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Clostridium Difficile Infection in Non–HIV-Immunocompromised Patients and in HIV-Infected Patients

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Abstract

Clostridium difficile infection is a common cause of morbidity in patients with HIV infection and in patients with non-HIV immune deficiency. The frequency of C. difficile–associated diarrhea (CDAD) seen in these two patient populations has been attributed to immune deficiency, as well as to increased exposure to hospital environments and antibiotic therapy, both of which are major risk factors for CDAD. This article reviews recent data useful in the evaluation, treatment, and prevention of C. difficile infection in these patient groups. Recent publications relating to C. difficile infection in specific immunocompromised conditions are also discussed.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Hall IC, O’Toole E. Intestinal flora in new-born infants with a description of a new pathogenic anaerobe: Bacillus difficilis. Am J Dis Child. 1935;48:390–402.

    Google Scholar 

  2. Bartlett JG, Chang TE, Gurwith M. Antibiotic-associated pseudomembranous colitis due to toxin-producing Clostridia. N Engl J Med. 1978;298(10):531–4.

    Article  PubMed  CAS  Google Scholar 

  3. Viscidi R, Willey S, Bartlett JG. Isolation rates and toxigenic potential of Clostridium difficile isolates from various patient populations. Gastroenterology. 1981;81(1):5–9.

    PubMed  CAS  Google Scholar 

  4. Kuijper EJ, Coignard B, Tull P. Emergence of Clostridium difficile-associated disease in North America and Europe. Clin Microbiol Infect. 2006;12(S6):2–18.

    Article  PubMed  CAS  Google Scholar 

  5. Clabots CT, Johnson S, Olson MM, et al. Acquisition of Clostridium difficile by hospitalized patients. J Infect Dis. 1992;166:561–7.

    Article  PubMed  CAS  Google Scholar 

  6. Kyne L, Hamel MB, Polavaram R, Kelly CP. Health care costs and mortality associated with nosocomial diarrhea due to Clostridium difficile. Clin Infect Dis. 2002;34:346–53.

    Article  PubMed  Google Scholar 

  7. Sanchez TH, Brooks JT, Sullivan PS, et al. Bacterial diarrhea in persons with HIV infection, United States, 1992–2002. Clin Infect Dis. 2005;41:1621–7.

    Article  PubMed  Google Scholar 

  8. •• Cohen SH, Gerding DN, Johnson S, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31(5):431–55. This publication describes the most recent consensus guidelines for the diagnosis, treatment, and prevention of C. difficile infection from the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA).

    Article  PubMed  Google Scholar 

  9. Voth DE, Ballard JD. Clostridium difficile toxins: mechanism of action and role in disease. Clin Microbiol Rev. 2005;18(2):247–63.

    Article  PubMed  CAS  Google Scholar 

  10. Loo VG, Poirier L, Miller MA, et al. A predominately clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med. 2005;353:2442–9.

    Article  PubMed  CAS  Google Scholar 

  11. Sivapalasingham S, Blaser MJ. Bacterial diarrhea in HIV-infected patients. Why Clostridium difficile, and why now? Clin Infect Dis. 2005;41:1628–30.

    Article  Google Scholar 

  12. McFarland LV, Mulligan ME, Kwok RY, Stamm WE. Nosocomial acquisition of Clostridium difficile infection. N Engl J Med. 1989;320:204–10.

    Article  PubMed  CAS  Google Scholar 

  13. Viscidi R, Laughon BE, Yolken R, et al. Serum antibody responses to toxins A and B of Clostridium difficile. J Infect Dis. 1983;148:93–100.

    Article  PubMed  CAS  Google Scholar 

  14. Kyne L, Warny M, Qamar A, Kelly CP. Asymptomatic carriage of Clostridium difficile and serum levels of IgG antibody against toxin A. N Eng J Med. 2000;342:390–7.

    Article  CAS  Google Scholar 

  15. Kyne L, Warny M, Qamar A, Kelly CP. Association between antibody response to toxin A and protection against recurrent Clostridium difficile diarrhea. Lancet. 2001;357:189–93.

    Article  PubMed  CAS  Google Scholar 

  16. • Leav BA, Blair B, Leney M, et al. Serum anti-toxin B antibody correlates with protection from recurrent Clostridium difficile infection (CDI). Vaccine. 2010;28:965–69. This recent study demonstrates that antibodies generated against toxin B may be as important as or more important than antibodies against toxin A in the immune response to C. difficile infection.

    Article  PubMed  CAS  Google Scholar 

  17. DeMilito A, Nilsson A, Titanji K, et al. Mechanisms of hypergammaglobulinemia and impaired antigen-specific humoral immunity in HIV-1 infection. Blood. 2004;103:2180–6.

    Article  CAS  Google Scholar 

  18. Hunziker L, Recher M, Macpherson AJ, et al. Hypergammaglobulinemia and autoantibody induction mechanisms in viral infections. Nat Immunol. 2003;4:343–9.

    Article  PubMed  CAS  Google Scholar 

  19. McDonald LC, Owings M, Jernigan DB. Clostridium difficile infection in patients discharged from U.S. short-stay hospitals, 1996–2003. Emerg Infect Dis. 2006;12:409–15.

    PubMed  Google Scholar 

  20. McFarland LV, Elmer GW, Stamm WE, Mulligan ME. Correlation of immunoblot type, enterotoxin production, and cytotoxin production with clinical manifestations of Clostridium difficile in a cohort study of hospitalized patients. Infect Immun. 1991;59:2456–62.

    PubMed  CAS  Google Scholar 

  21. Cheng SH, Lu JJ, Young TG, et al. Clostridium difficile-associated disease: comparison of symptomatic infection versus carriage rate on the basis of risk factors, toxin production, and genotyping results. Clin Infect Dis. 1997;25:157–8.

    Article  PubMed  CAS  Google Scholar 

  22. Akerlund T, Svenungsson B, Lagergren A, Burman LG. Correlation of disease severity with fecal toxin levels in patients with Clostridium difficile-associated diarrhea and distribution of PCR ribotypes and toxin yields in vitro of corresponding isolates. J Clin Microbiol. 2006;44(2):353–8.

    Article  PubMed  Google Scholar 

  23. Stubbs SL, Brazier JS, O’Neill GL, Duerden BI. PCR targeted to the 16S-23S rRNA gene intergenic spacer region of Clostridium difficile and construction of a library consisting of 116 different PCR ribotypes. J Clin Microbiol. 1999;37:461–3.

    PubMed  CAS  Google Scholar 

  24. Pepin J, Valiquette L, Alary ME, et al. Clostridium difficile-associated diarrhea in a region of Quebex from 1991 to 2003. Can Med Assoc J. 2004;171:466–72.

    Article  Google Scholar 

  25. Fawley WN, Parnell P, Verity J, et al. Molecular epidemiology of endemic Clostridium difficile infection and the significance of subtypes of the United Kingdom epidemic strain (PCR Ribotype 1). J Clin Microbiol. 2005;43:2685–96.

    Article  PubMed  CAS  Google Scholar 

  26. Wilkins TD, Lyerly DM. Clostridium difficile testing: after 20 years, still challenging. J Clin Microbiol. 2003;41(2):531–4.

    Article  PubMed  Google Scholar 

  27. Lyras D, O’Connor JR, Howarth PM, et al. Toxin B is essential for virulence of Clostridium difficile. Nature. 2009;458:1176–9.

    Article  PubMed  CAS  Google Scholar 

  28. Onderdonk AB, Garrett WS. Gas gangrene and other Clostridium-associated diseases. In: Mandel et al. editors. Mandel, Douglas, and Bennett’s principles and practice of infectious diseases, 7th edition. Elsevier; 2009: Chapter 246.

  29. •• Crobach MJT, Dekkers OM, Wilcox MH, Kuijper EJ. European Society of Clinical Microbiology and Infectious Diseases (ESCMID): data review and recommendations for diagnosing Clostridium difficile-infection (CDI). Clin Microbiol Infect. 2009;15:1053–66. In this review, a comprehensive analysis of all available data regarding C. difficile assays is performed with updated recommendations for testing.

    Article  PubMed  CAS  Google Scholar 

  30. Sharp S, Ruden LO, Pohl JC, et al. Evaluation of the C.Diff Quick Chek Complete assay, a new glutamate dehydrogenase and A/B toxin combination lateral flow assay for use in rapid, simple diagnosis of Clostridium difficile disease. J Clin Microbiol. 2010;48:2082–6.

    Article  PubMed  Google Scholar 

  31. • Eastwood K, Else P, Charlett A, Wilcox M. Comparison of nine commercially available Clostridium difficile toxin detection assays, a real-time PCR assay for Clostridium difficile tcdB, and a glutamate dehydrogenase detection assay to cytotoxin testing and cytotoxigenic culture methods. J Clin Microbiol. 2009;47:3211–17. This recent article describes a side-by-side comparison of multiple assays for CDI including a newly developed PCR test.

    Article  PubMed  Google Scholar 

  32. Knetsch CW, Bakker D, de Boer RF, et al. Comparison of Real-Time PCR techniques to cytotoxigenic culture methods for diagnosing Clostridium difficile infection. J Clin Microbiol. 2011;49(1):227–31.

    Article  PubMed  CAS  Google Scholar 

  33. Van Den Berg RJ, Vaessen N, Endtz T, et al. Evaluation of a real-time PCR and conventional diagnostic methods for the detection of Clostridium difficile-associated diarrhoea in a prospective multicentre study. J Med Microbiol. 2007;56:36–42.

    Article  PubMed  Google Scholar 

  34. Peterson LR, Manson RU, Paule SM, et al. Detection of toxigenic Clostridium difficile in stool samples by real-time polymerase chain reaction for the diagnosis of C. difficile-associated diarrhea. Clin Infect Dis. 2007;45:1152–60.

    Article  PubMed  CAS  Google Scholar 

  35. Ansari J, Choo B, Fernando I. Fatal Clostridium difficile infection associated with vinorelbine chemotherapy:case report and literature review. J Infect Chemother. 2010;16:210–2.

    Article  PubMed  Google Scholar 

  36. Teasley DG, Gerding DN, Olson MM, et al. Prospective randomized trial of metronidazole versus vancomycin for the treatment of Clostridium difficile-associated diarrhea and colitis. Lancet. 1983;2:1043–6.

    Article  PubMed  CAS  Google Scholar 

  37. Wenisch C, Parschalk B, Hasenhundl M, et al. Comparison of vancomycin, teicoplanin, metronidazole, and fusidic acid for the treatment of Clostridium difficile-associated diarrhea. 1996;22:813–18.

  38. • Zar FA, Bakkanagari SR, Moorthi KM, et al. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis. 2007;45:302–07. This study classified CDAD cases by severity using six clinical variables and demonstrated that vancomycin was superior to metronidazole for the treatment of severe CDAD.

    Article  PubMed  CAS  Google Scholar 

  39. Musher DM, Aslam S, Logan N, et al. Relatively poor outcome after treatment of Clostridium difficile colitis with metronidazole. Clin Infect Dis. 2005;40:1586–90.

    Article  PubMed  CAS  Google Scholar 

  40. Pelaez T, Alcala L, Alonso R, et al. Reassessment of Clostridium difficile susceptibility to metronidazole and vancomycin. Antimicrob Agents Chemother. 2002;46:1647–60.

    Article  PubMed  CAS  Google Scholar 

  41. Alonso R, Gros S, Pelaez T, et al. Molecular analysis of relapse vs re-infection in HIV-positive patients suffering from recurrent Clostridium difficile-associated diarrhoea. J Hosp Infect. 2001;48:86–92.

    Article  PubMed  CAS  Google Scholar 

  42. Pepin J, Saheb N, Coulombe MA, et al. Emergence of flouroquinolones as the predominant risk factor for Clostridium-difficile associated diarrhea. Clin Infect Dis. 2005;41:1254–60.

    Article  PubMed  CAS  Google Scholar 

  43. Johnson S, Schriever C, Galang M, et al. Interruption of recurrent Clostridium difficile-associated diarrhea episodes by serial therapy with vancomycin and rifaximin. Clin Infect Dis. 2007;44:846–8.

    Article  PubMed  CAS  Google Scholar 

  44. • Lowy I, Molrine DC, Leav BA, et al. Treatment with monoclonal antibodies against Clostridium difficile toxins. N Eng J Med. 2010;362(3):197–205. This is the first randomized controlled trial of intravenous immunoglobulin therapy in the treatment of CDI. Results from this trial suggest that IVIG therapy may decrease the risk of CDI recurrence.

    Article  PubMed  CAS  Google Scholar 

  45. Floch MH. Fecal biotherapy, fecal transplant and the microbiome. J Clin Gastroenterol. 2010;44(8):529–30.

    Article  PubMed  Google Scholar 

  46. • Grehan MJ, Borody TJ, Leis SM, et al. Durable alteration of the colonic microbiota by the administration of donor fecal flora. J Clin Gastroenterol. 2010;44(8):551–61. Although multiple previous studies have demonstrated the effectiveness of fecal biotherapy in prevention of CDI recurrence by recolonization of the colonic lumen, this study demonstrates that the fecal flora of individuals can be reliably manipulated using donor feces.

    Article  PubMed  Google Scholar 

  47. Eddi R, Malik MN, Shakov R, et al. Chronic kidney disease as a risk factor for Clostridium difficile infection. Nephrology. 2010;15(4):471–5.

    Article  PubMed  Google Scholar 

  48. • Das R, Feuerstadt P, Brandt LJ. Glucocorticoids are associated with increased risk of short-term mortality in hospitalized patients with Clostridium difficile-associated disease. Am J Gastro. 2010;105:2040–49. This is the first major study to demonstrate increased mortality associated with glucocorticoid administration in the setting of CDAD.

    Article  CAS  Google Scholar 

  49. Gellad ZF, Alexander BD, Liu BC, et al. Severity of Clostridium difficile-associated diarrhea in solid organ transplant patients. Transpl Infect Dis. 2007;9:276–80.

    Article  PubMed  CAS  Google Scholar 

  50. • Bobak D, Arfons LM, Creger RJ, Lazarus HM. Clostridium difficile-associated disease in human stem cell transplant recipients:coming epidemic or false alarm? Bone Marrow Transplant. 2008;42:705–13. In this review, the current heterogeneous data regarding CDI in BMT are compiled and analyzed.

    Article  PubMed  CAS  Google Scholar 

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Disclosure

D.L. Raines: none; F.A. Lopez: author royalties from UpToDate, Inc.

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Authors and Affiliations

  1. Department of Medicine, Section of Gastroenterology, Louisiana State University Health Sciences Center, 1542 Tulane Avenue Suite 423, New Orleans, LA, 70112, USA

    Daniel L. Raines

  2. Department of Medicine, Section of Infectious Disease, Louisiana State University Health Sciences Center, 1542 Tulane Avenue Suite 425, New Orleans, LA, 70112, USA

    Fred A. Lopez

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  1. Daniel L. Raines
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Correspondence to Daniel L. Raines.

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Raines, D.L., Lopez, F.A. Clostridium Difficile Infection in Non–HIV-Immunocompromised Patients and in HIV-Infected Patients. Curr Gastroenterol Rep 13, 344–350 (2011). https://doi.org/10.1007/s11894-011-0196-6

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