Marshall Leisa L, Peasah Samuel, Stevens Gregg A
Consult Pharm. 2017 Jan 1;32(1):24-41. doi: 10.4140/TCP.n.2017.24.
Provide a systematic review of the primary literature on efforts to reduce Clostridium difficile infection (CDI) occurrence and improve outcomes in older adults.
DATA SOURCES, STUDY SELECTION, DATA EXTRACTION: PubMed and CINAHL databases were searched for research studies using search terms CDI, CDI prevention, reduction, control, management, geriatric, elderly, adults 65 years of age and older. The MeSH categories Aged and Aged, 80 and older, were used. A second search of PubMed, CINAHL, National Guideline Clearinghouse, and TRIP databases was conducted for primary, secondary, and tertiary literature for CDI epidemiology, burden, and management in adults of all ages, and prevention and management guidelines. Of the 2,263 articles located, 105 were selected for full review: 55 primary and 50 secondary, tertiary. Primary literature selected for full review included studies of interventions to prevent, reduce occurrence, control, manage, or improve outcomes in adults 65 years of age and older. Patient settings included the community, assisted living, nursing facility, subacute care, or hospital.
The main outcome measures for research studies were whether the studied intervention prevented, reduced occurrence, controlled, managed, or improved outcomes. Studies were conducted in acute or long-term hospitals, with a few in nursing facilities. Interventions that prevented or reduced CDI included antibiotic policy changes, education, procedure changes, infection control, and multi-intervention approaches. There were few management studies for adults 65 years of age and older or for all adults with results stratified by age. Treatments studied included efficacy of fidaxomicin, metronidazole, vancomycin, and fecal microbiota transplant. Though clinical outcomes were slightly less robust in those 65 years of age and older, age was not an independent predictor of success or failure. The current prevention and management guidelines for adults of all ages, as well as special considerations in skilled nursing facilities, extracted from the secondary/tertiary literature selected, are summarized.
There are a limited number of studies designed for older adults. Our findings suggest that guideline recommendations for adults are adequate and appropriate for older adults. Exposure to antibiotics and Clostridium difficile remain the two major risk factors for CDI, reinforcing the importance of antibiotic stewardship and infection control.
对关于降低老年人艰难梭菌感染（CDI）发生率及改善其预后的主要文献进行系统综述。
数据来源、研究选择、数据提取：在PubMed和CINAHL数据库中检索研究，检索词为CDI、CDI预防、降低、控制、管理、老年、年长、65岁及以上成年人。使用了医学主题词（MeSH）类别“年龄与老龄化”以及“80岁及以上”。对PubMed、CINAHL、国家指南文库和TRIP数据库进行了第二次检索，以获取关于各年龄段成年人CDI流行病学、负担及管理以及预防和管理指南的一级、二级和三级文献。在检索到的2263篇文章中，105篇被选作全面综述：55篇一级文献和50篇二级、三级文献。选作全面综述的一级文献包括针对65岁及以上成年人预防、降低发生率、控制、管理或改善预后的干预措施研究。患者环境包括社区、辅助生活机构、护理机构、亚急性护理机构或医院。
研究的主要结局指标是所研究的干预措施是否预防、降低发生率、控制、管理或改善了预后。研究在急性或长期医院进行，少数在护理机构。预防或降低CDI的干预措施包括抗生素政策改变、教育、程序改变、感染控制以及多干预方法。针对65岁及以上成年人或所有成年人且按年龄分层结果的管理研究很少。所研究的治疗方法包括非达霉素、甲硝唑、万古霉素和粪便微生物群移植的疗效。尽管65岁及以上人群的临床结局略逊一筹，但年龄并非成功或失败的独立预测因素。总结了从所选二级/三级文献中提取的各年龄段成年人的现行预防和管理指南以及专业护理机构中的特殊考虑因素。
针对老年人设计的研究数量有限。我们的研究结果表明，针对成年人的指南建议对老年人是充分且合适的。接触抗生素和艰难梭菌仍然是CDI的两个主要危险因素，这凸显了抗生素管理和感染控制的重要性。
