Infection control measures to limit the spread of Clostridium difficile

Vonberg, Ralf‐Peter; Kuijper, Ed J.; Wilcox, Mark H.; Barbut, Frédéric; Tüll, Peet; Gastmeier, Petra; Broek, P.J. van den; Colville, A.; Coignard, B.; Daha, Thea; Debast, Sylvia B.; Duerden, B. I.; Hof, Susan van den; Kooi, Tjallie van der; Maarleveld, H.J.H.; Nagy, Elisabeth; Notermans, Daan W.; O'Driscoll, J.; Patel, Bhavika B.; Stone, Sheldon; Wiuff, Camilla

doi:10.1111/j.1469-0691.2008.01992.x

Cited by 266 publications

(203 citation statements)

References 170 publications

(269 reference statements)

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“…This result is consistent with reports of similar outbreaks in which such interventions were enforced in conjunction with early detection of infection (2,20).…”

Section: Discussionsupporting

confidence: 82%

See 1 more Smart Citation

Clostridium difficile outbreak in Costa Rica: control actions and associated factors

Wong-McClure¹,

Guevara-Rodríguez²,

Abarca-Gómez³

et al. 2012

Rev Panam Salud Publica

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“…This result is consistent with reports of similar outbreaks in which such interventions were enforced in conjunction with early detection of infection (2,20).…”

Section: Discussionsupporting

confidence: 82%

“…This study also confirms the importance of rapid implementation of such interventions (20) to reduce transmission of the disease and the impact of the outbreak.…”

Section: Discussionsupporting

confidence: 61%

Clostridium difficile outbreak in Costa Rica: control actions and associated factors

Wong-McClure¹,

Guevara-Rodríguez²,

Abarca-Gómez³

et al. 2012

Rev Panam Salud Publica

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“…Additionally; it has been shown that the skin surfaces of patients with CDI diarrhea that resolved 2 weeks before is still contaminated with C. diffi cile that may be transferred to an examining gloved hand ( 177 ). One recommendation is to maintain contact precautions for 48 h aft er diarrhea ceases ( 178 ). Some institutions have implemented contact precautions for the duration of hospitalization as part of their infection control interventions for CDI ( 168 ).…”

Section: Management Of CDI and Co-morbid Conditionsmentioning

confidence: 99%

Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections

Surawicz

Brandt

Binion

et al. 2013

American Journal of Gastroenterology

1,477

1,408

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Clostridium diffi cile infection (CDI) is a leading cause of hospital-associated gastrointestinal illness and places a high burden on our health-care system. Patients with CDI typically have extended lengths-of-stay in hospitals, and CDI is a frequent cause of large hospital outbreaks of disease. This guideline provides recommendations for the diagnosis and management of patients with CDI as well as for the prevention and control of outbreaks while supplementing previously published guidelines. New molecular diagnostic stool tests will likely replace current enzyme immunoassay tests. We suggest treatment of patients be stratifi ed depending on whether they have mild-to-moderate, severe, or complicated disease. Therapy with metronidazole remains the choice for mildto-moderate disease but may not be adequate for patients with severe or complicated disease. We propose a classifi cation of disease severity to guide therapy that is useful for clinicians. We review current treatment options for patients with recurrent CDI and recommendations for the control and prevention of outbreaks of CDI. Am J Gastroenterol 2013; 108:478-498; doi: 10.1038/ajg.2013 12. In patients in whom oral antibiotics cannot reach a segment of the colon, such as with Hartman's pouch, ileostomy, or colon diversion, vancomycin therapy delivered via enema should be added to treatments above until the patient improves. (Conditional recommendation, low-quality evidence)13. The use of anti-peristaltic agents to control diarrhea from confi rmed or suspected CDI should be limited or avoided, as they may obscure symptoms and precipitate complicated disease. Use of anti-peristaltic agents in the setting of CDI must always be accompanied by medical therapy for CDI. (Strong recommendation, low-quality evidence) Management of severe and complicated CDI14. Supportive care should be delivered to all patients and includes intravenous fl uid resuscitation, electrolyte replacement, and pharmacological venous thromboembolism prophylaxis. Furthermore, in the absence of ileus or signifi cant abdominal distention, oral or enteral feeding should be continued. 17. Vancomycin delivered orally (500 mg four times per day) and per rectum (500 mg in a volume of 500 ml four times a day) plus intravenous metronidazole (500 mg three times a day) is the treatment of choice for patients with complicated CDI with ileus or toxic colon and / or signifi cant abdominal distention. (Strong recommendation, low-quality evidence)18. Surgical consult should be obtained in all patients with complicated CDI. Surgical therapy should be considered in patients with any one of the following attributed to CDI: hypotension requiring vasopressor therapy; clinical signs of sepsis and organ dysfunction (renal and pulmonary); mental status changes; white blood cell count ≥ 50,000 cells / μ l, lactate ≥ 5 mmol / l; or failure to improve on medical therapy after 5 days. (Strong recommendation, moderate-quality evidence) Management of recurrent CDI (RCDI)19. The fi rst recurrence of CDI can be treated ...

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“…Infection is often chronic and difficult to eradicate (O'Brien et al, 2007). C. difficile is transmitted as dormant endospores that are highly resistant to killing by heat, antibiotics, oxidizing agents, UV radiation and many other treatments that are usually effective for killing bacteria (Vonberg et al, 2008;Setlow, 1995). C. difficile spores germinate in the intestine to produce vegetatively growing cells capable of producing toxins A and B, which have been implicated in disease progression and severity (Bartlett et al, 1977;McDonald et al, 2005).…”

Section: Introductionmentioning

confidence: 99%

The dlt operon confers resistance to cationic antimicrobial peptides in Clostridium difficile

2011

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The dlt operon in Gram-positive bacteria encodes proteins that are necessary for the addition of D-alanine to teichoic acids of the cell wall. The addition of D-alanine to the cell wall results in a net positive charge on the bacterial cell surface and, as a consequence, can decrease the effectiveness of antimicrobials, such as cationic antimicrobial peptides (CAMPs). Although the roles of the dlt genes have been studied for some Gram-positive organisms, the arrangement of these genes in Clostridium difficile and the life cycle of the bacterium in the host are markedly different from those of other pathogens. In the current work, we determined the contribution of the putative C. difficile dlt operon to CAMP resistance. Our data indicate that the dlt operon is necessary for full resistance of C. difficile to nisin, gallidermin, polymyxin B and vancomycin. We propose that the D-alanylation of teichoic acids provides protection against antimicrobial peptides that may be essential for growth of C. difficile in the host. INTRODUCTIONClostridium difficile causes a potentially fatal intestinal disease that is increasing in incidence and severity (Dubberke et al., 2010). Infection is often chronic and difficult to eradicate (O'Brien et al., 2007). C. difficile is transmitted as dormant endospores that are highly resistant to killing by heat, antibiotics, oxidizing agents, UV radiation and many other treatments that are usually effective for killing bacteria (Vonberg et al., 2008;Setlow, 1995). C. difficile spores germinate in the intestine to produce vegetatively growing cells capable of producing toxins A and B, which have been implicated in disease progression and severity (Bartlett et al., 1977;McDonald et al., 2005).Upon germination, actively growing C. difficile must contend with the onslaught of host defences present in the intestinal environment. The host produces a number of innate immune factors, such as cationic antimicrobial peptides (CAMPs) and bacteriolytic enzymes that protect the intestine from invading bacterial pathogens (Müller et al., 2005;Gudmundsson & Agerberth, 1999). Some of these CAMPs are products of host cells and others are produced by the intestinal microflora. These host effectors are attracted to the overall negative charge of bacterial cells and, as a consequence, bacterial resistance to these effectors can be achieved by charge modification of cell wall and membrane components (Nizet, 2006;Peschel, 2002). In many Gram-positive bacteria, this charge modification occurs by D-alanyl esterification of teichoic acid in the cell wall, which results in an increased positive charge on the cell (Neuhaus & Baddiley, 2003). The addition of D-alanine esters to teichoic acids is typically mediated by the products of the dlt operon, which encodes four proteins: DltA, a D-alanine : D-alanyl carrier protein ligase; DltB, a D-alanyl transfer protein; DltC, the D-alanyl carrier protein; and DltD, a D-alanine esterase. All four proteins are required for successful addition of D-alanine to the cell wall (Ne...

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Infection control measures to limit the spread of Clostridium difficile

Cited by 266 publications

References 170 publications

Clostridium difficile outbreak in Costa Rica: control actions and associated factors

Clostridium difficile outbreak in Costa Rica: control actions and associated factors

Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections

The dlt operon confers resistance to cationic antimicrobial peptides in Clostridium difficile

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