OBJECTIVES: To assess the effectiveness of shortened regimens of vancomycin or fidaxomicin in the treatment of Clostridioides difficile infection (CDI). METHODS: Adult patients with CDI hospitalized from January 2022 to May 2023 were included in this observational study. In patients with CDI treated with vancomycin or fidaxomicin, antibiotic treatment was discontinued after either 5 or 7 days of vancomycin or 5 days of fidaxomicin if there was a clinical response and improvement in laboratory parameters. The control cohort was treated with the standard 10 day regimen of either vancomycin or fidaxomicin. The follow-up was 60 days. Causative C. difficile strains were characterized by ribotyping and toxin gene detection when available. RESULTS: Twenty-five patients (median age 76 years) received shortened treatment with vancomycin (n = 21), or fidaxomicin (n = 4). Five cases fulfilled the criteria for severe CDI. Twenty-three patients completed follow-up; two died from causes other than CDI, and two developed recurrent CDI (8.0%). Ribotypes (RTs) 001 and 014 were the most prevalent with 20% each. In two C. difficile isolates, binary toxin genes were detected (RTs 078 and 023). In the control group of 22 patients recurrent CDI developed in 5 patients (22.7%). No statistically significant differences were found between the groups. CONCLUSIONS: Shortened treatment regimens for CDI with vancomycin and fidaxomicin were shown to be effective in our cohort of patients compared with 10 days of treatment. The recurrence rate was lower in the study group. A larger, prospective, double-blind, randomized, multicentre study is needed to support our findings.

• MeSH
• antibakteriální látky * terapeutické užití   aplikace a dávkování   MeSH
• Clostridioides difficile * genetika   účinky léků   klasifikace   MeSH
• fidaxomicin * terapeutické užití   aplikace a dávkování   MeSH
• klostridiové infekce * farmakoterapie   mikrobiologie   MeSH
• lidé středního věku MeSH
• lidé MeSH
• ribotypizace * MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• vankomycin * terapeutické užití   aplikace a dávkování   MeSH
• výsledek terapie MeSH
• Check Tag
• lidé středního věku MeSH
• lidé MeSH
• mužské pohlaví MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• pozorovací studie MeSH

• MeSH
• Clostridioides difficile * účinky léků   MeSH
• dítě MeSH
• fidaxomicin * farmakologie   terapeutické užití   MeSH
• klostridiové infekce * farmakoterapie   MeSH
• lidé MeSH
• randomizované kontrolované studie jako téma MeSH
• Check Tag
• dítě MeSH
• lidé MeSH

Recently, the recommendations for the treatment of Clostridioides difficile infection (CDI) have been updated. However, in addition to the clinical efficacy data, the drug of choice should ideally represent optimal antimicrobial stewardship, with an emphasis on rapid restoration of the gut microbiota to minimize the risk of infection relapses. Oral administration of metronidazole results in low concentration in stool, and interaction with fecal microbiota reduces its antimicrobial bioactivity. Reported elevated minimum inhibitory concentrations of metronidazole in epidemic C. difficile ribotypes and the emergence of plasmid-mediated resistance to metronidazole represent additional potential risks for clinical failure. If metronidazole is the only CDI treatment option, antimicrobial susceptibility testing on agar containing heme should be performed in C. difficile isolate. Compared with metronidazole, oral vancomycin and fidaxomicin reach very high concentrations in the stool, and therefore can quickly reduce C. difficile shedding. Health care facilities with higher CDI incidence and/or occurrence of epidemic ribotypes should not use metronidazole because prolonged C. difficile shedding can increase the risk for further C. difficile transmission. Only fidaxomicin has a narrow spectrum of antimicrobial activity, which might be, together with persistence on spores, the main contributing factor to reduce the recurrent CDI rates.

• MeSH
• antibakteriální látky farmakologie   terapeutické užití   MeSH
• Clostridioides difficile * MeSH
• fidaxomicin terapeutické užití   MeSH
• klostridiové infekce * farmakoterapie   epidemiologie   mikrobiologie   MeSH
• lidé MeSH
• metronidazol farmakologie   terapeutické užití   MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH

x

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• MeSH
• antibakteriální látky aplikace a dávkování   farmakologie   terapeutické užití   MeSH
• Clostridioides difficile * patogenita   účinky léků   MeSH
• fekální transplantace metody   MeSH
• fidaxomicin farmakologie   terapeutické užití   MeSH
• klostridiové infekce diagnóza   farmakoterapie   prevence a kontrola   MeSH
• lidé MeSH
• metronidazol farmakologie   terapeutické užití   MeSH
• pseudomembranózní enterokolitida diagnóza   farmakoterapie   mikrobiologie   prevence a kontrola   MeSH
• tigecyklin farmakologie   terapeutické užití   MeSH
• vankomycin farmakologie   terapeutické užití   MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• směrnice pro lékařskou praxi MeSH

BACKGROUND: Clostridioides difficile infections (CDI) are traditionally attributed to an older adult patient group but children can also be affected. Although the causative pathogen is the same in both populations, the management of CDI may differ. OBJECTIVES: To discuss the current literature on CDI in the paediatric population and to provide CDI diagnostics and treatment guidance. SOURCES: The literature was drawn from a search of PubMed from January 2017 to July 2021. CONTENT: In the paediatric population, laboratory diagnostics for CDI should preferably be combined with laboratory diagnostics for other gastrointestinal pathogens. Coinfections of CDI are also possible. Though the detection of toxigenic C. difficile using a molecular assay may simply reflect colonisation rather than infection, detection of C. difficile free toxins A/B in faeces is much more indicative of true infection. CDI in children below 2 years of age and in the absence of risk factors is very difficult to diagnose and requires careful clinical judgement pending additional studies. Fidaxomicin has been shown to be superior to vancomycin with a sustained clinical response up to 30 days after the end of CDI treatment in children. Metronidazole is less effective than vancomycin in adults and there are no supporting data for its use in children. In recurrent CDI, treatment should be adjusted according to the drug or drug regimen used for the treatment of a previous episode(s). In multiple recurrent CDI, faecal microbiota transplantation can be effective. IMPLICATIONS: If CDI laboratory testing is indicated in children with diarrhoea, the likelihood of C. difficile colonisation and coinfection with other intestinal pathogens should be considered. The currently available data support a change in the treatment strategy of CDI in children.

• MeSH
• antibakteriální látky terapeutické užití   MeSH
• Clostridioides difficile * MeSH
• dítě MeSH
• fidaxomicin terapeutické užití   MeSH
• klostridiové infekce * diagnóza   epidemiologie   terapie   MeSH
• lidé MeSH
• senioři MeSH
• vankomycin terapeutické užití   MeSH
• Check Tag
• dítě MeSH
• lidé MeSH
• senioři MeSH
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH

Akutní gastroenteritida se běžně vyskytuje v klinické praxi pediatrů. Většinou se jedná o tzv. self-limited onemocnění s nekomplikovaným průběhem. Autoři uvádějí případ adolescenta s gastroenteritidou vedoucí k těžkému akutnímu poškození ledvin. Pro významný pokles glomerulární filtrace musela být zahájena eliminační terapie. V intermitentní hemodialýze jsme pokračovali sedm dní až do dostatečného zlepšení renálních funkcí. Clostridioides difficile byl identifikován jako příčina zvracení, krvavých průjmů a následné dehydratace. Pokud je nám známo, jedná se o první případ infekce C. difficile doprovázeného akutním poškozením ledvin vyžadující eliminační léčbu u dítěte.

Acute gastroenteritis is commonly seen in pediatric clinical practice. It is a largely self-limited disease with a benign course. We present a case of teenager with gastroenteritis resulting in severe acute kidney injury. The decline in glomerular filtration was so significant that renal replacement therapy had to be initiated. We had to continue in intermitent hemodialysis for seven days until sufficient improvement in renal function. Clostridioides difficile was identified as a cause of vomiting, bloody diarrhea and subsequent dehydration. To our knowledge, this is the first reported case of C. difficile-associated diarrhea accompanied by acute kidney injury requiring renal replacement therapy in a child.

• MeSH
• akutní poškození ledvin * etiologie   patologie   terapie   MeSH
• dialýza ledvin MeSH
• fidaxomicin terapeutické užití   MeSH
• gastroenteritida MeSH
• klostridiové infekce komplikace   MeSH
• lidé MeSH
• mladiství MeSH
• náhrada funkce ledvin metody   MeSH
• polymerázová řetězová reakce metody   MeSH
• průjem MeSH
• Check Tag
• lidé MeSH
• mladiství MeSH
• Publikační typ
• kazuistiky MeSH

Infekce vyvolané Clostridioides difficile (CDI) jsou tradičně připisovány starším dospělým pacientům, ale mohou jimi být postiženy i děti. U dětí by v indikovaných případech měla být laboratorní diagnostika CDI kombinována s testováním přítomnosti dalších gastrointestinálních patogenů, které jsou hlavně u mladších dětí častou příčinou průjmu. To bylo potvrzeno i v kohortě 652 dětí s průjmem hospitalizovaných ve Fakultní nemocnici v Motole, kde u 71 PCR pozitivní testů na přítomnost toxigenního C. difficile byla u 33.8 % (n = 24) prokázána jiná infekční příčina pomocí multiplexového PCR. Průkaz toxigenního C. difficile pomocí PCR neodliší kolonizaci od aktivní infekce, tudíž pozitivní PCR test je nutné doplnit o stanovení přítomnosti toxinů A/B. Z výše uvedených 71 PCR pozitivních stolic bylo 65 dotestováno imunoenzymatickým testem a současná pozitivita C. difficile GDH a toxinů A/B byla detekována pouze u 44,6 % stolic (n = 24), ale u téměř poloviny těchto vzorků (n = 10) byla současně prokázána další infekční příčina průjmu. U recidivující CDI by měl být stejně jako u první epizody kladen důraz na kombinovanou laboratorní diagnostiku k vyloučení koinfekce jiným střevním patogenem, případně k vyloučení pouhé kolonizace C. difficile. V porovnání s dospělými hospitalizovanými pacienty jsou dostupná klinická data u dětí limitovaná a je zapotřebí dalších prospektivních studií pro stanovení prevalence CDI a účinnosti léčebných režimů.

Clostridioides difficile infections (CDI) are traditionally attributed to adults, but children can also be affected. In children, when indicated, laboratory diagnosis of CDI should be combined with testing for the presence of other gastrointestinal pathogens that are a common cause of diarrhoea, particularly in younger children. This was also confirmed in a cohort of 652 children with diarrhoea admitted to the Motol University Hospital, where 71 PCR positive tests for toxigenic C. difficile revealed another infectious cause in 33.8% (n = 24) by multiplex PCR. The detection of toxigenic C. difficile by PCR does not distinguish between colonisation and active infection, so the stool sample with a positive PCR test should be tested also for the presence of toxins A/B. Of the above 71 PCR-positive stools, 65 were further tested with the immunoenzymatic assay, and simultaneous positivity of C. difficile GDH and A/B toxins was detected only in 44.6% of stools (n = 24), but in almost half of these samples (n = 10), another infectious cause of diarrhoea was detected. In recurrent CDI, as in the first episode, emphasis should be placed on combined laboratory diagnostics to exclude co-infection with another intestinal pathogen or colonization with C. difficile. Compared with adult inpatients, available clinical data in children are limited and further prospective studies are needed to determine the prevalence of CDI and the efficacy of treatment regimens.

• MeSH
• Clostridioides difficile MeSH
• dítě MeSH
• fidaxomicin terapeutické užití   MeSH
• infekce spojené se zdravotní péčí MeSH
• klostridiové infekce * diagnóza   epidemiologie   terapie   MeSH
• lidé MeSH
• metronidazol terapeutické užití   MeSH
• prospektivní studie MeSH
• vankomycin terapeutické užití   MeSH
• Check Tag
• dítě MeSH
• lidé MeSH

PURPOSE: We aimed to evaluate the efficacy of different antibiotic regimens for the treatment of Clostridioides difficile infection (CDI) with regard to the CDI episode number and disease severity. METHODS: An observation cohort study included 271 CDI patients hospitalised between 2013-2016. Univariate logistic regression was used to evaluate the association between patients' clinical outcome (sustained clinical cure or recurrence) in a 60-day follow-up and the antibiotic regimen used (oral metronidazole, oral vancomycin, combination of oral vancomycin and metronidazole, oral fidaxomicin). Subgroup analyses, based on CDI episode number and severity, were performed. RESULTS: In the overall population, fidaxomicin was superior to metronidazole, vancomycin or their combination, for a sustained clinical response and in the prevention of recurrent CDI (rCDI). In the subgroup analyses, fidaxomicin was superior to vancomycin or metronidazole for a sustained clinical response and in the prevention of rCDI in the initial episode, first recurrence and non-severe cases. In the oral treatment of severe CDI, fidaxomicin had a similar treatment outcome to vancomycin and none of the antibiotic treatments were superior in the prevention of rCDI. Fidaxomicin, vancomycin, or a combination of metronidazole and vancomycin, had similar outcomes for sustained clinical response and prevention of rCDI in patients with multiple rCDI. CONCLUSION: Fidaxomicin was superior to metronidazole or vancomycin for the treatment of the initial episode, first recurrence, and non-severe CDI.

• MeSH
• antibakteriální látky farmakologie   MeSH
• aplikace orální MeSH
• Clostridioides difficile účinky léků   MeSH
• fidaxomicin farmakologie   MeSH
• hospitalizace MeSH
• klostridiové infekce farmakoterapie   mikrobiologie   MeSH
• kohortové studie MeSH
• lidé středního věku MeSH
• lidé MeSH
• logistické modely MeSH
• metronidazol farmakologie   MeSH
• recidiva MeSH
• senioři MeSH
• vankomycin farmakologie   MeSH
• výsledek terapie MeSH
• Check Tag
• lidé středního věku MeSH
• lidé MeSH
• mužské pohlaví MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• pozorovací studie MeSH

SCOPE: In 2009, the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) published the first treatment guidance document for Clostridioides difficile infection (CDI). This document was updated in 2014. The growing literature on CDI antimicrobial treatment and novel treatment approaches, such as faecal microbiota transplantation (FMT) and toxin-binding monoclonal antibodies, prompted the ESCMID study group on C. difficile (ESGCD) to update the 2014 treatment guidance document for CDI in adults. METHODS AND QUESTIONS: Key questions on CDI treatment were formulated by the guideline committee and included: What is the best treatment for initial, severe, severe-complicated, refractory, recurrent and multiple recurrent CDI? What is the best treatment when no oral therapy is possible? Can prognostic factors identify patients at risk for severe and recurrent CDI and is there a place for CDI prophylaxis? Outcome measures for treatment strategy were: clinical cure, recurrence and sustained cure. For studies on surgical interventions and severe-complicated CDI the outcome was mortality. Appraisal of available literature and drafting of recommendations was performed by the guideline drafting group. The total body of evidence for the recommendations on CDI treatment consists of the literature described in the previous guidelines, supplemented with a systematic literature search on randomized clinical trials and observational studies from 2012 and onwards. The Grades of Recommendation Assessment, Development and Evaluation (GRADE) system was used to grade the strength of our recommendations and the quality of the evidence. The guideline committee was invited to comment on the recommendations. The guideline draft was sent to external experts and a patients' representative for review. Full ESCMID endorsement was obtained after a public consultation procedure. RECOMMENDATIONS: Important changes compared with previous guideline include but are not limited to: metronidazole is no longer recommended for treatment of CDI when fidaxomicin or vancomycin are available, fidaxomicin is the preferred agent for treatment of initial CDI and the first recurrence of CDI when available and feasible, FMT or bezlotoxumab in addition to standard of care antibiotics (SoC) are preferred for treatment of a second or further recurrence of CDI, bezlotoxumab in addition to SoC is recommended for the first recurrence of CDI when fidaxomicin was used to manage the initial CDI episode, and bezlotoxumab is considered as an ancillary treatment to vancomycin for a CDI episode with high risk of recurrence when fidaxomicin is not available. Contrary to the previous guideline, in the current guideline emphasis is placed on risk for recurrence as a factor that determines treatment strategy for the individual patient, rather than the disease severity.

• MeSH
• antibakteriální látky * terapeutické užití   MeSH
• Clostridioides difficile MeSH
• dospělí MeSH
• fidaxomicin MeSH
• klostridiové infekce * diagnóza   farmakoterapie   MeSH
• lidé MeSH
• monoklonální protilátky MeSH
• recidiva MeSH
• široce neutralizující protilátky MeSH
• směrnice pro lékařskou praxi jako téma * MeSH
• společnosti lékařské MeSH
• vankomycin MeSH
• Check Tag
• dospělí MeSH
• lidé MeSH
• Publikační typ
• časopisecké články MeSH

• MeSH
• antibakteriální látky škodlivé účinky   MeSH
• Clostridioides difficile patogenita   růst a vývoj   MeSH
• fekální transplantace MeSH
• fidaxomicin terapeutické užití   MeSH
• klostridiové infekce * diagnóza   přenos   terapie   MeSH
• lidé MeSH
• metronidazol aplikace a dávkování   terapeutické užití   MeSH
• pseudomembranózní enterokolitida * patofyziologie   přenos   MeSH
• rifaximin terapeutické užití   MeSH
• střevní mikroflóra účinky léků   MeSH
• tigecyklin aplikace a dávkování   terapeutické užití   MeSH
• vankomycin aplikace a dávkování   terapeutické užití   MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• přehledy MeSH