test, but they still use it. Interestingly, they wanted to bring it to the United States because we have a lot of CDI and it would be a good way to test the dog in the lab, but the requirements for quarantine and so forth were too tough.

 

The next slide has to do with polymerase chain reaction (PCR). PCR is probably the most commonly used test. It is a molecular test, so it is essentially 100% sensitive but not very specific.[7] There will be many more carriers than there are cases, so you have to make clinical correlations in order to properly understand that test. The other test, of course, is the enzyme immunoassay (EIA), which is commonly used in about 30% of laboratories. It has the opposite lesion, which is that it is more specific but less sensitive. It is not a molecular test and is probably not adequately sensitive to detect about a third of cases.

 

 

Stool transplant is hot. It has been done since 1958 and has been in a large number of series. What is important here is the summary of late information with guidelines from the IDSA and the US Food and Drug Administration (FDA), who are now into this in a big way. According to the IDSA, the indications for stool transplant are relapsing CDI 3 times or more. They also advocated for acute disease, but the published experience for that is not very robust — good, but not very robust. The stool that is transplanted can be put in in a hospital, in a clinic, or at the patient’s home. It can be put in by the patient. The method can be by endoscopy, by enema, by nasogastric tube, or by any other way that you can get it there, such as capsules. The important thing is to get the stool into the colon. How you get it there is probably not terribly important. Who selects the donor? We usually have the patient select a donor, but there are other places that use alternative systems. There are several other sources now, including a website operated by medical students called OpenBiome which will send you a stool for $250. You have to be aware that the screening test for a stool transplant costs about $600, and no insurance or third-party payer will pay for this. It is a patient expense that patients need to be warned about.

 

 

In terms of clinical management, I’ve summarized a lot of data here. The risks are well known: advanced age, antibiotics (especially fluoroquinolones and cephalosporins), and exposure to the healthcare system. That was the message from before. In other words, the patient acquired the disease not at the current hospital but often from a previous hospitalization, a nursing home where they were previously a resident, or an outpatient clinic. They acquired it in the healthcare system but not necessarily this hospital at this time.

Know the test. The first question to ask when somebody says that there is a positive test for a patient is “which test?” If it’s PCR, worry about false positives. If it’s an EIA, worry about false negatives.

For determining the prognosis, the signs to watch for are shown here. Renal function, white blood cell count, lactate level, and albumin level are all barometers for the severity of disease. Of course, there are also the issues of ileus, toxic megacolon, and so forth.

I’ve talked about epidemiology quite a bit. We call it “hospital-associated C difficile” and not “hospital-acquired” for the reasons that I mentioned. There is no new information about treatment except that fidaxomicin is the new kid on the block. It’s probably the best drug, but it’s also very expensive. For stool transplants, be aware that many of the people watching this will not do stool transplants. What you need to do is know someone in your community to whom you can refer patients if there is an indication, preferably a place that has a fair amount of experience. Also be aware that there are published guidelines on when to do it. For the first time, the FDA has gotten engaged, and now they call stool a drug. You have to jump through some hoops. You have to get a treatment investigational new drug (IND) application. They have some rules about knowing who the donor is or the donor source. All of that can be sorted out at the site of the transplant, but it’s probably a good idea to keep that in mind when you’re communicating with patients.

Those are my highlights for what is going on in the field of C difficile today.

C diff: An Update From the Expert. Medscape. May 20, 2014.

 

References

  1. Steiner C, Barrett M, Terrel L. HCUP Projections: Clostridium Difficile Hospitalizations 2011 to 2012. 2012 HCUP Projections Report # 2012-01 July 10, 2012. U.S. Agency for Healthcare Research and Quality. http://www.hcup-us.ahrq.gov/reports/projections/CDI_Regional_projections_Final.pdf Accessed April 30, 2014.
  2. Debast SB, Bauer MP, Kuijper EJ; Committee. European Society of Clinical Microbiology and Infectious Diseases: update of the treatment guidance document for Clostridium difficile infection. Clin Microbiol Infect. 2014;20 Suppl 2:1-26.
  3. Crook DW, Walker AS, Kean Y, et al; Study 003/004 Teams. Fidaxomicin versus vancomycin for Clostridium difficile infection: meta-analysis of pivotal randomized controlled trials. Clin Infect Dis. 2012;55 Suppl 2:S93-103.  Abstract
  4. Centers for Disease Control and Prevention (CDC). Vital signs: preventing Clostridium difficile infection. MMWR Morb Mortal Wkly Rep. 2012;61:157-162. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6109a3.htm Accessed April 30, 2014.
  5. Walker AS, Eyre DW, Wyllie, DH, et al; Infections in Oxfordshire Research Database. Characterisation of Clostridium difficile hospital ward-based transmission using extensive epidemiological data and molecular typing, PLoS Medicine. 2012;9:1001172. http://www.plosmedicine.org/article/fetchObject.action?uri=info%3Adoi%2F10.1371%2Fjournal.pmed.1001172&representation=PDF Accessed April 30, 2014.
  6. Bomers MK, van Agtmael MA, Luik H, van Veen MC, Vandenbroucke-Grauls CM, Smulders YM. Using a dog’s superior olfactory sensitivity to identify Clostridium difficile in stools and patients: proof of principle study. BMJ. 2012;345:e7396.
  7. Loo VG, Bourgault AM, Poirier L, et al. Host and pathogen factors for Clostridium difficile infection and colonization. N Engl J Med. 2011;365:1693-1703.  Abstract