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Antibiotic resistance of Clostridium difficile isolates
Abstract
The activity of metronidazole, vancomycin, clindamycin and teicoplanin against Clostridium difficile strains isolated from various origins in Poland was investigated. MIC was determined for metronidazole, clindamycin and teicoplanin. The disc-diffusion method was used for the vancomycin susceptibility test. Three out of thirty-eight strains were resistant to vancomycin and twenty-eight were susceptible to teicoplanin. A widespread MIC was observed for clindamycin and metronidazole. No correlation between the origin of the strain, toxigenicity and susceptibility to teicoplanin, clindamycin, vancomycin and metronidazole was evident.
... The vancomycin structure contains a glycosylated hexapeptide chain and aromatic rings cross-linked by aryl ether bonds and exhibits poor absorption in the gastrointestinal tract [68]. To date, only in Poland have researchers reported three strains of C. difficile that are resistant to vancomycin, using the disc diffusion method [69]. Two additional methods have been used to detect vancomycin susceptibility: the agar dilution method and the Etest method. ...
... D71V, T82V, D81N, A83V, A118V, and A118T are the most common mutation sites in GyrB. In addition to these, D426N, D426V, R447K, R447L, S416A, E466K, A503S, S366A, and D501E are also the susceptible sites for mutations in GyrB [69,93,94]. ...
Clostridium difficile (C. difficile) is the most prevalent causative pathogen of healthcare-associated diarrhea. Notably, over the past 10 years, the number of Clostridium difficile outbreaks has increased with the rate of morbidity and mortality. The occurrence and spread of C. difficile strains that are resistant to multiple antimicrobial drugs complicate prevention as well as potential treatment options. Most C. difficile isolates are still susceptible to metronidazole and vancomycin. Incidences of C. difficile resistance to other antimicrobial drugs have also been reported. Most of the antibiotics correlated with C. difficile infection (CDI), such as ampicillin, amoxicillin, cephalosporins, clindamycin, and fluoroquinolones, continue to be associated with the highest risk for CDI. Still, the detailed mechanism of resistance to metronidazole or vancomycin is not clear. Alternation in the target sites of the antibiotics is the main mechanism of erythromycin, fluoroquinolone, and rifamycin resistance in C. difficile. In this review, different antimicrobial agents are discussed and C. difficile resistance patterns and their mechanism of survival are summarized.
... Vancomycin and metronidazole are still the two primary antibiotics used in the treatment of C. difficile infection (Noren, 2010). Although susceptible C. difficile to vancomycin and metronidazole have been reported from many countries (Huang et al., 2009) but resistant and reduced sensitivity strains of this bacterium to these clinically important antibiotics have also been isolated (Pelaez et al., 2008Pelaez et al., , 2005 Dworczynski et al., 1991). The aim of the present study was to determine recovery rate of C. difficile from different sources by three methods and to find out susceptibility patterns of C. difficile isolated from different sources. ...
... The new antibiotics against C. difficile with reduced susceptibility to vancomycin were also tested (Pelaez et al., 2005). In 1991, the first isolate of C. difficile not susceptible to vancomycin appeared in Poland but the study was performed by a disk diffusion method (Dworczynski et al., 1991). The first isolates of C. difficile not susceptible to vancomycin appeared in Spain in 1996, although none showed full resistance to these agents (Pelaez et al., 2002). ...
The aim of this study was to determine antibiotic susceptibility of Clostridium difficile isolated from
different sources. Two hundred stool samples of staff, patients (at admission to the wards and the same
patients after seven days of hospitalization), and 135 samples of hospital environment were collected.
Three standard methods including direct plating onto cycloserine-cefoxitin fructose agar, alcohol shock
and enrichment culture with 0.1% sodium taurocholate were used to isolate C. difficile. All C. difficile
isolates identified by biochemical tests and were tested by disk diffusion agar using 15 antibiotic disks.
MIC of isolates was determined for vancomycin and metronidazol by Etest. Seventy C. difficile were
isolated from different sources. No resistant isolates to vancomicin and metronidazol were detected by
disk diffusion or Etest. The rate of recovery by 0.1% sodium taurocholate enrichment method and
alcohol shock was significantly higher than those by CCFA (pv 0.02, pv 0.04).
... The assay method is timeconsuming, and the use of susceptibility breakpoints is based on the therapeutic levels of drugs in serum and not on the levels in the intraluminal area, where higher drug concentrations can be achieved (1,19). At present, metronidazole resistance in C. difficile is considered anecdotal and vancomycin resistance has been, to the best of our knowledge, reported only once (16), although on that occasion the method used was not the present standard. ...
... To our knowledge, isolates of C. difficile that were not susceptible to vancomycin were reported only three times, from Poland in 1991 (16), although the study was performed by a disk diffusion method. Our data also showed that 13 strains (3.1%) had decreased susceptibility to vancomycin. ...
Clostridium difficile is the most frequently identified enteric pathogen in patients with nosocomially acquired, antibiotic-associated diarrhea.
The drugs most commonly used to treat diseases associated with C. difficile are metronidazole and vancomycin. Most clinical laboratories assume that all C. difficile isolates are susceptible to metronidazole and vancomycin. We report on the antimicrobial susceptibilities of 415 C. difficile isolates to metronidazole and vancomycin over an 8-year period (1993 to 2000). The overall rate of resistance to metronidazole
at the critical breakpoint (16 μg/ml) was 6.3%. Although full resistance to vancomycin was not observed, the overall rate
of intermediate resistance was 3.1%. One isolate had a combination of resistance to metronidazole and intermediate resistance
to vancomycin. Rates of resistance to metronidazole and vancomycin were higher among isolates from human immunodeficiency
virus-infected patients. Molecular typing methods proved the absence of clonality among the isolates with decreased susceptibilities
to the antimicrobials tested.
... Studies from different countries have demonstrated an increase in C. difficile resistance to vancomycin. In Poland, approximately 8% of patients with CDI were found to have strains resistant to vancomycin (three out of 38 isolates) [58]. In Spain, approximately 6% of CDI sample isolates showed intermediate resistance to vancomycin [56]. ...
Clostridium is a genus comprising Gram-positive, rod-shaped, spore-forming, anaerobic bacteria that cause a variety of diseases. However, there is a shortage of information regarding antibiotic resistance in the genus in Saudi Arabia. This comprehensive analysis of research results published up until December 2021 intends to highlight the incidence of antibiotic resistance in Clostridium species in Saudi Arabia. PubMed, Google Scholar, Web of Science, SDL, and ScienceDirect databases were searched using specific keywords, and ten publications on antibiotic resistance in Clostridium species in Saudi Arabia were identified. We found that the rates of resistance of Clostridium difficile to antibiotics were as follows: 42% for ciprofloxacin, 83% for gentamicin, 28% for clindamycin, 25% for penicillin, 100% for levofloxacin, 24% for tetracycline, 77% for nalidixic acid, 50% for erythromycin, 72% for ampicillin, and 28% for moxifloxacin; whereas those of C. perfringens were: 21% for metronidazole, 83% for ceftiofur, 39% for clindamycin, 59% for penicillin, 62% for erythromycin, 47% for oxytetracycline, and 47% for lincomycin. The current findings suggest that ceftiofur, erythromycin, lincomycin, and oxytetracycline should not be used in C. perfringens infection treatments in humans or animals in Saudi Arabia.
... Yapılan çalışmalarda metronidazol direnci %2-6.3 olarak bildirilmiştir 13,14 . Vankomisine dirençli ilk C.difficile suşu 1991'de Polonya'da bildirilmiş 15 , ardından vankomisine dirençli suşların sıklığında artış (2000'de %2.7-3.1, 2005'te %21.6) gözlenmiştir 14,16,17 . Çalışmamızda değerlendirilen suşların tümü CDE tedavisinde ilk seçenek olan metronidazol ve vankomisine duyarlı olarak saptanmıştır. ...
Clostridium difficile infection is one of the most important hospital-acquired infections. Infections caused by hypervirulent C.difficile strains which produce toxins at high levels, have higher morbidity and mortality rates, more complications and relapses. They are characterized by higher sporulation ratios and resistance rates for fluoroquinolones. In order to prevent serious morbidities, mortalities and remarkable increase in health costs, highly pathogenic C.difficile strains must be identified before causing severe outbreaks. The aim of this study was to determine the antimicrobial susceptibilities and molecular characteristics of 61 C.difficile strains isolated by culture from toxin-positive fecal samples of patients who were admitted to three different laboratories in Ankara, between September 2012 and November 2014. Antimicrobial susceptibilities were determined by using gradient test strips and results were interpreted according to the current CLSI and EUCAST criteria. The presence of toxin genes was investigated by polymerase chain reaction (PCR), and mutations in the tcdC gene were determined by sequence analysis following PCR amplification. Genetic characterization of one hypervirulent strain was performed by Public Health Institution of Turkey using the CenoType CDiff (Hain Lifescience, Germany) test. All strains were susceptible to vancomycin and metronidazole. Three (4.9%) isolates were resistant to moxifloxacin with a minimum inhibitory concentration (MIC) of > 8 μg/ml. The MIC50 and MIC90 values for erythromycin and clindamycin were 1.5-3 μg/ml, and 2-4 μg/ml, respectively. All strains carried the tcdA and tcdB genes, and 1 (1.6%) was positive for the binary-toxin (cdtA and cdtB) genes. The binary-toxin positive strain carried a 54 bp deletion as well as a single nucleotide change in the tcdC gene. Various single nucleotide changes were found in the tcdC gene of 12 strains (19.6%). Our results have shown that, hypervirulent strains exist in our country, but we have no evidence for the presence of ribotype 027 yet. On the other hand, when the increasing incidence of these strains through out the world is taken into consideration, it would be of great importance to perform surveillance studies and characterize the isolated strains.
... Vancomycin resistance has rarely been reported. In 1991, a Polish report using disc diffusion found vancomycin resistance in three out of 38 strains (45). Although resistance is rare, decreased susceptibility to vancomycin has been reported several times. ...
... Wenisch and colleagues [62] showed in a randomized clinical trial that teicoplanin was as effective as metronidazole and vancomycin in achieving clinical cure of CDI, was equivalent in the rapidity of response and was more effective than metronidazole in achieving fecal cytotoxicity resolution. Teicoplanin has a high cost and is associated with an increased resistance rate [99]. ...
CDI is increasing in incidence and severity. Clinicians must have a low threshold to consider the diagnosis and to treat patients with the clinical syndrome and risk factors before laboratory confirmation of the diagnosis. In patients who have signs of advanced disease, escalation of care with antimicrobial strategies and multidisciplinary care including surgical consultation is necessary. Furthermore, lowering the threshold for surgery compared with traditional approaches likely results in improved survival. Novel surgical approaches may obviate total abdominal colectomy and the associated immediate and long-term morbidity in this often fragile patient population, thus allowing clinicians to embrace surgical therapy earlier in the course of severe, complicated disease.
... 27,28 Only one C. difficile strain resistant to vancomycin has been described, and decreased susceptibility to this antibiotic has been reported in some studies. 26,29 The mechanisms of reduced susceptibility to metronidazole and vancomycin in this bacterium are still unknown. ...
Multidrug resistance and antibiotic resistance mechanisms were investigated in 316 Clostridium difficile clinical isolates collected during the first European surveillance on C. difficile in 2005.
MICs of eight different antibiotics were determined using Etest. Reserpine- and carbonyl cyanide m-chlorophenylhydrazone-sensitive efflux was tested using the agar dilution method. Molecular analysis of the resistance mechanisms was performed using PCR assays, PCR mapping and sequencing.
One hundred and forty-eight C. difficile strains were resistant to at least one antibiotic and 82 (55%) were multidrug resistant. In particular, 48% of these isolates were resistant to erythromycin, clindamycin, moxifloxacin and rifampicin. New genetic elements or determinants conferring resistance to erythromycin/clindamycin or tetracycline were identified. Even if most multiresistant strains carried an erm(B) gene, quite a few were erm(B) negative. In-depth analysis of the underlying mechanism in these isolates was carried out, including analysis of 23S rDNA and the ribosomal proteins L4 and L22. Interestingly, resistance to rifampicin was observed in multidrug-resistant strains in association with resistance to fluoroquinolones. Mutations in the rpo(B) and gyrA genes were identified as the cause of resistance to these antibiotics, respectively.
Characterization of multidrug-resistant C. difficile clinical isolates shows that antibiotic resistance is changing, involving new determinants and mechanisms and providing this pathogen with potential advantages over the co-resident gut flora. The present paper provides, for the first time, a comprehensive picture of the different characteristics of multidrug-resistant C. difficile strains in Europe in 2005 and represents an important source of data for future comparative European studies.
... However, C. difficile has been found to possess multiple-antibiotic resistance genes (36). Since C. difficile clinical isolates resistant to both vancomycin and metronidazole have been reported (13,15), a major concern is that these drugs may be less effective in the future. ...
Clostridium difficile causes antibiotic-associated diarrhea and colitis in humans through the actions of toxin A and toxin B on the colonic mucosa. At present, broad-spectrum antibiotic drugs are used to treat this disease, and patients suffer from high relapse rates after termination of treatment. This study examined the role of both toxins in pathogenesis and the ability of orally administered avian antibodies against recombinant epitopes of toxin A and toxin B to treat C. difficile-associated disease (CDAD). DNA fragments representing the entire gene of each toxin were cloned, expressed, and affinity purified. Hens were immunized with these purified recombinant-protein fragments of toxin A and toxin B. Toxin-neutralizing antibodies fractionated from egg yolks were evaluated by a toxin neutralization assay in Syrian hamsters. The carboxy-terminal region of each toxin was most effective in generating toxin-neutralizing antibodies. With a hamster infection model, antibodies to both toxins A and B (CDAD antitoxin) were required to prevent morbidity and mortality from infection. In contrast to vancomycin, CDAD antitoxin prevented relapse and subsequent C. difficile reinfection in the hamsters. These results indicate that CDAD antitoxin may be effective in the treatment and management of CDAD in humans.
... Vancomycin and metronidazole are the therapeutic drugs of choice for C. difficile diarrhea. However, resistance to vancomycin has been described [9], and the choice of antibiotic drugs may have to be modified in the future. ...
Antimicrobial resistance is becoming increasingly important in the treatment of enteric infections, particularly those due
to Shigella, Vibrio cholerae, enterotoxigenic Escherichia coli (associated with traveler's diarrhea), and Salmonella typhi. The rate of antimicrobial resistance is highest in the developing world, where the use of antimicrobial drugs is relatively
unrestricted. Of greatest immediate concern is the need for an effective, inexpensive antimicrobial that can be used safely
as treatment for small children with dysentery due to Shigella, primarily Shigella dysenteriae type 1.
... 39 Los fármacos utilizados en el tratamiento son vancomicina y metronidazol; sin embargo, ya se ha notificado resistencia al primero, por lo que se deben buscar nuevas alternativas terapéuticas. 40 Campylobacter jejuni A pesar de que Campylobacter es susceptible a la acción bactericida del ácido gástrico, la ingestión de la bacteria en vehículos que mantienen un rápido tránsito por el estómago -como el agua y la leche-y que, por tanto, evaden la barrera natural de la acidez gástrica, permite el paso de la bacteria al intestino. El periodo de incubación varía de 1 a 7 días, y los pacientes excretan de 10 6 a 10 9 Campylobacter por gramo de materia fecal; si no son tratados, la excreción puede llevarse de 2 a 3 semanas. ...
... There are, however, a few reports of reductions in susceptibilities to MTZ and VAN (4,7,25). Our group has already registered a 6% rate of resistance to MTZ, and 3% of our C. difficile isolates have shown reduced susceptibility to VAN (19). ...
We evaluated the in vitro activity of ramoplanin, an antimicrobial compound that inhibits cell wall synthesis by acting at
the level of lipid intermediate formation, against Clostridium difficile. We included strains with reduced susceptibilities to vancomycin (vancomycin-intermediate [Vani] strains) or with resistance to metronidazole (Mtzr), in order to assess the potential utility of ramoplanin for the treatment of C. difficile-associated diarrhea. We tested the activity of ramoplanin against a total of 105 nonduplicate clinical isolates of toxigenic
C. difficile, including 8 Vani isolates and 6 Mtzr isolates, obtained from our laboratory. Ramoplanin was active against all strains tested at concentrations ranging from 0.03
to 0.5 μg/ml (MICs at which 50 and 90% of isolates were inhibited, 0.25 μg/ml; geometric mean MIC, 0.22 μg/ml). All isolates,
independently of their levels of susceptibility to vancomycin or metronidazole, were considered susceptible to ramoplanin
(MICs, ≤0.5 μg/ml).
Clostridium difficile, commonly found in nature, is a nosocomial opportunistic pathogen which causes formation of various clinical disorders including antibiotic associated diarrhea, fulminant colitis and pseudomembranous colitis. C. difficile is thought to be responsible for almost all of the pseudomembranous colitis and 15-25% of the antibiotics related diarrhea. Also it is known that hypervirulent strains generally have high recurrence rate and cause severe infections or even death. Although there is not enough data that C.difficile infects people by transmition via food, there is a significant increase in infections caused by C. difficile in recent studies. In addition to this knowledge bacteria have been isolated from various samples which animal foods, raw or ready to eat foods, vegetables, salads, the waters of sea, lake and river, seafood, soil and environmental samples. All of these bring to mind a question that C. difficile is whether or not a food-borne pathogen. Toxigenic characteristics of some strains of C. difficile detected in foods, resistance to antibiotics in various ratios and their spreading easily properties due to endospores resistant to difficult conditions have further increased the importance of this bacterium. In this review, the information about general characteristics, pathogenesis, infection sources, risk factors, presence in food, isolation from food and idendification of C. difficile have been given.
The discovery of antibiotics and other antimicrobials, and their widespread application in human medicine since the middle of the twentieth century has saved millions of human lives. Additionally, their application in veterinary medicine and especially in food science has constituted an important way of controlling the dispersion of microbial pathogens. This has played a major role not only in the dramatic increase in average life expectancy in humans, but also in extending the “shelf life” of foods; however, antibiotic overuse and misuse, together with the microbial ability to share DNA by horizontal gene transfer, have resulted in the generation of antibiotic-resistant bacterial strains that quickly spread throughout the world. As a result, the antibiotic of choice can be rendered totally ineffective both in human therapy and as a food additive. The focus of this chapter is a handful of gram-negative and gram-positive bacteria that are developing antibiotic resistance and represent a major hazard in food preservation.
Clostridium difficile is a common causative organism of antimicrobial-associated diarrhea and is often responsible for nosocomial infection. C. difficile infection has traditionally been treated with metronidazole (MNZ) or vancomycin (VCM); however, MNZ-resistant strains have reported in some countries. In this study the broth microdilution method was used to determine the minimum inhibitory concentrations (MICs) of 15 drugs against 157 clinical isolates of C. difficile in Japan. All C. difficile isolates tested were susceptible to MNZ; MIC(50) was 0.25 μg/ml, MIC(90) was 0.5 μg/ml, and MIC range was 0.06-1 μg/ml. C. difficile isolates were also susceptible to VCM; MIC(50) was 0.5 μg/ml, MIC(90) was 1 μg/ml, and MIC range was 0.12-2 μg/ml. Susceptibility to teicoplanin was also similar: MIC(50) was 0.12 μg/ml, MIC(90) was 0.12 μg/ml, and MIC range was 0.03-0.25 μg/ml. The susceptibility of C. difficile isolates must be monitored continuously because a strain with reduced susceptibility to MNZ or VCM might emerge in the future.
Clostridium difficile infection (CDI) is the primary cause of antibiotic-associated diarrhea and is a significant nosocomial disease. In the past ten years, variant toxin-producing strains of C. difficile have emerged, that have been associated with severe disease as well as outbreaks worldwide. This review summarizes current information on C. difficile pathogenesis and disease, and highlights interventions used to combat single and recurrent episodes of CDI.
This was an in vitro study to analyse the susceptibility of Clostridium difficile isolates to rifampin and rifaximin.
Stool samples from patients who had nosocomial diarrhoea and C difficile toxin B at a university hospital between August 2006 and December 2007 were cultured for C difficile. Susceptibility of C difficile isolates to rifaximin and rifampin was determined by agar dilution and E strips, respectively. C difficile isolates were analysed via PCR for genes encoding toxins A and B, for binary toxin (BT), and for partial deletions of the tcdC gene (tcdC-del).
Rifaximin exhibited high-level activity against 359 C difficile isolates, with MIC(50) <0.01 microg/ml and MIC(90) 0.25 microg/ml; rifampin had MIC(50) <0.002 microg/ml and MIC(90) 4 microg/ml. Among isolates analysed, 55 (15%) were positive for BT and tcdC-del. 28 (8% of 359) isolates were resistant to rifampin (> or = 32 microg/ml), of which 6 (2% of 359) were resistant to rifaximin and rifampin with MIC values > or = 32 microg/ml. 2 of the 28 isolates resistant to rifampin were A(+)/B(+)/BT(+)/tcdC-del(+), 5 were A(+)/B(+)/BT(-)/tcdC-del(+), 4 were A(+)/B(+)/BT(+)/tcdC-del(-), 13 were A(+)/B(+)/BT(-)/tcdC-del(-), and 4 had no detectable toxin genes. Of the 11 isolates resistant to rifaximin alone, 1 was A(+)/B(+)/BT(-)/tcdC-del(+), 2 were A(+)/B(+)/BT(+)/tcdC-del(-), 6 were A(+)/B(+)/BT(-)/tcdC-del(-), and 2 had no detectable toxin genes.
The study demonstrates that rifaximin has high-level activity against C difficile in vitro. Determination of resistance to rifampin by E strip did not predict rifaximin resistance.
Clostridium difficile is the leading cause of hospital-acquired diarrhoea and the number of outbreaks has risen markedly since 2003. The emergence and spread of resistance in C. difficile is complicating treatment and prevention. Most isolates are still susceptible to vancomycin and metronidazole (MTZ), however transient and heteroresistance to MTZ have been reported. The prevalence of resistance to other antimicrobial agents is highly variable in different populations and in different countries, ranging from 0% to 100%. Isolates of common polymerase chain reaction (PCR) ribotypes are more resistant than uncommon ribotypes. Most of the resistance mechanisms that have been identified in C. difficile are similar to those in other Gram-positive bacteria, including mutation, selection and acquisition of the genetic information that encodes resistance. Better antibiotic stewardship and infection control are needed to prevent further spread of resistance in C. difficile.
en los paises en vias de desarrollo. Debido a la frecuen-cia con que se presentan estas enfermedades, la pres-cripcion y la automedicacion de antibioticos para lasmismas se ve favorecida. Se ha considerado que el usoinapropiado o excesivo de antibioticos genera la apa-ricion de cepas resistentes, fenomeno que se ha hechomuy evidente en el ambito hospitalario,
Clostridium difficile infection is an increasing burden to the health care system, totaling more than $1 billion/year in the United States. Treatment of patients with C difficile infection with metronidazole or vancomycin reduces morbidity and mortality, although the number of patients that do not respond to metronidazole is increasing. Despite initial response rates of greater than 90%, 15%-30% of patients have a relapse in symptoms after successful initial therapy, usually in the first few weeks after treatment is discontinued. Failure to develop specific antibody response has recently been identified as a critical factor in recurrence. The review discusses the different management strategies for initial and recurrent symptomatic C difficile infections.
A prospective study on the susceptibility of Clostridium difficile to metronidazole and vancomycin using the Etest and disk diffusion test was performed over a 6-month period. One hundred strains were tested; one strain was highly resistant to metronidazole (MIC = 64 micrograms/mL). The zone size of inhibition by the disk diffusion test correlated with the MIC as determined by the Etest (regression coefficient = -0.043 for metronidazole and -0.044 for vancomycin, p < 0.001 for both antibiotics). However, the correlation coefficient was low for both metronidazole (r = 0.574) and vancomycin (r = 0.473); hence the zone of inhibition by disk diffusion test could not predict the MIC satisfactorily. Metronidazole is still the first-line antibiotic for the treatment of C. difficile-associated diarrhea because the incidence of metronidazole resistant strains remains very low. However, the efficacy of metronidazole in the treatment of infections attributable to isolates with high-level metronidazole resistance may be compromised because the fecal concentration of metronidazole is relatively low when compared with the MIC values of the less susceptible strains. Oral vancomycin is the drug of choice under such circumstances, as its fecal concentration is much higher than that of metronidazole.
We examined the in vitro activity of linezolid against Clostridium difficile, including isolates with reduced susceptibility to metronidazole or vancomycin. The MIC at which 50% of the isolates were
inhibited (MIC50) and MIC90 were 0.5 and 2 μg/ml, respectively (range, 0.03 to 4 μg/ml). MICs were always ≤ 4 μg/ml, and thus, all isolates were considered
susceptible.
To review the literature related to the treatment and infection control of Clostridium difficile-associated diarrhea (CDAD).
A MEDLINE search (1966-August 2001) of the English literature was conducted.
C. difficile is a leading cause of antibiotic-related diarrhea. The clinical spectrum extends from simple diarrhea to fulminant colitis. Cessation of antibiotic therapy alone is sufficient for mild cases; however, the majority of cases require oral metronidazole as the drug of choice. Vancomycin orally is reserved for patients who have failed to respond to metronidazole, are pregnant, or are severely ill. There is an important role for infection control interventions.
CDAD is a common infection. Appropriate antibiotic treatment and infection control policies can prevent the spread and reduce the morbidity associated with this disease.
The drugs of choice used to treat C. diffcile associated diarrhoea (CDAD) are metronidazole and vancomycin. C. difficile strains isolated in most laboratories are susceptible to metronidazole and vancomycin. Communication about emergence of antimicrobial resistance among C. difficile strains in some countries to metronidazole and intermediate resistance to vancomycin are alarming. This study was performed to determine the susceptibility to metronidazole and vancomycin of 140 C. difficile strains isolated from patients with CDAD hospitalised in academic hospital between 1999-2002. Resistance to metronidazole and vancomycin was not observed.
The drug of choice used to treat Clostridium difficile-associated diarroea (CDAD) are metronidazole and vancomycin. Information about emergence of antimicrobial resistance among C. difficile strains to metronidazole and intermediate resistance to vancomycin in some countries are alarming. This study was performed to determine the susceptibility to metronidazole and vancomycin of 193 C. difficile strains isolated in our diagnostic laboratory between year 1998 and 2003 from patients adults and children suffering from CDAD. Among these strains, 142 produced toxin A and B (TcdA(+)TcdB(+)), 43 only B (TcdA(-)TcdB(+)) and 8 were nontoxigenic. We have not observed any differences in susceptibility to metronidazole and vancomycin between all C. difficile strains under investigation (toxinogenic and non-toxinogenic). Resistance to metronidazole and vancomycin was not observed.
Current and future treatment modalities for Clostridium difficile-associated disease (CDAD) are reviewed.
C. difficile, an anaerobic, spore-forming, gram-positive [corrected] rod, is the enteric pathogen most frequently identified in patients with antibiotic-associated, nosocomially acquired diarrhea. Infection can lead to severe gastrointestinal illness which can develop into pseudomembranous colitis. Recent outbreaks in North America involved more virulent C. difficile strains, more severe infections, and more complicated treatment courses. Because of the potential for increased toxin-associated damage due to increased toxin exposure time, CDAD treatment often involves cessation of the inciting antibiotic, C. difficile-targeted antibiotic therapy, electrolyte normalization, fluid replacement, and antimotility agent avoidance. First-line therapy for CDAD is treatment with the antibiotic metronidazole. Vancomycin is often used in more severe cases and for treatment-resistant organisms. Treatment regimens may also include probiotics, bile-acid sequestrants, and, in limited cases, intravenous immunoglobulin (IVIG). Alternative treatments for refractory and persistent CDAD include intracolonic vancomycin, nitazoxanide, rifaximin, IVIG, and probiotics. Several target proteins have been proposed for C. difficile vaccine production, including the flagellar cap protein FliD, flagellin FLiC, a cell wall protein (Cwp) (comprising amino- and carboxyl-terminal domains), a protease Cwp 84, and toxins A and B. Rarely, pseudomembranous colitis, a severe complication of CDAD, must be treated through surgical intervention.
CDAD is a major concern for health care systems and clinicians. New diagnostic tests with increased sensitivity for detecting CDAD with a short turnaround time are necessary for early treatment and prevention. Continued research for more effective treatments and vaccine development for CDAD is also needed.
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