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Lab Testing Is Critical For Persistent Diarrhea To Accurately Diagnose and Treat

An accurate diagnosis via laboratory testing is critical for effectively treating persistent diarrhea lasting more than 2 weeks, as the often poorly recognized syndrome can be caused by different pathogens than acute diarrhea, according to a clinical review recently published in JAMA.

“I’d like to educate doctors about the importance of taking the history and assessing duration of illness,” Herbert L. DuPont, MD, Director of the Center for Infectious Diseases at The University of Texas Health Science Center at Houston School of Public Health, said in a press release. “For acute diarrhea, the lab has a minimal role, restricted to patients passing bloody stools. If a patient has had diarrhea for 2 weeks or more, the doctor should focus on the cause of the disease through laboratory testing, with an emphasis on parasites.”

DuPont performed a review of relevant literature published up to February 2016 to provide an overview of the epidemiology, etiology, diagnosis and management of persistent diarrhea in immunocompetent patients.

Common causes of persistent diarrhea

Although acute diarrhea is usually caused by viruses or toxins, persistent diarrhea is usually caused by bacteria or parasites, DuPont wrote.

Protozoa are the most common parasitic cause of persistent diarrhea, including Giardia, Cryptosporidium and Cyclospora, whereas Entamoeba histolytica, Cystoisospora belli, Dientamoeba fragilis, Strongyloides stercoralis and Microsporidia species are less common.

Bacterial species that may cause persistent diarrhea include enteroaggregative Escherichia coli, Shigella, Campylobacter, Salmonella, Vibrio parahaemolyticus, Arcobacter butzleri and Aeromonas species.

Clostridium difficile can cause recurrent diarrhea in patients receiving antibiotics in health care settings, and viral agents, such as norovirus, and helminths can also cause persistent diarrhea.

“Parasites are more common in the developing world. Consequently, persistent diarrhea is more common in these areas and in local populations or people traveling to these locations,” DuPont wrote. “Persistent diarrhea occurs in approximately 3% of international travelers to developing regions.” Parasitic infection is less common in industrialized regions, where foodborne and waterborne pathogens and C. difficile are more common causes, he added.

Persistent diarrhea can also have noninfectious causes, including lactase deficiency, ingested osmotic substances, postinfectious irritable bowel syndrome, functional bowel diseases, inflammatory bowel disease, celiac disease, ischemic or microscopic colitis, carbohydrate malabsorption, cancer and other idiopathic illnesses.

Complete evaluation, new diagnostic methods

Duration of illness should be determined by health care providers when developing an evaluation plan, and the clinical assessment of patients with persistent diarrhea lasting more than 14 days should include a complete history, physical examination and diagnostic testing for infectious or noninfectious etiologies.

“The longer the duration of illness, the more likely it is that parasitic pathogens or noninfectious causes will eventually be identified,” DuPont wrote.

Previously, bacterial pathogens were identified using stool culture-based methods, and parasites are often identified using commercial enzyme immunoassay tests or microscopy. However, the recent advent of multiplex polymerase chain reaction (PCR) platforms enable simultaneous testing for a number of bacterial, viral and parasitic enteropathogens by identifying their DNA sequences.

The xTAG Gastrointestinal Pathogen Panel (Luminex Corp) tests for 14 viruses, bacteria, and parasites and the FilmArray GI panel (Biofire Diagnostics) tests for 22 viruses, bacteria, and parasites.

“These new tests are easy to use, are capable of detecting a broad range of pathogens and represent a significant improvement over culture-based diagnostic approaches,” DuPont said in the press release. “The technology needs to be more widely available. Diagnosis is critical when treating persistent diarrhea.” However, false positive results are problematic, he wrote.

Treatment depends on diagnosis

After treating any dehydration with oral rehydration therapy, a laboratory test should be performed to determine the cause of persistent diarrhea to determine the appropriate treatment. However, a single 1,000 mg dose of empirical azithromycin is appropriate concurrent to the lab test for adults who have traveled to the developing world, as bacterial causes that lab tests cannot usually identify are common.

Although antimicrobial agents are recommended for a number of pathogens, the antibiotic choice should be optimized based on the pathogen’s susceptibility to prevent antimicrobial resistance.

TO READ THE ARTICLE IN ITS ENTIRETY CLICK ON THE LINK BELOW:

Study Finds Community – acquired Clostridium difficile (Cdiff) Infection (CDI) Greater Than Hospital-acquired CDI

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ASM Microbe 2016 (Poster 290)

Community-onset CDI cases increased at a higher rate than hospital-acquired cases—accounting for almost half of the cases—in an examination of clinical data from 154 U.S. hospitals over eight years, according to research presented at the ASM Microbe 2016 (Poster 290)

Researchers from Merck and Becton Dickinson wanted to examine this trend, and looked at where CDI began by analyzing clinical data from 154 hospitals from 2008 to 2015.

>> Thank You Merck and Becton Dickinson For Conducting This Study <<

A CDI case was defined as a positive C. difficile toxin or molecular assay of a stool specimen obtained from a patient without a positive assay in the previous eight weeks.

First, they looked at the overall CDI rate in those facilities in that eight-year period and found 154,629 total CDI cases.

Then the teased out whether the case was acquired in the community or hospital. They also dived a little deeper to understand which community cases really were “community” that is there was no hospital stay within a certain time before the onset of disease, explained Andy DeRyke, PharmD, director scientific strategy lead at Merck, and one of the researchers.

They used these three definitions:
Community-onset-community-associated: CDI occurred in an outpatient setting or within three calendar days after hospital admission and the patient had not had an overnight hospital stay in the prior 12 weeks before onset of infection;
Community-onset-hospital-associated: CDI occurred in an outpatient setting or within three days after hospital admission, but the patient had spent at least one night in the hospital in the prior 12 weeks to the onset of infection; and
Hospital-onset: CDI occurred after spending three days in the hospital.

Although not knew information—other studies as well as the Centers for Disease Control and Prevention (CDC) have reported community-acquired infection—they were surprised by how many cases were community acquired.

From 2008 to 2015, the total number of CDI cases increased from 14,686 to 25,273 (72% increase, P<0.01).

Those that were Community-onset-community-associated rose from 6,586 to 13,975 (112%, P<0.01).

While the cases that probably stemmed from a hospital exposure also increased, the rate was much lower, according to Dr. DeRyke.

Those that were community-onset-hospital-associated rose from from 4,545 to 6,524 (44%, P<0.01); while hospital-onset rose from from 3,555 to 4,775 (34%, P<0.01).

The community-onset-community-associated cases accounted for half of overall cases and proportionately increased from 45% in 2008 to 55% in 2015 (P<0.01).

They also looked at cases geographically and found that the Midwest had the highest CDI rate in the country.

“The rates of C. diff are increasing over time,” he said. “Despite all these efforts to eliminate C. diff, it continues to increase.”

Ambulatory patients and caregivers will find the same problems that hospitals have in trying to rid the environment of C. difficile, he said. “The problem is, it’s everywhere,” he said and recommended that any person caring for a patient with CDI make sure that they wash their hands frequently and disinfect with bleach.

https://cdifffoundation.org/hand-washing-updates/

 

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

http://www.idse.net/Hospital-acquired-infection/Article/06-16/C-diff-Not-Just-a-Hospital-Problem-Anymore/36793

C Diff Foundation Welcomes Barley Chironda, RPN, CIC

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We are pleased to welcome Barley Chironda, RPN, CIC  to the C Diff Foundation in the role of Infection Prevention Advocate.

Barley Chironda, RPN, CIC is a Nurse and is the Social Media Manager of IPAC Canada and the current President of IPAC- GTA.

He is also the National Healthcare Sales Director and Infection Control Specialist with Clorox Canada. Mr. Chironda is certified in Infection prevention and control (CIC™) and has worked extensively in Infection Control.  He is typically found engaged in motivating hospital staff, patients and the public on proper infection prevention practices.

Mr. Chironda’s roles allow great participation in quality improvement interventions related to patient and public safety. Therefore Barley has been an integral to the successful decline in Clostridium difficile infections through implementing innovative technology and quality improvement behavioral change.

Barley takes great pride in sharing information via social media and is often engaging the public on Twitter™ and LinkedIn™, partaking in resource distribution related to innovative and novel Infection prevention strategies.

 

C.diff Spores and More Discuss Current C.difficile Infection Objectives For Hospitals Within the United Kingdom With James McIlroy, Founder of EuroBiotix CIC

 

Listen To The JUNE 7, 2016 Podcast

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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.

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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 HeZarPhotoWebsiteTop (2)ad 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.

To access the C. diff. Spores and More program page and library, please click on the following link:    www.voiceamerica.com/show/2441/c-diff-spores-and-more

Take our show on the go…………..download a mobile app today

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Programming for C. diff. Spores and More ™  is made possible through our official  Sponsor;  Clorox Healthcare

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Clostridium difficile (C.diff.) Infection (CDI) Rates In the United States and Across the Globe Have Increased In the Last Decade, Along With Associated Morbidity and Mortality

ahrq-logo-pic

 

 

Early Diagnosis, Prevention, and Treatment of Clostridium difficile: Update

Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
5600 Fishers Lane
Rockville, MD 20857
March 2016

 

Clostridium difficile is a gram-positive, anaerobic bacterium generally associated through ingestion. Various strains of the bacteria may produce disease generating toxins
and TedA and TedB, as well as the lesser understood binary toxin.

Our use of the term indicates this review’s focus is the presence of clinical disease rather than asymptomatic carriage of C. difficile CDI symptoms can range from mild diarrhea to severe cases including pseudomembranous colitis and toxic megacolon and death.

Estimated U.S. health care associated CDI incidence in 2011 was 95.3 per 100,000, or about
293,000 cases nationally. Incidence is higher among females, whites, and persons 65 years of
age or older. (1)

About one third to one half of health-care onset CDI cases begin in long term care,thus residents in these facilities are at high risk.  Incidence rates may increase by four or five-fold during outbreaks.

Community associated CDI, where CDI occurs outside the institutional setting,
is also on the rise, though still generally lower than institution associated rates and may be in part due to increased surveillance. Estimated community associated CDI was 51.9 per 100,000, or   159,700 cases in 2011.  (1)

Community-associated CDI complicates measuring the effectiveness of  prevention within an institutional setting. 3  Additionally, the pathogenesis of CDI is complex and not
completely understood, and onset may occur as late as several months after hospitalization or antibiotic use

The estimated mortality rate for health -care associated CDI ranged from 2.4 to 8.9 deaths per

100,000 population in 2011.(1) For individuals ≥65 years of age, the mortality rate
was 55.1 deaths per 100,000; (1)

CDI was the 17th leading cause of death in this age group (4)
Hypervirulent C. difficile  strains have emerged since 2000 . These affect a wider population

that includes children, pregnant women, and other healthy
adults, many of whom lack standard risk profiles such as previous hospitalization or antibiotic use.(5)

The hypervirulent strains  account for 51 percent of CDI, compared to only 17 percent
of historical isolates. (6)

Time from symptom development to septic shock may be reduced in the hypervirulent strains, making quick diagnosis and proactive treatment regimens critical for positive outcomes.

To read more on  TREATMENT, PREVENTION, KEY QUESTIONS ——

https://www.effectivehealthcare.ahrq.gov/ehc/products/604/2208/c-difficile-update-report-160329.pdf

Early Diagnosis, Prevention, and Treatment of Clostridium difficile: Update

Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
5600 Fishers Lane
Rockville, MD 20857
March 2016

 

Sources:

1Appendix J. References for Appendixes
1.Alcala L, Reigadas E, Marin M, et al.
Comparison of GenomEra C. difficile and Xpert
C. difficile as confirmatory tests in a multistep
algorithm for diagnosis of Clostridium difficile
infection.
J Clin Microbiol 2015 Jan;53(1):332
5. PMID: 25392360.
2.Barkin JA, Nandi N, Miller N, et al.
Super iority
of the DNA amplification assay for the
diagnosis of C. difficile infection: a clinical
comparison of fecal tests.
Dig Dis Sci 2012Oct;57(10):2592-
9. PMID: 22576711.
3.Bruins MJ, Verbeek E, Wallinga JA, et al.
Evaluation of three enzyme immunoassay
s and a loo mediated isothermal amplification test
for the laboratory diagnosis of Clostridium
difficile infection. Eur J Clin Microbiol Infect
Dis 2012 Nov;31(11):3035 9. PMID:
22706512.
4.Buchan BW, Mackey TL, Daly JA, et al.
Multicenter clinical evalu
ation of the portrait
toxigenic C. difficile assay for detection of
toxigenic Clostridium difficile strains in clinical
stool specimens. J Clin Microbiol 2012
Dec;50(12):3932-
6. PMID: 23015667.
5.Calderaro A, Buttrini M, Martinelli M, et al.
Comparative analysis of different methods to
detect Clostridium difficile infection. New
Microbiol 2013 Jan;36(1):57-
63. PMID:
23435816.
6.Carroll KC, Buchan BW, Tan S, et al.
Multicenter evaluation of the Verigene
Clostridium difficile nucleic acid assay.
J ClinMicrobiol 2013 Dec;51(12):4120-
5. PMID:24088862