Class of 2012 Abstract / Specific Aims: The incidence of non-response, recurrence, relapse, and rate of complications of Clostridium difficile infections treated with combination of metronidazole and vancomycin versus vancomycin or metronidazole alone over a one-year period by treatment and strain type (i.e. NAP1/BI/027) were evaluated. The incidence of mortality in patients with moderate to severe Clostridium difficile associated diarrhea prescribed metronidazole, vancomycin, or combination metronidazole plus vancomycin as initial therapy was also determined. Additionally, significant factors associated with the use of combination vancomycin-metronidazole as initial therapy for moderate to severe CDAD were characterized. Methods: T This retrospective medical record review has been approved by the Institutional Review Board. Adult patients with stool specimens tested for detection of Clostridium difficile toxin B by PCR between April 2010 and March 2011 at a tertiary care, academic medical center were evaluated. Patients were included in the study if diagnosed with moderate to severe disease and received either monotherapy with metronidazole, monotherapy with oral vancomycin, or combination therapy with metronidazole and oral vancomycin for at least 80% of the first 10 days of treatment. Patients who are discharged alive within 72 hours of admission or who received therapy for less than 48 hours were excluded. Main Results: All patients (N=411) with laboratory evidence of Clostridium difficile during the study time period were evaluated. A total of 26 subjects who received oral vancomycin monotherapy and 56 subjects who received oral vancomycin along with metronidazole for at least 80% of the first 10 days of treatment were identified. Of the subjects who received oral vancomycin monotherapy during the first ten days of therapy, 5 (19%) were classified has a treatment failure or died within the first 21 days of therapy and 5 (19%) had either a recurrence or reappearance of Clostridium difficile associated diarrhea between 22 and 65 days post start of therapy. Of the subjects who received a combination of oral vancomycin and metronidazole during the first 10 days of therapy, 14 (25%) were classified has a treatment failure or died within the first 21 days of therapy and 22 (39%) had either a recurrence or reappearance of Clostridium difficile associated diarrhea between 22 and 65 days post start of therapy. In the combination therapy group, 5 (9%) were reported to have an ileus, toxic megacolon, or necrotic bowel during the first 10 days of therapy. Conclusions: In this study, the subjects who received a combination of oral vancomycin and metronidazole had higher rates of clinical failure, death, and recurrence than subjects who received monotherapy. Current guideline statements recommend combination therapy only in patients with an ileus with Clostridium difficile-associated diarrhea.

El texto completo de este trabajo no está disponible en el Repositorio Académico UPC por restricciones de la casa editorial donde ha sido publicado. / OBJECTIVE: An estimated 20-30% of patients with primary Clostridium difficile infection (CDI) develop recurrent CDI (rCDI) within 2 weeks of completion of therapy. While the actual mechanism of recurrence remains unknown, a variety of risk factors have been suggested and studied. The aim of this systematic review and meta-analysis was to evaluate current evidence on the risk factors for rCDI. DESIGN: We searched MEDLINE and 5 other databases for subject headings and text related to rCDI. All studies investigating risk factors of rCDI in a multivariate model were eligible. Information on study design, patient population, and assessed risk factors were collected. Data were combined using a random-effects model and pooled relative risk ratios (RRs) were calculated. RESULTS: A total of 33 studies (n=18,530) met the inclusion criteria. The most frequent independent risk factors associated with rCDI were age≥65 years (risk ratio [RR], 1.63; 95% confidence interval [CI], 1.24-2.14; P=.0005), additional antibiotics during follow-up (RR, 1.76; 95% CI, 1.52-2.05; P<.00001), use of proton-pump inhibitors (PPIs) (RR, 1.58; 95% CI, 1.13-2.21; P=.008), and renal insufficiency (RR, 1.59; 95% CI, 1.14-2.23; P=.007). The risk was also greater in patients previously on fluoroquinolones (RR, 1.42; 95% CI, 1.28-1.57; P<.00001). CONCLUSIONS: Multiple risk factors are associated with the development of rCDI. Identification of modifiable risk factors and judicious use of antibiotics and PPI can play an important role in the prevention of rCDI.

No description available.

Reproduction de : Mémoire du DES : Pharmacie spécialisée : Nantes : 2009. Reproduction de : Thèse d'exercice : Pharmacie : Nantes : 2009. / Bibliogr.

published_or_final_version / Microbiology / Master / Master of Medical Sciences

No description available.

Clostridium difficile is a Gram-positive bacterium that is the most common cause of hospital-associated and antimicrobial-associated diarrhea in humans. Monteiro and co-workers have discovered that C. difficile expresses three cell-surface polysaccharides, named PS-I, PS-II and PS-III. Interestingly, PS-I was determined to be present in a ribotype 027 strain, the ribotype responsible for recent deadly outbreaks worldwide. In this work, the total chemical synthesis of the PS-I pentasaccharide with a linker molecule by a linear synthesis strategy from four monosaccharide building blocks is described: α-L-Rhap-(1→3)-β-D-Glcp-(1→4)-α-D-Glcp-(1→2)-α-D-Glcp-(1→O(CH2)5NH2 3 ↑ 1 α-L-Rhap The synthesized PS-I pentasaccharide will be conjugated to a protein carrier for evaluation as an anti-C. difficile glycoconjugate vaccine.

Clostridium difficile infection (CDI) is a disease associated with the wide-spread use of antibiotics and causes 450,000 infections and almost 30,000 deaths in the United States annually. Recurrence is a major problem, with approximately 1/3rd of patients relapsing after antibiotic treatment for CDI. Fecal Microbiota Transplantation (FMT) has emerged as a novel therapy for recurrent CDI, but the majority of the literature to date is made up of uncontrolled case series, so FMT’s true efficacy compared with standard antibiotic regimens remains unknown. Only a few randomized control trials (RCTs) have been published, and these have studied small numbers of patients and exhibited marked methodological heterogeneity. As such, there is uncertainty about the appropriate indications for FMT with respect to recurrent CDI, as well as the best methodology for the procedure, which has been carried our using various fecal preparations and modes of delivery. In particular, questions remain about if FMT should be recommended for patients with a first CDI recurrence, and if minimally invasive methods of performing FMT such as administration of enteric coated capsules are more efficacious than standard antibiotic treatments. We propose a double blind, placebo controlled, RCT that will be run as two parallel RCTs, where Trial 1 will enroll patients experiencing a first CDI recurrence, and Trial 2 will enroll patients experiencing a second or later CDI recurrence. The treatment arms in each trial will receive FMT in the form of orally administered frozen capsules, while the control arms will receive standard antibiotic treatments based on the number of recurrences they have experienced. If shown to be efficacious in a large RCT, oral capsulized FMT alone as treatment for recurrent CDI has the potential to increase access to FMT, decrease unnecessary antibiotic use, and substantially reduce morbidity and mortality attributable to CDI.

LIMA, Bruno Bezerra. Efeitos das toxinas A e B do Clostridium difficile sobre a via de WNT/Beta-catenina em células epiteliais intestinais. 2014. 79 f. Tese (Doutorado em Farmacologia) – Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, 2014. / Submitted by denise santos (denise.santos@ufc.br) on 2015-05-19T12:12:30Z No. of bitstreams: 1 2014_tese_bblima.pdf: 2558018 bytes, checksum: 9b5ba19b7dbb3fd33020f7fcd72564f7 (MD5) / Approved for entry into archive by denise santos(denise.santos@ufc.br) on 2015-05-19T12:37:54Z (GMT) No. of bitstreams: 1 2014_tese_bblima.pdf: 2558018 bytes, checksum: 9b5ba19b7dbb3fd33020f7fcd72564f7 (MD5) / Made available in DSpace on 2015-05-19T12:37:54Z (GMT). No. of bitstreams: 1 2014_tese_bblima.pdf: 2558018 bytes, checksum: 9b5ba19b7dbb3fd33020f7fcd72564f7 (MD5) Previous issue date: 2014 / Clostridium difficile toxins A and B (TcdA and TcdB) are homologous glycosyltransferases that inhibit a group of small GTPases within host cells, but several mechanisms underlying their pathogenic activity remain unclear. Here, we evaluated the effects of TcdA and TcdB on the Wnt/Beta-catenin pathway, the major driving force behind the proliferation of epithelial cells in colonic crypts. IEC-6 and RKO cells stimulated with Wnt3a-conditioned medium were incubated with 10, 50 and 100 ng/mL of TcdA or TcdB for 24h, resulting in a dose-dependent inhibition of the Wnt signaling, as demonstrated by a T-cell factor (TCF) reporter assay. This was further confirmed by immunofluorescence staining for nuclear localization of Beta-catenin and western blotting for Beta-catenin and c-Myc (encoded by a Wnt target gene). Moreover, our western blot analysis showed a decrease in the Beta-catenin protein levels, which was reversed by z-VAD-fmk, a pan-caspase inhibitor. Nonetheless, TcdA was still able to inhibit the Wnt/Beta-catenin pathway even in the presence of z-VAD-fmk, lithium chloride (a GSK3B inhibitor), or constitutively active Beta-catenin, as determined by a TCF reporter assay. Furthermore, pre-incubation of RKO cells with TcdA for 12h also attenuated Wnt3a-mediated activation of Wnt signaling, suggesting that inactivation of Rho GTPases plays a significant role in that inhibition. Taken together, these findings suggest that attenuation of the Wnt signaling by TcdA and TcdB is important for their anti-proliferative effects. / As toxinas A e B do Clostridium difficile (TcdA e TcdB) são glicosiltransferases homólogas que inibem um grupo de pequenas GTPases dentro da célula hospedeira, contudo, vários mecanismos envolvidos na atividade patogênica dessas toxinas permanecem desconhecidos. No presente estudo, avaliamos os efeitos das TcdA e TcdB na via de Wnt/Beta-catenina que representa a força motora principal responsável pela proliferação das células epiteliais nas criptas colônicas. Foram utilizadas células IEC-6 (células epiteliais de criptas de Rattus novergicus) e RKO (células de adenocarcinoma de cólon humano). Estas células foram estimuladas com meio condicionado contendo Wnt3a e incubadas com 10, 50 ou 100 ng/mL de TcdA ou 1, 5 ou 10 ng/mL de TcdB por 24h, resultando em uma inibição dose-dependente da via de sinalização canônica de Wnt, como demonstrado pelo ensaio de repórter de fator de célula T (TCF). Esse resultado foi corroborado pelos dados da imunofluorescência com marcação para a localização nuclear de Beta-catenina e por western blotting para Beta-catenina e c-MYC (gene-alvo da via de Wnt). Além disso, os dados do experimento de western blot evidenciaram uma diminuição dos níveis da proteína Beta-catenina, o qual foi prontamente revertido por z-VAD-fmk, um pan-inibidor de caspase. Entretanto, a TcdA ainda foi capaz de inibir a via de Wnt/Beta-catenina mesmo na presença do z-VAD-fmk, cloreto de lítio (um inibidor de GSK3Beta) ou plasmídeo de Beta-catenina constitutivamente ativo, como determinado pelo ensaio do TCF (TOPFlash/Luciferase). O estudo evidenciou ainda que a pré-incubação de células RKO com TcdA por 12h também atenuou a ativação da via de Wnt mediada por Wnt3a, o que sugere que a inativação de RhoGTPases, particularmente Rac1, possui um papel nessa inibição. Em conclusão, esses achados sugerem que a inibição da via canônica de Wnt pelas TcdA e TcdB representa um mecanismo importante da sua patogênese e explica seus efeitos anti-proliferativos.

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / Clostridium difficile à um bacilo Gram positivo, anaerÃbio estrito, formador de esporos e produtor de toxinas. Atualmente, representa a principal causa de diarreia hospitalar associada ao uso de antibiÃticos. Pacientes oncolÃgicos sÃo um dos principais grupos de risco para infecÃÃo por C. difficile (CDI), visto que o uso de agentes quimioterÃpicos pode alterar a mucosa intestinal. AlÃm disso, estes pacientes normalmente sÃo imunodeprimidos e frequentemente utilizam antibiÃticos de largo espectro. Tendo em vista a patogenicidade do C. difficile e a importÃncia da doenÃa induzida por essa bactÃria em ambiente hospitalar este estudo visou determinar a incidÃncia e caracterizaÃÃo fenotÃpica e genotÃpica de cepas de C. difficile isoladas de pacientes oncolÃgicos internados do Hospital Haroldo JuaÃaba, Fortaleza, CearÃ. Durante o perÃodo de 12 meses (maio/2013 a maio/2014) foram coletadas 41 amostras de fezes diarreicas. Toxinas A e/ou B foram detectadas a partir das fezes por meio de um kit de detecÃÃo comercial ELISA. Em seguida, as amostras foram cultivadas em Agar Cicloserina, Cefoxitina, Frutose (CCFA) e incubadas em anaerobiose. As cepas isoladas foram processadas e realizadas identificaÃÃo fenotÃpica e anÃlise de detecÃÃo dos genes das toxinas e do fragmento do gene tpi (identificaÃÃo definitiva) por PCR convencional. A sensibilidade das cepas isoladas a 12 antimicrobianos foi determinada por meio de E-test. TambÃm foi realizado a genotipagem das cepas por meio da anÃlise molecular PFGE. 46,3% (19/41) das amostras foram positivas para presenÃa das toxinas A/B por ELISA e/ou cultura do C. difficile. Dessas amostras, foram isolados C. difficile de trÃs amostras (15,8% - 3/19). Em todos os isolados foram detectados os genes tpi, tcdA e tcdB. O domÃnio de ligaÃÃo da toxina binÃria (cdtB) nÃo foi detectado assim como tambÃm nÃo foram observadas deleÃÃes no gene tcdC nos isolados. Todas as cepas apresentaram o mesmo genÃtipo, NAP4. Com relaÃÃo à sensibilidade das cepas aos antimicrobianos foi verificado resistÃncia a dois ou mais antimicrobianos (azitromicina, tetraciclina, ciprofloxacina, levofloxacina, ceftriaxona e cefotaxima). 57,9% (11/19) faziam uso de antibiÃticos e quimioterÃpicos. Este trabalho descreveu a incidÃncia de CDI em pacientes oncolÃgicos, e evidenciou pela primeira vez a presenÃa de C.difficile em casos associados a comunidade (CA-CDI) nesses pacientes no Brasil, ressaltando a importÃncia do estudo dessa bactÃria para a compreensÃo da situaÃÃo epidemiolÃgica dessa infecÃÃo e de sua dispersÃo entre unidades hospitalares brasileiras. / Clostridium difficile is a strictly anaerobic, spore-forming, toxin-producing Gram positive bacillus. Currently, it is the main cause of nosocomial diarrhea associated with antibiotic use. Cancer patients are a major risk group for C. difficile infection (CDI), since the use of chemotherapeutic agents can alter the intestinal mucosa. Furthermore, these patients are often immunosuppressed and often use broad spectrum antibiotics. Considering the pathogenicity of C. difficile and the importance of this infection in hospitalized patients, this study aimed to determine the incidence and the phenotypical and genotypical characterization of strains of C. difficile isolated from cancer patients at Haroldo JuaÃaba Hospital, Fortaleza, CearÃ. During the 12 month period (May/2013 to May/2014) 41 diarrheic fecal samples were collected. Toxins A/B were detected from feces through a commercial ELISA detection kit. Then, the samples were cultivated on cefoxitine-cycloserine-frutose agar (CCFA) and incubated anaerobically. Isolates were submitted to several analyses, including phenotypical identification, detection of toxin genes and of a fragment of the tpi gene (definitive identification) by conventional PCR. The susceptibility of the strains to 12 antimicrobial agents was determined by E-test. Genotyping of the strains was also performed through molecular PFGE analysis. Out of 41 samples, 46.3% (19/41) were positive for either one or both of the performed tests: detection of toxin A/B and/or culture of C. difficile. C. difficile was recovered from three samples (15.8% - 3/19). The tpi, tcdA and tcdB genes were detected in all of the isolates. The binding domain of the binary toxin (cdtB) was not detected as well as no deletions were observed in the tcdC gene of the analysed isolates. All strains belonged to the same genotype, NAP4. Regarding the antimicrobial susceptibility of the strains, resistance to two or more antibiotics (azithromycin, tetracycline, ciprofloxacin, levofloxacin, ceftriaxone and cefotaxime) was observed. Out of the 19 positive patients, 57.9% (11/19) were using antibiotics and under chemotherapy. This paper describes the incidence of CDI in patients with cancer, and shows for the first time the detection of community-associated Clostridium difficile infection (CA-CDI) in those patients in Brazil, highlighting the importance of studying this bacterium for understanding the epidemiological situation of this infection and its spread among Brazilian hospitals.