Professional Documents
Culture Documents
Director of Microbiology
VA Boston Health Care System
West Roxbury, Massachusetts
Overview
Case reports
Historical
perspective
Organism & key
properties
Changing
epidemiology
Disease
Diagnosis
Treatment
Infection control
Case Study 1
60 yo male admitted to hospital for community
acquired pneumonia, treated with levofloxacin and
discharged
7 days later, seen at another hospital because of
12-15 pound weight gain over last few days (my
abdomen has never been so big) and
hypertension (213/106)
Afebrile, WBC of 8.5, albumin 3.1, creatinine 0.9, no
diarrhea noted
Admitted, treated for hypertension and ciprofloxacin
given to complete treatment for CAP; discharged 3 days
later
Day 2
Day 4
Day 5
Historical Perspective
In the 1960s it was noted that patients on
antibiotics developed diarrhea1
staphylococcal colitis
Originally thought to be caused by S. aureus and treated with
oral bacitracin
Stool cultures routinely ordered for S. aureus
Antibiotic Associated
Pseudomembranous Colitis Due to
Toxin-Producing Bacteria
Bartlett and co-workers1 demonstrated
cytotoxicity in tissue culture and enterocolitis in
hamsters from stool isolates from patients with
pseudomembranous colitis
Isolate was C. difficile
Quiz Time
Q. Why did it take so long to associate the
organism C. difficile with the disease?
A. Organism was (is) found in healthy
infants
Q. Why do antibiotics sometimes cause
diarrhea (unrelated to C. difficile)?
A. Disrupt the intestinal flora which plays a
major role in digestion of food
Clostridium difficile
Gram-positive, anaerobic, spore-forming
bacillus
Vegetative cells die quickly in an aerobic
environment
Spores are a survival form and live for a
very long time in the environment
Grows on selective media in 2 days and
smells like horse manure (p-cresol)
Importance of Spores
Resistant to heat, drying, pressure, and
many disinfectants
Resistant to all antibiotics because
antibiotics only kill or inhibit actively
growing bacteria
Spores survive well in hospital
environment
Spores are not a reproductive form, they
represent a survival strategy
Source of Infections
Spores in hospital, nursing home, or long-term
care environment associated with ill patients
Large numbers of spores on beds, bed-rails, chairs,
curtains, medical instruments, ceiling, etc.
Case Study 2
31 yo pregnant female (14 weeks, twins) seen at
a local ER with history of
MMWR 54:(47);1201-1205.
Role of Antibiotics
All antibiotics (including metronidazole and
vancomycin) are associated with CDI
High-risk group
Clindamycin
Cephalosporins/penicillins/beta-lactams
Fluoroquinolones
Pathogenesis
Historical Perspective
Most CDI were mild
Diarrhea was main symptom
Pseudomembranous colitis and toxic
megacolon were rare
Discontinuing antibiotics worked in many
cases
High response rate to metronidazole and
vancomycin
Incidence of CDI
United States
CDI is not a reportable disease so exact
number of cases and deaths remain unknown
Based on discharge diagnoses, CDI cases
have tripled over last 5 years
United Kingdom
Deaths in UK ~ 9,000/year
Pathogenesis
Toxigenic strains produce 2 large protein
exotoxins that are associated with virulence
Toxins A and B
Mutants strains that do not make toxins A and B are
not virulent
Some strains make a third toxin known as Binary
Toxin
By itself, not pathogenic
May act synergistically with toxins A and B in severe colitis
More common in animal strains
Pathogenesis of CDI
Antimicrobial
Asymptomatic
C. difficile
colonization
C. difficile exposure
Hospitalization
C. difficile
infection
From Johnson S, Gerding DN. Clin Infect Dis. 1998;26:1027-1036; with permission.
Pathogenesis
Changing Epidemiology
Increasing morbidity and mortality noted
beginning in 2000
Outbreaks in US & Canada (>200 deaths)
Was this due to poor infection control,
emergence of antibiotic resistance, or
something else?
A new, hypervirulent strain was detected
Epidemic Strain
1.
2.
3.
4.
Not So Fast
2 recent papers questioned whether this
strain is more virulent
NAP-1 strain was detected around 25% of
time in their hospital (BID in Boston) but was
not associated with increased severity of
disease (non-epidemic setting)1
18 and 39 bp deletion containing strains were
not associated with increased severity of CDI
at the Mayo Clinic2
Age >65 and prior NH stay implicated
1. Cloud, J. et al. 2009. Cl Gastro and Hept. 7:868-873
2. Verdoorn, B. P. et al. Diag Micro and ID. 10.1016/j.diagmicrobio.2009.0815
Symptoms of CDI
Asymptomatic colonization
Diarrhea
mild moderate severe
Laboratory Diagnosis of
C. difficile Infection (CDI)
Cost
Ease of use
The Specimen
Fresh is best (test within 2 hours)
Liquid or loose, not solid
If unable to test within 2 hours, refrigerate
at 4C for up to 3 days
Freeze at -70C (not -20C) if testing will
be delayed
Specimen quality will influence test results
In: Manual Clin Micro. 9th ed. 2007;p. 897.
Toxigenic Culture
(Culture and CCNA)
Laboratory
Diagnosis
Cell Culture
Neutralization
Assay (CCNA)
Stool Culture
1.
2.
3.
4.
5.
6.
Parameter
Range
Sensitivity
32 98.7%
Specificity
92 100%
PPV
76.4 96%
NPV
88 100%
EIA Testing
Advantages
Rapid
Inexpensive
Relatively easy
No costly equipment
Batch or single test
formats
Disadvantages
Great variations in
published sensitivity
and specificity
Technologist error
Contamination
Two-Step Tests
Screening Tests
Glutamate dehydrogenase
(GDH)
Detects nearly all true
positives as well as false
positives
Low PPV
High sensitivity
Very few false negatives
1-3
Confirmatory Tests
CCNA
Add 1-2 days
CX followed by CCNA
Add 3-4 days
PCR
Possibility of false positives
due to colonization
Molecular-Based Assays
Polymerase Chain Reaction (PCR)
3 FDA Approved test kits
2 of them are less expensive but more labor
intensive
1 is easy enough to do that even I can do it, but is
expensive
Treatment
Treatment of
Mild to Moderate Disease
Stop antibiotic(s) if medically reasonable
Metronidazole
Oral or IV, 500 mg TID for 10-14 days is
standard therapy
520% failure rate
20% relapse rate
Can use a full 2nd course for failure/relapse
but beyond 2 courses, switch to vancomycin
Failures not due to metronidazole resistance
May be administered PO or IV
Development of resistance rare
Historical first-line agent
Vancomycin
125 mg QID
IV=intravenously; PO=orally.
Fekety R. Am J Gastroenterol. 1997;92:739-750.
Gerding DN, et al. Infect Control Hosp Epidemiol. 1995;16:459-477.
American Society of Health-System Pharmacists. Am J Health-Syst Pharm. 1998;55:1407-1411.
Metronidazole vs Vancomycin
Zar et al1 classified patients as mild or
severe CDI
In mild disease, vancomycin was slightly
better than metronidazole (98% vs 90%)
Not statistically significant
Mild CDI
35 BM/day
WBC 15,000/mm3
Mild abdominal pain due to CDI
Moderate CDI
69 BM/day
WBC 15,001 to 20,000/mm3
Moderate abdominal pain due to CDI
Severe CDI
10 BM/day
WBC 20,001/mm3;
Severe abdominal pain due to CDI
Any one of the 3 defining characteristics assigns a patient to the more severe category.
Louie T, et al. The 47th Annual ICAAC Meeting, Sept. 17-20, 2007; Chicago, IL. Abstract k-425-a.
Metronidazole vs Vancomycin
vs Tolevamer
Patients stratified as mild, moderate, or severe
Original goal of study was to evaluate tolevamer
as a treatment for CDI
Drug
Mild
Moderate
Severe
Tolevamer
59
46
37
Metronidazole
79
76
65
Vancomycin
85
80
85
Management of Severe,
Complicated CDI
Potential role of intravenous immunoglobulin G (IVIG)1-6
Antitoxin A IgG predicts clinical outcome of CDI
Serum antibodies to toxins A and B are prevalent in
healthy populations
Recent studies in severe disease5,6
Well tolerated in small numbers of patients
Conflicting data regarding outcome improvement
(mortality and need for colectomy)
Often administered when surgery is considered imminent
1. Salcedo J, et al. Gut 1997;41:366-370.
2. Beales ILP. Gut. 2002;51:456.
3. Kyne L, et al. N Engl J Med. 2000;342:390-397.
Other Treatments
IVIG*
Probiotics
Rifaximin
Chasers
Nitazoximide
Rifampin
* Patients who produce antibody to toxins A and B usually do well so IVIG has been
tried.
Rifampin
Nitazoxanide
Rifaximin chaser
Recurrent CDI
S. boulardii
P=0.04
*Metronidazole or vancomycin for 1014 days plus placebo or S. boulardii 1 g daily 4 weeks.
1. McFarland. JAMA. 1994;271:1913-1918.
2. Surawicz et al. Clin Infect Dis. 2000;31:1012-1017.
Infection Control
Wash hands with warm soap and water
Mechanical removal of spores
Alcohol does not kill spores
Stool is pre-treated with alcohol when growing
C. difficile
WWS = warm
water and soap
CWS = cold
water and soap
2.5
WWA = warm
water and
antibacterial
1.5
1
1.8
1.8
0.5
0
AHW = alcohol
hand wipe
1.4
** ** *
*0.6
-0.1
AHR = alcohol
hand rub
-0.5
-1
WWS
CWS
WWA
AHW AHR
Environmental Disinfection
Removal/thorough cleaning of environmental
sources can decrease incidence
Use chlorine-containing agents (at least
5000 ppm available chlorine 10 minutes contact
time) for environmental contamination, especially
in outbreak areas
Fogging
Summary
CDI is increasing in incidence, severity and poor
outcomes
Laboratory diagnosis is challenging
Carefully evaluate what works best in your setting
Y Chromosome
Gitschier, J., Science, 1993 (261) p. 679
10.3
10.5
10.7
11.0
11.1
q
11.5
11.8
12.0
Thank you