Hookman Perry, Barkin Jamie S
University of Miami Miller School of Medicine, Division of Gastroenterology, Mount Sinai Medical Center, Miami Beach, FL 33140, USA.
World J Gastroenterol. 2009 Apr 7;15(13):1554-80. doi: 10.3748/wjg.15.1554.
A new, hypervirulent strain of Clostridium difficile, called NAP1/BI/027, has been implicated in C. difficile outbreaks associated with increased morbidity and mortality since the early 2000s. The epidemic strain is resistant to fluoroquinolones in vitro, which was infrequent prior to 2001. The name of this strain reflects its characteristics, demonstrated by different typing methods: pulsed-field gel electrophoresis (NAP1), restriction endonuclease analysis (BI) and polymerase chain reaction (027). In 2004 and 2005, the US Centers for Disease Control and Prevention (CDC) emphasized that the risk of C. difficile-associated diarrhea (CDAD) is increased, not only by the usual factors, including antibiotic exposure, but also gastrointestinal surgery/manipulation, prolonged length of stay in a healthcare setting, serious underlying illness, immune-compromising conditions, and aging. Patients on proton pump inhibitors (PPIs) have an elevated risk, as do peripartum women and heart transplant recipients. Before 2002, toxic megacolon in C. difficile-associated colitis (CDAC), was rare, but its incidence has increased dramatically. Up to two-thirds of hospitalized patients may be infected with C. difficile. Asymptomatic carriers admitted to healthcare facilities can transmit the organism to other susceptible patients, thereby becoming vectors. Fulminant colitis is reported more frequently during outbreaks of C. difficile infection in patients with inflammatory bowel disease (IBD). C. difficile infection with IBD carries a higher mortality than without underlying IBD. This article reviews the latest information on C. difficile infection, including presentation, vulnerable hosts and choice of antibiotics, alternative therapies, and probiotics and immunotherapy. We review contact precautions for patients with known or suspected C. difficile-associated disease. Healthcare institutions require accurate and rapid diagnosis for early detection of possible outbreaks, to initiate specific therapy and implement effective control measures. A comprehensive C. difficile infection control management rapid response team (RRT) is recommended for each health care facility. A communication network between RRTs is recommended, in coordination with each country's department of health. Our aim is to convey a comprehensive source of information and to guide healthcare professionals in the difficult decisions that they face when caring for these oftentimes very ill patients.
一种新型的、高毒力的艰难梭菌菌株，称为NAP1/BI/027，自21世纪初以来，一直与艰难梭菌暴发相关，这些暴发伴随着发病率和死亡率的增加。该流行菌株在体外对氟喹诺酮类耐药，而在2001年之前这种情况并不常见。该菌株的名称反映了其通过不同分型方法所显示的特征：脉冲场凝胶电泳（NAP1）、限制性内切酶分析（BI）和聚合酶链反应（027）。2004年和2005年，美国疾病控制与预防中心（CDC）强调，艰难梭菌相关性腹泻（CDAD）的风险增加，不仅是由包括抗生素暴露在内的常见因素导致，还包括胃肠道手术/操作、在医疗机构的长期住院、严重的基础疾病、免疫功能低下状况以及老龄化。使用质子泵抑制剂（PPI）的患者风险升高，围产期妇女和心脏移植受者也是如此。2002年之前，艰难梭菌相关性结肠炎（CDAC）中的中毒性巨结肠很少见，但现在其发病率已大幅增加。高达三分之二的住院患者可能感染艰难梭菌。入住医疗机构的无症状携带者可将该病原体传播给其他易感患者，从而成为传播媒介。在炎症性肠病（IBD）患者的艰难梭菌感染暴发期间，暴发性结肠炎的报告更为频繁。患有IBD的艰难梭菌感染患者的死亡率高于无基础IBD的患者。本文综述了关于艰难梭菌感染的最新信息，包括临床表现、易感宿主、抗生素选择、替代疗法以及益生菌和免疫疗法。我们还综述了已知或疑似艰难梭菌相关性疾病患者的接触预防措施。医疗机构需要准确、快速的诊断以便早期发现可能的暴发，从而启动特异性治疗并实施有效的控制措施。建议每个医疗机构组建一个全面的艰难梭菌感染控制管理快速反应团队（RRT）。建议在与各国卫生部协调的情况下，建立RRT之间的通信网络。我们的目的是提供全面的信息来源，并指导医护人员在照顾这些通常病情严重的患者时做出艰难决策。
